Mentalizing as Common Ground for Psychotherapy: Educating Patients and Clinicians

1. Mentalizing as Common Ground for Psychotherapy:Educating Patients and Clinicians Jon G. Allen, Ph.D. The Menninger Clinic Baylor College of Medicine jallen@menninger.edu

2. Collaboration Colleagues • Peter Fonagy, Mary Target & Anthony Bateman; Efrain Bleiberg, Pasco Fearon, Toby Haslam-Hopwood, Elliot Jurist, George Gergely, Jeremy Holmes, Linda Mayes, Richard Munich, Lois Sadler, John Sargent, Carla Sharp, Arietta Slade, Helen Stein, Stuart Twemlow, Laurel Williams Consortium • University College London, Anna Freud Centre, Yale Child Study Center, The Menninger Clinic, Human Neuroimaging Laboratory at Baylor College of Medicine

3. 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 personality disorder: Mentalization-Based Treatment. New York: Oxford University Press. Bateman & Fonagy (2006). Mentalization-Based Treatment for borderline personality disorder: A practical guide. New York: Oxford University Press. Allen & Fonagy, Eds. (2006). Handbook of Mentalization-Based Treatment. Chichester, UK: John Wiley & Sons. Allen, Fonagy, & Bateman (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing.

4. Definitions of “mentalizing” mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior as conjoined with intentional 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

5. Part I Mentalizing as a common factor in psychotherapeutic treatment

6. 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 developmental psychopathology in 1989 (Fonagy) and extended to treatment of BPD (Bateman & Fonagy) Advocated as a common factor in psychotherapeutic treatment (Allen, Fonagy & Bateman)

7. Much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than those that distinguish them from each other. —Jerome Frank (1961): Persuasion and healing What is the therapeutic alliance if not an attachment bond? —Jeremy Holmes (2001): The search for the secure base

8. Mentalizing is the most fundamental common factor among psychotherapeutic treatments…perforce, clinicians mentalize in conducting psychotherapies and also engage their patients in doing so. —Allen, Fonagy, & Bateman, Mentalizing in Clinical Practice In advocating mentalization-based treatment we claim no innovation. On the contrary, mentalization-based treatment is the least novel therapeutic approach imaginable. —Allen & Fonagy, Handbook of Mentalization-Based Treatment mentalizing, even if not always explicit in our language, is implicit in many forms of psychotherapy…Allen and colleagues, of course, have already said this, when they suggest: “You’re already doing it.” And indeed we are, if we’re doing our job. —Oldham (2008), Epilogue to Mentalizing in Clinical Practice

9. Two broad questions What is distinctive about mentalizing? as a treatment approach? as a concept? What’s all the fuss about?

10. Plakun’s Y model: Generic and specific facets cognitive-behavioral psychodynamic formulation boundaries alliance empathic listening common factors

11. Plakun’s Y model: Generic and specific facets cognitive-behavioral psychodynamic mentalizing

12. Treatments for BPD Dialectical Behavior Therapy Mentalization-Based Therapy Transference-Focused Psychotherapy mentalizing relatively single-minded focus on mentalizing process: consistency; a style of psychotherapy Implication: extensive overlap between MBT and other treatment approaches to BPD

13. Mentalizing: Generic and specific facets Third-Generation Cognitive-Behavioral Therapies Mentalizing Focus in Psychotherapy metacognitive approaches Acceptance and Commitment Therapy (ACT) mindfulness practice mentalizing

14. The Menninger Clinic: Historical Context Long-term psychoanalytically oriented hospital treatment throughout most of its history in Topeka, Kansas Gradual reductions in hospital stays coupled with increasing array of partial-hospital and outpatient services Increasing theoretical eclecticism (e.g., CBT, DBT, psychoeducational approaches) Downsizing to specialty inpatient treatment programs with 4-8 week lengths of stay Relocation to Houston, Texas to partner with Baylor College of Medicine Jump-starting treatment for treatment-resistant patients

15. Developing the “common factor” approach to mentalizing at The Menninger Clinic Wide range of disorders beyond BPD: depression, anxiety, trauma, substance abuse, other PDs Professionals in Crisis program emphasizes mentalizing; initiated psychoeducational intervention Clinicians’ resistance to “mentalizing” sounds foreign already know it all Increasing desire for conceptual coherence in a psychotherapeutic culture (integrative function) Belatedly educating clinicians after educating patients Mentalization-Based Adolescent Treatment Program developed in consultation with Peter Fonagy, Mary Target, & Anthony Bateman

