Mentalizing in psychoanalytic ideas and cognitive neuroscience: Freud’s dream or Freud’s nightmare? Peter Fonagy PhD FBA with Anthony Bateman MD University College London & the Anna Freud Centre [email protected]

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Meet the Mentalizing Mafia  

UCL/AFC/Tavistock (The ‘British Family’)   Prof George Gergely

  Dr Liz Allison

  Prof Pasco Fearon   Prof Alessandra Lemma   Prof Mary Target

  Prof Eia Asen   Prof Anthony Bateman

 

University of Leuven & UCL/AFC   Dr Patrick Luyten

  Dr Trudie Rossouw

Some more maffiosi  

Menninger Clinic/Baylor Medical College (The USA branch)   Dr Jon Allen

  Dr Carla Sharp

  Dr Lane Strathearn

  Dr Efrain Bleiberg

  Dr Brooks King-Casas

  Prof Flynn O’Malley

  Dr Read Montague

 

Yale Child Study Centre   Prof Linda Mayes

  Prof Nancy Suchman

And further recent recruits to the ‘Family”   Dawn Bales

  Dr Mirjam Kalland

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

  Professor Finn Skårderud

  Professor Sigmund Karterud

• Bart Vandeneede • Annelies Verheught-Pleiter • Rudi Vermote • Joleien Zevalkink • Bjorn Philips

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

What is Mentalizing?

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

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   Mentalizing may be commonplace, but it is not simple and it is not easy  

Number of articles on Web of Science Database

Articles using ‘mentalization’ in title or abstracts

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

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

Mentalizing is a Freudian Theory (but it is not Freudian technique)

Some common criticisms of mentalization theory: Old wine in new bottles?   A particularly

ugly term to describe Freud’s, Bion’s, Winnicott’s and Marty’s concepts.

  Explicitly

acknowledged:

  “mentalization was the least original concept” in the dictionary of psychological thought.  “mentalizing-focused treatment is the least novel therapeutic approach imaginable, simply because it revolves around a fundamental human capacity—indeed, the capacity that makes us human” (Allen & Fonagy, 2006, p.24).

Mentalization has been described in the psychoanalytic literature under various headings (see Lecours & Bouchard, 1997)

  All

derive from Freud’s concept of “Bindung” (linking).

 In the distinction of primary and secondary processes Freud (1911) stressed that “Bindung” was both a qualitative change from a physical (immediate) to a psychical associative quality of linking  Mental processes arise from the binding of somatic drive energies into thought, that is, transforming something that is non-mental into something mental (Freud, 1895).

Freud: Mentalizing as thinking before acting

 

Thinking is a holding action that provides a realistic pathway from feeling impelled by a drive to finding the object of satisfaction.  Freud’s conception that thinking arises in response to an absence of the need-gratifying object: “no breast, therefore imagine [mentalize] a breast” (p. 36).

 

Freud recognized, of course, that other persons are the primary source of satisfaction and, foreshadowing our understanding of the development of mentalizing, he wrote, “it is in relation to a fellow human-being that a humanbeing learns to cognize” (quoted in Pribram & Gill, 1976 p. 116).

Mentalizing and Kleinian Theory   Klein’s

(1945) notion of the depressive position is analogous to the notion of the acquisition of mentalizing  Both entail the recognition of hurt and suffering in the other as well as that of one’s own role in the process

Bion and Mentalizing: Containment  

The containment function of thinking:  pressing internal impulses are transformed into tolerable and thinkable experiences  “alpha-function” delineates the transformation of internal events experienced as concrete (“betaelements”) into tolerable thinkable experiences  “a capacity for tolerating frustration thus enables the psyche to develop thought as a means by which the frustration that is tolerated is itself made more tolerable” (p. 307)

 

Bion also saw the mother-child relationship as at the root of the symbolic capacity.

