Presentatie Peter Fonagy - Creating Connections

Mentalizing and theattachment process”Peter Fonagy FBADirector, Mental Health Program, UCLPChief Executive, Anna Freud CentreMenninger Clinic, 22 nd March 2013

Some of the Mentalizing Mafia• UCL/AFC/Tavistock‣ Dr Liz Allison‣ Prof George Gergely‣ Dr Pasco Fearon‣ Professor Alessandra Lemma‣ Professor Mary Target‣ Professor Eia Asen‣ Prof Anthony Bateman‣ Dr Trudie Rossouw• University of Leuven& UCL/AFC‣ Dr Patrick Luyten‣ Dr Dickon Bevington

Some more mafiosi (The USA branch)• Menninger Clinic/Baylor Medical College (The USA branch)‣ Dr Jon Allen‣ Dr Carla Sharp‣ Dr Lane Strathearn‣ Dr Efrain Bleiberg‣ Dr Brooks King-Casas‣ Professor Flynn O‟Malley‣ Dr Read Montague• Yale Child Study Centre‣ Prof Linda Mayes‣ Professor Nancy Suchman

Number of articles on Web of Science DatabaseArticles using ‘mentalization’ in title or abstractsSource: http://apps.webofknowledge.com, Data collected 10.3.2013

The latest from the Mentalizing MafiaNEW!IMPROVED!JUST RELEASED!Washes brainswhiter!Longer than allpreviousversions!American Psychiatric Publishing, Inc 2012

You will neveramount to anythingif you hold a balllike that!Let the boydream Ivan,He is a borndilettante!I want to write myPhD on the “Useof low signal-tonoiseratio stimulifor highlighting thefunctionaldifferencesbetween the twocerebralhemispheres”.You look smugnow but youwill lose yourhair just likeDad

Mentalizing: Cognitive vs. Emotional• Emotional Mentalizing‣The capacity to experience affective reactionsto the observed experiences of others• Cognitive Mentalizing‣Role-taking ability: The capacity to engage in thecognitive process of adopting another’spsychological point of view.‣Making inferences regarding the other’saffective and cognitive mental states

Distinguishing Emotional and Cognitive MzLevel ofComparisonBehaviorsNeuroanatomicalnetworksEmotionalEmotion recognition,emotional contagion,motor empathy, sharedpainIFG, IPL, ACC, AICognitiveCognitive ToM, AffectiveToM, Perspective-takingvmPFC, dmPFC, TPJ,MTLPhylogenesis Rodents PrimatesDevelopmentalstageNeurochemicalmechanismInfantsOxytocinAdolescenceDopamineShamay-Tsoory 2011

Mentalizing brain networksMENTALIZINGShamay-Tsoory 2011

Neurochemistry of Mentalizing• Cognitive empathy is related todopaminergic circuits‣This neurotransmitter plays a crucial role in thematuration of the frontal lobe from preschoolyears (Lackner, et al., 2010)• Emotional empathy is related tooxytocinergic functioning (Hurlemann, et al., 2010)

Emotional Mentalizing and Oxytocin• Facilitates empathic facial recognition and in-group trust(Bakermans-Kranenburg, in press)• It increases perceived salience of social cues (Shamay-Tsoory etal., 2009)• It improves empathic accuracy for less socially proficientindividuals (Bartz et al., 2010)• Emotional empathic approach recruits mainly left frontalareas. Oxytocin improves altruistic behavior inindividuals with relatively higher right frontal activity(Huffmeijer et al., 2012)• By enhancing activity in the Insula and IFG, it improvesunderstanding of others’ emotions, and reducesanxiety by decreasing amygdalar activity, facilitatingcontingent responses of help and compassion (Bakermans-Kranenburg, in press)

The Empathic Brain MechanismsEmotional empathy: SimulationInferior frontal gyrus(IFG)Inferior parietal lobule(IPL)•Both zones are rich in mirror neurons•Implied in emotional contagion since infancy•Implied in emotion recognition