16. Complaints “Mentalization” has an intellectualizing and potentially dehumanizing ring to it and must be humanized: We must keep in mind that the mental states perceived and the process of perception are suffused with emotion; mentalizing is a form of emotional 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 everyday word rather than a technical concept

17. New words The word in language is half someone else’s. It becomes ‘one’s 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 who appropriated them and who now speaks them…Language is populated—overpopulated—with the intentions of others. Expropriating it, forcing it to submit to one’s own intentions and accents, is a difficult and complicated process. —Wertsch: Mind as action

18. 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 appraisals and reappraisals

19. 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

20. Two impairments of mentalizing (besides misuse):too little or too much imaginativeness distorted mentalizing nonmentalizing mentalizing concreteness, indifference, aversion grounded imagination imagination gone wild (paranoia) mindblindness excrementalizing

21. Overlapping concepts (hairsplitting) mindblindness: antithesis of mentalizing; employed originally to characterize autism mindreading: applies to others and focuses on cognition theory of mind: conceptual framework for mentalizing, focuses on cognitive development metacognition: focuses primarily on cognition in the self decentering: observe one’s 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

22. Mentalizing as an umbrella term Full range of mental states Self and others Implicit (intuitive) and explicit (deliberate) processes Varying time frame present past future Varying scope narrow (e.g., feeling at the moment) broad (e.g., autobiographical narrative)

23. 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 single score, is time-consuming and costly, and has limited research Research should focus on more limited-domain concepts for which (primarily self-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

24. Mentalizing: links to other domains of knowledge EVOLUTIONARY BIOLOGY MENTALIZING ATTACHMENT PSYCHOANALYSIS NEUROBIOLOGY THEORY OF MIND PHILOSOPHY ethics philosophy of mind

25. Mentalizing: links to other domains of knowledge EVOLUTIONARY BIOLOGY MENTALIZING attachment THEORY OF MIND PHILOSOPHY PSYCHOANALYSIS NEUROBIOLOGY ethics philosophy of mind

26. Part II Attachment trauma and impaired mentalizing: A focus for psychotherapy

27. impersonal trauma interpersonal trauma attachment trauma nonhuman agent attachment figure human agent Trauma spectrum

28. Attachment trauma: Two senses • Trauma that occurs in an attachment relationship, in childhood or adulthood • Trauma that adversely affects the capacity for secure attachment—the bane of the therapeutic relationship

29. Dual liability associated with attachment trauma in childhood (Fonagy & Target) • provokes extreme, repeated stress • undermines the development of the capacity to regulate distress • insecure (disorganized) attachment • impaired mentalizing capacity • impaired self-regulation

30. Intergenerational transmission of mentalizing A mother’s capacity to hold in her own mind a representation of her child as having feelings, desires, and intentions allows the child to discover his own internal experience via his mother’s representation of it; this representation takes place in different ways at different stages of the child’s development and of the mother-child interaction. It is the mother’s observations of the moment to moment changes in the child’s mental state, and her representation of these first in gesture and action, and later in words and play, that is at the heart of sensitive caregiving, and is crucial to the child’s ultimately developing mentalizing capacities of his own [Slade, 2005]

31. Intergenerational transmission of mentalizing mentalizing [is] the mechanism by which (1) the mother-child relationship exerts its influence on the attachment security of the child and (2) the mother-child relationship influences the child’s socio-cognitive development…secure attachment is fostered through accurate and appropriate parental mentalizing of the child, which in turn positively stimulates the development of the mentalizing capacity of the child. As a result, the mentalizing child is able to form a secure attachment to the parent…The parent’s capacity to engage in accurate and appropriate mentalizing may be disrupted by a variety of child characteristics, most notably temperament. The process by which secure attachment is fostered via accurate and appropriate parental mentalizing is therefore likely to be bidirectional. (Sharp & Fonagy, 2008, Social Development)

32. High parental reflective functioning (mentalizing) Sometimes she gets frustrated and angry (child mental state) in ways I’m not sure I understand (opacity of child’s mental state). She points 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 I’m not sure how she’s feeing (opacity of child's mental state) especially when she’s upset. Sometimes she’ll want to do something and I won’t let her because it’s dangerous and so she'll get angry (mother recognizes diversity of mother and child mental states). (Slade, 2005)

