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Introduction to Mentalization
A Training Workshop

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

Some Free Publicity

JUST RELEASED! NEW! IMPROVED!

Washes brains whiter!

Longer than all previous versions!

2012 American Psychiatric Publishing, Inc

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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?

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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 dont 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

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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 mothers 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 McDonalds. 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

CBT: The value of understanding the relationship between my thoughts and feelings and my behaviour.

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.

COMMON

Mentalizing as an Integrative framework

LANGUAGE

PSYCHODYNAMIC: The value of Understanding the nature of resistance to therapy, and the dynamics of here-and-now in the therapeutic relationship.

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

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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

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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 ones mind may be influenced, surprised, changed and enlightened by learning about anothers mind

Mentalization and Overlapping Constructs (Choi-Kain & Gunderson, Am J Psychiat 2008)

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Mindfulness
Keeping ones consciousness alive to the present reality Observing and describing ones 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 No Empathy Affect consciousness No

Implicit

No

Yes

Explicit

yes

Yes

Yes

Yes

Selforientated Other orientated Cognitive/ Affect

Yes

Yes

Minimal

Yes

No

Minimal

Yes

Yes

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)

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Treatment vectors in re-establishing mentalizing in borderline personality disorder

ImplicitAutomatic Impression Controlled driven ExplicitControlled

Mental interior focused

Appearance Inference

Mental exterior focused

Cognitive agent:attitude propositions Imitative frontoparietal mirror neurone system Emotional contagion Autonomy

Certainty emotion Doubt of of cognition

Affective self:affect state propositions

Belief-desire MPFC/ACC inhibitory system

Mayes (2001) Adaptation of Arnstens Dual Arousal Systems Model: Implication of the Hyper-activation of Attachment
Prefrontal capacities Posterior cortex and subcortical capacities

Performance

Changing switchpoint threshold

Point 1a Point 1

Low

High

Arousal

Parallel contributions to mentalizing: Meeting of minds

attachment & arousal Developmental competence

PATIENT
HEALTH CARE SYSTEM

mentalization attachment & arousal mentalizing mentalizing attachment & arousal

Current performance

Current performance

CLINICIAN

mentalization attachment & arousal

Developmental competence

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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 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

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

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With selective loss of sense of mental interiors, external features are given inappropriate weight and misinterpreted as indicating dispositional states

Youre 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

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Failures of imagination in mindblindness

Subjectivity & humanity Demonizing

Dehumanising

Concrete & Egocentric Non-mentalizing

Restrained imagination Mentalizing

Imaginary & projective Distorted mentalizing

Mentalizing: Implicit v Explicit

IMPLICIT EXPLICIT

Perceived Nonconscious Nonverbal Unreflective e.g. mirroring

Interpreted Conscious Verbal Reflective e.g. explaining

Mentalizing interactively and emotionally

Mentalizing interactively
Each person has the other persons 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

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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 victims distress Mind uninfluenced and unchanged easily control and protection of self from shame/humiliation paramount Distorted mentalizing paranoid demonizing e.g. interpreting the childs 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.

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Being misunderstood
Although skill in reading minds is important, recognising the limits of ones 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

Some theory

Clinical Features of Borderline Personality Disorder (DSM-IV: 5 of 9)

a pattern of unstable intense relationships, inappropriate, intense anger unstable relationships frantic efforts to avoid abandonment affective dysregulation affective instability, impulsive actions impulsivity recurrent self-harm & suicidality, chronic feelings of emptiness or boredom aggression (dysphoria), transient, stress-related paranoid thoughts identity disturbance severe dissociative symptoms

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The social brain

1. Medial prefrontal cortex
Mentalising proper
o Implicit ability to infer mental states such as beliefs, feelings and desires

mPFC
Fletcher et al., 1995; Gallagher et al., 2000; Gilbert et al., 2006 (meta-analysis)

