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Zoe Goldberg

on 18 May 2014

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Transcript of Mentalisation

Trajectory of Mentalisation
Ability to understand and be understood by others is essential to ascribe meaning to human behaviour and function in an interpersonal environment (McGauleyet al., 2011)
Evidence shows foundations for an individual’s mentalising ability are held within the theories of attachment
With insecure attachment comes and inadequacy at mentalising and inability to distinguish between the self and others (Fonagy et al., 2011)
As seen in patients with DID, BPD & ASPD insecure attachments linking to childhood experiences of trauma and impairment in reflective function = devastating to the development of personality and psychopathology is likely to occur (Seligman, 2007)
developing a secure attachment in the therapeutic setting
dealing with the phobias of attachment loss
allowing for the individual to develop their capacity to mentalise in a safe environment (Stewart et al., 2011).
Mentalising needs to be both cognitively and emotionally orientated to allow for memories to be held as occurring in the past and it seems that this has slowly been achieved in Lynn’s case (Stewart et al., 2011).
Therapeutic Process
Mentalising - originally termed by Peter Fonagy
The capacity of an individual to understand and reflect the mental states, affects and cognitions of the self and others. (Stewart, Dadson, & Fallding, 2011)
The Application of Attachment Theory and Mentalization in Complex Tertiary Structural Dissociation: A Case Study
Stewart, B. L., Dadson, M. R., & Fallding, M. J. (2011) Journal of Agression, Maltreatment and Trauma , 20, 322-343.

where it starts
Infants ability to mentalise is determined by the
they have with their
Caregivers should be able to participate in
marked mirroring
with their infant (Stewart et al., 2011).
This allows for the infant to understand that the caregiver is
his or her
mental state,
to divide the care givers state from his or her own state but also acknowledge that the caregiver is receptive to the infant’s state of mind (Stewart et al., 2011).
From this, the child should be able to see himself or herself in the eyes of the caregiver and is able to understand that the caregivers view is not the same as her or his own sense of self (Seligman, 2007).
Current perspectives

Given up for adoption

Foster care 9 months

Adoptive parents were 1st denied to adopt

Unsupportive environment


exposed sexual abuse at age 3 by neighbour

Age 8 sexual abuse by brother until16 then removed from home

Sexual Abuse during summers by uncle and other men

Married to abusive husband (also neglected)

3 children- failed to bond with them

Brother and her speak but she has fought with him

Zoe Goldberg
insecure attachments
, the caregivers marked mirroring is absent or lacking which stunts the infants understanding of the distinction between mental states of the self and others (Fonagy et al. , 2000).
disorganised attachments
, the caregiver elicits both
reassurance and fear
in the child resulting in the child’s
inability to organise the self
, mentalisation is restricted which is a typical feature in patients with borderline personality disorder and dissociative identity disorder (DID) (Fonagy et al., 2000).
Capacity to think reflectively allows individual to feel understood and secure in his or her environment
When this faculty is interrupted it is likely that psychopathology will result, since without a reflective function, individuals have no way of allowing for alternative explanations of their subjective realities (Seligman, 2007).
Historical Context
Mentalisation traced back to the 1960’s concept of philosophy of mind - further developed in the 1980’s (Ensink & Mayes, 2010).

The philosophy of mind acted as a mediator to gain access into one’s own mental states and the minds of others.

1960/70's, interest in children’s cognitive development and how they understood their social environments, became the topic of many research enquiries

In 1983, an experiment conducted by Wimmer and Permer on a false belief task, allowed for the development of the theory of mind (Ensink & Mayes, 2010).
In this task, a boy buys a chocolate with his mother while shopping for groceries and upon returning home places the chocolate in a specific place where he will later retrieve it and eat it. While the boy is out the room, his mother puts the chocolate somewhere else. It is at this point in the task where children were asked to imagine where the boy will look for his chocolate when he renters the room.
Requires children to
the information of where the mother put the chocolate in order
to understand the boy’s perception
of where the chocolate would, in other words, identifying that the boy has a false belief (Ensink & Mayes, 2010).
Since children between the ages of four and five were able to pass this task, it was hypothesised that the
ability to mentalise only becomes concrete after four years of age
(Ensink & Mayes, 2010)
Executive Functions
Executive functioning-range of cognitive abilities including; memory, attention and goal-directed problem solving (Ensink & Mayes, 2010)
Regions involved in EF correlate with areas associated with mental state reasoning and emotion processing
Executive Functions
Mirror Neurons
Mirror Neurons
When a monkey performed a goal orientated task, such as reaching for an object, these neurons would fire. However, interestingly these neurons also fired when merely witnessing another partake in goal orientated behaviour
In humans mirror neurons play a role in understanding actions and the intentions of others (Brass, Schmitt, Spengler, & Gergely, 2007). Since mirror neurons seem to be coded for a goal, it seems likely that it is for this reason that it allows us to understand the intentions of another.
Current Theories
Fonagy et al. (2000) was able to link the attachment theory to the theory of mind by providing an account of attachment and reflective function.
Secure attachment
- corresponds to autonomous attachment strategy in adults based on the Adult Attachment Interview (AAI) (Fonagy et al., 2000)

