Tag Archives: Fonagy

Peter Fonagy on Metallization

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.

“Habits”

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The second subject that my mothers’ group asked that we discuss is that of “habits”. When I use the word “habit”, I mean a pattern of behavior that is hard to break even when you try very hard. We usually refer to the patterns we want to break as “bad habits”, but of course there are good habits, too. I like to use the principles of nonlinear systems theory to understand the establishment and maintenance of habits. That is not as complicated as it might sound.

Nonlinear systems theory says that “organization”, or patterns, emerge from the interactions of the component parts of a system (von Bertalanffy, 1968). In a family system, this would mean that when family members (parents, children) interact with one another, they create particular ways of behaving (patterns of behavior) that include characteristics of the individuals involved, their home environment, and the time (of day, month, and year). For example, what Sander calls the infant’s first organization, the diurnal sleep cycle, is established through the repetition of small caregiving acts – nursing, burping, bathing, and changing – that the caregiver and infant experience together, as they are repeated in the same order each day over and over again (Sander, 2008). When the baby grows older, the family establishes bedtime routines that parents and children tend to follow every night. Of course these rituals change with the age of the child and the time of the year, so that during school vacations the patterns usually loosen. Whereas families can typically describe to you their bedtime routines, they are usually not aware of the powerful significance of routines in their lives until something happens – houseguests, illness, a family trip – that disrupts the routine. It is then that the family recognizes the role of these patterns in the coherence of family life.

There are two other dominant characteristics of habits. The first has to do with motivation, or intention. Why would anyone intend to establish a bad habit or be motivated to maintain it, you might ask. Well, there are actually many reasons, and not surprisingly, most of them are out of awareness. Some of them are “non-conscious” in that they were never represented in language or other symbols in the brain and most of the time never will be. They usually have to do with efforts to escape perceived threat and are generated by the central nervous system in parts of the brain below the cortex (thinking part of the brain), such as what we refer to as “fight or flight”. You may wonder how fight or flight could qualify as a habit since it doesn’t happen all the time. I would respond that in highly stressed families, individuals feel threatened much of the time, and they develop a “habit” of reacting with aggression or running away (the flight may be a form of withdrawing or tuning out). People make up reasons to explain to themselves why they are behaving that way. For example, “I have to get him to school!” or “I am too tired to deal with this right now.” Even more insidious, they make up stories to explain why the other person (these “habits” originate in relationships) is causing them to behave that way, for example, “He is a little monster!” (Fonagy et al, 2005). Continue reading →

Child’s Play

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.Today I am writing about children’s creative play. I was inspired to do so by a unique construction hanging down the stairwell that leads to my office. It was placed there a couple of weeks ago, but I have left it there because I am so fond of it. It is – as a young observer called it – “a wad of tissue on a string”. It is actually facial tissue tied with colored yarn, but he is mostly right. This construction was created by another child, and for her I think it had the meaning of exploring my spaces, taking me over aggressively but also lovingly, as she dangled it over the top of the banister and let it sink slowly down three floors to rest on the carpet of the cellar level. In the small area at the bottom of the stairs, she then imagined having an “office” of her own, claiming the wooden ledge as her “desk”. Then to clearly establish her hegemony, she carefully wrote a sign: “Please do not take this down. Thank you.” Asking me how to spell my name, she finished off her notice with the name, “Alex Harrison”.

The magic of this construction is not in its ingredients – tissue, colored yarn, maybe a little tape – but in the imagination that turned these humble household objects into a powerful narrative. These objects cannot compare with the complicated electronics that my little patients are usually so fond of. Even the other toys in my office – dolls, blocks, vehicles, etc. – do not have quite the potential of these objects. Other children agree. All of them have noticed the tangle of colored yarn and wondered what was at the bottom, marveled at the mysterious meaning of the object and its relationship to me.

The boy who referred to it as “a wad of tissue” is very adept at games on computers and i-phones, even at his young age. In spite of this, he spent a whole session with me raising up the “wad” on its yarn pulley, untangling the tangles and considering the effect of the tangles on its smooth sailing, lowering it again, discussing with me the trajectories of each lowering and wondering what was influencing it to move further to one side or the other. Considering the difficulties this child has disentangling himself from his mother and negotiating transitions and the “ups and downs” of life, I thought he and I were doing just what we needed to be doing to make him stronger.

