Epistemic trust and attachment: A fresh look at therapeutic processes in personality disorder.

Transcription

1 Epistemic trust and attachment: A fresh look at therapeutic processes in personality disorder. Peter Fonagy OBE PhD FBA FMedSci FASSc The Anna Freud Centre, London Department of Clinical, Educational & Health Psychology, University College London P.Fonagy@UCL.AC.UK IAC Conference London, July 1 st 2007; Chair Prof Pasco Fearon

2 Plan of talk Irrelevant boasting Social aspects of attachment and some limitations of attachment theory Epistemic trust and ostensive cues and the role of mentalization The impact of maltreatment on social learning Evidence from the study of trust in personality disorder Implications for a treatment model: how does psychotherapy with PD work?

3 The things I feel proud of (just showing off, not relevant so you don t need to listen!)

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

5 More Family Members (The USA branch) Menninger Clinic/Baylor Medical College/U Laval/Harvard (The USA branch) Dr Carla Sharp Dr Jon Allen Dr Efrain Bleiberg Dr Lane Strathearn Dr Karin Ensink Professor Lois Choi-Kain Dr Read Montague Dr Elisabeth Newlin Yale Child Study Centre UCL & Catholic University, Santiago Prof Linda Mayes Nicolas Lorenzini

6 And European recruits to the Family Dr Dawn Bales Professor Finn Skårderud Prof Martin Debané Professor Sigmund Karterud Professor Svenja Taubner Dr Chloe Campbell Dr Tobi Nolte Dr Peter Fuggle Prof Miriam Steele Prof. Howard Steele Dr Rudi Vermote Dr Joleien Zevalkink DrBjorn Philips

7 The journey from attachment to communication

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 Articles Published Citing Papers About Mentalizing or Mentalization

10 1.2E Google Ngram of mentalization Google s Ngram Viewer shows the percentage a word is present in a corpus of 5.2 million books published from the years 1500 to E-08 % of usage 6E-08 4E-08 2E Year Source: Google Ngram Viewer

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12 Some Free Publicity NEW! SLIGHTLY IMPROVED! Washes brains whiter! But hurry! Only 2,000 copies left! RECENTLY RELEASED! Longer than the previous version! 2016 Oxford University Press, PLC

13 Our sense of self & capacity for self-regulation are acquired through interpersonal interaction Caregiver s marked mirroring of baby s constitutional self-states enables him to begin to form representations of his experience, laying the foundation for mentalizing

14 Criticisms of attachment theory From psychoanalysis: mechanistic reductionistic no real metapsychology broad classifications that lose the subtlety and detail of the original material From anthropology: culturally blind socially oblivious misses different family configurations, e.g., alloparenting empirically based on WEIRD people WEIRD: Western, Educated, Industrialised, Rich & Democratic Fonagy & Target, 2007; Röttger-Rössler, 2014; Otto, 2011)

15 Rethinking the centrality of attachment in developmental psychopathology PDs are enduring behaviors; their features include an intrapersonal component (dysregulation of arousal, impulse, and affect), an interpersonal component (dysfunctional relationship patterns), and a social component (which creates conflicts with others and with social institutions). Attachment theory accounts for these characteristics of PDs and provides an ideal standpoint to understand these disorders, integrating psychological, psychiatric, genetic, developmental, neuroscientific, and clinical perspectives. OK! ATTACHMENT IS NOT EVERYTHING!

16 Attachment not universal: Historically childhood is a state of enduring murderous abuse and brutality (Arie s, 1973; Stone, 1977) Infanticide in 19 th C Milan was 30-40% (Marten, 2010) Women living in extremely deprived conditions in Brazilian ghettoes, allowing the death of their infants with apparently little sorrow, but become loving mothers to subsequent children or to children who they previously gave up on as hopeless cases, but appear to go on to survive Different social environment are likely to trigger different attachment styles as more adaptive

17 Stability of attachment: Meta-analytic findings K = 127 (255 ESs) Across all studies, stability of attachment: r = 0.39 (medium) However, stability is moderated by: Length of time interval Age at T * * * * * * * Correlation T1 -> T months 7-12 months months months Publication year months * months >180 months * p <.05 for ES * * * 1 year 1-2 years 2-5 years 6-12 years >13 years Type of measure * * * * * * < Behavioural Behavioural to representational Representational Pinquart, M., et al. (2013) Attachment and Human Development

18 John Bowlby: Thoughts from 1951 Just as children are absolutely dependent on their parents for sustenance, so in all but the most primitive communities, are parents, especially their mothers, dependent on a greater society for economic provision. If a community values its children it must cherish their parents Maternal care and mental health. WHO 1 Monograph Series, No. 2. Geneva, Switzerland: World Health Organization, p. 84. Attachment evolved to enable the child to adapt to their prevailing social environment and cannot be separated from the social system

