Being “Held in Mind”: Mentalizing and Psychotherapy

1. Being “Held in Mind”: Mentalizing and Psychotherapy Jon Hunter & Michael Cord Collaborative Mental Health Care Network February, 2010

2. “Other people, machines of independent mystery” “Mentalization enables children to ‘read’ people’s minds.”

3. The Sally Anne Test (theory of mind) Frith & Frith Science Vol. 286 26 nov. 1999

5. Development – secure parent Parent: • Appreciates type and intensity of emotional signal from the child • Conveys explanatory model for internal state • Conveys sense of (adult) containment or mastery about state (think about psychotherapeutic comments)

6. Development – secure parent Mature (parental) mentalization: Reflecting, containing, alleviating “You’re tired, aren’t you after such a long day, you need to nap, then you’ll feel better”

7. Development - insecure parent • “The mother unconsciously forces the child into the adaptive strategy which she finds most reassuring” (Fonagy) • “Infant’s pattern of relating reflects parent’s habitual pattern of dealing with the infant’s unpleasurable states” Parent works to decrease the distress signal, rather then its cause

8. Frequent maternal interactional errors with disorganized children (Vondra, Barnett) • Laughs when infant distressed • Uses friendly tone with threatening posture • Handles infant as if inanimate • Uses ‘haunted’ or frightened voice • Mocks or teases infant • Withholds or removes toy • Directs infant to do something, and then not to do it… “Frightening or frightened” parents

9. Clinical clues to good mentalizing capacity- • Represents self and others as thinking and feeling “I assume she must’ve felt angry because…”

10. Illustration 1: • Patient is reflecting on the way she feels when her boyfriend is preoccupied, distant and dismissive: “…I just want to be held in mind”

11. Clinical clues to good mentalizing capacity- • Sensitive to characteristics of mental states an appreciation of developmental phases, limited power of wishes…

12. Illustration 2: • Patient’s sister married to alcoholic abusive man • Turns to 18 year-old son for comfort and support • Patient is furious and tells sister: “you have to give him a stone to stand on”

13. Clinical clues to good mentalization capacity- • Sensitive to diversity of mental states amongst people appreciating how much needs to be told, what it’s emotional impact will be

14. Illustration 3: • Patient is able to work at 3 jobs, and is recognized as very helpful, reliable and capable. • When she needs help people rarely respond, and she ‘writes them off’ • She states: “They’re just supposed to know that when I ask I need it right away”

15. Clinical clues to good mentalization capacity- • Links mental states to observed behaviours ’teases out’ reasons for behaviour

16. Illustration 4: • 35 y.o. woman, long difficult history of BPD, AN&BN, cocaine abuse, depression. • Therapy x >10 years • Stopped at U.S. border and required to have form filled in by MD. • Long discussion in therapy…form not completed by therapist • Results in being barred from entry to U.S. • “you asshole, you wanted me to suffer”

17. Clinical clues to good mentalization capacity- • Appreciates possibility of change in mental states, and its relevance for change in behaviour “I feel this way now, but if that happens, who knows?” • Acknowledges difference between observed behaviour and internal state: “He acted unconcerned, but must’ve been nervous”

18. Illustration 5: • Young father recently widowed • 4 year old son refers to his 7 year old brother by their private ‘sibling’ name • Father uses that name in same conversation, despite ‘rule’ against it… because he knows that is the best reference in the young brother’s mind • Explains all, with humour, to elder son

19. Mentalization, Definitions: • “We mentalize when we treat others as people rather then objects” (Allan, pg.93) • “Knowing ourselves from the outside, and others from the inside” (Jeremy Holmes)

20. Using mentalization to guide intervention • Just as secure attachment is a necessary precondition for mentalization, so a secure ‘therapeutic’ base is required for the ‘exploration’ of psychotherapy …Help them find their mind, via your mind

21. Goals • “Making sense” • Promote mentalizing, not discovering a secret, or elucidating a symptom • Increase coherence: “A continuous me’ or “Autobiographical competence” (Holmes)

22. Techniques(think developmentally) • Promote safety • Focus on the here-and-now • Create an expectation about: 1) Observing… 2) Labelling… 3) Communicating … … internal states - affect, wishes, vulnerabilities

23. Techniques • “Mark” internal states –pay attention to your patient ! • ‘Wonder’ about intentions • “Small” interpretations, delivered at moments when mentalization is present- (vs. overarching comments about conflict, past events…)

24. Techniques • Increase clarity of representation of internal states • Vary object of mentalization: self, other, relationships • Increase coherence of narrative • Strengthen impulse control and self-regulation • Avoid ‘canned’ expressions of concern “learn to recognize what they say to themselves, the choices they make, in terms of ignoring or approaching others”

25. Techniques-the 2 things: Useful for understanding countertransference: • Who does this patient see me as ? or • Who does this patient think I see them as?

26. Formulation Automatic Behaviour Procedural Memory THREAT Mentalizing Choice

27. Case presentations ? “I was thinking about what a friend had said, I was hoping it was a lie”