Download EMOTION: Information as Subjective Feeling

Changing Minds 2: how does
psychotherapy change your mind?
Professor Gwen Adshead
General over view
• What is wrong with the minds of people in
mental distress?
• Common themes: The Self and Others
• Disorders of thought and mentalisation
• Therapies that change mentalising
• Acknowledgements: Professor Peter Fonagy,
Professor Anthony Bateman, Professor Jon
Allen, Dr Jay Sarkar, Dr Martin Humphrey.
• Morris Nitsun: therapist and artist
What’s wrong with people with mental
distress?
• Man is a social animal
• Homo narrans: man is the story telling animal
• To live with others in groups, people need to
tell a coherent story of themselves
• A story by which they recognise themselves
across time
• But which can change when the environment
changes
To tell your story
• You need to be able to organise your thoughts
• You need to be able to regulate your feelings
and the degree to which you get stressed and
aroused
• You need to be able to regulate the distance
between yourself and others
• You need to be able to think about your mind
and the minds of others
What’s wrong with people with mental
distress ? What can’t they do?
• Arousal regulation and self-soothing
• Negative Affect regulation
• Regulation of distance and closeness in interpersonal
relationships: (attachment disorders)
• Experience an integrated sense of self
• Disorders of embodiment
• Reality testing deficits
• Thinking errors: jumping to conclusions, bias
• Dysfunctional time relationships
• Defects of mentalisation: thinking about other people’s minds
3 in 1 or ‘Triune’ Brain (Maclean 1990)
1 BRAIN, 3 MINDS and ONE SELF
COGNITION: Information as Knowledge
Capacity for conceptual information processing,
reason, meaning-making and decision making.
EMOTION: Information as Subjective Feeling
Capacity for experiencing, identifying and articulation
of feeling and affect, which adds motivational
colouring to somatic and cognitive processing.
SOMATIC: Information as Behavioural Outputs
Processing
through
the
body
that
involves
physiological experiences that are associated with
impulses, movement, postural changes, orienting and
defensive responses, and ANS arousal.
HOW DO OUR BODIES (AUTOMATIC BRAIN)
DEFEND US ?
Hyperaroused
Sympathetic
Optimal Arousal
Ventral vagal
parasympathetic
Hypoaroused
Dorsal vagal
parasympathetic
Danger
Safety
Fight- Flight
response
“Social Engagement”
Exploratory behaviour
Life threat
Freeze- submit
Helplessness
response
Bottom-up processing
Defences and disorder
 There is a problem (defect) with the brain
function in terms of arousal, attention, reality
testing, threat perception, pain management
 There is a problem with the psychological
responses (defence) to the defect: meaningmaking; self-other interpretations, secondary
defences against stress
 Erratic behaviour in response to immature
defence
So the problems lie…
• In how we ‘see’ the world : ourselves and
others in it
• Appraisals and interpretations of stress, loss
and danger: especially bodily experience
• Responses to those interpretations: defences,
memory, time and image
• The story we tell of our situation
• What change we envisage as solution
Secure attachment and the
development of the R Brain
Development of mentalising
• A function of the attachment relationship
between parent and child
• Secure attachment promotes reflective function
i.e. thinking about one’s own state of mind
• Which extends over time to being able to
conceive of others’ states of mind; and be
curious
• The intentional stance: related to group safety: is
this person a predator?
Model of intergenerational transmission and
developmental psychopathology
child
attachment
security
parental attachment
security
child
mentalizing
parental mentalizing in
relation to childhood
attachment
parental
mentalizing of
child
emotion
regulation
psychosocial
functioning
adapted from Sharp &
Fonagy (2008) Social
Development
The function of mentalising
• To help regulate affects and arousal at times
of stress
• To help make and maintain social relationships
in groups
• To help support the coherence of Self
narratives
• “The story I tell now is not the story I told
then”
Mentalising underpins the social mind
 General self-other awareness and distinction
 Empathy and perspective taking
 Mindfulness
 Theory of mind
 The intentional stance: ‘reading’ other minds
 Part of our mammalian heritage: is this person
predator, prey or partner?