19 Sensitivity is biologically a group phenomenon Use of the sensitivity construct restricted to single-caregiver observations (predominantly mother infant interactions) Non-Western communities have simultaneous multiple caregiving without clear place-bound or time-bound task division (Hrdy, 1992) Need to assess the caregiver network s sensitive responsiveness to the infant when simultaneous multiple caregiving is the norm (Mesman et al., 2016) Being responded to sensitively most of the time by many people fosters trust in the availability of the entire network secure attachment is to a system rather than an individual

20 The universal socialization task for cultures regarding attachment concerns the learning of trust, not ensuring the secure attachment of an individual child to a single caregiver in a dyadic relationship. The question that is important for many, if not most, parents and communities is not, Is [this individual] child securely attached?, but rather, How can I ensure that my child knows whom to trust and how to share appropriate social connections to others? How can I be sure my child is with others and situations where he or she will be safe. Thomas S. Weisner, 2014

21 A historical overview of shifting frames Changing one s favourite instinct: Up to age 40: The psychosexual AND aggression instinct Freud and classical psychoanalysis Age 40-60: The instinct for attachment Bowlby, Ainsworth and early infant researchers o Attachment theory extended to mentalizing can encompass: Sexuality failure of early mirroring Aggression failure of affect regulation and impact awareness Age 60 to : The instinct for communication Tomasello, Gergely, and modern developmental research o Communication defines attachment relationships Secure attachment ensures capacity to learn from experience

22 Attachment is not everything but it is Early attachment has limited predictive power Poor prediction from early attachment to later attachment Later unfolding of genetic endowment (Fearon, 2013) Attachment styles change in adaptation to genes and environment (Roisman, 2007; Pinquart, 2013) Poor prediction from early attachment to later problems Sexuality and aggression Social relatedness Communication Attachment is associated with rather than causing psychopathology Mental disorder can be conceptualised as impairments in the capacity of the individual for social learning expressed in terms of epistemic trust vs. epistemic hypervigilance or freezing Attachment relationships provide the sufficient conditions for epistemic trust Gergely, 2007; 2012; Csibra, 2009; 2011; Fonagy, 2014; in press.

23 From attachment to communication: via sociobiology

24 The theory of natural pedagogy and epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014) New form of evolution (late Pleistocene) based on learning and the transmission of cultural knowledge

25 As soon as you need to create tools to make tools the process of tool-making becomes, distanced from its ultimate function, opaque in its intent and necessitates communication

26 How do young humans learn to use the bewildering array of tools that surround them efficiently?

27 Five distinctive features of a CULTURE (Whitehead & Rendell The Cultural Lives of Whales and Dolphins A characteristic technology that engenders A moral component, with rules that buttress the way we do things and punishments for infraction that creates An acquired, not innate, distinction between insiders and outsiders that permits A cumulative character that builds up over time that necessitates Teaching and learning that requires Epistemic vigilance

28 The theory of natural pedagogy and epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014) New form of evolution (late Pleistocene) based on learning and the transmission of cultural knowledge The challenge of discerning of epistemic trustworthiness and the need for EPISTEMIC VIGILANCE! ET= Epistemic Trust

29 The theory of natural pedagogy and epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014) New form of evolution (late Pleistocene) based on learning and the transmission of cultural knowledge The challenge of discerning of epistemic trustworthiness and the need for ET= EPISTEMIC VIGILANCE! Epistemic Trust The pedagogic stance is triggered by ostensive communicative cues (E.G. turntaking contingent reactivity, eye contact)

30 The theory of natural pedagogy and epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014) New form of evolution (late Pleistocene) based on learning and the transmission of cultural knowledge The challenge of discerning of epistemic trustworthiness and the need for EPISTEMIC VIGILANCE! The pedagogic stance is triggered by ostensive communicative cues (E.G. turntaking contingent reactivity, eye contact) Ostensive cues have in common Person recognized as a self ET= Epistemic Trust Paid special attention to (noticed as an agent)

31 Triggering the Pedagogical Stance Ostensive cues function to trigger epistemic trust: Opening channel to receive knowledge about social and personally relevant world (CULTURE) Going beyond the specific experience and acquire knowledge relevant in many settings Triggers opening of an evolutionarily protected epistemic channel for knowledge acquisition Mimicry may be protected by human evolution because it generates epistemic trust Social smile (recognition of self) increases imitation because smile generates epistemic trust and opens channel to receive knowledge

