Twilight Meeting of ACAMH
London and South-East
“Interpreting the Dodo Bird:
Speculations about a mechanism of
disease and the mechanism of cure”
Peter Fonagy
The Anna Freud Centre
P.Fonagy@UCL.AC.Uk
With collabora,on of Patrick Luyten and Liz Allison Boas,ng about mentalizing (but only briefly) • Tradi,onal common factors • Common principles • Cross modality predictors Some of the Mentalizing Mafia •  UCL/AFC/Tavistock Ø  Dr Liz Allison
Prof George Gergely
Professor Pasco Fearon
Professor Mary Target
Prof Anthony Bateman
Ø  Professor Alessandra Lemma
Ø  Professor Eia Asen
Ø  Dr Trudie Rossouw
•  University of Leuven & UCL/AFC Dr Patrick Luyten
Ø  Dr Dickon Bevington
Some more mafiosi (The USA branch) •  Menninger Clinic/Baylor Medical College (The USA branch) Ø  Dr Jon Allen
Ø  Dr Carla Sharp
Ø  Dr Lane Strathearn
Ø  Dr Efrain Bleiberg
Ø  Dr Brooks King-Casas
Ø  Professor Flynn O’Malley
Ø  Dr Read Montague
Ø  Dr Elisabeth Newlin
•  Yale Child Study Centre Ø  Prof Linda Mayes
Ø  Professor Nancy Suchman
And European recruits to the ‘Family” Ø  Dawn Bales
Ø  Professor Finn Skårderud
Ø  Dr Mirjam Kalland
Ø  Professor Sigmund Karterud
• Cindy Decoste
• Catherine Freeman
• Ulla Kahn
• Morten Kjolbe
• Benedicte Lowyck
• Tobi Nolte
• Marjukka Pajulo
• Svenja Taubner
• Bart Vandeneede
• Annelies Verheught-Pleiter
• Rudi Vermote
• Joleien Zevalkink
• Bjorn Philips
• Dr Peter Fuggle
Clear evidence of a conflict of interest JUST RELEASED!
NEW!
IMPROVED!
Washes brains
whiter!
American Psychiatric Publishing, Inc 2012
Longer than all
previous
versions!
What is mentalizing? Mentalizing is a form of imagina&ve mental ac,vity about others or oneself, namely, perceiving, experiencing and interpre,ng human behaviour in terms of inten&onal mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons). Mentaliza,on and Overlapping Constructs (Choi-­‐Kain & Gunderson, Am J Psychiat 2008) Cognitive Behaviourism: The value
of understanding the relationship
between my thoughts and feelings
and my behaviour.
BRAIN
COMMON
Systems Theory: The value of
understanding the relationship
between the thoughts and feelings
of family members and their
behaviours, and the impact of these
on each other.
Mentalizing
as integrative
framework
explains
change???
Psychodynamic: The value of
understanding the nature of resistance
to therapy, and the dynamics
here-and-now in the therapeutic
relationship.
MIND
LANGUAGE
BIOLOGICAL, SOCIAL and
ECOLOGICAL: The value
of understanding the impact of
context upon mental states: development,
deprivation, opportunity, hunger, fear...
With thanks to Dr Dickon Bevington
Measuring MentalizaEon (Baron-­‐Cohen et al., 2001) Reading the Mind in the Eyes Test Surprised-A
Joking-C
Sure about something-B
Happy-D
Mentalizing at the World Cup: How does Robert Green feel aZer le[ng in the USA goal? Upset
Disappointed
Angry
Frustrated
Shared neural circuits for mentalizing about the self and others (Lombardo et al., 2009; J. Cog. Neurosc.) Self mental state
Other mental state
Overlapping for
Self and Other
You will never
amount to anything
if you hold a ball
like that!
I want to write my
PhD on the “Use
of low signal-tonoise ratio stimuli
for highlighting
the functional
differences
between the two
cerebral
hemispheres”.
Let the boy
dream Ivan,
He is a born
dilettante!
