Empathy, Attachment, and Mentalization 同理心 依戀 與心智化

Transcription

1 Empathy, Attachment, and Mentalization 同理心 依戀 與心智化 Jou, Lih-Chih 周勵志 新光醫院精神科台灣向日葵全人關懷協會

2 Affect Regulation & Memory Reconsolidation 情感調節與記憶重塑

3 母嬰互動 心理治療 what good therapists do with their patients is analogous to what successful parents do with their children. 好治療師對他們病人所做的類似於成功的父母對他們孩子所做的 Holmes J, The search for the secure base: Attachment theory and psychotherapy. New York: Brunner-Routledge 2001, p. xi

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5 Mother-infant Interaction 母嬰互動 1/3 of the time are correctly another 1/3 of the occasions appropriate corrected The successful repair of misattunements may be crucial for the infant s normal development. Lewis JM Am J Psychiatry; 2000, 157:1375-8

6 Mother-infant Interaction 母嬰互動 成功修復 successful repair turns despair into positive emotions. Tronick EZ, Gianino A, 1986 當無能修復時 When not successful repair -begin to feel helpless (without mastery) -turn away from relationships & focus on self-regulation. -a negative affective core to the sense of self Lewis JM Am J Psychiatry; 2000, 157:1375-8

7 Infant Imitation 嬰兒模仿 20 minutes (Kugiumtzakis,1985; Reissland,1988) 42 minutes (Meltzoff & Moore, 1983) Mouth opening (Heimann & Schaller, 1985; Legerstee, 1991) Lip pursing, eye blinking (Kugiumtzakis,1985) Head movements, cheek movements (Fontaine, 1984) Hand Gestures (Meltzoff & Moore, 1989) Vocal sounds such as /m/, /a/, and /ang/ as early as 40 minutes after birth (Kugiumtzakis,1993)

8 Discrimination & Imitation of Facial Expression 面部表情的區別與模仿 Human neonates (average age, 36 hours) discriminated three facial expressions (happy, sad, and surprised) posed by a live model Field TM, et al Science 1982, 218:

9 Instinct Behavior 本能行為 1. 先天上已定型的行為模式 (fixed action pattern;fap) 2. 與生俱來的, 由基因所掌控, 是一組序列性的行為 3. 通常由簡單的刺激引起發, 例如 : 1) 人類的眨眼 2) 打噴嚏和唾液的分泌及嬰兒的微笑等

10 人際同步增進親和 Social Cognition 2009; 27:

11 Mirroring the Affects of the Child 鏡映孩童情感... the precursor of the mirror is the mother s face. Winnicott DW, 1971, p. 111

12 看見 vs. 看穿 Problematic Mirroring 有問題的鏡映 If the mother s face is unresponsive, then a mirror is a thing to be looked at but not looked into. Winnicott DW, 1971, p. 113

13 Overlap of activation between reorienting, empathy & theory of mind Decety J, Lamm C, Neuroscientist 2007, 13:

14 鏡像神經元 1992 年義大利神經科學家 Giacomo Rizzolatti 和他的研究生一起研究小猴腦部的運作, 當小猴伸出手拿東西的時候, 腦部的 premotor cortex 就會運作, 因為 premotor cortex 負責計劃和行動 在一次試驗中, 研究生在小猴面前吃冰淇淋, 意外發現小猴腦部 " 鏡像神經元 " 的存在 : 小猴看著研究生吃冰淇淋, 身體雖然沒有任何動作, 但是腦中的 premotor cortex 卻開始運作, 好似他是吃冰淇淋的人

15 模仿先於辨識 嬰兒大腦中的鏡像神經元是自我和他人交互作用而成

16 Brain Structure & Empathy (I) A theory of mind system or network that is widely distributed and made up of interactive nodes, probably in the medial prefrontal regions, the superior temporal sulcus, the inferior frontal region, and the cerebellum. Frith CD, Frith U Science 1999; 286:

17 The primary motor & premotor cortices also used to directly simulate another person's (or animal's) observed actions. Image from "The Brain from Top to Bottom" online brain encyclopedia

18 Brain Structure & Empathy (II) Mirror neurons (I) I. Ventral premotor cortex, II. First identified in monkey studies, respond when a primate observes certain hand movements performed by another primate or by a human or when the animal performs the same movements itself. Gabbard, Glen O Am J Psychiatry 2005; 162:648-55

19 Brain Structure & Empathy (III) Mirror neurons (II) III. Encoding object-oriented actions, whether they are performed or observed. IV. May have a crucial role in goal detection and therefore in action understanding. Gabbard, Glen O Am J Psychiatry 2005; 162(4):648-55

