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Why important?
Figure 2.x Understanding BPD in terms of the suppression of mentalization
Pretend Mode
Psychic Equivalence
Teleological Mode
Pseudo Mentalisation
Concrete Understanding
Misuse of Mentalisation
Unstable Interpersonal Relationships Affective Dysregulation Impulsive Acts of Violence, Suicide, Self-Harm Psychotic Symptoms
Overview
Theoretical considerations Clinical assessment of mentalizing: the mentalizing profile Structured assessment of mentalizing Therapeutic implications
Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). The assessment of mentalization. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (pp. 43-65). Washington, DC: American Psychiatric Association.
Team
Psychoanalysis Unit London (UK): Peter Fonagy, Anthony Bateman, Mary Target UPC Kortenberg (Belgi): Rudi Vermote, Benedicte Lowyck, Yannic Verhaest, Bart Vandeneede Yale University (USA): Sidney J. Blatt, Linda Mayes, Helena Rutherford, Michael Crowley Psychoanalysis Unit Leuven: Nicole Vliegen, Liesbet Nijssens, Naouma Siouta, Tamara Ruijten University of Durham (UK): Elizabeth Meins Viersprong & MBT consortium The Netherlands
Some Theory
What is mentalizing?
Mentalizing is a form of imaginative mental activity about others or oneself, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).
What is mentalization?
It is a capacity we use all the time It is what we need:
To collaborate To compete To teach To learn To know who we are To understand each other and ourselves
Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355-1381.
Dimensions of mentalization: implicit/automatic vs explicit/controlled Psychological understanding drops and is rapidly replaced by confusion about mental states under high arousal
That handkerchief which I so loved and gave thee Thou gavest to Cassio. By heaven, I saw my handkerchief in's hand.
Controlled
Automatic
Arousal
Psychotherapists demand to explore issues that trigger intense emotional reactions involving conscious reflection and explicit mentalization are inconsistent with the patients ability to perform these tasks when arousal is high
Arousal
That handkerchief which I so loved and gave thee ThouLateral gavest to Cassio. Amygdala PFC temporal Lateral PFC Medial Ventromedial PFCin's hand. By heaven, I saw my handkerchief
cortex
Controlled
Automatic
Arousal
With selective loss of sense of mental interiors, external features are given inappropriate weight and misinterpreted as indicating dispositional states
Emotion
Self affect state propositions
Mentalize This!
Ik denk niet dat het makkelijk zal worden, maar we komen er wel! Maar ja, zonder mij zal het toch niet lukken
With diminution of cognitive mentalization the logic of emotional mentalization (self-affect state proposition) comes to be inappropriately extended to cognitions.
Mentalize This!
Mijn vader heeft altijd gezegd dat ik niets kon
Ik voel me zo rot
BPD
BPD
Assessment of Mentalization
Why important?
Figure 2.x Understanding BPD in terms of the suppression of mentalization
Pretend Mode
Psychic Equivalence
Teleological Mode
Pseudo Mentalisation
Concrete Understanding
Misuse of Mentalisation
Unstable Interpersonal Relationships Affective Dysregulation Impulsive Acts of Violence, Suicide, Self-Harm Psychotic Symptoms
Demand questions explicitly probing for mentalization Exploring mentalizing in specific relationships and high arousal contexts Exploring mentalization with regard to symptoms and complaints Attention to interpersonal process: selfcorrecting tendency of Mz and ability to allow the clinician to correct mentalizing lapses
General Strategy
Assess general mentalizing abilities Assess specific mentalizing abilities: Mentalizing profile based on polarities Non-mentalizing modes Individual differences in attachment Allows to predict what is likely to happen in treatment Tailoring of interventions
why did your parents behave as they did during your childhood? do you think your childhood experiences have an influence on who you are today? did you ever feel rejected as a child? in relation to losses, abuse or other trauma, how did you feel at the time and how have your feelings changed over time? have there been changes in your relationship with your parents since childhood?
