Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
Borderline personality, mentalizing and mother-infant interaction
Prof Anthony Bateman AAIMHI WA Meeting Perth
n Mrs. Darling first heard of Peter when she was tidying up her children's minds. It is the nightly custom of every good mother after her children are asleep to rummage in their minds and put things straight for next morning, repacking into their proper places the many articles that have wandered during the day.
n If you could keep awake (but of course you can't) you would see your own mother doing this and you would find it very interesting to watch. It's quite like tidying up drawers. You would see her on her knees, I expect, lingering humorously over some of your contents, wondering where on Earth you picked this thing up, making discoveries sweet and not so sweet, pressing this to her cheek, as if it were a nice kitten, and hurriedly stowing that out of sight.
n When you wake in the morning, the naughtiness and evil passions with which you went to bed have been folded up small and placed at the bottom of your mind and on the top, beautifully aired, are spread out the prettier thoughts, ready for you to put on.”
J.M. Barrie in Peter Pan
The development of the ‘mentalizing self’
n The capacity to mentalize emerges through interaction with the caregiver:
n The quality of the attachment relationship Ø If the parent is:
o Able to reflect on infant’s intentions accurately
o Does not overwhelm the infant Ø Then this:
o Assists in developing affect regulation
o Helps develop child’s sense of a mind and of a reflective self
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).
Mentalization: The basics n Attachment and mentalization are loosely coupled
systems existing in a state of partial exclusivity.
n Mentalization has its roots in the sense of being understood by an attachment figure, Ø it can be more challenging to maintain mentalization
in the context of an attachment relationship (e.g. the relationship with the therapist) (Gunderson, 1996).
n BPD associated with hyperactive attachment systems as a result of their history and/or biological predisposition
n But without activation of the attachment system in therapy borderline PD patients will never learn to function psychologically in the context of interpersonal relationships.
Psychological Self:
2nd Order Representations
Physical Self: Primary
Representations
Representation of self-state: Internalization of object’s image
Constitutional self in state of arousal
Expression
Reflection
Resonance
Infant CAREGIVER
symbolic organisation of internal state
signal non-verbal
expression
Affect & Self Regulation through Mirroring
With apologies to Gergely & Watson (1996) Fonagy, Gergely, Jurist & Target (2002)
How Attachment Links to Affect Regulation
DISTRESS/FEAR
Exposure to Threat
Proximity seeking
Activation of attachment
The forming of an attachment bond
Down Regulation of Emotions EPISTEMIC
TRUST
BONDING
Bowlby’s Attachment Theory
n Need of human infant to seek protection and security through physical contact with the caregiver
n Attachment system Caregiving system n Attachment behaviours Caregiving behaviours
Ø proximity seeking - touching Ø clinging - holding Ø smiling - soothing
n Affectional bond: expectation of being offered care
Attachment Styles Our attachment to others can be described as: 1. Secure 2. Insecure -Ambivalent (sometimes called anxious) 3. Insecure – Distanced (sometimes called avoidant) 4. Disorganised
Implicit- Automatic- Non -conscious- Immediate.
Explicit- Controlled Conscious Reflective
Mental interior cue focused
Mental exterior cue focused
Cognitive agent:attitude propositions
Affective self:affect state propositions
Imitative frontoparietal mirror neurone system
Belief-desire MPFC/ACC inhibitory system
Multifaceted Nature of Mentalization Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
amygdala, basal ganglia, ventromedial prefrontal cortex (VMPFC), lateral temporal cortex (LTC) and the dorsal anterior cingulate cortex (dACC)
lateral and medial prefrontal cortex (LPFC & MPFC), lateral and medial parietal cortex (LPAC & MPAC), medial temporal lobe (MTL),rostral anterior cingulate cortex (rACC)
Associated with several areas of prefrontal cortex
Associated with inferior prefrontal gyrus
the medial prefrontal cortex, ACC, and the precuneus
frontoparietal mirror-neuron system
medial frontoparietal network activated
recruits lateral fronto-temporal network
Relational Aspects of Mentalization n Overlap between neural locations of mentalizing
self and other may be linked to intersubjective origin of sense of self Ø We find our mind initially in the minds of our parents
and later other attachment figures thinking about us Ø The parent’s capacity to mirror effectively her child’s
internal state is at the heart of affect regulation Ø 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
Ø Failure to find the constitutional self in the other has potential to profoundly distort the self representation (exaggerated mirroring of child’s anxietyè aggravates anxiety rather than soothe)
Ø The same applies to child with inadequate sense of independent self within therapeutic relationship
What goes wrong for mentalizing and attachment?
