Minding the Child

Mentalization-Based Interventions with Children, Young People and their Families

Nick Midgley, Ioanna Vrouva

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136336409
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

What is 'mentalization'? How can this concept be applied to clinical work with children, young people and families? What will help therapists working with children and families to 'keep the mind in mind'? Why does it matter if a parent can 'see themselves from the outside, and their child from the inside'?

Minding the Child considers the implications of the concept of mentalization for a range of therapeutic interventions with children and families. Mentalization, and the empirical research which has supported it, now plays a significant role in a range of psychotherapies for adults. In this book we see how these rich ideas about the development of the self and interpersonal relatedness can help to foster the emotional well-being of children and young people in clinical practice and a range of other settings.

With contributions from a range of international experts, the three main sections of the book explore:

• the concept of mentalization from a theoretical and research perspective
• the value of mentalization-based interventions within child mental health services
• the application of mentalizing ideas to work in community settings.

Minding the Child will be of particular interest to clinicians and those working therapeutically with children and families, but it will also be of interest to academics and students interested in child and adolescent mental health, developmental psychology and the study of social cognition.

Part I

The concept of ‘mentalization’:
theory and research

Chapter 1

What is mentalization?

The concept and its foundations in
developmental research

Peter Fonagy and Elizabeth Allison

Introduction: What is mentalization?

When we mentalize we are engaged in a form of (mostly preconscious) imaginative mental activity that enables us to perceive and interpret human behaviour in terms of intentional mental states, e.g. needs, desires, feelings, beliefs, goals, purposes and reasons (Allen et al., 2008). Mentalizing must be imaginative because we have to imagine what other people might be thinking or feeling. We can never know for sure what is in someone else's mind (Fonagy et al., 1997b). Moreover, we suggest (perhaps counterintuitively) that a similar kind of imaginative leap is required to understand our own mental experience, particularly in relation to emotionally charged issues. We shall see that the ability to mentalize is vital for self-organization and affect regulation.

The ability to infer and represent other people's mental states may be uniquely human. It seems to have evolved to enable humans to predict and interpret others’ actions quickly and efficiently in a large variety of competitive and cooperative situations. However, the extent to which each of us is able to master this vital capacity is crucially influenced by our early experiences as well as our genetic inheritance. In this chapter, we discuss the evolutionary function of attachment relationships, arguing that their major evolutionary advantage is the opportunity that they give infants to develop social intelligence, as well as to acquire the capacity for affect regulation and attentional control. We review evidence from the developmental literature on the social influences on attachment and mentalization. We then describe how our understanding of ourselves and others as mental agents grows out of interpersonal experience, particularly the child – caregiver relationship (Fonagy et al., 2002), and how the development of the ability to mentalize may be compromised in children who have not benefited from the opportunity to be understood and thought about in this way by a sensitive caregiver. Finally, we offer some reflections on the challenges of mentalizing in family interactions.

Origins of the concept of mentalization

We first developed our concept of mentalization in the context of a large empirical study, in which security of infant attachment with each parent turned out to be strongly predicted, not only by that parent's security of attachment during the pregnancy (Fonagy et al., 1991a), but even more by the parent's ability to think about and understand their childhood relationship to their own parents in terms of states of mind (Fonagy et al.,1991b). We proposed that there was a vital synergy between attachment processes and the development of the child's ability to understand interpersonal behaviour in terms of mental states (Fonagy et al., 1997a, 2002).

Alongside this empirical research, inspiration for the development of the concept of mentalization also came from psychoanalytic work with borderline patients. In an early paper effectively co-authored with George Moran, we identified the repudiation of a concern with mental states as a key aspect of borderline psychopathology (Fonagy, 1991). The first time we used the term mentalization was in 1989 (Fonagy, 1989), influenced by the Ecole Psychosomatique de Paris, but we used the term as operationalized by developmental researchers investigating theory of mind (ToM; Leslie, 1987). The failure of mentalizing had of course been apparent to most psychoanalysts working with these patients, particularly Bion, Rosenfeld, Green, Kernberg and the North American object relations theorists. In an early paper reviewing ideas concerning mentalization in relation to classical psychoanalytic concepts, this intellectual indebtedness was carefully documented (Fonagy & Higgitt, 1989). The basic suggestion was that the capacity for representing self and others as thinking, believing, wishing or desiring does not simply arrive at age four, as an inevitable consequence of maturation. Rather, it is a developmental achievement that is profoundly rooted in the quality of early relationships. Its liability to disappear under stress in borderline conditions was seen as an appropriate focus for psychoanalytically oriented psychological intervention.

