1. Mentalization and
attachment: The
implication for community
based therapies
Peter Fonagy PhD FBA
University College London
& the Anna Freud Centre
P.Fonagy@UCL.AC.Uk

2. Some of the Mentalizing Mafia
 UCL/AFC/Tavistock  Dr Liz Allison
 Prof George Gergely
 Professor Alessandra Lemma
 Dr Pasco Fearon
 Professor Mary Target
 Professor Eia Asen
 Prof Anthony Bateman
 Dr Trudie Rossouw
 University of Leuven
& UCL/AFC
 Dr Patrick Luyten  Dr Dickon Bevington

3. Some more maffiosi (The USA branch)
 Menninger Clinic/Baylor Medical College (The USA branch)
 Dr Jon Allen  Dr Carla Sharp
 Dr Lane Strathearn  Dr Efrain Bleiberg
 Dr Brooks King-Casas
 Professor Flynn O’Malley
 Dr Read Montague
 Yale Child Study Centre
 Prof Linda Mayes  Professor Nancy Suchman

4. And European recruits to the ‘Family”
 Dawn Bales  Professor Finn Skårderud
 Dr Mirjam Kalland
 Professor Sigmund Karterud
•Cindy Decoste •Svenja Taubner
•Catherine Freeman •Bart Vandeneede
•Ulla Kahn •Annelies Verheught-Pleiter
•Morten Kjolbe •Rudi Vermote
•Benedicte Lowyck •Joleien Zevalkink
•Tobi Nolte •Bjorn Philips
•Marjukka Pajulo •Dr Peter Fuggle
And Rose Palmer for help with the preparation of this presentation.

6. Let the boy
You will never dream Ivan,
amount to anything He is a born
if you hold a ball dilettante!
like that!
I want to write my
PhD on the “Use You look smug
of low signal-to- now but you
noise ratio stimuli will lose your
for highlighting the hair just like
functional Dad
differences
between the two
cerebral
hemispheres”.

7. Mentalization
What is it?
How does it arise?
Why does it matter?
How do we use it in therapy?

8. A working definition of mentalization
Mentalizing is a form of imaginative
mental activity, namely, perceiving and
interpreting human behaviour in terms
of intentional mental states (e.g. needs,
desires, feelings, beliefs, goals,
purposes, and reasons).

9. Brains and social behavior vary across different mammalian species
Insectivors:
Regulated maternal
behaviors
Chimpanzees:
Societies of a few dozen
Modern Humans:
Societies of millions of
interacting people
Humans exceedingly skilled
at large scale social
interaction
Competition for social skills
led to the evolutions of
cognitive mechanism for
collaborating with others
Fuelled evolution of human
brain.
Therefore correlation in
mammals between size of
social group and volume of
neocortex

10. The social brain: A variety of studies -
stories, sentences, cartoon, animations
medial prefrontal cortex (mPFC), temporo-parietal junction (TPJ),
posterior superior temporal sulcus (pSTS), amygdala, anterior
cingulate cortex (ACC), anterior insula (AI), inferior frontal gyrus (IFG)
and interparietal sulcus (IPS)

11. The uniqueness of homo sapiens
 No animal, not even the most intelligent of non-human
primates, can discern the difference between the act
of a conspecific due to serendipity and one rooted in
intention, wish, belief or desire.
 The capacity to mentalize has also been argued to
account for the other major difference between
humans and other apes:
 self awareness and self-consciousness as a path to
emulation bringing with it social emotions such as
embarrassment, shame and guilt
 the species specific striving to be more than a ‘beast’, to live
beyond one’s body, to aspire to a spirit that transcends
physical reality and step beyond one’s own existence
 social origin of the self (simulation).

12. Mentalizing:
Further definitions and scope
 To see ourselves from the outside and
others from the inside
 Understanding misunderstanding
 Having mind in mind
 Mindfulness of minds
 Introspection for subjective self-
construction – know yourself as others
know you but also know your subjective
self

13. Articles using ‘mentalization’ in
title or abstracts
Number of articles on Web of Science Database
Source: http://apps.webofknowledge.com, Data collected 10.1.2012

14. Clear evidence of mentalizing?
JUST RELEASED!
NEW!
IMPROVED!
Longer than all
previous
Washes brains versions!
whiter!
2012
American Psychiatric Publishing, Inc

15. Mentalization and Overlapping Constructs
(Choi-Kain & Gunderson, Am J Psychiat 2008)

16. Measuring Mentalization (Baron-
Cohen et al., 2001) Reading the Mind
in the Eyes Test
Friendly - A Sad - B
Surprised - C Worried - D

17. Measuring Mentalization (Baron-Cohen et
al., 2001) Reading the Mind in the Eyes Test
Surprised-A Sure about something-B
Joking-C Happy-D

18. Measuring Mentalization (Baron-
Cohen et al., 2001) Reading the Mind
in the Eyes Test
Joking-A Flustered-B
Desire-C Convinced-D

