Tag Archives: Peter Fonagy

Peter Fonagy Lecture at IPMH I: Mentalization Based Therapy

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MBT (Mentalization Based Therapy) focuses on how the person feels now, rather than on the past. Imagine yourself talking to a client. Try to think about how you would think about the situation the person is describing. When the other person isn’t making sense, it is because he is not bearing in mind the person he is talking to – you. That means he isn’t “mentalizing”.

The therapist makes “simple sound-bite” interventions that are affect-oriented (related to love, desire, hurt, catastrophe, excitement), and focus on the patient’s mind, not on his behavior, nor on his past. MBT relates to a current event or activity, and identifies non-mentalizing as getting in the way of the patient’s stated goals.

Technically, the therapist in MBT notes breaks in the patient’s mentalizing – when the patient starts to talk as if the world is against him and he is the helpless victim, for example – and rewinds the conversation to the moment before the patient stops mentalizing. Suppose the patient is explaining a disagreement with her boss and then says that her boss treats her the way all men treat her, in fact the way you, the therapist, is treating her right now – by not ‘hearing’ her! In fact, she should leave right now since she is just wasting her time in this therapy!” You might then go back to what the boss said to her that morning and explore how it feels the same as what is going on now between you. How is she feeling ‘not heard’ by you? You accept responsibility for contributing in some way you do not yet understand, for generating this terrible feeling in the patient.

In MBT the mind of the patient becomes the focus of the treatment. Your job as therapist is to help the patient learn about the complexities of his thoughts and feelings about himself and others, how that relates to his responses, plus how “errors” in his understanding of himself can lead to actions that cause problems for him. It is not your job to tell the patient how he feels, what he thinks, how he should behave, or what the underlying reasons are. Instead, you are helping him build new competencies for maintaining a self-reflective mind even under the stress of intense affect. Peter recommends adopting a “not knowing” stance, conveying to the patient a sense that mental states are opaque.

In the therapy, the therapist first of all helps the patient become better regulated. That sounds familiar, doesn’t it? You want to lower arousal as much as possible. Then you validate the patient’s perceptions. Finally, you begin the painstaking work of trying to get the patient to see the situation from another person’s point of view – that is “mentalizing”. Suppose the patient says, “I am just a bad mother.” That is not mentalizing. You stay with what she is saying right here, recognize the self critical feelings are flooding back, and do not turn your attention to the past. If she is not mentalizing when she tells you about herself as a mother, go to another subject and help her regain her more mature perspective, then return to her distress as a mother.

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“Ghosts in the Nursery”

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For this mothers’ group meeting the mothers chose the topic of the relationship with their own mothers. This is a very important subject and one that has been central to thinking in psychology for about half a century now. I will organize my thoughts about it into three categories. The first is psychoanalytic or psychodynamic thinking about the subject. The second is Attachment Theory, and the third is the developmental perspective introduced by Tronick in his Mutual Regulation Model (Tronick, 2007).

First of all, Sigmund Freud didn’t pay much attention to the mother’s relationship to her own mother in his theorizing. In fact, he didn’t blame the mother much at all. In his famous case of a child with a horse phobia, “Little Hans” – although there was plenty of evidence of Little Hans’ mother’s emotional difficulties and of his parents’ marital conflict at the time (this was revealed rather recently when the Sigmund Freud Archives revealed information gained from interviews of the father and of Little Hans himself as an adult) – Freud attributed most of Little Hans’ problems to Hans’ own inner conflicts generated by his developmental stage and position in the family – his “Oedipal Conflict” (Freud, 1909), (Chused, 2007).

The early child analysts who studied with Sigmund Freud’s daughter, Anna Freud, gave more thought to the influence of parenting. Anna Freud and Dorothy Burlingham created “Hampstead War Nurseries” in which the impact of children’s separation from their mothers was observed and the recommendation was made to keep children with their families whenever possible, even during the bombings (Midgely, 2007). One of the circle of early child analysts around Anna Freud, Berta Bornstein, wrote a classical paper describing her analytic treatment of the little boy she called “Frankie” (Bornstein, 1949). In this paper she hypothesized that Frankie’s mother’s relationship with her own mother – and to her preferred older brother – affected her own difficulty bonding to newborn Frankie and influenced her continuing relationship with her son.

Another follower of Anna Freud was Selma Fraiberg, who became famous for her book about early child development called “The Magic Years”. Fraiberg made an important contribution in our understanding of early development through clinical her work with the mother-child relationship. She wrote a classic paper called “Ghosts in the Nursery” about the influence of a woman’s experience with her mother on her relationship with her own child (Fraiberg, Adelson, & Shapiro, 1975). In this paper, Fraiberg states, “In every nursery there are ghosts. They are visitors from the unremembered past of the parents; the uninvited guests at the christening” (p. 387). One of Fraiberg’s followers, Alicia Lieberman, has written about a counteracting influence that she calls, “The Angels in the Nursery” (Lieberman et al, 2005).   Continue reading

Healing the Attachment System

 

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My observations in India – just as my much longer experience in El Salvador – have led me to question the idea that the way to heal attachment disorders is either by the establishment of a potentially secure attachment relationship through adoption or foster parenting, or through intensive and lengthy psychotherapy. That is not to say that I saw uniformly effective healing in either place, but just that I observed alternative healing methods that seemed to me to have promise. 

In each children’s home, for example, there are multiple caregivers, at least one central parental figure, and (when all is going well) a secure environment. The secure environment is not only associated with the person of the caregiver but is also related to adequate food and shelter and freedom from threat. At Love and Hope, Rachel is the central parental figure, and the children also have important relationships with the tias and tios (female and male caregivers), the cook (as witnessed in the “papusa maker” video), and a social worker and psychologist on staff; the high caregiver-child ratio is one of the strengths of the home. At Deenabandhu, there are two central parental figures – Prajna and Prof. Jayadev – and the important continuity of one (the same) skilled and caring teacher throughout the early years of school. In addition to these strengths in each home there are the important relationships between and among the children – age mates and older-younger pairs. Perhaps the power of the peer relationships is enhanced by aspects of the culture; in El Salvador it is not uncommon to see a young boy carrying a baby on his hip. At any rate, the richness of the interpersonal environment offers many opportunities for finding security in a trusting relationship, contingent social interactions, and the subjective experience of caring and personal recognition. 

 

 It is important to recognize the apparently contradictory results of the Romanian orphanage studies that point to the dangers of early institutionalization and the need for a primary caregiving relationship such as through adoption or foster care (Zeanah et al, 2011, Fox et al, 2010). When viewing the films of the children in these orphanages, the caregivers appear to be surprisingly pleasant and sometimes engaging in friendly, even helpful, interactions with the children. The main problem, I guess, is the lack of contingency of caregiver responses, especially in infancy. That is, the children are fed without reference to their cues or initiatives, aggression in the free play situation is not responded to helpfully, and the caregivers do not play with the children. I guess I would suggest that the big difference I observed between what I saw in the films of the Romanian orphanages and what I saw at Love and Hope and Deenabandhu is greater personal involvement of the caregivers and the children so that relationships were encouraged, the children were known for who they were as little individuals, and there was a lot of interaction between caregivers and children – in play and in academic learning. This is related to the idea of “magic moments“, or “lost momentos magicos” of earlier posts. 

I am reminded of Bruce Perry’s observations that traumatized children initially do better when allowed to seek out particular caregivers to fill specific personal needs – such as one caregiver to roughhouse with, another to provide food, another for comfort at times of emotional distress, another to help with homework. I am also reminded of Peter Fonagy’s therapeutic model of mentalization. That model avoids directly engaging the attachment system without simultaneously working on building reflective capacity that can guard against what one might call the “regressive pull” to intense destructive relationship patterns that were established in early childhood. Fonagy’s model was originally designed to treat adults with Borderline Personality Disorder, many of whom have experienced early trauma. However, it seems to me to be equally relevant to children – at least those with the cognitive capacity for mentalization – who cannot trust adult caregivers and cannot comfort or care for themselves. None of this means that developing a trusting and loving caregiving relationship with a single person is not healing. It is just to say that – at least now in my thinking – I am leaning towards the idea that there are multiple ways of healing the attachment system of children who have experienced trauma and severe neglect.

 

I hope my readers can make comments on this posting.

 

Bos K, Zeanah C, Fox N, Drury S, McLaughlin K, & Nelson C, Psychiatric outcomes in young children with a history of institutionalization, Harvard Review of Psychiatry, January/February, 2011, pp. 15-24; Fox S, Levitt P, & Nelson C, How the timing and quality of early experiences influences the development of brain architecture, Child Development, January/February, 2010, Vol. 81, Number 1, pp. 28-40).

 

Photograph by Ginger Gregory

 

 

 

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Discipline

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 This is just a brief posting on a big subject that always seems disjointed to me when it is discussed out of context, but also a subject that parents and other caregivers have such headaches about that it deserves attention now and then.

There are two main points I want to make about discipline in this piece. The first is, discipline serves to maintain safety and to communicate values. The second is that discipline frequently gets mixed up with deep – both unconscious and nonconscious – reactions in the caregiver that influence the way the discipline is delivered. We all know both of these points. I am going to simply comment on examples of good discipline I have observed both at Deenabandhu and at Love and Hope and try to identify some of the features that make them effective. As for the deep reactions of the caregivers and how they influence the caregiver’s behavior, I will leave that for a later entry. Some insights for parents about this issue can be found in Parenting from the Inside Out (Siegel and Hartzell, 2003).

One observation I have made is that it is often easier in children’s homes than in single families to establish a consistent set of rules and consistent consequences for noncompliance with those rules. At Love and Hope these rules for behavior are listed in colorful posters on the walls of the dining hall. These rules also communicate the Christian values – such as generosity and compassion – that play such an important role in the life of the Home. Consistency takes some of the stress out of discipline from the point of view of the caregiver. That is very important, because those deep unwelcome reactions that cause caregivers to “blow up” at their children are in part stress reactions. In other words, the loss of perspective and even loss of control on the caregiver’s part is probably mostly generated by stress. If the caregiver can stay calm and reflect on the situation, he or she is more likely to respond to the child’s behavior appropriately (that is, in a way that fits his or her best values). 

There are many ways to address the stress reactions that interfere with good discipline practices, and consistency in rules and consequences is only one of them. When caregivers can gain insight into the deep reactions, it is also useful. However, insight is a “top down” phenomenon, and often the stress reactions of the lower parts of the brain trump attempts to keep perspective with the thinking brain. When the caregiver can also use a “bottom up” response to stress, insight is even more effective. Bottom up strategies include ways of calming, or regulating, oneself. 

One way of doing that is to disengage, that is, try to distance oneself from the intensity of the situation. That can be very helpful and is commonly called “time outs” either for the child or for the caregiver. Physical distance is often a critical part of this strategy. Another partial solution to this caregiver dilemma is the support of another caregiver, either in a partnership or in a group. When individuals develop supportive relationships with each other, they offer not only ideas, but also implicit patterns of mutual regulation that can be engaged when one caregiver is stressed, and that is calming. It is a cliché to speak of two parents working as a team in setting limits for their children. Yet, the stress generated by a noncompliant child can polarize caregiving teams, also. So, it is best to try to use all of these strategies when disciplining children. 

Finally, there is the function of communicating values. This relates to Peter Fonagy’s “epistemic cues”. Values in a culture are transmitted by the way the caregiver communicates, not just what he or she communicates. If the caregiver, in the context of a trusting relationship, lets the child know that the child’s behavior is simply not acceptable – through calm but firm voice, facial expression, and gestures, indicating significance by emotional tone – the child will learn that behavior is unacceptable. This is key because cultural values fit the cultures they belong in, and they cannot be transposed from one culture to the next.

Let me give you an example of what seemed to me to be effective but also culturally specific discipline from Deenabandhu. At Deenabandhu, just as at Love and Hope, the expectations for behavior are clear, as are the consequences and usually involve taking away something small such as no television on one of the rare occasions when it is allowed. The little boys were throwing food in the courtyard. Prajna gave them a consequence. She explained to them and to me that food is given to them to eat by the benefactors of the ashram and produced by the efforts of the farmers, and that therefore wasting food is not acceptable. You can see that this reasoning would not work particularly well in most families in the U.S., but it works here. The values that are being communicated reflect the meaning of giving and serving that I mentioned in an earlier posting. Another time, Prajna gave the boys a similar consequence for running through the courtyard without restricting themselves to the lighted areas. It initially seemed to me a pity to stop them, because they were having so much fun and interacting so well as a group. However, Prajna explained that there might be snakes in the dark (sometimes cobras! One boy had recently been bitten by a non-poisonous snake.) And also trampling the plants was not acceptable. Then I understood.

Siegel, D. & Hartzell, M. (2003). Parenting from the Inside Out: How a Deeper Self-Understanding Can Help You Raise Children Who Thrive, New York, Penguin Group.

photograph by Ginger Gregory

 

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The Act of Serving

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As I consider these comforting rhythms of daily life, especially those involved in food preparation, I remember the video I have of Love and Hope that I call “The Papusa Maker”. Sarah Measures took the film, and she pointed out to me how much the little girl of 6-years old watching the cook make the papusas was learning. Of course, she was learning how to make papusas, but she was learning much more. She was learning “sequencing” by watching the cook as she moved through the specific acts involved in making papusas, in the same order, again and again. She was learning to tolerate frustration as she constrained her own activity. She was also learning about respecting boundaries as she observed an older boy flip one of the papusas, giving him instructions, but not attempting to do the job belonging to an older child until she herself was a big girl. In addition, she was most likely exercising her imagination, dreaming of herself as a “papuser maker”. 

I then wondered what I could learn from my observations of meal preparation that I could bring back to my families in the U.S. It is hard to recreate a lengthy, methodical process of food preparation in the U.S., where busy multi-tasking two-career parents have a hard time even sitting down to “take out” with their children, let alone letting their children watch them prepare multiple courses from scratch. It does occur to me that the experience of a child watching an adult perform a meaningful sequence of repetitive acts in the context of a caring relationship offers a learning opportunity we rarely consider in the U.S.  I am aware that one cannot transpose the features of one culture onto another, but I am hoping those reading this posting will send me some ideas about how parents in the U.S. can create for their children some of the comforting rhythms and learning of food preparation at Deenabandhu and Love and Hope. 

This preparation takes hours, but the children have already risen before sunrise and eaten their gruel to assuage their hunger before their activities. They join us at breakfast after these are completed. The children sit on the floor and chant their prayer. Most of the children chant in an animated way but some stifle a yawn. Then one of the children designated as server, or one of the adults, serves all of us. The act of serving also has special meaning.

Prajna explained to me that the act of serving is an experience of giving, the expression of generosity; it communicates love and in that sense is self-enhancing. This belief was given special meaning by an experience I had with Prajna one evening at the girls’ dining hall. 

Prajna and I walked to the girls’ residence to give them supper. An amazing sight ensued. We carried with us a metal container of the rice and vegetable meal the cooks had prepared.  Prajna crouched in the middle of a circle of about 15 young girls with the container of food between her legs. Dipping her cupped hand into the food, she scooped out a round handful and ceremoniously place the ball of rice into the cupped hands of a waiting child. This was repeated for each child in the circle, Rajna adjusting her body position so that she was facing each child as she served her. When they were all served, Prajna asked, “Next?” and the girls eagerly extended their little hands. One after another she cupped her hand and served another ball of food to each waiting girl. It was the ceremony that was most impressive, including the face-to-face, social moment in which language and the face and the body were all engaged in a rhythmic, repetitive, perfectly contingent social activity. I thought that if this occurred on a weekly basis it would be essentially healing. I think it is what Bruce Perry talks about, and Peter Fonagy too.

 

 

photograph by Ginger Gregory

 

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Infant Parent Mental Health Weekend: Beatrice Beebe and Claudia Gold

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Beatrice Beebe:

Beebe presented her dyadic systems approach to face to face interactions – key domains of interaction – facial mirroring, vocal rhythm coordination, distress regulation. Dyadic systems view of face to face interaction informs nonverbal communication across the lifetime. These patterns of communication become organized into predictable, contingent interaction sequences that that generate expectations of each other’s behavior in the relationship. All this occurs in the realm of procedural knowledge. Heller and Haynal study.   

Study of mother-infant (M-I) face to face interaction with split screen videotaping, videotape with one camera on each partner, second by second coding. Code orientation, touch, vocalization, facial expression, etc. Studying mothers and infants focuses on what goes on in the interaction outside of language.

Dyadic systems model proposes that all face to face interactions are simultaneous product of self and interactive regulation. DS view is that the way you co-construct relatedness is unique for the dyad; it respects the uniqueness of the individual and also of the dyad. How the mother responds to the baby partly is a function of how she regulates herself and how the baby responds to the mother is partly a function of how the baby regulates himself. The degree of the stability of the moment to moment behavior is a measure of an individual’s self-contingency [rhythm of regulation]. How does the rhythm of one partner affect the rhythm of the other? Mothers who over-stabilize themselves are less able to track their babies because they are so involved in regulating, out of awareness,[attentive to] their own state, whereas mothers who are more flexible in degree of self-predictability are better able to track their babies. The organization of the dyad is within and between. The key point is that the rhythm within your body that you think of as your own is partly organized by how you are related to your partner. This idea of the emergence of the “self” from the experience of being in a relationship is an organizing principle of the course and was repeated in the presentation by Peter Fonagy later in the weekend.

Infants are able to detect regularity and perceive contingencies. They predict when events will occur. This results in expectancies. These contingencies can be in facial expression, gaze, every communication modality [many things]. They occur in a split second time frame. It is usually the baby who breaks the gaze in gaze contingency. The degree of self and interactive procedural contingencies in an infant-mother pair is affected by the mother’s anxiety, self criticism, dependency, and depression post-partum; and these contingencies are correlated with attachment. Mothers with post partum depression may vigilantly coordinate with [look at] the baby’s face , through corresponding facial changes of her own, while not attending to the baby’s focus of attention [intention, what the baby is doing.] 

The commonest mother-infant therapy situation is one in which the mother cannot tolerate the normal interruptions of gaze aversion the baby initiates to self regulate. If the mother pursues, calls, chases, this stresses the baby and makes it harder for the baby to look back at the mother. Mothers often feel rejected when this happens. One way to deal with this therapeutically is to explain to the mother, “This is the way babies work” and explain the baby’s need to gaze away to regulate himself before he looks back. Beebe says that “the baby’s agency is in the co-construction of relatedness”. She describes what she calls the “chase and dodge” situation in which the baby tries to turn away momentarily to self regulate and the mother follows him, stressing him further.

Beebe showed us ways of regulating a baby’s distress: (1) join the rhythm of the baby’s distress but in a milder intensity [version]; (2) join increments of facial distress; (3) join vocal distress, join the cry rhythm; (4) wait, join the dampened state; (5) disruption and repair.

The caregiver can give the distressed child a structuring rhythm, keeping the volume low but a predictable pattern with a little variation, and put her hand on his belly or make her hand available so that the baby can use it for self-soothing.

Problems occur when there is (1) teasing of the baby by the caregiver, such as when the mother repetitively puts her finger or the nipple in and then takes it out, without any connection to the baby’s cues; (2) mutually escalating over-arousal; and (3) when mother denies the baby’s distress and smiles or looks surprised. (4) mothers look away more from the baby’s face, pays less attention to the infant who is distress; (5) mothers “loom” into the baby’s space.

When Beebe works with a mother and videotape, she asks “what the baby feels” at a particular point in the tape, and if the mother’s response is incorrect, she will say something like, “Well, actually, I think what he is feeling is X.”

Beebe showed us many fascinating films of mothers and infants. She said that in her clinical work with mother-infant pairs she “tries to link three stories – the story of the complaint, the story of the nonverbal, and the story of the parents’ histories.

Two excellent references for Beatrice Beebe are:

-Beebe B, Cohen P, Sossin K, & Markese S (Eds). (2012). Mothers, Infants, and Young Children of September 11, 2001, New York, Routledge Press.

– Beebe et al. (2010). The origins of 12-month attachment: A microanalysis of 4-month mother infant interaction, Attachment and Human Development, New York, Routledge, 12 (1-2): 3-143.

 

Claudia Gold:

Claudia Gold, a recent graduate of our program and now the author of the blog, http://claudiamgoldmd.com/, and the celebrated book, Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World Through Your Child’s Eyes, 1st Da Capo Press, ed. 2011, was our last speaker of the weekend. She talked to us about how the study of psychoanalysis, the mentorship of Peter Fonagy and the research group at Yale, and her participation in the UMB IPMHC Course helped her move from a career as a primary care pediatrician to a career as a behavioral pediatrician with a specialty in mentalization. 

Reminding us that primary care clinicians have the largest professional interface with young children and their families and have relationships with these children and families over time that involve implicit trust. Yet, whereas 30% of their practice involves emotional or behavioral concerns, these pediatricians have limited knowledge or tools – behavior management, parent training, and medication – to deal with them. Considering this challenge, Claudia made a paradigm shift in her own practice and now in the wider world of parents and children, by identifying her primary task as promoting reflective functioning. By “holding a child in mind”, Claudia attempts to teach parents to be curious about the meaning of their child’s behavior, to have empathy for them, to contain and regulate their child’s behavior and also to better regulate themselves. In addition to her practice in Western Mass., Claudia is beginning to work on an Early Childhood Social Emotional Health Program at the Newton-Wellesley Hospital.

 

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