The social brain

2. pSTS/TPJ
Prediction
o Biological motion, eye gaze

pSTS/TPJ

Perspective-taking
o Different physical points of view

mPFC Pelphrey et al., 2004a,b; Kawawaki et al., 2006 (review); Mitchell 2007

The social brain

3. Amygdala
Attaching reward values to stimuli
o Approach vs. avoid
pSTS/TPJ

Facial expressions

mPFC Dolan 2002; LeDoux 2000; Winston et al., 2002; Phelps et al., 2000, 2003

Amygdala

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The social brain

4. Temporal poles
Social scripts, complex event knowledge Temporal pole
pSTS/TPJ

mPFC Funnell, 2001; Damasio et al., 2004; Moll et al., 2001, 2002, 2005 (review)

Amygdala

Mentalization and Overlapping Constructs (Choi-Kain & Gunderson, Am J Psychiat 2008)

Measuring Mentalization
Friendly - A

(Baron(Baron-Cohen et

al., 2001) Reading the Mind in the Eyes Test

Sad - B

Surprised - C

Worried - D

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Measuring Mentalization (Baron-Cohen et

al., 2001) Reading the Mind in the Eyes Test

SurprisedSurprised-A

Sure about somethingsomething-B

JokingJoking-C

HappyHappy-D

Measuring Mentalization
JokingJoking-A

(Baron(Baron-Cohen et

al., 2001) Reading the Mind in the Eyes Test

FlusteredFlustered-B

DesireDesire-C

ConvincedConvinced-D

Mentalizing at the World Cup: How does Robert Green feel after letting in the USA goal?
Upset Angry

Disappointed

Frustrated

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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 parents capacity to mirror effectively her childs 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 childs anxiety aggravates anxiety rather than soothe) The same applies to child with inadequate sense of independent self within therapeutic relationship

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Baron-Cohens (2005) model of the social brain The Intention Detector

The Emotion Detector - Left inferior frontal gyrus - Mirror neurons - Right medial prefrontal cortex - inferior frontal cortex - Bilateral anterior cingulate - Superior temporal gyrus

Eye Direction Detector - Posterior superior temporal sulcus

Shared Attention Mechanism

- Bilateral anterior cingulate - Medial prefrontal cortex - Body of caudate nucleus The Empathising System - Fusiform gyrus - Amygdala - Orbito-frontal cortex Theory of Mind Mechanism - Medial prefrontal cortex - Superior temporal gyrus - Temporo-parietal junction

EMOTION UNDERSTANDING

BELIEF-DESIRE REASONING

Mentalizing as a multidimensional neuroscience construct

Implicit - automatic versus explicit - controlled mentalization (Satpute & Lieberman, 2006) Mentalization based on internal versus external features of self and others(Satpute & Lieberman, 2006) Cognitive versus affective mentalization (ShamayTsoory, Aharon-Peretz, & Perry, 2008)

Two distinct neural networks are shared by selfknowing and knowing others (Lieberman, 2007; Uddin et al., 2007)
frontoparietal mirror-neuron system (Keysers & Gazzola, 2006; Rizzolatti, Ferrari, Rozzi, & Fogassi, 2006). the medial prefrontal cortex, ACC, and the precuneus (Frith, 2007; Frith & Frith, 2006; Uddin et al., 2007)

Mentalizing Profile of Prototypical BPD patient

Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381. BPD 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
cingulate cortex (dACC) medial frontoparietal network activated lateral and medial prefrontal cortex (LPFC & MPFC), lateral and medial parietal cortex (LPAC & MPAC), medial temporal lobe (MTL),rostral anterior cingulate cortex (rACC)

ExplicitControlled Conscious Reflective Mental exterior cue focused Affective self:affect state propositions

BPD
recruits lateral fronto-temporal network

BPD
Associated with several areas of prefrontal cortex Associated with inferior prefrontal gyrus

BPD
frontoparietal mirror-neuron system the medial prefrontal cortex, ACC, and the precuneus

Belief-desire MPFC/ACC inhibitory system

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Other possible polarities

Ambiguous vs. unambiguous Belief vs. preference here and now vs. there and now (allocentric perspective)

The Nature of Attachment

Environmental Influences on the Development of Social Cognition

Maternal disciplinary style (Ruffman, Perner, & Parkin, 1999; Vinden, 2001) Other features of the emotional climate within the family (e.g., Cassidy et al., 1992; Denham, Zoller, & Couchoud, 1994) The inclination of mothers to take the psychological perspective of their child, including maternal mind-mindedness and reflective function in interacting with or describing their infants (Fonagy, Steele, Steele & Holder, 1996; Fonagy & Target, 1997; Meins et al., 2003; Meins, Fernyhough, Wainwright, Das Gupta, Fradley, et al., 2002; Peterson & Slaughter, 2003; Slade, 2005; Sharp, Fonagy; & Goodyer, 2006)