As he and I huddled together in our explorations, I was aware of feeling happy and engaged in my work. The feeling is a kind of playfulness, a letting go of the constraints of reality and entering – with a companion – into a magical world of rainbows (colored yarn), wads of tissue (gift wrapped presents), castles in the air (three level staircase), and forbidding dungeons (the cellar at the bottom of the stairs). Of course, the real “work” lies in facing the monsters in the dungeon together (the child’s fears and problem behavior), but in order to conquer those monsters you have to find them, and you find them by creating this magic world with a trusty traveling companion.

The world of rainbows and dungeons is obviously not exclusive to child psychotherapy. That is the magic of it – it is the possession of every child. But it has to be exercised, practiced, and that means putting away the computer, the i-phone, and the television, for long enough to enter this other space stay awhile.

The little boys in the photograph of this posting are finding this play space in the dirt of the playground. The children at the preschool found it in the pirate play and in the hunt for bears. The girl in my practice found it in her creation of the “office” at the foot of my stairs and the magic wad on pulleys that led to it. When the child is developing the capacity to create this world of pretend he/she is simultaneously building an internal capacity for flexibility, for impulse control, for empathy. That is what the pediatricians and scientists tell us from their observations and experiments (Baron-Cohen, Fonagy, Slade, Winnicott, to name a few). It is also what I know from my experience.

Sometimes it is hard to explain that to parents who understandably want a “solution” to a problem behavior – a method for shaping behavior, a behavioral strategy. Of course, I understand this. But behavioral strategies that address a discrete behavior do not always generalize; they cannot grow the brain in the elemental and natural way that pretend play can do. Now, I am in favor of anything that works, so I do support good behavioral therapies. Yet, I am always aiming in my work with children for opportunities to scaffold the growth of the important developmental capacity for imaginative play, and I am always delighted when I can awaken the child in myself to join my young patients in creating a “pretend” solution of their own.

Baron-Cohen S (1994). Mindblindness: An essay on autism and theories of mind. Cambridge, MA: MIT Press.

Fonagy P, Gergely G, Jurist EL, Target M (2002). Affect Regulation, Mentalization, and the Development of Self. New York: Other Press.

Slade A (1994). Making meaning and making believe: Their role in the clinical process, in Children at Play, Edited by Slade A, Wolff DP, New York: Oxford University Press, pp. 81-107.

Winnicott DW (1971). Playing and Reality, London: Routledge.

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Photograph by Ginger Gregory

Trouble on the Playground

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This posting is the first in a series about a problem that challenges many parents that I know – how to help their child with problems on the playground or the lunchroom at school.

In this case, the child comes up to the parent and complains that kids were being mean to her at school. Now, of course, first you have to find out if this is correct. If it is true, it is an important problem and a subject for another blog. Here I am talking about a child who frequently perceives herself as a victim in social interactions whereas the teacher and you suspect that the real problem is the child’s difficulty negotiating a complicated social situation among her peers. Let’s imagine the case of a 9-year old girl, Sophie. The story the Sophie tells you will be something like this: “Janie was mean to me today and then Mrs. Jones was mean to me, too. I just can’t take it any more.”

Inside, you feel sad and frustrated at the same time. You have heard this story or one like it many times. Sophie has trouble keeping up with the rapidly flowing improvisational process of 9-year old girls on the playground. It is easier in the classroom, where there is structure – planned activities, assigned roles – but on the playground she can’t figure out to join a group, or when something changes in the fluid activity of the girls, she often seems to just get lost and drop out of the action. As a result, Sophie frequently has no one to play with and has little success in initiating play with her classmates. You wonder why the teachers seem to disappear at recess, when your Sophie needs them more than ever. On top of everything, you are upset by Sophie’s including Mrs. Jones in the “mean” category. You thought that Sophie had a good relationship with Mrs. Jones, in contrast with her last year’s teacher, so this makes you feel even more disappointed.