A second line of analytic inspiration came from work with children undertaken as part of a project to construct a manual for child analysis and subsequent work in developmental science by Mary Target and Peter Fonagy (Fonagy et al., 2002; Fonagy & Target, 1996, 2000, 2007; Target & Fonagy, 1996). This work helped us to think more deeply about the normal development of thinking or mentalizing capacity, and the more primitive modes of thought that precede its emergence. In trying to map the emergence of mentalization on the basis of material from records of child analysis and clinical and research work with children in other contexts, we came up with a heuristic map of the emergence of mentalization that turned out to be extremely valuable in understanding some qualitative aspects of the thinking of patients in borderline states. In particular, we noticed that the types of thinking that many have identified as a hallmark of borderline personality disorder were not dissimilar to the ways young children normally tend to treat their internal experience.

Our theory of the developmental emergence of the capacity to mentalize challenges the Cartesian assumption that the mind is transparent to itself and that our ability to reflect on our own minds is innate. We contend that optimal development of the capacity to mentalize depends on interaction with more mature and sensitive minds, and thus a consideration of the role played by attachment in this development is indispensable. We have come to conceive of mentalization as a multidimensional construct, whose core processing dimensions are underpinned by distinct neural systems. Thus, mentalization involves both a self-reflective and an interpersonal component; it is based both on observing others and reflecting on their mental states, it is both implicit and explicit and concerns both feelings and cognitions (Fonagy & Luyten, 2009; Lieberman, 2007; Luyten et al., submitted; Saxe, 2006). When they are working together in optimal combination, the neural systems underpinning these components enable the child to represent causal mental states, distinguish inner from outer reality, infer others’ mental states from subtle behavioural and contextual cues, moderate behaviour and emotional experience and construct representations of his or her own mental states from perceptible cues (arousal, behaviour or context).

Attachment and mentalization

Early caregiving relationships are probably key to normal development in all mammals, including humans (Hofer, 1995). John Bowlby, the founder of attachment theory, postulated a universal human need to form close bonds. Bowlby originally proposed that the basic evolutionary function of the attachment instinct was to ensure that infants would be protected from predators (Bowlby, 1969). The baby's attachment behaviours (e.g. proximity seeking, smiling, clinging) are reciprocated by adult attachment behaviours (touching, holding, soothing) and these responses reinforce the baby's attachment behaviour toward that particular adult.

However, the evolutionary role of the attachment relationship goes far beyond giving physical protection to the human infant. The infant's attachment behaviours are activated when something about his environment makes him feel insecure. The goal of the attachment system is an experience of security. Thus, the attachment system is first and foremost a regulator of emotional experience (Sroufe, 1996).

None of us are born with the capacity to regulate our own emotional reactions. As the caregiver understands and responds to the newborn infant's signals of moment-to-moment changes in his state, a dyadic regulatory system gradually evolves. The infant learns that he will not be overwhelmed by his emotional arousal while he is in the caregiver's presence, because the caregiver is there to help him re-establish equilibrium. Thus, when he starts to feel overwhelmed, he will seek or signal to the caregiver in the hope of soothing and the recovery of homeostasis. By the end of the first year, the infant's behaviour seems to be based on specific expectations. His past experiences with the caregiver are aggregated into representational systems which Bowlby (1973) termed ‘internal working models’ (IWMs).

Bowlby proposed that the IWMs of the self and others established in infancy provide prototypes for all later relationships. Because IWMs function outside of awareness, they are change-resistant (Crittenden, 1990). The stability of attachment has been demonstrated by longitudinal studies of infants assessed with the Strange Situation (Ainsworth et al., 1978) and followed up in adolescence or young adulthood with the Adult Attachment Interview (AAI, George et al., 1985). Longitudinal studies have shown a 68 to 75 per cent correspondence between attachment classifications in infancy and classifications in adulthood (e.g. Main, 1997). This is an unparalleled level of consistency between behaviour observed in infancy and outcomes in adulthood, although it is important to remember that such behaviour may be maintained by consistent environments as well as by patterns laid down in the first year of life.

