Introduction to
Mentalization
Forewarning
In advocating mentalization-based treatment we
claim no innovation. On the contrary,
mentalization-based treatment is the least novel
therapeutic approach imaginable: it addresses
the bedrock human capacity to apprehend mind
as such. Holding mind in mind is as ancient as
human relatedness and self-awareness.
—.
Chichester: J. Wiley, 2006
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For further Information
p.fonagy@ucl.ac.uk
anthony@mullins.plus.com
All slides available at:
http://www.ucl.ac.uk/psychoanalysis/unitstaff/staff.htm
Bateman, A and Fonagy, P (2006)
Mentalization Based Treatment – a
practical guide OUP: Oxford
Allen, J, Fonagy, P and Bateman, A (2008)
Mentalizing in Clinical Practice APPI
Washington
Exercise – mentalization or
mentalizing?
What is mentalization or mentalizing?
Give 3 key aspects of the psychological
processes that the concept tries to encapsulate
Should we use mentalization or mentalizing?
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 I don’t like about mentalizing
Off-putting jargon for a concept intended to capture
the essence of our humanity
Sounds too cognitive and intellectual, ironic when
(a) we are most keen to promote mentalizing of
emotion and mentalizing in the midst of emotional
states (e.g., “holding heart and mind in heart and
mind” captures the spirit better than holding mind in
mind)
(b) a lot of mentalizing is not conscious, deliberate,
and reflective but rather automatic, intuitive, and
implicit
Concept is too broad and all-encompassing such that it
can explain virtually anything; we need to focus on
different facets of mentalizing
What I like about mentalizing
An unusual word that captures attention, not
simply assimilated into current concepts (e.g.,
empathy)
Breadth of the concept gets therapists and
patients in the general ballpark
Helpful to have a verb (as contrasted with
mindfulness, psychological mindedness,
metacognition, and “mentalization”)—
emphasizes agency, something we aspire to
do more skillfully
No exact synonym despite many related
concepts
A common mentalizing failure
I love this story told by the mother of a five-year-old
girl. The child had taken a stethoscope out of her
mother’s doctor bag and was playing with it. As she
put the stethoscope to her ears, her mother thought
proudly, She seems interested in medicine. Maybe she
will grow up and become a doctor like me. After a time
the little girl put the listening end of the stethoscope
up to her mouth and exclaimed, ‘Welcome to
McDonald’s. May I take your order, please?’ At this,
the mother had to laugh with her daughter, and smiled
to herself about how easily we can project our ideas on
one another.
Kornfield, The wise heart
—
SYSTEMIC: 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.
CBT: The value of understanding
the relationship between
my thoughts and feelings and
my behaviour.
COMMON
Mentalizing
as an
Integrative
framework
PSYCHODYNAMIC: The value of
Understanding the nature of resistance
to therapy, and the dynamics of
here-and-now in the therapeutic
relationship.
LANGUAGE
SOCIAL ECOLOGICAL: The value
of understanding the impact of
context upon mental states;
deprivation, hunger, fear, etc...
Mindblindness
Imagine what your world would be like if you were
aware of physical things but were blind to the
existence of mental things. I mean of course blind
to things like thoughts, beliefs, knowledge,
desires, and intentions, which for most of us selfevidently underlie behaviour
Baron-Cohen S (1995) Mindblindness
The Artful use of Science
To do anything well you must have the
humility to bumble around a bit, to follow
your nose, to get lost, to goof. Have the
courage to try an undertaking and possibly
do it poorly. Unremarkable lives are marked
by the fear of not looking capable when
trying something new.