You look smug
now but you
will lose your
hair just like
Dad
The DoDo Bird flying in psychotherapy •  Can’t show differences too easily •  If therapies worked the way indicated some should work beber than others The “Dodo Bird Verdict” §  Since 1975, meta-­‐analyses show no superiority of any bona fide psychotherapy §  Change does not depend on specific techniques §  Common factors are the main influencers on change APA, 2012; Zuroff et al., 2010; Lutz et al., 2007
The “Dodo Bird Verdict” Comparison of bona-fide treatments
META-ANALYSES
All bona fide treatments are equally
efficacious for the intervention in
alcoholism
(pooled effect sizes after randomly assigning negative values = 0)
All bona fide treatments are equally
efficacious for the intervention in PTSD
(pooled effect sizes after randomly assigning negative values = 0)
All bona fide treatments are equally
efficacious for children and adolescents
with depression, anxiety, conduct
disorder and ADHD
(pooled effect sizes after randomly assigning negative values = 0)
Benish et al, 2008; Imel et al., 2008; Miller et al., 2008; Spielmans et al., 2007
Driesen et al., (2013), AJP Screen
N=4866
Baseline 570
CBT
N=164
PDT
N=164
Lost 42%
Lost 45%
ITT analysis
ITT analysis
CBT vs. Psychodynamic Psychotherapy for Major Depression (N=341) §  CBT Ø  16 individual sessions Ø  Manualised (Molenaar et al., 2009) Ø  N= 164 §  Psychodynamic Therapy
Ø  16 individual sesisons
Ø  Manualised (de Jonhge, 2005)
Ø  N=177
Driesen et al., 2012
Outpa,ents with anorexia nervosa (ANTOP) study Lancet, 2013 PDT
N=80
Lost 28%
TAU
N=82
CBT
N=80
Lost 18%
Lost 44%
Outpatients with anorexia nervosa
Lancet,
Body w(ANTOP)
eight astudy
nd end of t2013
reatment, 3-­‐months and 12-­‐months follow-­‐up Social Anxiety: CBT vs PPT Leichsenring et al., 2013 AJP CBT
PDT
W/L
36%
26%
9%
60%
52%
15%
Remission
Response
The “Dodo Bird Verdict” §  In August 2012, the American Psychological Associa,on approves: “RecogniEon of …a variety of psychotherapies are effective with
Psychotherapy children,
adults, and older adults
…different forms of psychotherapy typically
produce relatively similar outcomes
EffecEveness” … comparisons of different forms of
psychotherapy most often result in relatively
nonsignificant difference
(1)  most valid and structured
psychotherapies are roughly equivalent
in effectiveness and
(2)  patient and therapist characteristics,
which are not usually captured by a
…variations in outcome are more heavily influenced patient's diagnosis or by the therapist's
use of a specific psychotherapy,
by patient characteristics e.g., chronicity,
complexity, social support, and intensity—and by affect the results
clinician and context factors than by particular
diagnoses or specific treatment "brands”
APA, 2012
“Common factors” research in psychotherapy • Tradi,onal common factors • Common principles • Cross modality predictors What happens when you ask a room of psychotherapists whose approach is the most effec,ve? OK. What time will you be home tomorrow??
What can be done to end this unseemly behaviour? 2
4
The Paradigma,c Common Factor •  Centrality of the therapeuEc relaEonship –  establishment of a strong working alliance, •  My therapist and I have figured out a good way to work on my sad or angry emo,ons. •  My therapist and I work well together on things that bother or upset me –  therapist capacity for understanding •  My therapist really understands what bothers or upsets me •  I feel uncomfortable talking about my thoughts and feelings with my therapist –  feeling supported and cared about •  I don’t get much support from my therapist (reversed) •  I feel like my therapist is on my side and tries to help me –  agreement between pa,ent and therapist on treatment goals. •  I use my 5me with my therapist to make changes in my thoughts and behavior •  I would rather not work on my problems or issues with my therapist The working alliance controversy Castonguay et al. (1996) Depressed pa,ents treated with CBT took
measures of:
•  level of alliance
•  therapist focus on distorted thinking
•  alliance significantly associated with outcome
•  greater focus on distorted thinking associated
with poorer outcomes
•  effect disappears if alliance levels controlled
for
Therapeu,c Alliance Predicts Symptom Improvement Session by Session Falkenström et al., (2013) Journal of Counseling Psychology
A sample of 646 patients (76% women, 24% men) in primary care psychotherapy
Administered the Working Alliance Inventory and CORE session by session,
Reciprocal Influence of Alliance to the Group and Outcome in Day Treatment for Ea,ng Disorders Tasca & Lampard (2012) Journal of Counseling Psychology 59, 507–517
SO WHY DOES IMPROVED ALLIANCE IN SESSIONt-1
LEAD TO IMPROVEMENT IN SESSIONt?