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Range of Environmental Influences on the Development of Social Cognition The quality of childrens primary attachment relationship facilitates theory of mind development leading to passing standard theory of mind tasks somewhat earlier (e.g., de
Rosnay & Harris, 2002; Fonagy & Target, 1997; Fonagy, Redfern, & Charman, 1997 Harris, 1999; Meins, Fernyhough, Russell, & Clark-Carter, 1998; Raikes & Thompson, 2006; Steele, Steele, Croft, & Fonagy, 1999; Symons, 2004; Thompson, 2000; Ontai & Thompson, 2002)
Not all studies find this relationship and it is more likely to be observed for emotion understanding then ToM

Attachment as an Addiction
MacLean (1990) speculated that substance abuse and drug addiction were attempts to replace opiates or endogenous factors normally provided by social attachments Panksepp (1998) a common neurobiology to
motherinfant, infantmother, and romantic attachment

Insel (2003) Social attachment is an addictive disorder?

The mesocorticolimbic dopaminergic reward circuit in addiction process

Amygdala/ bed nucleus of ST

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CINGULATE

CINGULATE

HEALTHY MOTHERS OF FIRST INFANTS N=13

THALAMUS - BG AMYGDALA MIDBRAIN FACE-OBJECT VISUAL CORTEX THALAMUS - BG AMYGDALA MIDBRAIN

own baby pictures minus other baby pictures

CINGULATE

own baby pictures minus houses

HEALTHY FATHERS OF FIRST INFANTS N=8

THALAMUS - BG

BASAL GANGLIA AMYGDALA

FACE-OBJECT VISUAL CORTEX

Swain et al., in preparation

Do Different Affective States Trigger the Attachment System Equally?

Crying Neutral Smiling

Whats in a Smile? Maternal Brain Responses to Infant Facial Cues (Strathearn L, Li J, Fonagy P, Montague PR, submitted)

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Brain response of mothers viewing their own babys face

Security, oxytocin change and hypothalamic activation

*

OWN

UNKNOWN

>
Hypothalamus Midbrain

Pons Pituitary region

(-3,2,-16)

Maternal security and hemodynamic change

5 4.5 4 % signal change

mPFC VS

3.5 3 2.5 2 1.5 1 0.5 0 -0.5 -1 -1.5

y=11

x=-6

R Ventral Striatum
(t=3.1, P<0.005)

R mPFC
(t=3.0, P<0.01)

Secure
1.2 1

Insecure/Dismissing

% signal change

Insula VS

0.8 0.6 0.4 0.2 0 -0.2 -0.4

y=6

y=16

-0.6 R Ventral Striatum

(t=3.0, P<0.01)

R Insula
(t= -3.9, P<0.0005)

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Simple test of mindmind-mindedness

Friendly - A

Sad - B

Surprised - C

Worried - D

Simple test of mindmind-mindedness

SurprisedSurprised-A

Sure about somethingsomething-B

JokingJoking-C

HappyHappy-D

Oxytocin and performance on Mind in the Eyes test (Domes et al., 2008)

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The development of mentalization

The development of mentalization

Weeks after birth the baby smiles at humans (social beings) in preference to objects
Can tell its own body (shell) from that of another persons

2 months after birth infants prefer the subtle patterns of contingency in face-to-face interactions, including turn taking and correlated affect (Gergely and Watson, 1999; Murray and Trevarthen, 1985). By 9 months, infants are able to follow another person's gaze to a location outside of their visual field
A key first step in establishing joint attention (Moore, 2008).

