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Introduction toMentalization
A Training Workshop
ForewarningIn advocating mentalization-based treatment weclaim no innovation. On the contrary,mentalization-based treatment is the least noveltherapeutic approach imaginable: it addressesthe bedrock human capacity to apprehend mindas such. Holding mind in mind is as ancient ashuman relatedness and self-awareness.
.
Chichester: J. Wiley, 2006
Some Free Publicity
2012American Psychiatric Publishing, Inc
JUST RELEASED!
NEW!IMPROVED!
Washes brainswhiter!
Longer than allpreviousversions!
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For further Information
p.fonagy@ucl.ac.uk
anthony@mullins.plus.com
All slides available at:
http://www.ucl.ac.uk/psychoanalysis/unit-staff/staff.htm
Bateman, A and Fonagy, P (2006)Mentalization Based Treatment apractical guide OUP: Oxford
Allen, J, Fonagy, P and Bateman, A (2008)Mentalizing in Clinical Practice APPIWashington
Exercise mentalization ormentalizing?
What is mentalization or mentalizing?
Give 3 key aspects of the psychologicalprocesses that the concept tries to encapsulate
Should we use mentalization or mentalizing?
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A common mentalizing failure
I love this story told by the mother of a five-year-oldgirl. The child had taken a stethoscope out of hermother s doctor bag and was playing with it. As sheput the stethoscope to her ears, her mother thoughtproudly, She seems interested in medicine. Maybe shewill grow up and become a doctor like me. After a timethe little girl put the listening end of the stethoscopeup to her mouth and exclaimed, Welcome toMcDonald s. May I take your order, please? At this,the mother had to laugh with her daughter, and smiledto herself about how easily we can project our ideas onone another.
Kornfield, The wise heart
Mentalizingas an
Integrativeframework
CBT: The value of understandingthe relationship between
my thoughts and feelings andmy behaviour.
SYSTEMIC: The value ofunderstanding the relationship
between the thoughts andfeelings of family members andtheir behaviours, and the impact
of these on each other.
PSYCHODYNAMIC: The value ofUnderstanding the nature of resistance
to therapy, and the dynamics ofhere-and-now in the therapeutic
relationship.
SOCIAL ECOLOGICAL: The valueof understanding the impact ofcontext upon mental states;deprivation, hunger, fear, etc...
COMMON LANGUAGE
Mindblindness
Imagine what your world would be like if you wereaware of physical things but were blind to theexistence of mental things. I mean of course blindto things like thoughts, beliefs, knowledge,desires, and intentions, which for most of us self-evidently underlie behaviour
Baron-Cohen S (1995) Mindblindness
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The Artful use of Science
To do anything well you must have thehumility to bumble around a bit, to followyour nose, to get lost, to goof. Have thecourage to try an undertaking and possiblydo it poorly. Unremarkable lives are markedby the fear of not looking capable whentrying something new.
Epictetus, Manual
Mentalizing:A new word for an ancient concept
Implicitly and explicitly interpretingthe actions of oneself and other asmeaningful on the basis ofintentional mental states
(e.g., desires, needs, feelings,beliefs, & reasons)
Introduction to theory of mentalisation
The normal ability to ascribe intentions andmeaning to human behaviour
Ideas that shape interpersonal behaviour
Make reference to emotions, feelings, thoughts,intentions, desires
Shapes our understanding of others and ourselves
Central to human communication andrelationships
Underpins clinical understanding, the therapeuticrelationship and therapeutic change
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Mentalizing: further definitions andscope
To see ourselves from the outside andothers from the inside
Understanding misunderstanding
Having mind in mind
Past, present, and future
Introspection for subjective self-construction know yourself as othersknow you but also know your subjectiveself
Characteristics of mentalising
Central concept is that internal states (emotions,thoughts, etc) are opaque
We make inferences about them
But inferences are prone to error
Overarching principal is to take the inquisitive
stance=
Interpersonal behaviour characterised by anexpectation that ones mind may be influenced,surprised, changed and enlightened by learning
about anothers mind
Mentalization and Overlapping Constructs(Choi-Kain & Gunderson, Am J Psychiat 2008)
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Mindfulness
Keeping ones consciousness alive to the present
reality Observing and describing ones own experience
whilst participating non-judgementally
Two domainsAttention regulation
Acceptance and openness to experience
Four SkillsObserving
Describing
Acting with awareness
Accepting without judgement
Mentalisation and conceptual cousins
Component Mindfulness PsychologicalMindedness
Empathy Affectconsciousness
Implicit No No Yes No
Explicit yes Yes Yes Yes
Self-orientated
Yes Yes Minimal Yes
Otherorientated
No Minimal Yes Yes
Cognitive/Affect
Cog=Affect Cog=Affec t Affect>Cog Affec t>Cog
Multiple dimensions of mentalizingin psychodynamic psychotherapy Differentiating self and other in psychotherapyAdopting the perspective of the other to the self
Reducing the impact of the other on the self
Moving from implicit - automatic mentalization toexplicit controlled mentalizationChallenging automatic assumptions
Elaborating internal representations of mental statesof self and others - external and internal mentalizingChallenging superficial judgements based on
appearances
Connect feelings with thoughts (affect and cognition)Overcoming splitting of affect and cognition (the feeling of
feelings)
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Implicit-
Automatic
Explicit-
Controlled
Mentalinteriorfocused
Mentalexteriorfocused
Cognitiveagent:attitudepropositions
Affectiveself:affect statepropositions
Imitativefrontoparietalmirror neuronesystem
Belief-desireMPFC/ACCinhibitorysystem
Impression driven
Appearance
Certainty of emotion
Treatment vectors in re-establishing mentalizingin borderline personality disorder
Controlled
Inference
Doubt of cognition
Emotional contagionAutonomy
Mayes (2001) Adaptation of Arnstens Dual ArousalSystems Model: Implication of the Hyper-activation ofAttachment
Performance
Arousal
Point 1a
Point 1
HighLow
Posterior cortex and
subcortical capacities
Prefrontal capacities
Changing
switchpoint
threshold
Parallel contributions to mentalizing:
Meeting of minds
PATIENT
attachment & arousal
mentalization
attachment & arousal
mentalizing
mentalizing
attachment & arousal
mentalization
attachment & arousal
Developmentalcompetence
Currentperformance
Currentperformance
DevelopmentalcompetenceCLINICIAN
HEALTH CARE SYSTEM
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Dimensions of mentalization: implicit/automaticvs explicit/controlled
Psychological understanding drops and israpidly replaced by confusion about mentalstates under high arousal
That handkerchief which I so loved and gave theeThou gavest to Cassio.By heaven, I saw my handkerchief in's hand.