19. Mentalizing at the World Cup: How does Robert
Green feel after letting in the USA goal?
Upset Angry
Disappointed Frustrated

21. Shared neural circuits for mentalizing about the
self and others (Lombardo et al., 2009; J. Cog. Neurosc.)
Self mental state
Other mental state
Overlapping for
Self and Other

22. Relational Aspects of Mentalization
 Overlap between neural locations of mentalizing
self and other may be linked to intersubjective
origin of sense of self
 We find our mind initially in the minds of our parents
and later other attachment figures thinking about us
 The parent’s capacity to mirror effectively her child’s
internal state is at the heart of affect regulation
 Infant is dependent on contingent response of
caregiver which in turn depends on her capacity to be
reflective about her child as a psychological being
 Failure to find the constitutional self in the other has
potential to profoundly distort the self representation
(exaggerated mirroring of child’s anxiety aggravates
anxiety rather than soothe)
 The same applies to child with inadequate sense of
independent self within therapeutic relationship

23. Affect & Self Regulation Through
Psychological Representation
of self-state:
Mirroring
Self: co n
ting
Internalization e nt d
2nd Order of object’s image ex p ispl
ay
Representations und ressio
erst
ood n of Expression
affe
ct
symbolic organisation
of internal state
Physical Self: Reflection
Primary
Representations signal
Constitutional self al
Resonance
no n-verb
in state of arousal pressio
n
ex
Infant CAREGIVER
Fonagy, Gergely, Jurist & Target (2002)
With apologies to Gergely & Watson (1996)

24. Theory: Birth of the Agentive Self
Attachment figure “discovers” infant’s mind (subjectivity)
Internalization
Representation of
infant’s mental
state Core of
psychological
self
Inference
Attachment figure Infant
Infant internalizes caregiver’s representation to form psychological self
Safe, playful interaction with the caregiver leads to the integration of primitive
modes of experiencing internal reality  mentalization

25. ‘The baby looks at his mother’s face and
finds himself there’
D. Winnicott
‘She/he thinks that I think, therefore I am’

26. Bidirectional Influences of the
Development of Mentalization
 Poor affect regulation obviously makes sensitive
caregiving more challenging
 The impact of some environmental influences are evidently
exaggerated by certain genetic attributes (e.g. the short allele of
the 5-HTT gene Barry, Kochanska, & Philibert, 2008).
 Limitation of voluntarily directing attention and accurate
and solid interpersonal understanding necessary for
mature affect regulating attachment relationships.
 Inability to mentalize disrupts attachment relationships
 Disrupted attachments undermine further development of
mentalizing
 The very process that could help the child to overcome
the problems arising out of interpersonal challenges is
undermined by the difficulties in the child’ attachment
system

27. The development
of mentalization
from infancy to
adolescence and
beyond

28. The development of mentalization
 Weeks after birth the baby smiles at humans
(social beings) in preference to objects
 Can tell its own body (shell) from that of another
person’s
 2 months after birth infants prefer the subtle
patterns of contingency in face-to-face
interactions, including turn taking and correlated
affect (Gergely and Watson, 1999; Murray and
Trevarthen, 1985).
 By 9 months, infants are able to follow another
person's gaze to a location outside of their visual
field
 A key first step in establishing joint attention (Moore,
2008).

29. From 12 months babies deliberately engage and
redirect attention of caregiver (pointing and vocalizing)
 Joint ( “triadic”) attention provides a
platform by which two or more people
coordinate and communicate their
intentions, desires, emotions, beliefs, and/or
knowledge about a third entity (e.g. an
object or a common goal) (Tomasello et al.,
2005).
 By 2.5 years children implement complex
social tactics – teasing, lying, saving face
(Reddy, 2008: How infants know minds)

30. False belief task: unexpected transfer
(Wimmer & Perner, 1983)
Test question
Where will he look
first heshe Mum
After that, leaves
Thenfor putsbook?
Then hisleaves to
Maxi to tidy up
his
comes somein book
Mumdothe garden
Now,takes it work
to in Maxi returns
and puts the
play book in the
thethe room book
out in bookshelf
of the kitchen.
looking forcupboard,
the his
cupboard

31. Effect of Age in 178 separate studies
2nd ½ of 4th year
4y 2nd 4y of 4th year
½
Very robust developmental trends most manipulations ineffective
Meta-analysis of False Belief Studies (Wellman et al., 2009)

32. The embodied mind and research on
the human infant
 Massive denial of infant mentation outside of
psychoanalysis until about 75 years ago
 Half a century ago infants were commonly subjected to
surgery without anesthetic (curare was used to stop
squirming inconvenient for the surgeon) Can infants
have minds when they are no yet able to speak?
 Astounding discoveries concerning early social
awareness in infants
 Mentalization is embodied before it is cognitive
 Freud may have been correct about the mental life
being somatically grounded (the body is at the root of
meaning.

