borderline personality, mentalizing and mother- infant interaction€¦ · mentalization: the...

Borderline personality, mentalizing and mother-infant interaction

Prof Anthony Bateman AAIMHI WA Meeting Perth

n Mrs. Darling first heard of Peter when she was tidying up her children's minds. It is the nightly custom of every good mother after her children are asleep to rummage in their minds and put things straight for next morning, repacking into their proper places the many articles that have wandered during the day.

n  If you could keep awake (but of course you can't) you would see your own mother doing this and you would find it very interesting to watch. It's quite like tidying up drawers. You would see her on her knees, I expect, lingering humorously over some of your contents, wondering where on Earth you picked this thing up, making discoveries sweet and not so sweet, pressing this to her cheek, as if it were a nice kitten, and hurriedly stowing that out of sight.

n When you wake in the morning, the naughtiness and evil passions with which you went to bed have been folded up small and placed at the bottom of your mind and on the top, beautifully aired, are spread out the prettier thoughts, ready for you to put on.”

J.M. Barrie in Peter Pan

The development of the ‘mentalizing self’

n  The capacity to mentalize emerges through interaction with the caregiver:

n  The quality of the attachment relationship Ø If the parent is:

o  Able to reflect on infant’s intentions accurately

o Does not overwhelm the infant Ø Then this:

o  Assists in developing affect regulation

o Helps develop child’s sense of a mind and of a reflective self

What is mentalizing?

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

Mentalization: The basics n  Attachment and mentalization are loosely coupled

systems existing in a state of partial exclusivity.

n  Mentalization has its roots in the sense of being understood by an attachment figure, Ø it can be more challenging to maintain mentalization

in the context of an attachment relationship (e.g. the relationship with the therapist) (Gunderson, 1996).

n  BPD associated with hyperactive attachment systems as a result of their history and/or biological predisposition

n  But without activation of the attachment system in therapy borderline PD patients will never learn to function psychologically in the context of interpersonal relationships.

Psychological Self:

2nd Order Representations

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 organisation of internal state

signal non-verbal

expression

Affect & Self Regulation through Mirroring

With apologies to Gergely & Watson (1996) Fonagy, Gergely, Jurist & Target (2002)

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 Emotions EPISTEMIC

TRUST

BONDING

Bowlby’s Attachment Theory

n  Need of human infant to seek protection and security through physical contact with the caregiver

n  Attachment system Caregiving system n  Attachment behaviours Caregiving behaviours

Ø  proximity seeking - touching Ø  clinging - holding Ø  smiling - soothing

n  Affectional bond: expectation of being offered care

Attachment Styles Our attachment to others can be described as: 1. Secure 2. Insecure -Ambivalent (sometimes called anxious) 3. Insecure – Distanced (sometimes called avoidant) 4. Disorganised

Implicit- Automatic- Non -conscious- Immediate.

Explicit- Controlled Conscious Reflective

Mental interior cue focused

Mental exterior cue focused

Cognitive agent:attitude propositions

Affective self:affect state propositions

Imitative frontoparietal mirror neurone system

Belief-desire MPFC/ACC inhibitory system

Multifaceted Nature of Mentalization Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.

amygdala, basal ganglia, ventromedial prefrontal cortex (VMPFC), lateral temporal cortex (LTC) and the dorsal anterior cingulate cortex (dACC)

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

Associated with several areas of prefrontal cortex

Associated with inferior prefrontal gyrus

the medial prefrontal cortex, ACC, and the precuneus

frontoparietal mirror-neuron system

medial frontoparietal network activated

recruits lateral fronto-temporal network

Relational Aspects of Mentalization n  Overlap between neural locations of mentalizing

self and other may be linked to intersubjective origin of sense of self Ø  We find our mind initially in the minds of our parents

and later other attachment figures thinking about us Ø The parent’s capacity to mirror effectively her child’s

internal state is at the heart of affect regulation Ø Infant is dependent on contingent response of

caregiver which in turn depends on her capacity to be reflective about her child as a psychological being

Ø Failure to find the constitutional self in the other has potential to profoundly distort the self representation (exaggerated mirroring of child’s anxietyè aggravates anxiety rather than soothe)

Ø The same applies to child with inadequate sense of independent self within therapeutic relationship

What goes wrong for mentalizing and attachment?

