What is Mentalizing and Why Do It?

1. What is Mentalizing and Why Do It? Jon G. Allen, Ph.D. The Menninger Clinic Baylor College of Medicine jallen@menninger.edu

2. Collaboration The Menninger Clinic Baylor College of Medicine Human Neuroimaging Laboratory at Baylor Anna Freud Centre University College London Yale Child Study Center Colleagues • Peter Fonagy & Mary Target; Anthony Bateman • Efrain Bleiberg, Pasco Fearon, George Gergely, Toby Haslam-Hopwood, Jeremy Holmes, Elliot Jurist, Linda Mayes, Richard Munich, Lois Sadler, John Sargent, Carla Sharp, Arietta Slade, Helen Stein, Stuart Twemlow, Laurel Williams

3. For further information Allen JG, Bleiberg, E, Haslam-Hopwood, GTG (2003). Mentalizing as a compass for treatment. Menninger Clinic, Houston, TX. Allen JG, Fonagy P, Bateman AW (2008). What is mentalizing and why do it? (Appendix to chapter on psychoeducation in Mentalizing in Clinical Practice).

4. Overview Defining mentalizing Attachment and the development of mentalizing Mentalizing impairments in psychiatric disorders Promoting mentalizing in treatment

5. Part I Defining mentalizing

6. Defining mentalizing Quickies • holding mind in mind • attending to mental states in self and others • mindfulness of mind Mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior as conjoined with intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) Mentalizing versus “mentalization” • the advantages of a verb, mentalizing as mental action

7. Origins of “Mentalize” First recorded use of the word, 1807 First appeared in Oxford English Dictionary, 1906 • give a mental quality to; picture in the mind • cultivate mentally Used in French psychoanalytic literature in late 1960s Employed in understanding autism in 1989 (Morton) Employed in understanding developmental psychopathology in 1989 (Fonagy)

8. A capsule history: Three waves of mentalizing • autism conceptualized as a stable failure of mentalizing based on neurobiological deficits (“mindblindness”) • borderline personality disorder conceptualized as context-dependent failures of mentalizing (distrust, anxiety, frustration in attachment relationships), for which mentalization-based treatment was developed • mentalizing a core common factor in a wide range of therapies (psychodynamic psychotherapy, interpersonal psychotherapy, cognitive therapy); educating patients and families accordingly

9. Broad scope of mentalizing thoughts feelings self others empathy

10. Mentalizing implicitly versus explicitly perceived nonconscious nonverbal unreflective e.g., mirroring interpreted conscious verbal reflective e.g., explaining IMPLICIT EXPLICIT

11. Mentalizing as an umbrella term Full range of mental states Implicit and implicit processes Self and others Varying time frame present past future Varying scope narrow (e.g., feeling at the moment) broad (e.g., autobiographical narrative)

12. Complaint “Mentalization” has an intellectualizing and potentially dehumanizing ring to it and must be humanized: • We must keep in mind that the mental states perceived and the process of perception are suffused with emotion; mentalizing is a form of emotional knowing • Jeremy Holmes: • thinking about feelings • feeling about thinkings • Holding heart and mind in heart and mind

13. Mentalizing emotion Mentalizing while remaining in the emotional state 1. identifying feelings • labeling basic emotions • awareness of conflicting emotions • attributing meaning to emotions (narrative) 2. modulating emotion • downward and upward 3. expressing emotion • outwardly and inwardly

14. Holding mind in mind

15. Holding mind in mind in emotional states

16. Brain areas associated with mentalizing Perceiving social and emotional cues fusiform gyrus (identifying individuals, e.g., by face) superior temporal sulcus (perceiving agency and intention) temporal pole (interpreting social scenarios) amygdala (detecting emotion, especially threat) Resonating emotionally mirror neurons (activated by performing and observing actions and by feeling and observing emotions) Mentalizing emotion and interpersonal interactions medial prefrontal cortex anterior cingulate cortex “mentalizing region”

17. From mentalizing to defensive “fight-or-flight” posterior-subcortical capacities automatic simple habitual switch point prefrontal capacities executive complex flexible low arousal high arousal