From 12 months babies deliberately engage and redirect attention of caregiver (pointing and vocalizing)

Joint ( triadic) attention provides a platform by which two or more people coordinate and communicate their intentions, desires, emotions, beliefs, and/or knowledge about a third entity (e.g. an object or a common goal) (Tomasello et al., 2005). By 2.5 years children implement complex social tactics teasing, lying, saving face (Reddy, 2008: How infants know minds)

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False belief task: unexpected transfer

(Wimmer & Perner, 1983)

Test question
Where will he look After that, Mum to first for his book? Then she leaves Then he leaves to Maxi puts his comes to tidy Mum and takes puts it the inup book doin some work in Now, Maxi returns play the garden book in the the room the kitchen. out the of bookshelf the cupboard, looking for his book cupboard

Effect of Age in 178 separate studies

2nd 4yof 4th year

2nd 4y of 4th year

Very robust developmental trends most manipulations ineffective Meta-analysis of False Belief Studies (Wellman et al., 2009)

The embodied mind and research on the human infant

Massive denial of infant mentation outside of psychoanalysis until about 75 years ago
Half a century ago infants were commonly subjected to surgery without anesthetic (curare was used to stop squirming inconvenient for the surgeon) Can infants have minds when they are no yet able to speak?

Astounding discoveries concerning early social awareness in infants

Mentalization is embodied before it is cognitive Freud may have been correct about the mental life being somatically grounded (the body is at the root of meaning.

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Sensitivity to others state of mind

False belief for baby True belief for Smurf True belief for baby False belief for Smurf

M Kovcs et al. Science 2011;330:1830-1834

Sensitivity to others state of mind

Ball Not There False belief for baby
The infant but not the Smurf believes that the ball should be there

Ball Not There True belief for baby False belief for Smurf
Infant knows ball is not there But Smurf believes it should be there

Neither infant nor the smurf believe that ball is there

Neither infant nor the Smurf believe that the ball should be there

The two key conditions in Smurf Study: Infant of 7 months considers what agent (Smurf) believes about the status of ball
Published by AAAS et al. Science 2010, 330:1830-1834 M Kovcs

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Boring Epistemology
Explanations in psychology How we acquire beliefs What we observe as infants

The progress of biological explanations of psychopathology

Historically three attempts to ground the assumptions of causation to instinct Three major human instincts have been the focus of explanations of development and its distortion in psychological disorder
1. The psychosexual instinct Freud and classical psychoanalysis 2. The instinct for attachment Bowlby, Ainsworth and early infant researchers 3. The instinct for communication Gergely, Tronick and modern infant research

Species-specific ways to acquire beliefs based on communication

We can accept a culturally transmitted 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 deductive relations to the contents of other beliefs inductive relations to the evidence, in accordance with the principles of theoretical rationality.

To accept on account of the authority (deferentially transmitted, Recanati, 1997)

its source is known, remembered and judged to be reliable (or trustworthy) taken to be shared common knowledge among members of ones community

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Deciding between competing accounts in context of authority

Decision between competing accounts are made in terms of relevance defined as cognitive benefit (Sperber & Wilson, 1995)
automatically computed trade-off between the cognitive effects produced by the novel implications arrived at and the cognitive effort devoted to processing these implications

Deferentially transmitted knowledge

may remain cognitively (or epistemically) opaque to the individual may make more transparent by tracking its inferential connections to the contents of other beliefs and to later acquired relevant evidence may remain cognitively opaque to the individuals throughout their lives.

The Transmission of Culture and Why Therapy Works

How do we know who to learn from? How does Trust relates to attachment? How do you do it? Why does it work?

The need for human natural pedagogy

We are born into a world populated with manmade tools whose functional properties, appropriate manner of application or method of (re)production often remain in many respects epistemically opaque The cognitive opacity of kind or category-relevant aspects of human-made functional artifacts raises a learnability problem (of relevance-selection) for the nave juvenile observational learner

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Management of Attention Self Regulation Inhibitory Control Learning and Educational Achievement

Attachment Security

Social Cognition

Reestablish Epistemic Trust

Interpersonal Skills

Classroom Behavior Friendship Patterns

Pathways from Attachment to Educational Achievement

Getting comfortable in the social world

Adapting to the social world is a steep learning curve

Getting comfortable in the social world

Me play drums??

For example, it is not obvious what is the true function of all the objects we use.