Attachment Disorganisation in Disrupted Early Relationships
DISTRESS/FEAR
Exposure to threat
Proximity seeking
Activation of attachment
The ‘hyperactivation’ of the attachment system
Adverse Emotional Experience
A biobehavioral switch model of the relationship between stress and controlled versus automatic mentalization (Based on Luyten et al., 2009)
Attachment - Arousal/Stress
DISTRESS/FEAR
Adverse emotional experience rooted in
traumatic relationships
Inhibition of mentalisation
Intensification of attachment needs
Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse
Inaccurate judgements of affect, Delayed development of mentalization understanding
Failure to understand how emotions relate to situations and behavior
Implicit- Automatic- Non -conscious- Immediate.
Explicit- Controlled Conscious Reflective
Mental interior cue focused
Mental exterior cue focused
Cognitive agent:attitude propositions
Affective self:affect state propositions
Imitative frontoparietal mirror neurone system
Belief-desire MPFC/ACC inhibitory system
Imbalance of mentalization generates problems Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
Impulsive, quick assumptions about others thoughts and feelings not reflected on or tested, cruelty
Does not genuinely appreciate others’ perspective. Pseudo-mentalizing, Interpersonal conflict ‘cos hard to consider/reflect on impact of self on others
Unnatural certainty about ideas Anything that is thought is REAL Intolerance of alternative ways of seeing things.
Overwhelming dysregulated emotions, Not balanced by cognition come To dominate behavior. Lack of contextualizing of feelings leads to catastrophyzing
Rigid assertion of self, controlling others’ thoughts and feelings.
Hypersensitive to others’ Moods, what others say. Fears ‘disappearing’
Hyper-vigilant, judging by appearance. Evidence for attitudes and other internal states hasto come from outside
Lack of conviction about own ideas Seeking external reassurance Overwhelming emptiness, Seeking intense experiences
BPD
BPD
BPD
BPD
Prementalizing Modes of Subjectivity n Psychic equivalence:
Ø Mind-world isomorphism; mental reality = outer reality; internal has power of external
Ø Intolerance of alternative perspectives èconcrete understanding Ø Reflects domination of self:affect state thinking with limited internal focus
n Pretend mode: Ø Ideas form no bridge between inner and outer reality; mental world
decoupled from external reality Ø “dissociation” of thought, hyper-mentalizing or pseudo-mentalizing Ø Reflects explicit mentalizing being dominated by implicit, inadequate internal
focus, poor belief-desire reasoning and vulnerabilty to fusion with others
n Teleological stance: Ø A focus on understanding actions in terms of their physical as opposed to
mental constraints Ø Cannot accept anything other than a modification in the realm of the physical
as a true index of the intentions of the other. Ø Extreme exterior focus, momentary loss of controlled mentalizing Ø Misuse of mentalization for teleological ends (harming others) becomes
possible because of lack of implicit as well as explicit mentalizing
Prementalizing Modes n Psychic equivalence:
Ø Child will be ‘mis-seen’ Ø Misattributions likely and difficult (if not impossible for the infant or child) to challenge Ø “He knew (infant aged 8 weeks suffered fractured ribs) I was just about to go out for a fag
when he started crying…” Ø In Lighthouse MBT-P we call this the Projecting Beam
n Pretend mode: Ø Care for the infant may correspond broadly to his needs but likely to be misattuned and
child’s experience will be a mixture of having needs met while not being accurately, markedly mirrored; can often result in frustration triggering psychic equivalence then resulting in compliance in the infant over time
Ø Baby who sleeps 16 -17 hours every day, never cries, but gains weight, slow meeting milestones, mother appears bland but ‘looks normal and affectionate’ (social worker observation)
Ø “dissociation” of thought, hyper-mentalizing or pseudo-mentalizing and vulnerability to fusion with others
Ø can be present in Factitious and Induced Illness n Teleological stance:
An infant may well be seen as responsible for mental state of parent is invariably in a precariousposi+on.“Iknowshehatesme,shecan’tbeartolookatme”“Hethrewhiscarrotsonthefloor,hethrewtheplate.IwasjustsoangrywithhimIjusthadtoputhiminthehallway,andwalkawaytocalmdown.Atthe@meitfeltliketheworstthinghecouldpossiblyhavedoneandnowlookingbackIthink,‘Ohhejustthrewhiscarrotsonthefloor.’Inthatmomenttherejec@onofthecarrotsfeltliketherejec@onofallmyloveandallthegoodItrytodo.ItwaslikehewasonemorepersoninmylifetellingmethatwhateverIdoisnotgoodenough.”