34. Sensitivity to others’ state of mind
False belief for baby
True belief for Smurf
True belief for baby
False belief for Smurf
Á M Kovács et al. Science
2011;330:1830-1834

35. Sensitivity to others’ state of mind
Ball Not There Ball Not There
True belief for baby
False belief for baby False belief for Smurf
The infant but not the Infant knows ball is not there
Smurf believes that But Smurf believes it should
the ball should be there be there
Neither infant nor Neither infant nor
the smurf believe the Smurf believe that
that ball is there the ball should be there
The two key conditions in Smurf Study: Infant of 7 months
considers what agent (Smurf) believes about the status of ball
Á M Kovács et al. Science 2010, 330:1830-1834
Published by AAAS

36. Principle of Fairness
 According to the Principle of Fairness,
agents should deal fairly with others
distribution of resources
compensation for work
 Sloane, Baillargeon, and Premack (2010)
9 months olds
Animate or inanimate giraffes
Reasonable expectation applies only to
animate objects
(e.g., Boyd & Richardson, 2003; Fehr et al., 2008; Haidt & Joseph, 2007;
Jackendoff, 2009; Olson & Spelke, 2008; Premack , 2007; Sigmund et al., 2002)

37. Animate giraffes condition

38. Test trials
I have toys Yay! Yay!

39. Inanimate giraffes condition:
Same giraffes – no movement

40. Results–9 mnths olds: looking time
Animate Giraffes Inanimate Giraffes
Condition Condition
Unequally distributed toys
Equally distributed toys
Mean Looking Time (sec)
*

41. The infantile origins of
psychopathology
 Infants have genetically inbuilt ‘healthy’ social
expectations
 Social experience to be developmentally ‘good
enough’ has to comply with these expectations
 Fit in with biologically prepared mechanisms which
evolved to transmit human culture
 Be consistent with neural development (i.e. capacity
to integrate new information)
 Violations of expectations toxic because not only they
‘teach’ inappropriate content but undermine
mechanisms for the social acquisition of knowledge
and the emergence of an agentive sense of self

42. The role of
contingent
caregiver
responding in
the development
of cognitions

43. Natural Pedagogy theory
(Csibra & Gergely, 2006; 2009, in press)
 A human-specific, cue-driven social cognitive
adaptation of mutual design dedicated to ensure
efficient transfer of relevant cultural knowledge
 Humans are predisposed to ’teach’ and ’learn’
new and relevant cultural information from each
other
 Human communication is specifically adapted to
allow the transmission of
 a) cognitively opaque cultural knowledge
 b) kind-generalizable generic knowledge
 c) shared cultural knowledge

44. The Pedagogical Stance is triggered by
Ostensive-Communicative cues
 Examples of ostensive communication
cues
eye-contact
turn-taking contingent reactivity
special tone (motherese)
 Ostensive cues function:
to signal that the other has a Communicative
Intention addressed to the infant/child
to Manifest New and Relevant information
about a referent

45. Experimental illustration of ostensive cues
Gergely, Egyed et al. (in press)
Subjects : 4 groups of 18-month-olds
Stimuli: Two unfamiliar objects

46. 1: Baseline – control group
No object-directed attitude demonstration
Simple Object
Request by
Experimenter A
Subjects: n= 20 Age: 18-month-olds

47. Ostensive Communicative Demonstration
Requester: OTHER person (Condition 1)
Other
person

49. Non-Ostensive (Non-Communicative) Demonstration
Requester: OTHER person (Condition 2)
Other
person

51. Condition 4: Non-Ostensive (Non-Communicative)
Demonstration Requester: SAME person
Same
person

53. Epistemic trust and secure
attachment
 Secure attachment is isomorphic with inducing
in the infant/child a sense of epistemic trust 
that the information relayed by the teacher may
be trusted (i.e. learnt from)
 Evidence
 Cognitive advantage of secure attachment
 Contingent responsiveness to the infant’s own (at first,
automatic) expressive displays in secure attachment
 During “mirroring” interactions, the other will “mark”
her referential emotion displays in a ‘manifestative’
manner to instruct the infant

54. How Attachment Links to Affect Regulation
DISTRESS/FEAR
BONDING
Down Regulation of Emotions
Exposure to Threat Activation of attachment
EPISTEMIC
TRUST
Proximity seeking
The forming of an attachment bond

55. Implications: The nature of psychotherapy
 The mind is found within the other not within itself
 Evolution has ‘prepared’ our brains for
psychological therapy
 We are eager to learn about the opaque mental
world from those around us
 They are prepared to learn most readily about minds
in conditions of epistemic trust
 Epistemic mistrust follows maltreatment or abuse
and therapists ignores this knowledge at their peril
 Therapy is not just about the what but the how of
learning
 Opening the person’s mind via establishing
contingencies so (s)he once again can trust the social
world by changing expectations
 Not what is taught in therapy that teaches but

56. The role of
oxytocin in
social
understanding

57. Secure attachment is facilitative of
mentalizing
 Children pass theory of mind tasks earlier
if
Had secure attachment relations with parents
in infancy
If parent’s own state of mind in relation to
attachment was secure
Family members relate to each other in payful,
mentalizing way
 Mechanism may well be mediated by
oxytocin

