School of Social Work

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1 SPRINGFIELD COLLEGE School of Social Work Preparing Social Workers for Leadership in the 21st Century Journal of Advanced Generalist Social Work Practice Published by Springfield College School of Social Work Volume 12, Number 1

2 Journal of Advanced Generalist Social Work Practice

3 Editorial Board Faculty at the Springfield College School of Social Work Walter J. Mullin, PhD, Professor, Co-Editor Ann W. Roy, PhD, Professor, Co-Editor Miguel Arce, MSW, Associate Professor James Canning, PhD, Professor Karen Clark-Hoey, PhD, Assistant Professor William Fisher, EdD, Professor and Director of Field Education Glenn Gemma, MSW, Assistant Director of Field Education Joseph R. Gianesin, PhD, Professor John Habif, MSW, Associate Professor Thomas Harrigan, MSW, Assistant Director of Field Education Anthony Hill, EdD, Assistant Professor Effrosini Kokaliari, PhD, Associate Professor Linda Smith, DSW, Professor Joyce Taylor, PhD, Assistant Professor Francine J. Vecchiolla, PhD, Professor and Dean Joseph Wronka, PhD, Professor The mission of the Springfield College School of Social Work is to teach social work practice and knowledge to prepare its students to meet universal human needs, and to engender mutually beneficial interaction between individuals and societal systems at all levels based on principles of economic and social justice, dignity, and human rights. The School offers the only master of social work program in New England that can be completed part time in three years with weekend classes. It also offers a full-time weekday program that can be completed in two years. An advanced standing master of social work program is available to qualified graduates of bachelor of social work programs that are accredited by the Council on Social Work Education. The school also offers a combined master of social work/juris doctorate, a four-year program in conjunction with Western New England University School of Law. The School of Social Work is part of Springfield College s long history of service to others. The School of Social Work is located in at the College s Brennan Center The Journal of Advanced Generalist Social Work Practice is an annual publication. Copies are available by contacting Springfield College School of Social Work, 263 Alden Street, Springfield, MA Mailing Address: 263 Alden Street Springfield, MA Phone: (413) , (413) springfieldcollege.edu/ssw Location: Springfield College Brennan Center 45 Island Pond Road Springfield, MA 01109

4 Journal of VOL. 12 Advanced NO. 1 Generalist Social Work Practice Published by Springfield College School of Social Work v Introduction Walter J. Mullin, PhD, and Ann W. Roy, PhD, Co-Editors Articles 1 The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder Andrew DiFiore 20 Coping Strategies of Parentally Bereaved Children Melissa Sonier 26 The Fragmented Self of Norma Jeane: The Use of Self Psychology in Understanding and Treating the Psyche of Marilyn Monroe Laura B. DeAngelo 35 Finding Strengths to Help a Client Who is Persistently Delusional Abbie Rieley Vita 44 Experiences of People in Close Relationships with Combat Veterans Suffering From Post-Traumatic Stress Disorder Abbie Rieley Vita 60 Students Living Sober Through Persistence and Academic Achievement Keith Jones and Christen Maglio 83 JB and Control of His Impulses: A Single-System Design Elizabeth C. LaRaia

5 Introduction to The Journal of Advanced Generalist Social Work Practice Many of us are familiar with the term generalist. What readily comes to mind is a social worker who has chosen to pursue a career path that entails a breadth of knowledge in a variety of domains, rather than to specialize in any one arena. The term advanced generalist social work practice (AGSWP), however, does not have as commonly understood a definition. In fact, used in the context of graduate social work education, this term has taken on a variety of definitions, often dependent upon the nature of the environment where a school of social work with an advanced generalist approach is located. For example, a school of social work in a rural environment, where distances are great and the availability of social, economic, and health resources tends to be scarce, might readily adopt an advanced generalist approach. Why so? For one, with its emphasis on three levels of social work practice micro, mezzo, and macro a graduate social work student is prepared for social work practice that requires her to have a broad and varied range of skills to meet the multifaceted needs of a rural community. For example, this social worker may need to work with clients who have a depression that began as a response to the harsh realities of an economically struggling rural community or to work with older adults who are or have become isolated as their children move away to look for better work opportunities. Very likely, this same professional social worker will be tapped to use her administrative, policy, and grant-writing skills as director of the community agency. AGSWP is a model that also works within an inner city, urban environment. Here, a school of social work may provide graduate students with an advanced generalist approach to meet the overwhelming economic, social, and health/mental health needs of the urban community. A deep understanding of human behavior, knowledge of best practices, and the capacity to practice culturally competent social work are essential to meet the needs of an urban community. Concomitantly, there is a need for the professional social worker to