33. Model of intergenerational transmission and developmental psychopathology child attachment security parental attachment security parental mentalizing in relation to childhood attachment child mentalizing emotion regulation psychosocial functioning parental mentalizing of child adapted from Sharp & Fonagy (2008) Social Development

34. Intergenerational transmission of trauma Disturbed and abusive parents obliterate their children’s 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 the parents’ projections and distortions. The infant then takes on the parent’s hatred and aggression, a primitive form of identification with the aggressor [Slade 2005]

35. “Trauma” broadly construed DBT: affectivedysregulation invalidating environment ALONE absence of experience of being mentalized feeling abandoned neglected, unloved, invisible AFRAID unbearable emotional states IMPAIRED MENTALIZING CAPACITY + BPD

36. Mentalizing failure in traumatizing behavior traumatizer terrorizing mindblind ALONE absence of experience of being mentalized feeling abandoned neglected, unloved, invisible AFRAID unbearable emotional states IMPAIRED MENTALIZING CAPACITY +

37. Non-mentalizing modes of experience psychic equivalence: world=mind; mental representations are not distinguished from the external reality that they represent, such that mental states are experienced as real, as in dreams, flashbacks, and paranoid delusions. [clinical example: “dead”] pretend:mental states are separated from reality but maintain a sense of unreality inasmuch as they are not linked to or anchored in reality teleological: an action-oriented mode in which mental states such as needs and emotions are expressed in action; only actions and their tangible effects—not words—count. mentalized:actions are understood in conjunction with mental states (as contrasted to the teleological mode), and mental states have neither an exaggerated sense of reality nor unreality but rather are appreciated as representing multiple perspectives on reality (as contrasted with the psychic equivalence and pretend modes).

38. PTSD and psychic equivalence psychic equivalence mentalizing mind represents world mind=world REEXPERIENCING flashbacks & nightmares REMEMBERING as painful experience

39. 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 to communicate the truth. The success of each depends upon deceiving us about 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; we are not to know that he wants us to believe something he supposes to be false. The fact about himself that the bullshitter hides, on the other hand, is that the truth-values of his statements are of no central interest to him; what we are not to understand is that his intention is neither to report the truth nor to conceal it. This does not mean that his speech is anarchically impulsive, but that the motive guiding and controlling it is unconcerned with how the things about which he speaks truly are. Frankfurt:On Bullshit

40. An ironic mentalizing perspective on self-knowledge There is nothing in theory, and certainly nothing in experience, to support the extraordinary judgment that it is the truth about himself that 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 inherent than the natures of other things. And insofar as this is the case, sincerity itself is bullshit. Frankfurt:On Bullshit

41. Applications to BPD Persons with BPD often mentalize adequately but are highly vulnerable to losing mentalizing, especially when attachment needs are activated in the context of insecure attachments (e.g., distrust; threat of loss or betrayal) frantic responses to perceived abandonment can be construed as posttraumatic reexperiencing of painful emotional states in the context of non-mentalizing attachment relationships the core “trauma” in BPD might be the failure to develop robust mentalizing capacities stemming from relative deficiency of mentalizing in early attachment relationships (with or without abuse) this trauma is associated with impaired affect regulation and impaired social cognition, especially in attachment contexts (i.e., when attachment needs are evoked), including in psychotherapy relationships, which have the potential to undermine mentalizing if too stimulating

42. 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 and frantic efforts to avoid abandonment) three times longer periods of good vocational functioning

43. Minding the Baby: Sadler, Slade, & Mayes High-risk, first-time inner city parents and infants Extends from pregnancy to child’s second birthday Nurse home visitation Infant-parent psychotherapy promote mother’s mentalizing re: the self (e.g., verbalizing feelings about pregnancy) promote mother’s mentalizing re: the infant (e.g., speaking for the infant)

44. Mentalization-Based Adolescent Treatment Program:Efrain Bleiberg, Laurel Williams, Carla Sharp Develop assessment and treatment for emerging personality disorder Assessment Diagnoses Mentalizing capacity Executive and cognitive functioning Trauma history Emotion regulation and risky behaviors Family functioning (parenting style, attachment, mentalizing)

45. Part III Promoting an alliance through psychoeducation

46. 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 Mentalizing in clinical practice)

47. Broad scope of mentalizing thoughts feelings self others empathy

48. Holding mind in mind

49. Holding mind in mind in emotional states

50. Part IV Cultivating mentalizing in psychotherapy: Mentalizing begets mentalizing