The Empathic Brain MechanismsEmotional empathy: Shared emotion and painAnterior cingulatecortex(ACC)Insula•These areas respond to both observed and felt pain•Their intensity of their activation correlates with the explicit judgment aboutseverity of pain•Observed pain activation decreases depending on the context: unfamiliarpeople, people of different race, alexithymia, and in medical practitioners

The Empathic BrainCognitive mentalizing: Theory of MindTemporoparietalJunction (TPJ)Mainly responsible fortransient mentalinferences aboutother people, theirgoals, desires andbeliefs.Medial PrefrontalCortex (mPFC)Attribution of more enduringtraits and qualities.dmPFC: understandingothers’ beliefsvmPFC: others’ emotionsand the difference betweenself and othersHippocampus (HC)Mainly responsibleautobiographicalmemory: past usedto understandevents happening tothe self and othersGweon, et al., 2012; Shamay-Tsoory, 2011

The Empathic BrainCognitive empathy: Theory of Mind, MentalizingOther brain areasimplicated in ToMTemporal Poles(TP)PrecuneusSuperior Temporal SulcusSTS

The Mentalizing BrainInferior frontal gyrusThe mirror neuronsystem is a first step:Emotional ContagionFrith & Frith, 2006Temporo-parietal junction& superior temporal sulcusVisio-spatial and cognitiveperspective-takingFrontal and prefrontal CortexTemporal polesIntegration of perceivedinformation about others,learnt information aboutunique persons andcontextual informationmPFC: Anticipating what oneself or others will feel andbehavior predictionMedial orbital cortex: Emotional perspective-takingVentral regions of the medial frontal cortex: thinking aboutcommunicative intentions

Mentalization and Overlapping Constructs(Choi-Kain & Gunderson, Am J Psychiat 2008)

Mentalizing Profile: A multidimensional modelFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.Implicit-Automatic-Non -conscious-Immediate.Mentalinteriorcuefocusedamygdala, basal ganglia,ventromedial prefrontalcortex (VMPFC),lateral temporal cortex (LTC)and the dorsal anteriorcingulate cortex (dACC)medial frontoparietalnetwork activatedAROUSALAROUSALlateral and medial prefrontal cortex(LPFC & MPFC), lateral and medialparietal cortex (LPAC & MPAC),medial temporal lobe (MTL),rostralanterior cingulate cortex (rACC)recruits lateral fronto-temporalnetworkExplicit-ControlledConsciousReflectiveMentalexteriorcuefocusedCognitiveagent:attitudepropositionsAROUSALAssociated with several areasof prefrontal cortexAssociated with inferior prefrontalgyrusAffectiveself:affect statepropositionsImitativefrontoparietalmirror neuronesystemfrontoparietal mirror-neuronsystemAROUSALthe medial prefrontal cortex,ACC, and the precuneusBelief-desireMPFC/ACCinhibitorysystem

Mentalizing Profile Associated with ArousalFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.Implicit-Automatic-Non -conscious-Immediate.Mentalinteriorcuefocusedamygdala, basal ganglia,ventromedial prefrontalcortex (VMPFC),lateral temporal cortex (LTC)and the dorsal anteriorcingulate cortex (dACC)medial frontoparietalnetwork activatedAROUSALAROUSALlateral and medial prefrontal cortex(LPFC & MPFC), lateral and medialparietal cortex (LPAC & MPAC),medial temporal lobe (MTL),rostralanterior cingulate cortex (rACC)recruits lateral fronto-temporalnetworkExplicit-ControlledConsciousReflectiveMentalexteriorcuefocusedCognitiveagent:attitudepropositionsAROUSALAssociated with several areasof prefrontal cortexAssociated with inferior prefrontalgyrusAffectiveself:affect statepropositionsImitativefrontoparietalmirror neuronesystemfrontoparietal mirror-neuronsystemAROUSALthe medial prefrontal cortex,ACC, and the precuneusBelief-desireMPFC/ACCinhibitorysystem