6 have skills in social policy analysis and to provide macro interventions where necessary to change inequitable laws at the state level, or local agency policies that negatively impact urban clients. Across the country, social workers deliver services in a multitude of settings, performing vastly different roles in each setting but always seeking to facilitate and improve human functioning. AGSWP is a practice approach that prepares students to apply theory and intervention skills in all these settings. The approach is based on knowledge of the interaction between the person and environment, giving credit to each person s unique individual characteristics. It is an approach rooted in humanism. Interventions are designed in such a way as to support a person s own capacities and strengths, always remaining respectful of the individual s own choices to determine the course of his or her own life. In AGSWP, life s problems are understood as the result of troubled human relationships, including the personal relationships of daily life as well as those with larger social systems. The resolution of these problems, however, is also found in the connections to other people in reality, by finding a social solution. The AGSWP social worker is a collaborator. AGSWP traces its roots to the early days of social work, when both micro and macro approaches were based on an understanding of larger social problems and the circular cause and effect on the person and society at large. In the early days of the profession, social work practice focused on poverty, child abuse/neglect, and medical illness. With awareness of the impact of these problems on individuals, social workers searched for ways to assist people to build lives that were free of these problems. As the profession evolved, it became clear that effective work with individuals would benefit by integrating psychological concepts. These approaches, however, were always at risk of missing the ways that larger social or political issues contributed to the individual s problem. Since many social workers are employed in agencies that deliver direct interventions to clients, it is reasonable to understand a social worker s confusion about how to actually implement an effective AGSWP approach in his or her daily work. There is no concrete answer to this dilemma. Instead, the AGSWP approach requires that social workers first orient themselves to understanding both that problems exist on the personal, micro level, as well as a result of larger system operations. Knowing, for example, that an emotional problem may exist because of a person s experience with racism or because a child is placed in a school that cannot adequately accommodate him, the social worker goes beyond merely focusing on the symptoms of

7 vi Journal of Advanced Generalist Social Work Practice mental illness. Next, social workers allow themselves to be flexible in the roles they take with each of their clients. While they might offer psychotherapy to one person, they may utilize case management with another; all the while employed at the same agency with the same mission. In addition to this introduction to the journal, there are seven other articles. In the first article, the author defines mentalizing and offers a case of a client diagnosed with borderline personality disorder. He then demonstrates the benefit of understanding mentalization for direct practice work. In discussing the concept of mentalization, the author discusses the importance of secure attachment relationships toward developing the capacity to mentalize. In the second article, the author discusses childhood grief. She uses attachment theory to emphasize the ways that secure attachments facilitate healthy grieving. The author asserts that reading with children is a helpful approach for children who have lost a parent. She also discusses the benefits of religion and spirituality. In the third article, the author writes about Marilyn Monroe s lifelong mental health struggles. The author uses self psychology as a way to understand Marilyn Monroe s emotional struggles. The fourth article is presented as a case study, in which the author demonstrates the benefits of taking a strengths approach with a person who has a severe mental illness. The author acknowledges strengths and utilizes an approach that relies on self-determination and client empowerment. The fifth article tackles the subject of post-traumatic stress disorders (PTSD). In this article, the author uses a qualitative research approach to investigate the experiences of people who are in close relationships with veterans suffering from PTSD. The author of the sixth article describes the experience of working at a recovery high school as it worked to help students with substance-use problems. The authors demonstrate how motivational enhancement interviewing (MET) enhances clients motivation to change. In the final article, the author uses a single-system research design to access the impact of cognitive-behavioral therapy in changing a client s impulsive behavior. The author then measures changes in development using the Self-Refection and Insight Scale (SRIS). Walter J. Mullin, PhD Ann W. Roy, PhD