Attachment Disorganisation in Disrupted Early Relationships

DISTRESS/FEAR

Exposure to threat

Proximity seeking

Activation of attachment

The ‘hyperactivation’ of the attachment system

Adverse Emotional Experience

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

Attachment - Arousal/Stress

DISTRESS/FEAR

Adverse emotional experience rooted in

traumatic relationships

Inhibition of mentalisation

Intensification of attachment needs

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

Inaccurate judgements of affect, Delayed development of mentalization understanding

Failure to understand how emotions relate to situations and behavior

Implicit- Automatic- Non -conscious- Immediate.

Explicit- Controlled Conscious Reflective

Mental interior cue focused

Mental exterior cue focused

Cognitive agent:attitude propositions

Affective self:affect state propositions

Imitative frontoparietal mirror neurone system

Belief-desire MPFC/ACC inhibitory system

Imbalance of mentalization generates problems Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.

Impulsive, quick assumptions about others thoughts and feelings not reflected on or tested, cruelty

Does not genuinely appreciate others’ perspective. Pseudo-mentalizing, Interpersonal conflict ‘cos hard to consider/reflect on impact of self on others

Unnatural certainty about ideas Anything that is thought is REAL Intolerance of alternative ways of seeing things.

Overwhelming dysregulated emotions, Not balanced by cognition come To dominate behavior. Lack of contextualizing of feelings leads to catastrophyzing

Rigid assertion of self, controlling others’ thoughts and feelings.

Hypersensitive to others’ Moods, what others say. Fears ‘disappearing’

Hyper-vigilant, judging by appearance. Evidence for attitudes and other internal states hasto come from outside

Lack of conviction about own ideas Seeking external reassurance Overwhelming emptiness, Seeking intense experiences

BPD

BPD

BPD

BPD

Prementalizing Modes of Subjectivity n  Psychic equivalence:

Ø  Mind-world isomorphism; mental reality = outer reality; internal has power of external

Ø  Intolerance of alternative perspectives èconcrete understanding Ø  Reflects domination of self:affect state thinking with limited internal focus

n  Pretend mode: Ø  Ideas form no bridge between inner and outer reality; mental world

decoupled from external reality Ø  “dissociation” of thought, hyper-mentalizing or pseudo-mentalizing Ø  Reflects explicit mentalizing being dominated by implicit, inadequate internal

focus, poor belief-desire reasoning and vulnerabilty to fusion with others

n  Teleological stance: Ø  A focus on understanding actions in terms of their physical as opposed to

mental constraints Ø  Cannot accept anything other than a modification in the realm of the physical

as a true index of the intentions of the other. Ø  Extreme exterior focus, momentary loss of controlled mentalizing Ø  Misuse of mentalization for teleological ends (harming others) becomes

possible because of lack of implicit as well as explicit mentalizing

Prementalizing Modes n  Psychic equivalence:

Ø  Child will be ‘mis-seen’ Ø  Misattributions likely and difficult (if not impossible for the infant or child) to challenge Ø  “He knew (infant aged 8 weeks suffered fractured ribs) I was just about to go out for a fag

when he started crying…” Ø  In Lighthouse MBT-P we call this the Projecting Beam

n  Pretend mode: Ø  Care for the infant may correspond broadly to his needs but likely to be misattuned and

child’s experience will be a mixture of having needs met while not being accurately, markedly mirrored; can often result in frustration triggering psychic equivalence then resulting in compliance in the infant over time

Ø  Baby who sleeps 16 -17 hours every day, never cries, but gains weight, slow meeting milestones, mother appears bland but ‘looks normal and affectionate’ (social worker observation)

Ø  “dissociation” of thought, hyper-mentalizing or pseudo-mentalizing and vulnerability to fusion with others

Ø  can be present in Factitious and Induced Illness n  Teleological stance:

An infant may well be seen as responsible for mental state of parent is invariably in a precariousposi+on.“Iknowshehatesme,shecan’tbeartolookatme”“Hethrewhiscarrotsonthefloor,hethrewtheplate.IwasjustsoangrywithhimIjusthadtoputhiminthehallway,andwalkawaytocalmdown.Atthe@meitfeltliketheworstthinghecouldpossiblyhavedoneandnowlookingbackIthink,‘Ohhejustthrewhiscarrotsonthefloor.’Inthatmomenttherejec@onofthecarrotsfeltliketherejec@onofallmyloveandallthegoodItrytodo.ItwaslikehewasonemorepersoninmylifetellingmethatwhateverIdoisnotgoodenough.”