Here are my suggestions for handling the situation. They derive from Peter Fonagy’s model of “mentalization” (Fonagy et al, 2011).

1. First, wait until she is calm to talk to her. If she is in an agitated state or begins to get into one when you begin to respond to her, comfort her and tell her that you will talk about it later. You also pay attention to your own feelings. If you are upset, you will not be able to comfort her, and talking to her calmly will be difficult.

2. Do not argue with her. That will turn you into a bad guy. For example, do not ask (even if you are thinking it), “Do you think you might have done something to make Janie upset before she was mean to you?”

3. Sympathize with her feelings. “It must be terrible to feel that everyone is against you!’

4. Break down her description of events into small pieces. Parent: “Help me understand. You were just playing a game with Ann, and Janie came up and asked if she could play with you, and you said, ‘No’.” Sophie: “It was a game that only two people can play.” Parent: “Oh, of course. Only two people can play that game. But didn’t you just tell me that recently Janie didn’t save a place by her at the lunch table and you felt very sad?” Sophie: “Yes. She never saves me a seat, and I always save one for her.” Parent: “Hmm, but I guess you must felt kind of sad and left out when you had to sit at another table?” Sophie: “Yes, and I never do that to her.” Parent: “OK. But you know how bad it feels to be left out.” Sophie: “Yes.” Parent: “Just for a moment, what if we imagined that Janie felt left out when you were playing a game with Ann for only two people.” Sophie: “No, because it was for only two people.” Parent: “You are exactly right. The game was for two people, but I am guessing that Janie might have felt left out anyway just the same way you felt left out at the lunch table, because there might have been a reason she didn’t save you a seat since I know Janie really likes you.” Sophie: “Well, she did say that she tried to save me a seat, but I didn’t believe her.” Parent: “I know. It is hard to believe someone when you feel so terribly disappointed.”

5. Slowly continue to introduce the inherent inconsistencies in her story (It may take several iterations of this experience to get to this stage) so that you can help her arrive at a version of the story that is not as black and white as she perceived it initially.

This process has been described by Fonagy and his colleagues and has as its goal the achievement of the developmental capacity of what they call “mentalization”, related to the cognitive psychology concept of “theory of mind” (TOM). TOM is demonstrated in the “false belief” experiment (Gopnik & Astington, 1988). In this experiment, a child is shown something deceptive (such as a doll in a crayon box). When a stranger comes into the room the child is asked what the stranger expects to find in the box. Three year olds generally said that the stranger will expect to find the doll, but five-year olds realize that the stranger isn’t privy to the deception and respond, “crayons”. This capacity to imagine another’s mind and realize that your own beliefs are not necessarily “real” vanishes in everyone in some contexts, such as under extreme stress, but it is hard for some children to achieve in the first place. That is not because they are unintelligent but because that particular developmental step needs extra help. Our imaginary “Sophie” might be perfectly capable of empathizing with another person when she is not stressed. but when she is stressed, such as when she is on the playground or lunchroom at school, she may lose this capacity. You can help your child by realizing that she is struggling with this part of her development and scaffolding this process.

Fonagy P, Gergely G, Jurist E, & Target M (2011). Affect Regulation, Mentalization, and the Development of the Self, Kindle Edition.

Gopnik A & Astington J. (1988). Children’s understanding of representational change and its relation to the understanding of false belief and appearance-reality distinction, Child Development 59:26-37.

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How to Talk to Your Child About Complex Subjects

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At a gathering of family and close friends recently, a young couple asked me a question about their almost 3-year old son. I had observed the child and had found him to be intelligent, charming, and warmly connected to his parents. He also seemed sensitive, perhaps one of Kagan’s “inhibited” children (Kagan & Moss, 1983). The child, whom I will call “David” (not his real name), had been anxiously asking his parents about whether he might be put in jail, about whether he was a “bad guy”. He seemed to associate these fears to bible stories he was hearing in Sunday school, particularly the stories of Daniel and the Lion’s Den, and the story of Jesus being arrested. This was confusing to his parents, because in their understanding of these narratives, it was the “good guys” who were arrested. His parents told me that they constantly reassure him that he is a good boy, that they love him, and that he is safe. David’s parents further explained that he seems to ask these questions about being thrown in jail whenever a stranger is in the house, asking whether that person is going to throw him in jail. His parents decided to avoid stories about jail and to limit the bible stories since many of the concepts seemed too complex for him to process at this age. They asked me what I thought.