8 The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder Andrew DiFiore Borderline personality disorder (BPD) is characterized by longstanding, ingrained patterns of affective instability, fear of real or perceived abandonment, interpersonal difficulties, and identity disturbance. The disorder is estimated to affect percent of the adult population (Kernberg & Michaels, 2009; Lenzenweger, Lane, Loranger, & Kessler, 2007; Swartz, Blazer, George, & Winfield, 1990; Zanarini et al., 2011). While earlier statistics had concluded as much as a 3:1 ratio (American Psychiatric Association, 1994) of women to men living with the diagnosis, some recent studies have described equal prevalence among sexes, partially due to biases in diagnosis (Grant et al., 2008; Skodol & Bender, 2003). Mental health clinics often see a disproportionately high number of clients with BPD, with some estimates suggesting that 20 percent of inpatient residents meet the diagnostic criteria for the disorder. This is often due to the high incidence of self-harming behaviors (e.g., cutting, burning of the skin) common in the diagnosis (Kernberg & Michaels, 2009; Linehan, 1993). Clients with BPD typically have intense, passionate interpersonal relationships wrought with oscillations between idealization and devaluation of the other person, and transient dissociative and quasi-psychotic episodes are not uncommon. High rates of comorbidity with other disorders, including major depressive disorder (MDD), bipolar disorder, substance abuse disorders, and anxiety disorders are frequently found with BPD (Grant et al., 2008; Linehan, 1993). While no one cause has been determined to lead to the onset of BPD, Fonagy and Bateman (2008) have proposed that early attachment trauma and

9 poor-quality attachment relationships in infancy and childhood create deficits in the development of neurobiology responsible for emotional regulation, leading to hyper-arousal of the attachment system during times of intense emotional arousal, a problem that is seen as central to the disorder. Research has also identified risk factors including physical and sexual abuse, childhood neglect, family violence, and early separation and loss of an important attachment figure that are associated with the development of the disorder (Liotti & Pasquini, 2000). Rates of suicide completion are estimated to be between 9 percent and 10 percent (Bender et al., 2001; Paris, 2004) in individuals with BPD, positioning the disorder as a serious clinical concern with implications on public health. ATTACHMENT THEORY The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder 2 John Bowlby (1969) pioneered research on attachment in early childhood, demonstrating that repeated caregiver-child dyadic affective and cognitive interactions led to the creation of internal working models that serve as a blueprint for future attachment relationships and interpersonal expectations throughout the entire lifespan, and function to organize and develop the personality and the self. Under ideal, secure attachment conditions, a child can explore the world with a sense of emotional and physical safety and security while allowing his or her sense of self to develop (Bowlby, 1969, 1988). Conversely, when a child is repeatedly exposed to environments that are wrought with instability and caregivers who are neglectful and emotionally insensitive or unavailable, a child s worldview becomes one in which the world and/or caregiver is unstable and unsafe, and these beliefs become internalized. For example, a child whose primary caregiver is emotionally distant and insufficiently attentive to the needs of the child may begin to regard others as unresponsive and not worthy of trust. Children who develop positive attachments have a secure base to return to when they explore the world. They are able to safely evaluate others, adapt and adjust to emotional responses and behavior, and reach out to others in times of stress and anxiety. Mary Ainsworth further developed the attachment perspective by conducting an experiment she called the Strange Situation, which led to the identification of three attachment styles in children: secure, anxious/ ambivalent, and avoidant (Ainsworth & Bell, 1970). In this experiment, children entered a room in which there was a stranger, with their mothers. Each child was left to play while both the mother and the stranger were in the room. Then, the mother would leave the room, leaving the child with the

10 3 Journal of Advanced Generalist Social Work Practice stranger. Children were observed during periods of separation from and reunion with their mothers and rated on dimensions such as proximity seeking, avoidance of the mother, and searching for the mother (Ainsworth & Wittig, 1969). She and her co-researchers concluded that securely attached children are aware that their caregivers will be available and soothe them when they are upset. Anxious/ambivalently attached children do not easily become soothed by caregivers and will hesitantly explore their worlds. Avoidant children do not seek out caregivers in times of distress and tend to not have preferences between caregivers and strangers when they need to be soothed. Later, Mary Main, one of Ainsworth's students, identified a fourth attachment style, which she named disorganized, characterized by odd, dazed behaviors, slowed or frozen motor movements, and indecision between the desire to approach the caregiver to be soothed and avoid a caregiver who is frightened or frightening (Wallin, 2007). Researchers have concluded that there is a correlation between this disorganized attachment and BPD, in that the approach-avoidance behavior seen in disorganized children is also a fundamental characteristic of the interpersonal functioning of individuals with BPD (Clarkin, Levy, Lenzenweger, & Kernberg, 2004; Holmes, 2004; Main, 1995). A child who has come to fear or distrust an attachment figure on whom he or she relies for safety and comfort becomes confused, unsure of his- or herself, and unsure about whom he or she can trust. These attachment patterns can persist throughout childhood and remain into adulthood. John Bowlby did not regard attachment as a fixed phenomenon (Bowlby, 1988). Rather, attachment styles are malleable, and inputs from social environments and interpersonal relationships can lead to changes in them. Therapeutic interventions such as attachment-focused therapy (AFT), based on attachment, have demonstrated success in repairing insecure attachments (Kilmann, Urbaniak, & Parnell, 2006; Ringel, 2004; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000). Longitudinal studies have supported the fluidity of attachment over the lifespan, with attachment generally moving toward security as the individual ages (Tomlinson, Carmichael, Reis, & Aron, 2010; Zhang & Labouvie-Vief, 2004). The presence of an attachment figure or the internalized representation of one provides comfort and security. Just as insecure attachment during adulthood can be repaired, secure attachment in adult relationships can be disrupted when attachment to an individual s prototypical attachment figure becomes derailed. Attachment in adulthood can be measured by the adult attachment interview (AAI), a semi-structured interview that assesses early attachment

