Mentalization and attachment the implication for community based therapies

Editor's Notes

• #9: There is fairly general qgreement where mentalization is located in the brain.
• #12: The capacity to mentalize has also been argued to account for the other major difference between humans and other apes: (1) self awareness and self-consciousness as a path to simulation bringing with it social emotions such as embarrassment, shame and guilt; (2) the species specific striving to be more than a ‘beast’, to live beyond one’s body, to aspire to a spirit that transcends physical reality and step beyond one’s own existence; (3) the social origin of the self in the recognition of oneself in the mental state of the other as the root to a sense of selfhood (see Allen, Fonagy, & Bateman, 2008 for a more comprehensive review of the concept)
• #16: This Venn diagram maps the conceptual overlaps between mentalization and four related concepts including mindfulness, psychological mindedness, empathy, and affect consciousness, which are represented by the four circles. The lines which bifurcate the diagram according to its three dimensions (i.e., self-/other-oriented, implicit/explicit, and cognitive/affective) are dashed to illustrate the permeable and nonabsolute nature of these divisions. In the self/ other dimension, mindfulness focuses more on mental states within oneself, while empathy is primarily understood in terms of one’s imagination of mental states within others. Both affect consciousness and psychological mindedness concern both sides of the self and other distinction. While mindfulness and psychological mindedness emphasize both cognitive and affective aspects of mental states and function explicitly, affect consciousness and empathy relate more primarily to affective mental contents and function both explicity and implicity. Mentalization lies at the intersection of these concepts but the boundaries between them are not distinctly drawn.
• #20: Mentalization allows us to have common experiences – we need to coordinate our emotional experiences to function in large social groups. Imagine what would happen if we all felt differently about Lampard’s disallowed goal! Fortunately not the case.
• #21: Have to be able to step into the shoes of another person -
• #22: CAN DEVELOPMENTAL PSYCHOLOGUY RESEARCH HELP US GET CLOSER TO THE POTENTIAL SOCIAL EXPEREINCES THAT COULD SET OF THE EPIGENETIC CASCADE THAT Dr Moshe Szyf was describing to us yesterday? INTERSUBJECTIVE ORIGINS OF THE SELF
• #23: JUST HOW IMPORTANT CONTINGENT RESPONDING TO AFFECT IS WE KNOW FROM STILL FACE PARADIGM (GERGELY)
• #28: What is the control syste
• #33: There has been formidable resistance to envision the rich affective and mindful life that we now know infants do have from birth, probably for a considerable time prior to birth to the small person who cry when hungry or smile after a good feed. Psychoanalysts who dared attribute complex mental states to infants were ridiculed and pilloried (e.g. Glover, 1945). Half a century ago infants were commonly subjected to surgery without anesthetic (curare was used to stop squirming inconvenient for the surgeon)  Can infants have minds when they are no yet able to speak? Modern cognitive and affective neurosciences confirms Freud’s assumption that mental life was somatically grounded, the body being at the root meaning making. Neuroscience findings consistently suggest that higher order representational systems (abstract and metaphoric thought, social cognition) are reliant on bodily markers and simulation of how we perceive and experience our body in action (e.g. Barsalou, 2008; Gallese, 2007).
• #35: Logical structure of events in Experiment 1. ( A ) In all four conditions, the agent enters the scene, placing a ball on a table ( 13 ) (Movie S1). The ball then rolls behind an occluder. ( B ) In the agent’s presence, the ball stays behind the occluder (a and c), or leaves the scene (b and d). As a result, the agent (A) “believes” either that the ball is behind the occluder or that there is no ball behind the occluder. Then, the agent leaves the scene. ( C ) In the agent’s absence, the ball leaves the scene (c), returns behind the occluder (d), or does not move (a and b). Thus, the participant (P) either believes the ball to be behind the occluder (a and d), or to have left (b and c). ( D ) The agent reenters the scene, and the occluder is lowered. In half of the trials of all conditions, participants see the ball behind the occluder. We measure ball detection latencies as a function of (i) the participant’s belief (P+, ball behind occluder, versus P–, no ball behind occluder) and (ii) the agent’s “belief” (A+, ball behind occluder, versus A–, no ball behind occluder), resulting in two true belief conditions and two false belief conditions. The figure does not reflect the actual timing of the events. To control for the timing differences, we used pairs of conditions matched for their timing properties ( 13 ).
