Tag Archives: autism

Peter Fonagy on Metallization

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Peter Fonagy and his colleagues have introduced and elaborated the concept of metallization. Metallization includes the developmental capacity to reflect on one’s inner life and to imagine the inner life of another person. It is central to important other capacities such as the capacity of empathy and self control. The relationship between empathy and metallization is easy to understand in that you have to be able to imagine what another person is thinking and feeling in order to empathize with him. Self control, on the other hand, takes more explanation. As the child develops the capacity to reflect on what is going on inside of himself, he begins to be able to make sense of the motivations for his actions and also for the consequences of his actions on others. He sees a playmate cry when he pushes him or when he grabs a toy away from her. With the help of an adult caregiver, he realizes that his action caused distress to the other child. Then he starts to make a connection between his inner desire to have the toy or his anger at the other child and his action of pushing or grabbing. He also realizes that if he wants to play with the other child, he will have to control his impulse to push or to grab. All of this cognitive and emotional activity is scaffolded by the caregiving relationship and grows into a competency for self reflection and also for self control. Fonagy and his group call this competency metallization.

All individuals, including adults, lose their capacity for mentalizing when they are highly stressed. The individual’s ability to mentalize therefore depends both on the robustness and flexibility of their developmental competency and also on the stress in their lives.

Metallization distinguishes humans from other apes. Animals are very poor at recognizing whether an act of a conspecific is due to serendipity or is rooted in intention, wish, belief, or desire. The capacity to recognize these intention, wishes, desires, and beliefs of the other person is sometimes called “metallization”. It has been argued to account for the major difference between humans and other apes.” (Fonagy, 2014). (Peter says that dogs can mentalize humans but not other dogs. That could explain a lot!)

We all depend on one another to know ourselves. A working definition of mentalization is that of a form of imaginative mental activity, perceiving and interpreting human behavior. Mentalizing is the capacity to see ourselves from the outside and to see others from the inside. It has to do with seeing oneself as an agent, as an intentional being and also seeing others as intentional beings. The capacity to mentalize allows us to create a narrative continuity over time. Mentalization is an integrative framework.

The Development of Mentalization: The newborn has a social brain. She detects and prefers social agents, gazing longer at faces with open eyes and to direct versus averted gaze, showing greater activation of the anterior temporal cortex to voices versus non-voices, and differential activation of the orbitofrontal cortex and insula to happy versus sad voices. The newborn is prepared for mimicry by the mirror neuron systems in the prefrontal and parietal regions, and oxytocin and vasopressin mediate mutuality in the infant-caregiver relationship. In fact, administering oxytocin in the nose makes adults better at reading the expression of others’ intentions.

The Reward Circuits Are More Active in Secure Mothers: The oxytocin levels of mothers whose AAI’s (Adult Attachment Inventory) were read as secure before the birth of their child, went up when they interacted with their children. By contrast, in the case of mothers with “insecure” AAI’s, the oxytocin levels went down. Later on, the pituitary, the part of the brain that generates oxytocin, released more oxytocin in secure mothers. Also, the mesocorticolimbic areas were more active for secure mothers when looking at their babies smiling. All this suggests that the reward circuits are more active in secure moms. Fonagy suggests that this is because when the baby is crying, secure moms have an elevation of activity in the Ventral Striatum, whereas insecure moms do not. Rather, insecure moms have activation in insula (negative memories). Looking at their baby when he is sad makes her sad. You could argue that the absence of oxytocin in insecure moms gives them difficulty mirroring their awareness that it is the baby’s sadness and not theirs. That would make it harder for the baby to manage his sad affect.

Provisional Model for the Developmental Roots of Mentalization : The “secure” mother generates increased oxytocin when interacting with her baby, in association with a more mentalizing (marked-contingent) maternal response to the baby’s distress. The baby perceives the mother’s empathy, while at the same time appreciating that she herself is OK and available to comfort him. This improves the baby’s regulatory state. The evolving capacity of the baby to perceive his mother as having a different mental state from his own is consistent with the development of mentalization and the infant’s resilience. On the other hand, if the mother herself is insecure and generates a reduced level of oxytocin, she makes a “non-mentalizing response” to her infant, reacting not only with her own distress but with an escalating distress response that communicates helplessness. This is not comforting to the infant and may increase his sense of helplessness and fear. He is at risk of not developing the capacity to discriminate between what is in his mind and what is in his partner’s mind, which makes him more vulnerable.

Fonagy referred to a paper in which the maternal oxytocin response predicts mother-infant gaze: in the case of the antenatally secure mother with high oxytocin, the mother looks longer at her infant, especially in the recovery phase of the still face experiment, and there is more imitation of the infant’s intention (Kim, Fonay & Strathearn in press). This is interpreted as the mother’s capacity to tolerate the infant’s distress and is therefore emotionally available to the infant.

Numerous studies reveal the development of an important group of social capacities related to reciprocity, the sharing of mental states, self-awareness, and identification. Joint attention is usually achieved at 9-12 mos. This capacity involves the medial prefrontal cortex and posterior temporal sulcus and is incredibly important. In order for humans to have culture, a shared sense of where they are, they have to develop the idea that when they are looking at the same thing as others in their culture, they are thinking the same thing.