LoveSpurned/ArousalDimensions of mentalization: implicit/automaticvs explicit/controlled in OthelloControlledThatWhy,handkerchiefhow now, ho! fromwhichwhenceIarisethso lovedthis?and gave theeThou Are we gavest turn'd Turks, to Cassio. and to ourselves do thatBy Which heaven, I hath saw forbid my the handkerchief Ottomites? in's hand.For Christian shame, put by this barbarous brawl:Automatic

Dimensions of mentalization: implicit/automaticvs explicit/controlled in Othello‟s brainThat handkerchief which I so loved and gave theeThou Lateral gavest to Cassio.By heaven, temporal Lateral I saw PFC Amygdalamy handkerchief Medial Ventromedial PFC PFCin's hand.cortexControlledAutomaticArousal

Dimensions of mentalization: implicit/automaticvs explicit/controlledPsychological understanding drops and israpidly replaced by confusion about mentalstates under high arousalThat handkerchief which I so loved and gave theeThou gavest to Cassio.By heaven, I saw my handkerchief in's hand.ControlledAutomaticArousal

Dimensions of mentalization: implicit/automaticvs explicit/controlledPsychotherapist‟s demand to explore issuesthat trigger intense emotional reactionsinvolving conscious reflection and explicitmentalization are inconsistent with thepatient‟s ability to perform these tasks whenarousal is highArousal

Early Development of Mentalizing• 6 and 10-month-old infants show preference forcharacters that help others over characters that arenot cooperative or hindering (Hamlin, Wynn, & Bloom, 2007)• Infants as young as 12 months of age begin tocomfort victims of distress (Warneken & Tomasello, 2009)• Children aged 14-18 months display spontaneous andunrewarded helping behaviours (Warneken & Tomasello, 2009)• Children aged 18-25 months are inclined tosympathize with others in strife, which implies anearly form of emotional perspective-taking (Decety, 2011)

Development of empathy: Regression?At 17 months of age,34.6% of children helpedanother child who wasfeeling sickA year after, 17% of boysand 12% girls stoppedshowing this behavior19% of children who do notshow empathic behavior at 29months of age, had shown it 1year before•Ceasing to exhibit prosocialbehaviors during toddlerhood is anormative aspect of early socialdevelopment•Prosocial behaviors becomeregulated during preschool yearsBaillargeon et al., 2007; Baillargeon et al., 2011; Brownell, 2013; Hay, 1994•Children learn to inhibitprosocial behaviors as theybecome aware of the implicitrules of social and moral conduct•They learn where, when andwhom to help: reciprocity,equity and deservedness

Development of EmpathyMoral behaviorEmpathic behaviortowards othersRule-compatible behaviorwithout supervisionEmpathic behaviorduring toddlerhoodprevents externalizingpathology and predictsdevelopmentaladaptationIt causes greaterpositive reciprocityin the relationship withclose figuresPositive relationshipfoster mental healthand positivesocializationtrajectoriesKochanska et al., 2010

Development of empathyEmotional empathy develops very early• It relies on somato-sensoriomotor resonance and mimicryNewborns and infants become distressedshortly after another infant starts cryingMimicry of facialexpressionsstarts around 10weeks

Development of EmpathyCognitive empathy develops later• It relies on more sophisticated functions‣Theory of mind (ToM)‣Executive function‣Self-regulationThis allows for regulated responsesto others’ distress, without feelingdistressed oneself• These are implemented in the prefrontal cortex‣It develops more slowly than the rest of the brain‣Reaches maturity during adolescenceGreimel, et al., 2010; Decety, 2011

Sensitivity to others‟ state of mindFalse belief for babyTrue belief for SmurfÁ M Kovács et al. Science2011;330:1830-1834True belief for babyFalse belief for Smurf