Epictetus, Manual
Mentalizing:
A new word for an ancient concept
Implicitly and explicitly interpreting
the actions of oneself and other as
meaningful on the basis of
intentional mental states
(e.g., desires, needs, feelings,
beliefs, & reasons)
Introduction to theory of mentalisation
The normal ability to ascribe intentions and
meaning to human behaviour
Ideas that shape interpersonal behaviour
Make reference to emotions, feelings, thoughts,
intentions, desires
Shapes our understanding of others and ourselves
Central to human communication and
relationships
Underpins clinical understanding, the therapeutic
relationship and therapeutic change
Mentalizing: further definitions and
scope
To see ourselves from the outside and
others from the inside
Understanding misunderstanding
Having mind in mind
Past, present, and future
Introspection for subjective selfconstruction – know yourself as others
know you but also know your subjective
self
Characteristics of mentalising
Central concept is that internal states (emotions,
thoughts, etc) are opaque
We make inferences about them
But inferences are prone to error
Overarching principal is to take the “inquisitive
stance”
=
Interpersonal behaviour characterised by an
expectation that one’s mind may be influenced,
surprised, changed and enlightened by learning
about another’s mind
Mentalization and Overlapping Constructs
(Choi-Kain & Gunderson, Am J Psychiat 2008)
Mindfulness
Keeping one’s consciousness alive to the present
reality
Observing and describing one’s own experience
whilst participating non-judgementally
Two domains
Attention regulation
Acceptance and openness to experience
Four Skills
Observing
Describing
Acting with awareness
Accepting without judgement
Mentalisation and conceptual cousins
Component Mindfulness Psychological
Mindedness
Empathy
Affect
consciousness
Implicit
No
No
Yes
No
Explicit
yes
Yes
Yes
Yes
Selforientated
Yes
Yes
Minimal
Yes
Other
orientated
No
Minimal
Yes
Yes
Cognitive/
Affect
Cog=Affect
Cog=Affect
Affect>Cog
Affect>Cog
Multiple dimensions of mentalizing
in psychodynamic psychotherapy
Differentiating self and other in psychotherapy
Adopting the perspective of the other to the self
Reducing the impact of the other on the self
Moving from implicit - automatic mentalization to
explicit – controlled mentalization
Challenging automatic assumptions
Elaborating internal representations of mental states
of self and others - external and internal mentalizing
Challenging superficial judgements based on
‘appearances’
Connect feelings with thoughts (affect and cognition)
Overcoming splitting of affect and cognition (the feeling of
feelings)
Treatment vectors in re-establishing mentalizing
in borderline personality disorder
ImplicitAutomatic
Impression
Controlled
driven
Appearance
Inference
Mental
interior
focused
Certainty
emotion
Doubt of of
cognition
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
ExplicitControlled
Emotional
contagion
Autonomy
Mental
exterior
focused
Affective
self:affect state
propositions
Belief-desire
MPFC/ACC
inhibitory
system
Mayes’ (2001) Adaptation of Arnsten’s Dual Arousal
Systems Model: Implication of the Hyper-activation of
Attachment
Prefrontal capacities
Performance
Posterior cortex and
subcortical capacities
Changing
switchpoint
threshold
Point 1a
Point 1
Low
High
Arousal
Parallel contributions to mentalizing:
Meeting of minds
attachment & arousal
PATIENT
mentalization
attachment & arousal
mentalizing
Developmental
competence
Current
performance
HEALTH CARE SYSTEM
mentalizing
Current
performance
attachment & arousal
CLINICIAN
mentalization
attachment & arousal
Developmental
competence
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
Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychotherapist’s demand to explore issues
that trigger intense emotional reactions
involving conscious reflection and explicit
mentalization are inconsistent with the
patient’s ability to perform these tasks when
arousal is high
Arousal
Dimensions of mentalization: internally vs externally
focused (mental interiors vs visible clues)
Internal
I wonder if he feels
his mother loved
him?
External
He looks tired;
perhaps he slept
badly
With selective loss of sense of mental interiors, external features
are given inappropriate weight and misinterpreted as indicating
dispositional states
You’re covering your eyes; you can hardly bear to look at me
Dimensions of mentalization: Cognitive vs
affective mentalization
Cognition
Agent attitude
propositions
‘I think he thought that
Charlie ate his
chocolate’
Associated with several
areas of prefrontal cortex
Emotion
Self affect state
propositions
‘I feel upset about it’
Associated with inferior
prefrontal gyrus
Dimensions of mentalization: Cognitive vs
affective mentalization
With diminution of cognitive mentalization the logic of
emotional mentalization (self- affect state proposition)
comes to be inappropriately extended to cognitions.