11 The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder 4 experiences. Individuals rate themselves as secure, preoccupied, unresolved, dismissing, or unclassified, based on responses they give about here-and-now feeling states, developmental risk factors, interpersonal functioning, interactions with parents, early memories, and descriptions of the parent-child relationship (Main & Solomon, 1986). Disorganized attachment in infancy and childhood translates to unresolved attachment in adulthood, according to the AAI, with dissociation and emotional withdrawal being frequent reactions to interpersonal distress (Holmes, 2004; Main, 1995). Usage of the AAI has been found to predict positive-affect regulation skills in individuals found to have secure attachments (Bouthillier, Julien, Dubé, Bélanger, & Hamelin, 2002). A composite of studies using the AAI demonstrates 50 to 80 percent of clients with BPD can be classified as either having preoccupied or unresolved attachment styles (Barone, 2003; Barone, Fossati, & Guiducci, 2011; Diamond, Stovall-McClough, Clarkin, & Levy, 2003; Fonagy et al., 1996; Lyons-Ruth, Melnick, Patrick, & Hobson, 2007). Because of the centrality of interpersonal difficulties found in BPD, the attachment perspective provides a rich framework to work from, combining human development with the intrapsychic domain and the interpersonal, relationship-based paradigm. MENTALIZATION Secure attachment with caregivers can lead to the capacity to imagine and understand intentional mental states in self and others (wishes, thoughts, feelings, and desires) (Dennet, 1987), almost as if being able to read the minds of others. The child and caregiver are attuned to one another. Labeled mentalization, this ability is a developmental task acquired during the first few years of life, cultivated through secure attachments and emotional and cognitive interactions with caregivers who are able to mirror the child s emotional states as to allow the child to internalize self and others affective and cognitive representations (Gergely & Watson, 1996). This conveys to the child an experience of being understood and contributes to the child learning to manage emotional states. An inability to understand mental states of self and others is understood to be integral to the affect dysregulation so common in clients with BPD (Fonagy & Bateman, 2007). Relational or developmental trauma such as sexual abuse, neglect, abandonment, and divorce can rupture the caregiver-child affective bond and, consequently, the attachment relationship, derailing mentalization (Fonagy et al., 2002; Harman, 2004). The concept of mentalization, rooted in attachment theory, Kleinian thought (Stein, 2003), the philosophical concept theory of mind ( I have a mind

12 5 Journal of Advanced Generalist Social Work Practice of my own, different than yours, and my own understandings of situations and people are different than yours ), and neurobiology (Fonagy et al., 2002), has been described by Dennett (1987) as the intentional stance, or an individual s ability to conceptualize and understand the minds of others, almost as if an individual is able to read minds to understand the intentions of others thoughts and behavior. Stein (2003) describes similarities between mentalization and Melanie Klein s conceptualizations of the depressive and paranoid-schizoid positions (Klein, 1935). The infant who has attained the depressive position is able to integrate the goodness and badness of others and understand and feel remorse when he or she has hurt others, because the infant has achieved the ability to feel guilt (Grotstein, 2009). Further, the separation-individuation that the infant is able to experience in the depressive position allows the infant to understand others (i.e., caregivers, parents) as their own separate persons with their own minds that are separate and different than the infant s. Conversely, the paranoid-schizoid position is seen as promoting a firmly non-mentalizing stance, in which splitting occurs and the child (or adult) retreats toward a mental state that Fonagy et al. (2002) refer to as pretend mode, in which the individual s inner world is severed from external reality (Grotstein, 2009; Klein, 1935; Stein, 2003). For example, a child is said to be mentalizing when he or she decides to lie to the caregiver. The child is aware that what he or she is saying is not the same as what the caregiver knows. The child understands that his or her reality is not the same as the other person s reality (Fonagy et al., 2002; Slade, 2000). Additionally, the child knows that there are other persons who have their own minds and that how those other people see the child is not the same way that the child sees him- or herself. Caregivers support the development of mentalization through attunement to a child s inner world. This mirroring and marking of affective states, thoughts, and behaviors allows a child to make sense of who he or she is, or in other words, develop a coherent sense of self (Stern, 1985). This mentalizing approach is wholly psychodynamic, because it examines child-caregiver interactions from a pre-verbal or pre-oedipal stage but does take into account cognitive and metacognitive factors, as mentalizing does involve here and now practices of thinking about thinking. Mentalization is not a phenomenon that simply exists or that is absent. Rather, it is on a continuum. Clients with BPD are theorized to have a reduced capacity for mentalizing (Fonagy et al., 2002) due to a contributory history of insecure attachments. Bateman and Fonagy (2004) have proposed that a disruption in mentalizing is the primary feature in BPD, similar to Linehan s