58. Oxytocin and performance on Mind in
the Eyes test (Domes et al., 2008)

59. Shared
characteristics of
evidence based
therapies for BPD
likely to enhance
the organization
of mental states?

60. Clinical summary of MBT
 Focus is on a break in mentalizing – psychic
equivalence, pretend, teleological
 Rewind to moment before the break in subjective
continuity
 Explore current emotional context in session by
identifying the momentary affective state between
patient and therapist
 Identify therapist’s contribution to the break in
mentalizing (humility)
 Seek to mentalize the therapeutic relationship

61. So what should the therapist aim do?
 In MBT, the mind of the patient becomes the focus
of treatment.
 Help the patient learn about the complexities of his
thoughts and feelings about himself and others, how
that relates to his responses, and how ‘errors’ in
understanding himself and others lead to actions
 It is not for the therapist to ‘tell’ the patient about
how he feels, what he thinks, how he should
behave, what the underlying reasons are,
conscious or unconscious, for his difficulties.
 any therapy approach to BPD which moves towards
‘knowing’ how a patient ‘is’, how he should behave and
think, and ‘why he is like he is’, could be harmful.
 We recommend an inquisitive or ‘not-knowing’
stance. Conveys a sense that mental states are
opaque

62. Evidence based or promising treatments
SFT
CAT
MBT
TFP
DBT
STEPPS
DBT MBT

63. MBT is in its infancy as an EST
Prof. Anthony Bateman, MD Prof. Peter Fonagy, PhD FBA

64. Psychotherapy for BPD
 A range of structured treatment programmes for
BPD shown to be effective in studies
DBT
TFP  Do they work for
SFT
CBT the reasons the
SPT developers suggest?
DDP
CAT
GPM
MBT

65. Gaps in Therapy Outcomes Research
 Nosolid evidence for who will benefit
from what type of psychotherapy
 ‘Inexacttherapies’  partial
effectiveness
 ‘Attachment to methods’ 
‘guildification’ of interventions

67. Mentalizing Elements of BPD
Therapies (1)
 Extensive effort to maintain engagement in treatment
(validation in conjunction with emphasis on need to
address therapy interfering behaviours) 
acceptance and recognition
 Include a model of pathology that is explained to the
patient  increased cognitive coherence (early phase)
 Active therapist stance: Explicit intent to validate and
demonstrate empathy, generate strong attachment
relationship  foundation of alliance (epistemic trust)
 Focus on emotion processing and connection between
action and feeling (suicide feeling == abandonment
feelings)  restore cognitive representation of
emotion

68. Mentalizing Elements of BPD
Therapies (2)
 Inquiry into patients’ mental states (behavioral
analysis, clarification, confrontation)  strengthen
representations of mental states
 Structure of treatment provides increased activity,
proactivity and self-agency (eschew expert stance,
“sit side-by-side”)  enhance intentionality (mental
state drives action)
 Structure is manualized with adherence monitored
 support therapist in non-mentalizing context
 Commitment to the approach  ditto
 Supervision to identify deviation from structure and

69. Mentalizing Elements of Therapies (3):
Components of the process of effective
interaction
 Establishing attachment through contingent
responding  epistemic trust (working alliance)
opens ‘information superhighway to cultural
knowledge”
 Create compassion towards subjective
experience  enable ‘liberal’ attitude towards self-
states  mindfulness of minds
 Enhance mentalized affectivity  feeling of feeling
felt  inititiate virtuous cycle of finding self in other
 enable finding the other in the self

70. Social Systems Can
be Described as
More or Less
Mentalizing

71. Expanding the model to Social Systems
 Human beings were not designed to be
brought up in a nuclear family
 The human brain was designed to adapt to
social environments beyond childhood
 Current social conditions place intolerable
burdens on the nuclear family
Economic pressures to be part of the workforce
Inadequate social support for parenting
Social isolation of the nuclear family
 a “Perfect Storm” from perspective of
human evolution

72. Alloparenting is not a new idea!

73. Typical Size of Human Family
Group Across Evolution
50
45
Size of family group
40
35
30
25
20
15
10
5
0
10,000BC 1,500BC 1850AD 1900AD 1980AD
Humans spent 99% of history living in groups of 35-40 people

74. Humans as part of a wider ecosystem
Connected Connected Connected Connected Connected
Mind Mind & Body Families Communities Environment

75. Some features of a successfully
mentalizing social system
 Is relaxed and flexible, not “stuck” in one point of
view
 Can be playful, with humour that engages rather
than hurting or distancing
 Can solve problems by give-and-take between own
and others’ perspectives
 Advocates describing ones own experience, rather
than defining other people’s experience or intentions
 Conveys individual “ownership” of behaviour
rather than a sense that it “happens” to them
 Is curious about other people’s perspectives, and
expect to have their own views extended by others’