Winnicott and Mentalizing  

Outlined the role of maternal mirroring in the development of a mentalized sense of self

 

Recognized the importance of the caregiver’s psychological understanding of the infant for the emergence of the ‘true self’  the psychological self developed through the perception of oneself in another person’s mind as thinking and feeling.  Parents who cannot reflect with understanding on their children’s inner experiences, and respond accordingly, deprive their children of a core psychological structure which they need to build a viable sense of self.

Mentalization in France from an Economic Viewpoint

 

Marty (1968, 1990)

  mentalization as a protective buffer in the preconscious system that prevents progressive disorganisation   mentalization as connecting drive excitations and mental representations and thereby creating both “fluidity” and “constancy”   mentalization ensures freedom in the use of associations as well as permanence and stability  

Luquet (1981, 1988)   the development of different forms of thinking and the reorganisation of inner experience alongside this development   distinguished primary mentalization (the absence of mentalization)   secondary symbolic mentalization (closely connected to sensory data and primary unconscious fantasies, but also seen as representative of these processes and observable in dreams, art and play   third level is verbal thought - most distant from bodily processes.

Attachment and attunement, mirroring, psychic equivalence, teleological thinking and pretend mode are core concepts to us & all have their roots in psychoanalysis

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

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

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

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

How Attachment Links to Affect Regulation & Epistemic Trust DISTRESS/FEAR

BONDING

Down Regulation of Emotions Exposure to Threat

Activation of attachment EPISTEMIC TRUST

Proximity seeking

The forming of an attachment bond

Ego functions linked to early attachment that are key to understanding vulnerability to trauma in BPD (Fonagy, 2003) IMHJ, 24(3), 212-239,

Developmental Functions of Early Attachment Affect Representation Affect Regulation

Attentional Mechanisms Control of Consciousness

Mentalizing Capacities Reflective Function

Interpersonal Interpretive Function  Vulnerability to Trauma

The Development of Affect Regulation   Closeness

of the infant to another human being who via contingent marked mirroring actions facilitates the emergence of a symbolic representational system of affective states and assists in developing affect regulation (and selective attention)  secure attachment   For normal development the child needs to experience a mind that has his mind in mind  Able to reflect on his intentions accurately  Does not overwhelm him  Not accessible to neglected children

Mirroring sadness

Unmarked mirroring

Marked mirroring

High congruent & marked mirroring

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

oxytocin

may well be mediated by

Intranasal oxytocin increases fathers’ observed responsiveness during play Placebo

*

Oxytocin

*

*

Sensitivity Structure Nonintrusive

Nonhostility

Child Child response involvement

Naber et al., (2010), Psychoneuroendocrinology 35, 1583—1586

Simple test of mind-mindedness Cautious-A

Bored-C

Insisting-B

Aghast-D

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

Gaze duration during oxytocin exposure

BIOL PSYCHIATRY 2008;63:3–5

Is there a human language which does not recognize love to be blind? Common regions of deactivation with maternal and romantic love: • Long term memory system • Mentalizing (social judgment) network (Bartels & Zeki, 2008)

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  

Dimensions of mentalization: implicit/automatic vs explicit/controlled in Othello That so loved Why, handkerchief how now, ho! fromwhich whenceIariseth this? and gave thee Thou to Cassio. Are wegavest turn'd Turks, and to ourselves do that Which heavenI hath Ottomites? By heaven, sawforbid my the handkerchief in's hand.

Cont For Christian shame, put by this barbarous brawl: rolled Controlled Automatic Autom atic

Love Spurned/ Arousal

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

That handkerchief which I so loved and gave thee ThouLateral gavest to Cassio. Amygdala PFC temporal Lateral PFCmy Medial Ventromedial PFCin's hand. By heaven, I saw handkerchief

cortex Cont rolled Controlled

Automatic Autom atic

Arousal

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

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 ro l l e d

Autom

atic

Arousal

Attachment Disorganized by Maltreatment DISTRESS/FEAR

Adverse Emotional Experience Exposure to maltreatment

Activation of attachment

Proximity seeking

The ‘hyperactivation’ of the attachment system

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

Attachment - Arousal/Stress

The Primary Process Modes of Psychic Reality That Antedate Mentalisation   Psychic

equivalence :