Understanding benefit from working alliance •  Is it to do with learning about oneself? – Most unlikely because improvement occurs between end of session and beginning of next session •  So what is it about working alliance that actually improves the paEent? – a bizarre delayed reverse causality? – a`achment mediated – but through what process? – opening up a social learning process that benefits the pa,ent between sessions Can we do any beber than agreeing with the Do Do Bird? “Everybody has won, and all must have prizes.” 3
0
The DoDo bird sounds like a pigeon
If we can’t do better than say everything works than my career as a
treatment developer is over and I might as well turn into a DoDo bird!
3
1
Oh dear! “So the paradigmaEc common factor is…” 3
2
The paradigma,c common factor is… “Uh-­‐oh…here we go again…” 3
3
All together now…mentalizing!!! Mentalize!
3
4
OhHonestly,
come on how
Fonagy…for
do you
goodness
think your
sake
audience
practice
is
what feeling?
you preach!
3
5
How do you think your audience might be feeling right now? Bored
Is it
tea-time yet?
Sleepy
Fonagy should
write a new talk
3
6
Listening to an account of mentalizing as the effec,ve component of all therapies for BPD OK, now back to the drawing board! 3
8
The Transmission of Culture and Why Therapy Works • How do we know who to learn from? • How does trust relate to abachment? • How do you get people to trust you? • Why does trust make a difference? Ins,ncts in explana,ons of psychopathology (Gergely, in press) •  Historically three a`empts to ground the assump,ons of clinical causa,on to ins,nct •  Three major human insEncts have been the focus of explana,ons of development and its distor,on in psychological disorder – 1. The psychosexual AND agression ins,nct – Freud and classical psychoanalysis – 2. The ins,nct for a`achment – Bowlby, Ainsworth and early infant researchers – 3. The ins,nct for communicaEon – Gergely, Tronick and modern infant research The ascent of homo sapiens Species-­‐specific ways to acquire beliefs •  We can accept a culturally transmibed belief for two reasons (Sperber, 1997, 2001, Sperber et al., 2010) –  its content –  the authority of its source •  To accept because of content –  grasp its deducEve rela,ons to the contents of other beliefs –  inducEve rela,ons to the evidence, in accordance with the principles of theoreEcal raEonality. •  To accept on account of the authority (‘deferen&ally’ transmibed, Recana,, 1997) –  its source is known, remembered and judged to be reliable (or trustworthy) –  taken to be shared common knowledge among members of one’s community Gergely’s argument for the need for human natural pedagogy •  We are born into a world populated with man-­‐
made tools whose func,onal proper,es, appropriate manner of applica,on or method of (re)produc,on oZen remain in many respects epistemically opaque è NEED COMMUNICATION •  The cogni,ve opacity of kind or category-­‐
relevant aspects of human-­‐made func,onal arEfacts raises a learnability problem (of relevance-­‐selec,on) for the naïve juvenile observa,onal learner •
Natural Pedagogy theory (Csibra & Gergely, 2006; 2009, 2012)
A human-­‐specific, cue-­‐driven social cogni,ve adapta,on of mutual design dedicated to ensure efficient transfer of relevant cultural knowledge •  Humans are predisposed (EVOLVED) to ’teach’ and ’learn’ new and relevant cultural informa,on from each other •  Human communicaEon is specifically adapted to allow the transmission of a) cogni,vely opaque cultural knowledge b) kind-­‐generalizable generic knowledge c) shared cultural knowledge Defini,on of Ostensive SEmuli Bertrand Russel, 1940; Sperber & Wilson (1995)
