Mentalizing and the mindful clinician - a prescription for

Mentalizing and the mindful

clinician - a prescription for

compassionate care.

Prof Anthony W Bateman

Visiting Professor University

College, London; Affiliate Professor

of Psychotherapy Copenhagen

University

Summary

Wards in same hospital show difference in:

Rates of violence

self-harm

absconding and other incidents

Use of manual restraint

Coercive use of medication

The problems tend to group together suggesting common cause(s)

Is it ‘us’; is it ‘them’; is it ‘both’; is it all/none of above.

Domains relevant to problems

Patient characteristics

Patient community

Outside hospital – e.g. home

Physical environment

Regulatory framework.

Staff team

Patient characteristics

Symptoms and demography

Paranoia; PD and BPD – interpersonal

problems and

abuse/irritability/reactivity/alcohol and drugs

Modifiers – psychotherapy; nursing

support; ward atmosphere

Patient community

Patient-patient interaction – contagion and

discord

Patient Modifiers – anxiety management;

psychological understanding; premorbid

personality

Staff modifiers – explanation; information;

role modelling; patient education; not too

little and not too much presence

Flashpoints – crowding; queuing; waiting;

noise; bullying; stealing

Outside hospital

Stressors – Visitors; relatives; dependency

and institutionalisation; demands from

home

Staff modifiers – carer relative involvement;

family therapy; active patient support

Flashpoints – Bad news; home crisis; loss

of relationship

Physical environment

Physical environment - Locked doors;

seclusion; fabric and comfort

Staff modifiers – care and attention to

property; décor maintenance;

Patient – modifiers – respect for property;

sharing; admission process

Regulatory framework

External factors – legal restrictions; national

policy; complaints; appeals; prosecutions;

hospital policy

Staff modifiers – Justice; respect for rights;

hope; information giving; flexibility.

Flashpoints – compulsory detention;

admission process; appeal refusal;

complaint not upheld; enforced treatment;

exit refused

Staff Team

Internal structure – rules; routine;

efficiency; ideology

Staff modifiers – leadership; staff anxiety;

control; psychological understanding;

teamwork and consistency; positive

appreciation

Flashpoints – denial if requests; demands;

limit setting; ignoring patients

Mentalizing

Mentalizing and the mindful

clinician

What is happening in the patient’s mind to

make him/her behave like this?

Can I, the clinician

talk to him to elicit his current mental state

Identify the dominant emotion and belief

Accept our contribution to creating this state

Be compassionate about his current narrative

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).

The learner

1. The

learner’s

imagined self

narrative

5. Opening of

epistemic

channel for

knowledge

transfer

4. The epistemic match

2. The informer’s

image of the

learner’s self

narrative

3. The learner’s

image of the

informer’s image

of the learner’s

self narrative

The informer

Creating a peaceful school

learning environment

Stuart W. Twemlow, Peter Fonagy,

Eric M. Vernberg, Jennifer A. Mize,

Edward J. Dill, Todd D. Little,

John A. Sargent

Assumptions, Aims and Adjuncts

The whole school community contributes

to bullying-related dysfunction

Peaceful collaboration with others

requires prioritizing their subjective

states, thus placing limits upon the urge

to violently control the behaviour of less

powerful members of the group

Assumptions, Aims and Adjuncts CAPSLE aims constantly to focus on the mental

states of all those involved in the power dynamics

of interpersonal violence (the bystander as well

as the bully and the victim) through:

a positive climate campaign to draw attention to the

subjective experiences of bully, victim, and bystander

a classroom management plan that requires teachers

to elaborate the thoughts and feelings associated with

acts of aggression in the classroom

a defensive martial arts program based on mindfulness

peer or adult mentorship that create additional

opportunities for reflective interpersonal interaction

reflection time which offers opportunities for the class

to consider shared immediate past experience together

Increasing Mentalization Should Reduce

Violence: The Peaceful Schools Project

9 schools randomly assigned to

CAPSLE

School Psychiatric Consultation

Treatment as usual

oProgrammes as usual

Design

3 year study

2 years of formal manualized intervention

3rd year test of generalisation

10 Schools, including 2,712

Children, Stratified and Cluster

Randomized

19 Eligible Elementary Schools,

Including 6,522 K-5th Grade Children

10 Elementary Schools Elected To

Participate, Including 2,712 Children

1 School

(178 Children)