13 The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder 6 (1993) suggestion that emotional dysregulation is at the heart of the disorder. The way toward developing the ability to mentalize can be derailed by disruptions in meaningful attachments or trauma. Personality is thought to develop through interpersonal relations with attachment styles reflecting the overall quality of the interactions. Winnicott (1953) uses the term good enough mother to describe the mother (or caregiver) who attends to the relationship that she has with the infant, repairs any breaks in the dyad, and accurately marks and mirrors the child s mental states while taking interest and wondering about the infant s inner world. Emotion regulation is thought to come from the development and persistence of these secure attachments and depends on how sensitive a caregiver is to a child s various affective states (Stern, 1985; Tronick, 2007). As important as attachment relationships are to developing the capacity to mentalize, neurobiological factors also play a contributory role. Fonagy, Luyten, and Strathearn (2011) suggest that increased activity of the neuropeptide oxytocin in the mother is associated with maternal bonding and the activation of the attachment system. The raised level of oxytocin potentially creates a heightened awareness to the inner world of the infant and attention to its mental state and, thus, a better understanding of its mind, promoting mentalization. In children who have been neglected or mistreated, lower concentrations of oxytocin have been reported (Fries, Ziegler, Kurian, Jacoris, & Pollak, 2005), along with decreased amounts of oxytocin contained in cerebrospinal fluid of adult women who had reported histories of emotional abuse and neglect (Heim et al., 2009). In individuals with BPD, the clinical administration of oxytocin was shown to reduce dysphoric feelings in a population that reported trauma histories while also causing an attenuation of the hormone cortisol, which is released in times of stress and anxiety (Simeon et al., 2011). Trauma prepares the brain for a constant fight, flight, or freeze response, which can have debilitating effects on the brain as well as the body, including cardiovascular problems (McEwen, 2002). Repeated exposure to trauma can significantly inhibit the neurobiological processes necessary for normal activation of the attachment system in the brain, temporarily disrupting memory and mentalizing. Fonagy et al. (2002) posit that attachment trauma strikes at the basis of attachment trust and the non-mentalizing mode that results in a retreat to psychic equivalence, during which the individual experiences his or her inner world as equal to the outside world and, consequently, is traumatized over and over again, viewing others and the world as distrustful, unsafe, and threatening. Attachment trauma

14 7 Journal of Advanced Generalist Social Work Practice can also cause a regression into the primitive (pre-oedipal) pretend mode, in which reality testing is impaired and the individual is unable to experience his or her inner world as having any relationship or implications to the outside world (Fonagy et al., 2002). In the context of normal development, these two modes are integrated, giving way to mentalization. MENTALIZATION AS A RELATIONAL PROCESS Mentalization concerns itself with relationships. It develops and blossoms within mutual interactions in prototypical relationships, is fed through positive interactions with others, and is the foundation of knowing one s self in relation to others through implicit and explicit understandings of emotions, behaviors, thoughts, and desires (Fonagy et al., 2002; Jurist, 2010; Slade, 2000). In the development of mentalization, which should be contrasted with the simpler self-awareness, the individual begins to see his or herself as a unique person in the world, able to understand others from their perspectives and see the self from an outsider s point of view. Pure self-awareness is a one-person task; mentalization involves knowing mind from mind. In the caregiver-child relationship, caregivers attune themselves to the child s affects and wonder about what the child is experiencing, mirroring the child. In turn, the child begins to reflect an understanding of the caregiver, empathizing and understanding the caregiver as another person (Fonagy & Target, 2007). Intersubjective theory helps illuminate the relational nature of mentalization. Benjamin (1990) states, The other must be recognized as another subject in order for the self to fully experience his or her subjectivity in another s presence (p. 35). Mentalization flourishes within interactions of affective experiences between caregiver and child. For example, during play, a mother holds a rattle above the head of her child and shakes it. The child looks up to the source of the sound, clearly different than the soothing sound of the mother s voice. The child looks back at the mother with a curious, yet gleeful look as the mother shifts her gaze toward the rattle as she shakes it again. She looks back at her child, reflecting the curiosity, as if to say, What is that? The child can follow the gaze of the mother from the rattle, back to meeting the child s own eyes, solidifying an understanding that the mother is taking part in a mutual discovery process, in which she shares the infant s curiosity and happiness. With the relational turn in contemporary psychoanalytic thinking, much has been discussed (see Mitchell, 1988, for a more detailed summation