Cycles of inhibition of mentalizing
Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Try to control or change others
Frightening, undermining, frustrating, distressing or
coercive interactions
Loss of certainty that thoughts are
not real
Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Frightening, undermining, frustrating, distressing or
coercive interactions
Try to control or change others or oneself
Person 1
Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Try to control or change others or oneself
Frightening, undermining, frustrating, distressing or
coercive interactions
Person 2
Vicious Cycles of Mentalizing Problems within the Family/Parent-child
Mentalizing failures in trauma
AFRAID, terrified,
overwhelmed, helpless, out of
control +
ALONE, abandoned,
neglected, unloved, without needed comforting and making sense
T
R
A
U
M
A
unmentalized
+
terrorizing mindblind
traumatizer
traumatized
Developmental impact of attachment trauma
attachment trauma
hyperarousal
impaired mentalizing
secure attachment
optimal arousal
mentalizing
0
1
2
3
4
5
6
Sexual risk taking (Slope=1.79, SE=0.81, p<.03)
Parent rated aggression (Slope=1.17, SE=0.57, p<0.04)
Hostile behavior (Slope=0.09, SE=0.10, n.s.)
Coef
ficie
nt fo
r Pre
occu
pied
Atta
chm
ent
Age 13 (n=217)Age 15 (n=201)Age 17 (n=172)
Attachment class and BPD features:
0
0.5
1
1.5
2
2.5
3
Sexual risk taking Parent rated aggression Hostile behavior
Coef
ficie
nt fo
r Dis
mis
ing
Atta
chm
ent Age 13 (n=217)
Age 15 (n=201)Age 17 (n=172)
Preoccupied attachment
Dismissing attachment
Preoccupied attachment predicts increased sexual risk taking and aggressive behaviors over the course of adolescence, as well as steeper rates of growth in these behaviors Given that these behaviors reflect impulsivity, deficits in self-regulation (core features of BPD)è preoccupied attachment may be related to the development of BPD. Observed in several other studies.
Kobak, Zajac & Smith, C. (2009)
0
1
2
3
4
5
6
Secure Preoccupied Fearful Dismissing
Commmunity Controls (n=64)
MDD (n=64)
BPD (n=109)
Self-Reported Attachment Styles and BPD
Mea
n sc
ore
Choi-Kain et al. (2009)
Disorganized attachment (D)
n Behavior lacks an observable goal n Look fearful n Behavior is bizarre n May try to leave after the reunion or freeze
• A disorganised attachment pattern is noticeable in the unstable relationships BPD patients usually have
Holmes, 2004; De Zulueta, 2006; Barone, 2003 • Zero order partial correlations between BPD and disorganised
attachment in clinical population: 0.44 for adolescents and 0.48 for adults (p≤0.001)
Westen et al., 2006
• In a sample of 140 BPD subjects, 40% presented disorganised attachment
Barone, Fossatu & Gulducci, 2011
• In a review of 13 studies, the percentage of BPD patients presenting disorganised attachment has been estimated between 32.2% and 89%. This percentage raised to 100% among BPD patients with history of trauma.
Agrawal et al., 2004
• Among these studies, earlier ones show stronger correlations between BPD and disorganisation (around 0.8). Subsequent studies showed a somewhat weaker association (0.5-0.6)
Levy, 2005
• A longitudinal study found that disorganisation during infancy was unrelated to adult BPD features. More important predictors were maltreatment and maternal disrupted emotional communication
Lyons-Ruth et al., 2005
BPD and disorganised attachment
Attachment and cognitive functioning: the development of competence in logical reasoning
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
7 9 11 13 15Age
secure insecure disorganised
Source: Jacobson et al
Circle of Security Marvin, Cooper, Hoffman & Powell (2002)
n Child’s Exploratory System and Needs Ø The child can move off and explore, if he
believes and expects that the attachment figure will be available if, or when, needed
n Attachment System Ø The child needs the attachment figure to be
available to protect, comfort, delight, and organize his feelings when he becomes overwhelmed
Cooper, Hoffman, Marvin &Powell , 2000
Impact of Empathic Failure
n “Whatever she fails to recognize in him he is likely to fail to recognize in himself. In this way, it is postulated, major parts of a child’s developing personality can become split off from, that is, out of communication with, those parts of his personality that his mother recognizes and responds to, which in some cases include features of personality that she is attributing to him wrongly.” Bowlby (1988) p.132
The journey from attachment to communication
The theory of natural pedagogy and epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014)
n New form of evolution (late Pleistocene) based on learning and the transmission of cultural knowledge
n The challenge of discerning of epistemic trustworthiness and the need for EPISTEMIC VIGILANCE!