 Mind-world isomorphism; mental reality = outer reality; internal has power of external  Experience of mind can be terrifying (flashbacks)  Projection of fantasy felt compellingly real  Intolerance of alternative perspectives (“I know what the solution is and no one can tell me otherwise ”)  Self-related negative cognitions are TOO REAL! (feeling of badness felt with unbearable intensity)

The Primary Process Modes of Psychic Reality That Antedate Mentalisation   Pretend mode:  Ideas form no bridge between inner and outer reality; mental world decoupled from external reality  “A domain which became separated from the real external world…free from exigencies of life, like a kind of reservation” (Freud, 1924, p.187; see also Steiner, Britton & Grotstein)  Linked with emptiness, meaninglessness and dissociation in the wake of trauma  Lack of reality of internal experience permits selfmutilation and states of mind where continued existence of mind no longer contingent on continued existence of the physical self

The Primary Process Modes of Psychic Reality That Antedate Mentalisation  

Teleological stance:  Expectations concerning the agency of the other are present but these are formulated in terms restricted to the physical world  A focus on understanding actions in terms of their physical as opposed to mental outcomes  Patients cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other.  Only actions that have physical impact are felt to be able to alter mental states of self and other o  ‘Manipulative’ physical acts (self-harm) o  Demand for acts of demonstration of affection by others

Understanding suicide and self-harm in terms of the temporary loss of mentalization   Loss



 Increase attachment needs  triggering of attachment system    Failure

of mentalization 

 Psychic equivalence  intensification of unbearable experience  Pretend mode  hypermentalization meaninglessness, dissociation   Teleological solutions to crisis of agentive self manipulative suicide attempts, self-cutting

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

Adverse emotional experience rooted in traumatic relationships

Intensification of attachment needs

Inhibition of mentalisation Inaccurate judgements of affect, Delayed development of mentalization understanding Failure to understand how emotions relate to situations and behavior

Mentalizing Profile of Prototypical BPD patient Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381. BPD Implicitamygdala, basal ganglia, Automaticventromedial prefrontal Non -conscious- cortex (VMPFC), lateral temporal cortex (LTC) Immediate. and the dorsal anterior Mental interior cue focused Cognitive agent:attitude propositions Imitative frontoparietal mirror neurone system

cingulate cortex (dACC) medial frontoparietal network activated

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

BPD recruits lateral fronto-temporal network

BPD Associated with several areas of prefrontal cortex

Associated with inferior prefrontal gyrus

BPD frontoparietal mirror-neuron system

the medial prefrontal cortex, ACC, and the precuneus

ExplicitControlled Conscious Reflective Mental exterior cue focused Affective self:affect state propositions

Belief-desire MPFC/ACC inhibitory system

Treatment vectors in re-establishing mentalizing in borderline personality disorder ImplicitAutomatic

Impression Controlled driven

Appearance Inference

Mental interior focused

Certainty emotion Doubt of of cognition

Cognitive agent:attitude propositions Imitative frontoparietal mirror neurone system

ExplicitControlled

Emotional sensitivity Autonomy

Mental exterior focused

Affective self:affect state propositions

Belief-desire MPFC/ACC inhibitory system

Activating (provoking) risk factors (emotional abuse, trauma, non-mentalizing social system)

Genetic vulnerability

Poor control of attention

Poor affect regulation

Attachment system disorganized by trauma & stress

Fragile interpersonal understanding Early attachment environment

Vulnerability risk factors

Imbalance of dimensions of Mz (social misjudgements, paranoid thoughts, mentalizing failure)

Hyper-reactive attachment system Pre-mentalistic modes of subjective functioning (psychic equivalence pretend mode teleological thinking

Formation risk factors (interpersonal stress, experience of rejection)

For Electronic version please e-mail: [email protected]