Main (2000) showed that securely attached children have a greater capacity to mentalise
attachment corresponds to dismissing attachment styles in adults
Anxious -resistant
attachment leads to preoccupied attachment in adults
Disorganised attachment,
a fourth category, occurs when a caregiver evokes both fear and reassurance in a child resulting in mentalisation that prevents self organisation
Studies have indicated that
plays a role in relation to
With increased arousal or stress, mentalisation responses shift from controlled to automatic, yet this shift is also dependent on the attachment history of the individual (Fonagy et al., 2011).
It was found that
securely attached
mothers, when observing babies cry, showed great
regions of oxytocin, however
mothers showed a
in these areas (Fonagy et al., 2011). A possible reason for this is because distressing signals from an infant are linked to their own upsetting memories which may prevent insecure mothers from providing marked mirroring to their children.
Since mirroring is needed for children to internalise their own experience of sadness through the representations expressed by the mother, when the mother fails to mirror the child, self organized emotional responses in the child are inadequately formed. (Fonagy et al., 2011)


neurotransmitters such as oxytocin play a role in attachment - indirectly influence mentalisation (Fonagy et al.,2011). Oxytocin- released in large concentrations during pregnancy, childbirth and breastfeeding, enhances mentalisation capacity mother - allows her to optimise understanding of her infant’s needs and emotions
Behaviours elicited by oxytocin secretion in mother, allows her to be sensitive to her infant’s needs which allows for the development of secure attachment between the mother and infant, ultimately allowing for the child’s understanding of other mental states.

In support assumption that oxytocin mediates attachment, maltreated children found to have lower concentrations of oxytocin in their systems compared to children with secure attachments. In another study it was found that neglected or abused women also had lower concentrations of oxytocin in their system

Mentalisation in the Clinical setting
Mentalisation based therapy(MBT) - used in treatment of patients with borderline personality disorder, disruptive children and adolescents as well as a threatened parent child relationship based on early deprivation, trauma or substance abuse (Ensink & Mayes, 2010).
Unlike psychotherapy, mentalisation-based therapy is
not symptom-based
; rather therapy focuses on the processes of
(Ensink & Mayes, 2010). Experiencing our own states as being understood by others,- ascribe meaning to human behaviour which shapes our perception of ourselves and others (McGauleyet al., 2011).
Having the
to attend to one’s own and others mental states is what makes psychotherapy effective, and thus it is important to establish these foundations in MBT (Ensink & Mayes, 2010)
MBT was found to reduce the use of medication, hospital visits and self-harm and improved interpersonal functioning in patients with borderline personality disorder (McGauley et al., 2011).

Lynn being presented initially for help with anorexia nervosa was soon diagnosed as having among many personality disorders including BPD,
dissociative identity disorder

“disrupts the normal integration of consciousness, memory, identity, emotion…”(American Psychiatric Association, 2013)

of this disorder are the presence of
two or more personality states
where individuals experience intrusions into their consciousness and sense of self, an
altered sense of self,
amnesia and changes in perception(American Psychiatric Association, 2013) .

of documented cases, the highest risk factor for DID is interpersonal; physical and
sexual abuse in childhood
(American Psychiatric Association, 2013)

Putting theory into practice
As a child, Lynn had
no consistent
reliable attachment
figure which resulted in her
disorganised attachment