Sensitivity to others‟ state of mindBall Not ThereFalse belief for babyThe infant but not theSmurf believes thatthe ball should be thereBall Not ThereTrue belief for babyFalse belief for SmurfInfant knows ball is not thereBut Smurf believes it shouldbe thereNeither infant northe smurf believethat ball is thereNeither infant northe Smurf believe thatthe ball should be thereThe two key conditions in Smurf Study: Infant of 7 monthsconsiders what agent (Smurf) believes about the status of ballÁ Published M Kovács by AAAS et al. Science 2010, 330:1830-1834

The social brain: pSTS/TPJ• Seeing the other‟spoint of view‣ Predictiono Biological motion, eyegazeo Predicting complexmovements‣ Perspective-takingo Joint attentiono Different physical pointsof viewmPFCpSTS/TPJPelphrey et al., 2004a,b; Kawawaki et al., 2012 (review); Mitchell 2013

Brain Regions for Perceiving and Reasoning AboutOther People in School-Aged Children (Saxe et al.)Right TPJmPFCPrecuneusLeft TPJ

Grace and her friend are taking a tour of a chemicalplant. When Grace goes over to the coffee machine toour some coffee, Grace’s friend asks for some sugarin hers. There is a white powder next to the coffee in acontainer marked “toxic” and Grace gives two spoonfulsto her friend.

Disruption of the right temporoparietal junction withtranscranial magnetic stimulation reduces the role ofbeliefs in moral judgments (Young et al., PNAS)*

Mentalizing can be taught• Prosocial behaviors in children emerge around the 2 years ofage and are largely non-heritable (Deater-Deckard, 2003; Brownell, 2013)‣ They are linked with positivity in the relationship with parents(Spinrad, 2009)‣ Maternal responsiveness at child‟s 9 months of age predictschild‟s empathy at 22 moths of age (Kochanska, 1999)‣ Mothers with negative preconceptions about parenting havechildren who show less empathy towards their mothers (Kiang,Moreno & Robinson, 2004)‣ Punitive and harsh parenting is negatively related to prosocialbehaviors (Asbury et al., 2003)Warm and sensitive attachment relationship encouragesempathy and perspective taking(Farrant et al, 2012)

Empathy and Attachment• Avoidant attachment shows a characteristic way ofdetachment that impedes mentalization andtherefore empathy:‣ Avoidant children aged 4-5 years in play with peers,are either manipulative and exploitative or victims ofa manipulative relationship. They oscillate betweenbeing victims and victimizers• Empathy requires regulation of negative emotions:‣ Fearful and insecurely attached 16 and 22 monthsold girls show progressively less empathy forstrangers in distress‣ During that time span, empathic concern for theirmother’s distress increasedVan Der Mark, Van Ijzendoorn & Bakermans-Kranenburg, 2002; Troy & Sroufe, 1987

Empathy and AttachmentThe development of empathyrequires an early attachment relationwith a warm and responsive adultChildren of responsive mums showmore concerned attention and lowerpersonal distress when confronted todistress of the mother and of a strangerReactivity to stress is present in youngchildren, but only some can regulateit and react empathicallyKiang, Moreno & Robinson, 2004; Novartis Foundation, 2007; Spinrad & Stifter, 2009

The Development of Affect Regulation• Closeness of the infant to another humanbeing who via contingent marked mirroringactions facilitates the emergence of asymbolic representational system of affectivestates and assists in developing affectregulation (and selective attention) secureattachment• For normal development the child needs toexperience a mind that has his mind in mind‣Able to reflect on his intentions accurately‣Does not overwhelm him‣Not accessible to neglected children

High congruent & marked mirroring

Empathy and AttachmentThis effect of positive attachment is also observed in adults:Priming attachmentsecurity in adultsEmpathicreactionsPersonaldistressAttachment avoidance andanxiety are inversely related toempathyAttachment anxiety is positivelyrelated to personal distressWhen perceiving distress, insecurely attached people fail to recruit cortical brainareas normally used to down-regulate negative emotions (ACC and MPFC), whichhinders empathic behaviors of help and comfortGillath, 2005; Mikulincer et al., 2001; 2005