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Getting comfortable in the social world

Luckily, humans have evolved to teach and learn from each other quickly and efficiently
8 8

Getting comfortable in the social world

-..quickly and efficiently if certain conditions are met

8

Natural Pedagogy theory (Csibra & Gergely, 2006; 2009, 2012)

A human-specific, cue-driven social cognitive adaptation of mutual design dedicated to ensure efficient transfer of relevant cultural knowledge Humans are predisposed to teach and learn new and relevant cultural information from each other Human communication is specifically adapted to allow the transmission of a) cognitively opaque cultural knowledge b) kind-generalizable generic knowledge c) shared cultural knowledge

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Two basic kinds of intentional agency observed by infants (Gergely, 2010).

Observing instrumental actions
Observe agents perform instrumental actions as a means to satisfy their subjective desires and preferences Requires the third-personal ascription to the agent of a goal or intention to achieve some desirable outcome in light of her beliefs about the world, in accordance with the principle of practical rationality (Dennett, 1987; Fodor, 1992).

Observing actions of agents with communicative intentions

Fulfillment depends on their being recognized by their addressees. To make sense of an agents ostensive communicative action, Infants must make sense of the agents communicative intention (Csibra, 2010) to enable inferences to the intended meaning.

Definition of Ostensive Stimuli (Sperber & Wilson, 1995)

The signals whereby an agent makes manifest to an addressee her communicative intention: to manifest some new relevant information for the addressee (i.e. her informative intention). Infants display species-specific sensitivity to, and preference for, some non-verbal ostensive behavioral signals Examples of ostensive communication cues
(see Csibra, 2010, Csibra & Gergely, 2009 for reviews)

eye-contact turn-taking contingent reactivity special tone (motherese)

The Pedagogical Stance is triggered by Ostensive-Communicative cues

Ostensive cues have in common
Infant recognized as a self Paid special attention to (noticed as an agent)

Ostensive cues function:

to signal that the other has a Communicative Intention addressed to the infant/child to Manifest New and Relevant information about a referent

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Ostensive cues referential expectation in infant

6-month-olds followed an agents gaze-shift to one of two objects but only when it had been preceded by either eye contact or infant-directed speech (ostensive signals) addressed to the infant (Senju and Csibra, 2008). An automated eye-tracker based study used an infantinduced contingent reactivity paradigm to demonstrate that 8-month-olds gaze follow an unfamiliar objects bodily orientation response towards one of two targets, but only when the object had been reacting contingently before (producing self-propelled body movements such as tilting) to being looked at by the infant (Deligianni et al., 2011).

Experimental illustration of ostensive cues Gergely, Egyed et al. (in press)

Subjects : 4 groups of 18-month-olds 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

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Ostensive Communicative Demonstration Requester: OTHER person (Condition 1)

Other person

Non-Ostensive (Non-Communicative) Demonstration Requester: OTHER person (Condition 2)

Other person

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Condition 4: Non-Ostensive (Non-Communicative) Demonstration Requester: SAME person

Same person

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Epistemic trust and secure attachment

Secure attachment is created by a system that also induces a sense of epistemic trust that the information relayed by the teacher may be trusted (i.e. learnt from) Evidence
Cognitive advantage of secure attachment Contingent responsiveness to the infants own (at first, automatic) expressive displays in secure attachment During mirroring interactions, the other will mark her referential emotion displays in a manifestative manner to instruct the infant

How Attachment Links to Affect Regulation

DISTRESS/FEAR

BONDING

Down Regulation of Emotions Exposure to Threat

EPISTEMIC TRUST

Activation of attachment

Proximity seeking

The forming of an attachment bond

Getting comfortable in the social world

but this special interpersonal channel for learning about the social world is not always tuned in.
1 0

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Tuning in to the interpersonal channel

When there is abuse, there is no trust, the mind Trust opens up the social communication is blocked andenabling it is impossible to move forward superhighway, us to learn and change
1 0

Tuning in to the interpersonal channel

Win theopens other up person s trust by responding Trust the social communication and they will tune in thoughts, to you! showing contingently to their feelings and superhighway, enabling us to learn and change them that you are hearing and thinking about whats going on in their mind
1