Psychotherapy with borderline personality disorder: A mentalization based approach Peter Fonagy PhD FBA with Anthony Bateman MD University College London & the Anna Freud Centre [email protected]

Outpatient treatment of borderline PD: MBT-BPD

The simple idea behind MBT-BPD    

Failure of mentalization in attachment associated contexts is key aspect of BPD psychopathology An individual with BPD is vulnerable to the collapse of subjectivity associated with   intolerable mental pain   amplified experience of negative emotions   cognitive dyscontrol

 

A psychotherapeutic approach focusing on sensitively and gently expanding and clarifying the patient’s representations of mental states serves to reduce impulsivity and improves sense of subjective well-being.

The MBT technique   Simple

sound-bite interventions   Affect focused (love, desire, hurt, catastrophe, excitement)   Focus on patients mind (not on behaviour)   Relate to current event or activity – mental reality (evidence based or in working memory)   Use of therapist’s mind as model (? disclosure)   Identify non-mentalizing and recover it on the many occasions when apparently lost

Clinical summary of intervention   Identify

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 your contribution to the break in mentalizing   Seek to mentalize the transference

Least involved

Most involved

Interventions: Spectrum Supportive/empathic Clarification, elaboration, challenge Basic mentalizing and affect focus Interpretive mentalizing Mentalizing the transference

So what should the therapist aim do?  

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.

 

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

Therapist Stance  

Not-Knowing   Neither therapist nor patient experiences interactions other than impressionistically   Identify difference – ‘I can see how you get to that but when I think about it it occurs to me that he may have been pre-occupied with something rather than ignoring you’.   Acceptance of different perspectives   Active questioning   Eschew your need to understand – do not feel under obligation to understand the non-understandable.

 

Monitor you own mistakes   Model honesty and courage via acknowledgement of your own mistakes o  Current o  Future   Suggest that mistakes offer opportunities to re-visit to learn more about contexts, experiences, and feelings

Therapist stance      

 

 

Empathic is about how they are thinking and feeling, getting them to describe important Cannot explore before empathy Use not knowing what to say as clue that something does not make sense and there is something to be curios about Curiosity about experience, probing about patients experience serves to validate the experience Normalizing is component of moving to transference work – stating feelings in first person: “I would feel X, so surprised you appear not to…”

Clarification of current affective interpersonal experience   Define

the current affective state shared attention between patient and therapist   Do this tentatively from your own perspective then try to match to patient’s  Try to generate alternative perspectives   Do

not suggest it is the patient’s experience   Link the current affective state to therapeutic work within the session itself as far as possible

A typical micro-sequence 1.  2.  3. 

4.  5.  6. 

Take the patient’s point of view Re-describe in your own words what you understand Elaborate the patient’s point of view, clarify, deepen, expand, watch for taking things for granted (making preconscious assumptions) Present alternative perspective(s) – how else one could feel Listen to reaction and be alert to having triggered pretend mode Contextualise how new understanding effects relational context (including therapy)

Intervention: Challenge   Aim

is to bring non-mentalizing to an abrupt halt even if only momentarily   Surprise the patient’s mind; trip their mind back to a more reflective process   Grasp the moment if they seem to respond   Intervention should be outside the expected frame  force them to have to think, leave script   Use humour when possible

Mentalizing Functional Analysis            

Stop and Rewind to point before mentalizing was lost Stop and Explore a point when mentalizing was taking place – system restore! Micro-slice mental states towards the self destructive act  not aiming to explain but to recover mentalizing Continually move around self and other mental states Place responsibility for keeping mind on-line back with the patient Ask patient to identify when she could have possibly re-established self-control

Mentalizing Functional Analysis  

Empathy and support  You must not have known what to do?  Oh dear! That must be disappointing after all this time.

 

Define interpersonal context        

 

Detailed account of days or hours leading up to selfharm with emphasis on feeling states Moment to moment exploration of actual episode Explore communication problems Identify misunderstandings or over-sensitivity

Identify affect  

 

Explore the affective changes since the previous individual session linking them with events within treatment Review any acts thoroughly in a number of contexts including individual and group therapy.