Withdrew From

Treatment as

Usual

Condition

675 Children

Treatment as Usual

In 3 Schools

824 Children

SPC

In 3 Schools

1,035 Children

CAPSLE

In 3 Schools

Only 3rd-5th Grade Children

Completed Research Instruments

SPC Children

Participating

296 in Year 1

283 in Year 2

323 in Year 3

CAPSLE Children

Participating

391 in Year 1

356 in Year 2

395 in Year 3

Treatment as Usual

Children Participating

271 in Year 1

221 in Year 2

217 in Year 3

Key Results of The Peaceful Schools

Project: Peer Nomination

SPC vs TAU

Increase in helpful bystanding (p<.05)

o evident only in the first year of the intervention

CAPSLE vs TAU

significant on four out of the eight primary

outcome variables

peer-reported aggression (p < .05)

peer-reported victimization (p < .01)

aggressive bystanding (p < .05)

empathic mentalizing with victim (p < .01)

Mean Proportions of Observed

Disruptive Behaviors Over Two Years

of Active Intervention

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Time 1 Time 2

Control

CAPSLE

SPC

Tests of simple effects between 1st and 2nd year of intervention

CAPSLE: t(106) = 5.21, p < .001, d=.94 (95% CI: -1.0, 2.9)

SPC: t(106) = .50, p > .05

TAU: t(106) = .13, p > .05

Mean Proportions of Observed Off-task

Behaviors Over Two Years of Active

Intervention

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

Time 1 Time 2

Control

CAPSLE

SPC

Tests of simple effects between 1st and 2nd year of intervention

CAPSLE: t(106) = 8.26, p < .001, Cohen’s d=1.61 (95% CI: -.38, 3.6)

SPC: t(106) = 1.19, p > .05

TAU: t(106) = .14, p > .05

Some basic

mentalizing interventions

Implications for understanding and treating borderline

personality disorder as a social

vulnerability disorder

Borderline Personality Disorder

Self-ConceptSocial

Interaction

Emotion

Dysregulation

What do you feel looking at this picture?

I depend on others a lot

I can‘t manage when people don‘t respond

to me

I am an outsider

I am different from others (shame)

Others will reject me

I do not deserve being part of the group

(guilt)

I am ugly (self-contempt- self disgust)

Reported Social Cognitions in BPD

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

RS

Q-S

core

0

1

2

3

4

5

acuteBPD

remittedBPD

HC

RS

Q-S

co

re

0

1

2

3

4

5

acuteBPD

remittedBPD

cognitive RS

affective RS

HC acute

BPD

remitted

BPD

N=77 N=15N=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

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

ControlP<.001

P<.001

Direction of bias

Nicol et al., 2013 Plos One

Did you feel ostracized?

BPD patients significantly more often feel ostracized

under inclusion and uncontrollable conditionsStaebler et al., 2011; Domsalla, Lis, Bohus et al., 2013

Topology: relationships between

domains in therapist interventions

Addressing

Non-Mentalizing Modes

Addressing

Non-Mentalizing Modes

Mentalizing

Process

Mentalizing

Process

Safe in

Hig

h A

nxiety

Relational

MentalizingSafe

in

Low

An

xie

ty

Mentalizing the

Affective Narrative

Aims of Formulation Aims

Organise thinking for therapist and patient – each sees different minds

Modelling a mentalising approach in formal way – do not assume that patient can do this (explicit, concrete, clear and exampled)