76. Some components of a successfully
mentalizing social system
1. Relational strengths
- curiosity
- safe uncertainty
- contemplation and reflection
- perspective taking
- forgiveness
- impact awareness
- non-paranoid attitude
2. General values and attitudes
- tentativeness
- humility (moderation)
- playfulness and humour
- flexibility
- ‘give and take’
- responsibility and accountability

78. Mentalizing and Non-Mentalizing Social
Systems
 Mentalization develops in and is sustained
by the social system we live in
 Social systems that are compassionate
(care about us) have physical (oxytocin) and
psychological (feel held in mind) impact
which enhance accurate self-awareness and
awareness of the mental state of others
 Social systems that disrespect human
subjectivity (how a person is likely to feel)
recreate the evolutionary environment that
encodes for self-sufficiency (dismissing of
subjectivity) create environment for bullying

79. Non-Mentalizing Disorganized Social
Systems
 Social systems that create fear and
hyperactivate attachment can destroy
thinking capacity and force the system back
to pre-mentalistic modes of social thinking
 Such social systems can be self-reinforcing
and therefore highly stable in their instability
 They undermine the very social mechanism
that could alter their character: human
collaboration (negotiation and creativity)

80. Vicious cycles of inhibition of mentalizing
within a disorganized social system
Powerful emotion
Frightening, undermining,
frustrating, distressing or
coercive interactions Poor mentalising
Loss of certainty Inability to understand
or even pay attention
that thoughts are to feelings of others
not real
Try to control or Others seem
change others incomprehensible

81. Vicious Cycles of Non- Mentalizing Within a
Dysfunctional Social System
Powerful emotion Powerful emotion
Frightening, undermining, Poor mentalising Frightening, undermining, Poor mentalising
frustrating, distressing or frustrating, distressing or
coercive interactions coercive interactions
Person 1 Inability to understand Person 2 Inability to understand
or even pay attention or even pay attention
to feelings of others to feelings of others
Try to control or Try to control or
change others or change others or
oneself oneself
Others seem Others seem
incomprehensible incomprehensible

82. Non-Mentalizing Disorganized Social
Systems: Psychic Equivalence Systems
 Mind-world isomorphism; mental reality =
outer reality; internal has power of external
 Attitudes to ideas and feelings
Thoughts are real and therefore they have to be
controlled
There are singular solutions to social reality,
there are no alternative ways of seeing things,
there is intolerance to perspectives
Models of minds are simple (black and white),
schematic and rigidly held  acts of prejudice
Negative ideas (threats) become terrifying

83. Non-Mentalizing Disorganized Social
Systems: Pretend systems
 Ideas form no bridge between inner and outer
reality; mental world decoupled from external reality
 Attitudes to ideas and feelings
 People think and feel but this can have no consequence
leading to an empty and meaninglessness social
existence
 There is selfishness and extreme egocentrism emerging
out of the unreality of anything other than one’s own
thoughts and feelings
 Lack of reality of internal experience permits
interpersonal aggression and deliberate harm because
other minds are not felt to exist and the mind is no
longer felt as contingent on continued existence of the
physical self
 Frequently there is endless ‘communication’ and
searching but it is destined to yield no change

84. Non-Mentalizing Disorganized Social
Systems: Teleological Systems
 Expectations concerning the agency of the other
are present but these are formulated uniquely in
terms restricted to the physical world
 Only what is material can be meaningful
 Attitudes to ideas and feelings
 A focus on understanding actions in terms of their
physical as opposed to mental outcomes
 Only a modification in the realm of the physical is
regarded as a true index of the intentions of the other.
 Only action that has physical impact is felt as potentially
capable of altering mental state in both self and other
o Physical acts of harm  aggression is seen as legitimate
o Demand for physical acts of demonstration of intent by others
 payment, acts of subservience, retributive justice

85. So how to create a mentalizing community?
 Activate attachment by creating contingent
responding  an attitude of caring and genuine
interest
 Enhance the curiosity which members of the
community have about each others’ thoughts and
feelings  mentalizing
 Be careful to identify when mentalization has turned
into pseudomentalization (pretending to know)
 Focuses on misunderstanding (mentalization is
the understanding of misunderstanding)
 Curiosity coupled with respectful not knowing
 Maintain respectful distance from ideas

86. Neural dimensions
of mentalization
in BDP:
Controlled vs
automatic
mentalization

87. The social brain: A variety of studies -
stories, sentences, cartoon, animations
medial prefrontal cortex (mPFC), temporo-parietal junction (TPJ),
posterior superior temporal sulcus (pSTS), amygdala, anterior
cingulate cortex (ACC), anterior insula (AI), inferior frontal gyrus (IFG)
and interparietal sulcus (IPS)