Implications: The nature of psychotherapy

Mentalizing may be key to psychotherapy not because we need to learn about our minds to learn about those of others Mentalizing is a generic way of establishing epistemic trust
Our subjectivity being understood is necessary key to open up wish to learn about world including social world Experience of feeling thought about makes us feel safe enough to think about social world

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Implications: The nature of psychotherapy

Pernicious aspect of trauma is the destruction of trust in social knowledge of all kinds Epistemic mistrust follows maltreatment or abuse and therapists ignores this knowledge at their peril Psychotherapy may be effective for two reasons
Content Source

Therapy is not just about the what but the how of learning
Opening the persons mind via establishing contingencies so (s)he once again can trust the social world by changing expectations Not what is taught in therapy that teaches but evolutionary capacity for learning from other is rekindled

Gaps in Therapy Outcomes Research No solid evidence for who will benefit from what type of psychotherapy

Inexact therapies effectiveness

partial

Attachment to methods guildification of interventions

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Common (Mentalizing) Elements of Therapies with Severe Disorders

Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) acceptance and recognition Include a model of pathology that is explained to the patient increased cognitive coherence (early phase) Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship foundation of alliance (epistemic trust) Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) restore cognitive representation of emotion

Common (Mentalizing) Elements of Therapies with Severe Disorders

Inquiry into patients mental states (behavioral analysis, clarification, confrontation) strengthen representations of mental states Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, sit side-by-side) enhance intentionality (mental state drives action) Structure is manualized with adherence monitored support therapist in non-mentalizing context Commitment to the approach ditto Supervision to identify deviation from structure and support for adherence ditto (therapist needs lots)

Intersubjectivity and Affect Regulation

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Theory: Birth of the Agentive Self

Attachment figure discovers infants mind (subjectivity)
Internalization Representation of infants mental state

Core of psychological self

Attachment figure

Inference

Infant

Infant internalizes caregivers representation to form psychological self Safe, playful interaction with the caregiver leads to the integration of primitive modes of experiencing internal reality mentalization

The Development of Affect Regulation

Closeness of the infant to another human being who via contingent marked mirroring actions facilitates the emergence of a symbolic representational system of affective states and assists in developing affect regulation (and selective attention) secure attachment For normal development the child needs to experience a mind that has his mind in mind
Able to reflect on his intentions accurately Does not overwhelm him Not accessible to neglected children

The development of regulated affect

Psychological Self: 2nd Order Representation
Representation of self-state: Internalization of objects image

..Symbolization of Emotion
Expression

Physical Self: Primary Representations

symbolic binding of internal state

Reflection Resonance

Constitutional self in state of arousal

With apologies to Gergely & Watson (1996)

Fonagy, Gergely, Jurist & Target (2002)

Infant

CAREGIVER

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Mirroring sadness

Unmarked mirroring

Marked mirroring

High congruent & marked mirroring

Low congruent & low marked mirroring

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?
Hyperactivation of Attachment and Social Cognition

Dimensions of mentalization: implicit/automatic vs explicit/controlled in Othello

That which I so loved and gave thee Why,handkerchief how now, ho! from whence ariseth this? Thou gavest to Cassio. Are we turn'd Turks, and to ourselves do that Which heaven hath forbid the Ottomites? in's hand. By heaven, I saw my handkerchief
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. Amygdala PFC temporal Lateral PFC Medial Ventromedial PFC By heaven, I saw my handkerchief in's hand.
cortex

Controlled

Automatic

Arousal

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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 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

Attachment Disorganisation in Disrupted Early Relationships

DISTRESS/FEAR

Adverse Emotional Experience Exposure to maltreatment

Activation of attachment

Proximity seeking

The hyperactivation of the attachment system

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The hyper-reactivity of the attachment system in BPD

We assume that the attachment system in BPD is hypersensitive (triggered too readily) Indications of attachment hyperactivity in core symptoms of BPD
Frantic efforts to avoid abandonment Pattern of unstable and intense interpersonal relationships Rapidly escalating tempo moving from acquaintance to great intimacy

Both maternal and romantic love elicit an overlapping set of deactivations

middle prefrontal, inferior parietal and middle temporal cortices mainly in the right hemisphere, as well as the posterior cingulate cortex
attention, long-term memory, variable involvement in both positive but mainly negative emotions
o underpin interface of mood related memory & cognition

temporal poles, parietotemporal junction and mesial prefrontal cortex

social trustworthiness, moral judgements, theory of mind tasks, solely negative emotions, attention to own emotions
o underpin determining other peoples emotions and intentions

