Changing Minds 2: how does psychotherapy change your mind?

1. Changing Minds 2: how does psychotherapy change your mind? Professor Gwen Adshead

2. General over view • What is wrong with the minds of people in mental distress? • Common themes: The Self and Others • Disorders of thought and mentalisation • Therapies that change mentalising • Acknowledgements: Professor Peter Fonagy, Professor Anthony Bateman, Professor Jon Allen, Dr Jay Sarkar, Dr Martin Humphrey. • Morris Nitsun: therapist and artist

4. What’s wrong with people with mental distress? • Man is a social animal • Homo narrans: man is the story telling animal • To live with others in groups, people need to tell a coherent story of themselves • A story by which they recognise themselves across time • But which can change when the environment changes

5. To tell your story • You need to be able to organise your thoughts • You need to be able to regulate your feelings and the degree to which you get stressed and aroused • You need to be able to regulate the distance between yourself and others • You need to be able to think about your mind and the minds of others

6. What’s wrong with people with mental distress ? What can’t they do? • Arousal regulation and self-soothing • Negative Affect regulation • Regulation of distance and closeness in interpersonal relationships: (attachment disorders) • Experience an integrated sense of self • Disorders of embodiment • Reality testing deficits • Thinking errors: jumping to conclusions, bias • Dysfunctional time relationships • Defects of mentalisation: thinking about other people’s minds

7. 3 in 1 or ‘Triune’ Brain (Maclean 1990)

8. 1 BRAIN, 3 MINDS and ONE SELF COGNITION: Information as Knowledge Capacity for conceptual information processing, reason, meaning-making and decision making. EMOTION: Information as Subjective Feeling Capacity for experiencing, identifying and articulation of feeling and affect, which adds motivational colouring to somatic and cognitive processing. SOMATIC: Information as Behavioural Outputs Processing through the body that involves physiological experiences that are associated with impulses, movement, postural changes, orienting and defensive responses, and ANS arousal.

10. HOW DO OUR BODIES (AUTOMATIC BRAIN) DEFEND US ? Hyperaroused Sympathetic Danger Fight- Flight response Optimal Arousal Ventral vagal parasympathetic Safety “Social Engagement” Exploratory behaviour Freeze- submit Helplessness response Life threat Hypoaroused Dorsal vagal parasympathetic

11. Bottom-up processing

13. Defences and disorder • There is a problem (defect) with the brain function in terms of arousal, attention, reality testing, threat perception, pain management • There is a problem with the psychological responses (defence) to the defect: meaning-making; self-other interpretations, secondary defences against stress • Erratic behaviour in response to immature defence

14. So the problems lie… • In how we ‘see’ the world : ourselves and others in it • Appraisals and interpretations of stress, loss and danger: especially bodily experience • Responses to those interpretations: defences, memory, time and image • The story we tell of our situation • What change we envisage as solution

15. Secure attachment and the development of the R Brain

16. Development of mentalising • A function of the attachment relationship between parent and child • Secure attachment promotes reflective function i.e. thinking about one’s own state of mind • Which extends over time to being able to conceive of others’ states of mind; and be curious • The intentional stance: related to group safety: is this person a predator?

17. 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

18. The function of mentalising • To help regulate affects and arousal at times of stress • To help make and maintain social relationships in groups • To help support the coherence of Self narratives • “The story I tell now is not the story I told then”

19. Mentalising underpins the social mind • General self-other awareness and distinction • Empathy and perspective taking • Mindfulness • Theory of mind • The intentional stance: ‘reading’ other minds • Part of our mammalian heritage: is this person predator, prey or partner? • A neurobiological basis

20. Trauma disrupts reflective function • In childhood or in adulthood • Chronic fear experiences and/or failure of care • The experience of hostility from another and absence of soothing • Neglect in childhood • Begins antenatally: maternal stress affects gene expression in the neonate, which affects protein synthesis in stress regulation systems

21. Dysfunctional neural networks • Failure of top down regulation by orbito-frontal cortex (OFC) • Erratic function in the limbic system or hippocampal system • Disorganisation of neural networks linking OFC, amygdala and hippocampus via disruption of neurotransmitter function

22. If you can’t reflect… • You can’t see yourself • You can’t see others • You may become confused about what is real and what is not • You may be confused about where you and your body end and others begin How do you see the world with no eyes? I see it feelingly….

24. What could help? • Better affect and arousal regulation • Better understanding of stress and distress and how it affects us • Better awareness of Self and how I function and see the world • What am I not thinking about? • Could I change the way I see myself? Others? • Is there another way to think about this?

25. Professors Bateman & Fonagy

26. Mentalising Based Therapy • A conscious cognitive process of being aware of one’s own mind, and the minds of others • Based on attachment theory and evolutionary psychology: evidence of adaptive unconscious (Wilson, 2010) • Keeping mind in mind: appraisal of other’s intentions and experience • Implicit and explicit

27. Three impairments of mentalizing too little, too much, misuse distorted mentalizing nonmentalizing mentalizing concreteness, indifference, aversion grounded imagination imagination gone wild (paranoia) Mindblindness and predator mode hypermentalizing

29. Symptoms of mental disorders • Poor arousal regulation and embodiment: impulsivity, somatisation and acting out • Poor affect regulation: self-medication with substances, use of others to regulate mood • Poor interpersonal skills and mentalising: • alienate others, can’t use the social world, attacks on the social, oscillating attachment and rejection, attacks on vulnerability • Failure of reality testing : Intermittent psychotic states

30. So what happens in psychotherapy? • Restore or improve mentalising by • Challenging thinking errors and fixed dysfunctional beliefs • Reducing the tendency to act on distorted thoughts or feelings • Improving mood regulation and coping with painful emotions • Raising awareness of felt and thought experience and dysfunctional attachments • Changing time perspectives: what was then is not now

31. All Psychological therapies • Try to help people understand themselves better • Not avoid distress: reality testing • Help people understand how anxiety and distress distort thinking • And how negative thoughts drive mood • Reappraise fixed beliefs about themselves and others in relationships • Try to increase a sense of agency and hope

32. Problems • Psychotherapy takes time: weeks for minor problems, 18 months for complex problems • It may be painful and scary • It means trying something new • It may mean thinking something new • It takes trust in another person or persons • It can have unforeseen effects

34. Current therapies for mental distress • CBT ( individual and group) • DBT ( ditto) • MBT (Ditto) • SFT (ditto) • TFP • Mindfulness and ACT (either separately or part of DBT) • POT • OMG!

35. Do they work? • Evidence that psychological therapies change the brain • Like any new learning does • New information affects the way that neural-transmitters are released or processed at neural synapses • What you learn affects the way your brain works, which affects the way your mind works

37. What do they have in common? • They support enhanced mentalising either explicitly or implicitly • If effective, they promote enhanced sense of agency and decrease negative behaviours • Changing perspective or narrative • The therapist needs to be consistent, patient, empathic, attuned “I’m still the same person, I just think completely differently”

38. Attention to language • ‘I just have to pick up the pieces and go on’ ( you were in pieces) ‘After [she] died, I was shattered…. Completely shattered’

39. The therapist by Magritte

40. Blocks to therapy • Engagement and expectations • Ruptures in the alliance • Hostility, enmeshment and repetition of toxic attachments • Therapist’s feelings: conscious and unconscious, positive and negative • Therapist’s behaviours: payback, appeasement, rejection, helplessness

41. Engagement is important Failure to complete treatment is common (e.g. ranging from 30-50%). Failure to complete is associated with a worse outcome than if the individual had never been offered treatment. So need to improve engagement: patient readiness and therapist preparedness