15 of concepts) on incorporating classical (i.e., Freudian) ideas into the twoperson psychology that makes up relational, intersubjective, and interpersonal theory. The classical or intra-psychic realm has been concerned with libidinal pleasures and satisfaction of drives, while the intersubjective position has been frank about explaining that drives are object seeking, thus, they are relational in that the attainment of pleasure through drive discharge requires an external object (Stern, 1985; Stolorow, 2002). Freud (1905, 1921) details, perhaps unintentionally, the relational or intersubjective process of drive satisfaction and object relations in his descriptions of the infant s inner world and the necessity of an external object in how the infant attains pleasure and satisfaction. Earlier child development theories that infants are unable to recognize the self, differentiate among the self, others, and the environment, and are innately self occupied have been challenged by research that suggests babies can identify the physical self in space and make adjustments based on a variety of stimuli, especially touch (Gergely & Watson, 1999). The socio-affective extension of this involves the idea that infants can recognize subjective mental states of the self as being similar to corresponding mental states (p. 210) of others and thus are experienced simultaneously with the caregiver (Fonagy et al., 2002). This sharing of minds is hypothesized to develop affect regulation and is key to mentalization. The mirroring that the caregiver engages in when sharing the mental state with the infant serves as a communication that the caregiver is aware of the mental state that the infant is experiencing. Breakdowns in this process are implicated in BPD; the caregiver, whether by his or her own affective dysregulation or transmission of trauma (Keren & Tyano, 2001) is unavailable or unequipped to engage the infant in these cognitive-affective exchanges. CASE ILLUSTRATION The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder 8 Pamela, an African-American woman in her young twenties who identifies as a lesbian, came into the mental health clinic on the urging of her partner, a woman 13 years her senior. Pamela described a relationship with her partner wrought with argument and frequent conflict, many times over text messaging. The turbulence in the relationship came to a head with Pamela s partner threatening to leave Pamela if she did not go to therapy. Pamela grew up in an urban area in a household as an only child, with a mother she describes as distant and judgmental and a grandmother who was often unpredictable and inconsistent in her support of her. She describes both her mother and

16 9 Journal of Advanced Generalist Social Work Practice grandmother as largely unresponsive to her needs as a child, with both acting as if responding to her needs was a nuisance. Her father was absent from the home throughout all of her childhood, and Pamela states that she has only met him a few times and that he only contacts her when he needs something. Her mother moved to another part of the country when Pamela was young to be with another man, whom she eventually had children with, leaving Pamela to live with her grandmother through latency and adolescence. During times of interpersonal stress and feeling emotionally unsupported by her mother and grandmother, Pamela found retreat in video games and fantasy movies. She would escape to these often violent worlds, in which she was in control, and she could pretend. Despite doing well in high school, Pamela dropped out of a local community college because she felt like she could not concentrate, and she regularly smoked cannabis, which she says helped calm her down but also made her lethargic, causing her to miss class. When she was 16-years-old, Pamela engaged in her first episode of self-harm, cutting her left arm with a razor after the end of a relationship. Stating that she felt empty and worthless when the relationship failed, she cut herself to punish her former partner, stating that she did it so the partner would know how she felt, all the while knowing that she did not wish to commit suicide. She has stated that although she couldn't feel much of the pain from cutting herself, it felt good to cut. Pamela had an avoidant attachment style, often becoming unresponsive to her partner during times of conflict and leaving their shared apartment to drive around by herself for hours. During the frequent text messaging arguments between Pamela and her partner, she would intentionally withhold her replies for hours, punishing her partner with the lack of a timely response while withdrawing emotionally, unable to describe how she felt. At the same time, Pamela would remark about her partner s own passive-aggressive behavior and how much it angered her when her partner would claim that nothing was wrong when refusing to have a conversation with Pamela when things worsened in the relationship. This was similar to times in her adolescence when she needed to communicate with her mother about her sexuality. Pamela stated that her mother and grandmother would refuse to discuss the topic with her, condemning her sexual orientation and depriving her of a secure base to share her private experiences. Pamela detailed a long history of intense affective reactions, many times when faced with interpersonal stress and the threat of someone close to her leaving. When relationships soured, Pamela would withdraw emotionally

