Mentalization-Based

Practice with Children, Adults and

Families

Eia Asen

FTAANZ Wellington
4th September 2012
 Mentalization – what is it?

Mentalizing is a form of imaginative mental activity,

namely, perceiving and interpreting human behaviour
in terms of intentional mental states
(e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).
To understand the other's (or one’s own) behaviour in terms of activity
that has taken place inside their minds.

Both a cognitive process (psychological insight) and an emotional

process, i.e. ‘the capacity to regulate and experience one’s own and
others’ emotions in a non-defensive way without becoming
overwhelmed or shut down’ (Sharp and Fonagy, 2008)
 What is the function of mentalizing?

Primary function of mentalizing:

To predict, explain and justify the actions of
others by inferring the intentional mental states
that cause them
As a key aspect of the self’s ‘secondary
cognitive emotional reappraisal mechanism’
(Gergely)
A key determinant of self-organisation and
affect regulation
Some features of good mentalizing

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’

4
 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
Related concepts

Empathy – awareness of, and resonance with, an emotional state of

distress in another person (others, not self)
Psychological mindedness – capacity to relate one’s actions to
thoughts and feelings (self-mentalization)
Mind-mindedness – mentalization within attachment relationship
security
Mindfulness – Zen-inspired attitude of openness which accepts,
tolerates and validates current experience (‘thoughts are just
thoughts and not ‘you’ or ‘reality’) – more cognitive focus

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.

Mentalizing
as an
COMMON Integrative LANGUAGE
framework

PSYCHODYNAMIC: The value of SOCIAL ECOLOGICAL: The value

understanding the nature of resistance of understanding the impact of
to therapy, and the dynamics of context upon mental states;
here-and-now in the therapeutic deprivation, hunger, fear, etc...
relationship.
 READING THE MIND IN THE EYES

Guilt?

Fear?

Seductive?
The eye region can signal specific social information, such as guilt, fear or
flirtatiousness and a study found that abused children could not read these
expressions which might predispose to certain PDs.
Examples from the Reading the Mind in the Eyes (Baron-Cohen et
al., 2001)

surprised sure about something

joking happy
Examples from the Reading the Mind in the Eyes (Baron-Cohen et
al., 2001)

friendly sad

surprised worried
 Simple test of mind-mindedness

Joking-A Flustered-B

Desire-C Convinced-D
 Simple test of mind-mindedness

Cautious-A Insisting-B

Bored-C Aghast-D
 Ingredients of ‘Good’ Mentalizing
Perception of one’s own mental functioning
Self-inquisitive stance
Developmental perspective (autobiographical continuity)
Realistic scepticism and cautious optimism
Internal conflict awareness
Awareness of the impact of affect
Acknowledgment of un- or pre-conscious functioning
Belief in changeability
Humility
Taking responsibility / assuming accountability

Relational Capacity
Curiosity
Assuming minds are opaque
Non-compulsive contemplation and reflection
Perspective-taking
Forgiveness
Impact awareness
Capacity to trust, non – paranoid attitude
Willingness to take turns / ‘give and take’
Playfulness and self-mocking humour
Belief in changeability

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The development of the ‘mentalizing self’

The ‘social biofeedback model’

(Gergely and Watson):

The capacity to mentalize emerges

through interaction with the caregiver
via a process of contingent marked
mirroring
Assists in developing affect
regulation
Develops child’s sense of a mind and
of a reflective self
Learning About My Mind, Your Mind

Mind in mind Contingent

Marked
Mirroring Sam-I-am
 Theory: Birth of the Agentive Self
Attachment figure “discovers” infant’s mind (subjectivity)

Internalization

Representation of
infant’s mental
state Core of
psychological
self

Inference
Attachment figure Infant
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 Î mentalization
 Background to Oxytocin Story
OT (a neuroactive hormone) directly synthesized in the hypothalamus and
projects to brain areas that are associated with emotions and social
behaviors (e.g., amygdala and cingulate cortex) associated with mamalian
childbirth and breast feeding
OXT plays a role in attachment and prosocial behavior in animals
OXT associated with trust, generosity and watching emotional videos in
humans (Bazzara & Zak, 2009)
The dual role of OXT in attachment (Heinrichs & Domes, 2008)
Activating reward /attachment system (push mechanism)
Deactivating neurobehavioural systems involved in mediating social avoidance
thus promote approach (pull mechanism)
Gaze duration during oxytocin exposure

BIOL PSYCHIATRY 2008;63:3–5

Relational Aspects of Mentalization
We find our mind initially in the minds of our parents and later
other attachment figures thinking about us
The parent’s capacity to mirror effectively her child’s internal
state is at the heart of affect regulation
Infant is dependent on contingent response of caregiver
which in turn depends on her capacity to be reflective about
her child as a psychological being
Neglect therefore has pernicious consequences for affect
regulation (especially for infants with genetic predisposition
to intense emotional experience)

Fonagy et al., 2007, J. Child Psychology Psychiatry, 48(3/4), 288-328.