This disorganisation strategy, coupled with severe childhood
resulted in Lynn’s
deficit in the ability to mentalise
as well as the development of numerous personality disorders. The therapists involved with Lynn needed to integrate her dissociative states and the proposed method of assisting Lynn was through a combination of the therapeutic model of structural dissociation and mentalisation based therapy (Stewart et al., 2011).
Dissociative Identity Disorder
The structural dissociation theory proposes that the presence of
more than one personality
state, is divided into apparently normal parts
which are adapted to
daily living
and at least two emotional parts
which are fixated on the
traumatic experience
and engage in destructive behaviours (Steele, van der Hart, & Nijenhuis, 2005). ANP’s and EP’s are
not integrated
which is a result of actions and phobias that preserve the dissociation (Steele et al.,2005).
MBT takes place within the model of structural dissociation which consists of three phases. In the
first phase
, the focus of Lynn’s therapy was based on
of dissociation and traumatic enactment and stabilizing Lynn in order to combat phobias associated with
attachment loss
. The
second phase
involved the treatment of
traumatic memories
and overcoming phobias related to the perpetrator while the
third phase
, still incomplete, involves
integration and rehabilitation
. Mentalisation within these three phases focuses on the reflectivity of the therapist in directing the patient to integrate narratives
Phase 1- facilitate mentalisation by reducing traumatic enactment and building a secure attachment
Integration of narratives by holding memories as something of the past
ANP’s integrate traumatic experiences into consciousness (Stewart et al., 2011)
accomplished EP’s however their fear of losing the attachment had to be conquered, since traumatised patients with disorganised attachments have a predisposition to link attachment and fear (Seligman, 2007)
To cope with the anxiety of attachment loss, self soothing behaviours used
The use of a childhood coping object,the prism (Lynn’s home &therapeutic office)
This device is used to facilitate mentalisation by first adjusting the foundations of attachment
Some EP's would report their "alien self"
Alien self is the child’s own assumptions of the self based on the inconsistent model developed in accordance with the caregivers conflicting responses to the child
Do not challenge the beliefs of each EP but to allow for the appropriate marked mirroring in which the parent failed, in order to accommodate a secure attachment (Stewart et al., 2011 ).
The therapist aims to contain the EP’s feelings and reflect on them in order to facilitate mentalisation; “You’re feeling disgusting… Those feelings seem like they are really overwhelming for you… yet … I care about what happens to you” (Stewart et al., 2011, p. ).
Phase 2 - Treat traumatic experiences
Lynn became preoccupied with traumatic enactments of past memories. ( her brother visted at work)
Enactments perceived as painful re-experiences of traumatic event, cannot be conceived as something merely going on in the mind (Seligman, 2007)
Therapy focus on placating enactments and allowing Lynn to feel safe by engaging in self-soothing behaviours.
Mentalisation would have to evolve from not only perceiving the current mental state of a specific EP or ANP, but now integrating the different narratives and being able to hold that integration and make meaning of it in one of the more mature ANP’s to develop Lynn’s sense of self

Accomplished by each EP being responsible for its own meaning making by cognitively and affectively holding its narrative and reflecting, with the therapists on what parts of the narrative were meaningful.
By Lynn creating a narrative that described each event and the pain felt and strength gained from that event, memories became more integrated which allowed for them to be held as something that had occurred in the past (Stewart et al., 2011) .
Once each EP had developed its own narrative and regulated its affect so that acceptance and remembrance of the trauma replaced enactments of the trauma the dominant adult ANP will go through the same process
After this was accomplished, she never re-enacted any traumatic experiences.

Phase 3- Integration and Rehabilitation
Integrating the EP’s and ANP’s
Integration somewhat achieved by an increase in Lynn’s mentalisation capacities - facilitated by the development of secure attachments in the therapeutic setting and the resolution of her traumatic experiences

• Lynn became resistant-capacity to mentalise decreased only believed in her subjective reality
• Seligman (2007) cautions premature interpretation- suggesting alternatives to the subjective reality could be experienced as abandonment
Tackled this resistance by including a co-therapist in the session
If Lynn misinterpreted what primary therapist was saying -co therapist interprets Lynn’s perception of the primary therapists’ words and gives his own interpretation.
Allowed for the co-therapist to interrupt Lynn’s subjective perspective of the primary therapist and allows her to acknowledge that she could not properly read his mind or know his feelings (Stewart et al., 2011).
Risk - suggesting to Lynn that her subjective perception of primary therapist was in fact not real : reverted to her phobia of attachment loss , resisted mentalisation.
Difficult accomplish with only one therapist yet works in Lynn's case and maybe will in similar cases.
Study- prisoners with ASPD: when a patient gave an account of an emotionally charged event, the arousal hindered their ability to mentalise, at which point therapists would ask group members to try provide a reflective perspective (McGauley et al., 2011).
This can be contrasted to Lynn’s resistance based on the emotional experience that had to be processed. Although Lynn’s parts would have made group therapy difficult, in future group based mentalisation therapy may prove to be effective in deflecting emotion-triggered resistance.

Seligman (2007) points to the use of metaphor in facilitating mentalisation and organising the self.
Metaphor allows for the individual to take the position of observer to the self, which allows the metaphor to act as a protective layer for interpretation to take place (Seligman, 2007).
Transitional function to allow for dialogue of an individual’s subjectivity by talking about the patient as a third person and allowing a transitional space for self reflection (Seligman, 2007)
Sand game played by Lynn and the primary therapist where the two build a scene together out of figures. This allowed for Lynn to speak of her fears of the therapist being unsafe in a way that felt less threatening
Lynn’s capacity to mentalise is still only directed at being able to understand her own mental states as being separate from others
no indication that she has reached the ability to understand the states of others.
In a child EP the sand games seems to be an adequate way of allowing for the understanding of one’s own mental state yet in a more mature ANP, Seligman’s use of metaphor might prove to be efficient.
A distinct set of social cognitive processes ( part of EF) are based on the mirror neuron system
This system may be responsible for social interactions and thus the ability to mentalise.
Mirror neurons were first discovered in a study using macaque monkeys
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