n The pedagogic stance is triggered by ostensive communicative cues (E.G. turn-taking contingent reactivity, eye contact)
n Ostensive cues have in common Ø Person recognized as a self Ø Paid special attention to (noticed as an agent)
ET= Epistemic
Trust
Triggering the Pedagogical Stance n Ostensive cues function to trigger epistemic
trust: Ø Opening channel to receive knowledge about social
and personally relevant world (CULTURE) Ø Going beyond the specific experience and acquire
knowledge relevant in many settings Ø Triggers opening of an evolutionarily protected
epistemic channel for knowledge acquisition n Mimicry may be protected by human evolution
because it generates epistemic trust Ø Social smile (recognition of self) increases imitation
because smile generates epistemic trust and opens channel to receive knowledge
Subjects : 4 groups of 18-month-olds Stimuli: Two unfamiliar objects
Experimental illustration of ostensive cues Gergely, Egyed et al. (2013)
1: Baseline – control group
Simple Object
Request by Experimenter A
Subjects: n= 20 Age: 18-month-olds
No object-directed attitude demonstration
Ostensive Communicative Demonstration
Other person
Requester: OTHER person (Condition 1)
Non-Ostensive (Non-Communicative) Demonstration
Other person
Requester: OTHER person (Condition 2)
Condition 4: Non-Ostensive (Non-Communicative)
Same person
Demonstration Requester: SAME person
A 50:50 animal from Corriveau et al.
50% pig : 50% bear If Mother names hybrid as pig then stranger always names it bear
A 50:50 animal from Corriveau et al. 50% cow : 50% horse
If Mother names hybrid as horse then stranger always
names it cow
A 75:25 animal from Corriveau et al.
75% rabbit : 25% squirrel Mother always names hybrid as squirrel and stranger always names it rabbit
A 75:25 animal from Corriveau et al.
75% bird : 25% fish Mother always names hybrid as fish and stranger always names it as bird
Proportion of Trials on Which Children Chose Their Mother for Information by Attachment Group and by task
Perc
ent M
othe
rs C
hose
n
Avoidant 0 Secure
20
40
60
80
Attachment Classification at 18 months
*
N=146
***
Anxious Resistant
Disorganised
***
***
*** ***
***
Novel Object
50-50 Hybrid
75-25 Hybrid
Corriveau, Harris, Meins et al., Child Dev,, 80, 750-761.
Conclusions from attachment and epistemic trust studies
n Security of attachment èfeeling recognizedè increases likelihood of trust in the source of communication when it is reasonably credible Ø Also empowers confidence in own experience and
belief (empowers judgment) n Avoidance leads to epistemic mistrust while
anxious attachment generates overreliance on views of attachment figure
n Disorganized attachment èmisattunement è mistrust of both attachment figure and stranger Ø Who to trust? è epistemic hyper-vigilance
Social Cues that Create Epistemic Trust n Attachment to person who responded sensitively in
early development is special condition for generating epistemic trust ècognitive advantage of security è including neural development (Van Ijzendoorn et al.)
n Generally any communication marked by recognition of the listener as intentional agent will increase epistemic trust and likelihood of communication being coded as Ø Relevant Ø Generalizable Ø To be retained in memory as relevant
n OSTENSIVE CUES TRIGGER EPISTEMIC TRUST WHICH TRIGGERS A SPECIAL KIND OF ATTENTION TO KNOWLEDGE RELEVANT TO ME
Parents with borderline personality
disorder and social vulnerability
Borderline Personality Disorder
Self-Concept Social
Interaction
Emotion Dysregulation
Mentalizing Positive Emotions in Borderline Personality Psychopathology and Psychotherapy: A randomized phase-based multiple-baseline study Tine Harpøth, Mickey Kongerslev, Anthony Bateman & Erik Simonsen Psychiatric Research Unit, Region of Zealand, Denmark
n The ”broaden and build” theory proposes that positive emotions - independently of negative emotions - help people build lasting resources.
n Enhancing positive emotions through psychological interventions may increase resilience.