• #36: Results of Experiments 4 to 7. Looking times in 7-month-old infants. Bars represent average looking times, and error bars show SEM (see Fig. 1 for condition labels). (A) Results of Experiment 4 (true belief). Looking times for the condition when infants (and the agent) believed the ball to be behind the occluder (P+A+) and for the condition when neither the infants nor the agent believed the ball to be behind the occluder (P–A–). (B) Results of Experiment 5 (false belief; agent present in the last scene). Looking times for the condition when only the agent (falsely) believed the ball to be behind the occluder (P–A+) (Movie S1), and for the condition when neither they nor the agent believed the ball to be behind the occluder (P–A–) . (C) Results of Experiment 6 (no outcome control). Looking times for two conditions that were identical to the ones used in Experiment 4, except that the occluder was not lowered at the end of the movies. Thus, infants did not see whether the ball was present behind the occluder. As a result, there were no confirmed nor violated beliefs. (D) Results of Experiment 7 (false belief; agent absent in the last scene). Looking times for the two conditions where the agent was replaced with a pile of boxes in the very last scene (corresponding to Fig. 1D). We compared the condition where only the agent (falsely) believed the ball to be behind the occluder (P–A+) with the condition where neither the infants nor the agent believed the ball to be behind the occluder (P–A–). n analogy to Experiment 2, Experiment 7 asked whether infants would maintain others’ beliefs even in the agent’s absence. Specifically, infants were presented with the baseline condition (where both the infant and the agent believed that the ball was not there) and a condition where only the agent believed the ball to be behind the occluder. Before the occluder was lowered, however, a pile of boxes, rather than the agent, entered the scene. As in Experiment 5, infants looked longer than in the baseline condition when the agent (who was not present when the occluder was lowered) believed that the ball was behind the occluder [ F (1,13) = 6.75, P = 0.02] ( Fig. 3D ). Hence, like adults in Experiment 2, infants seem to compute others’ beliefs online and to maintain them even in the absence of the agent. Possibly, the boxes could have prompted participants to think of the agent and his beliefs, although there was no relation between the boxes and the agent. However, even if the boxes reminded participants the agent, our results can be explained only if participants computed the agent’s beliefs and sustained them even though the agent was not present. Together, our results suggest that the mere presence of social agents is sufficient to automatically trigger online belief computations not only in adults, but also in 7-month-old infants. Once the beliefs have been computed, adults and infants maintain them even in the absence of the agent, presumably for later use in social interactions. Hence, from 7 months on, an age by which infants attribute goals and intentionality ( 14 ), humans automatically compute other’s beliefs and seem to hold them in mind as alternative representations of the environment. As a result, at least in implicit tasks like ours, others’ (false) beliefs can influence infants’ and adults’ behavior similarly to their own (true) beliefs. The finding that others’ beliefs can be similarly accessible as our own beliefs might seem problematic for an individual, because it may make one’s behavior susceptible to others’ beliefs that do not reliably reflect the current state of affairs. However, the rapid availability of others’ beliefs might allow for efficient interactions in complex social groups. These powerful mechanisms for computing others’ beliefs might, therefore, be part of a core human-specific “social sense,” and one of the cognitive preconditions for the evolution of the uniquely elaborate social structure in humans.
• #55: Hyperactivation of attachment system may be core aspect of BPD 2c
• #56: Just how important contingencies are for all of us
• #58: Oxytocin is the VIAGRA of mentalization
• #59: Around in great quantity (breast feeding) when the infant needs it most – when it totally depends on being understood Oxytocin turns us towards the face to try to find the mind therein
• #61: Psychic equivalence : Mind-world isomorphism; mental reality = outer reality; internal has power of external  Fran Intolerance of alternative perspectives  ”YOU LOOKED AT YOUR WATCH” Pretend mode : Ideas form no bridge between inner and outer reality; mental world decoupled from external reality  FRAN “ dissociation” of thought, hyper-mentalizing or pseudo-mentalizing  ENDLESS HOURS OF ‘THERAPY’ Teleological stance : A focus on understanding actions in terms of their physical as opposed to mental constraints Cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other. Long version2 has some new slides in it
• #62: Long version2 has some new slides in it
• #63: NOT ALL PROTOCOLS HAVE THE SAME EVIDENCE BASE WE ARE UNDER NO ILLUSIONS ABOUT MBT AS AN EST
• #65: ONE MAY BE FORGIVEN FOR CONTEMPLATING IF ANY Treatment WITH A 3 LETTER ACRONYM HAS A CHANCE OF IMPROVING THE WELLBEING OF INDIVIDUALS WITH BPD All provide structure – Perhaps it is the structure that is crucial because allows people to think. If we just provide a structure that tells therapists what to do will we remove the effective component.
• #66: The brain is not organized into neural networks localized based on professional associations.