20 Brain Areas Associated with Mentalizing Perceiving social and emotional cues fusiform gyrus (identifying individuals, e.g., by face) superior temporal sulcus (perceiving agency and intention) temporal pole (interpreting social scenarios) amygdala (detecting emotion, especially threat) Resonating emotionally mirror neurons (activated by performing and observing actions and by feeling and observing emotions) Mentalizing emotion and interpersonal interactions medial prefrontal cortex anterior cingulate cortex mentalizing region

21 同理心 Poses a paradox, may be used for both helpful and hurtful purposes Decety J, Moriguchi Y BioPsychoSocial Medicine 2007, 1:22 doi: m/xml/book_covers/ w.jpg

22 Definition 定義 Perceive the internal frame of reference 內在參考架構 of another with accuracy and with the emotional components & meanings Without ever losing the as if condition. Carl Rogers, 1959 The capacity to think & feel 思考與感受 oneself into the inner life of another person. Heinz Kohut, 1984

23 Component 組成 (a) an affective response 情感反應 to another person, which often, but not always, entails sharing that person s emotional state; (b) a cognitive capacity 認知能力 to take the perspective of the other person; (c) some regulatory mechanisms 調節機制 that keep track of the origins of self and otherfeelings Decety J, Jackson P Behav Cogn Neurosci Rev 2004; 3:71-100

24 Processes Involved in Empathy Identification 認同 Incorporation 併入 Reverberation 回響 : cognition and affect Detachment 隔絕 : flexibility Reik T, 1949

25 聽完病人的傷痛 跟著一起去跳樓 - 同情 sympathy 擦乾眼淚, 鼓勵向前行 - 同理 empathy

26 同情心 vs. 同理心 一起感覺 同理心 替他感覺 同情心 注意力在對方注意力在傾聽者 ( 自己 ) 注重於 你覺得如何 注重於 我覺得如何 表達 我瞭解和接受你有這些感覺, 對你真的是如此 辨別及接受對方的感覺為何 表達 我瞭解了, 我把這些感覺接受為我的感覺, 對我也真的是如此 我所感覺到的感覺應該就是他的感覺 瞭解 ~ 讓對方擁有自己的感覺投射 ~ 認為他該與我有相同的感覺, 是主觀的

27 cogprints.org/1042/0/preston_de_waal.html

28 Choi-Kain LW, Gunderson JG Am J Psychiatry Sep;165(9):

29 The wolf is a highly social animal, generally living within the same pack for most, if not all, of its life. Survival depends very much upon the pack.

30 依附 ( 一 ) a. Social mammals are fundamentally incapable of maintaining basic neurophysiologic homeostasis on their own. b. Attachment system is not only an organizing feature of basic neurophysiologic function but the central organizing system in the brain of higher mammals. Field 1985; Hofer 1984; kraemer 1992; Reite & Capitanio 1985; Amini 1996

31 依附 ( 二 ) c. Human behaviors pertaining to relationships may not readily influenced by the more advanced cognitive structures. Field 1985; Hofer 1984; kraemer 1992; Reite & Capitanio 1985; Amini 1996 d. Affective attunement, are permanently encoded in memory in some fashion. Amini 1996

32 Psychiatry1996; 59:213-39

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34 Affect, Memory, Attachment (I) Affect: Survival & reproductive fitness (Darwin1872) a. Brainstem:neurotransmitter system, autonomic function, motor nuclei for facial nerve b. Limbic system:endocrine system, learning & memory system, social/emotional behaviors. c. Neocortex:complex cognitive tasks, experiential awareness Amini F et al Psychiatry1996;59(3):213-39

35 依附 ( 三 ) Mother and her infant interact creates the child's first internal representation -another person -an interaction -a relationship. Critical for the subsequent psychological development of the child. The interaction goes both ways. Kandel ER Am J Psychaitry 1999; 156:

36 依附 ( 四 ) The development of these internal representations can only be induced during certain early and critical periods in the infant's life. During these critical periods, and only during these periods, the infant (and its developing brain) must interact with a responsive environment (an "average expectable" environment, to use Heinz Hartmann's term) Kandel ER Am J Psychaitry 1999; 156:

37 Mind & Brain Windows in time early childhood (15 months to 4 years), late childhood (6-10 years), puberty mid-adolescence Ornitz, E M Developmental aspects of neurophysiology. In Child and Adolescent Psychiatry: A Comprehensive Textbook (2nd ed), 1996

