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MentalizationCraigan Usher, MDOregon Health & Science University

Three Pillars of Evidence-Based

Medicine

Best Research EvidenceClinical JudgmentPatient Values and Preference

Mentalization

Closely related to the term empathy, mentalizing refers to the process of thinking:

1- about others’ thoughts and feelings (acknowledging that others have a mind) and;

2) reflecting on one’s own thoughts and feelings (standing outside yourself to describe yourself).

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Mentalizing?

A boy is enjoying a summer day at the beach. He spots something in the distance that captures his interest. Off he goes, straight toward the goal. But on the way he steps over everything in his path: blankets, newspapers, hands, feet, torsos.*

*Coates S. Foreword to Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

Mentalizing?

You are going on vacation and inform your patient.

“So you want to get away from me, do you?”

“What leads you to believe that?”

“Oh, I just know. I know how you people operate.”

Mentalizing?

•Asked by a research assistant why the girl in this picture is saying--“Look, it’s a telephone,” a kindergartner responds, “because it’s a banana-phone.”

*Happe’, FG (1994). An Advanced Test of Theory of Mind: Understanding Story Characters’ Thoughts and Feelings by Able Autistic, Mentally Handicapped and Normal Children and Adults. Journal of Autism and Developmental Disorders 24(2): 129-154

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Mentalizing?

Asked why his six year-old would jump into his (the father’s) Ford F-150, put it in neutral and roll down the driveway, a father responds: “‘cuz he has bipolar disorder.”

Mentalizing?

A teenager approaches his first day of high school with fear and trepidation: “I’m not going to school. No way! Everyone will make fun of me there.”

Problems Mentalizing

NON-MENTALIZING

MENTALIZINGDISTORTED

MENTALIZING

CONCRETE & STIMULUS

BOUND

GROUNDED IMAGINATION

IMAGINARY &PROJECTIVE

*Allen, J.G. (2006). Mentalizing in Practice in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

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Mentalization: lecture organization1) What is mentalization?

2) What are the neural structures subserving social cognition in general and mentalization in specific?

3) What are mirror neurons?

4) What are the stages of mentalization acquisition?

5) How does attachment relate to mentalization? How about drug use?

6) What are some ways to promote mentalization?

Fonagy’s Mentalization

Mentalization is a form of preconscious imaginative mental activity, namely perceiving and interpreting human behavior in terms of intentional mental states; for example--

needs

desires

feelings

beliefs

goals

purposes

reasons

Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. 2007 New York: Wiley

Old School

D.W. Winnicott (British Psychoanalyst)

“A sign of health in the mind is the ability of one individual to enter imaginatively and accurately into the thoughts and feelings and hopes and fears of another person; to allow the other person to do the same to us.”

Winnicott, D.W. (1970) Cure as quoted in A. Phill ips Winnicott,Cambridge, 2004, Harvard University Press.

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Mentalization’s Conceptual Cousins

Empathy

Mindfulness

Theory of Mind / Mindblindness (antonym)

Emotional Intelligence

Psychological Mindedness

French: Pensée Operatoire / English: Alexithymia (antonym)

*Allen, J.G. (2006). Mentalizing in Practice in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

DefinitionsPsychic Equivalence: Mind = External Reality (like in a dream where the dreamer experiences everything as real)

Pretend Mode: The ability to hold an “as if” stance, realizing that things are not always as they appear or are experienced.

Components of Social Cognition

Three Neural Systems of Social Cognition:

Social-Detection (AWARENESS)

Affect Regulation (MEANING)

Cognitive Regulation (REASONING)

Adolphs R. Cognitive neuroscience of human social behavior. Nat Rev Neurosci 2003 4:165-178*Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

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Awareness

Fusiform Gyrus (pink)

Superior Temporal Sulcus (red line)

Anterior Temporal Cortex

*Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

The Digimon Problem:an impediment to Social Awareness

• OR

Grelotti DJ, Klin AJ, Gauthier I (2005) fMRI activation of the fusiform gyrus and amygdala to cartoon characters but not to faces in a boy with autism. Neuropsychologia 43(3):373-85.

van Kooten IA, Palmen SJ, von Cappeln, et al. Neurons in the fusiform gyrus are fewer and smaller in autism. Brain 2008 Mar 10--epub

Representative photomicrographs of 200 micrometer thick coronal

section of the brain hemispheres from a control patient (A,C,E) and a patient with autism, showing either

the entire hemisphere (A,B) or area 17 (C,D) and the fusiform

gyrus (FG) (E,F)

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Heider-Simmel 1944

Point-Light Walkers

Heberlin AS, Adolphs R, Tranel D, & Damasio H (2004). Cortical regions for judgements of emotions and personality traits for point-light walkers. Journal of Cognitive Neuroscience, 16(7), 1143-1158.