Controlled Automatic
Arousal
Dimensions of mentalization: implicit/automaticvs explicit/controlled
Arousal
Psychotherapist
s demand to explore issuesthat trigger intense emotional reactionsinvolving conscious reflection and explicitmentalization are inconsistent with thepatient s ability to perform these tasks when
arousal is high
Dimensions of mentalization: internally vs externallyfocused (mental interiors vs visible clues)
Internal External
I wonder if he feelshis mother lovedhim?
He looks tired;perhaps he sleptbadly
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With selective loss of sense of mental interiors, external featuresare given inappropriate weight and misinterpreted as indicatingdispositional states
You re covering your eyes; you can hardly bear to look at me
Dimensions of mentalization: Cognitive vsaffective mentalization
Agent attitudepropositions
I think he thought thatCharlie ate hischocolate
Associated with severalareas of prefrontal cortex
Cognition Emotion
Self affect statepropositions
I feel upset about it
Associated with inferiorprefrontal gyrus
With diminution of cognitive mentalization the logic ofemotional mentalization (self- affect state proposition)comes to be inappropriately extended to cognitions.
I feel sad, you must have hurt me
Dimensions of mentalization: Cognitive vsaffective mentalization
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Failures of imagination inmindblindness
Dehumanising
Mentalizing
Demonizing
Concrete &Egocentric
Restrainedimagination
Imaginary &projective
Non-mentalizing Distortedmentalizing
Subjectivity &humanity
Mentalizing: Implicit v Explicit
IMPLICIT EXPLICIT
PerceivedNonconsciousNonverbal
Unreflectivee.g. mirroring
InterpretedConsciousVerbal
Reflectivee.g. explaining
Mentalizing interactively andemotionally
Mentalizing interactivelyEach person has the other persons mind in
mind (as well as their own)
Self-awareness + other awareness
Mentalizing emotionallyMentalizing in midst of emotional states
Feeling and thinking about feeling (mentalizedaffectivity)
Feeling felt
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Example of mentalizinginteractively and emotionally
The appetite which we call LUST is a sensualpleasure, but not only that; there is in it also adelight of the mind: for it consisteth of twoappetites together, to please, and to be pleased;and the delight (we) take in delighting, is notsensual, but a pleasure of joy of the mind,consisting in the imagination of the power (we)have so much to please.
Thomas Hobbes, quoted in Simon Blackburn (2004) Lust
Mentalizing and psychopathy:Compart-mentalization
Psychopathy entails elements of intactmentalizing
Partial mindblindness:Failure of imaginative empathyFailure to identify with victims distress
Mind uninfluenced and unchanged easily control andprotection of self from shame/humiliation paramountDistorted mentalizing paranoid demonizing e.g.
interpreting the childs frustrating behaviour asintended to torment the parent
Mentalizing objects and others
Our relations with other people do not have the samestructure as our relations with inanimate objects, plantsor machines. We do not deal with our family members,friends, colleagues or fellow citizens, as we do withvolcanoes, fields of wheat or k itchen mixers, namely, bytrying to figure out the nature and layout of their innardsso that we can predict and perhaps control them.
What we hope of another with whom we interact is not thathe or she will go through some gyrations which we havealready planned in detail, but that he or she will makesome contributions to moving forward the joint and co-operative enterprise in which we are both, more of lessexplicitly, engaged
Heal, J (2003) Mind, Reason and Imagination: Selected Essays in Philosophy of Mind and LanguageCUP: Cambridge.