This question is fascinating from several points of view. First of all, it highlights the difference between the meanings an adult makes of certain narratives and those made by a preschool child. Second, it underscores the often discrepant levels of maturation of different developmental capacities in the same child. Third, it reveals aspects of a crucial cultural context that forms the way narratives transmit important beliefs and values in a society. Consideration of these factors may help parents in their efforts to talk to their children about complex subjects.

What about what Tronick calls the “age possible” meanings that two people of different developmental ages make of the same story (Tronick, 2007)? An example is offered by the 4-year old whose mother was trying to explain to her the generational relationship of people at a family reunion. The mother explained, “Your nana is your daddy’s mommy.” The little girl thought for a moment and then asked in wonder, “But how did she get him into the car seat?” I am also reminded of a little patient, a 3-year old who witnessed people jumping from the World Trade Towers on television and in a play session suggested to me that children could “jump big” in a playground because it is “softer” (Harrison & Tronick, 2007). I took her to be referring to a “soft landing”, though I knew that no number of soft mattresses at the foot of the WTT could have cushioned the fall of the jumpers. In David’s case, the meaning he derived from “being put in jail” was that you were a bad guy, period. He was not able to consider a nuanced meaning in which a good guy was unjustly jailed. It is clear that good guys and bad guys are on his mind these days. Remember the “terrible two’s”?. His age-typical anxiety about the result of noncompliance to parental demands (whether real acts of noncompliance or imagined ones) led him to fear that his “bad guy” feelings and thoughts would brand him as a bad guy and cause someone to throw him in jail. A “stranger” is a preferable enforcer of that terrible punishment, because a stranger can be seen as “all bad”. If it were one of his beloved parents who threatened him with jail, how could he manage the stress of fearing one that he also loved and depended on?

The second issue is that of discrepant developmental capacities. Human development is not a smooth, linear process. It occurs in a messy process of hits and misses, halts and bumps forward, and reiterative efforts to master. In many children, this messy process occurs at very different rates and in different ways in different domains of competency. For example, some children have precocious motor coordination but are slow to speak. Others speak sophisticated sentences early but struggle to do one rung of the monkey bars or are insecure about climbing and jumping. If you have significant discrepancies in your developmental capacities, you are left with a subjective sense of inner imbalance, sometimes even of incipient chaos, in the background. It does not always bother you, but when you experience a threat, it can emerge. This could be called “anxiety”, but that is a rather crude description of a complicated subjective experience. I do not know David well enough to guess about whether he has a discrepant developmental profile. The inheritance of “inhibited” genes is another possibility. However, I do know many children who fit this picture of uneven development.

Finally, there is the interesting factor of culture. In an earlier posting, I wrote about how another 3-year old sat through a 6-hour wedding dinner with a minimum of fuss. I described what I saw his French parents do in order to teach him to sit at the table for long stretches. In any culture many core beliefs are transmitted by narratives. Children hear these narratives repeated over and over from early on and learn the culturally shared meanings that their parents convey to them. However, the meaning is not transmitted by language alone. Peter Fonagy talks about this process. He says, “Human communication is specifically adapted to allow the transmission of cognitively opaque cultural knowledge, kind-generalizable generic knowledge, and shared cultural knowledge” (Fonagy, lecture IPMH, May, 2012). This knowledge is transmitted by what he calls “ostensive communication cues” such as eye contact, turn taking with contingent reactivity, and special vocal tones. In a study Fonagy cited, infants of 18 months old were asked by the researcher to pass an object, a doll. In the control group, the researcher gave no cues directed to the infant, but in the study group, the researcher first smiled and said hello to the infant. Then in both groups, the researcher smiled at one doll and made a disgust face at the other. At that point, another researcher came into the room and the baby was asked to give the second person a doll. Only in the group in which the experimenter had smiled and said hello, did the babies give the second person the doll the first experimenter had smiled at, the doll designated as desirable . In other words, the researcher had initiated a relationship with the baby and in that context, the baby attended to the “ostensive cues” (smiling or disgust face) she then gave him. The infant trusted the researcher who smiled and said hello and then judged the information she gave him to be reliable.