Point-Light Walkers

Heberlin AS, Adolphs R, Tranel D, & Damasio H (2004). Cortical regions for judgements of emotions and personality traits for point-light walkers. Journal of Cognitive Neuroscience, 16(7), 1143-1158.

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Affect / Arousal Regulation--assigning significance to social

stimuli• Amygdala--anxiety / emotional learning

• Hypothalamus--warmth/love

• Nucleus Accumbens--reward

• bed of the nucleus of the Stria Terminalis

*Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

Ekman Faces

-1970’s-Fore Tribe ofPapua New Guinea

Anger Fear Disgust

Surprise Happiness Sadness

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Amygdala / Emotional Hijacking

Efrain Bleiberg--presentation at American Psychoanalytic Association program 21 January 2007 “Mentalization & Play...”

Cognitive Regulation / ReasoningFunctions:

Inhibiting pre-potent responses (effortful control)

Mediating goal-directed behavior

Mentalizing (Perspective-taking / Theory of Mind Tasks)

Structures:

Dorsomedial Pre-Frontal Corex

Ventral Pre-Frontal Cortex

Anterior Cingulate Gyrus

Mentalizing: A Two Part System

1 Mirror Neuron System (immediate, nonconscious reading)

2 Fronto-corticol (declarative / explicit recognition “mentalizing proper” )

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Mirror Neurons

Thoughts on Mirror Neurons

Features:

They fire with visual AND auditory cueing

Empathy scores correlate with mirror neuron activity

They are mediated by intention...

Two Flavors based on Intention:

Strictly Congruent--absolute mirroring (1/3)

Broadly Congruent--task completion (2/3)

*Iacoboni M and Mazziota C (2007) Mirror Neuron System: Basic Findings and Clinical Applications. Ann Neurol 62:213-218

Mirror Neurons

Iacoboni M, Molnar-Szakacs I, Gallese V et al (2005) Grasping the Intentions of Others with One's Own Mirror Neuron System PLoS Biol. March; 3(3): e79.

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Anterior Cingulate Cortex

Anterior Insula

Anterior Cingulate Cortex

Anterior Insula

PainPain

Decety J, Jackson PL. The functional architecture of human empathy. Behav Cogn Neurosi Rev. 2004 3(2):71-100

Jean Decety, PHD - University of ChicagofMRI Empathy photos

The False Belief Test

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Second-order Theory of Mind

• “Look, this banana is a phone!”

*Happe’, FG (1994). An Advanced Test of Theory of Mind: Understanding Story Characters’ Thoughts and Feelings by Able Autistic, Mentally Handicapped and Normal Children and Adults. Journal of Autism and Developmental Disorders 24(2): 129-154

Explicit Mentalizing: Strange Stories, Computer Games with

People• Medial Pre-frontal Cortex (MPFC)

• Bilateral Superior Temporal Sulcus (STS)

• Temporal Pole (TP) adjacent to the Amygdala

Moriguchi Y Ohnishi T Mori T et al (2007) Changes of brain activity in the neural substates for theory of mind during childhood and adolescence. Psychiatry & Clinical Neurosciences 61:355-363Gallagher HL Jack AI Roepstorff A Frith CD (2002) Imagine the intentional stance in a competitive game. Neuroimage 16:814-21

Mirroring & Empathy at The DinerImitation affects how we judge the person we’re interacting with.

More likely to think of them as competent.

More likely to project our thoughts/feelings onto a person who mimics our behavior.

50% Tip Increase with Imitation

Van Baaren RB, Holland RW, et al. Mimicry for Money: behavioral consequences of imitation. Journal of Experimental Social Psychology, 29, 393-398. 2003.

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More on MirroringVan Baaren RB, Holland RW, Kawakami K, & van Knippenberg A. (2004) Mimicry and proscoail behavior. Psychological Science 15, 71-74

MIRROR, MIRROR: therapy tips1) Meet them where they

are at: affectively/body posture.

2) Look for things that you enjoy about your patients; make psychological contact.

3) Reflect with them (dig deeper, more on this...later).

Development of Mentalization

Stage 1: 6 months - 1 year

6mos- Animate objects self-propelled.

9mos- Rational, efficient actions based on clear goal.

*Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

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Development of MentalizationStage 2 (1 to 3 years)

Intentions versus Actual Outcome Understood (Baby Sign / Pointing)

Joint Attention / Teasing and Provocation of Younger Siblings

Stage 3 (3 to 5 years)

Beliefs (Thoughts which have an impact on how feelings are understood)

Peer relationships (influencing and being influenced) become more important

Stage 4 (5 + years)

Second Order Theory of Mind (beliefs about beliefs)

“White lies”

Mixed emotions better understood

Mentalization and The Good Life

Data from the Rush Neurobehavioral Center Clinical Assessment of Children’s Social-Emotional Cognition Assessment Project (Rondout) showed:

No statistically significant correlation between VIQ or Pragmatic Judgement subtest of the CASL and Social Acceptance

Usher-McKown-Lipton Mentalization Matters: Perspective-taking as a Predictor of Social Acceptance in School-aged Children submitted to APsaA 2008 Meeting

Small, but statistically significant correlation between SS Performance and Social Acceptance.