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Being misunderstood
Although skill in reading minds is important,recognising the limits of ones skill isessential
First, acting on false assumptions causesconfusion
Second, being misunderstood is highlyaversive
Being misunderstood generates powerfulemotions that result in coercion, withdrawal,hostility, over protectiveness, rejection
Some theory
Clinical Features of Borderline Personality
Disorder (DSM-IV: 5 of 9) a pattern of unstable intense relationships,
inappropriate, intense anger
frantic efforts to avoid abandonment
affective instability,
impulsive actions
recurrent self-harm & suicidality,
chronic feelings of emptiness or boredom(dysphoria),
transient, stress-related paranoid thoughts
identity disturbance severe dissociativesymptoms
unstable relationships
affective dysregulation
impulsivity
aggression
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The social brain
mPFC
1. Medial prefrontalcortex
Mentalising propero Implicit ability to infer
mental states such asbeliefs, feelings anddesires
Fletcher et al., 1995; Gallagher et al., 2000;Gilbert et al., 2006 (meta-analysis)
The social brain
mPFC
pSTS/TPJ 2. pSTS/TPJ
Predictiono Biological motion, eye
gaze
Perspective-takingo Different physical points
of view
Pelphrey et al., 2004a,b; Kawawaki et al., 2006 (review);Mitchell 2007
The social brain
mPFC
pSTS/TPJ 3. Amygdala
Attaching rewardvalues to stimuli
o Approach vs. avoid
Facial expressions
Dolan 2002; LeDoux 2000;Winston et al., 2002; Phelps et al., 2000, 2003
Amygdala
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The social brain
mPFC
pSTS/TPJ
Temporal pole
4. Temporal polesSocial scripts,
complex eventknowledge
Funnell, 2001; Damasio et al., 2004;Moll et al., 2001, 2002, 2005 (review)
Amygdala
Mentalization and Overlapping Constructs(Choi-Kain & Gunderson, Am J Psychiat 2008)
M e a s u r i n g M e n t a l i z a t i o n
M e a s u r i n g M e n t a l i z a t i o n M e a s u r i n g M e n t a l i z a t i o n
M e a s u r i n g M e n t a l i z a t i o n ( B a r o n
( B a r o n ( B a r o n
( B a r o n -
--
- C o h e n e t
C o h e n e t C o h e n e t
C o h e n e t
a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t
a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t
a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t
W o r r i e d
W o r r i e d W o r r i e d
W o r r i e d -
--
- D
DD
DS u r p r i s e d
S u r p r i s e d S u r p r i s e d
S u r p r i s e d -
--
- C
CC
C
F r i e n d l y
F r i e n d l y F r i e n d l y
F r i e n d l y -
--
- A
AA
A
S a d
S a d S a d
S a d -
--
- B
BB
B
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S u r p r i s e d
S u r p r i s e d S u r p r i s e d
S u r p r i s e d -
--
- A
AA
A S u r e a b o u t s o m e t h i n g
S u r e a b o u t s o m e t h i n g S u r e a b o u t s o m e t h i n g
S u r e a b o u t s o m e t h i n g -
--
- B
BB
B
J o k i n g
J o k i n g J o k i n g
J o k i n g -
--
- C
CC
C
H a p p y
H a p p y H a p p y
H a p p y -
--
- D
DD
D
Measuring Mentalization (Baron-Cohen etal., 2001) Reading the Mind in the Eyes Test
J o k i n g
J o k i n g J o k i n g
J o k i n g -
--
- A
AA
A F l u s t e r e d
F l u s t e r e d F l u s t e r e d
F l u s t e r e d -
--
- B
BB
B
D e s i r e
D e s i r e D e s i r e
D e s i r e -
--
- C
CC
C
C o n v i n c e d
C o n v i n c e d C o n v i n c e d
C o n v i n c e d -
--
- D
DD
D
M e a s u r i n g M e n t a l i z a t i o n
M e a s u r i n g M e n t a l i z a t i o n M e a s u r i n g M e n t a l i z a t i o n
M e a s u r i n g M e n t a l i z a t i o n ( B a r o n
( B a r o n ( B a r o n
( B a r o n -
--
- C o h e n e t
C o h e n e t C o h e n e t
C o h e n e t
a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t
a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t
a l . , 2 0 0 1 ) R e a d i n g t h e M i n d i n t h e E y e s T e s t
Mentalizing at the World Cup: How does Robert
Green feel after letting in the USA goal?
Upset Angry
Disappointed Frustrated
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Shared neural circuits for mentalizing about theself and others (Lombardo et al., 2009; J. Cog. Neurosc.)
Self mental state
Other mental state
Overlapping forSelf and Other
Relational Aspects of Mentalization Overlap between neural locations of mentalizing
self and other may be linked to intersubjectiveorigin of sense of self We find our mind initially in the minds of our parents
and later other attachment figures thinking about usThe 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 bereflective about her child as a psychological being
Failure to find the constitutional self in the other haspotential to profoundly distort the self representation(exaggerated mirroring of childs anxiety aggravatesanxiety rather than soothe)
The same applies to child with inadequate sense ofindependent self within therapeutic relationship
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Baron-Cohens (2005) model of thesocial brain
The Emotion Detector
- Left inferior frontal gyrus- Mirror neurons
The Intention Detector- Right medial prefrontal cortex
- inferior frontal cortex- Bilateral anterior cingulate- Superior temporal gyrus
Eye Direction Detector
- Posterior superiortemporal sulcus
Shared Attention Mechanism- Bilateral anterior cingulate- Medial prefrontal cortex- Body of caudate nucleus
The Empathising System- Fusiform gyrus- Amygdala- Orbito-frontal cortex
Theory of Mind Mechanism- Medial prefrontal cortex- Superior temporal gyrus- Temporo-parietal junction
EMOTION UNDERSTANDING BELIEF-DESIRE REASONING
Mentalizing as a multidimensionalneuroscience construct Implicit - automatic versus explicit - controlled
mentalization (Satpute & Lieberman, 2006)
Mentalization based on internal versus externalfeatures of self and others(Satpute & Lieberman,2006)
Cognitive versus affective mentalization (Shamay-Tsoory, Aharon-Peretz, & Perry, 2008)
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 precuneusFrith, 2007; Frith & Frith, 2006; Uddin et al., 2007)
Implicit-Automatic-Non -conscious-Immediate.
