Transcript Mentalizing in the Treatment of Borderline Personality

What is Mentalizing
and Why Do It?
Jon G. Allen, Ph.D.
The Menninger Clinic
Baylor College of Medicine
[email protected]
Collaboration
The Menninger Clinic
Baylor College of Medicine
Human Neuroimaging Laboratory at Baylor
Anna Freud Centre
University College London
Yale Child Study Center
Colleagues
 Peter Fonagy & Mary Target; Anthony Bateman
 Efrain Bleiberg, Pasco Fearon, George Gergely, Toby HaslamHopwood, Jeremy Holmes, Elliot Jurist, Linda Mayes, Richard
Munich, Lois Sadler, John Sargent, Carla Sharp, Arietta
Slade, Helen Stein, Stuart Twemlow, Laurel Williams
For further information
Allen JG, Bleiberg, E, Haslam-Hopwood, GTG
(2003). Mentalizing as a compass for
treatment. Menninger Clinic, Houston, TX.
Allen JG, Fonagy P, Bateman AW (2008).
What is mentalizing and why do it?
(Appendix to chapter on psychoeducation
in Mentalizing in Clinical Practice).
Overview
Defining mentalizing
Attachment and the development of mentalizing
Mentalizing impairments in psychiatric disorders
Promoting mentalizing in treatment
Part I
Defining mentalizing
Defining mentalizing
Quickies
• holding mind in mind
• attending to mental states in self and others
• mindfulness of mind
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)
Mentalizing versus “mentalization”
• the advantages of a verb, mentalizing as mental action
Origins of “Mentalize”
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)
A capsule history: Three waves of mentalizing
• autism conceptualized as a stable failure of
mentalizing based on neurobiological deficits
(“mindblindness”)
• borderline personality disorder conceptualized as
context-dependent failures of mentalizing (distrust,
anxiety, frustration in attachment relationships),
for which mentalization-based treatment was
developed
• mentalizing a core common factor in a wide range
of therapies (psychodynamic psychotherapy,
interpersonal psychotherapy, cognitive therapy);
educating patients and families accordingly
Broad scope of mentalizing
thoughts
feelings
self
others
empathy
Mentalizing implicitly versus explicitly
IMPLICIT
EXPLICIT
perceived
interpreted
nonconscious
conscious
nonverbal
verbal
unreflective
reflective
e.g., mirroring
e.g., explaining
Mentalizing as an umbrella term
Full range of mental states
Implicit and implicit processes
Self and others
Varying time frame
present
past
future
Varying scope
narrow (e.g., feeling at the moment)
broad (e.g., autobiographical narrative)
Complaint
“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
 Jeremy Holmes:
1. thinking about feelings
2. feeling about thinkings
 Holding heart and mind in heart and mind
Mentalizing 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
Holding mind in mind
Holding mind in mind in emotional states
Brain areas associated with mentalizing
Perceiving social and emotional cues
fusiform gyrus (identifying individuals, e.g., by face)
superior temporal sulcus (perceiving agency and intention)
temporal pole (interpreting social scenarios)
amygdala (detecting emotion, especially threat)
Resonating emotionally
mirror neurons (activated by performing and observing actions and
by feeling and observing emotions)
Mentalizing emotion and interpersonal interactions
medial prefrontal cortex
anterior cingulate cortex
“mentalizing region”
From mentalizing to defensive “fight-or-flight”
executive
complex
flexible
prefrontal
capacities
posteriorsubcortical
capacities
automatic
simple
habitual
switch point
low arousal
high arousal
Part II
Attachment and the development of mentalizing
Mentalizing: links to other domains of knowledge
THEORY OF MIND
EVOLUTIONARY
BIOLOGY
NEUROBIOLOGY
MENTALIZING
PSYCHOANALYSIS
ATTACHMENT
ethics
PHILOSOPHY
philosophy of mind
Mentalizing: links to other domains of knowledge
THEORY OF MIND
EVOLUTIONARY
BIOLOGY
NEUROBIOLOGY
MENTALIZING
PSYCHOANALYSIS
ATTACHMENT
ethics
PHILOSOPHY
philosophy of mind
Core functions of attachment
safe haven provides a feeling of security
(regulation of emotional distress)
secure base fosters exploration of the outer
world and the inner world, including
exploring the mind (mentalizing)
Intergenerational transmission: Overview
parental security of attachment ↔ parental mentalizing capacity
mind-minded interactions with infant
infant secure attachment (comfort seeking)
enhanced mentalizing capacity in childhood
Non-mentalizing begets non-mentalizing
intense emotional
distress
non-mentalizing
interactions
Part III
Mentalizing impairments and psychiatric disorders
Vicious circles
psychiatric
symptoms
Substance abuse
Depression
Anxiety
impaired
mentalizing
Trauma
Personality disorders
Resilience: from vicious to benign circles
psychiatric
symptoms
improved
mentalizing
impaired
mentalizing
improved
functioning
Vicious circles in deliberate self-harm
SELF
OTHER
abandonment
unbearable
emotional state
alarm &
anger
EXPRESSIVE FUNCTION
self-harm
tension relief
concern
Pushing the pause button: mentalizing
abandoned/stressed
unbearable emotional state
mentalizing
self-harm
bearable emotional state
constructive coping
Part IV
Promoting mentalizing in treatment
Developmental science informs mentalizing:
Therapists learning from parents
Conditions that promote mentalizing
secure attachment ‹—› mentalizing
Formulations of skillful mentalizing
Main: metacognitive monitoring
Fonagy: reflective functioning
Slade: mentalizing of the child
Meins: mind-minded commentary in interaction
The gist of psychotherapy
John Bowlby: the role of the psychotherapist is “to
provide the patient with a secure base from which
he can explore the various unhappy and painful
aspects of his life, past and present, many of which
he finds it difficult or perhaps impossible to think
about and reconsider without a trusted companion
to provide support, encouragement, sympathy,
and, on occasion, guidance.” [A Secure Base]
Jon Allen: “The mind can be a scary place.”
Patient: “Yes, and you wouldn’t want to go in there
alone!”
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
The Mentalizing Stance (attitude)




inquisitive, curious, playful, open-minded
“not knowing” (cleverness is a cardinal sin)
not creating the capacity but rather promoting
attentiveness to the activity of mentalizing
consistent with the relation between secure
attachment and mentalizing, advocating a spirit
of good will and compassion while
acknowledging that we also must mentalize in a
distrusting mode
Mentalizing Programs for borderline personality disorder:
Day Hospital Program (Bateman & Fonagy)
•
•
5 days/week; 18-36 months
individual, group, expressive therapies; 9 hours/week
Intensive Outpatient Program
•
•
once weekly individual & group therapy
18 months duration
Effectiveness (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
Parallel contributions to mentalizing: Meeting of minds
attachment & arousal
mentalizing
Patient
attachment & arousal
mentalizing
current
functioning
attachment & arousal
current
functioning
mentalizing
attachment & arousal
developmental
history
mentalizing
Family
developmental
history
Why mentalize?
Mentalizing enables us to determine whom we can
trust (and when we can relax mentalizing)
Mentalizing enables us to establish and maintain
secure attachment relationships through mutual
empathy (takes two)
Mentalizing entails self-awareness, which is essential
for self-compassion (empathizing with oneself) and
for regulating emotions (e.g., pushing the “pause
button”)