Cycles of inhibition of mentalizing

Powerful emotion

Poor mentalising

Inability to understand or even pay attention to feelings of others

Others seem incomprehensible

Try to control or change others

Frightening, undermining, frustrating, distressing or

coercive interactions

Loss of certainty that thoughts are

not real

Powerful emotion

Poor mentalising





Try to control or change others or oneself

Person 1

Powerful emotion

Poor mentalising






Person 2

Vicious Cycles of Mentalizing Problems within the Family/Parent-child

Mentalizing failures in trauma

AFRAID, terrified,

overwhelmed, helpless, out of

control +

ALONE, abandoned,

neglected, unloved, without needed comforting and making sense

T

R

A

U

M

A

unmentalized

+

terrorizing mindblind

traumatizer

traumatized

Developmental impact of attachment trauma

attachment trauma

hyperarousal

impaired mentalizing

secure attachment

optimal arousal

mentalizing

0

1

2

3

4

5

6

Sexual risk taking (Slope=1.79, SE=0.81, p<.03)

Parent rated aggression (Slope=1.17, SE=0.57, p<0.04)

Hostile behavior (Slope=0.09, SE=0.10, n.s.)

Coef

ficie

nt fo

r Pre

occu

pied

Atta

chm

ent

Age 13 (n=217)Age 15 (n=201)Age 17 (n=172)

Attachment class and BPD features:

0

0.5

1

1.5

2

2.5

3

Sexual risk taking Parent rated aggression Hostile behavior

Coef

ficie

nt fo

r Dis

mis

ing

Atta

chm

ent Age 13 (n=217)

Age 15 (n=201)Age 17 (n=172)

Preoccupied attachment

Dismissing attachment

Preoccupied attachment predicts increased sexual risk taking and aggressive behaviors over the course of adolescence, as well as steeper rates of growth in these behaviors Given that these behaviors reflect impulsivity, deficits in self-regulation (core features of BPD)è preoccupied attachment may be related to the development of BPD. Observed in several other studies.

Kobak, Zajac & Smith, C. (2009)

0

1

2

3

4

5

6

Secure Preoccupied Fearful Dismissing

Commmunity Controls (n=64)

MDD (n=64)

BPD (n=109)

Self-Reported Attachment Styles and BPD

Mea

n sc

ore

Choi-Kain et al. (2009)

Disorganized attachment (D)

n Behavior lacks an observable goal n  Look fearful n Behavior is bizarre n May try to leave after the reunion or freeze

•  A disorganised attachment pattern is noticeable in the unstable relationships BPD patients usually have

Holmes, 2004; De Zulueta, 2006; Barone, 2003 •  Zero order partial correlations between BPD and disorganised

attachment in clinical population: 0.44 for adolescents and 0.48 for adults (p≤0.001)

Westen et al., 2006

•  In a sample of 140 BPD subjects, 40% presented disorganised attachment

Barone, Fossatu & Gulducci, 2011

•  In a review of 13 studies, the percentage of BPD patients presenting disorganised attachment has been estimated between 32.2% and 89%. This percentage raised to 100% among BPD patients with history of trauma.

Agrawal et al., 2004

•  Among these studies, earlier ones show stronger correlations between BPD and disorganisation (around 0.8). Subsequent studies showed a somewhat weaker association (0.5-0.6)

Levy, 2005

•  A longitudinal study found that disorganisation during infancy was unrelated to adult BPD features. More important predictors were maltreatment and maternal disrupted emotional communication

Lyons-Ruth et al., 2005

BPD and disorganised attachment

Attachment and cognitive functioning: the development of competence in logical reasoning

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

7 9 11 13 15Age

secure insecure disorganised

Source: Jacobson et al

Circle of Security Marvin, Cooper, Hoffman & Powell (2002)

n Child’s Exploratory System and Needs Ø The child can move off and explore, if he

believes and expects that the attachment figure will be available if, or when, needed

n Attachment System Ø The child needs the attachment figure to be

available to protect, comfort, delight, and organize his feelings when he becomes overwhelmed

Cooper, Hoffman, Marvin &Powell , 2000

Impact of Empathic Failure

n  “Whatever she fails to recognize in him he is likely to fail to recognize in himself. In this way, it is postulated, major parts of a child’s developing personality can become split off from, that is, out of communication with, those parts of his personality that his mother recognizes and responds to, which in some cases include features of personality that she is attributing to him wrongly.” Bowlby (1988) p.132