So, in response to my young friends’ question, I would say that I support their decision to protect David from anxiety provoking bible stories for the present. In avoiding certain bible stories they are acknowledging a dysynchrony between the dominant contemporary middle class U.S. culture and a culture in which bible stories are a primary means of transmitting beliefs. In the latter culture, bible stories would not just be read but from early on would be told as stories, with accompanying “ostensive cues”. In that culture, the parent would communicate – with eye contact, turn taking rhythms, and tone of voice – who the bad guys and who the good guys are in every story, over and over. In that way, David would learn the salient meanings – with associated values – of his culture. Of course, he might still have fears of being a bad guy, because of his age-typical struggles with his aggression and negativity. It is less likely, though, that his fears would focus on bible stories.

Harrison, Alexandra & Tronick, Ed (2007). Now we have a playground: Emerging new ideas of therapeutic action”, J Amer Psychoanal Assoc., 55/3: 853-874.

Kagan, Jerome & Moss, Howard A (1983) From Birth to Maturity: A Study in Psychological Development, Yale University Press.

Tronick, Ed (2007). The Neurobehavioral and Social-Emotional of Infants and Children, WW Norton.

photograph by Joshua Sparrow

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Growing Flexibility in Your Child

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Recently, a mother asked me how she could help her son become less rigid in his play so that he would be more successful in his play with peers. As I sat down to respond to her question in email, I began to think about what an important question this was, and I felt inspired to write a blog posting about it.

I think of “rigidity” in terms of being the opposite of flexibility. In that sense, being rigid about something is something we all do when we are stressed, when we can’t manage flexibility. Kids develop more and more competency in dealing with the unpredictability and variability life brings them – more competency in being flexible – as they grow, and the more competent in this regard they become, the less scaffolding they need from their caregivers. Some kids need more support than others, but all need help from their caregivers in learning to be flexible. By caregivers, I mean parents, babysitters, and teachers.

One of the ways caregivers help children in this developmental process is to imagine what is going on inside the child’s mind and body. (I use the word “imagine” for two reasons. One is that you can’t really ever “know” what is going on inside another person. The other reason I will describe in a moment.)

What is the child’s intention? Where is the child in relation to accomplishing his goal? In other words, what is his state? Is he relaxed and focused? Is he comfortable but a little scattered? Is he fatigued and unfocused? Getting better and better at imagining about your child’s “state” and intention will help you attune to his needs and be able to support him. It also keeps you focused on his agency. I think of agency as perhaps the single most important factor (after basic needs, of course) in helping children (or adults) grow – protecting it, supporting its development.

As caregivers get better and better at imagining what is going on with their child, they can then help the child take a small step in the direction the child was already heading (according to the child’s intention). This idea derives from the work of Lev Vygotsky, a Russian learning theorist at the turn of the last century, who among other things described the “zone of proximal development” – the best way to help a child learn (Vygotsky, 1967, 1978).

For example, suppose the child says in a dreamy way, as if he is musing about some plan, “On the way to school let’s stop at I-Party and get a pirate costume so that I can wear it when we play pirate ship on the playground.” The mother realizes that (1) I-Party isn’t open at 8:30 in the morning, even if she were willing to darken the doorway of that store that kids love so much; (2) They barely get to school on time anyway, given the demands of their everyday life; (3) the child hasn’t even gotten out of his pajamas yet, let alone eaten his breakfast, so doing this strange and strenuous errand is not at the top of her mind!

According to what I am recommending, first, the mother would check out his state. He has just gotten up and is in a physiological as well as psychological transition state. That means he isn’t going to manage flexibility very well. But as the mother observes him, she notices that he seems rather comfortable. He isn’t whining. He is speaking thoughtfully, and his little body is relaxed, his face smooth. She would then imagine his intention. Clearly, that is to be a pirate, probably the captain of a pirate ship. In other words, he is going to be commanding, swash buckling, and an essential member of a tight group, his pirate mates. “Hmm,” she thinks. “This fantasy has potential!”

