Collaboration
Colleagues Peter Fonagy, Mary Target & Anthony Bateman; Efrain Bleiberg, Pasco Fearon, Toby HaslamHopwood, Elliot Jurist, George Gergely, Jeremy Holmes, Linda Mayes, Richard Munich, Lois Sadler, John Sargent, Carla Sharp, Arietta Slade, Helen Stein, Stuart Twemlow, Laurel Williams Consortium University College London, Anna Freud Centre, Yale Child Study Center, The Menninger Clinic, Human Neuroimaging Laboratory at Baylor College of Medicine
Books
Fonagy, Gergely, Jurist & Target (2002). Affect regulation, mentalizing, and the development of the self. New York: Other Press. Bateman & Fonagy (2004). Psychotherapy for borderline personality disorder: Mentalization-Based Treatment. New York: Oxford University Press. Bateman & Fonagy (2006). Mentalization-Based Treatment for borderline personality disorder: A practical guide. New York: Oxford University Press. Allen & Fonagy, Eds. (2006). Handbook of Mentalization-Based Treatment. Chichester, UK: John Wiley & Sons. Allen, Fonagy, & Bateman (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing.
Definitions of mentalizing
mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior as conjoined with intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons)
Shorthand attending to mental states in self and others holding mind in mind
holding heart and mind in heart and mind mindfulness of mind understanding misunderstandings
Part I
Much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than those that distinguish them from each other.
Jerome Frank (1961): Persuasion and healing
What is the therapeutic alliance if not an attachment bond? Jeremy Holmes (2001): The search for the secure base
Mentalizing is the most fundamental common factor among psychotherapeutic treatmentsperforce, clinicians mentalize in conducting psychotherapies and also engage their patients in doing so. Allen, Fonagy, & Bateman, Mentalizing in Clinical Practice
In advocating mentalization-based treatment we claim no innovation. On the contrary, mentalization-based treatment is the least novel therapeutic approach imaginable.
Allen & Fonagy, Handbook of Mentalization-Based Treatment
mentalizing, even if not always explicit in our language, is implicit in many forms of psychotherapyAllen and colleagues, of course, have already said this, when they suggest: Youre already doing it. And indeed we are, if were doing our job.
Oldham (2008), Epilogue to Mentalizing in Clinical Practice
common factors
mentalizing
Transference-Focused Psychotherapy
Mentalization-Based Therapy
relatively single-minded focus on mentalizing process: consistency; a style of psychotherapy
Implication: extensive overlap between MBT and other treatment approaches to BPD
mentalizing
mentalizing
Complaints
Mentalization has an intellectualizing and potentially dehumanizing ring to it and must be humanized: We must keep in mind that the mental states perceived and the process of perception are suffused with emotion; mentalizing is a form of emotional knowing A grammatical preference for the verb (or gerund) emphasizes agency, activity, and process; mentalizing is mental action; something we do Aspiring to render mentalizing an everyday word rather than a technical concept
New words
The word in language is half someone elses. It becomes ones own only when the speaker populates it with his own intention.many words stubbornly resist, others remain alien, sound foreign in the mouth of the one who appropriated them and who now speaks themLanguage is populatedoverpopulatedwith the intentions of others. Expropriating it, forcing it to submit to ones own intentions and accents, is a difficult and complicated process.
Wertsch: Mind as action
Emotion (affect) is mentalized when felt Mental elaboration includes understanding and attributing meaning to feelings, which includes continuous conscious cognitive appraisals and reappraisals
Two impairments of mentalizing (besides misuse): too little or too much imaginativeness
distorted mentalizing imagination gone wild (paranoia)
nonmentalizing
concreteness, indifference, aversion mindblindness
mentalizing
grounded imagination
excrementalizing
Criticisms of mentalizing
Choi-Kain & Gunderson (Am J Psychiatry, in press)
The concept is broad and multidimensional The core measure, the Reflective Functioning Scale, yields only a single score, is time-consuming and costly, and has limited research Research should focus on more limited-domain concepts for which (primarily self-report) measures have been developed (e.g., theory of mind, mindfulness, psychological mindedness, empathy, affect consciousness) Separates self and others Differentiates four facets
Identifying mental states Differentiating subjective from objective (mental states as representational) Relating mental states to each other and behavior Integrating metacognitive knowledge into abstract narratives
NEUROBIOLOGY
EVOLUTIONARY BIOLOGY
MENTALIZING
PSYCHOANALYSIS
ethics
ATTACHMENT PHILOSOPHY
philosophy of mind
NEUROBIOLOGY
EVOLUTIONARY BIOLOGY
MENTALIZING
PSYCHOANALYSIS
ethics
ATTACHMENT PHILOSOPHY
philosophy of mind
Part II
Trauma spectrum
impersonal trauma interpersonal trauma attachment trauma
nonhuman agent
human agent
attachment figure