18. Part II Attachment and the development of mentalizing

19. Mentalizing: links to other domains of knowledge EVOLUTIONARY BIOLOGY MENTALIZING ATTACHMENT PSYCHOANALYSIS NEUROBIOLOGY THEORY OF MIND PHILOSOPHY ethics philosophy of mind

20. Mentalizing: links to other domains of knowledge EVOLUTIONARY BIOLOGY MENTALIZING attachment THEORY OF MIND PHILOSOPHY PSYCHOANALYSIS NEUROBIOLOGY ethics philosophy of mind

21. Core functions of attachment safe haven provides a feeling of security (regulation of emotional distress) secure base fosters exploration of the outer world and the inner world, including exploring the mind (mentalizing)

22. Intergenerational transmission: Overview parental security of attachment ↔ parental mentalizing capacity mind-minded interactions with infant infant secure attachment (comfort seeking) enhanced mentalizing capacity in childhood

23. insecure attachment intense emotional distress Non-mentalizing begets non-mentalizing non-mentalizing interactions

24. Part III Mentalizing impairments and psychiatric disorders

25. Vicious circles Substance abuse Depression Anxiety Trauma Personality disorders psychiatric symptoms impaired mentalizing

26. Resilience: from vicious to benign circles psychiatric symptoms improved mentalizing impaired mentalizing improved functioning

27. Vicious circles in deliberate self-harm SELF OTHER abandonment alarm & anger unbearable emotional state EXPRESSIVE FUNCTION self-harm concern tension relief

28. Pushing the pause button: mentalizing abandoned/stressed unbearable emotional state mentalizing self-harm constructive coping bearable emotional state

29. Part IV Promoting mentalizing in treatment

30. Developmental science informs mentalizing: Therapists learning from parents Conditions that promote mentalizing secure attachment ‹—› mentalizing Formulations of skillful mentalizing Main: metacognitive monitoring Fonagy: reflective functioning Slade: mentalizing of the child Meins: mind-minded commentary in interaction

31. The gist of psychotherapy John Bowlby: the role of the psychotherapist is “to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.” [A Secure Base] Jon Allen: “The mind can be a scary place.” Patient: “Yes, and you wouldn’t want to go in there alone!”

32. Much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than those that distinguish them from each other. —Jerome Frank (1961): Persuasion and healing

33. The Mentalizing Stance (attitude) • inquisitive, curious, playful, open-minded • “not knowing” (cleverness is a cardinal sin) • not creating the capacity but rather promoting attentiveness to the activity of mentalizing • consistent with the relation between secure attachment and mentalizing, advocating a spirit of good will and compassion while acknowledging that we also must mentalize in a distrusting mode

34. Mentalizing Programs for borderline personality disorder: Day Hospital Program (Bateman & Fonagy) • 5 days/week; 18-36 months • individual, group, expressive therapies; 9 hours/week Intensive Outpatient Program • once weekly individual & group therapy • 18 months duration Effectiveness (Day Hospital vs. Treatment as Usual) • 8-year follow-up (5 years post-termination of MBT) • 23% versus 74% of patients made suicide attempts • fewer ER visits and hospital days; less medication use • 13% versus 87% met criteria for BPD at end of follow-up • Significant differences in impulsivity and interpersonal functioning (including marked improvement in intense-unstable relationships and frantic efforts to avoid abandonment) • three times longer periods of good vocational functioning

35. attachment & arousal developmental history mentalizing Patient attachment & arousal current functioning mentalizing mentalizing current functioning attachment & arousal Family mentalizing developmental history attachment & arousal Parallel contributions to mentalizing: Meeting of minds

36. Why mentalize? Mentalizing enables us to determine whom we can trust (and when we can relax mentalizing) Mentalizing enables us to establish and maintain secure attachment relationships through mutual empathy (takes two) Mentalizing entails self-awareness, which is essential for self-compassion (empathizing with oneself) and for regulating emotions (e.g., pushing the “pause button”)