88. Multifaceted Nature of Mentalization
Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
Implicit- Explicit-
amygdala, basal ganglia, lateral and medial prefrontal cortex
Automatic- ventromedial prefrontal (LPFC & MPFC), lateral and medial Controlled
Non -conscious- cortex (VMPFC), parietal cortex (LPAC & MPAC), Conscious
lateral temporal cortex (LTC) medial temporal lobe (MTL),rostral
Immediate. and the dorsal anterior anterior cingulate cortex (rACC) Reflective
cingulate cortex (dACC)
Mental Mental
interior medial frontoparietal recruits lateral fronto-temporal exterior
network activated network
cue cue
focused focused
Cognitive Affective
agent:attitude Associated with several areas Associated with inferior prefrontal
self:affect state
propositions of prefrontal cortex gyrus propositions
Imitative Belief-desire
the medial prefrontal cortex,
frontoparietal frontoparietal mirror-neuron
ACC, and the precuneus
MPFC/ACC
system
mirror neurone inhibitory
system system

89. Mentalizing Profile of Prototypical BPD patient
Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
BPD
Implicit- Explicit-
Automatic- Controlled
Non -conscious- Conscious
Immediate. Reflective
Mental BPD External
interior visible
cue cues
focused focused
BPD Affective
Cognitive
agent:attitude self:affect state
propositions propositions
BPD
Imitative Belief-desire
frontoparietal MPFC/ACC
mirror neurone inhibitory
system system

90. Crucial role of Attachment History in
facilitating/inhibiting Mentalization in the face
of stress
 Arousal/stress inhibits controlled (‘reflective’)
mentalization
 This leads to automatic mentalizing
dominated by reflexive (unrerflective)
assumptions regarding self and others under
stress, which may not be obvious in low stress
conditions
 Reemergence of non-mentalizing modes
Luyten, P., Mayes, L. C., Fonagy, P., & Van Houdenhove, B. (2010). The interpersonal regulation of stress: A
developmental framework. Manuscript submitted for publication.
Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and
treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355-1381.
Fonagy, P., Luyten, P., Bateman, A., Gergely, G., Strathearn, L., Target, M., et al. (2010). Attachment and
personality pathology. In J. F. Clarkin, P. Fonagy & G. O. Gabbard (Eds.), Psychodynamic psychotherapy for
personality disorders. A clinical handbook (pp. 37-87). Washington, DC: American Psychiatric Publishing.

91. Dimensions of mentalization: implicit/automatic
vs explicit/controlled in Othello
That handkerchief which Iariseth this? and gave thee
Why, how now, ho! from whence so loved
Thou gavest to Cassio.
Are we turn'd Turks, and to ourselves do that
By heaven, Ihath forbid the Ottomites? in's hand.
Which heaven saw my handkerchief
Cont For Christian shame, put by this barbarous brawl:
rolled
Controlled Automatic
Autom
atic
Love
Spurned/

92. Dimensions of mentalization: implicit/automatic
vs explicit/controlled in Othello
That handkerchief which I so loved and gave thee
ThouLateral to Cassio.
gavest
temporal PFCAmygdala
Lateral Medial Ventromedial PFC
PFC
By heaven, I saw my handkerchief in's hand.
cortex
Cont
rolled
Controlled Automatic
Autom
atic
Arousal

93. Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychological understanding drops and is
rapidly replaced by confusion about mental
states under high arousal
That handkerchief which I so loved and gave thee
Thou gavest to Cassio.
By heaven, I saw my handkerchief in's hand.
Cont
rolled
Controlled Automatic
Autom
atic
Arousal

94. Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychotherapist’s demand to explore issues
that trigger intense emotional reactions
involving conscious reflection and explicit
mentalization are inconsistent with the
patient’s ability to perform these tasks when
arousal is high
Cont
rolled
Autom
atic
Arousal

95. Dimensions of mentalization: internally vs externally
focused (mental interiors vs visible clues)
Internal External
I wonder if he feels He looks tired;
his mother loved perhaps he slept
him? badly

96. With selective loss of sense of mental interiors, external features
are given inappropriate weight and misinterpreted as indicating
dispositional states
Intern
al
Exter
nal
You’re covering your eyes; you can hardly bear to look at me

97. Dimensions of mentalization: Cognitive vs
affective mentalization
Cognition Emotion
 Agent attitude  Self affect state
propositions propositions
“I think he thought that
England would beat “I feel sad about it too”
Germany”
Associated with inferior
Associated with several prefrontal gyrus
areas of prefrontal cortex

98. Dimensions of mentalization: Cognitive vs
affective mentalization
 With diminution of cognitive mentalization the logic of
emotional mentalization (self- affect state proposition)
comes to be inappropriately extended to cognitions.
Cogn
ition
Emot
ion
“I feel sad, you must have hurt me”

99. A biobehavioral switch model of the relationship
between stress and controlled versus automatic
mentalization (Based on Luyten et al., 2009)
Attachment - Arousal/Stress

100. Maltreatment
 Maltreatment intensifies attachment
relationships: when there is distress / fear, the
attachment system is triggered and the
attachment figure is sought out
 The attachment system of a maltreated child is
hyperactivated: there is a rapid escalation of
intimacy and the child seeks comfort from an
unsafe attachment figure. The child is therefore
at risk of receiving more maltreatment – which
gives rise to a cycle
 During this episode mentalization is inhibited