According to Vygotsky (I am imagining this, here) the mother would say something like, “Wow. A pirate costume. That would be so great to wear when you play pirate ship! Let’s start getting dressed and think about what kind of pirate costume you would like! Would you have a hat?” What she is doing in this imaginary scenario is (1) recognizing the child’s physiological and psychological state; (2) recognizing the child’s intention; and (3) on that basis negotiating a shared agenda with him, in this case the shared agenda being getting dressed and off to school while planning a wonderful playtime during playground time. This is building competency for flexibility.

The other reason for stressing “imagining” is that the capacity for imagining, sometimes called “reflective function” is a core competency in development. Being able to imagine means being able to control your impulses (your body) and consider alternatives. If you can’t “imagine” those alternatives, you don’t have much flexibility and you tend to insist on one demand (“I need it!”). That is because you perceive the world in black and white terms and can’t see the whole world of gray in between. Parents and teachers help the child learn about that world of gray. That grows flexibility.

Currently, many child developmental researchers think that the development of flexibility and “reflective function”, so necessary in adult life, begins with the capacity of the caregiver to respond in a contingent way to the infant’s initiatives, and is developed further in the play of caregiver and child, that becomes imaginative play (pirate ships) of the child (Fonagy et al, 2005). Then, if the child can manage adequate flexibility, he can engage in imaginative play with peers at a level of greater complexity and continue to grow.

One of the problems I have noted in this otherwise excellent theory is that it is rather one-sided and focuses on what the caregiver does better or worse while neglecting the contribution of the child. As we know, some children are constitutionally better prepared to be flexible than others. Some children have early life experiences, such as medical illnesses or disruptions in their caregiving relationships that challenge them in this process. Child development is always a two-way street.

If when the mother takes these three steps with her child and in step one notices that he is slouched, his face is puckered in a frown, and his voice is whiny, she is not going to be able to negotiate the same shared agenda with him. She will have to spend more time helping him regulate his state as first priority. On this morning, she might bring him a piece of toast to eat while he is getting dressed (if that is not too out of the family rules and rituals); she might take the process of helping him through the transitions from sleep to wake, from home to school, at a slower pace from the outset; and she will ratchet down her expectations and her demands for compliance, realizing that he is struggling to just feel OK. If he says something about wanting to get a pirate costume in this state, the mother might start the same way, acknowledging the great idea of a pirate costume, but she would leave more time for getting dressed (not easy, I know!), talk him through it more (“Let’s put that foot in a sock and then think about the pirate hat!”), and make fewer demands.

As always, I appreciate the inspiration I get from the parents and children I get to know. They help me continue to grow in my ideas, and also in my flexibility!

Fonagy, P., Gyorgy, G., Jurist, E., & Target, M. (2004). Affect Regulation, Mentalization, and the Development of the Self, London: Karnac Books.

Vygotsky, L.S. (1967). Play and its role in the mental development of the child, Soviet Psychology, 5, 6-18.

Vygotsky, L.S. (1978). Mind in Society, edited by M. Cole, V. John-Steiner, S. Scribner, and E. Souberman, Cambridge, MA: Cambridge University Press.

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Peter Fonagy Presentation II

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The Way Humans Learn About Their Culture

The way this kind of learning occurs helps us understand how the knowledge communicated between parent and child becomes “what is known” and “how it is done” in a large group of people, and then what about this gets passed down over generations. This does not occur through intentional, cognitive learning, but instead happens through the use of “ostensive communication cues”. These cues include such behaviors as eye contact, turn taking patterns, and specific tones of voice such as the falsetto voices mothers use to talk to their babies referred to as “motherese”. Fonagy explains that what establishes these ostensive cues most reliably is the same thing that generates secure attachment – sensitive, attuned behavior towards the baby, giving the baby the sense that the adult is trustworthy and therefore that the information is reliable. Fonagy stresses that all human life is built on social knowledge, and that if you deprive the child of “epistemic trust”, you deprive him of the possibility of benefiting from what he needs to succeed in the society into which he was born. Relationships are absolutely crucial to the transmission of cultural knowledge.