Empathy and Attachment• Dismissively attached women when empathizing:• Show more activation in motor, limbic, and mirrorsystems• Implies implicit and unmodulated emotional involvement• Impairment in self-other differentiation• Deactivation of fronto-medial areas: ACC and medialpre-frontal cortex• Implies emotional disinvestment towards social emotions,typical of dismissive subjects• It compensates the overactivated implicit involvementEmotional overactivation in dismissive subjects does notresult in empathy, but in the retrieval of autobiographicalmemories of painful attachment experiences, which triggeravoidance strategies when observing painLenzi, et al., 2012

Theory: Birth of the “Alien” Self inDisorganized AttachmentThe caregiver’s perception is inaccurate or unmarked or bothAttachment Mirroring fails ChildFigureAbsence of arepresentation ofthe infant’smental stateThe nascent selfrepresentationalstructureThe AlienSelfInternalisation of a non-contingent mentalstate as part of the selfThe child, unable to “find” himself as an intentional being, internalizes arepresentation of the other into the self with distorted agentive characteristicswhich disorganizes the self creating splits within the self structure

Theory: Self-destructiveness andExternalisation Following TraumaTorturing alien selfSelf representationPerceivedotherSelf-harm stateUnbearably painfulemotional states:Self experiencedas evil/hatefulAttack from within is turned against body and/or mind.

Theory: Self-destructiveness andSelf-destructive relationshipsTorturing alien selfSelf representationTorturing alien selfExternalizationPerceivedotherSelf-harm stateUnbearably painfulemotional states:Self experiencedas evil/hatefulContainerAddictive bondSelf experiencedas as hated evil and attacked hatefulVictimized stateProjective identification is used to reduce the experience of unbearably painful emotional state ofattack from within – externalisation becomes a matter of life and death and addictive bond andterror of loss of (abusing) object develops

Externalisation & Violence Following TraumaTorturing alien selfSelf representationTorturing alien selfExternalizationPerceivedotherSelf-harm stateUnbearably painfulemotional states:Self experiencedas evil/hatefulContainerAddictive bondViolent actSelf experiencedas as righteously as hated evil and vindicated attacked hatefulViolent stateProjective identification is used to reduce the experience of unbearably painful emotional state ofattack from within – externalisation becomes a matter of life and death, the violent act protectsagainst experience of intrusion and addictive bond and terror of loss of abused object candevelop

Empathy deficits and attachmentIn children with disruptive behavior disordersChildren with higher levels ofcallous/unemotional traitsare more likely to showdisorganized attachmentIn line with impairments inattending to, recognizing andresponding to other people’semotionsDisrupted attachment amplifynegative effects oftemperamental aspects oncallous/unemotional traitsEarly attachmentdisturbances impairchildren‟s ability to reflect onand respond to other people’semotional statesThese traits are associated with emotionalrecognition deficits and low levels of prosocialbehaviorPasalich et al., 2012

Mentalizing Profile of Prototypical BPD patientFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.Implicit-Automatic-Non-conscious-ImpressionisticMentalinteriorcuefocusedBPDamygdala, basal ganglia,ventromedial prefrontalcortex (VMPFC),lateral temporal cortex (LTC)and the dorsal anteriorcingulate cortex (dACC)medial frontoparietalnetwork activatedlateral and medial prefrontal cortex(LPFC & MPFC), lateral and medialparietal cortex (LPAC & MPAC),medial temporal lobe (MTL),rostralanterior cingulate cortex (rACC)BPDrecruits lateral fronto-temporalnetworkExplicit-ControlledConsciousReflectiveMentalexternalcuefocusedCognitiveagent:attitudepropositionsAssociated with several areasof prefrontal cortexBPDAssociated with inferior prefrontalgyrusAffectiveself:affect statepropositionsImitativefrontoparietalmirror neuronesystemBPDfrontoparietal mirror-neuronsystemthe medial prefrontal cortex,ACC, and the precuneusBelief-desireMPFC/ACCinhibitorysystem