Explicit-ControlledConsciousReflective
Mentalinteriorcuefocused
Mentalexteriorcuefocused
Cognitiveagent:attitudepropositions
Affectiveself:affect statepropositions
Imitativefrontoparietalmirror neuronesystem
Belief-desireMPFC/ACCinhibitorysystem
BPD
BPD
BPD
BPD
Mentalizing Profile of Prototypical BPD patientFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
amygdala, basal ganglia,ventromedial prefrontalcortex (VMPFC),lateral temporal cortex (LTC)and the dorsal anteriorcingulate cortex (dACC)
lateral and medial prefrontal cortex(LPFC & MPFC), lateral and medialparietal cortex (LPAC & MPAC),medial temporal lobe (MTL),rostralanterior cingulate cortex (rACC)
Associated with several areasof prefrontal cortex
Associated with inferior prefrontalgyrus
the medial prefrontal cortex,ACC, and the precuneus
frontoparietal mirror-neuronsystem
medial frontoparietalnetwork activated
recruits lateral fronto-temporalnetwork
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Other possible polarities
Ambiguous vs. unambiguous
Belief vs. preference
here and now vs. there and now(allocentric perspective)
The Nature of
Attachment
Environmental Influences on the Development
of Social Cognition Maternal disciplinary style (Ruffman, Perner, &
Parkin, 1999; Vinden, 2001) Other features of the emotional climate within
the family (e.g., Cassidy et al., 1992; Denham,Zoller, & Couchoud, 1994)
The inclination of mothers to take thepsychological perspective of their child,including maternal mind-mindednessandreflective functionin interacting with ordescribing their infants (Fonagy, Steele, Steele &Holder, 1996; Fonagy & Target, 1997; Meins et al.,2003; Meins, Fernyhough, Wainwright, Das Gupta,Fradley, et al., 2002; Peterson & Slaughter, 2003;Slade, 2005; Sharp, Fonagy; & Goodyer, 2006)
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Range of Environmental Influences on theDevelopment of Social Cognition The quality of childrens primary attachment
relationship facilitates theory of minddevelopmentleading to passing standardtheory of mind tasks somewhat earlier (e.g., deRosnay & Harris, 2002; Fonagy & Target, 1997;Fonagy, Redfern, & Charman, 1997 Harris, 1999;Meins, Fernyhough, Russell, & Clark-Carter, 1998;Raikes & Thompson, 2006; Steele, Steele, Croft, &Fonagy, 1999; Symons, 2004; Thompson, 2000;Ontai & Thompson, 2002)
Not all studies find this relationship and it is more likely tobe observed for emotion understanding then ToM
Attachment as an Addiction
MacLean (1990) speculated that substanceabuse and drug addiction were attempts toreplace opiates or endogenous factors normallyprovided by social attachments
Panksepp (1998) a common neurobiology to
motherinfant,
infantmother, and
romantic attachment
Insel (2003) Social attachment is an addictivedisorder?
The mesocorticolimbic dopaminergicreward circuit in addiction process
Amygdala/
bed nucleus of
ST
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own baby pictures minus other baby pictures own baby pictures minus houses
HEALTHYMOTHERS OF
FIRST INFANTS
N=13
HEALTHYFATHERS OF
FIRST INFANTS
N=8
THALAMUS - BG
FACE-OBJECT
VISUAL CORTEX
BASAL GANGLIA
AMYGDALA
THALAMUS - BG
AMYGDALA
MIDBRAIN
FACE-OBJECT
VISUAL CORTEX
CINGULATE CINGULATE
THALAMUS - BG
AMYGDALA
MIDBRAIN
CINGULATE
Swain et al., in preparation
Crying Neutral Smiling
Do Different Affective States Triggerthe Attachment System Equally?
What s in a Smile? Maternal Brain Responses to Infant Facial
Cues (Strathearn L, Li J, Fonagy P, Montague PR, submitted)
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Brain response of mothers viewing theirown baby s face
>
(-3,2,-16)
OWN UNKNOWN
*
Hypothalamus
Midbrain
Pons
Pituitaryregion
Security, oxytocin change and hypothalamic activation
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1
1.2
R V en tra l S tr ia tu m R Insu la
%signalchange
Secure Insecure/Dismissing
(t=3.0, P
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Simple test of mindSimple test of mindSimple test of mindSimple test of mind----mindednessmindednessmindednessmindedness
W o r r i e d
W o r r i e d W o r r i e d
W o r r i e d -
--
- D
DD
DS u r p r i s e d
S u r p r i s e d S u r p r i s e d
S u r p r i s e d -
--
- C
CC
C
F r i e n d l y
F r i e n d l y F r i e n d l y
F r i e n d l y -
--
- A
AA
A
S a d
S a d S a d
S a d -
--
- B
BB
B
Simple test of mindSimple test of mindSimple test of mindSimple test of mind----mindednessmindednessmindednessmindedness
S u r p r i s e d
S u r p r i s e d S u r p r i s e d
S u r p r i s e d -
--
- A
AA
A S u r e a b o u t s o m e t h i n g
S u r e a b o u t s o m e t h i n g S u r e a b o u t s o m e t h i n g
S u r e a b o u t s o m e t h i n g -
--
- B
BB
B
J o k i n g
J o k i n g J o k i n g
J o k i n g -
--
- C
CC
C
H a p p y
H a p p y H a p p y
H a p p y -
--
- D
DD
D
Oxytocin and performance on Mind in
the Eyes test (Domes et al., 2008)
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The development
of
mentalization
The development of mentalization Weeks after birth the baby smiles at humans
(social beings) in preference to objectsCan tell its own body (shell) from that of another
person s
2 months after birth infants prefer the subtlepatterns of contingency in face-to-faceinteractions, including turn taking and correlated
affect (Gergely and Watson, 1999; Murray andTrevarthen, 1985).
By 9 months, infants are able to follow anotherperson's gaze to a location outside of their visualfieldA key first step in establishing joint attention (Moore,
2008).
From 12 months babies deliberately engage and
redirect attention of caregiver (pointing and vocalizing)
Joint ( triadic) attention provides aplatform by which two or more peoplecoordinate and communicate theirintentions, desires, emotions, beliefs, and/orknowledge about a third entity (e.g. anobject or a common goal) (Tomasello et al.,2005).
By 2.5 years children implement complexsocial tactics teasing, lying, saving face(Reddy, 2008: How infants know minds)
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False belief task: unexpected transfer
Maxi puts hisbook in thecupboard
Then he leaves toplay in the garden
After that, Mumcomes to tidy up
the roomMum takes the bookout of the cupboard,
and puts it inthe bookshelf
Then she leaves todo some work in
the kitchen.Now, Maxi returns
looking for his book
Where will he lookfirst for his book?