n Specific intervention ‘mentalizing positive emotions’ n Outcomes: General psychopathology; personality
disorders and BPD pathology; Differential emotions; Resilience (Ego-resilience scale (ER-89) and Perseverance and passion for long-term goals (GRIT-S); Life Satisfaction Satisfaction with Life Scale (SWLS);Therapeutic alliance (patient-rated) Working Alliance Inventory (WAI)
n
n I depend on others a lot n I can‘t manage when people don‘t respond
to me n I am an outsider n I am different from others (shame) n Others will reject me n I do not deserve being part of the group
(guilt) n I am ugly (self-contempt- self disgust)
Reported Social Cognitions in BPD
Rejection-sensitivity (anxiously expect, readily perceive, over reaction) in different patient populations
Stäbler et al., 2011
Rejection Sensitivity in acute and remitted BPD patients
HC
RS
Q-S
co
re (
0-3
0)
0
5
10
15
20
acuteBPD
remittedBPD
HC
RSQ-Score
0
1
2
3
4
5
acuteBPD
remittedBPD
HC
RSQ-Score
0
1
2
3
4
5
acuteBPD
remittedBPD
cognitive RS
affective RS
HC
acute BPD
remitted BPD
N=77 N=15 N=75
Bungert et al. BPDED, 2015
UCLA Loneliness Scale (n=40 female BPD; 40 HC)
Figure 1. Graph of social judgement scores for each of six dimensions.
Nicol K, Pope M, Sprengelmeyer R, Young AW, Hall J (2013) Social Judgement in Borderline Personality Disorder. PLoS ONE 8(11): e73440. doi:10.1371/journal.pone.0073440 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0073440
Approachable as Unapproachable
Unapproachable as Approachable
Trustworthy as Untrustworthy
Untrustworthy as Trustworthy
Judgment bias for approachability and trustworthiness of faces.
NS NS
BPD
Control P<.001
P<.001
Direction of bias
Nicol et al., 2013 Plos One
Trust in Borderline Personality Disorder King-Casas, Sharp, Lomax-Bream, Lohrenz, Fonagy, & Montague (2008) Science, 321, 806-810. n Studying social behavior in task that involves
Ø Live interaction with unknown but real person Ø Engages mesocorticolimbic dopaminergic reward
circuit
n Total patients screened è assessed è scanned: Ø BPD: 1,060 è 224 è 62 Ø Mood control: 622 è 235 è 22 Ø Normal control: 877 è 398 è 116
X 3
Investor Trustee
$20
A dynamic version of the Trust game (10 rounds) BPD: The absence of Basic Trust
Camerer & Weigelt, (Econometrica, 1988) Berg, Dickhaut & McCabe (Games and Economic Behavior, 1995)
Average Repayment:
repay everything
repay nothing
repay investment (33%)
Investor Sent MU sent / MU available
36 non-psychiatric investors 42 BPD investors
Trustee Repaid MU sent / MU available
rounds
60%
50%
40%
30%
20%
10% 1 3 4 7 9 5 6 8 10 2
60%
50%
40%
30%
20%
10% 1 3 4 7 9 5 6 8 10 2
36 non-psychiatric trustees 42 BPD trustees
Effects of inclusion on subsequent interaction
z = 0
x = 0
Reaction to Small Investments
(I < .25) minus (I > .5); p < .004, uncorrected, n = 36 trustees
anterior insula
anterior cingulate cortex (ACC)
Sanfey et al, TICS, 2006
response to “unfair” offers in an Ultimatum Game
(take it or leave it)
A Neural Signature of ‘Borderlineness’ in Trust Task
Cyberball
Did you feel ostracized?
BPD patients significantly more often feel ostracized under inclusion and uncontrollable conditions Staebler et al., 2011; Domsalla, Lis, Bohus et al., 2013
(Domsalla, Lis, Bohus et al., SCAN, 2013)
Social perception: fMRI
BPD patients showed a stronger engagement of the dorsal anterior cingulate and medial prefrontal cortex particularly in inclusion conditions =
HYPERMENTALIZING
Virtual Reality Group Interaction Paradigm
Become acquainted
Appraisal
Exclusion
Inclusion
Reappraisal Social
Cooperation
VR Group Interaction Paradigm
Social expectations before and after feedback
Do you expect that people will invite you?