The Mystery of Psychotherapy: The Unique Duality of Love and Mentalization

Attachment Disorganisation in Psychotherapy Mild Distress/ Anxiety Emotionally challenging experiences in relation to the therapist in client with insecure Emotional Challenge attachment history

Activation of the attachment system generating ‘proximity seeking’

Therapeutic sensitivity (caregiving) affectional bond to therapist

The psychotherapeutic ‘hyperactivation’ of the attachment system

Attachment Disorganisation in Psychotherapy Mild Distress/ Anxiety Emotionally challenging experiences in relation to the therapist in client with insecure Emotional Challenge attachment history

Activation of the attachment system generating ‘proximity seeking’

Therapeutic sensitivity (caregiving) affectional bond to therapist

The psychotherapeutic ‘hyperactivation’ of the attachment system

Two perspectives on the hyperactivation of attachment 1. 

An opportunity to be seized   opportunity to experience, express, reflect upon and resolve high-conflict interpersonal relationships

2. 

A sign that caution is needed   intense activation of the neuro-behavioral system underpinning attachment is associated with deactivation of mentalizing (social trustworthiness, moral judgments, ‘theory of mind’ tasks, attention to own emotions ‘transference love is indeed blind’)

Implications of the hyperactivation of attachment for psychotherapy: Finding the balance  

   

When working with patients with disorganized self structures, the therapist must be aware of moment to moment changes in patient’s mental state Must be ready to step back from the heat of the encounter Timing is art of therapy: interpretations demanding considerable reflective capacity should not be given when patient is least able to adopt an intentional stance to parse and implement the implication of the therapist’s comment

The Uniqueness of Psychotherapy Activates attachment system    Deactivates  

 Moral judgmental thinking  Long term memories that would be normally retrieved  Impact of negative affect

Chance to re-think past, consider current thoughts without moral stricture, moderate negative affect    Psychic change  

 (if attachment system is not hyperactivated!!)

The origins of dynamic psychotherapy -- Schiller in 1788 describes the phenomenon of deactivated constraints on cognition: ..on the the other hand, where there is a creative mind, Reason – so it seems to me – relaxes its watch upon the gates, and the ideas rush in pell-mell, and only then does it look them through and examine them in a mass. Schiller (1788) as cited by Freud (1900)

The origins of dynamic psychotherapy – Freud (1900) recognizes the same phenomenon but misses the crucial role of attachment (the therapeutic relationship) in the facilitation of the process: ..an attitude of uncritical self-observation, is by no means difficult. Most of my patients achieve it after their first instructions. I myself can do so very completely, by the help of writing down my ideas as they occur to me. Freud (1900) The Interpretation of Dreams. p.103

Clinical Intervention: Self Harm and the Alien Self

Theory: Birth of the Agentive Self Attachment figure “discovers” infant’s mind (subjectivity) Internalization Representation of infant’s mental state

Core of psychological self

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

Theory: Birth of the “Alien” Self in Disorganized Attachment The caregiver’s perception is inaccurate or unmarked or both Attachment Child Mirroring fails The nascent self Figure Absence of a representation of the infant’s mental state

representational structure

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

Theory: Self-destructiveness and

Externalisation Following Trauma

Torturing alien self

Perceived other

Self representation

Unbearably painful emotional states: Self experienced as evil/hateful

Self-harm state Attack from within is turned against body and/or mind.