•  The signals whereby an agent makes manifest to an addressee her communicaEve intenEon: to manifest some new relevant informaEon for the addressee (i.e. her informa,ve inten,on). –  NOT PART OF EPISODIC MEMORY BUT PART OF SEMANTIC and PROCEDURAL MEMORY (CULTURAL KNOWLEDGE) •  Infants display species-­‐specific sensiEvity to, and preference for, some non-­‐verbal ostensive behavioral signals (see Csibra, 2010, Csibra & Gergely, 2009 for reviews) •  Examples of ostensive communicaEon cues –  eye-­‐contact –  turn-­‐taking conEngent reacEvity –  special tone (‘motherese’) Triggering the Pedagogical Stance •  The pedagogic stance is triggered by ostensive communica,ve cues (E.G. EYE CONTACT) •  Ostensive cues have in common –  Infant recognized as a self –  Paid special aben,on to (noEced as an agent) •  Ostensive cues funcEon to trigger epistemic trust: –  Opening channel to receive knowledge about social and personally relevant world (CULTURE) –  Going beyond the specific experience and acquire knowledge relevant in many se[ngs –  Triggers opening of an evolu,onarily protected epistemic superhighway for knowledge acquisi,on The Developmental Evidence •  Learning from babies learning •  Evidence for transferring knowledge for episodic to seman,c memory •  Link to con,ngent responding •  Why abachment is key to learning Innate Sensi,vity to Con,ngency Experimental Evidence of Referen,al Expecta,ons •  Ostensive cues generate referenEal expectaEon in infant –  An automated eye-­‐tracker based study used an infant-­‐induced conEngent reacEvity paradigm to demonstrate that 8-­‐month-­‐
olds gaze follow an unfamiliar object’s bodily orienta,on response towards one of two targets, but only when the object had been reacEng conEngently before (producing self-­‐
propelled body movements such as ,l,ng) to being looked at by the infant (Deligianni et al., 2011). 8-­‐month-­‐old c
an f
eel a
ddressed (Deligianni et al., 2011) Babies detect contingent activity of such objects and
follow them with their gaze.
•  During the familiarization
phase, all 5 objects are
present
•  The objects in the four corners
were animated unpredictably
•  The central object had two
conditions:
•  Interactive/contingent: It
responds to infant gaze
behaviour with movement and
sound.
•  Independent: It does not
respond to infant’s behaviour
Deligianni, Senju, Gergely et al., 2011
8-­‐month-­‐old c
an f
eel a
ddressed (Deligianni et al., 2011) Babies detect contingent activity of such objects and
follow them with their gaze.
•  During the familiarization
phase, all 5 objects are
present
•  The objects in the four corners
were animated unpredictably
•  The central object had two
conditions:
•  Interactive/contingent: It
responds to infant gaze
behaviour with movement and
sound.
•  Independent: It does not
respond to infant’s behaviour
Deligianni, Senju, Gergely et al., 2011
8-­‐month-­‐old can feel addressed Babies detect contingent activity of such objects and
follow them with their gaze.
Test Phase
• The central object “looks” on the
direction of one of the other
objects
• Will the infant follow the central
object’s “gaze”?
Deligianni, Senju, Gergely et al., 2011
8-­‐month-­‐old can feel addressed Babies detect contingent activity of such objects and
follow them with their gaze.
•  Infants ability to detect
contingency is not dependent
on the presence of any other
social cues, like faces or human
voices.
•  It is suggested that infants may
have interpreted the non-human
object as an agent with
communicative and referential
intention towards them.