“I feel sad, you must have hurt me”
Failures of imagination in
mindblindness
Dehumanising
Subjectivity &
humanity
Demonizing
Concrete &
Egocentric
Restrained
imagination
Imaginary &
projective
Mentalizing
Distorted
mentalizing
Non-mentalizing
Mentalizing: Implicit ‘v’ Explicit
IMPLICIT
Perceived
Nonconscious
Nonverbal
Unreflective
e.g. mirroring
EXPLICIT
Interpreted
Conscious
Verbal
Reflective
e.g. explaining
Mentalizing interactively and
emotionally
Mentalizing interactively
Each person has the other person’s mind in
mind (as well as their own)
Self-awareness + other awareness
Mentalizing emotionally
Mentalizing in midst of emotional states
Feeling and thinking about feeling (mentalized
affectivity)
Feeling felt
Example of mentalizing
interactively and emotionally
The appetite which we call LUST is a sensual
pleasure, but not only that; there is in it also a
delight of the mind: for it consisteth of two
appetites together, to please, and to be pleased;
and the delight (we) take in delighting, is not
sensual, but a pleasure of joy of the mind,
consisting in the imagination of the power (we)
have so much to please.
Thomas Hobbes, quoted in Simon Blackburn (2004) Lust
Mentalizing and psychopathy:
Compart-mentalization
Psychopathy entails elements of intact
mentalizing
Partial mindblindness:
Failure of imaginative empathy
Failure to identify with victim’s distress
Mind uninfluenced and unchanged easily – control and
protection of self from shame/humiliation paramount
Distorted mentalizing – paranoid demonizing e.g.
interpreting the child’s frustrating behaviour as
intended to torment the parent
Mentalizing objects and others
Our relations with other people do not have the same
structure as our relations with inanimate objects, plants
or machines. We do not deal with our family members,
friends, colleagues or fellow citizens, as we do with
volcanoes, fields of wheat or kitchen mixers, namely, by
trying to figure out the nature and layout of their innards
so that we can predict and perhaps control them.
What we hope of another with whom we interact is not that
he or she will go through some gyrations which we have
already planned in detail, but that he or she will make
some contributions to moving forward the joint and cooperative enterprise in which we are both, more of less
explicitly, engaged
Heal, J (2003) Mind, Reason and Imagination: Selected Essays in Philosophy of Mind and Language
CUP: Cambridge.
Being misunderstood
Although skill in reading minds is important,
recognising the limits of one’s skill is
essential
First, acting on false assumptions causes
confusion
Second, being misunderstood is highly
aversive
Being misunderstood generates powerful
emotions that result in coercion, withdrawal,
hostility, over protectiveness, rejection
Mentalization: Some
theory
What is it?
How does it arise?
Why does it matter?
How do we use it in therapy?
Brains and social behavior vary across different mammalian species
Insectivors:
Regulated maternal
behaviors
Chimpanzees:
Societies of a few dozen
Modern Humans:
Societies of millions of
interacting people
Humans exceedingly skilled
at large scale social
interaction
Competition for social skills
led to the evolutions of
cognitive mechanism for
collaborating with others
Fuelled evolution of human
brain.
Therefore correlation in
mammals between size of
social group and volume of
neocortex
The uniqueness of homo sapiens
No animal, not even the most intelligent of non-human
primates, can discern the difference between the act
of a conspecific due to serendipity and one rooted in
intention, wish, belief or desire.
The capacity to mentalize has also been argued to
account for the other major difference between
humans and other apes:
self awareness and self-consciousness as a path to
emulation bringing with it social emotions such as
embarrassment, shame and guilt
the species specific striving to be more than a ‘beast’, to live
beyond one’s body, to aspire to a spirit that transcends
physical reality and step beyond one’s own existence
social origin of the self (simulation).
