mentalizing as common-grounds for therapy - allen

8/13/2019 Mentalizing as Common-Grounds for Therapy - Allen

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Mentalizing as Common Groundfor Psychotherapy:

Educating Patients and Clinicians

Jon G. Allen, Ph.D.

The Menninger Clinic

Baylor College of Medicine

[email protected]


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CollaborationColleagues

Peter Fonagy, Mary Target & Anthony Bateman;Efrain Bleiberg, Pasco Fearon, Toby Haslam-

Hopwood, Elliot Jurist, George Gergely, JeremyHolmes, Linda Mayes, Richard Munich, Lois Sadler,John Sargent, Carla Sharp, Arietta Slade, HelenStein, Stuart Twemlow, Laurel Williams

Consortium

University College London, Anna Freud Centre,Yale Child Study Center, The Menninger Clinic,Human Neuroimaging Laboratory at Baylor Collegeof Medicine


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Books

Fonagy, Gergely, Jurist & Target (2002).Affect regulation, mentalizing,and the development of the self. New York: Other Press.

Bateman & Fonagy (2004). Psychotherapy for borderline personalitydisorder: Mentalization-Based Treatment. New York: OxfordUniversity Press.

Bateman & Fonagy (2006). Mentalization-Based Treatment forborderline personality disorder: A practical guide. New York: OxfordUniversity Press.

Allen & Fonagy, Eds. (2006). Handbook of Mentalization-BasedTreatment. Chichester, UK: John Wiley & Sons.

Allen, Fonagy, & Bateman (2008). Mentalizing in clinical practice.Washington, DC: American Psychiatric Publishing.


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Definitions of mentalizing

mentalizing is a form of imaginative mental activity, namely,perceiving and interpreting human behavior as conjoined withintentional mental states (e.g., needs, desires, feelings,beliefs, goals, purposes, and reasons)

Shorthand attending to mental states in self and others holding mind in mind holding heart and mind in heart and mind

mindfulness of mind understanding misunderstandings


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Part I

Mentalizing as a common factorin psychotherapeutic treatment


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A capsule history of mentalizing

First recorded use of the word, 1807

First appeared in Oxford English Dictionary, 1906

give a mental quality to; picture in the mind;

cultivate mentally

Used in French psychoanalytic literature in late 1960s

Employed in understanding autism in 1989 (Morton)

Employed in understanding developmentalpsychopathology in 1989 (Fonagy) and extended

to treatment of BPD (Bateman & Fonagy)Advocated as a common factor in psychotherapeutic

treatment (Allen, Fonagy & Bateman)


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What is the therapeutic alliance if not an attachment bond?

Jeremy Holmes (2001):The search for the secure base

Much, if not all, of the effectiveness of different forms ofpsychotherapy may be due to those features that all have incommon rather than those that distinguish them from each other.

Jerome Frank (1961):Persuasion and healing


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In advocating mentalization-based treatment we claim no innovation.

On the contrary, mentalization-based treatment is the least noveltherapeutic approach imaginable.

Allen & Fonagy, Handbook of Mentalization-Based Treatment

Mentalizing is the most fundamental common factoramong

psychotherapeutic treatmentsperforce, clinicians mentalize inconducting psychotherapies and also engage their patients in doingso. Allen, Fonagy, & Bateman, Mentalizing in Clinical Practice

mentalizing, even if not always explicit in our language, is implicit in

many forms of psychotherapyAllen and colleagues, of course, havealready said this, when they suggest: Youre already doing it. Andindeed we are, if were doing our job.

Oldham (2008), Epilogue to Mentalizing in Clinical Practice


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Two broad questions

What is distinctive about mentalizing?

as a treatment approach?

as a concept?

Whats all the fuss about?