• #67: 2c
• #68: Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) Includes a model of pathology that is explained to the patient ( Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) Structure is manualized with adherence monitored Commitment to the approach Supervision to identify deviation from structure and support for adherence
• #69: Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) Includes a model of pathology that is explained to the patient ( Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) Structure is manualized with adherence monitored Commitment to the approach Supervision to identify deviation from structure and support for adherence
• #70: Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) Includes a model of pathology that is explained to the patient ( Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) Structure is manualized with adherence monitored Commitment to the approach Supervision to identify deviation from structure and support for adherence
• #72: Long version2 has some new slides in it
• #76: Long version2 has some new slides in it
• #79: Long version2 has some new slides in it
• #80: Long version2 has some new slides in it
• #81: Long version2 has some new slides in it
• #83: Thoughts are real and therefore they have to be controlled – Orwellian thought police There are singular solutions to social reality, there are no alternative ways of seeing things, there is intolerance to perspectives (concrete and egocentric – if I thought it it is real, no self questioning) Models of minds are simple (black and white), schematic and rigidly held (demonization and dehumanization) – distorted mentalizing ( Negative ideas (threats) become terrifying Long version2 has some new slides in it
• #84: People think and feel but this can have no consequence leading to an empty and meaninglessness social existence There is selfishness and extreme egocentrism emerging out of the unreality of anything other than one ’ s own thoughts and feelings Lack of reality of internal experience permits interpersonal aggression and deliberate harm because other minds are not felt to exist and the mind is no longer felt as contingent on continued existence of the physical self Frequently there is endless ‘ communication ’ and searching but it is destined to yield no change Long version2 has some new slides in it
• #85: A focus on understanding actions in terms of their physical as opposed to mental outcomes Only a modification in the realm of the physical is regarded as a true index of the intentions of the other. Only action that has physical impact is felt as potentially capable of altering mental state in both self and other Physical acts of harm Demand for acts of demonstration of intent by others Long version2 has some new slides in it
• #86: Long version2 has some new slides in it
• #87: C
• #92: Early in the play Othello is presented as a reasonable man who tries to calm his hot-headed fellows, asking them to think about the reasons for their impulsive behaviour when they get into a brawl. However, later on as Iago’s insinuations plant the seed of doubt about his wife Desdemona’s fidelity in his mind, his arousal level increases to the point where he leaps to conclusions about her thoughts and feelings without controlled explicit mentalizing)
• #93: Early in the play Othello criticises others for their inability to control their impulse
• #98: This Venn diagram maps the conceptual overlaps between mentalization and four related concepts including mindfulness, psychological mindedness, empathy, and affect consciousness, which are represented by the four circles. The lines which bifurcate the diagram according to its three dimensions (i.e., self-/other-oriented, implicit/explicit, and cognitive/affective) are dashed to illustrate the permeable and nonabsolute nature of these divisions. In the self/ other dimension, mindfulness focuses more on mental states within oneself, while empathy is primarily understood in terms of one’s imagination of mental states within others. Both affect consciousness and psychological mindedness concern both sides of the self and other distinction. While mindfulness and psychological mindedness emphasize both cognitive and affective aspects of mental states and function explicitly, affect consciousness and empathy relate more primarily to affective mental contents and function both explicity and implicity. Mentalization lies at the intersection of these concepts but the boundaries between them are not distinctly drawn.
• #99: SO What is the idea behind MBT?
• #100: Powerful activation of the attachment system is incompatible with meaningful (as opposed to ruminative) contemplation of mental states As attachment intensifies and arousal increases, mentalization switches from a primarily controlled, reflective, internally focused cognitively complex prefrontally guided process to an automatic, externally focused emotionally intense posterior cortically and sub-cortically driven one Emotional arousal in BPD  lose explicit mentalizing and become particularly attuned to the states of mind of individuals around them Able to perform experimental mentalizing tasks relatively well under low arousal (Arntz, Bernstein, Oorschot, Robson, & Schobre, 2006) Cannot explain the states of mind they experience under high arousal Show confusion about mental states as they are dominated by reflexive assumptions about the internal states of others psychotherapists of many orientations often aim to address and provide broader understandings for issues that trigger intense emotional reactions (challenging interpersonal situations, issues of shame, guilt, feelings of inadequacy etc). The demand for conscious reflection and explicit mentalization is inconsistent with the patient’s capacity to perform these tasks under high levels of arousal. This makes it particularly hard to change deeply ingrained implicit dispositional interpersonal ideas which rely on automatic and preconceived judgments of self and others.
• #107: Why is engaging the carergiver so important for the infant? Infant acquires affect regulation through close interaction with caregiver – comes to understand own emotional state Discovers himself through mirroring interactions
• #115: The TPJ is involved in perspective taking (Ruby & Decety, 2001, 2003, Aichhorn et al., 2006), in sense of agency (Farrer et al., 2002, 2003, Decety & Grezes, 2006) and mentalizing (Frith & Frith, 1999) The aFMC is involved in mentalizing (Frith & Frith, 1999, Firth & Frith, 2003, Amodio & Frith, 2006, Gilbert et al., 2006) and self-referential processing (Northoff and Bermpohl, 2004)
• #116: In fact, recent work by Brass’s group, using a within-subject experimental design with reflective mentalizing and imitation-inhibition tasks, suggests that there is a functional relationship between the inhibition of imitative behavior and the capacity for belief-desire reasoning (Brass et al., 2007). Thus it appears that the inhibition of imitative behavior involves cortical areas that are also related to mentalizing, self-referential processing and determining self agency. We assume that this overlap reflects common underlying processes such as self/other distinction and decoupling of self and other.