101. Inhibition of social understanding associated with
maltreatment can lead to exposure to further abuse
DISTRESS/FEAR
Adverse emotional
experience rooted in Intensification of attachment
traumatic relationships needs
Inhibition of mentalisation
Inaccurate judgements of affect,
Delayed development of mentalization understanding
Failure to understand how emotions relate to situations and behavior

102. Inhibition of social understanding associated with
maltreatment can lead to exposure to further abuse
DISTRESS/FEAR
Exposure to Intensification of attachment
maltreatment
Inhibition of mentalisation
Inaccurate judgements of facial affects,
Delayed theory-of-mind understanding
Failure to understand the situational determinants of emotions

103. Theory: Mayes’ (2001) Adaptation of Arnsten’s
Dual Arousal Systems Model
Prefrontal capacities
Posterior cortex and
subcortical capacities
Changing Point 1a
Performance
switchpoint
threshold
Point 1
Low High
Arousal

104. Mentalizing Profile Associated with Arousal
Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
AROUSAL
Implicit- Explicit-
amygdala, basal ganglia, lateral and medial prefrontal cortex
Automatic- ventromedial prefrontal (LPFC & MPFC), lateral and medial Controlled
Non -conscious- cortex (VMPFC), parietal cortex (LPAC & MPAC), Conscious
lateral temporal cortex (LTC) medial temporal lobe (MTL),rostral
Immediate. and the dorsal anterior anterior cingulate cortex (rACC) Reflective
cingulate cortex (dACC)
Mental AROUSAL Mental
interior medial frontoparietal recruits lateral fronto-temporal exterior
network activated network
cue cue
focused focused
AROUSAL Affective
Cognitive
agent:attitude Associated with several areas Associated with inferior prefrontal
self:affect state
propositions of prefrontal cortex gyrus propositions
AROUSAL
Imitative Belief-desire
the medial prefrontal cortex,
frontoparietal frontoparietal mirror-neuron
ACC, and the precuneus
MPFC/ACC
system
mirror neurone inhibitory
system system

105. Treatment vectors in re-establishing mentalizing
in borderline personality disorder
Impression driven
Controlled
Implicit- Explicit-
Automatic Controlled
Mental Appearance
Inference Mental
interior exterior
focused focused
Certainty of emotion
Doubt of cognition Affective
Cognitive
agent:attitude self:affect state
propositions propositions
Emotional contagion
Autonomy
Imitative Belief-desire
frontoparietal MPFC/ACC
mirror neurone inhibitory
system system

106. Identity diffusion:
The functional
overlap
hypothesis

107. Mentalizing as a multidimensional
neuroscience construct
 Two distinct neural networks are shared by self-
knowing and knowing others (Lieberman, 2007;
Uddin et al., 2007)
 frontoparietal mirror-neuron system (Keysers & Gazzola,
2006; Rizzolatti, Ferrari, Rozzi, & Fogassi, 2006).
 the medial prefrontal cortex, ACC, and the precuneus
(Frith, 2007; Frith & Frith, 2006; Uddin et al., 2007)
 The inhibition of imitative behavior involves cortical
areas that are also related to mentalizing, self-
referential processing and determining self agency
 Failure of medial prefrontal and temporo-parietal
mentalizing function in BPD  difficulties in
decoupling their representations of another person’s
experience from their self-representations.

108. Evidence for shared representations
Cognitive psychology
 observation has a strong influence on movement
execution (e.g. Brass et al., 2000, 2001, Kilner et al., 2003,
Stuermer et al., 2000)
Social psychology
 chameleon effect (Chartrand & Bargh, 1999)
Cognitive neuroscience
 activation of motor related areas by action observation
(e.g. Grezes & Decety, 1999, Iacoboni et al., 1999, 2001,
Calvo-Merino et al., 2005, 2006)
Neurophysiology
 mirror neurons (e.g. Rizzolatti & Craighero, 2004)
DISCOS, LONDON 09

110. The origins of shared representations

111. The imitation-inhibition task
congruent baseline incongruent

112. The imitation-inhibition task
Lift the index finger when a `1` appears
and the middle finger when a `2` appears.
+
+

113. Results
congruent baseline incongruent
Brass, Bekkering, Wohlschläger & Prinz, 2000

114. The neural signature of imitation-inhibition
incongruent vs. congruent
anterior fronto-median cortex (aFMC)
temporo-parietal junction area (TPJ)
Brass, Derrfuss & von Cramon, 2005

115. Functional role of aFMC and TPJ
Gilbert et al. (2006) Decety & Grezes (2006)
imitation-inhibition (Brass et al., 2009)
red= mentalizing (only BA 10) red=mentalizing yellow=agency

116. Functional-overlap hypothesis
The inhibition of imitative behaviour involves
cortical areas that are also related to mentalizing,
self-referential processing and determining self
agency.
 We assume that this overlap reflects common
underlying processes such as self/other distinction
and decoupling of self and other.
Capacity to inhibit imitative behavior may be key
to enabling us to generate a sense of ‘me-ness’
through achieving a ‘not-other’-ness
DISCOS, LONDON 09

