22.06.2012

Mentalization Based Therapy for Families

Some Free Publicity JUST RELASED! NEW! IMPROVED!

Ja-Vegard Nilsen Finn Skårderud

Much longer than all previous versions!

Washes minds whiter!

Oslo, 7. juni 2012

2012 American Psychiatric Publishing, Inc

Mentalizing: further definitions and scope for thinking about it To see ourselves from the outside and others from the inside Understanding misunderstanding Having mind in mind Being mind minded Being mindful (of minds) Past, present, and future Seeing oneself as an intentional being Creating phenomenological coherence about self and others Introspection for self-construction – know yourself as others know you but also know your subjective self

Mentalizing can be seen as essential for: sense of self constructive social interactions mutuality of relationships sense of personal security … SO mentalizing is a core psychological process worthy of focus in treatment.

SYSTEMIC: The value of understanding the relationship between the thoughts and feelings of family members and their behaviours, and the impact of these on each other.

CBT: The value of understanding the relationship between my thoughts and feelings and my behaviour.

COMMON

Mentalizing as an Integrative framework

PSYCHODYNAMIC: The value of understanding the nature of resistance to therapy, and the dynamics of here-and-now in the therapeutic relationship.

LANGUAGE

SOCIAL ECOLOGICAL: The value of understanding the impact of context upon mental states; deprivation, hunger, fear, etc...

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22.06.2012

Some features of good mentalizing

Learning About My Mind, Your Mind

1. Is curious / inquisitive about own and other people’s perspectives (‘safe uncertainty’ – Mason) 2. Being flexible – not stuck in one point of view 3. Can be playful – using humour to engage (vs avoid) 4. Can solve problems using give and take between different people’s views 5. Can differentiate one’s own experience from that of others 6. Conveys ‘ownership’ of own behaviour 7. Uses ‘grounded imagination’

Mind in mind

Contingent Marked Mirroring

Sam-I-am

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How Attachment Links to Affect Regulation

Theory: Birth of the Agentive Self Attachment figure “discovers” infant’s mind (subjectivity) DISTRESS/FEAR Internalization BONDING

Down Regulation of Emotions Exposure to Threat

Activation of attachment

Representation of infant’s mental state

Core of psychological self

BONDING

Proximity seeking

The forming of an attachment bond

Attachment figure

Inference

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

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22.06.2012

Theory: Birth of the “Alien” Self in Disorganized

Mirroring sadness

Attachment The caregiver’s perception is inaccurate or unmarked or both Attachment Figure Child Mirroring fails The nascent self representational structure

Absence of a representation of the infant’s mental state

The Alien Self Internalisation of a non-contingent mental state as part of the self The child, unable to “find” himself as an intentional being, internalizes a representation of the other into the self with distorted agentive characteristics which disorganizes the self creating splits within the self structure

Unmarked mirroring

Marked mirroring

Mirroring happiness

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

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

Unmarked mirroring

Marked mirroring

EEG study of the responses of maltreated and non-maltreated children to viewing an angry face (Cicchetti & Curtis, 2005 Dev. & Psychopath.)

Maltreated group

Normal child

Abused child

A Developmental trajectory, with high frequency fluctuations: Mentalization is fragile “Programmed for overwhelm”

Comparison group

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22.06.2012

Dimensions of mentalization: implicit/automatic vs explicit/controlled

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.

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

Automatic

Arousal

Arousal

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

Mentalization Based Work with Familes

Basic Clinical Principles Consideration, interpretation and appraisal of mental states (in self and other) essential for healthy relationships Aim of treatment is to help family maintain capacity to mentalize even in stressful situations

Clinical summary of intervention 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

The focus is on processes (mind not behaviour) - positive changes in mentalizing act as a catalyst for further changes: ‘MENTALIZING BEGETS MENTALIZING AND HEALTHIER PSYCHOLOGICAL FUNCTIONING’ (Bateman and Fonagy, 2012)

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22.06.2012

The MBT-F-Loop

Mentalizing stance

Notice And Name

Terminating Non-mentalizing Highlighting mentalizing

Inquisitive

Generalise (and Consider Change)

Checking

Mentalize The Moment

Holding the balance

Core Features - The MBT-F Loop (ii)

Core Features - The MBT-F-Loop (iii)

Notice And Name

Checking

• Checking is a powerful enactment of the Therapist's Stance Respectful curiosity, expressed tentatively, about mental states. • Checking the Links Accurate mentalizing increases the narrative coherence of an event • Checking as confirming the limits of our 'mind-reading'. Checking understandings also powerfully affirms the mentalizing notion that we do not have privileged access to the contents of each other's minds • Checking as affirming of the value of mentalizing. Implicit in our checking understandings and feelings is that we affirm the importance of understanding other peoples' mental states.

Core Features- The MBT-F-Loop (iv) Core Features- The MBT-F-Loop (iv)

• To share and provoke curiosity amongst and between the family members. • Attitude that learning about how others are thinking and feeling is enlightening. • “This is fascinating, I wonder Sally what it feels like for you when your dad does x?” “Dad, what do you think it feels like for Sally? If one could see thought bubbles come out of your wife’s head, what might be in there about how she thinks Sally feels right now? ” • Checking and encouraging family members to rehearse their own Checking. The major aim of status quo mentalizing: To set a context for what could be termed ‘emotional brainstorming’.

An attempt to move away from discussing a specific interaction that occurred during the session and to 'widen the lens’ towards: Mentalize The Moment

GENERALISING: Capturing more generalised understandings relating to this specific observation. Generalise (and Consider Change)

INVITING VISION: Generating possible applications of these understandings, by "inviting vision" of alternative strategies. PLANNING: Planning the implementation of these changes.

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Core Features- The MBT-F-Loop (v)

The Four Stage Loop -1 Follow these 4 stages…

Checking

Checking back at the end of the loop

1. Noticing and Naming: •Observing patterns of interaction •Checking for consensus • Questioning the problem

2. Mentalize the Moment •Being curious yourself •Provoking curiosity in the coparents •Pausing, reviewing and marking

Each family member views what happened from a meta-perspective. Evaluating what may have been a new and emotionally charged experience, giving them the opportunity to reflect together about what happened and the possible consequences.

“What did you make of what happened? Can you talk together about what this was like for each and all of you? Are there any conclusions you can draw from this?”

Mind Scanning

3. Generalizing and considering change •Widening the lens •Considering constructive alternatives •Planning action or Considering Specific Action

4. Checking feeling states •Checking feelings •Checking links between thoughts, actions and feelings •Checking out your own Mentalizing

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Mentalizing a Picture write down / discuss a) b) c) d) e)

what atmosphere is contained in the picture? what is / are person(s) feeling? what is / are person(s) trying to communicate? what is on the painter’s / photographer’s mind? What does it trigger in you?

Mentalizing Music

MBT-F Manual What atmosphere is portrayed? what is the composer trying to communicate? what is the performer thinking / feeling? Web-based, ‘open source’: http://tiddlymanuals.tiddlyspace.com/ Downloadable Editable (for the adventurous - note licensing restrictions though)

what feelings / thoughts / desires / wishes / hopes are triggered in you?

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