38 依附 ( 五 ) Evolutionarily significant Clearly enhances the infant's chances for survival Allowing the immature brain to use the parents' mature functions to organize its own life processes. Infant's attachment mechanism is mirrored in the parents' emotionally sensitive responses to the infant's signals. Kandel ER Am J Psychaitry 1999; 156:

39 Core Functions 核心功能 安全避風港 Safe haven provides a feeling of security (regulation of emotional distress) 安全堡壘 Secure base fosters exploration of the outer world and the inner world, including exploring the mind (mentalizing)

40 Attachment Figures 依附對象 Provide protection, promote safe exploration of the environment and help the infant learn to regulate emotions in a pro-adaptive, effective way. 保護 安全地探索環境 情感調節 Hruby R, Hasto J, Minarik P Neuro Endocrinol Lett 2011;32:111-20

41 Internal Working Model 內在運作模式 對依附者所產生的感受 情緒 知覺會內化形成內在客體表徵, 也會形成對自我 對他人 對環境的概念以及適應行為 內在運作模式的特質, 主要取決於依附對象 (Collins & Reads) 陳秉華,1996

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44 Role reversal 角色逆轉 The caregiver needs or expects the baby to be entertaining, to be good, or to be comforting, without sufficient sense of the baby s own needs. When the child is cognitively and emotionally unprepared to reply on his own device, his internalized ego state will represent the self that takes care of others.

45 Pairs of Attachment Style 配對的依附型態 Caregiver 照顧者 Secure Dismissing Preoccupied Disorganized/Unresolved Infant 嬰兒 Secure Avoidant Ambivalent/Preoccupied Disorganized/Unresolved * * Role reversal or aggressively directive & punitive at 6 Y/O

46 Theory of Mind: False Belief Test

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48 Process of Mentalization 心智化歷程 心靈對等模式 (psychic equivalence modes): 約兩歲半以前 假扮模式 (pretend modes): 兩歲半左右起 反思模式 (reflective modes): 大約六歲

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51 Birth of the Agentive Self 主事自體的誕生 嬰兒內化照顧者的表徵以形成心理自體 Psychological self 內化 嬰兒心智狀態的表徵 核心心理自體 依附對象 推論 嬰兒 依附對象發現嬰兒心靈 ( 主體性 Subjectivity) 51 Bateman & Fonagy, 2004

52 The Development of Affect Regulation Closeness of the infant to another human being who via contingent (mirroring) actions generates a symbolic representational system of mental states and assists in developing affect regulation and selective attention secure attachment For normal development the child needs to experience a mind that has his mind in mind Able to reflect on his intentions accurately Does not overwhelm him Not accessible to neglected children

53 The Development of Regulated Affect..Symbolization of Emotion Psychological Self: 2 nd Order Representation Representation of self-state: Internalization of object s image Expression Physical Self: Primary Representations symbolic binding of internal state Constitutional self in state of arousal Reflection Resonance Infant With apologies to Gergely & Watson (1996) CAREGIVER

54 Reflective Parenting & Development of Mentalization 小屁屁濕了嗎? 一個人站太久了嗎? 想要換尿布了喔? 想要抱抱嗎? Having the person in mind. Bridge the focus on physical reality & internally directed attention. Fonagy P, Target M Dev Psychopathol 1997; 9:

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56 治療歷程概述 依附 Attachment 心智化 Mentalizing

57 Relation 關係 在治療中, 只有透過自己與治療師間親近關係的體驗 Experiencing close relation, 才能得到幫助

58 心理治療系統觀 ( 一 ) I. The interpersonal relationship between therapist and client is the tool for creating the needed change. II. Initially the relations with the therapist will repeat the same patterns of interpersonal relations that caused the distress. Peled & Geva:Brain Organization & Psychodynamics J. Psychother Pract Res 1999; 8:24-39

59 心理治療系統觀 ( 二 ) III. The skilled therapist identifies these patterns and reacts in a way that gradually changes the attitudes of the client toward similar future situations. IV. Successively, this change continues both in and outside of the therapeutic setting. Peled & Geva:Brain Organization & Psychodynamics J Psychother Pract Res 1999; 8:24-39

60 Mentalized Affectivity Elements of mentalized affectivity I. identifying II. modulating III. expressing

61 Development of Self 自體的發展 鏡映 Mirroring 理想化 Idealizing 孿生 Twinship * 治療關係的演進作之親 : 父母 - 子女作之師 : 老師 - 學生作之友 : 夥伴 同儕

62 Transference Relationship Current Relationships outside the transference Past Relationships Triangle of Insight adapted from Menniger,1958

63 Something More Intellectual -Insight 洞察 Experiential -Doing 改變 -Being 存在

64 謝謝聆聽, 敬請指教!