A working definition of mentalization
Mentalizing is a form of imaginative
mental activity, namely, perceiving and
interpreting human behaviour in terms
of intentional mental states (e.g. needs,
desires, feelings, beliefs, goals,
purposes, and reasons).
Mentalizing: further definitions and
scope for thinking about it
To see ourselves from the outside and others from
the inside
Understanding misunderstanding
Having mind in mind
Being mind minded
Being mindful (of minds)
Past, present, and future
Seeing oneself as agentive an intentional being
Creating phenomenological coherence about self
and others
Mentalization and Overlapping Constructs
(Choi-Kain & Gunderson, Am J Psychiat 2008)
The brain and
social
understanding
The social brain: A variety of studies stories, sentences, cartoon, animations
medial prefrontal cortex (mPFC), temporo-parietal junction (TPJ),
posterior superior temporal sulcus (pSTS), amygdala, anterior
cingulate cortex (ACC), anterior insula (AI), inferior frontal gyrus (IFG)
and interparietal sulcus (IPS)
Mentalizing: Cognitive vs. Emotional
Emotional Mentalizing
The capacity to experience affective reactions
to the observed experiences of others
Cognitive Mentalizing
Role-taking ability: The capacity to engage in the
cognitive process of adopting another’s
psychological point of view.
Making inferences regarding the other’s
affective and cognitive mental states
Mentalizing brain networks
M
E
N
T
A
L
I
Z
I
N
G
Shamay-Tsoory 2011
Multifaceted Nature of Mentalization
Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
Implicitamygdala, basal ganglia,
Automaticventromedial prefrontal
Non -conscious- cortex (VMPFC),
lateral temporal cortex (LTC)
Immediate.
and the dorsal anterior
Mental
interior
cue
focused
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
lateral and medial prefrontal cortex
(LPFC & MPFC), lateral and medial
parietal cortex (LPAC & MPAC),
medial temporal lobe (MTL),rostral
anterior cingulate cortex (rACC)
cingulate cortex (dACC)
medial frontoparietal
network activated
Associated with several areas
of prefrontal cortex
frontoparietal mirror-neuron
system
recruits lateral fronto-temporal
network
Associated with inferior prefrontal
gyrus
the medial prefrontal cortex,
ACC, and the precuneus
ExplicitControlled
Conscious
Reflective
Mental
exterior
cue
focused
Affective
self:affect state
propositions
Belief-desire
MPFC/ACC
inhibitory
system
Imbalance of mentalization generates problems
Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
BPD
ImplicitExplicitImpulsive, quick assumptions
Does not genuinely appreciate others’
AutomaticControlled
about others thoughts and feelings perspective. Pseudo-mentalizing,
Non -conscious- not reflected on or tested, cruelty Interpersonal conflict ‘cos hard to Conscious
consider/reflect on impact of self
Immediate.
Reflective
on others
BPD
Mental
Mental
interior
cue
focused
Hyper-vigilant, judging
by appearance.
Evidence for attitudes and other
internal states hasto come from
outside
Lack of conviction about own ideas
Seeking external reassurance
Overwhelming emptiness,
Seeking intense experiences
exterior
cue
focused
BPD
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
Unnatural certainty about ideas
Anything that is thought is REAL
Intolerance of alternative ways
of seeing things.
Affective
Overwhelming dysregulated emotions, self:affect state
Not balanced by cognition come
propositions
To dominate behavior. Lack of
contextualizing of feelings leads to
catastrophyzing
BPD
Hypersensitive to others’
Moods, what others say.
Fears ‘disappearing’
Rigid assertion of self, controlling
others’ thoughts and feelings.
Belief-desire
MPFC/ACC
inhibitory
system
Prementalizing Modes of Subjectivity
Psychic equivalence:
Mind-world isomorphism; mental reality = outer reality; internal has power of
external
Intolerance of alternative perspectives concrete understanding
Reflects domination of self:affect state thinking with limited internal focus
Managed by avoiding being drawn into non-mentalizing discourse
Pretend mode:
Ideas form no bridge between inner and outer reality; mental world
decoupled from external reality
“dissociation” of thought, hyper-mentalizing or pseudo-mentalizing
Reflects explicit mentalizing being dominated by implicit, inadequate internal
focus, poor belief-desire reasoning and vulnerability to fusion with others
Managed in therapy by interrupting a non-mentalizing process
Teleological stance:
A focus on understanding actions in terms of their physical as opposed to
mental constraints
Cannot accept anything other than a modification in the realm of the physical
as a true index of the intentions of the other.