0
2
4
6
8
10
12
Inklusion Exklusion
HC BPD
70
58
47
35
23
11
0
%
Inclusion Exclusion
Social expectations before and after feedback
Would you like to invite others?
n Social inclusion in the VRGIP Ø Has little influence on people with
BPD Ø Increases suspicion Ø BPD become less co-operative than
under exclusion conditions
Results
n Start from a position of distrust n Assume you are to be disadvantaged and
seen as an outsider n Sensitivity to unfairness n Interprete social cues as being an outsider n Positive social cues aversive and increase
suspicion n Feel impoverished and become either
mean or over-generous in social interaction
Summary
Implications for
treatment
The Natural Pedagogy Model of PD
History of Adversity
Insecure/ Disorganized Attachments
Emotion Dysregulation
Failure of Ostension
Loss of Balanced
Mentalizing
Social Dysfunction Communication Failures
High Epistemic
Vigilance or Hypervigilance
Limits on Social
Learning Processes
Epistemic Mistrust Imperviousness to Social Influence
Social Disruption
Compromised Social
Network
Loss of Interest in Social
Communication
Sensitive caregiving
Caregiver’smentalizingoftheinfantactsasthe
prototypicalostensivecue
Secure attachment
Epistemic trust
Learningchannelopens(selec6vely)
Self-control & self-
learning Learning about the
world
Thislaysthefounda+onsfor…
Learning about others
Whichenables… Mentalizing
Successful navigation of social world
Neglect/a;achmenttrauma
Ostensivecuesarenotprocessed,wereabsent
ormisleading
Insecure/disorganizedaBachment
Absenceofepistemic
trust
Learningchannelisclosed,indiscriminatelyopenorbothbyturns
Epistemichyper-vigilance
Excessivecredulity
Epistemicdilemma
Mentalizingdifficul6es
Problemsnaviga+ngsocialworld
Problemsunderstanding
othersInall3cases,theindividualstrugglestolearneffec+vely
abouteitherselforworld
Video feedback
Aims to improve the parent’s: n nurturing n understanding of what their child’s behaviour
means n responses to cues and expressions of the child’s
feelings n behaviour so that it is not frightening to the child n mastery of their own feelings when nurturing the
child.
Parental sensitivity and behaviour training
Aims to help parent’s: n understand their child’s behaviour n improve their responsiveness to their
child’s needs n manage difficult behaviour.
Home visiting Includes observing the child (not using video) with their parents
Aims: to help parent’s improve their communication and relationship with their child by:
n using role modelling n reinforcing positive interactions and parental empathy n parental education on child development .
Parental Stance
n Not-Knowing Ø Curiosity and interest Ø Uncertainty Ø Testing out Ø Active questioning of one’s assumptions Ø Asking others
n Monitor you own misunderstandings Ø Surprise and re-appraisal Ø Errors offer opportunities to re-visit to learn more
about contexts, experiences, and feelings leading to effective actions
Increase of emotional arousal
(including depression)
Activation of secondary attachment strategies
mentalizing impairment
Impaired social interaction
Loss of personal resilience
A vicious cycle in BPD
Fonagy & Luyten, 2009; Northoff et al., 2006; Mennin et al., 2013; Lemma, Target & Fonagy, 2011
Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Frightening, undermining, frustrating, distressing or
coercive interactions
Try to control or change others or oneself
Person 1
Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Try to control or change others or oneself
Frightening, undermining, frustrating, distressing or
coercive interactions
Person 2
Vicious Cycles of Mentalizing Problems within the Family/Parent-child
Lighthouse Project (Gerry Byrne et al)
n The lighthouse beams Ø illuminating beam (the mentalizing stance, wanting to
know the child Ø scanning beam (ready to notice, keeping an eye and
an ear out for the child) and the safe harbour (snap judgements in which a child can be mis-seen)
n Secure and insecure attachment patterns are represented by the metaphors Ø Safe Harbour (secure), Ø Piracy and Battleships (insecure conflicted/
ambivalent), Ø Raft (avoidant) Ø Rocks Beneath the Surface (disorganized)
Lighthouse Project (Gerry Byrne et al)
n The Wrecking Light acknowledges that in the parent’s own childhood they may have suffered abuse, that is that an adult offered a false beam that signaled Safe Harbour but led to abuse and trauma.
n Night Seas addresses the role of the unconscious in children’s (and parents’) fears and anxieties and acknowledges the increased risk of loss of mentalization and of risk of harm to the child around bedtime and at night through increased stress and exhaustion in parents
Thank you for mentalizing!
For further information [email protected] Slides available at: http://www.ucl.ac.uk/psychoanalysis/people/bateman