17 The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder 10 until they ended, leaving her feeling empty. She reported that her fears of being abandoned would often be verbalized in angry accusations of betrayal and infidelity levied at her partners, and that she would often insist that her partners were the ones who wished to leave her. This projection of her fears onto her partners and her inability to understand the mental states of others resulted in many relationships failing shortly after they began. Pamela was unable to reconcile her private experiences with reality; her fear that others would abandon her meant that they really would, showing a retreat into psychic equivalence. Importantly, she was unable to notice the workings of her own mind, as she repeatedly engaged in her interactions without awareness. I was Pamela s social worker at the clinic. When meeting with her, I would note my own discomfort when she would tell me she knew I did not want to work with her. Rather than let myself become paralyzed by these projections, I sharpened my own mentalizing abilities, careful to not slip into a lazy claim that I in fact knew how she felt. Instead, I used the feelings of frustration and anxiety that she was able to evoke in me to develop the skills of noticing how both of our minds worked together in the room. SOCIAL WORK INTERVENTION Sessions with Pamela ranged from calm, upbeat discussions about her job and hopes for the future, during which I remained engaged, supportive, and reflective of her while creating an environment of validation and unconditional empathy, to angry outbursts about her current partner and her family s unwillingness to support her in her choices of romantic partners. She generally came to the clinic early for her sessions but often would not wait in the waiting area where other clients would wait, stating that she didn t like being in there and that she preferred to wait in the hallway adjacent to the waiting area. At times, Pamela would share fantasies with me about her desire to design fashionable clothing or violent desires to punish family members who had wronged her. On one occasion, her car needed repair, and her uncle was unable to fix it. She spoke of her retreat into a world where it was acceptable for her to run him over with her car for his inability to understand her and the problem with her car. When I explored the reasons for her anger with her uncle, she claimed that he was stupid, didn t know what he was doing, and just wanted to tinker around with her car with no real plans to fix it. My response to this was to ask her to reflect on that incident and think about another explanation for his inability to fix the car. I also wondered aloud with her how someone else might perceive the situation. At this point, I was demonstrating alongside Pamela the

18 11 Journal of Advanced Generalist Social Work Practice ability to know mind from mind, or to mentalize. Pamela was visibly upset and showed some indications that she had become agitated. I probed her a bit more, validating her anger at the situation not coming to a resolve but wondering what made her refrain from hurting her uncle. At this point, she said she felt a strong desire to get away from the situation, to run away. She then stated that she did not wish to discuss the incident any further. Another session soon followed that I had to cancel abruptly due to illness. The following week, I checked in with Pamela at the beginning of the session to explore what that was like for her, for me to suddenly cancel on her with little notice. She stated that she felt stood up and rejected, as if I had no concern for her need to see me. After this, she became quiet for some time. Inviting her to sit with the silence for a moment, I broke it open, asking her what she noticed in that period of quiet. Pamela said she still felt abandoned by me and that next time, I should be more considerate of her time. I realized that here I needed to validate her concerns while attuning to her mental state. She stayed with the idea that this incident was typical with basically everyone I ve ever dated, and it felt the same way when others had left her. Mentalizing the transference, I sought clarification from Pamela, wondering aloud if perhaps I was not fully understanding how she was interpreting my absence and seeking to understand how she was so sure that I had abandoned her. Finally, we identified the difference in our experiences of the event, came into an understanding of them, and then accepted them, allowing Pamela to consider an alternative perspective. I then asked Pamela if that seemed to make any sense to her, and she mumbled an affirmative response. Several sessions later, Pamela arrived over 20 minutes late for the session. Her habit of coming to sessions a few minutes late had previously been largely unaddressed, but given the longer-than-average tardiness, I felt that it was appropriate to comment, in a warm manner, how I had noticed that she had been coming late to sessions regularly and that perhaps there was something she was avoiding talking about. I noted that in past sessions, when she had either showed up late or been on time and stated that she didn t have anything to talk about that particular week, nearly always something came up in session that she admitted she was avoiding. When the subject of her habitual lateness was broached, she became defensive and angry, denying that she was late. I maintained a steady, calm manner and reflected my understanding of her anger and suggested that perhaps she felt as if I was judging her. Mentalizing is at its heart an intersubjective process, and being able to attend to the repair of the relationship is critical when working with clients such