• #117: In fact, recent work by Brass’s group, using a within-subject experimental design with reflective mentalizing and imitation-inhibition tasks, suggests that there is a functional relationship between the inhibition of imitative behavior and the capacity for belief-desire reasoning (Brass et al., 2007). Thus it appears that the inhibition of imitative behavior involves cortical areas that are also related to mentalizing, self-referential processing and determining self agency. We assume that this overlap reflects common underlying processes such as self/other distinction and decoupling of self and other. the capacity to inhibit imitative behavior may be key to enabling us to generate a sense of ‘me’-ness through achieving a ‘not-other’-ness. In other words, each time we interpret the actions of another, there may be a sequence in which an initial imitative matching response with the other within a motor neuron self-other system interacts with the reflective mentalizing self-other system. Thus by necessity this involves an inhibition of the mirror system and reduces the extent of ‘primary identification’ with the other. Long version2 has some new slides in it
• #118: Thus,, we might extrapolate the hypothesis that the failure of medial prefrontal and temporo-parietal mentalizing function might leave the individual with difficulties in decoupling their representations of another person’s experience from their self-representations. Hence, if this is correct, patients with BPD feel vulnerable to loosing a sense of self in interpersonal interchange because they cannot adequately inhibit the alternative state of mind which is imposed on them through social contagion. Perhaps, then, the evident determination to ‘manipulate and control’ the mind of others that is so characteristic of BPD patients should be best seen as a defensive reaction, defending the integrity of the self within attachment contexts. Otherwise, without such control, they might feel excessively vulnerable to loosing their sense of separateness and individuality. Long version2 has some new slides in it
• #125: Consistent findings show that the stronger the alliance the greater the therapeutic change (eg Horvath & Bedi 2002; Orlinsky et al 2004) Therapeutic alliance is therefore often posited as a mediator and mechanism of therapeutic change Studies evaluating alliance during treatment often show that alliance predicts improvement in symptoms at end of treatment However, this in itself does not show that alliance plays a causal or mediational role
• #126: Subjects are asked to watch a 15-minute film about four characters getting together for a dinner party. Themes of each segment cover friendship and dating issues. Each character experiences different situations through the course of the film that elicit emotions and mental states such as anger, affection, gratefulness, jealousy, fear, ambition, embarrassment, or disgust. The relationships between the characters vary in the amount of intimacy (friends – strangers) and thus represent different social reference systems on which mental state inferences have to be made. During administration of the task, the film is stopped at 45 points during the plot and questions referring to the characters' mental states (feelings, thoughts, and intentions) are asked (e.g., “What is Betty feeling?”, “What is Cliff thinking?”). Participants are provided with four responses options: (i) a hypermentalizing response, (ii) an undermentalizing response, a (iii) no mentalizing response and a (iv) accurate mentalizing response. To derive a summary score of each of the subscales, points are simply added, so that, for instance, a subject who chose mostly hypermentalizing response options would have a high hypermentalizing score. Similarly, participants' correct responses are scored as one point and added. To calculate an overall mentalizing score, mentalizing errors are subtracted from accurate mentalizing, such that for the overall score, a higher score indicates accurate mentalizing. The MASC is a reliable instrument that has proven sensitive in detecting subtle mindreading difficulties in adults of normal IQ41, young adults63, as well as patients with bipolar disorder42, and autism64
• #128: Borderline Personality Features Scale for Children (BPFSC). The Difficulties in Emotion Regulation Strategies Scale (DERS). The DERS59 provides a comprehensive assessment of difficulties in ER, including awareness and understanding of emotions, acceptance of emotions, the ability to engage in goal-directed behavior and refrain from impulsive behavior when experiencing negative emotions, as well as the flexible use of situationally appropriate strategies to modulate emotional responses. It consists of 36 items that are scored on a 5 point Likert scale, ranging from 1 ( ‘almost never (0-10%)’ ) to 5 ( ‘almost always (91-100%)’ ). A higher total score indicates greater emotion dysregulation. The highest possible total score is 180. The measure has demonstrated adequate construct and predictive validity and good test-retest reliability in undergraduate students59, and was recently validated in a community sample of adolescents71. The DERS has been used previously in inpatient adolescent samples72, 73. In the present sample, internal consistency of this measure was good with a Cronbach’s alpha of .86.