Theory: Self-destructiveness and

Externalisation Following Trauma

Torturing alien self

Perceived other

Self representation

Unbearably painful emotional states: Self experienced as evil/hateful

Self-harm state

Torturing alien self Externalization

Container

Self Selfexperienced experienced asas hated evil and and attacked hateful

Addictive bond

Victimized state

Projective identification is used to reduce the experience of unbearably painful emotional state of attack from within – externalisation becomes a matter of life and death and addictive bond and terror of loss of (abusing) object develops

If someone was causing you pain or simply tormenting you, perhaps not everyday for the whole day, parts of a day, or for days and weeks on end, You could if you were brave or desperate enough, defend yourself, by perhaps attacking (and eliminating) your persecutor. But what if this thing you hate, was inhabiting your head? You can’t exactly say please leave my body, you can’t do anything to get it to just pack up and leave because technically, physically that isn’t possible. You can say fuck you. I hate you. You can self-harm with the hugest force your body can withstand, with all you can muster.

You can do that. You can be very very angry and show them who’s boss, you won’t stand for it, you won’t take it lying down. You want to be heard, you want to say right, you think you can hurt me? I’ll show you, I’ll show you how much I can hurt you! But you and this thing, you are inhabiting one body. You attack this thing you attack yourself. You don’t have a choice though. That’s a sacrifice you make over and over. Eventually, you realise the only way to get rid of this thing, once and for all is getting rid of yourself. What choice do you really have?

No doctor can specify the problem. No medication can fix the problem that can’t be specified. You fail to understand yourself. You can’t explain to your family and docs, they can’t help you because you do not talk. You doubt yourself “do I even have a problem?” People in real life often treat you like you don’t have a real problem. They talk to you stupidly, you complain that they don’t understand, you look a fool. Perhaps that is why you don’t talk to them anymore. Maybe you don’t have a problem anyway.

You are a child, quite possibly you are just making this up for some attention, finding an excuse for why you can’t stay in college or get a job. Maybe you don’t have an excuse, you are just a stubborn little child. From what everyone tells you perhaps that is true. You have doubt. You are willing to listen to someone else. For now that is the only reason why you are not, at this moment trying to do it.

Understanding suicide and self-harm in terms of the temporary loss of mentalization   Loss



 Increase attachment needs  triggering of attachment system    Failure

of mentalization 

 Psychic equivalence  intensification of unbearable experience  Pretend mode  hypermentalization meaninglessness, dissociation   Teleological solutions to crisis of agentive self suicide attempts, self-cutting

Self-harm   Function

 To re-establish the self-structure following loss of mentalizing   Intervention  Explore reasons for destabilisation of selfstructure  ‘Tell me when you first began to feel anxious that you might do something?’  Mentalizing functional analysis

How do I deal with? Self-harm   Affect

 Feeling of badness = I am bad (psychic equivalence) = Self-harm  Explore rejection, loss, hurt, abandonment, and panic  Emptiness and experience of a void or ‘black hole’  Link to context

Transference and Countertransference

Interventions: Interpretive Mentalizing  

Transference tracers – always current  Linking statements and generalization o  ‘That seems to be the same as before and it may be that o  ‘So often when something like this happens you begin to feel desperate and that they don’t like you’

 Identifying patterns o  It seems that whenever you feel hurt you hit out or shout at people and that gets you into trouble. May be we need to consider what happens otherwise.

 Making transference hints o  I can see that it might happen here if you feel that something I say is hurtful

 Indicating relevance to therapy o  That might interfere with us working together

Interventions: Mentalizing the Transference  

Working in the transference  Emphasis on current  Demonstrate alternative perspectives  Contrast patient’s perception of the therapist to selfperception or perception of others in the group  Link to selected aspects of the treatment situation (to which they may have been sensitised by past experience) or to therapist  Highlight underlying motivation as evidenced in therapy

Components of mentalizing the transference              

Validation of experience Exploration in the current relationship Accepting and exploring enactment (therapist contribution, therapist’s own distortions) Collaboration in arriving at an understanding Present an alternative perspective Monitor the patient’s reaction Explore the patient’s reaction to the new understanding

Interventions: Mentalizing the Transference   Dangers

of using the transference

 Avoid interpreting experience as repetition of the past or as a displacement. This simply makes the borderline patient feel that whatever is happening in therapy is unreal  Thrown into a pretend mode  Elaborates a fantasy of understanding with therapist  Little experiential contact with reality  No generalization

Components of mentalizing the countertransference   Monitor

states of confusion and puzzlement   Share the experience of not-knowing   Eschew therapeutic omnipotence   Attribute negative feelings to the therapy and current situation rather than the patient or therapist (initially)   Aim at achieving an understanding the source of negativity or excessive concern etc.

