Mentalization Based Therapy for Families

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1 Mentalization Based Therapy for Families NEW! IMPROVED! Some Free Publicity JUST RELASED! Ja-Vegard Nilsen Finn Skårderud Oslo, 7. juni 2012 Washes minds whiter! Much longer than all previous versions! 2012 American Psychiatric Publishing, Inc 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 an intentional being Creating phenomenological coherence about self and others Introspection for self-construction know yourself as others know you but also know your subjective self Mentalizing can be seen as essential for: sense of self constructive social interactions mutuality of relationships sense of personal security SO mentalizing is a core psychological process worthy of focus in treatment. 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... 1

2 Some features of good mentalizing Learning About My Mind, Your Mind 1. Is curious / inquisitive about own and other people s perspectives ( safe uncertainty Mason) 2. Being flexible not stuck in one point of view 3. Can be playful using humour to engage (vs avoid) 4. Can solve problems using give and take between different people s views 5. Can differentiate one s own experience from that of others 6. Conveys ownership of own behaviour 7. Uses grounded imagination Mind in mind Contingent Marked Mirroring Sam-I-am 9 How Attachment Links to Affect Regulation DISTRESS/FEAR Theory: Birth of the Agentive Self Attachment figure discovers infant s mind (subjectivity) Internalization Down Exposure Regulation to Threat of Emotions BONDING BONDING Activation of attachment Representation of infant s mental state Core of psychological self Proximity seeking Attachment figure Inference Infant The forming of an attachment bond 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 2

3 Theory: Birth of the Alien Self in Disorganized Attachment The caregiver s perception is inaccurate or unmarked or both Attachment Figure Mirroring fails Child Absence of a representation of the infant s mental state The nascent self 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 Mirroring sadness Unmarked mirroring Marked mirroring Mirroring happiness The baby looks at his mother s face and finds himself there D. Winnicott She/he thinks that I think, therefore I am P. Fonagy Unmarked mirroring Marked mirroring EEG study of the responses of maltreated and non-maltreated children to viewing an angry face (Cicchetti & Curtis, 2005 Dev. & Psychopath.) Normal child Maltreated group Abused child A Developmental trajectory, with high frequency fluctuations: Mentalization is fragile Programmed for overwhelm Comparison group 3

4 Dimensions of mentalization: implicit/automatic vs explicit/controlled 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. 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 Controlled Automatic Arousal Arousal A biobehavioral switch model of the relationship between stress and controlled versus automatic mentalization (Based on Luyten et al., 2009) Mentalization Based Work with Familes Basic Clinical Principles Consideration, interpretation and appraisal of mental states (in self and other) essential for healthy relationships Aim of treatment is to help family maintain capacity to mentalize even in stressful situations The focus is on processes (mind not behaviour) - positive changes in mentalizing act as a catalyst for further changes: Clinical summary of intervention Focus is on a break in mentalizing psychic equivalence, pretend, teleological Rewind to moment before the break in subjective continuity Explore current emotional context in session by identifying the momentary affective state between patient and therapist Identify therapist s contribution to the break in mentalizing (humility) Seek to mentalize the therapeutic relationship MENTALIZING BEGETS MENTALIZING AND HEALTHIER PSYCHOLOGICAL FUNCTIONING (Bateman and Fonagy, 2012) 4

5 Mentalizing stance The MBT-F-Loop Notice And Name Terminating Non-mentalizing Inquisitive Holding the balance Highlighting mentalizing Generalise (and Consider Change) Checking Mentalize The Moment Core Features - The MBT-F Loop (ii) Core Features - The MBT-F-Loop (iii) Notice And Name Checking Checking is a powerful enactment of the Therapist's Stance Respectful curiosity, expressed tentatively, about mental states. Checking the Links Accurate mentalizing increases the narrative coherence of an event Checking as confirming the limits of our 'mind-reading'. Checking understandings also powerfully affirms the mentalizing notion that we do not have privileged access to the contents of each other's minds Checking as affirming of the value of mentalizing. Implicit in our checking understandings and feelings is that we affirm the importance of understanding other peoples' mental states. Core Features- The MBT-F-Loop (iv) To share and provoke curiosity amongst and between the family members. Core Features- The MBT-F-Loop (iv) Attitude that learning about how others are thinking and feeling is enlightening. This is fascinating, I wonder Sally what it feels like for you when your dad does x? Dad, what do you think it feels like for Sally? If one could see thought bubbles come out of your wife s head, what might be in there about how she thinks Sally feels right now? Checking and encouraging family members to rehearse their own Checking. The major aim of status quo mentalizing: To set a context for what could be termed emotional brainstorming. Mentalize The Moment Generalise (and Consider Change) An attempt to move away from discussing a specific interaction that occurred during the session and to 'widen the lens towards: GENERALISING: Capturing more generalised understandings relating to this specific observation. INVITING VISION: Generating possible applications of these understandings, by "inviting vision" of alternative strategies. PLANNING: Planning the implementation of these changes. 5

6 Core Features- The MBT-F-Loop (v) Checking Checking back at the end of the loop Each family member views what happened from a meta-perspective. Evaluating what may have been a new and emotionally charged experience, giving them the opportunity to reflect together about what happened and the possible consequences. What did you make of what happened? Can you talk together about what this was like for each and all of you? Are there any conclusions you can draw from this? The Four Stage Loop -1 Follow these 4 stages 1. Noticing and Naming: Observing patterns of interaction Checking for consensus Questioning the problem 4. Checking feeling states Checking feelings Checking links between thoughts, actions and feelings Checking out your own Mentalizing 2. Mentalize the Moment Being curious yourself Provoking curiosity in the coparents Pausing, reviewing and marking 3. Generalizing and considering change Widening the lens Considering constructive alternatives Planning action or Considering Specific Action 32 Mind Scanning Mentalizing a Picture write down / discuss a) what atmosphere is contained in the picture? b) what is / are person(s) feeling? c) what is / are person(s) trying to communicate? d) what is on the painter s / photographer s mind? e) What does it trigger in you? Mentalizing Music MBT-F Manual What atmosphere is portrayed? what is the composer trying to communicate? what is the performer thinking / feeling? Web-based, open source : Downloadable Editable (for the adventurous - note licensing restrictions though) what feelings / thoughts / desires / wishes / hopes are triggered in you? 6

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