Extreme exterior focus, momentary loss of controlled mentalizing
Misuse of mentalization for teleological ends (harming others) becomes
possible because of lack of implicit as well as explicit mentalizing
Attachments and
the development
of social
understanding
Measuring Mentalization (Baron(Baron-Cohen et
al., 2001) Reading the Mind in the Eyes Test
Friendly - A
Surprised - C
Sad - B
Worried - D
Measuring Mentalization (Baron-Cohen et
al., 2001) Reading the Mind in the Eyes Test
SurprisedSurprised-A
JokingJoking-C
Sure about somethingsomething-B
HappyHappy-D
Measuring Mentalization (Baron(Baron-Cohen et
al., 2001) Reading the Mind in the Eyes Test
JokingJoking-A
FlusteredFlustered-B
DesireDesire-C
ConvincedConvinced-D
Mentalizing at the World Cup: How does Robert
Green feel after letting 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
Relational Aspects of Mentalization
Overlap between neural locations of mentalizing
self and other may be linked to intersubjective
origin of sense of self
We find our mind initially in the minds of our parents
and later other attachment figures thinking about us
The parent’s capacity to mirror effectively her child’s
internal state is at the heart of affect regulation
Infant is dependent on contingent response of
caregiver which in turn depends on her capacity to be
reflective about her child as a psychological being
Failure to find the constitutional self in the other has
potential to profoundly distort the self representation
(exaggerated mirroring of child’s anxiety aggravates
anxiety rather than soothe)
The same applies to child with inadequate sense of
independent self within therapeutic relationship
How Attachment Links to Affect Regulation
DISTRESS/FEAR
BONDING
Down
Regulation
of Emotions
Exposure
to Threat
Activation of attachment
EPISTEMIC
TRUST
Proximity seeking
The forming of an attachment bond
Attachment Disorganisation in Disrupted
Early Relationships
DISTRESS/FEAR
Exposure
to threat
Adverse
Emotional
Experience
Activation of attachment
Proximity seeking
The ‘hyperactivation’ of the attachment system
The two-dimensional space defined by attachment anxiety and
avoidance, showing Bartholomew’s 4 categories
High avoidance
Dismissing
avoidant
-ve view of other
Fearful
avoidant
Low
anxiety
High
anxiety
+ve view of self
-ve view of self
Secure
Preoccupied
Low avoidance
+ve view of other
High congruent & marked mirroring
Mirroring must not be too accurate, it
must be ‘marked’ (systematically
distorted) so child knows he is not
observing caregiver’s dispositional state
Unmarked mirroring
Marked mirroring
Affect & Self Regulation Through
Representation
Mirroring
Psychological
Self:
2nd Order
Representations
of self-state:
Internalization
of object’s image
Expression
symbolic organisation
of internal state
Physical Self:
Primary
Representations
Constitutional self
in state of arousal
Infant
Fonagy, Gergely, Jurist & Target (2002)
With apologies to Gergely & Watson (1996)
Reflection
Resonance
CAREGIVER
Theory: Birth of the Agentive Self
Attachment figure “discovers” infant’s mind (subjectivity)
Internalization
Representation of
infant’s mental
state
Core of
psychological
self
Attachment figure
Inference
Infant
Infant internalizes caregiver’s representation to form psychological self
Safe, playful interaction with the caregiver leads to the integration of primitive
modes of experiencing internal reality mentalization
The stable
instability and
predictable
unpredictability of
BPD
Crucial role of Attachment History in
facilitating/inhibiting Mentalization in the face
of stress
Arousal/stress inhibits controlled (‘reflective’)
mentalization
This leads to automatic mentalizing
dominated by reflexive (unrerflective)
assumptions regarding self and others under
stress, which may not be obvious in low stress
conditions
Reemergence of non-mentalizing modes
Luyten, P., Mayes, L. C., Fonagy, P., & Van Houdenhove, B. (2010). The interpersonal regulation of stress: A
developmental framework. Manuscript submitted for publication.