Test question
(Wimmer & Perner, 1983)
Effect of Age in 178 separate studies
4y 4y
Very robust developmental trends most manipulations ineffective
2nd of 4th year 2nd of 4th year
Meta-analysis of False Belief Studies (Wellman et al., 2009)
The embodied mind and research onthe human infant
Massive denial of infant mentation outside ofpsychoanalysis until about 75 years ago
Half a century ago infants were commonly subjected tosurgery without anesthetic (curare was used to stopsquirming inconvenient for the surgeon)Can infantshave minds when they are no yet able to speak?
Astounding discoveries concerning early socialawareness in infantsMentalization is embodied before it is cognitive
Freud may have been correct about the mental lifebeing somatically grounded (the body is at the root ofmeaning.
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Sensitivity to others state of mind
M Kovcs et al. Science2011;330:1830-1834
False belief for babyTrue belief for Smurf
True belief for babyFalse belief for Smurf
Published by AAAS
The infant but not theSmurf believes thatthe ball should be there
Infant knows ball is not thereBut Smurf believes it shouldbe there
Neither infant northe Smurf believe thatthe ball should be there
Neither infant northe smurf believethat ball is there
Ball Not There Ball Not There
M Kovcs et al. Science 2010, 330:1830-1834
The two key conditions in Smurf Study: Infant of 7 monthsconsiders what agent (Smurf) believes about the status of ball
Sensitivity to others state of mind
False belief for babyTrue belief for babyFalse belief for Smurf
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Boring Epistemology
Explanations in psychology
How we acquire beliefs
What we observe as infants
The progress of biologicalexplanations of psychopathology
Historically three attempts to ground theassumptions of causation to instinct
Three major human instincts have been the focusof explanations of development and its distortionin psychological disorder1. The psychosexual instinct Freud and classical
psychoanalysis2. The instinct for attachment Bowlby, Ainsworth and
early infant researchers
3. The instinct for communication Gergely, Tronickand modern infant research
Species-specific ways to acquirebeliefs based on communication
We can accept a culturally transmitted belief for tworeasons (Sperber, 1997, 2001, Sperber et al., 2010) its content the authority of its source
To accept because of content grasp its deductive relations to the contents of other beliefs inductive relations to the evidence, in accordance with the
principles of theoretical rationality.
To accept on account of the authority (deferentiallytransmitted, Recanati, 1997) its source is known, remembered and judged to be reliable (or
trustworthy)
taken to be shared common knowledge among members ofones community
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Deciding between competingaccounts in context of authority
Decision between competing accounts are made interms of relevance defined as cognitive benefit(Sperber & Wilson, 1995)automatically computed trade-off between the cognitive
effects produced by the novel implications arrived at and thecognitive effort devoted to processing these implications
Deferentiallytransmitted knowledgemay remain cognitively (or epistemically) opaque to the
individual
may make more transparent by tracking its inferentialconnections to the contents of other beliefs and to lateracquired relevant evidence
may remain cognitively opaque to the individuals throughouttheir lives.
The Transmission ofCulture and WhyTherapy Works
How do we know who to learn from?How does Trust relates to attachment?
How do you do it?
Why does it work?
The need for human naturalpedagogy
We are born into a world populated with man-made tools whose functional properties,appropriate manner of application or method of(re)production often remain in many respectsepistemically opaque
The cognitive opacity of kind or category-relevantaspects of human-made functional artifacts raisesa learnability problem (of relevance-selection) forthe nave juvenile observational learner
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Pathways from Attachment to Educational Achievement
AttachmentSecurity
Social CognitionLearning andEducationalAchievement
InterpersonalSkills
Self
RegulationInhibitoryControl
Managementof Attention
FriendshipPatterns
ClassroomBehavior
ReestablishEpistemicTrust
Adapting to the social world is a steep learning curve
Getting comfortable in the social world
Me play
drums??
For example, it is not obvious what is the true function of all
the objects we use.
Getting comfortable in the social world
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8
Luckily, humans have evolved to teach and learn fromeach other quickly and efficiently
Getting comfortable in the social world
8
-..quickly and efficiently if certain conditions are met
Getting comfortable in the social world
Natural Pedagogy theory(Csibra & Gergely, 2006; 2009, 2012) A human-specific, cue-driven social cognitive
adaptation of mutual design dedicated to ensureefficient transfer of relevant cultural knowledge
Humans are predisposed to teach and learnnew and relevant cultural information from eachother
Human communication is specifically adapted toallow the transmission of
a) cognitively opaque cultural knowledge
b) kind-generalizable generic knowledge c) shared cultural knowledge
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Two basic kinds of intentional agencyobserved by infants (Gergely, 2010).
Observing instrumental actions Observe agents perform instrumental actions as a means to
satisfy their subjective desires and preferences
Requires the third-personal ascription to the agent of a goal orintention to achieve some desirable outcome in light of her beliefsabout the world, in accordance with the principle of practicalrationality (Dennett, 1987; Fodor, 1992).
Observing actions of agents with communicativeintentions Fulfillment depends on their being recognized by their
addressees.
To make sense of an agents ostensive communicative action,
Infants must make sense of the agents communicativeintention (Csibra, 2010) to enable inferences to the intendedmeaning.
Definition of Ostensive Stimuli(Sperber & Wilson, 1995)
The signals whereby an agent makes manifest toan addressee her communicative intention: tomanifest some new relevant information for theaddressee (i.e. her informative intention).
Infants display species-specific sensitivity to, andpreference for, some non-verbal ostensive
behavioral signals (see Csibra, 2010, Csibra & Gergely, 2009 for reviews)
Examples of ostensive communication cueseye-contact turn-taking contingent reactivityspecial tone (motherese)
The Pedagogical Stance is triggered byOstensive-Communicative cues
Ostensive cues have in common
Infant recognized as a self
Paid special attention to (noticed as an agent)
Ostensive cues function:
to signal that the other has a CommunicativeIntention addressed to the infant/child
to Manifest New and Relevant informationabout a referent
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Ostensive cues referentialexpectation in infant
6-month-olds followed an agents gaze-shift to one oftwo objects but only when it had been preceded by eithereye contact or infant-directed speech (ostensivesignals) addressed to the infant (Senju and Csibra, 2008).