32 Experimental illustration of ostensive cues Gergely, Egyed et al. (2013) Subjects : 4 groups of 18-montholds Stimuli: Two unfamiliar objects

33 1: Baseline control group No object-directed attitude demonstration Simple Object Request by Experimenter A Subjects: n= 20 Age: 18-month-olds

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

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36 on-ostensive (Non-Communicative) Demonstration Requester: OTHER person (Condition 2) Other person

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

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40 Epistemic trust and mother infant attachment

41 Young Children s Trust in Their Mother s Claims (Corriveau, Harris, Meins et al., 2009) Longitudinal study of attachment, 147 children assessed for attachment in infancy Tested twice for epistemic trust aged 50 and 61 months Mother and a stranger make conflicting claims Task 1: name a novel object Task 2: name a hybrid animal made up 50% each of two animals Task 3: name a hybrid animal made up of 75% one animal and 25% of another Question: Who does the child spontaneously turn to? Who does the child believe?

42 Corriveau & Harris Studies of Epistemic Trust Mummy said it s a snegg and Joan (stanger) said it s a yoon. What do you think it s called, a snegg or a yoon? Mummy said it s a yiff and Joan said it s a zazz. What do you think it s called, a yiff or a zazz? Mummy said it s a crut and Joan said it s a larp. What do you think it s called, a crut or a larp?

43 A 50:50 animal from Corriveau et al. 50% pig : 50% bear If Mother names hybrid as pig then stranger always names it bear

44 A 50:50 animal from Corriveau et al. 50% cow : 50% horse If Mother names hybrid as horse then stranger always names it cow

45 A 75:25 animal from Corriveau et al. 75% rabbit : 25% squirrel Mother always names hybrid as squirrel and stranger always names it rabbit

46 A 75:25 animal from Corriveau et al. 75% bird : 25% fish Mother always names hybrid as fish and stranger always names it as bird

47 Proportion of Trials on Which Children Chose Their Mother for Information by Attachment Group and by task N=146 Percent Mothers Chosen *** *** *** *** *** *** * Novel Object Hybrid Hybrid 0 Avoidant Secure Resistant Disorganised Corriveau, Harris, Meins et al., Child Dev,, 80, Attachment Classification at 18 months

48 Social Cues that Create Epistemic Trust Attachment to person who responded sensitively in early development is special condition for generating epistemic trust cognitive advantage of security including neural development (Van Ijzendoorn et al.) Generally any communication marked by recognition of the listener as intentional agent will increase epistemic trust and likelihood of communication being coded as Relevant Generalizable To be retained in memory as relevant Feeling contingently responded to (mentalized) is the quintessential ostensive cue and therefore the primary biological signal that it is safe to learn

49 Individuals differ in the extent they are able to generate epistemic trust

50 Individual Differences in Creating Epistemic Trust Influential communicators use ostensive cues to maximum create illusion of recognizing agentiveness of listener Looking at audience Addressing current concern Communicating that they see problem from agent s perspective Seeing and recognizing individual struggle in understanding Massive difference in ability of individuals to influence (teachers, politicians, managers, therapist) explicable in terms of varying capacity to generate epistemic trust

51 OSTENSIVE CUEING Knowledge What you want experienced What they are to communicate as relevant interested & in generalizable EPISTEMIC TRUST

52 What you want to communicate What they are interested in Communicating without ostensive cueing will be experienced as irrelevant

53 What you want to communicate KNOWLEDGE TRANSFER BLOCKED What they are interested in

54 What you want to communicate What they are interested in When the speaker uses ostensive cues audience hear message as relevant to them

55 What you want to communicate What they are interested in

56 What you want to communicate What they are interested in

57 What you want to communicate What they are interested in RAPID, EFFICIENT KNOWLEDGE TRANSFER

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59 Meta-analytic studies of teacher effectiveness John Hattie is Professor of Education at the University of Auckland, New Zealand. 15 years research and synthesizes over 800 meta-analytic studies relating to the influences on achievement in schoolaged students. Builds a story about the power of teachers and of feedback, and constructs a model of learning and understanding. Is there a set of predictors to good teaching outcomes based on: The child? The home? The school? The curricula? The teacher? With grateful thanks to Dr Peter Fuggle

60 Meta-analytic studies of teacher effectiveness What makes a teacher the most effective? It is teachers seeing learning through the eyes of students The key ingredients are: Awareness of the learning intentions Knowing when a student is successful Having sufficient understanding of the student s understanding Know enough about the content to provide meaningful and challenging experiences Passion that reflects the thrills as well as awareness of the frustrations of learning. With grateful thanks to Dr Peter Fuggle