Deligianni, Senju, Gergely et al., 2011
Experimental illustration of ostensive cues
Gergely, Egyed et al. (2013)
Subjects : 4 groups of 18-montholds Stimuli: Two unfamiliar
objects
1: Baseline – control group
No object-directed attitude demonstration
Simple Object
Request by
Experimenter A
Subjects: n= 20 Age: 18-month-olds
Ostensive Communicative Demonstration
Requester: OTHER person (Condition 1)
Other
person
Non-Ostensive (Non-Communicative) Demonstration
Requester: OTHER person (Condition 2)
Other
person
Condition 4: Non-Ostensive (Non-Communicative)
Demonstration Requester: SAME person
Same
person
Abachment and Epistemic Trust • Why abachment is key to learning • The rela,onship of abachment security to the capacity to learn from experience Tes,ng the abachment-­‐epistemic trust hypothesis of Fonagy, Gergely & Target (JCCP, 2007) •  What extent does the nature of a child’s a`achment influence the child’s trust in abachment figure and others as informants –  securely abached in infancy display a flexible strategy, accep,ng claims made by their mother or by the stranger as appropriate –  insecure-­‐avoidant children withholding trust in their mother –  insecure-­‐resistant children withholding trust in the stranger –  Insecure-­‐disorganized epistemic hyper-­‐vigilance (mistrust both) Young Children’s Trust in Their Mother’s Claims (Corriveau, Harris, Meins et al., 2009) •
•
•
•
Longitudinal study of abachment, 147 children assessed for a`achment in infancy Tested twice for epistemic trust aged 50 and 61 months Mother and a stranger make conflicEng claims –  Task 1: name a novel object –  Task 2: name a hybrid animal made up 50% each of two animals –  Task 3: name a hybrid animal made up of 75% one animal and 25% of another •  Ques,on: –  Who does the child spontaneously turn to? –  Who does the child believe? Corriveau & Harris’ Studies of Epistemic Trust •  ‘‘Mummy said it’s a snegg and Joan (stanger) said it’s a yoon. What do you think it’s called, a snegg or a yoon?’’ •  ‘‘Mummy said it’s a yiff and Joan said it’s a zazz. What do you think it’s called, a yiff or a zazz?’’ •  ‘‘Mummy said it’s a crut and Joan said it’s a larp. What do you think it’s called, a crut or a larp?’’ Proportion of Trials on Which Children Chose Their Mother
for Information by Attachment Group
N=147
***
Percent Mothers Chosen
80
***
*
60
40
20
0
Avoidant
Corriveau, Harris, Meins et al.,
Child Dev,, 80, 750-761.
Secure
Resistant
Disorganised
Attachment Classification at 18 months
A 50:50 animal from Corriveau et al. 50% pig : 50% bear
If Mother names hybrid as pig
then stranger always names it
bear
A 50:50 animal from Corriveau et al. 50% cow : 50% horse
If Mother names hybrid as
horse then stranger always
names it cow
A 75:25 animal from Corriveau et al. 75% rabbit : 25% squirrel
Mother always names hybrid as squirrel
and stranger always names it rabbit
A 75:25 animal from Corriveau et al. 75% bird : 25% fish
Mother always names hybrid as fish
and stranger always names it as bird
Proportion of Trials on Which Children Chose Their Mother
for Information by Attachment Group and by task
N=146
Percent Mothers Chosen
Novel Object
***
80
50-50 Hybrid
***
75-25 Hybrid
*** ***
*
60
***
40
***
20
0
Avoidant
Corriveau, Harris, Meins et al.,
Child Dev,, 80, 750-761.
Secure
Resistant
Disorganised
Attachment Classification at 18 months
Conclusions from abachment and epistemic trust studies •  Security of abachment èfeeling recognizedè increases likelihood of trust in the source of communica,on when it is reasonably credible –  Also empowers confidence in own experience and belief (empowers judgment) •  Avoidance leads to epistemic mistrust while anxious a`achment generates overreliance on views of abachment figure •  Disorganized a`achment èmisabunement è mistrust of both abachment figure and stranger –  Who to trust? è epistemic hyper-­‐vigilance Evidence linking knowledge flexibility to secure abachment •  Abachment insecurity is associated with – higher levels of cogniEve closure – intolerance of ambiguity and dogmaEc thinking – stereotypic thinking – a tendency to make judgments on the basis of early informaEon and to ignore later data (primacy effect). – less likely to revise their knowledge in face of informa,on that challenges earlier assump,ons. •  The epistemic superhighway (learning from experience) in insecurely abached individuals is parEally closed. The Epistemic Quandary of the Disorganized Unresolved abachment strategy: Hyper-­‐vigilance •  Disorganized a`achment –  rooted presumably in a history of misa`unement –  leads to mistrust of informa,on from •  From own experience •  A`achment figures •  Strangers. •  The terrible quandary about ‘Who to trust?’ –  insecure abachment history precludes confidence in their own experience and belief è –  interminable epistemic search: •  seeking others to confirm or deny their own understanding •  not being able to trust the informaEon once receivedè •  ul,mately genera,ng a state of epistemic hyper-­‐vigilance. Epistemic trust and secure abachment •  Secure a`achment is created by a system that also induces a sense of epistemic trust è that the informa,on relayed by the teacher may be trusted (i.e. learnt from) •  Evidence – ConEngent responsiveness to the infant’s own (at first, automa,c) expressive displays in secure abachment – During “mirroring” interacEons, the other will “mark” her referen,al emo,on displays in a ‘manifesta,ve’ manner to instruct the infant – Cogni,ve advantage of secure abachment Attachment and cognitive functioning: the
development of competence in logical reasoning
secure
insecure
disorganised
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
7
9
11
Age
Source: Jacobson et al
13
15
How Abachment Links to Learning The forming of an attachment bond
DISTRESS/FEAR
BONDING
Down
Regulation
of Emotions
Exposure
to Threat
Activation of attachment
EPISTEMIC
TRUST
Proximity seeking
Social Cues that Create Epistemic Trust •  A`achment is special condiEon for genera,ng epistemic trust •  Generally any communicaEon marked by recogniEon of the listener as intenEonal agent will increase epistemic trust and likelihood of communicaEon being coded as – Relevant – Generalizable – To be retained in memory as relevant •  OSTENSIVE CUES TRIGGER EPISTEMIC TRUST WHICH TRIGGERS A SPECIAL KIND OF ATTENTION Individual Differences in Persuasion • Who can change whose mind? • Why can bring about change? Individual Differences in Crea,ng Epistemic Trust InfluenEal communicators – use ostensive cues to maximum – create ‘illusion’ of recognizing agen,veness of listener •
•
•
•
Looking at audience Addressing current concern Communica,ng that they see problem from agent’s perspecEve Seeing and recognizing individual struggle in understanding •  Massive difference in ability of individuals to influence (teachers, poli,cians, managers) explicable in terms of varying capacity to generate epistemic trust Meta-­‐analy,c studies of teacher effec,veness •  John Ha[e is Professor of Educa,on at the University of Auckland, New Zealand. •  15 years research and synthesizes over 800 meta-­‐analyses rela,ng to the influences on achievement in school-­‐aged students. •  Builds a story about the power of teachers and of feedback, and constructs a model of learning and understanding. •  Is there a set of predictors to good teaching outcomes based on: –  The child? –  The home? –  The school? –  The curricula? –  The teacher? –  The approaches to teaching? With grateful thanks to Dr Peter Fuggle
Meta-­‐analy,c studies of teacher effec,veness •  Things that do not work: – Mobility (shiZing schools) -­‐0.34 – Television -­‐0.14 – Summer vaca,on -­‐0.09 – Ability grouping 0.10 – Individualized instrucEon 0.20 – Homework 0.30 With grateful thanks to Dr Peter Fuggle
Meta-­‐analy,c studies of teacher effec,veness •  What makes a teacher the most effecEve? –  It is teachers seeing learning through the eyes of students; and students seeing teaching as the key to their ongoing learning •  The key ingredients are: –  Awareness of the learning intenEons –  Knowing when a student is successful –  Having sufficient understanding of the student’s understanding –  Know enough about the content to provide meaningful and challenging experiences •  Passion that reflects the thrills as well as awareness of the frustraEons of learning. With grateful thanks to Dr Peter Fuggle
Odds of a clinical episode in MBT by therapist The implica,ons for clinical work: Its organisa,on and delivery •  Rigidity and personality disorder •  Increase of epistemic trust as the driving force of change •  The unsung hero of therapy: the social context Epistemic hypervigilance and the nature of psychopathology q Social adversity (most deeply trauma) is the destrucEon of trust in social knowledge of all kinds èrigidity, being hard to reach q Cannot change because cannot accept new informa,on as relevant (to generalize) to other social contexts on the basis of their own experience or communica,on from a`achment figures or others q Personality disorder is not disorder of personality (except by old defini,on of being enduring) but inaccessibility to cultural communicaEon from }
q Partner q Therapist q Teacher Epistemic Mistrust Implica,ons: The nature of psychopathology q Epistemic mistrust which can follow experiences of maltreatment or abuse leads to epistemic hunger combined with mistrust q  Therapists ignore this knowledge at their peril q Personality disorder is a failure of communicaEon q  It is not a failure of the individual but a failure of a relaEonship q  It is associated with an unbearable sense of isolaEon in the pa,ent generated by epistemic mistrust q  Our inability to communicate with pa,ent causes frustraEon in us and a tendency to blame the vicEm q  We feel they are not listening but actually it is that they find it hard to trust the truth of what they hear Role of mentalizing in Learning System I All evidence based models present models of mind, disorder
and change that are accurate, helpful to patients and
increase capacity for understanding but need to get over
epistemic hypervigilance (‘not true’, ‘not relevant to me’)
q Mentalizing interven,ons demand collaboraEon (working together) q  Seeing from other’s perspecEve q  Trea,ng the other as a person q  Recognizing them as an agent q  Assuming they have things to teach you – since mental states are opaque q  Responding conEngently to a pa,ent Implica,ons: The nature of psychotherapy •  Mentalizing pa,ents may be a common factor to psychotherapy not because we need to learn about our minds or to learn about those of others •  Mentalizing is a generic way of establishing epistemic trust and therefore achieving change –  Our subjec,vity being understood is necessary key to open up wish to learn about world including social world –  Open a key biological route to informa,on transmission and possibility of change epistemic super-­‐highway –  Experience of feeling thought about makes us feel safe enough to think about social world 3 therapeu,c learning systems in the treatment of BPD •  Pedagogic System I concerns learning and teaching of content based on the model of the interven,on which serves as an ostensive cue and increase epistemic trust •  As trust increases and the epistemic superhighway gradually opens, paEents are moved to a state of mind where they can benefit from ‘our wisdom’ •  The importance of System I should neither be minimised nor overemphasised –  Therapies without a coherent body of knowledge based on systema,cally established principles are observed to fail –  Evidence on non-­‐specific factors in therapy and pa,ents’ reports on what they experienced as effec,ve warn against exaggeraEng the importance of Pedagogic System I BUT there are probably 1,246 models of psychotherapy… a model of mind,
a model of interaction,
a model of underlying dysfunction,
a model of therapeutic goals
9
3
Learning System I: Transmission of wisdom 9
4
Learning System I: Transmission of wisdom 9
5
Learning System I: Transmission of wisdom 9
6
Learning System I: Transmission of wisdom 9
7
Learning System I: Transmission of wisdom 9
8
Learning System I: Transmission of wisdom 9
9
Learning System I: Transmission of wisdom 1
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3 therapeu,c learning systems in the treatment of BPD •  The primary func,on of System I is to give substance (material) for System II to work with •  Psychotherapy changes the weight a paEent gives to a piece of communicaEon from the social world •  System I is ‘evidence based’ -­‐ it says what is true about a person and therefore can engage the 2nd system of change •  Because what is said has truth and relevance the pa,ent shiZs in epistemic vigilance and the weight she or he gives to communica,on received from the therapist ! Pedagogic System II Pedagogic System II: The general increase in Epistemic Trust §  Therapy is not just about the what but the how of learning: §  Opening the person’s mind via establishing epistemic trust (collaboraEon) so he/she can once again trust the social world by changing expecta,ons §  It is not just what is taught in therapy that teaches, but the evolu,onary capacity for learning from social situaEon is rekindled §  Therapy interven,ons are effec,ve because they open the person to social learning experience which then feed back in virtuous cycle Pedagogic System II: Ending Epistemic Isola,on §  Pedagogic System II: Learning about sources of knowledge è by providing a clear social illustraEon of trust we undo epistemic isola,on §  By using ostensive cues and establishing a sense that we are concerned to see the world from the paEent’s standpoint we model a situa,on of interpersonal epistemic trust §  Improved understanding of social situa,on è leads to beber understanding of the important otherè more trus,ng (less paranoid) interpersonal rela,onships èit opens up the poten,al to feeling sensi,vely responded to in virtuous cycle System III: Learning beyond therapy •  Enhanced mentalizing achieves improved social relaEonships •  Improved epistemic trust/abandonment of rigidity enables learning from experience •  But change is probably due to how a person uses their social environment, not to what happens in therapy •  Benefit remains conEngent on what is accessible to pa,ents in their par,cular social world •  We predict that psychotherapy is more likely to succeed if the individual’s social environment at the 5me of treatment is by and large benign Summary of the Model q The specific frame of the therapy around which mentalizing occurs q  the model of mind, q  the model of interacEon, q  the model of underlying dysfuncEon, q  the model of therapeuEc goals }