Studies suggest early emergence of the capacities for empathy and mentalizing. In the Baby and Smurf test, the baby’s capacity to put himself in the place of the smurf who has lost its ball is tested. The baby’s sensitivity to the smurf’s situation (the baby saw where the ball went but the smurf did not) is measured in terms of looking time. The baby at 7 months is capable of considering what the smurf believes about the status of the ball (AM Kovacs et al, Science 2011; 330:1830-1834). At 9 months, babies have a sense of fairness, as they demonstrate in an experiment in which of two giraffes one giraffe gets two toys and the other gets only one. Interestingly, it is relative deprivation, not absolute deprivation that predicts outcome. How well we are doing in relation to others around us has a profound influence on outcome.

The Romanian orphanage (orphanages in which the children were essentially deprived of a responsive caregiving relationship) studies show that the age beyond which the influences of deprivation cannot be repaired is between 6-18 mos. Children who were placed in these orphanages at birth and stayed for longer than 6-18 months demonstrated atypical development: signs of autism – reduced imitation, lessened response to name, lower social interest and social smiling, atypical eye contact. On the other hand, deprivation before 6 months (in cases in which the child was placed in a family at 6 months) has surprisingly little consequences.

A Cast of Thousands


A Case of Thousands

I recently received a neuropsychological testing report on a little patient of mine who has developmental problems in the general category of autistic spectrum disorder. The report was exceptional in its careful attention to detail – in the description of the tests, in the account of the child’s performance on the tests, and in the way it set out the implications that these subtest results had on the child’s learning and more general development. I was very pleased. Then I looked at the recommendation section, and I was disappointed. That is not to say that the recommendations were incorrect. They were detailed and comprehensive. However, they included recommendations for multiple specialists. 

Some of these specialists could provide services at school through the school system; the family is fortunate in that the city where they live makes many special needs services available to children in the school system. However, too many of the recommendations for specialists – such as a CBT therapist and an autism specialist in addition to my psychotherapy with the child – will not be provided by the school. This presents a dilemma for the family. Either the family finds the time and money to pay for these specialists and to take the child to these additional appointments, or the family lives with the worry that they are not giving the child all of what he needs – with long-term negative consequences.

I believe strongly in the team approach to the treatment of children with autistic spectrum disorders (ASD) or pervasive developmental disorders (PDD). However, I also believe in paying attention to the “family economy”, meaning the resources in time, money, and emotional reserve that the family has at its disposal. I have led a number of parent groups for parents of “quirky” children, and I have witnessed the anguish of parents who were trying to make decisions about allocating limited resources to the care of their ASD or PDD child. 

Also, perhaps because my husband is an economist, I am sensitive to the pull of the marketplace and the influence that has on recommendations for treatment. I am not suggesting that all these specialists do not believe that what they are offering is the very best and in fact necessary for the health of the children they treat. I am suggesting, though, that each specialty has a financial incentive to compete for patients. In addition, it is sometimes true that the more defined and therefore narrower perspective of a specialist may have a negative effect for two reasons. The first is that they may be less well prepared to integrate the various aspects of the child’s treatment than a therapist with a more general approach, and the second and related reason is that they may duplicate various aspects of the treatment, sometimes causing confusion and certainly costing more.

I do not hide my bias for a psychodynamic therapist to be at the center of the treatment of these children. That is my training and my conceptual model. However, I have other reasons for suggesting this plan. The first is that children with ASD and PDD essentially have problems with development, and developmental science now teaches that development occurs in the context of a relationship. Of all the therapeutic disciplines, psychodynamic therapy is the one that primarily emphasizes the therapeutic relationship. The second reason is that psychodynamic therapists aim to make meaning of the particular child’s experience, and to do that they must search for the unique personhood of that child and try to join it. This begins, as it does in normal development, with a shared focus of attention and proceeds to the sharing of complex experiences of affectively charged symbols. It is only through the energetic building of  a position of mutual understanding and collaboration that the therapist can help the child build new developmental capacities. 

The dynamic therapist, though, must not limit herself to the verbal narrative and symbolic play of these children. Instead, she must learn – especially from her O.T. colleagues, but also from child trauma researchers – how to help the child regulate himself, and then work with the parents to help them continue the work at home. She must focus relentlessly on the child’s agenda and support it by recognizing and joining it, then nudging it slightly forward by making contributions of her own, in a repetitive but flexible manner. This approach shares a lot with the DIR floor time method; I have learned a great deal from floor time practitioners. 

The therapist must also comment on the relationship between herself and her patient, and acknowledge patterns that may repeat themselves with parents, teachers, and peers. She must network with the parents and other caregivers and clinicians as frequently and consistently as possible. Through these therapeutic interventions, the therapist and child make links between the child’s inner world – emotions and fantasies – and his body (physiological arousal state and experience of body in action), and between his inner world and the outside world of objects and other people.  In essence, the psychodynamic therapist can fulfill many of the roles of other specialists, while keeping the meanings of the child’s inner world always in mind.  This is what I hope to do in the Cornerstone project beginning in September and what I also try to do in my own clinical practice. While I am learning more and more about ASD and PDD from current research in these fields, I don’t call myself an autism specialist, because what I am learning about these children applies and enriches my work with all my patients.


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