61 Therapist is greatest source of variance in psychotherapy outcome (Wampold et al. 2016) dds of a clinical episode in MBT by therapist

62 Individuals differ in the extent they are able to experience epistemic trust: The impact of maltreatment

63 Successful navigation of social world Learning from & about others Which enables Mentalizing This lays the foundations for Learning channel opens (selectively) Caregiver s mentalizing of the infant acts as the prototypical ostensive cue Learning about self Epistemic trust Sensitive caregiving Learning about the world Secure attachment

64 Maltreatment and the failure of epistemic trust An abusive or neglectful caregiving environment (the child is not mentalized) Ostensive cues are either absent or undermined by fear or confusion Epistemic vigilance is not relaxed Epistemic mistrust (hypervigilance) develops adults mind is not considered as a benign or reliable source of knowledge (deferential source Sperber) possible adult hatred, sadism, fear or indifference safer not to think about the caregiver s mental states at all

65 Maltreatment and the failure of epistemic trust Once epistemic trust is damaged and the mind is partially closed to processing new information access to exploring different ways of behaving and responding becomes highly restricted: The presentation of fresh information cannot be internalized as personally relevant or meaningful Knowledge (including social knowledge) is not updated A subjective sense of being stuck in isolation is created. Impaired epistemic trust serves to severely diminish learning and therefore also responsiveness to psychotherapeutic intervention

66 Hanson, JL., et al. (2017). The Journal of Child Psychology and Psychiatry Early maltreatment hinders associative learning The world is not a rewarding place 41 adolescents exposed to childhood physical abuse 40 adolescents with no history of maltreatment Choose one Choose one Probability of positive reward

67 Cowell, RA., et al. (2015) Development and Psychopathology Maltreatment and cognitive performance The role of age-of-onset and chronicity Children aged 3 to 9 years old maltreated children non-maltreated children

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69 In all 3 cases, the individual struggles to learn effectively about either self or world Epistemic hypervigilance Mentalizing difficulties with ostensive social cues Epistemic dilemma Excessive credulity Problems in learning from others Problems in adapting to social world Learning channel is closed, indiscriminately open or both by turns Ostensive cues are not processed, were absent or misleading Absence of epistemic trust Neglect/ attachment trauma Insecure/ disorganized attachment

70 Implications for understanding and treating personality disorders

71 Openness to the (social) environment is usually adaptive

72 Openness to the (social) environment is usually adaptive

73 Openness to the (social) environment is usually adaptive

74 but so is hypervigilance under certain circumstances

75 The nature of psychopathology in BPD Social adversity (most deeply trauma following neglect) is the destruction of trust in social knowledge of all kinds rigidity, being hard to reach Cannot change because cannot accept new information as relevant (to generalize) to other social contexts Personality disorder is not disorder of personality but inaccessibility to cultural communication relevant to self from social context Partner } Therapist Teacher Epistemic Mistrust

76 It is not the strongest or the most intelligent who will survive but those who can best manage change

77 Social Cognitions in BPD I cannot depend on others I am isolated and different from others I am an outsider I am different than others (shame) Others will reject me I do not deserve being part of the group (guilt) I am ugly (self-contempt / self disgust)

78 Rejection Sensitivity in acute and remitted BPD patients COGNITIVE RS 5 4 RSQ-Score RSQ-Score (0-30) HC acute BPD AFFECTIVE RS remitted BPD HC acute BPD remitted BPD RSQ-Score 3 2 N=75 N=77 N= HC acute BPD remitted BPD Bungert et al. BPDED, 2015

79 UCLA Loneliness Scale 40 female BPD 40 female HC

80 Cyberball

81 Inclusion

82 Exclusion

83 Automatic mode

84 Social perception: fmri (Domsalla, Lis, Bohus et al., SCAN, 2013)

85 Judgment bias for approachability and trustworthiness of faces. P<.001 Nicol et al., 2013 Plos One BPD P<.001 NS NS Control Approachable as Unapproachable Unapproachable as Approachable Trustworthy as Untrustworthy Untrustworthy as Trustworthy

86 Trust in Borderline Personality Disorder King-Casas, Sharp, Lomax-Bream, Lohrenz, Fonagy, & Montague Science, 321, Studying social behavior in task that involves Live interaction with unknown but real person Engages mesocorticolimbic dopaminergic reward circuit system Total patients screened assessed scanned: BPD: 1, Mood control: Normal control:

87 Disordered Social Exchange? X 3 $20 healthy investor BPD trustee

88 Average Repayment: repay everything repay investment (33%) repay nothing *King-Casas et al, in Science, 321,

89 Investor Sent MU sent / MU available 44 non-psychiatric investors 55 non-psychiatric investors 60% 50% 40% 30% 20% 10% 60% Trustee Repaid MU sent / MU available 44 non-psychiatric trustees 55 BPD trustees 50% 40% 30% 20% 10% *King-Casas et al, in Science, 321, rounds

90 A Neural Signature of Borderlineness in Trust Task (n=55)

91 (n=44) (n=55)

92 Specific to social-decision making, not non-social decision-making Specific to BPD, not mood disorder Unoka, Seres, Aspán, Bódi, Kéri (2009)

93 BPD unstable interpersonal relationships and trust Romantic Relationships Milano, A., et al., heterosexual unmarried couples in which women had BPD diagnosis 36 healthy control couples Couples were videotaped while discussing three topics: - Favourite films (neutral topic) - Most severe personal fear of sorrow in the last year (personally threatening topic) - Reasons which could potentially lead to breakup in the relationship (topic threatening to the relationship) Women Men * * * BPD * ** HC * How trustworthy is your partner? 1 0 Film Fear Separation Film Fear Separation

94 BPD unstable interpersonal relationships and trust Romantic Relationships Milano, A., et al., heterosexual unmarried couples in which women had BPD diagnosis 36 healthy control couples

95 And the consequences? If you assume you are to be treated as an outsider If you find it hard to interpret social context accurately If you cannot recognize when you are recognized as an agent If you contextualise social cues as indicating you are an outsider If you process positive social cues as irritating If you behave like an outsider You become an outsider

96 Implications: The nature of persistent pathology Epistemic mistrust which can follow perceived experiences of maltreatment or abuse leads to epistemic hunger combined with mistrust Therapists ignore this knowledge at their peril Personality disorder is a failure of communication It is not a failure of the individual but a failure of learning relationships (patient is hard to reach ) It is associated with an unbearable sense of isolation in the patient generated by epistemic mistrust Our inability to communicate with patient causes frustration in us and a tendency to blame the victim We feel they are not listening but actually it is that they find it hard to trust the truth of what they hear

97 Vulnerability to psychopathology

98 can be buttressed by foundations of epistemic trust that build resilience

99 Operationalizing Resilience in Adolescence Accelerated longitudinal cohort study N = 2,389 Functioning better than expected Friendships and family support predict current level of resilience Friendships predict resilience level next year Family support has a negative relationship with resilient psychosocial functioning over time (once concurrent association with resilience is controlled for).. Functioning less well than expected Harmelen et al., 2017

100 Building a social network in childhood and adolescence

101 hen the capacity to form bonds of trust is shaky and tends to break down

102 we lose our learning network and social expectations are not updated

103 Reconceptualising BPD: understanding not in terms of disease mechanisms

104 but as an absence of expected resilience or lack of epistemic trust

105 Implications for understanding how other therapies work

106 Three stages of a cumulative process that makes psychotherapy effective Communication System 1 Content Communication System 2 Epistemic trust in psychotherapy Communication System 1 Generalisation of epistemic trust Ostensive cuing: Conveys a convincing understanding of the patient as agent that generates self-recognition Opening to social learning Therapist Patient Increased interest in the therapist s mind and their use of thoughts and feelings Gradual reemergence of robust mentalizing Benign social environment

107 Role of Mentalizing for Learning in Therapy All evidence based models present models of mind, disorder and change that are accurate, helpful to patients and increase capacity for understanding but need to get over epistemic hypervigilance in communication ( not true, not relevant to me ) Mentalizing interventions demand collaboration (working together) Seeing from other s perspective Treating the other as a person Recognizing them as an agent Assuming they have things to teach you since mental states are opaque Responding contingently to a patient Mentalizing is the catalyst to activate effective ingredient of therapy

108 The Communication Systems of Psychotherapy: The re-emergence of social learning beyond therapy Improved epistemic trust Therapist responds sensitively Robust mentalizing Emotional reaction to social context Patient retreats from epistemic isolation Less rigidity in social interactions Accumulation of benign social experience Generalisation to wider social context Patient begins exercising their mentalizing skills Growing robustness of mentalizing capacity Generalisation of social learning is highly contingent on the environment being largely benign THE SOCIO-ECONOMIC ENVIRONMENT DOES BUFFER THE INDIVIDUAL PSYCHE

109 Thank you for bearing with us. The for the slides is: Slides from: Peter Fonagy, OBE FMedSci FBA Director, Integrated Mental Health Programme, UCLPartners Chief Executive, Anna Freud Centre Slides from: