mbt_training_theory.pdf

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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

[email protected]

[email protected]

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


mentalizing

mentalizing


mentalization


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


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


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 -

--

- 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 -

--

- 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


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 -

--

- 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 -

--

- 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 -

--

- 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.



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8

Luckily, humans have evolved to teach and learn fromeach other quickly and efficiently


8

-..quickly and efficiently if certain conditions are met


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.



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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

?


Dimensions of mentalization: implicit/automaticvs explicit/controlled in Othello


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


Dimensions of mentalization: implicit/automaticvs explicit/controlled in Othello


Lateral PFC Medial PFC

Lateraltemporalcortex

Amygdala Ventromedial PFC

Arousal


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Psychological understanding drops and israpidly replaced by confusion about mentalstates under high arousal



Arousal


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


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


Strategy B(defect)



(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


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)


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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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

mbt_training_theory.pdf

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