An automated eye-tracker based study used an infant-induced contingent reactivity paradigm to demonstratethat 8-month-olds gaze follow an unfamiliar objectsbodily orientation response towards one of two targets,but only when the object had been reactingcontingently before (producing self-propelled bodymovements such as tilting) to being looked at by the infant(Deligianni et al., 2011).
Subjects : 4 groups of 18-month-olds
Stimuli: Two unfamiliar objects
Experimental illustration of ostensive cuesGergely, Egyed et al. (in press)
1: Baseline control group
No object-directed attitude demonstration
Simple Object
Request by
Experimenter A
Subjects: n= 20 Age: 18-month-olds
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Ostensive Communicative Demonstration
Requester: OTHER person (Condition 1)
Otherperson
Non-Ostensive (Non-Communicative) Demonstration
Requester: OTHER person (Condition 2)
Otherperson
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Condition 4: Non-Ostensive (Non-Communicative)
Demonstration Requester: SAME person
Sameperson
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Epistemic trust and secureattachment
Secure attachment is created by a system thatalso induces a sense of epistemic trust thatthe information relayed by the teacher may betrusted (i.e. learnt from)
Evidence
Cognitive advantage of secure attachmentContingent responsiveness to the infants own (at first,
automatic) expressive displays in secure attachment
During mirroring interactions, the other will markher referential emotion displays in a manifestativemanner to instruct the infant
How Attachment Links to Affect Regulation
DISTRESS/FEAR
Exposure to Threat
Proximity seeking
Activation of attachment
The forming of an attachment bond
Down Regulation of Emot ions
EPISTEMICTRUST
BONDING
1
but this special interpersonal channel for learningabout the social world is not always tuned in.
Getting comfortable in the social world
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Trust opens up the social communicationsuperhighway, enabling us to learn and change
1
When there is abuse, there is no trust, the mindis blocked and it is impossible to move forward
Tuning in to the interpersonal channel
Trust opens up the social communicationsuperhighway, enabling us to learn and changeand they will tune in to you!
1
Win the other person
s trust by respondingcontingently to their feelings and thoughts, showingthem that you are hearing and thinking about what
sgoing on in their mind
Tuning in to the interpersonal channel
Implications: The nature of psychotherapy
Mentalizing may be key to psychotherapy notbecause we need to learn about our minds tolearn about those of others
Mentalizing is a generic way of establishingepistemic trustOur subjectivity being understood is necessary
key to open up wish to learn about worldincluding social world
Experience of feeling thought about makes usfeel safe enough to think about social world
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Implications: The nature of psychotherapy Pernicious aspect of trauma is the destruction of
trust in social knowledge of all kinds Epistemic mistrust follows maltreatment or abuse
and therapists ignores this knowledge at their peril Psychotherapy may be effective for two reasonsContentSource
Therapy is not just about the what but the how oflearningOpening the persons mind via establishing
contingencies so (s)he once again can trust the socialworld by changing expectations
Not what is taught in therapy that teaches butevolutionary capacity for learning from other is rekindled
Gaps in Therapy Outcomes Research
No solid evidence for who will benefitfrom what type of psychotherapy
Inexact therapies partialeffectiveness
Attachment to methods guildification of interventions
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Common (Mentalizing) Elements ofTherapies with Severe Disorders
Extensive effort to maintain engagement in treatment(validation in conjunction with emphasis on need toaddress therapy interfering behaviours) acceptance and recognition
Include a model of pathology that is explained to thepatient increased cognitive coherence (early phase)
Active therapist stance: Explicit intent to validate anddemonstrate empathy, generate strong attachmentrelationship foundation of alliance (epistemic trust)
Focus on emotion processing and connection betweenaction and feeling (suicide feeling == abandonmentfeelings) restore cognitive representation ofemotion
Common (Mentalizing) Elements ofTherapies with Severe Disorders Inquiry into patients
mental states (behavioralanalysis, clarification, confrontation) strengthenrepresentations 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
su ort for adherence ditto thera ist needs lots
Intersubjectivity
and Affect
Regulation
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Theory: Birth of the Agentive Self
Attachment figure discovers infant s mind (subjectivity)
Representation of
infant
s mental
state
Attachment figure Infant
Core of
psychological
self
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
Internalization
Inference
The Development of Affect Regulation Closeness of the infant to another human
being who via contingent marked mirroringactions facilitates the emergence of asymbolic representational system of affectivestates and assists in developing affectregulation (and selective attention) secureattachment
For normal development the child needs toexperience a mind that has his mind in mindAble to reflect on his intentions accurately
Does not overwhelm him
Not accessible to neglected children
Psychological
Self:
2nd Order
Representation
Physical Self:
Primary
Representations
Representation
of self-state:
Internalization
of object
s image
Constitutional self
in state of arousal
Expression
Reflection
Resonance
Infant CAREGIVER
symbolic binding
of internal state
The development of regulated affect . . S y m b o l i z a t i o n o f E m o t i o n
With apologies to Gergely & Watson (1996)Fona , Ger el , Jurist & Tar et (2002)
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Mirroring sadness
Unmarked mirroring Marked mirroring
High congruent & marked mirroring
Low congruent & low marked mirroring
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Hyperactivation
of Attachment
and Social
Cognition
?
That handkerchief which I so loved and gave theeThou gavest to Cassio.By heaven, I saw my handkerchief in's hand.