Affect regulation – self and others
The infant’s automatic emotional expressions and the care-giver’s
consequent affect-reflective facial and vocal displays come to be
linked in the infant's mind
This link means that the infant associates the control they have over
the caregiver’s response with an improved emotional state
This leads to an experience of themselves as regulating agents
The establishment of second order representation of affect states
creates the basis for affect regulation and impulse control
Affects can be experience as something recognizable to others and
shared
Expressions of affects by caregivers that are NOT contingent on the
infant’s affect will undermine and appropriate labelling of internal
states
These may then remain confusing, un-symbolized and likely to be
difficult to regulate
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‘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
 Parent- Infant Work - What to say….
Aim(s) to help parent
a) to distinguish between parent’s and child’s emotions
Do you think the baby is worried about that – or might you be worried
about that to? Do you think the baby knows how to take care of you? Do
you think he knows that you might want that he would look after you,
rather than the other way round?

b) to distinguish between parent’s internal and external reality

Do you think the child is really safe, or might this be a very strong wish
you have? (child not safe, as perceived by therapist)
Do you think the situation is dangerous , or do you think you might just be
worried about the child? (situation not dangerous as perceived by
therapist)

c) to distinguish between parent’s internal reality from other-child inter-

personal reality
Do you think he is trying to upset you deliberately, or is that what you
have come to expect from other important people in your family?
Do you think the child is really trying to trick you, or might you be afraid
that he might be like others who have?
 Parent-Infant Work - The Voice of the child
Therapist provides narrative from infant’s / child’s point of view

That’s a nice smile, mummy, I like it when you do that because I feel that
you are pleased with me
Yes, you got it, that’s where I like to be tickled
Oh mummy, when you look like that at me, I know I feel happy because you
look so happy
Mummy, when you make that blank face, I don’t know what to make of it
and I feel just lost
Mummy, where did you go? I was worried you might not come back?
Mummy I am bored, I don’t want to play with this anymore, the toys over
there are more interesting
Mummy that’s just too much - I don’t know what to focus on
Mummy, who is that strange lady who wants to play with me?
Mummy, you never look at me….are you bored with me?
Mummy, I like to get close to you, but I feel that you don’t seem to like it
Oh look how you lean backwards when I try to cuddle up to you
Mummy, when you speak like this and with that tone of voice, I feel really
anxious
 Aspects of Mentalizing

Implicit / Automatic vs Explicit / Controlled

(non conscious, non- (Conscious – or potentially cs -,
verbal, non reflective) verbalizable, reflective)

Affective vs Cognitive
External vs Internal
Self vs Other
Affect regulation
Attuned interactions with caregivers involve “affect mirroring”
This is the use of facial and vocal expression to represent to the child
the feelings the caregiver assumes the child to have
The child looks for a way of managing their distress and identifies in
the caregiver’s a representation of the child’s mental state which
can then be internalized and used as part of a higher order strategy
of affect regulation
The caregiver does this in a way to reassure and calm rather than
intensify emotions
Parental affect mirroring is central in fostering the capacity for affect
regulation

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The story so far..
Mentalizing begins very early

Dysfunctions of mentalizing are very likely to be entailed in a range of

different pathologies of childhood (not just childhood autism and
schizophrenia)

Individual differences in mentalizing are not primarily genetic

The capacity for mentalization may be both facilitated and undermined

by family relationships

Mentalizing may be a key mechanism through which influential

(protective and risk associated) aspects of family environment make
themselves felt in the formation of childhood disturbances

If so then social cognition may be an important focus for treatment and

prevention
EEG study of the responses of maltreated and non-maltreated children to viewing an
angry face (Cicchetti & Curtis, 2005 Dev. & Psychopath.)