The Implications of Mentalization for Helping People Grow (in psychotherapy or other ways)

When you are with someone who is not mentalizing, it is impossible to have a rational discussion with him. That is because he has a rigid position that is heavily influenced by his own internal beliefs and he cannot bring an open mind to the conversation. For example, if he perceives himself as a victim, he will see everything that happens to him as victimization by a cruel world, and if you try to explore with him how he might have contributed to the outcome by some of his actions, he will not agree and will probably feel victimized by you. This is fairly characteristic of many adolescents, and actually occurs in all of us if we are stressed to an extreme enough degree. One of the ways I see “normal” people let go of their mentalizing is when that person is a parent who is desperately worried about his child. In that case, the internal perception of helplessness in an uncaring world (if people really cared, they would do something!) is so overwhelming that the parent cannot imagine a situation in which there is nothing to be done but wait. Another situation is in high conflict divorces in which each parent perceives him or herself as the victim of the other, and cannot empathize with the other at all.

Fonagy stressed the need to insist on a mentalizing process in therapeutic or other helping engagements. This means that if the person you are working with insists on taking a “non-mentalizing”, or irrational and highly personalized point of view, you must focus on bringing the conversation into a mentalizing one instead of just “hearing out” a lengthy non-mentalizing explanation from the other person. That is because the “hearing out” is deceptive in that it involves the person reestablishing his rigid point of view instead of presenting an opinon that is open to alternative perspectives. Fonagy points out that when your interactive partner is not mentalizing, you stop mentalizing!

Most of the patients Fonagy has studied from the point of mentalization have a diagnosis of Borderline Personality Disorder, but he makes the point that we are all vulnerable to lose our capacity to mentalize under extreme stress. This personality disorder (BPD), he thinks, is a developmental problem, in other words, the failure to develop a competency (mentalization) that it is possible to still develop. Twin studies suggest that it is heritable and it is also associated with early maternal separation and abuse (Belsky, Caspi, Arnseneault, Bleidorn, Fonagy et al, 2012, Dev. and Psychopathology). This suggests that children with a family history of mental illness (any kind) and early parental separation, neglect, or abuse, should be the primary focus of attention of mental health clinicians.

Fonagy reiterates the genetics and early environmental influences activating the attachment system and disrupting mentalization, giving way to a disorganized sense of self and three problematic activities:

1. Psychic equivalence – in which a person thinks that just because they are thinking something, it is automatically true. Flashbacks are an extreme example, and intolerance of alternative perspectives is a more ordinary one.

2. Pretend mode – the mental world is decoupled from external reality. For example, a woman can be completely convinced that a man in her office is infatuated with her even though he has never given her evidence of this.

3. Teleological mode – physical action is seen as the only way to modify someone else’s mental state. An example is when a person insists on concrete evidence of your caring for them – including extra sessions or telephone calls or physical touching.

Fonagy recommends certain techniques for helping your interactive partner (patient, client, etc) to mentalize:

1. Take a stance of active questioning and “not knowing”. That means that you do not presume to know what is going on until the other person explains it to you. While “not knowing”, you gently insist on alternative perspectives. (“Of course, I don’t know, but when I think about it, it occurs to me that X might be happening instead of Y.”)

2. Monitor your own mistakes. That means acknowledging your inability to really know what is in the other’s mind and apologize for your mistakes.

3. Empathy.

4. Curiosity about the other’s experience.

5. Staying in the present instead of moving to the past.

6. Lower arousal by bringing it back to you: “What have I said that bothered you?”

7. Quickly step back if the person seems to be losing control.

8. Highlight the experience of “feeling felt”.

9. Identify a break in mentalizing and “rewind” to the moment before.

10. The main idea is to “create a space” in which the rhythms of mentalizing can occur, a safe place where you collaborate in creating a more flexible and adaptive meaning about what is bothering the person.

Fonagy has a new book out about how to understand mentalizing and how to practice it:

Anthony W. Bateman and Peter Fonagy, Handbook of Mentalizing in Mental Health Practice, American Psychiatric Association, 2012.

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