Modelling humility about nature of truth

Management of risk

Analysis of components of risk in intentional terms

Avoid over-stimulation through formulation

Beliefs about the self

Relationship of these to specific (varying) internal states

Historical aspects placed into context

Central current concerns in relational terms

Identification of attachment patterns – what is activated

Challenges that are entailed

Positive aspects

When mentalisation worked and had effect of improving situation

Anticipation for the unfolding of treatment

Impact of individual and group therapy

Empathic Validation:

Underpinning mentalizing process

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

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

Empathic Validation – Affect and Effect

Interest in and Reflection on Affect

Identification of feelings

Normalising when possible in context of

present and past

Seeing it through their eyes

What effect does this experience have on

them

Staff Teams

And

Working together

Anna Freud National Centre for Children and Families

CLIENT

Residential Worker

Youth Worker

NurseSocial Worker

Youth Offending Worker

42

Psych

Mother

Sexual Health Worker

Police officer

Football coach

Neg relatnship

Pos relatnship

STRONG relatn.

EPISTEMICTRUST


CLIENT

Residential Worker

Youth Worker

NurseSocial Worker


43

Psych

Mother


Police officer

Football coach


CLIENT

Residential Worker

Youth Worker

NurseSocial Worker


44

Psych

Mother


Police officer

Football coach

THE “KEY” WORKER IS NOT AN ORGANISATIONAL ROLE,IT IS WHO THE CLIENT SEES AS “GETTING ME” AT THAT TIME

Teams working together: The AMBIT approach

MentalizingMentalizing

© Bevington & Fuggle

How does AMBIT make people work collaboratively?

1. Putting learning at the centre of the team culture1. Putting learning at the centre of the team culture

2. Developing a whole team Approach which recognises the interdependence of colleagues within a team2. Developing a whole team Approach which recognises the interdependence of colleagues within a team

3. Using this team to support the development of strong individual key working relationships3. Using this team to support the development of strong individual key working relationships

4. Using a systems approach to emphasise interconnectednessand shared intentions across the wider multi-agency network. 4. Using a systems approach to emphasise interconnectednessand shared intentions across the wider multi-agency network.

AMBIT is as a whole team approach, it cannot be

undertaken by an individual

The capacity to make sense of the client’s behaviour isenhanced when we can see how some

trusted other person makes

sense of him/her

Mentalizing is intimately bound to

behaviour; it is about making better

decisions about what to do.

The capacity of colleagues to make

sense of themselves, their clients, and their

colleagues.

MENTALIZINGMENTALIZING

2. Developing a Whole Team Approach which Recognises the

Interdependence of Colleagues Within a Team

3. Using this Team to Support the Development of

strong Individual Key Working Relationships

The person needs to experience his/her mind being held accurately,

respectfully and safely in the mind of a trusted other

The person needs to experience his/her mind being held accurately,

respectfully and safely in the mind of a trusted other

AMBIT invests in a single key helping relationship

that the person may, perhaps over some time, come to

trust.

AMBIT invests in a single key helping relationship

that the person may, perhaps over some time, come to

trust.

The ‘keyworker’ is the worker who is the “key” professional in the mind of the person -the worker who they feel

most understood by.

The ‘keyworker’ is the worker who is the “key” professional in the mind of the person -the worker who they feel

most understood by.

Worker must be well integrated and supported by a team that understands the maintenance of their mentalizing as a shared

responsibility

Worker must be well integrated and supported by a team that understands the maintenance of their mentalizing as a shared

responsibility

Establishment of Individual Trusting

Relationships between Person and

Key Worker

Establishment of Individual Trusting

Relationships between Person and

Key Worker

The skill lies in paying as

much attention to the client as

to the wider system

The skill lies in paying as

much attention to the client as

to the wider system

AMBIT stance is an attempt to

articulate BALANCE between

these considerations

AMBIT stance is an attempt to

articulate BALANCE between

these considerations

4. Using a Systems Approach to Emphasise

Interconnectedness and Shared Intentions Across the

Wider Multi-Agency Network

Thank you for

considering mentalizing!

For further information

[email protected]

Slides available at:

http://www.ucl.ac.uk/psychoanalysis/people/bateman

Mentalizing and the mindful clinician - a prescription for

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