Normal child Abused child

Maltreated group

Comparison group
 Traumatic attachment history and affect dysregulation

Arousal/stress inhibits controlled (‘reflective’)

mentalization

This leads to automatic mentalizing dominated by

reflexive (unrerflective) assumptions regarding self
and others under stress, which may not be obvious
in low stress conditions

Re-emergence of non-mentalizing modes

How does relational trauma effect the
capacity to mentalize?
Even with extreme trauma, loss of mentalizing
capacity is mostly partial
Loss of capacity often ‘triggered’ by intense
attachment context and/or becoming stressed
Arnsten’s ‘The biology of being frazzled’ (1998) and the Dual
Arousal Systems Model
• Pre-frontal (controlled) vs sub-cortical (automatic) response
Leading to the re-emergence of non-mentalizing forms of
cognition
Mentalization may be temporarily inhibited by…

intense emotional arousal

intensification of attachment needs or

by a defensive turning away from the world,

seeing it as populated by hostile and
malevolent minds in the case of severe
maltreatment

31
Trajectory of MBT Interventions
Identify a break in mentalizing (“can we just pause here?”)
Check for understanding (“am I understanding this correctly?”)
Rewind to the moment before the break in subjective continuity (“can we just go
back to …”)
Identify affect (“what were you feeling at that point?” – instead of “what happened
next?”)
Explore emotional context (“what other situations come to mind when you feel /
experience this?”)
Define interpersonal context (moment to moment exploration of problematic
episode, identify affect)
Explicitly identify and own up to your own contribution to the break in mentalizing
(“what have I done for us to be at that point now?”)
Spot and explore positive mentalizing (“I really liked when you..”)
Provoke curiosity about psychological motives for actions

Stop, replay, explore & reflect

 The MBT-F-Loop

Notice
And
Name
C
he
g
kin

ck
in
ec

g
Ch

Generalise
(and Mentalize
Consider The
Checking
Change) Moment
 Biofeedback heart rate monitoring

•The watch enables the detection and monitoring of internal bodily

functions with great sensitivity and precision

•Insight into the scope and limits of self-regulation of the body and
associated mental states

•Individuals may experience them as providing a kind of sixth sense, or an

extra window into their bodies and minds.
 Systemic Biofeedback

Parent and child, or partners - both wear monitors:

learn to recognise mutual excitation and escalatory patterns.

learn situational awareness
develop de-stressing and safety net strategies
 HR [bpm] HR [bpm]
200 200
A child with severe attachment disorder
……….
180 180
Maximum intensity
160 160
Hard intensity
…..during an argument between his mother
140 140
Moderate intensity and step-father….
120 Light intensity 120

100 Very light intensity 100

…and after the argument, the child was still
80 80 emotionally charged and, despite not
60 60
moving or fidgeting and trying to breathe
calmly, his heart rate was still increased for
40 40 more than 20 mins
20 1 20
108 bpm
0 Time
10:09:52 10:29:52 10:49:52 11:09:52 11:29:52 11:49:52
Cursor values:
Time: 10:09:52
HR: 102 bpm

PersonMarlborough Ed Ce Date 20/05/200Heart ra08 bpm

ExercisChristopher Time 10:09:52 Heart ra96 bpm
Sport Running Duratio1:47:52.7
Note Selectio 10:09:52 - 11:57:44 (
 Example of symmetrical escalation between father and
HR [bpm] HR [bpm]
daughter – over a bacon sandwich
200 200

180 Maximum intensity 180

160 160
Hard intensity

140 140
Moderate intensity

120 Light intensity 120

100 Very light intensity 100

80 80

60 Issue of conflict and an example of 60

Took around 22
symmetrical escalation due to their
40 minutes to calm 40
mutuality behaviour
down
20 1 20
91 bpm
0 Time
08:37:29 09:07:29 09:37:29 10:07:29 10:37:29
Cursor values:
Time: 08:37:29
HR: 87 bpm
Calorie rate: 0 kcal/60min
MBT-F: What’s different from ‘ordinary’
Systemic Practice?

Emphasis on enhancing ‘good’ mentalizing

Emphasis on tackling blocks to, and impairment of, mentalizing, or challenging
non-mentalizing
Focus on emotion as a cue to what goes on inside people, with attention paid to
emotional regulation and how to affect it, aiming to strengthen self-control and
the capacity to regulate one’s feelings in the family context
Focus on encouraging people to tentatively speculate about, or label, hidden
feeling states in oneself and others
Promotion of awareness of one’s own and other persons’ mental states, in order to
increase mutual understanding
 MBT-F Manual

Web-based, ‘open source’:

www.tiddlymanuals.com
Downloadable
Editable (for the adventurous - note licensing restrictions
though)