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Plakuns Y model: Generic and specific facets

psychodynamiccognitive-behavioral

common factors

alliance

empathic listening

formulation

boundaries


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Plakuns Y model: Generic and specific facets

psychodynamiccognitive-behavioral

mentalizing


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Treatments for BPD

Mentalization-Based Therapy

mentalizing

Implication: extensiveoverlap between MBT

and other treatmentapproaches to BPD

Transference-Focused Psychotherapy

Dialectical Behavior Therapy

relatively single-minded focus onmentalizing process: consistency; a

style of psychotherapy


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Mentalizing: Generic and specific facets

Mentalizing Focus inPsychotherapy

mentalizing

metacognitive approaches

Third-Generation Cognitive-Behavioral Therapies

Acceptance and Commitment Therapy (ACT)mindfulness practice


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The Menninger Clinic: Historical ContextLong-term psychoanalytically oriented hospital treatmentthroughout most of its history in Topeka, Kansas

Gradual reductions in hospital stays coupled withincreasing array of partial-hospital and outpatient

servicesIncreasing theoretical eclecticism (e.g., CBT, DBT,psychoeducational approaches)

Downsizing to specialty inpatient treatment programs with4-8 week lengths of stay

Relocation to Houston, Texas to partner with BaylorCollege of Medicine

Jump-starting treatment for treatment-resistant patients


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Developing the common factor approach tomentalizing at The Menninger Clinic

Wide range of disorders beyond BPD: depression, anxiety,trauma, substance abuse, other PDs

Professionals in Crisis program emphasizes mentalizing; initiatedpsychoeducational intervention

Clinicians resistance to mentalizing

sounds foreign

already know it all

Increasing desire for conceptual coherence in apsychotherapeutic culture (integrative function)

Belatedly educating clinicians after educating patientsMentalization-Based Adolescent Treatment Program developed in

consultation with Peter Fonagy, Mary Target, & AnthonyBateman


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ComplaintsMentalization has an intellectualizing and potentially

dehumanizing ring to it and must be humanized:

We must keep in mind that the mental statesperceived and the process of perception aresuffused with emotion; mentalizing is a form ofemotional knowing

A grammatical preference for the verb (or gerund)

emphasizes agency, activity, and process;

mentalizing is mental action; something we do

Aspiring to render mentalizing an everydayword rather than a technical concept


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New words

The word in language is half someone elses. It becomesones own only when the speaker populates it with his own

intention.many words stubbornly resist, others remain

alien, sound foreign in the mouth of the one whoappropriated them and who now speaks themLanguage ispopulatedoverpopulatedwith the intentions of others.

Expropriating it, forcing it to submit to ones own intentionsand accents, is a difficult and complicated process.

Wertsch: Mind as action


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Mentalizing emotion (mentalized affectivity)Mentalizing

transforming non-mental into mental

mentally elaborating primitively mental experience

Emotion includes much that is potentially non-mentalized

non-conscious cognitive appraisals physiological arousal

action tendencies and motoric activation

expressive motor behavior

Emotion (affect) is mentalized when felt

Mental elaboration includes understanding and attributing meaning to

feelings, which includes continuous conscious cognitive appraisalsand reappraisals


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Mentalizing in the midst of emotion

Mentalizing while remaining in the emotional state

1. identifying feelings

labeling basic emotions

awareness of conflicting emotions

attributing meaning to emotions (narrative)

2. modulating emotion

downward and upward

3. expressing emotion outwardly and inwardly


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Two impairments of mentalizing (besides misuse):too little or too much imaginativeness

concreteness,indifference,aversion

groundedimagination

imagination gonewild (paranoia)

nonmentalizing

distorted

mentalizingmentalizing

mindblindness excrementalizing


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Overlapping concepts (hairsplitting)

mindblindness:antithesis of mentalizing; employed originally tocharacterize autism

mindreading:applies to others and focuses on cognition

theory of mind:conceptual framework for mentalizing, focuses on

cognitive developmentmetacognition:focuses primarily on cognition in the self

decentering:observe ones thoughts/feelings as events in mind

reflective functioning:measurement of mentalizing in attachment context

mindfulness:focuses on present and not limited to mental states

empathy:focuses on others and emphasizes emotional states

emotional intelligence:pertains to mentalizing emotion in self and others

psychological mindedness:broadly defined, the disposition to mentalize

insight:mental content that is the product of the mentalizing process


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Mentalizing as an umbrella termFull range of mental states