Dimensions of mentalization: implicit/automaticvs explicit/controlled in Othello
Controlled Automatic
Why, how now, ho! from whence ariseth this?Are we turn'd Turks, and to ourselves do thatWhich heaven hath forbid the Ottomites?For Christian shame, put by this barbarous brawl:
LoveSpurned/Arousal
That handkerchief which I so loved and gave theeThou gavest to Cassio.By heaven, I saw my handkerchief in's hand.
Dimensions of mentalization: implicit/automaticvs explicit/controlled in Othello
Controlled Automatic
Lateral PFC Medial PFC
Lateraltemporalcortex
Amygdala Ventromedial PFC
Arousal
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Dimensions of mentalization: implicit/automaticvs explicit/controlled
Psychological understanding drops and israpidly replaced by confusion about mentalstates under high arousal
That handkerchief which I so loved and gave theeThou gavest to Cassio.By heaven, I saw my handkerchief in's hand.
Controlled Automatic
Arousal
Dimensions of mentalization: implicit/automaticvs explicit/controlled
Arousal
Psychotherapist
s demand to explore issuesthat trigger intense emotional reactionsinvolving conscious reflection and explicitmentalization are inconsistent with thepatient s ability to perform these tasks when
arousal is high
Attachment Disorganisation in Disrupted
Early Relationships
DISTRESS/FEAR
Exposure to maltreatment
Proximity seeking
Activation of attachment
The hyperactivation of the attachment system
Adverse Emotional Experience
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We assume that the attachment system inBPD is
hypersensitive
(triggered tooreadily)
Indications of attachment hyperactivity in coresymptoms of BPDFrantic efforts to avoid abandonment
Pattern of unstable and intense interpersonalrelationships
Rapidly escalating tempo moving fromacquaintance to great intimacy
The hyper-reactivity of theattachment system in BPD
Both maternal and romantic love elicit anoverlapping set of deactivations
middle prefrontal, inferior parietal and middletemporal cortices mainly in the right hemisphere, aswell as the posterior cingulate cortex
attention, long-term memory, variable involvement in bothpositive but mainly negative emotions
o underpin interface of mood related memory & cognition
temporal poles, parietotemporal junction and mesialprefrontal cortex
social trustworthiness, moral judgements, theory of mindtasks, solely negative emotions, attention to own emotions
o underpin determining other peoples emotions and intentions
Schematic Representation ofAttachment Related Brain Activation
Interface of mood,(long term) memory
and cognition
Social trustworthinessnegative affectand mentalising
AttachmentSystem
(-) (-)
System A System B
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Assurances Game Payoff Matrix
ParticipantPartner Strategy A
(cooperate)Strategy B
(defect)
Strategy A(cooperate)
You get $6Your partner gets $6
You get $4Your partner gets $0
Strategy B(defect)
You get $0Your partner gets $4
You get $2Your partner gets $2
(Kollock, 1998; Kelley et al., 2003)
Response to partner s hypotheticalcooperation in Assurances Game
Cooperate
Defect
Group x Oxytocin: F(1, 23)=4.82, p < .05 (Bartz et al, in prep)
0
0.5
1
1.5
2
2.5
BPD Normal Control
Placebo
Oxytocin
Attachment Disorganisation in
Psychotherapy
Mild Distress/
Anxiety
Emotional Challenge
Proximity seeking
Activation of attachment
The psychotherapeutic hyperactivation ofthe attachment s stem
Emotionally ChallengingExperience in Relation to theTherapist
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Geneticvulnerability
Hyper-reactiveattachment
system
Attachment systemdisorganized bytrauma & stress
Early attachmentenvironment
Inhibition or decouplingof social cognition
(social misjudgements,paranoid thoughts,mentalizing failure)
Re-emergence ofpre-mentalistic modes
of subjectivity(psychic equivalence
pretend modeteleological thinking
Vulnerability riskfactors
Activating (provoking)risk factors (emotional abuse,
trauma, non-mentalizingsocial system)
Formation risk factors(interpersonal stress,
experience of rejection)
Poor affectregulation
Fragileinterpersonalunderstanding
Poor controlof attention
The Modes of Psychic Reality That AntedateMentalisation and Characterize Suicide/Self-harm
Psychic equivalence:Mind-world isomorphism; mental reality = outer
reality; internal has power of external
Experience of mind can be terrifying (flashbacks)
Intolerance of alternative perspectives (
I knowwhat the solution is and no one can tell meotherwise )
Self-related negative cognitions are TOO REAL!(feeling of badness felt with unbearable intensity)
The Modes of Psychic Reality That AntedateMentalisation and Characterize Suicide/Self-harm
Pretend mode: Ideas form no bridge between inner and outer reality;
mental world decoupled from external reality
Linked with emptiness, meaninglessness anddissociation in the wake of trauma
Lack of reality of internal experience permits self-mutilation and states of mind where continued existenceof mind no longer contingent on continued existence ofthe physical self
In therapy endless inconsequential talk of thoughts andfeelings
o The constitutional self is absent feelings do notaccompany thoughts
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The Modes of Psychic Reality That AntedateMentalisation and Characterize Suicide/Self-harm
Teleological stance:
Expectations concerning the agency of the other arepresent but these are formulated in terms restricted tothe physical world
A focus on understanding actions in terms of theirphysical as opposed to mental outcomes
Patients cannot accept anything other than amodification in the realm of the physical as a true indexof the intentions of the other.