19 The Capacity to Mentalize in People Diagnosed with Borderline Personality Disorder 12 as Pamela. I reflected my understanding of how my comment could have been perceived as harsh or critical to her and restated my intention of inquiring about her lateness to open a dialogue regarding the work we were doing, noting that a mentalizing stance involves my monitoring my own failures in my own mentalizing, as was the case in my assumption about her resistance. When I spoke to Pamela about what had happened, she remained silent and then made an idiosyncratic comment about a recent movie she had seen, suggesting again her tendency to not mentalize in times of emotional stress. The day following this session, Pamela engaged in self-injurious behavior, which she reported to me during the next session. In the session in which Pamela revealed her self-injurious behavior, in the form of taking a handful of over-the-counter pain medicine, the approach-avoidance behavior often found in clients living with a borderline personality organization was apparent. Pamela shared that she didn t want to come to her session that day and that she didn't feel like talking yet still managed to make it. She then said that she didn't want to talk about heavy stuff and asked to do some sort of activity. Noticing her sullen and withdrawn demeanor and her blunted affect, I suggested that we both join in a mindfulness exercise with some colored play slime. We took a few moments to observe the cold, wet slime in our hands and then described what we noticed and what came up for us. Pamela was silent, staring down at the floor, and made the admission of her overdose of the over-the-counter medication from the previous week. I felt that I had failed to fully understand her reaction to my comments the week before, and she had punished me by self-harming. I wondered about the inner conflict Pamela was experiencing. She said that she didn t want to come to therapy yet was there. Additionally, she has been clear that she is afraid of being left by those close to her (presumably me as well), yet she will do things that would likely drive others away from her. I then wondered aloud to Pamela, asking if the self-harm was punishment, self-sabotage, or even revenge. Her response showed me how she was able to attune to my own state of wonder and curiosity; Pamela said that she had a tendency to blow things up in relationships just as they were getting good and that she always wondered why she did that. As we continued to meet, Pamela continued to speak about a variety of conflicts with her partner on her mind. In one such session, Pamela described an exchange with her partner over Pamela s usage of the bathroom after taking a shower. She said she always gets dressed in the bedroom following a shower, because she doesn t like the small space and moisture of the bathroom when she

20 13 Journal of Advanced Generalist Social Work Practice is trying to dress herself. On this particular occasion, some of Pamela s partner s family were at their home visiting and were using the bedroom where Pamela would normally get dressed after her shower. Pamela became enraged at her partner, because she claimed her partner never understood her and was just doing that [having family use the bedroom, thus forcing Pamela to dress in the bathroom] to make her mad. I attempted to clarify how Pamela s inability to use the bedroom to dress equated her partner s lack of understanding. Pamela dismissed this, so I decided to provide her with my perspective for us to explore. I stated that I didn t feel that it was an unreasonable position for her partner to take, considering that she had family using the bedroom, and that I was confused as to how this incident was designed to make Pamela angry. Pamela insisted that I didn t understand, to which I countered with an intervention meant to promote mentalizing in the session by asking about it. With such a dismissive response to my concerns, I finally suggested that perhaps my own lack of understanding contributed to the angry, irritated state that she presently was in. She laughed, smiled, and said, Absolutely. I accepted this as a beginning acknowledgement that my comments interacted with her mind. In subsequent sessions, Pamela reported better relationship satisfaction with her partner. Her ability to identify feeling was greatly improved, and she said that she was able to use this increased self-awareness when she was upset with her partner and her friends and better communicate her needs and emotions to others. During one session after continuous weeks of progress, I remarked to Pamela that being more aware of her emotions and not allowing them to overwhelm her was like learning a new language. In the following session, Pamela reported having a dream in which she had traveled to Europe and was able to avoid trouble by talking her way out of being caught up in a potentially dangerous situation with some unnamed perpetrators. I suggested to her that perhaps her ability to negotiate tough situations in a foreign land (with presumably a foreign tongue) in her dream was akin to her burgeoning ability to understand others intentions better. DISCUSSION Mentalization is procured through meaningful emotional and cognitive interactions, implicit and explicit, where affective states are identified, emotional cues are read, and differences in self and others are identified and discerned, but where emotion does not deter the ability to notice the workings of the mind. Pamela began to develop an understanding of her partner s