Schematic Representation of Attachment Related Brain Activation

Attachment System

(-)
Interface of mood, (long term) memory and cognition

(-)
Social trustworthiness negative affect and mentalising

System A

System B

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Assurances Game Payoff Matrix

Participant Partner Strategy A (cooperate) Strategy B (defect)

Strategy A (cooperate)

You get $6 Your partner gets $6

You get $4 Your partner gets $0

Strategy B (defect)

You get $0 Your partner gets $4

You get $2 Your partner gets $2

(Kollock, 1998; Kelley et al., 2003)

Response to partners hypothetical cooperation in Assurances Game

Cooperate
2.5 2

1.5 Placebo Oxytocin 1

0.5

Defect
0

BPD

Normal Control

Group x Oxytocin: F(1, 23)=4.82, p < .05 (Bartz et al, in prep)

Attachment Disorganisation in Psychotherapy

Mild Distress/ Anxiety
Emotionally Challenging Experience in Relation to the Emotional Challenge Therapist

Activation of attachment

Proximity seeking

The psychotherapeutic hyperactivation of the attachment system

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Genetic vulnerability

Activating (provoking) risk factors (emotional abuse, trauma, non-mentalizing social system)

Poor control of attention

Inhibition or decoupling of social cognition (social misjudgements, paranoid thoughts, mentalizing failure)

Poor affect regulation

Attachment system disorganized by trauma & stress

Hyper-reactive attachment system

Re-emergence of pre-mentalistic modes of subjectivity (psychic equivalence pretend mode teleological thinking

Fragile interpersonal understanding Early attachment environment

Vulnerability risk factors

Formation risk factors (interpersonal stress, experience of rejection)

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm

Psychic equivalence:
Mind-world isomorphism; mental reality = outer reality; internal has power of external Experience of mind can be terrifying (flashbacks) Intolerance of alternative perspectives (I know what the solution is and no one can tell me otherwise ) Self-related negative cognitions are TOO REAL! (feeling of badness felt with unbearable intensity)

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm Pretend mode:
Ideas form no bridge between inner and outer reality; mental world decoupled from external reality Linked with emptiness, meaninglessness and dissociation in the wake of trauma Lack of reality of internal experience permits selfmutilation and states of mind where continued existence of mind no longer contingent on continued existence of the physical self In therapy endless inconsequential talk of thoughts and feelings o The constitutional self is absent accompany thoughts feelings do not

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The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm Teleological stance:
Expectations concerning the agency of the other are present but these are formulated in terms restricted to the physical world A focus on understanding actions in terms of their physical as opposed to mental outcomes Patients cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other. Only action that has physical impact is felt to be able to alter mental state in both self and other
o Manipulative physical acts (self-harm) o Demand for acts of demonstration (of affection) by others

Understanding suicide and self-harm in terms of the temporary loss of mentalization

Loss
Increase attachment needs attachment system triggering of

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

Theory: Birth of the Alien Self in

Disorganized Attachment
The caregivers perception is inaccurate or unmarked or both Attachment Child Mirroring fails The nascent self Figure
Absence of a representation of the infants 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

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Theory: Self-destructiveness and

Torturing alien self

Externalisation Following Trauma

Self representation

Perceived other

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

Torturing alien self Self representation

Externalisation Following Trauma

Torturing alien self Externalization

Perceived other

Unbearably painful emotional states: Self experienced as evil/hateful

Container

Self Selfexperienced experienced as as hated evil and and attacked hateful

Self-harm state

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

Assessment of Mentalization

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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

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

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 persons 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

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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

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

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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

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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
Youre trying to drive me crazy You hate me She does my head in. I cant think once she starts on me

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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 others feelings Self-serving empathic understanding A persons feelings are exaggerated or distorted in the service of someone elses agenda

Misuse of Mentalizing(2)
Coercion against or induction of the thoughts of others
Deliberate undermining of a persons capacity to think by humiliation Extreme form is sadistic or psychopathic use of knowledge of others 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

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