The journey from attachment to communication

The theory of natural pedagogy and epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014)

n New form of evolution (late Pleistocene) based on learning and the transmission of cultural knowledge

n The challenge of discerning of epistemic trustworthiness and the need for EPISTEMIC VIGILANCE!

n  The pedagogic stance is triggered by ostensive communicative cues (E.G. turn-taking contingent reactivity, eye contact)

n  Ostensive cues have in common Ø Person recognized as a self Ø Paid special attention to (noticed as an agent)

ET= Epistemic

Trust

Triggering the Pedagogical Stance n  Ostensive cues function to trigger epistemic

trust: Ø Opening channel to receive knowledge about social

and personally relevant world (CULTURE) Ø Going beyond the specific experience and acquire

knowledge relevant in many settings Ø Triggers opening of an evolutionarily protected

epistemic channel for knowledge acquisition n  Mimicry may be protected by human evolution

because it generates epistemic trust Ø Social smile (recognition of self) increases imitation

because smile generates epistemic trust and opens channel to receive knowledge

Subjects : 4 groups of 18-month-olds Stimuli: Two unfamiliar objects

Experimental illustration of ostensive cues Gergely, Egyed et al. (2013)

1: Baseline – control group

Simple Object

Request by Experimenter A

Subjects: n= 20 Age: 18-month-olds

No object-directed attitude demonstration

Ostensive Communicative Demonstration

Other person

Requester: OTHER person (Condition 1)

Non-Ostensive (Non-Communicative) Demonstration

Other person

Requester: OTHER person (Condition 2)

Condition 4: Non-Ostensive (Non-Communicative)

Same person

Demonstration Requester: SAME person

A 50:50 animal from Corriveau et al.

50% pig : 50% bear If Mother names hybrid as pig then stranger always names it bear

A 50:50 animal from Corriveau et al. 50% cow : 50% horse

If Mother names hybrid as horse then stranger always

names it cow


75% rabbit : 25% squirrel Mother always names hybrid as squirrel and stranger always names it rabbit


75% bird : 25% fish Mother always names hybrid as fish and stranger always names it as bird

Proportion of Trials on Which Children Chose Their Mother for Information by Attachment Group and by task

Perc

ent M

othe

rs C

hose

n

Avoidant 0 Secure

20

40

60

80

Attachment Classification at 18 months

*

N=146

***

Anxious Resistant

Disorganised

***

***

*** ***

***

Novel Object

50-50 Hybrid

75-25 Hybrid

Corriveau, Harris, Meins et al., Child Dev,, 80, 750-761.

Conclusions from attachment and epistemic trust studies

n Security of attachment èfeeling recognizedè increases likelihood of trust in the source of communication when it is reasonably credible Ø Also empowers confidence in own experience and

belief (empowers judgment) n Avoidance leads to epistemic mistrust while

anxious attachment generates overreliance on views of attachment figure

n Disorganized attachment èmisattunement è mistrust of both attachment figure and stranger Ø Who to trust? è epistemic hyper-vigilance

Social Cues that Create Epistemic Trust n  Attachment to person who responded sensitively in

early development is special condition for generating epistemic trust ècognitive advantage of security è including neural development (Van Ijzendoorn et al.)

n  Generally any communication marked by recognition of the listener as intentional agent will increase epistemic trust and likelihood of communication being coded as Ø Relevant Ø Generalizable Ø  To be retained in memory as relevant

n  OSTENSIVE CUES TRIGGER EPISTEMIC TRUST WHICH TRIGGERS A SPECIAL KIND OF ATTENTION TO KNOWLEDGE RELEVANT TO ME

Parents with borderline personality

disorder and social vulnerability

Borderline Personality Disorder

Self-Concept Social

Interaction

Emotion Dysregulation

Mentalizing Positive Emotions in Borderline Personality Psychopathology and Psychotherapy: A randomized phase-based multiple-baseline study Tine Harpøth, Mickey Kongerslev, Anthony Bateman & Erik Simonsen Psychiatric Research Unit, Region of Zealand, Denmark

n  The ”broaden and build” theory proposes that positive emotions - independently of negative emotions - help people build lasting resources.

n  Enhancing positive emotions through psychological interventions may increase resilience.