Attachment & Mentalization

Clinical Question: “How can one be a poor mentalizer, but still form strong attachments?”

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RomanceTurns off

Mentalization!

Mesocorticolimbic Activation (Dopamine release in the ventral tegmentum/nucleus accumbens) αnterior hypothalamus release of oxytocin and vasopressin Two System Shut-down:

System A

Responsible for attention and long-term memory.

Middle pre-frontal, inferior parietal, and middle temporal coritices in the right hemisphere

System B

Responsible for negative affect, judgement of social trustworthiness, ToM tasks, monitoring own emotion

Temporal poles, parietemporal junction, amygdala, mesial pre-frontal cortex

*Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

Attachment & Mentalization

Efrain Bleiberg--presentation at American Psychoanalytic Association program 21 January 2007 “Mentalization & Play...”

Attachment Supports Mentalization

1- Allows space for moderate levels of negative affect.

2- Promotes interest in mentalizing.

3- Parents demonstrate mentalizing by examining the thoughts and feelings of their children.

*Fonagy P. The Mentalization Based Focus Approach to Social Development in Handbook of Mentalization, ed J.G. Allen & P. Fongy. New York: Wiley

Borderline Personality DisorderFrantic efforts to avoid real or imagined abandonment.

A pattern of unstable and intense interpersonal relationships w/ idealization and devaluation.

Identity disturbance.

Impulsivity in at least two potentially self-damaging ways.

Recurrent suicidal behavior.

Affective instability.

Chronic feelings of emptiness, worthlessness.

Inappropriate anger.

Transient, stress-related paranoid ideation or severe dissociative bouts.

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The eye region can signal specific social information, such as guilt, fear orflirtatiousness and--one study of abused children could not read these

expressions (which might predispose to certain PDs) while non-abused controls were able to.

Reading the Mind in the Eyes

Guilt?

Fear?

Seductiveness?

Efrain Bleiberg--presentation at American Psychoanalytic Association program 21 January 2007 “Mentalization & Play...”

Mentalization Based Treatment (MBT)

Highly structured (ala DBT) MBT aims to promote mentalization and monitors for it’s appearance in:

distinguishing between appearance and reality

reflecting on mental states

monitoring thoughts, feeling, and language to give meaning

reasoning, using an appropriate knowledge base (where did you learn that?)

attending to primary themes without distraction from sub-dominant themes or emotional states

Short-term Mentalization and Relational Therapy (SMART)

• Generic

• 6-12 sessions

• Promote mentalistic parent-child interactions

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SMART Family Psychotherapy

Seven Emphases of Short-Term Mentalization And Relational Therapy (SMART)1) Identifying, highlighting, and praising examples of skillful

mentalizing.

2) Sharing and provoking curiosity.

3) Pausing and searching.

4) Identifying preferred non-mentalizing narratives.

5) Identifying and labeling hidden feeling states.

6) Using hypotheticals and counterfactuals.

7) Therapists making use of the self.

Mentalistic Prescribing• � How do you feel?

• � Are there ways in which you would like to think � feel � live differently?

• � How might medications help you achieve these goals?

• � Do you know about the benefits of the medications you are taking/that I am proposing?

• � Are you familiar with the side-effects of the medications you are taking/that I am proposing?

Divergent Paths

• 1--The Traditional Medical Model: Your brain is damaged and I have a cure for what ails neural structures about which you know little.

• 2--More Mentalistic Model: Your thoughts and feelings inform what you do. If you experienced these with less intensity or more regulation, how might that impact your life?

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Summary I

Mentalizing is closely related to empathy, but emphasizes the cognitive component of reflecting on the thoughts and feelings of others and of one’s self. Myriad brain structures/activities contribute to mentalizing.

The discovery of mirror neurons helps us, as clinicians, reflect on how we think, feel and do as others. When we allow ourselves to imitate others, we feel better connected with them and them with us.

Summary II

Deficits in the ability to mentalize involve disruption in social cognitive pathways and occur in disorders such as anxiety, depression, personality disorders, autism spectrum disorders, and schizophrenia.

Helping our patients better mentalize allows them richer connections with others and a deeper, more meaningful understanding of themselves.

Questions

Final Thought:

“Theory will cause me, unconsciously, when I do not expect it, to adopt a special listening….It is necessary to be passionate about theory so that in turn it can have an effect on us, and make us act without our knowledge.”

Resources:

The Handbook of Mentalization-Based Treatment

The Social Neuroscience of Empathy

Nasio, J.D. (1998). Five Lessons on the Psychoanalytic Theory of Jacques Lacan. New York: SUNY Press