Only action that has physical impact is felt to be able toalter mental state in both self and other
o Manipulative physical acts (self-harm)
o Demand for acts of demonstration (of affection) by others
Loss
Increase attachment needs triggering ofattachment system
Failure of mentalization
Psychic equivalence intensification of
unbearable experiencePretend modehypermentalization
meaninglessness, dissociation
Teleological solutions to crisis of agentive selfsuicide attempts, self-cutting
Understanding suicide and self-harm interms of the temporary loss of mentalization
Theory:Theory:Theory:Theory: Birth of the
Alien
Self inDisorganized AttachmentThe caregiver
s perception is inaccurate or unmarked or both
Absence of a
representation of
the infant
s
mental state
Attachment
Figure The nascent selfrepresentational
structure
The child, unable to
find
himself as an intentional being, internalizes a
representation of the other into the self with distorted agentive characteristics
Mirroring fails
Internalisation of a non-contingent mental
state as part of the self
Child
The Alien
Self
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T h e o r y :
T h e o r y : T h e o r y :
T h e o r y : Self-destructiveness and
Externalisation Following Trauma
Attack from within is turned against body and/or mind.
Perceived
other
Unbearably painful
emotional states:
Self experienced
as evil/hateful
Torturing alien self Self representation
Self-harm state
Self experiencedas evil and hateful
T h e o r y :
T h e o r y : T h e o r y :
T h e o r y : Self-destructiveness and
Externalisation Following Trauma
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
Perceived
otherUnbearably painful
emotional states:Self experienced
as evil/hateful
Torturing alien self Self representation
Container
Self experiencedas hated and attacked
Externalization
Torturing alien self
Addictive bondSelf-harm state Victimized state
Assessment ofMentalization
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PretendMode
PsychicEquivalence
TeleologicalMode
Temporary Failure of Mentalisation
Unstable Interpersonal RelationshipsAffective Dysregulation
Impulsive Acts of Violence, Suicide, Self-HarmPsychotic Symptoms
Figure 2.x Understanding BPD in terms of th e suppression of mentalization
PseudoMentalisation
ConcreteUnderstanding
Misuse ofMentalisation
Understanding suicide and self-harm interms of the temporary loss of mentalisation
Questions that can reveal quality ofmentalisation
why did your parents behave as they did duringyour childhood?
do you think your childhood experiences have aninfluence on who you are today?
any setbacks? did you ever feel rejected as a child?
in relation to losses, abuse or other trauma, howdid you feel at the time and how have yourfeelings changed over time?
have there been changes in your relationship withyour parents since childhood?
Elaboration of interpersonal event
Thoughts and feelings in relation to theevent
Ideas about the other persons mental stateat turning points in narrativeElaborate on actual experience
Reflecting on reconstructed past
Understanding own actions (actual pastand reflection on past)
Counter-factual follow-up questions
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Interpersonal interaction
Last night Rachel and I had an argumentabout whether I was doing enough aroundthe house. She thought I didnt do as muchas her and I should do more. I said I did asmuch as my work obligations allow. Rachelgot angry and we stopped talking to eachother. In the end I agreed to do theshopping from now on. But I ended upfeeling furious with her
What does non-mentalizing looklike?
Excessive detail to the exclusion ofmotivations, feelings or thoughts
Focus on external social factors, such asthe school, the council, the neighbours
Focus on physical or structural labels (tired,lazy, clever, self-destructive, depressed,short-fuse)
What does non-mentalizing looklike?
Preoccupation with rules, responsibilities,shoulds and should nots
Denial of involvement in problem
Blaming or fault-finding
Expressions of certainty about thoughts orfeelings of others
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What does good mentalizing looklike?
In relation to other peoples thoughts andfeelingsAcknowledgement of opaqueness
Absence of paranoia
Contemplation and reflection
Perspective taking
Genuine interest
Openness to discovery
Forgiveness
predictability
What does good mentalizing looklike?
Perception of own mental functioningAppreciation of changeability
Developmental perspective
Realistic scepticism
Acknowledgement of pre-conscious function
Awareness of impact of affect Self-presentation e.g. autobiographical
continuity
General values and attitudes e.g.tentativeness and moderation
What does extremely poor mentalizing
look like?
Anti-reflectivehostility
active evasion
non-verbal reactions
Failure of adequate elaborationComplete lack of integration
Complete lack of explanation
InappropriateComplete non-sequiturs
Gross assumptions about the interviewer
Literal meanin of words
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Assessment of mentalization
Distinguish four main types of problem - notmutually exclusive; more than one may apply tothe same person
Concrete understandingo Generalised lack of mentalising
Context-specific non-mentalisingo Non-mentalising is variable and occurs in particular contexts
Pseudo-mentalisingo Looks like mentalising but missing essential features
Misuse of mentalisingo Others minds understood and thought about, but used to hurt,
manipulate, control or undermine
Concrete understanding
General failure to appreciate feelings ofself or others as well as the relationshipsbetween thoughts, feelings and actions
General lack of attention to the thoughts,feelings and wishes of others and aninterpretation of behaviour (own or others)
in terms of the influence of situational orphysical constraints rather than feelingsand thoughts
May vary markedly in degree
Context Specific - Relational
Dramatic temporary failures ofmentalisation
Youre trying to drive me crazy
You hate me
She does my head in. I cant think once shestarts on me
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Pseudo-mentalising subtypes
Intrusive mentalisingOpaqueness of mental states not respected
Thoughts and feelings talked about, may be relativelyplausible and roughly accurate, but assumed withoutqualification
Overactive-inaccurate mentalisingLots of effort made, preoccupation with mental states
Off-the-mark and un-inquisitive
Destructively inaccurateDenial of objective reality, highly psychologically
implausible mental states inferred
Misuse of Mentalizing (1) Understanding of the mental state of the
individual is not directly impaired yet the wayin which it is usedis detrimental
May be unconscious but is assumed to bemotivated
Self-serving distortion of the others feelings
Self-serving empathic understandingA persons feelings are exaggerated or distorted
in the service of someone elses agenda
Misuse of Mentalizing(2) Coercion against or induction of the thoughts
of others
Deliberate undermining of a persons capacity tothink by humiliation
Extreme form is sadistic or psychopathic use ofknowledge of other
s feelings or wishes
Milder form is manipulation for personal gain
o inducing guilt
o engendering unwarranted loyalty
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