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.
Fonagy, P., Luyten, P., Bateman, A., Gergely, G., Strathearn, L., Target, M., et al. (2010). Attachment and
personality pathology. In J. F. Clarkin, P. Fonagy & G. O. Gabbard (Eds.), Psychodynamic psychotherapy for
personality disorders. A clinical handbook (pp. 37-87). Washington, DC: American Psychiatric Publishing.
Dimensions of mentalization: implicit/automatic
vs explicit/controlled in Othello
That
so loved
Why, handkerchief
how now, ho! fromwhich
whenceIariseth
this? and gave thee
Thou
to Cassio.
Are wegavest
turn'd Turks,
and to ourselves do that
Which
heavenIhath
Ottomites?
By
heaven,
sawforbid
my the
handkerchief
in's hand.
For Christian shame, put by this barbarous brawl:
Controlled
Automatic
Love
Spurned/
Arousal
Dimensions of mentalization: implicit/automatic
vs explicit/controlled in Othello
That handkerchief which I so loved and gave thee
ThouLateral
gavest to Cassio.
PFC
Amygdala
temporal
Lateral
PFCmy
Medial Ventromedial
PFCin's hand.
By heaven,
I saw
handkerchief
cortex
Controlled
Automatic
Arousal
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
Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychotherapist’s demand to explore issues
that trigger intense emotional reactions
involving conscious reflection and explicit
mentalization are inconsistent with the
patient’s ability to perform these tasks when
arousal is high
Arousal
The effect of attachment-related stress on the capacity to
mentalize: Induction imagery scripts to 12 participants (Nolte,
Hudac, Mayes, Fonagy & Pelphrey, 2009)
• Scripts obtained in a visit prior to scanning with the aim to
create stress-related arousal states
• Idiosyncratic content, personally meaningful
• Common themes attachment stress: e.g. relationship
breakup, funeral etc.
• Common themes normal stress: e.g. exam preparation,
lost objects etc.
• Edited, recorded, semi-standardized about 5 mins. of length
each
• Only scripts that were subjectively rated 8 or above on a 110 scale of subjective stress accepted.
• No differences in subjective level of stress ratings between
‘attachment’ and ‘normal’ stress
The effect of attachment-related stress on the
capacity to mentalize: Modified Reading Mind in Eyes
Nolte, Hudac, Mayes, Fonagy & Pelphrey (2013)
Stimuli
Subjects were asked to make a judgment as fast
and accurately as possible
Which attitude?
Resentful
Bored
Which age?
Twenty-three
Thirty
Examples of single trial stimuli, RMET
(top), control task (bottom).
Frontiers in Human Neuroscience,7, Article 816
The effect of attachment-related stress on the capacity
to mentalize: Behavioral measures of impact of stress
Nolte, Hudac, Mayes, Fonagy & Pelphrey (2013)
Accuracy scores
Frontiers in Human Neuroscience (2013),
7, Article 816
Baseline/ post normal stress:
p= 0.03
Baseline/ post attachment stress:
p=0.001
Post normal/ post attachment stress:
p=0.01
70
60
50
40
30
20
10
0
Baseline
post normal
stress
post
attachment
Attachment stress disrupts RMET performance more than
normal stress!
Regions differentially activated by mental-state and age judgments in the
RMET-R administered with no previous stress induction. Nolte et al., 2013
Frontiers in Human
Neuroscience (2013), 7,
Article 816
Regions that showed differential activation between mental state and age
judgments in the baseline RMET-R that were modulated by stress induction
type. (Attachment related stress versus general stress) Nolte et al. (2013)
Mental state judgments
Age judgments
ASI condition resulted in reduced mentalization-related activation in the
left posterior superior temporal sulcus(STS),left inferior frontal gyrus and
left temporoparietal junction(TPJ).