Prementalizing Modes of Subjectivity• Psychic equivalence:‣ Mind-world isomorphism; mental reality = outer reality; internal has power ofexternal‣ Intolerance of alternative perspectives concrete understanding‣ Reflects domination of self:affect state thinking with limited internal focus• Pretend mode:‣ Ideas form no bridge between inner and outer reality; mental worlddecoupled from external reality‣ “dissociation” of thought, hyper-mentalizing or pseudo-mentalizing‣ Reflects explicit mentalizing being dominated by implicit, inadequate internalfocus, poor belief-desire reasoning and vulnerabilty to fusion with others• Teleological stance:‣ A focus on understanding actions in terms of their physical as opposed tomental constraints‣ Cannot accept anything other than a modification in the realm of the physicalas a true index of the intentions of the other.‣ Extreme exterior focus, momentary loss of controlled mentalizing‣ Misuse of mentalization for teleological ends (harming others) becomespossible because of lack of implicit as well as explicit mentalizing

Treatment vectors in re-establishing mentalizingin borderline personality disorderImplicit-AutomaticImpression Controlled drivenExplicit-ControlledMentalinteriorfocusedInference AppearanceMentalexteriorfocusedCognitiveagent:attitudepropositionsCertainty Doubt of of cognition emotionAffectiveself:affect statepropositionsImitativefrontoparietalmirror neuronesystemEmotional Autonomy sensitivityBelief-desireMPFC/ACCinhibitorysystem

•Mentalizing and thepedagogic stance and ageneral theory forpsychotherapy?

The need for human naturalpedagogy• We are born into a world populated with manmadetools whose functional properties,appropriate manner of application or method of(re)production often remain in many respectsepistemically opaque• The cognitive opacity of kind or category-relevantaspects of human-made functional artifacts raisesa learnability problem (of relevance-selection) forthe naïve juvenile observational learner

The Theory of Natural Pedagogy (Csibra &Gergely, 2006; 2009, in press)• A human-specific, cue-driven social cognitiveadaptation of mutual design dedicated to ensureefficient transfer of relevant cultural knowledge• Humans are predisposed to ’teach’ and ’learn’new and relevant cultural information from eachother• Human communication is specifically adapted toallow the transmission of• a) cognitively opaque cultural knowledge• b) kind-generalizable generic knowledge• c) shared cultural knowledge

Definition of Ostensive Stimuli(Sperber & Wilson, 1995)• The signals whereby an agent makes manifestto an addressee her communicative intention:to manifest some new relevant information forthe addressee (i.e. her informative intention).• Infants display species-specific sensitivity to,and preference for, some non-verbal ostensivebehavioral signals (see Csibra, 2010, Csibra & Gergely, 2009 for reviews)• Examples of ostensive communication cues‣ eye-contact‣ turn-taking contingent reactivity‣ special tone („motherese‟)

The Pedagogical Stance is triggered byOstensive-Communicative cues• Ostensive cues have in common‣Infant recognized as a self‣Paid special attention to (noticed as an agent)• Ostensive cues function to trigger:‣Open channel to knowledge about social andpersonally relevant world (CULTURE)‣Go beyond the specific experience and acquireknowledge relevant in many settings‣Triggers opening of an epistemicsuperhighway for knowledge acquisition

Ostensive cues referentialexpectation in infant• 6-month-olds followed an agent‟s gaze-shift to one oftwo objects but only when it had been preceded by eithereye contact or infant-directed speech (ostensivesignals) addressed to the infant (Senju and Csibra, 2008).• An automated eye-tracker based study used an infantinducedcontingent reactivity paradigm to demonstratethat 8-month-olds gaze follow an unfamiliar object‟sbodily orientation response towards one of two targets,but only when the object had been reactingcontingently before (producing self-propelled bodymovements such as tilting) to being looked at by the infant(Deligianni et al., 2011).

Experimental illustration of ostensive cuesGergely, Egyed et al. (in press)Subjects : 4 groups of 18-month-oldsStimuli: Two unfamiliar objects

1: Baseline – control groupNo object-directed attitude demonstrationSimple ObjectRequest byExperimenter ASubjects: n= 20 Age: 18-month-olds

Ostensive Communicative DemonstrationRequester: OTHER person (Condition 1)Otherperson

Non-Ostensive (Non-Communicative) DemonstrationRequester: OTHER person (Condition 2)Otherperson

Condition 4: Non-Ostensive (Non-Communicative)Demonstration Requester: SAME personSameperson

Epistemic trust and secureattachment• Secure attachment is created by a system thatalso induces a sense of epistemic trust thatthe information relayed by the teacher may betrusted (i.e. learnt from)• Evidence‣ Cognitive advantage of secure attachment‣ Contingent responsiveness to the infant‟s own (at first,automatic) expressive displays in secure attachment‣ During “mirroring” interactions, the other will “mark”her referential emotion displays in a „manifestative‟manner to instruct the infant

How Attachment Links to Affect RegulationDISTRESS/FEARDown Exposure Regulation to Threat of EmotionsBONDINGEPISTEMICTRUSTActivation of attachmentProximity seekingThe forming of an attachment bond

Social Cues that Create Epistemic Trust• Attachment is special condition for generating epistemictrust• Generally any communication marked by recognition of thelistener as intentional agent will increase epistemic trustand likelihood of communication being coded as‣ Relevant‣ Generalizable‣ To be retained in semantic memory• Influential communicators‣ use ostensive cues to maximum‣ create „illusion‟ of recognizing agentiveness of listenero Looking at audienceo Addressing current concerno Communicating that they see problem from agent’s perspectiveo Seeing Recognizing individual struggle in understanding• Massive difference in ability of individuals to influence(teachers, politicians, managers) explicable in terms ofvarying capacity to generate epistemic trust

Meta-analytic studies of teacher effectiveness• John Hattie is Professor of Education at the University ofAuckland, New Zealand.• 15 years research and synthesises over 800 meta-analysesrelating to the influences on achievement in school-agedstudents.• Builds a story about the power of teachers and of feedback,and constructs a model of learning and understanding.• Is there a set of predictors to good teaching outcomes basedon:‣ The child?‣ The home?‣ The school?‣ The curricula?‣ The teacher?‣ The approaches to teaching?

Meta-analytic studies of teacher effectiveness• Things that do not work:‣Mobility (shifting schools) -0.34‣Television -0.14‣Summer vacation -.09‣Ability grouping 0.10‣Ability grouping .10‣Individualized instruction .20‣Homework .30

Meta-analytic studies of teacher effectiveness• What makes a teacher most effective?‣It is teachers seeing learning through the eyesof students; and students seeing teaching as thekey to their ongoing learning• The key ingredients are:‣ Awareness of the learning intentions‣ Knowing when a student is (feels) successful‣ Having sufficient understanding of the student‟sunderstanding‣ Know enough about the content to provide meaningfuland challenging experiences• Passion that reflects the thrills as well as awareness of thefrustrations of learning.

Implications: A mechanism of change• Mentalizing (seeing behaviorin terms of mental states)entails collaboration‣Seeing from other’sperspective‣Treating the other as aperson‣Recognizing them as anagent‣Assuming they have thingsto teach you – since mentalstates are opaque

Implications: The nature of psychopathology• Social adversity (most deeply trauma) is thedestruction of trust in social knowledge ofall kinds rigidity, being hard to reach• Cannot change because cannot accept newinformation as relevant (to generalize) toother social contexts• Personality disorder is not disorder ofpersonality (except by old definition of beingenduring) but inaccessibility to culturalcommunication from• Partner}• Therapist• TeacherEpistemic Mistrust

Implications: The nature of psychopathology• Epistemic mistrust follows experiences ofmaltreatment or abuse• Therapists ignore this knowledge at their peril• Personality disorder is a failure ofcommunication• It is not a failure of the individual but a failure of arelationship• It is associated with an unbearable sense ofisolation in the client generated by epistemicmistrust• Our inability to communicate with client causesfrustration in us and a tendency to blame thevictim• We feel they are not listening but actually it is thatthey find it hard to trust the truth of what they hear