Attachment relationships also play a key role in the transgenerational transmission of security. Secure adults are three or four times more likely to have children who are securely attached to them (van IJzendoorn, 1995). One might wonder if such powerful intergenerational effects are genetically mediated, but evidence from behaviour genetic studies offers no support for genetic transmission (e.g. Fearon et al., 2006). Parental attachment patterns predict unique variance in addition to temperament measures or contextual factors, such as life events, social support and psychopathology (Steele et al., unpublished manuscript). However, the precise mechanisms which ensure that securely attached mothers and fathers develop secure attachment relationships with their child have been difficult to identify (van IJzendoorn, 1995).

Insecure infant attachment, and particularly disorganized attachment, is a risk factor for suboptimal emotional and social development (Lyons-Ruth & Jacobvitz, 2008). But accumulating evidence shows that the develop-mental pathway from disorganized infant attachment to later psychological disorder is complex and sometimes circuitous. Rather than a developmentally reductionist model, moving directly from infancy to adulthood, we must envision a complex series of steps, each involving factors of risk and resilience interacting with past and future developmental phases. However, infant attachment may be a vulnerability factor that can illuminate the entire developmental process.

In our view, the major evolutionary advantage of attachment in humans is the opportunity it gives the infant to develop social intelligence. Alan Sroufe (1996) and Myron Hofer (2004) played a seminal role in extending the scope of attachment theory from an account of the developmental emergence of a set of social expectations, to a far broader conception of attachment as an organizer of physiological and brain regulation. Attachment ensures that the brain processes which serve social cognition are appropriately organized and prepared to enable us to live and work with other people.

There is increasing evidence suggesting that the formation of attachment relationships is supported by at least two neurobiological systems: (1) linking attachment experiences to reward and pleasure, motivating the caregiver (and in all likelihood the infant as well) to seek experiences of closeness; and (2) a neurobiological system linking enhanced social understanding to the attachment context, with closer bonds triggering biological systems that are likely to enhance sensitivity to social cues. Given the availability of a neurobiological pathway, what can the developmental psychology literature tell us about the link between attachment and mentalization?

Understanding the relationship of attachment and
mentalization

If attachment underpins the emergence of mentalization we would expect secure children to outperform insecure ones in this domain (measured as passing ToM tasks earlier). Many studies support this hypothesis (see Fonagy & Luyten, 2009 for a review). Generally it seems that secure attachment and mentalization may be subject to similar social influences. We briefly consider some of these influences below.

Mentalizing and parenting

Two decades of research have confirmed that parenting is the key determinant of attachment security. Can aspects of parenting account for the overlap between mentalization and attachment security? In particular, does parental mentalization of the child have an influence? The mother's capacity to think about her child's mind is variously called maternal mind-mindedness, insightfulness and reflective function (RF). These overlapping attributes appear to be associated with both secure attachment and mentalization in the child (see Sharp et al., 2006).

Elizabeth Meins (Meins et al., 2001), David Oppenheim (Oppenheim & Koren-Karie, 2002) and Arietta Slade (Slade et al., 2005) have all been able to link parental mentalization of the infant with the development of affect regulation and secure attachment in the child, mostly by analysing interactional narratives between parents and children. Although Meins assessed parents’ quality of narrative about their children in real time (i.e. while the parents were playing with their children) and Oppenheim's group did this in a more ‘off-line’ manner (parent narrating videotaped interaction), both concluded that maternal mentalizing was a more significant predictor of security of attachment than, say, global sensitivity. Slade and colleagues (Slade et al., 2005) also observed a strong relationship between attachment in the infant and the quality of the parent's mentalizing about the child. Low mentalizing mothers were more likely to show atypical maternal behaviour on the Atypical Maternal Behavior Instrument for Assessment and Classification (AMBIANCE; Bronfman et al., 1999), which relates not only to infant attachment disorganization but also to unresolved (disorganized) attachment status in the mother's Adult Attachment Interview (Grienenberger et al., 2005).

Taken together, these results suggest that mentalizing parents might well facilitate the development of mentalization in their children. Mindful parenting probably enhances both attachment s...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Contributors
• Foreword
• Acknowledgements
• Introduction
• Part I The concept of ‘mentalization’: theory and research
• Part II Clinic-based interventions
• Part III Community-based interventions
• Index