Differential functional connectivity to the left posterior STS during mental
state and age judgments after the ASI vs.the GSI. (Nolte et al., 2013)
The left middle frontal gyrus
and left anterior insula showed
greater functional connectivity
to the left posterior STS after
the ASI.
A biobehavioral switch model of the relationship
between stress and controlled versus automatic
mentalization (Based on Luyten et al., 2009)
Attachment - Arousal/Stress
Inhibition of social understanding associated with
maltreatment can lead to exposure to further abuse
DISTRESS/FEAR
Adverse emotional
experience rooted in
traumatic relationships
Intensification of attachment
needs
Inhibition of mentalisation
Inaccurate judgements of affect,
Delayed development of mentalization understanding
Failure to understand how emotions relate to situations and behavior
The mentalizing model of BPD
Distal factors
Constitutional
Factors
BPD: Core
features
Proximal factors
Early caregiving
context
Stress/
arousal
•
•
Hypersensitivity to
mental states
Attachment
Disruptions
•
Low threshold for
attachment
activation &
deactivation of MZ
Poor selfother
differentiation
Impairments
in integration
of cognition &
affect
Dysfunctional
relationships
Affect
dysregulation
Impulsivity
Pre-mentalizing
modes of social
cognition
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Identity diffusion
Dissociation
Feelings of inner
pain & emptiness
Severe interpersonal difficulties as
a consequence of disrupted
mentalizing
Theory: Birth of the “Alien” Self in
Disorganized Attachment
The caregiver’s perception is inaccurate or unmarked or both
Attachment
Child
Mirroring fails
The nascent self
Figure
Absence of a
representation of
the infant’s
mental state
representational
structure
The Alien
Self
Internalisation of a non-contingent mental
state as part of the self
The child, unable to “find” himself as an intentional being, internalizes a
representation of the other into the self with distorted agentive characteristics
which disorganizes the self creating splits within the self structure
Theory: Self-destructiveness and
Externalisation Following Adversity
Torturing alien self
Perceived
other
Self representation
Unbearably painful
emotional states:
Self experienced
as evil/hateful
Self-harm state
Attack from within is turned against body and/or mind.
Theory: Self-destructiveness and
Self-destructive relationships
Torturing alien self
Perceived
other
Self representation
Unbearably painful
emotional states:
Self experienced
as evil/hateful
Self-harm state
Torturing alien self
Externalization
Container
Self
Selfexperienced
experienced
asas
hated
evil and
and attacked
hateful
Addictive bond
Victimized state
Projective identification is used to reduce the experience of unbearably painful emotional state of
attack from within – externalisation becomes a matter of life and death and addictive bond and
terror of loss of (abusing) object develops
If someone was causing you pain or simply tormenting
you, perhaps not everyday for the whole day, parts of a
day, or for days and weeks on end,
You could if you were brave or desperate enough, defend
yourself, by perhaps attacking (and eliminating) your
persecutor.
But what if this thing you hate, was inhabiting your head?
You can’t exactly say please leave my body, you can’t do
anything to get it to just pack up and leave because
technically, physically that isn’t possible.
You can say fuck you. I hate you. You can self-harm with
the hugest force your body can withstand, with all you
can muster.
You can do that. You can be very very angry
and show them who’s boss, you won’t stand
for it, you won’t take it lying down. You want to
be heard, you want to say right, you think you
can hurt me? I’ll show you, I’ll show you how
much I can hurt you!
But you and this thing, you are inhabiting one
body. You attack this thing you attack yourself.
You don’t have a choice though. That’s a
sacrifice you make over and over.
Eventually, you realise the only way to get rid of
this thing, once and for all is getting rid of
yourself. What choice do you really have?
No doctor can specify the problem. No medication can
fix the problem that can’t be specified.
You fail to understand yourself. You can’t explain to
your family and docs, they can’t help you because
you do not talk.
You doubt yourself “do I even have a problem?”
People in real life often treat you like you don’t have a
real problem. They talk to you stupidly, you
complain that they don’t understand, you look a fool.
Perhaps that is why you don’t talk to them anymore.
Maybe you don’t have a problem anyway.
You are a child, quite possibly you are just
making this up for some attention, finding
an excuse for why you can’t stay in college
or get a job. Maybe you don’t have an
excuse, you are just a stubborn little child.
From what everyone tells you perhaps that is
true.
You have doubt. You are willing to listen to
someone else.
For now that is the only reason why you are
not, at this moment trying to do it.
Externalisation & Violence Following Trauma
Torturing alien self
Perceived
other
Self representation
Unbearably painful
emotional states:
Self experienced
as evil/hateful
Self-harm state
Torturing alien self
Externalization
Violent act
Container
Self
Self
Selfexperienced
experienced
experienced
as as
righteously
as
hated
evil and
andvindicated
attacked
hateful
Addictive bond
Violent state
Projective identification is used to reduce the experience of unbearably painful emotional state of
attack from within – externalisation becomes a matter of life and death, the violent act protects
against experience of intrusion and addictive bond and terror of loss of abused object can
develop
Understanding suicide and self-harm in
terms of the temporary loss of mentalization
Loss Increase attachment needs triggering of
attachment system Failure of mentalization Psychic equivalence intensification of
unbearable experience
Pretend mode hypermentalization
meaninglessness, dissociation Teleological solutions to crisis of agentive self
suicide attempts, self-cutting
Assessment of
Mentalization
Understanding suicide and self-harm in
terms of the temporary loss of mentalisation
Figure 2.x Understanding BPD in terms of the suppression of mentalization
Temporary Failure of Mentalisation
Pretend
Mode
Pseudo
Mentalisation
Psychic
Equivalence
Teleological
Mode
Concrete
Understanding
Misuse of
Mentalisation
Unstable Interpersonal Relationships
Affective Dysregulation
Impulsive Acts of Violence, Suicide, Self-Harm
Psychotic Symptoms
Questions that can reveal quality of
mentalisation
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?
any setbacks?
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?
Elaboration of interpersonal event
Thoughts and feelings in relation to the
event
Ideas about the other person’s mental state
at turning points in narrative
Elaborate on actual experience
Reflecting on reconstructed past
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 didn’t 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
What does non-mentalizing look
like?
Excessive detail to the exclusion of
motivations, feelings or thoughts
Focus on external social factors, such as
the school, the council, the neighbours
Focus on physical or structural labels (tired,
lazy, clever, self-destructive, depressed,
short-fuse)
What does non-mentalizing look
like?
Preoccupation with rules, responsibilities,
‘shoulds’ and ‘should nots’
Denial of involvement in problem
Blaming or fault-finding
Expressions of certainty about thoughts or
feelings of others
What does good mentalizing look
like?
In relation to other peoples thoughts and
feelings
Acknowledgement of opaqueness
Absence of paranoia
Contemplation and reflection
Perspective taking
Genuine interest
Openness to discovery
Forgiveness
predictability
What does good mentalizing look
like?
Perception of own mental functioning
Appreciation of changeability
Developmental perspective
Realistic scepticism
Acknowledgement of pre-conscious function
Awareness of impact of affect
Self-presentation e.g. autobiographical
continuity
General values and attitudes e.g.
tentativeness and moderation
What does extremely poor mentalizing
look like?
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 problem - 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
Context Specific - Relational
Dramatic temporary failures of
mentalisation
“You’re trying to drive me crazy”
“You hate me”
‘She does my head in. I can’t think once she
starts on me’
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
Misuse of Mentalizing (1)
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 other’s feelings
Self-serving empathic understanding
A person’s feelings are exaggerated or distorted
in the service of someone else’s agenda
Misuse of Mentalizing(2)
Coercion against or induction of the thoughts
of others
Deliberate undermining of a person’s capacity to
think by humiliation
Extreme form is sadistic or psychopathic use of
knowledge of other’s feelings or wishes
Milder form is manipulation for personal gain
o inducing guilt
o engendering unwarranted loyalty
o power games
o Understanding used as ammunition in a battle