n  Specific intervention ‘mentalizing positive emotions’ n  Outcomes: General psychopathology; personality

disorders and BPD pathology; Differential emotions; Resilience (Ego-resilience scale (ER-89) and Perseverance and passion for long-term goals (GRIT-S); Life Satisfaction Satisfaction with Life Scale (SWLS);Therapeutic alliance (patient-rated) Working Alliance Inventory (WAI)

n 

n  I depend on others a lot n  I can‘t manage when people don‘t respond

to me n  I am an outsider n  I am different from others (shame) n Others will reject me n  I do not deserve being part of the group

(guilt) n  I am ugly (self-contempt- self disgust)

Reported Social Cognitions in BPD

Rejection-sensitivity (anxiously expect, readily perceive, over reaction) in different patient populations

Stäbler et al., 2011

Rejection Sensitivity in acute and remitted BPD patients

HC

RS

Q-S

co

re (

0-3

0)

0

5

10

15

20

acuteBPD

remittedBPD

HC

RSQ-Score

0

1

2

3

4

5

acuteBPD

remittedBPD

HC

RSQ-Score

0

1

2

3

4

5

acuteBPD

remittedBPD

cognitive RS

affective RS

HC

acute BPD

remitted BPD

N=77 N=15 N=75

Bungert et al. BPDED, 2015

UCLA Loneliness Scale (n=40 female BPD; 40 HC)

Figure 1. Graph of social judgement scores for each of six dimensions.

Nicol K, Pope M, Sprengelmeyer R, Young AW, Hall J (2013) Social Judgement in Borderline Personality Disorder. PLoS ONE 8(11): e73440. doi:10.1371/journal.pone.0073440 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0073440

Approachable as Unapproachable

Unapproachable as Approachable

Trustworthy as Untrustworthy

Untrustworthy as Trustworthy

Judgment bias for approachability and trustworthiness of faces.

NS NS

BPD

Control P<.001

P<.001

Direction of bias

Nicol et al., 2013 Plos One

Trust in Borderline Personality Disorder King-Casas, Sharp, Lomax-Bream, Lohrenz, Fonagy, & Montague (2008) Science, 321, 806-810. n  Studying social behavior in task that involves

Ø Live interaction with unknown but real person Ø Engages mesocorticolimbic dopaminergic reward

circuit

n  Total patients screened è assessed è scanned: Ø BPD: 1,060 è 224 è 62 Ø Mood control: 622 è 235 è 22 Ø Normal control: 877 è 398 è 116

X 3

Investor Trustee

$20

A dynamic version of the Trust game (10 rounds) BPD: The absence of Basic Trust

Camerer & Weigelt, (Econometrica, 1988) Berg, Dickhaut & McCabe (Games and Economic Behavior, 1995)

Average Repayment:

repay everything

repay nothing

repay investment (33%)

Investor Sent MU sent / MU available

36 non-psychiatric investors 42 BPD investors

Trustee Repaid MU sent / MU available

rounds

60%

50%

40%

30%

20%

10% 1 3 4 7 9 5 6 8 10 2

60%

50%

40%

30%

20%

10% 1 3 4 7 9 5 6 8 10 2

36 non-psychiatric trustees 42 BPD trustees

Effects of inclusion on subsequent interaction

z = 0

x = 0

Reaction to Small Investments

(I < .25) minus (I > .5); p < .004, uncorrected, n = 36 trustees

anterior insula

anterior cingulate cortex (ACC)

Sanfey et al, TICS, 2006

response to “unfair” offers in an Ultimatum Game

(take it or leave it)

A Neural Signature of ‘Borderlineness’ in Trust Task

Cyberball

Did you feel ostracized?

BPD patients significantly more often feel ostracized under inclusion and uncontrollable conditions Staebler et al., 2011; Domsalla, Lis, Bohus et al., 2013

(Domsalla, Lis, Bohus et al., SCAN, 2013)

Social perception: fMRI

BPD patients showed a stronger engagement of the dorsal anterior cingulate and medial prefrontal cortex particularly in inclusion conditions =

HYPERMENTALIZING

Virtual Reality Group Interaction Paradigm

Become acquainted

Appraisal

Exclusion

Inclusion

Reappraisal Social

Cooperation

VR Group Interaction Paradigm

Social expectations before and after feedback

Do you expect that people will invite you?