The scaffolding for creating
epistemic trust
q The enhancing of mentalizing is also a common factor that achieves improved social relaEonships through increased epistemic trust q Improved sense of epistemic trust enables learning from experience èchange due to what happens beyond therapy q The enhancing of epistemic trust may be achieved by treatment but also a consequence of improved social relaEonships and consequent on the social world. Returning to Common factors research in psychotherapy • Tradi,onal common factors • Common principles • Cross modality predictors Common features of evidence based treatments •  What works: Focused, (semi-­‐)manualized treatments that tend to –  maximize effec5ve interven,ons/ingredients –  minimize iatrogenic interven,ons }
•  The three C’s of effec,ve treatment –  Coherence: offer a coherent and hope-­‐
providing approach to illness and cure –  Consistency: well-­‐balanced set of interven,ons based on a theory of the disorder and its cure –  ConEnuity: adherence to the model throughout the treatment The 4th ‘C’
Communication
Common Factors: The rela,onship •  Measures of the quality of the therapeuEc relaEonship load heavily on quality of communica,on –  Mentalizing in clinical se@ng è –  sense of collabora&onè –  increased epistemic trustè –  greater general openness to social learningè –  increasingly accurate interpreta&on of others’ inten5onsè –  further development of rela&onships imbued by epistemic trustè –  further improvement in learning from social experience Common Factors: The treatment frame •  The importance of establishing a clear treatment frame – the sense that the therapeu5c environment is safe and structured è – enhances poten5al for signaling è – enhances interpreta&on of ostensive cues è – and enables communica&on è – feeds into virtuous cycle. Gaps in Therapy Outcomes Research •  No solid evidence for who will benefit from what type of psychotherapy •  ‘Inexact therapies’ è parEal effec,veness •  ‘Abachment to methods’ è ‘guildificaEon’ of interven,ons •  The possibility of epistemic mistrust maintaining the separa,on of modali,es •  Essen,al that we achieve coherence within modality protocols (if anything goes nothing goes anywhere) Summing up and concluding • Par,cipa,on of pa,ent in therapy • Measuring outcomes rou,nely and frequently • Saying it on baby language SUMMARY OF POINTS MADE (1) •  Each evidence based (effec,ve) model of therapy for BPD provides knowledge to pa,ents about the nature of their problems, explains way they interact with others, the nature of their underlying dysfunc,on, and a model of therapeu,c goals mechanisms •  Mentaliza,on func,ons in therapy as an ostensive cue to open the capacity for listening in those who are “hard to reach” •  Informa,on (knowledge) about the pa,ent’s mind, specific to that modality, provides the medium to pa,ents to experience a sense of being understood which enhances ostensive cueing func,on of Mentalizing genera,ng an enhanced sense of being understood •  These laber two processes are co-­‐occurring and become mutually reinforcing in the context of the therapeu,c rela,onship SUMMARY OF POINTS MADE (2) •  Gradually (or suddenly) the pa,ent who is in a state of epistemic hyper-­‐vigilance associated with disorganized abachment relaxes their rigidity as their capacity for trust increases. They discover new way of learning about others and shiZs their threshold for modifying mental structures for interpre,ng behavior of others around them (it is the ‘willingness’ to modify structures that is the marker of change) •  This modifica,on enables them to experience social interac,ons more benign way and see more accurately the social situa,on they are actually in (for example, not to see immediately as rejec,ng any experience of temporary social disappointment) •  It is the recovery of the capacity for social informa,on exchange which it at the heart of psychotherapies, an ability to modify or benefit from benign social inten,ons, to update knowledge about the self and others in social situa,ons For electronic version please e-­‐mail: P.FONAGY@UCL.AC.UK