 A neurobiological basis
Trauma disrupts reflective function
• In childhood or in adulthood
• Chronic fear experiences and/or failure of care
• The experience of hostility from another and
absence of soothing
• Neglect in childhood
• Begins antenatally: maternal stress affects
gene expression in the neonate, which affects
protein synthesis in stress regulation systems
Dysfunctional neural networks
• Failure of top down regulation by orbitofrontal cortex (OFC)
• Erratic function in the limbic system or
hippocampal system
• Disorganisation of neural networks linking
OFC, amygdala and hippocampus via
disruption of neurotransmitter function
If you can’t reflect…
• You can’t see yourself
• You can’t see others
• You may become confused about what is real
and what is not
• You may be confused about where you and
your body end and others begin
How do you see the world with no eyes? I see it
feelingly….
What could help?
• Better affect and arousal regulation
• Better understanding of stress and distress
and how it affects us
• Better awareness of Self and how I function
and see the world
• What am I not thinking about?
• Could I change the way I see myself? Others?
• Is there another way to think about this?
Professors Bateman & Fonagy
Mentalising Based Therapy
• A conscious cognitive process of being aware
of one’s own mind, and the minds of others
• Based on attachment theory and evolutionary
psychology: evidence of adaptive unconscious
(Wilson, 2010)
• Keeping mind in mind: appraisal of other’s
intentions and experience
• Implicit and explicit
Three impairments of mentalizing
too little, too much, misuse
nonmentalizing
concreteness,
indifference,
aversion
Mindblindness
and predator
mode
mentalizing
grounded
imagination
distorted
mentalizing
imagination
gone wild
(paranoia)
hypermentalizing
Symptoms of mental disorders
• Poor arousal regulation and embodiment:
impulsivity, somatisation and acting out
• Poor affect regulation: self-medication with
substances, use of others to regulate mood
• Poor interpersonal skills and mentalising:
• alienate others, can’t use the social world, attacks on
the social, oscillating attachment and rejection,
attacks on vulnerability
• Failure of reality testing : Intermittent psychotic
states
So what happens in
psychotherapy?
• Restore or improve mentalising by
– Challenging thinking errors and fixed dysfunctional
beliefs
– Reducing the tendency to act on distorted thoughts or
feelings
– Improving mood regulation and coping with painful
emotions
– Raising awareness of felt and thought experience and
dysfunctional attachments
– Changing time perspectives: what was then is not now
All Psychological therapies
 Try to help people understand themselves better
 Not avoid distress: reality testing
 Help people understand how anxiety and distress
distort thinking
 And how negative thoughts drive mood
 Reappraise fixed beliefs about themselves and
others in relationships
 Try to increase a sense of agency and hope
Problems
• Psychotherapy takes time: weeks for minor
problems, 18 months for complex problems
• It may be painful and scary
• It means trying something new
• It may mean thinking something new
• It takes trust in another person or persons
• It can have unforeseen effects
Current therapies for mental distress
•
•
•
•
•
•
CBT ( individual and group)
DBT ( ditto)
MBT (Ditto)
SFT (ditto)
TFP
Mindfulness and ACT (either separately or part
of DBT)
• POT
• OMG!
Do they work?
• Evidence that psychological therapies change
the brain
• Like any new learning does
• New information affects the way that neuraltransmitters are released or processed at
neural synapses
• What you learn affects the way your brain
works, which affects the way your mind works
What do they have in common?
• They support enhanced mentalising either
explicitly or implicitly
• If effective, they promote enhanced sense of
agency and decrease negative behaviours
• Changing perspective or narrative
• The therapist needs to be consistent, patient,
empathic, attuned
“I’m still the same person, I just think
completely differently”
Attention to language
• ‘I just have to pick up the pieces and go on’
( you were in pieces)
‘After [she] died, I was shattered…. Completely
shattered’
The therapist by Magritte
Blocks to therapy
• Engagement and expectations
• Ruptures in the alliance
• Hostility, enmeshment and repetition of
toxic attachments
• Therapist’s feelings: conscious and
unconscious, positive and negative
• Therapist’s behaviours: payback,
appeasement, rejection, helplessness
Engagement is important
• Failure to complete treatment is common
(e.g. ranging from 30-50%).
• Failure to complete is associated with a
worse outcome than if the individual had
never been offered treatment.
• So need to improve engagement: patient
readiness and therapist preparedness