Understanding own actions (actual past and reflection on past) Counter-factual follow-up questions
Interpersonal interaction
Last night Rachel and I had an argument about whether I was doing enough around the house. She thought I didnt do as much as her and I should do more. I said I did as much as my work obligations allow. Rachel got angry and we stopped talking to each other. In the end I agreed to do the shopping from now on. But I ended up feeling furious with her
Self-presentation (e.g. autobiographical continuity vs. identity diffusion) General values and attitudes (e.g. tentativeness and moderation)
Anti-reflective hostility active evasion non-verbal reactions Failure of adequate elaboration Complete lack of integration Complete lack of explanation Inappropriate Complete non-sequiturs Gross assumptions about the interviewer Literal meaning of words
Assessment of mentalization
Distinguish four main types of problems - not mutually exclusive; more than one may apply to the same person
Concrete understanding
o Generalised lack of mentalising
Context-specific non-mentalising
o Non-mentalising is variable and occurs in particular contexts
Pseudo-mentalising
o Looks like mentalising but missing essential features
Misuse of mentalising
o Others minds understood and thought about, but used to hurt, manipulate, control or undermine
Concrete understanding
General failure to appreciate feelings of self or others as well as the relationships between thoughts, feelings and actions General lack of attention to the thoughts, feelings and wishes of others and an interpretation of behaviour (own or others) in terms of the influence of situational or physical constraints rather than feelings and thoughts May vary markedly in degree
Pseudo-mentalising subtypes
Intrusive mentalising
Opaqueness of mental states not respected Thoughts and feelings talked about, may be relatively plausible and roughly accurate, but assumed without qualification
Overactive-inaccurate mentalising
Lots of effort made, preoccupation with mental states Off-the-mark and un-inquisitive
Destructively inaccurate
Denial of objective reality, highly psychologically implausible mental states inferred
Understanding of the mental state of the individual is not directly impaired yet the way in which it is used is detrimental
May be unconscious but is assumed to be motivated Self-serving distortion of the others feelings Self-serving empathic understanding A persons feelings are exaggerated or distorted in the service of someone elses agenda
Misuse of Mentalizing(2)
Non-mentalizing modes
Teleological mode Psychic equivalence mode Extreme pretend mode
Teleological mode
Behavior and thought/intentions are equated Primacy of the physical/observable I only believe you when I see it
Extra sessions Need for physical contact Yawning means you are bored of me Going on holiday means you want to get rid of me Only what you see is real
Gergely, G., & Csibra, G. (2003). Teleological reasoning in infancy: The naive theory of rational action. Trends in Cognitive Sciences, 7, 287-292.
Psychic equivalence
What is thought is real Everything becomes too real (e.g., thoughts, feelings, lying on the couch) Decoupling of Mz or de-symbolization (concreteness of thought): Rejection literally hurts (Eisenberger et al., 2003) Very painful feelings of shame, sadness, emptiness, badness, which threaten to disintegrate the self -> evacuation by means of projection, dissociation, self-harm
Attachment figure
Attachment figure
Through coercive, controlling behavior the individual with disorganized attachment history achieves a measure of coherence within the self representation
Individual Differences
A biobehavioral switch model of the relationship between stress and controlled versus automatic mentalization
Attachment - Arousal/Stress
Autonomous [secure]
coherent: undefended access to consistent memories and judgments believable value attachment and acknowledge impact
Dismissing [avoidant]
cant remember / idealise / devalue
Preoccupied [resistant]
entangled in angry / passive / fearful associations
Attachment security
High threshold for switching under stress Fast recovery Ability for simultaneous activation of ATT system and Mz system Associated with effective affect/stress regulation Leads to so-called broaden and build cycles associated with attachment security (Frederickson, 2001)
o Security of internal mental exploration, even under stress o Ability to ask others for help = relationship-recruiting
Attachment hyperactivation
Lowered threshold for attachment activation and thus switch Longer time to recovery May explain typical pattern of
o Fast attachment to others o But to unreliable others because of deactivation of controlled mentalization o Hypervigilance to emotional states in others o Hypo-hypermentalization cycles (overly trustingoverly distrusting) o Through negative feedback: increasing hyperactivation of the ATT system and lowered threshold for decoupling of Mz
Activation of attachment
Proximity seeking
*Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the psychodynamic approach to personality. Journal of Research in Personality, 39, 22-45.
Disorganized attachment
Particularly maladaptive mix of hyperactivating and deactivating strategies Leading to hypermentalizationhypomentalization cycles
Strength of automatic response Moderate Strong Weak, but moderate to strong under increasing stress Strong
High Low: Hyperresponsivity Relatively high: Hyporesponsive, but failure under increasing stress Incoherent: hyperresponsive, but often frantic attempts to downregulate
Disorganized
Slow
BPD
BPD
Ordinary/Aver age
Internal
External Legend:
Self
Other
Cognitive
Affective
= Typical mentalizing profile for Borderline Personality Disorder = Typical mentalizing profile for Narcissistic Personality Disorder
Appearance Inference
Selective Trust!
Approaches to measure Mz
Limitations:
Time and cost-intensive Mostly uni-dimensional
Score on RF Scale
Description
Full or Exceptional Interviewees answers show exceptional sophistication, are surprising, quite complex or elaborate and consistently manifest reasoning in a causal way using mental states Marked Numerous statements indicating full RF, which show awareness of the nature of mental states, and explicit attempts at teasing out mental states underlying behaviour Definite or Ordinary Interviewee shows a number of instances of reflective functioning even if prompted by the interviewer rather than emerging spontaneously from the interviewee Questionable or Low Some evidence of consideration of mental states throughout the interview, albeit at a fairly rudimentary level
Moderate to high RF
Negative to limited RF
Absent but not Repudiated Reflective functioning is totally or almost totally absent Negative Interviewee systematically resists taking a reflective stance throughout the interview
-1
Yet:
remains time/cost-intensive Remains off-line measure <---> on-line
Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). The assessment of mentalization. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (pp. 43-65). Washington, DC: American Psychiatric Association.