Self and others

Implicit (intuitive) and explicit (deliberate) processes

Varying time framepresent

past

future

Varying scope

narrow (e.g., feeling at the moment)

broad (e.g., autobiographical narrative)


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Criticisms of mentalizing

Choi-Kain & Gunderson (Am J Psychiatry, in press)

The concept is broad and multidimensional

The core measure, the Reflective Functioning Scale, yields only a singlescore, is time-consuming and costly, and has limited research

Research should focus on more limited-domain concepts for which (primarilyself-report) measures have been developed (e.g., theory of mind,mindfulness, psychological mindedness, empathy, affect consciousness)

Semerari, Dimaggio et al., Metacognitive Assessment Scale

Separates self and others

Differentiates four facets

Identifying mental states

Differentiating subjective from objective (mental states as representational)

Relating mental states to each other and behavior

Integrating metacognitive knowledge into abstract narratives

Limitations of emphasizing process over content


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Mentalizing: links to other domains of knowledge

ATTACHMENT

EVOLUTIONARYBIOLOGY

PSYCHOANALYSIS

NEUROBIOLOGY

MENTALIZING

THEORY OF MIND

PHILOSOPHYphilosophy of mind

ethics


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Mentalizing: links to other domains of knowledge

ATTACHMENT

EVOLUTIONARYBIOLOGY

THEORY OF MIND

PHILOSOPHY

PSYCHOANALYSIS

NEUROBIOLOGY

MENTALIZING

philosophy of mind

ethics


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Part II

Attachment trauma and impaired mentalizing:

A focus for psychotherapy


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Trauma spectrum

nonhumanagent

attachmentfigure

human agent

impersonaltrauma

attachmenttrauma

interpersonaltrauma


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Attachment trauma: Two senses

Trauma that occurs in an attachmentrelationship, in childhood or adulthood

Trauma that adversely affects the capacityfor secure attachmentthe bane of thetherapeutic relationship


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Dual liability associated with attachmenttrauma in childhood (Fonagy & Target)

provokes extreme, repeated stress

undermines the developmentof the capacity toregulate distress

insecure (disorganized) attachment

impaired mentalizing capacity

impaired self-regulation


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Intergenerational transmission of mentalizing

A mothers capacity to hold in her own mind a representation ofher child as having feelings, desires, and intentions allows thechild to discover his own internal experience via his mothers

representation of it; this representation takes place in differentways at different stages of the childs development and of themother-child interaction. It is the mothers observations of themoment to moment changes in the childs mental state, and herrepresentation of these first in gesture and action, and later inwords and play, that is at the heart of sensitive caregiving, and is

crucial to the childs ultimately developing mentalizing capacitiesof his own [Slade, 2005]


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Intergenerational transmission of mentalizingmentalizing [is] the mechanism by which (1) the mother-childrelationship exerts its influence on the attachment security of thechild and (2) the mother-child relationship influences the childssocio-cognitive developmentsecure attachment is fostered through

accurate and appropriate parental mentalizing of the child, which inturn positively stimulates the development of the mentalizingcapacity of the child. As a result, the mentalizing child is able to forma secure attachment to the parentThe parents capacity to engagein accurate and appropriate mentalizing may be disrupted by avariety of child characteristics, most notably temperament. The

process by which secure attachment is fostered via accurate andappropriate parental mentalizing is therefore likely to bebidirectional. (Sharp & Fonagy, 2008, Social Development)


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High parental reflective functioning (mentalizing)

Sometimes she gets frustrated and angry (child mental state) inways Im not sure I understand (opacity of childs mental state). Shepoints to one thing and I hand it to her but it turns out that's not

really what she wanted (opacity). It feels very confusing to me(mother's mental state) when Im not sure how shes feeing (opacityof child's mental state) especially when shes upset. Sometimes shellwant to do something and I wont let her because its dangerous andso she'll get angry (mother recognizes diversity of mother and childmental states). (Slade, 2005)


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Model of intergenerational transmission and developmental psychopathology

psychosocialfunctioning

emotionregulation

childmentalizing

parental

mentalizing ofchild

childattachment

security

parental attachment

security

parental mentalizingin relation to

childhood attachment

adapted from Sharp & Fonagy(2008) Social Development


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Intergenerational transmission of trauma

Disturbed and abusive parents obliterate theirchildrens experience with their own rage, hatred,fear, and malevolence. The child (and his mental

states) is not seen for who he is, but in light of theparents projections and distortions. The infant

then takes on the parents hatred and aggression,a primitive form of identification with the aggressor

[Slade 2005]


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Trauma broadly construed

AFRAID

unbearableemotionalstates

+

ALONE

absence ofexperience of

being mentalized

feeling abandonedneglected, unloved,

invisible

IMPAIRED

MENTALIZINGCAPACITY

affectivedysregulationDBT:

invalidating environment BPD


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Mentalizing failure in traumatizing behavior

AFRAID

unbearable

emotionalstates

+

ALONEabsence of

experience ofbeing mentalized

feeling abandonedneglected, unloved,

invisible

IMPAIREDMENTALIZING

CAPACITY

mindblindterrorizing

traumatizer


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PTSD and psychic equivalence

psychicequivalence

mindrepresents

world

REEXPERIENCING

flashbacks &nightmares

mind=world

mentalizing

REMEMBERING

as painfulexperience


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The pretend mode: bullshitting

This is the crux of the distinction between [the bullshitter] and the liar.Both he and the liar represent themselves falsely as endeavouring tocommunicate the truth. The success of each depends upon deceiving usabout that. But the fact about himself that the liar hides is that he is

attempting to lead us away from a correct apprehension of reality; weare not to know that he wants us to believe something he supposes tobe false. The fact about himself that the bullshitter hides, on the otherhand, is that the truth-values of his statements are of no centralinterest to him; what we are not to understand is that his intention isneither to report the truth nor to conceal it. This does not mean that

his speech is anarchically impulsive, but that the motive guiding andcontrolling it is unconcerned with how the things about which he speakstruly are.

Frankfurt:On Bullshit


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An ironic mentalizing perspective on self-knowledge

There is nothing in theory, and certainly nothing in experience, tosupport the extraordinary judgment that it is the truth about himselfthat is easiest for a person to know. Facts about ourselves are not

peculiarly solid and resistant to skeptical dissolution. Our natures are,indeed, elusively insubstantial--notoriously less stable and less inherentthan the natures of other things. And insofar as this is the case,sincerity itself is bullshit.

Frankfurt:On Bullshit


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Applications to BPD

Persons with BPD often mentalize adequately but are highlyvulnerable to losing mentalizing, especially when attachmentneeds are activated in the context of insecure attachments (e.g.,distrust; threat of loss or betrayal)

frantic responses to perceived abandonment can be construed asposttraumatic reexperiencing of painful emotional states in thecontext of non-mentalizing attachment relationships

the core trauma in BPD might be the failure to develop robustmentalizing capacities stemming from relative deficiency ofmentalizing in early attachment relationships (with or withoutabuse)

this trauma is associated with impaired affect regulation and impaired

social cognition, especially in attachment contexts (i.e., whenattachment needs are evoked), including in psychotherapyrelationships, which have the potential to undermine mentalizing iftoo stimulating


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Mentalization-Based Therapy for BPDBateman & Fonagy,American Journal of Psychiatry, 2008

Effectiveness of MBT Day Hospital vs. Treatment as Usual 8-year follow-up (5 years post-termination of MBT)

23% versus 74% of patients made suicide attempts

fewer ER visits and hospital days; less medication use

13% versus 87% met criteria for BPD at end of follow-up

Significant differences in impulsivity and interpersonal functioning(including marked improvement in intense-unstable relationships andfrantic efforts to avoid abandonment)

three times longer periods of good vocational functioning


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Minding the Baby: Sadler, Slade, & Mayes

High-risk, first-time inner city parents and infants

Extends from pregnancy to childs second birthday

Nurse home visitation

Infant-parent psychotherapy

promote mothers mentalizing re: the self (e.g., verbalizing

feelings about pregnancy)

promote mothers mentalizing re: the infant (e.g., speaking

for the infant)


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Mentalization-Based Adolescent Treatment Program:

Efrain Bleiberg, Laurel Williams, Carla Sharp

Develop assessment and treatment for emergingpersonality disorder

Assessment

Diagnoses

Mentalizing capacity

Executive and cognitive functioning

Trauma history

Emotion regulation and risky behaviors

Family functioning (parenting style, attachment, mentalizing)


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Part III

Promoting an alliance through psychoeducation


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Psychoeducational Approach

Purposes promote a therapeutic alliance draw patients attention to a natural process

Curriculum understanding mentalizing and its development psychiatric disorders and mentalizing impairments

how treatment modalities promote mentalizing mentalizing exercises (projective, metaphors, role-playing, etc.)Incorporating mentalizing into other psychoeducational groups

Coping with trauma Coping with depression

Articles for patients and family members

Allen, Bleiberg, & Haslam-Hopwood (2003). Mentalizing as a compass for treatment.

Allen, Fonagy, Bateman (2008). What is mentalizing and why do it? (Appendix in Mentalizingin clinical practice)


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Broad scope of mentalizing

others

feelingsthoughts

self

empathy


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Holding mind in mind


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Holding mind in mind in emotional states


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Part IV

Cultivating mentalizing in psychotherapy:

Mentalizing begets mentalizing


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what good therapists do with their patients is analogousto what successful parents do with their children



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Mentalizing as the engine of attachment: Therapists

contribution (in caregiving role)

Fostering an attachment relationship; emotional proximity

Attentiveness to distress (empathy, attunement, responsiveness)

Marked emotional responsiveness: representing the patients emotion tothe patient rather than becoming fully immersed in it

Emotional self-awareness and self-regulation

Providing support, encouragement and help while appraising andrespecting the patients competence and autonomy

Questioning and challenging the patients perspective while providingalternative perspectives

Understanding how attachment patterns are reenacted from childhood toadulthood and in the transference with the caveat that process(mentalizing capacity) is emphasized over content (specific insights)

Note parallels to a secure base in supervision


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Core mentalizing competencies for therapists (and patients)

Affective competence (Diana Fosha)

How affect is handled relationally

The capacity to feel and deal while relating

Neither overwhelmed nor hostile to emotion in patient or self

Requires affect tolerance and affect regulation

Allows therapist to provide an affect-facilitating environment

Note: entails mentalized affectivity or mentalizing emotion

Narrative competence (Jeremy Holmes)

Psychological equivalent of immunological competence

Collaborative and coherent discourse (e.g., as in secure/autonomous AAInarratives)

Balancing prose and poetry, stories and images

Evident in story telling, story listening, story-understanding; story making andstory breaking


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Secure attachment is marked by coherent stories that convince andhang together, where detail and overall plot are congruent, andwhere the teller is not so detached that affect is absent, is notdissociated from the content of her story, nor is so overwhelmedthat her feelings flow formlessly into every crevice of the dialogue.

Insecure attachment, by contrast, is characterized either by storiesthat are over-elaborated and enmeshed, or by dismissive, poorlyfleshed-out accounts[there are] three prototypical pathologies ofnarrative capacity: clinging to rigid stories, being overwhelmed byunstoried experience, or being unable to find a narrative strongenough to contain traumatic pain.


Narrative competence


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Our Humanity: The art of mentalizing

Appeal to special abilities of analysts must not violate thefollowing principle: It must be possible to show that theclaimed capacities are refinements of ordinary humancapacities, and it must be made plausible why under specifiedcircumstances such refinement can actually occur. This can

be called the continuum principle, because it postulates thatthe abilities claimed for analysts must be on a continuumwith ordinary human abilities.

Carlo Strenger Between hermeneutics and science: An essay on theepistemology of psychoanalysis


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Mentalizing as the engine of attachment: patient

contribution to attachment relationships

Selection of attachment figures and appraisal of trustworthiness

Self-awareness regarding needs and feelings

Expression of emotional distress (affective competence) and context(narrative competence); associated emotion-regulation skills

Appraisal of the attachment figures receptiveness, attunement,responsiveness (i.e., the caregivers mentalizing)

Appraisal of the effectiveness of strategies to influence the caregiversresponsiveness

Ability to manage conflicts, understand misunderstandings, and repairruptures

Correcting and updating mental representations of self and others (internalworking models)

Reciprocating caregiving


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Mentalizing in maintaining an internalized secure base

Jeremy Holmes: the secure base can be seen not just as an eternal figure,but also as a representation of security within the individual psyche

Activating mental representations and memories of secure attachmentexperiences

Relating to oneself in an empathic manner, for example, protective,

encouraging, reassuring, accepting, compassionate, approving (mentalizingstance)

Engaging in comforting and self-soothing activities


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Parallel contributions to mentalizing: Meeting of minds in therapy

attachment & arousal


mentalizingdevelopmental

history

current

functioning

Patient

mentalizing

mentalizing

mentalizing



developmentalhistory

currentfunctioning

Therapist


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A patients perspective on Bowlby

John Bowlby: the role of the psychotherapist is toprovide the patient with a secure base from whichhe can explore the various unhappy and painfulaspects of his life, past and present, many of which

he finds it difficult or perhaps impossible to thinkabout and reconsider without a trusted companionto provide support, encouragement, sympathy,and, on occasion, guidance. [A Secure Base]

Jon Allen: The mind can be a scary place.

Patient: Yes, and you wouldnt want to go in therealone!


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The ability to think and talk about past pain is a protective factorleading to secure attachment, no matter how traumatic achildhood may have been. This inspiring finding is in itself an

endorsement of psychotherapy, on of whose main functions, it canbe argued, is to enhance reflective function [mentalizing].


Challenges: Simone Weil


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At the bottom of the heart of every human being, from earliest infancyuntil the tomb, there is something that goes on indomitably expecting,in the teeth of all experience of crimes committed, suffered, andwitnessed, that good and not evil will be done to him. It is this above allthat is sacred in every human being.

Affliction is by nature inarticulate. The afflicted silently beseech to be

given the words to express themselves. There are times when they aregiven none; but there are also times when they are given words, but ill-chosen ones, because those who choose them know nothing of theaffliction they would interpret.

Thought revolts from contemplating affliction, to the same degree that

living flesh recoils from death. A stag advancing voluntarily step by stepto offer itself to the teeth of a pack of hounds is about as probable as anact of attention directed towards a real affliction, which is close at hand,on the part of a mind which is free to avoid it.


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The Mentalizing Stance (mentalizing mindfully)

Psychological aspects inquisitive, curious, playful, open-minded

not knowing (cleverness as cardinal sin)

not creating the capacitybut rather promoting attentivenesstothe activity of mentalizing

Ethical aspects (as in parenting, for example) good will and compassion

acceptance and forgiveness

respect for autonomy

love


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Therapeutic paradox

activating attachment needs underminesmentalizing for patients with insecureattachment

psychotherapy activates attachment needs

patient must learn to mentalize in the context

of intense emotional states in attachmentrelationships

note contrast with mindfulness practice


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General tips on mentalizing in psychotherapy

You are doing it already

Cultivate alternative perspectives

Balance focus on self and others

Maintain an optimal level of emotional arousal

Challenge patients assumptions about your mental statesFocus on mental states in the here-and-now, in current

relationships and in the transference

Avoid attributing mental states to patients of which they areunaware; liable to be taken in as alien or rejected outright[extremely common in our setting with anger]

Use I statements


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Example of I Statements (Bateman & Fonagy)You are angry with me

versus

The way you are frowning makes me think that youmay be feeling angry about something and I amwondering what that may be about


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Mentalizing the transferencevalidating the patients experience of the patient-

therapist interaction

exploring the current patient-therapist relationship

accepting and exploring enactments, including thetherapists own contribution and the therapistsdistortions

collaborating in arriving at an understanding

presenting an alternative perspective

monitoring and exploring the patients reaction


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Transference work: transparency

The patient has to find himself in the mind of the therapist and, equally, the therapist has tounderstand himself in the mind of the patient if the two together are to develop a mentalizingprocess. Both have to experience a mind being changed by a mind (Bateman & Fonagy)

mentalizing as common-grounds for therapy - allen

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