Implications: The nature of psychotherapy• Mentalizing patients may be a common factor topsychotherapy not because we need to learn aboutour minds to learn about those of others• Mentalizing is a generic way of establishingepistemic trust and achieving change‣Our subjectivity being understood is necessary key toopen up wish to learn about world including socialworld‣ Open a key biological route to information transmissionand possibility of change epistemic super-highway‣Experience of feeling thought about makes us feelsafe enough to think about social world

Implications: The nature of psychotherapy• Therapy is not just about the what but thehow of learning:‣Opening the person’s mind viaestablishing epistemic trust (collaboration)so he/she can once again trust the socialworld by changing expectations‣It is not just what is taught in therapy thatteaches, but the evolutionary capacity forlearning from social situation is rekindled‣CAMHS interventions are effective becausethey open the child to social learningexperience which then feed back in virtuouscycle

Psychotherapy may be effective for two reasons• Learning content by focusing on trustworthyaspects of context‣We may have some wisdom that is worthcommunicating‣Once epistemic superhighway is open the client canlearn from us• Learning about sources of knowledge byproviding a clear social illustration of trust weundo epistemic isolation‣By using ostensive cues and establishing a sense thatwe are concerned to see the world from the client’sstandpoint we model a situation of interpersonal trust‣Improved understanding of social situation Leadsto better understanding of attachment figure moretrusting (less paranoid) interpersonal relationships itopens up the potential to feeling sensitively respondedto in virtuous cycle

Implications: Learning beyond therapy• What is the process at work:‣Limitless therapies - 1,246 different ways tounderstand‣But each model capable to provide a content totreatment that makes person feel understood‣The rationale of the treatment and the model ofpathology and the model of therapeutic effectgives the treatment the content to create theprocess‣Mentalizing by itself is not a realistic therapy – it doesnot tell the therapist what to focus on, just focusingthe patient on their thoughts and those of othersaround them will not achieve change‣Improvement based on learning from experiencebeyond therapy

Implications: Learning beyond therapy• The specific frame of the therapy around whichmentalizing occurs• the model of mind,• the model of interaction,• the model of underlying dysfunction,• the model of therapeutic goals• The enhancing of mentalizing is also a common factorthat achieves improved social relationships• Improved sense of epistemic trust enables learningfrom experience change due to what happensbeyond CAMHS• The enhancing of epistemic trust may be achievedby treatment but also a consequence of improvedsocial relationships and consequent on whathappened in the social world.

Gaps in Therapy Outcomes Research• No solid evidence for who will benefitfrom what type of psychotherapy• ‘Inexact therapies’ partialeffectiveness• ‘Attachment to methods’ ‘guildification’ of interventions

To Sum Up

Getting comfortable in the social worldAdapting to the social world is a steep learning curve

Getting comfortable in the social worldMe playdrums??For example, it is not obvious what is the true function of allthe objects we use.

8etting comfortable in the social worldLuckily, humans have evolved to teach and learn fromeach other quickly and efficiently…

9Getting comfortable in the social world-..quickly and efficiently if certain conditions are met…

9etting comfortable in the social world…but this special interpersonal channel for learningabout the social world is not always tuned in.

9Tuning in to the interpersonal channelWhen Trust there opens is abuse, up the there social is communicationno trust, the mindsuperhighway, is blocked and enabling it is impossible us to learn to move and change forward

9Tuning in to the interpersonal channelWin Trust the opens other person’s up the social trust communicationby respondingcontingently …and they will tune in to you!superhighway, to their enabling feelings us and to learn thoughts, and change showingthem that you are hearing and thinking about what’sgoing on in their mind…

MBT IS CHEAP AND COMFORTABLEAND HELPFUL IN A RANGE OF WAYS!!!

For Electronic version please e-mail: P.FONAGY@UCL.AC.UK