Attachment trauma: Two senses Trauma that occurs in an attachment relationship, in childhood or adulthood Trauma that adversely affects the capacity for secure attachmentthe bane of the therapeutic relationship
Dual liability associated with attachment trauma in childhood (Fonagy & Target) provokes extreme, repeated stress undermines the development of the capacity to regulate distress
insecure (disorganized) attachment impaired mentalizing capacity impaired self-regulation
child attachment security parental attachment security parental mentalizing in relation to childhood attachment child mentalizing emotion regulation psychosocial functioning
ALONE
AFRAID
unbearable emotional states
affective dysregulation
DBT:
invalidating environment
BPD
terrorizing
mindblind
ALONE
AFRAID
unbearable emotional states
Frankfurt: On Bullshit
Applications to BPD
Persons with BPD often mentalize adequately but are highly vulnerable to losing mentalizing, especially when attachment needs are activated in the context of insecure attachments (e.g., distrust; threat of loss or betrayal) frantic responses to perceived abandonment can be construed as posttraumatic reexperiencing of painful emotional states in the context of non-mentalizing attachment relationships the core trauma in BPD might be the failure to develop robust mentalizing capacities stemming from relative deficiency of mentalizing in early attachment relationships (with or without abuse) this trauma is associated with impaired affect regulation and impaired social cognition, especially in attachment contexts (i.e., when attachment needs are evoked), including in psychotherapy relationships, which have the potential to undermine mentalizing if too stimulating
Mentalization-Based Adolescent Treatment Program: Efrain Bleiberg, Laurel Williams, Carla Sharp Develop assessment and treatment for emerging personality disorder Assessment
Diagnoses Mentalizing capacity Executive and cognitive functioning Trauma history Emotion regulation and risky behaviors Family functioning (parenting style, attachment, mentalizing)
Part III
Psychoeducational Approach
Purposes
promote a therapeutic alliance draw patients attention to a natural process understanding mentalizing and its development psychiatric disorders and mentalizing impairments how treatment modalities promote mentalizing mentalizing exercises (projective, metaphors, role-playing, etc.) Coping with trauma Coping with depression
Curriculum
Articles for patients and family members Allen, Bleiberg, & Haslam-Hopwood (2003). Mentalizing as a compass for treatment. Allen, Fonagy, Bateman (2008). What is mentalizing and why do it? (Appendix in Mentalizing in clinical practice)
self
others
empathy
Part IV
what good therapists do with their patients is analogous to what successful parents do with their children
Jeremy Holmes (2001): The search for the secure base
How affect is handled relationally The capacity to feel and deal while relating Neither overwhelmed nor hostile to emotion in patient or self Requires affect tolerance and affect regulation Allows therapist to provide an affect-facilitating environment Note: entails mentalized affectivity or mentalizing emotion Psychological equivalent of immunological competence Collaborative and coherent discourse (e.g., as in secure/autonomous AAI narratives) Balancing prose and poetry, stories and images Evident in story telling, story listening, story-understanding; story making and story breaking
Narrative competence
Secure attachment is marked by coherent stories that convince and hang together, where detail and overall plot are congruent, and where the teller is not so detached that affect is absent, is not dissociated from the content of her story, nor is so overwhelmed that her feelings flow formlessly into every crevice of the dialogue. Insecure attachment, by contrast, is characterized either by stories that are over-elaborated and enmeshed, or by dismissive, poorly fleshed-out accounts[there are] three prototypical pathologies of narrative capacity: clinging to rigid stories, being overwhelmed by unstoried experience, or being unable to find a narrative strong enough to contain traumatic pain.
Jeremy Holmes (2001): The search for the secure base
developmental history
Patient
current functioning
mentalizing
Therapist
current functioning
developmental history
The ability to think and talk about past pain is a protective factor leading to secure attachment, no matter how traumatic a childhood may have been. This inspiring finding is in itself an endorsement of psychotherapy, on of whose main functions, it can be argued, is to enhance reflective function [mentalizing].
Jeremy Holmes (2001): The search for the secure base
Ethical aspects (as in parenting, for example) good will and compassion acceptance and forgiveness
Therapeutic paradox
activating attachment needs undermines mentalizing for patients with insecure attachment psychotherapy activates attachment needs patient must learn to mentalize in the context of intense emotional states in attachment relationships note contrast with mindfulness practice
The patient has to find himself in the mind of the therapist and, equally, the therapist has to understand himself in the mind of the patient if the two together are to develop a mentalizing process. Both have to experience a mind being changed by a mind (Bateman & Fonagy)