0

2

4

6

8

10

12

Inklusion Exklusion

HC BPD

70

58

47

35

23

11

0

%

Inclusion Exclusion

Social expectations before and after feedback

Would you like to invite others?

n Social inclusion in the VRGIP Ø Has little influence on people with

BPD Ø Increases suspicion Ø BPD become less co-operative than

under exclusion conditions

Results

n Start from a position of distrust n Assume you are to be disadvantaged and

seen as an outsider n Sensitivity to unfairness n  Interprete social cues as being an outsider n Positive social cues aversive and increase

suspicion n Feel impoverished and become either

mean or over-generous in social interaction

Summary

Implications for

treatment

The Natural Pedagogy Model of PD

History of Adversity

Insecure/ Disorganized Attachments

Emotion Dysregulation

Failure of Ostension

Loss of Balanced

Mentalizing

Social Dysfunction Communication Failures

High Epistemic

Vigilance or Hypervigilance

Limits on Social

Learning Processes

Epistemic Mistrust Imperviousness to Social Influence

Social Disruption

Compromised Social

Network

Loss of Interest in Social

Communication

Sensitive caregiving

Caregiver’smentalizingoftheinfantactsasthe

prototypicalostensivecue

Secure attachment

Epistemic trust

Learningchannelopens(selec6vely)

Self-control & self-

learning Learning about the

world

Thislaysthefounda+onsfor…

Learning about others

Whichenables… Mentalizing

Successful navigation of social world

Neglect/a;achmenttrauma

Ostensivecuesarenotprocessed,wereabsent

ormisleading

Insecure/disorganizedaBachment

Absenceofepistemic

trust

Learningchannelisclosed,indiscriminatelyopenorbothbyturns

Epistemichyper-vigilance

Excessivecredulity

Epistemicdilemma

Mentalizingdifficul6es

Problemsnaviga+ngsocialworld

Problemsunderstanding

othersInall3cases,theindividualstrugglestolearneffec+vely

abouteitherselforworld

Video feedback

Aims to improve the parent’s: n  nurturing n  understanding of what their child’s behaviour

means n  responses to cues and expressions of the child’s

feelings n  behaviour so that it is not frightening to the child n  mastery of their own feelings when nurturing the

child.

Parental sensitivity and behaviour training

Aims to help parent’s: n  understand their child’s behaviour n  improve their responsiveness to their

child’s needs n manage difficult behaviour.

Home visiting Includes observing the child (not using video) with their parents

Aims: to help parent’s improve their communication and relationship with their child by:

n  using role modelling n  reinforcing positive interactions and parental empathy n  parental education on child development .

Parental Stance

n  Not-Knowing Ø Curiosity and interest Ø Uncertainty Ø Testing out Ø Active questioning of one’s assumptions Ø Asking others

n  Monitor you own misunderstandings Ø Surprise and re-appraisal Ø  Errors offer opportunities to re-visit to learn more

about contexts, experiences, and feelings leading to effective actions

Increase of emotional arousal

(including depression)

Activation of secondary attachment strategies

mentalizing impairment

Impaired social interaction

Loss of personal resilience

A vicious cycle in BPD

Fonagy & Luyten, 2009; Northoff et al., 2006; Mennin et al., 2013; Lemma, Target & Fonagy, 2011

Powerful emotion

Poor mentalising






Person 1

Powerful emotion

Poor mentalising






Person 2

Vicious Cycles of Mentalizing Problems within the Family/Parent-child

Lighthouse Project (Gerry Byrne et al)

n  The lighthouse beams Ø illuminating beam (the mentalizing stance, wanting to

know the child Ø  scanning beam (ready to notice, keeping an eye and

an ear out for the child) and the safe harbour (snap judgements in which a child can be mis-seen)

n  Secure and insecure attachment patterns are represented by the metaphors Ø Safe Harbour (secure), Ø Piracy and Battleships (insecure conflicted/

ambivalent), Ø  Raft (avoidant) Ø Rocks Beneath the Surface (disorganized)

Lighthouse Project (Gerry Byrne et al)

n  The Wrecking Light acknowledges that in the parent’s own childhood they may have suffered abuse, that is that an adult offered a false beam that signaled Safe Harbour but led to abuse and trauma.

n  Night Seas addresses the role of the unconscious in children’s (and parents’) fears and anxieties and acknowledges the increased risk of loss of mentalization and of risk of harm to the child around bedtime and at night through increased stress and exhaustion in parents

Thank you for mentalizing!

For further information [email protected] Slides available at: http://www.ucl.ac.uk/psychoanalysis/people/bateman

borderline personality, mentalizing and mother- infant interaction€¦ · mentalization: the...

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