117. Implication for the phenomenology
of borderline personality disorder
 Failure of medial prefrontal and temporo-parietal mentalizing
function in BPD  difficulties in decoupling their
representations of another person’s experience from their
self-representations
 Patients with BPD feel vulnerable to loosing a sense of self
in interpersonal interchange because they cannot
adequately inhibit the alternative state of mind which is
imposed on them through social contagion.
 Perhaps the apparent determination to ‘manipulate and
control’ the mind of others characteristic of BPD patients
should be best seen as a defensive reaction, defending the
integrity of the self within attachment contexts.
 without such control, they might feel excessively vulnerable to
loosing their sense of separateness and individuality.

118. The Cassel Step-down Treatment
Study (Chiesa & Fonagy, in press)
 297 patients in personality disorder services
 (112 complete data, 31 males 81 females, 40% with
some tertiary education)
 Recruited through
 Cassel Residential inpatient programme (n=120)
 Cassel Community stepdown/outpatient programme
(n=113)
 MAU: Devon Personality Disorder services (n=64)
 Treatment input and staff resources
 Treatment hours 16.2-18.2 versus 3.2 hours
 Staff wte’s: residential 8.5 versus community 2.6

119. Adolescent
hypermentalizing
as the
vulnerability to
borderline PD

120. Movie for the Assessment of Social
Cognition (MASC) (Dziobek et al 2006)
 Requires subjects to watch a 15 min movie
about 4 characters at a dinner party
 The 4 characters (Sandra, Betty, Michael &
Cliff) each have different motives for
attending the party
 Video is paused 46 times for questions about
characters’ feelings, thoughts and intentions
 Friendship & dating issues are the
predominant themes

121. Movie for the Assessment of Social
Cognition (MASC) (Dziobek et al 2006)
Picture 1: Cliff is the first to arrive at Sandra’s house for the dinner party.
He and Sandra seem to enjoy themselves when Cliff is telling about his
vacation in Sweden

122. Movie for the Assessment of Social
Cognition (MASC) (Dziobek et al 2006)
Picture 2: When Michael arrives, he dominates the conversation,
directing his speech to Sandra alone

123. Movie for the Assessment of Social
Cognition (MASC) (Dziobek et al 2006)
Picture 3: Slightly annoyed by Michael’s bragging story, Sandra shortly looks in
Cliff’s direction and then asks Michael: ‘‘Tell me, have you ever been to Sweden?’’
Question: Why is Sandra asking this?

124. Movie for the Assessment of Social
Cognition (MASC) (Dziobek et al 2006)
 Example correct answers:
 To change to the topic that Cliff talked about before so
that he gets involved again
 To redirect the conversation to Cliff
 To integrate Cliff
 Example incorrect answers:
 To hear if Michael also has something interesting to say
about Sweden
 To see which of the two guys has a cooler story to tell
 She is very suspicious of Michael and thinks he is making
it up because he is the kind of person who tries to deal
with his inadequacy by making up stories so she wants to
see if Michael can corroborate Cliff’s story

125. Correlation Between Movie for the Assessment
of Social Cognition (MASC) and Borderline
Personality Features Scale for Children
(Sharp et al., 2011)
0.8 p<0.00005
N=107
0.6
0.4 n.s.
0.2
p<0.02
0
-0.2
-0.4
-0.6 Total Theory of Mind Excessive Theory of Mind No Theory of Mind
Source: Sharp et al, 2011, J. Amer. Acad. Child & Adolesc. Psychiatry, 50: 563-573

126. Correlations between mentalizing and emotion
regulation and borderline features (Sharp et al.,
2011)
(**)
Source: Sharp et al, 2011, J. Amer. Acad. Child & Adolesc. Psychiatry, 50: 563-573

127. Hypermentalizing leads to emotion disregulation
which leads to borderline personality features
(Sharp et al., 2011, J.Am. Acad. Child. Adol. Psychiat., 60, 563-573.)
0.42*** (0.19*)
0.27* 0.75**
Hypermentalizing Emotion (0.69**) BPD
Regulation
(MASC) (DERS) (BPFSC)
*p < .05, **p < .01, ***p < .001
Variable B SE B ß R2 P
Step 1
Hypermentalizing 1.56 .370 .383** .15 .0001
Step 2
Hypermentalizing .793 .270 .194* .58 < .0001
DERS .375 .036 .686**

128. Hypermentalizing is reduced with BPD
symptoms during inpatient treatment
(Sharp et al., submitted)
Tendency to hypermentalize is
malleable through milieu-
based inpatient treatment:
interpersonal-psychodynamic,
although cognitive-behavioral,
family systems, and
psychoeducational
approaches are incorporated
into the treatment approach.

129. MBT IS CHEAP AND COMFORTABLE
AND HELPFUL IN A RANGE OF WAYS!!!

130. For Electronic version please e-mail: P.FONAGY@UCL.AC.UK