Typical Countertransferences  

Pretend mode  Boredom, temptation to say something trivial  Sounding like being on autopilot, tempting to go along  Lack of appropriate affect modulation (feeling flat, rigid, no contact,)

 

Teleological  Anxiety  Wish to DO something (lists, coping strategies)

 

Psychic equivalence  Puzzlement, confused, unclear, excessive nodding  Not sure what to say, just going  Anger with the patient

Are there differences between therapies?

Evidence based or promising treatments SFT CAT MBT TFP DBT STEPPS

DBT

MBT

MBT is in its infancy as an EST

Design of intensive out-patient MBT randomized controlled trial.   Referrals

for Intensive Outpatient (IOP-MBT) and Structured Clinical Management (SCM) groups

  Random

allocation (minimisation for age, gender, antisocial PD)

  Individual

(50 mins) + Group (1.5 hrs) sessions weekly for 18 months

  Assessments

at admission, 6 months, 12 months, 18 months   Medication followed protocol

Therapists co-opted or recruited for the trial were randomly assigned to a 3 day training in MBTOP or SCM-OP with continued supervision  

All 11 therapists had  minimum of 2 years’ experience of treating patients in general psychiatric services following their generic training  minimum of 1 year’s experience treating patients with personality disorder  did not differ in their years of psychiatric experience (mean [SD]: MBT-OP, 6.16 [1.6]; SCM-OP, 6.8 [2.3] years)

VS.

The Therapies (Bateman & Fonagy, 2009, Am. J. Psychiat. and in press)  

MBT - weekly  Support and structure  Challenge  Basic mentalizing  Interpretive mentalizing  Mentalizing the transference  Medication review  Crisis management

 

SCM - weekly  Support and structure  Challenge  Advocacy  Social support work  Problem solving  Medication review  Crisis management

168 patients screened for eligibility

34 patients excluded: 10 did not attend interview 12 declined participation 5 did not meet inclusion criteria 4 met exclusion criteria 3 were uncontactable

Consort Diagram – IOP Study: Patient Recruitment Flow-Chart

134 randomized

71 patients allocated to MBT-OP

63 patients allocated to SCM-OP

6 attended < 6 months

10 attended < 6 months

13 attended 6-12 months

6 attended 6-12 months

52 completed treatment

47 completed treatment

71 included in analyses

63 included in analyses

Outcomes  

 

Primary outcome  proportion of each group without severe parasuicidal behavior as indicated by a) suicide attempt; b) lifethreatening self-harm; and c) hospital admission  formal research confirmed records Secondary outcomes (assessed at baseline, and at 6monthly intervals until the end of treatment at 18 months)  independently rated Global Assessment of Functioning (GAF) scores at beginning and end of treatments  self-reported psychiatric symptoms and social and interpersonal function

Clinical Characteristics Number

Exptl N=71

Control n=63

Suicide past 6 months Number of serious self-harm episodes past 6 months Days of hospitalization past 6 months

53

75.0%

42

67.0%

4.1

SD 4.9

3.8

SD 3.7

5.5

SD 11.6

6

SD 12.4

Hospitalized past 6 months

23

32.0%

19

30.0%

Major depressive disorder

41

57.7%

34

54.0%

Depressive disorders -inc dysthymia

56

78.9%

47

74.6%

Posttraumatic stress disorder

9

12.7%

10

15.9%

Number of Axis 1 diagnoses Number of Axis II diagnoses

2.8 2.4

SD 1.3 SD 1.1

2.8 2.3

SD 1.3 SD 1.0

Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) n.s.

p