Borderline personality, mentalizing and motherinfant. Prof Anthony Bateman AAIMHI WA Meeting Perth

Transcription

1 Borderline personality, mentalizing and motherinfant interaction Prof Anthony Bateman AAIMHI WA Meeting Perth

2 n Mrs. Darling first heard of Peter when she was tidying up her children's minds. It is the nightly custom of every good mother after her children are asleep to rummage in their minds and put things straight for next morning, repacking into their proper places the many articles that have wandered during the day.

3 n If you could keep awake (but of course you can't) you would see your own mother doing this and you would find it very interesting to watch. It's quite like tidying up drawers. You would see her on her knees, I expect, lingering humorously over some of your contents, wondering where on Earth you picked this thing up, making discoveries sweet and not so sweet, pressing this to her cheek, as if it were a nice kitten, and hurriedly stowing that out of sight.

4 n When you wake in the morning, the naughtiness and evil passions with which you went to bed have been folded up small and placed at the bottom of your mind and on the top, beautifully aired, are spread out the prettier thoughts, ready for you to put on. J.M. Barrie in Peter Pan

5 The development of the mentalizing self n The capacity to mentalize emerges through interaction with the caregiver: n The quality of the attachment relationship Ø If the parent is: o Able to reflect on infant s intentions accurately o Does not overwhelm the infant Ø Then this: o Assists in developing affect regulation o Helps develop child s sense of a mind and of a reflective self

6 What is mentalizing? Mentalizing is a form of imaginative mental activity about others or oneself, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).

7 n But without activation of the attachment system in therapy borderline PD patients will never learn to function psychologically in the context of interpersonal relationships. Mentalization: The basics n Attachment and mentalization are loosely coupled systems existing in a state of partial exclusivity. n Mentalization has its roots in the sense of being understood by an attachment figure, Ø it can be more challenging to maintain mentalization in the context of an attachment relationship (e.g. the relationship with the therapist) (Gunderson, 1996). n BPD associated with hyperactive attachment systems as a result of their history and/or biological predisposition

8 Affect & Self Regulation through Mirroring Psychological Self: 2 nd Order Representations Representation of self-state: Internalization of object s image Expression Physical Self: Primary Representations symbolic organisation of internal state Constitutional self in state of arousal signal non-verbal expression Reflection Resonance Infant Fonagy, Gergely, Jurist & Target (2002) With apologies to Gergely & Watson (1996) CAREGIVER

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

10 Bowlby s Attachment Theory n Need of human infant to seek protection and security through physical contact with the caregiver n Attachment system Caregiving system n Attachment behaviours Caregiving behaviours Ø proximity seeking - touching Ø clinging - holding Ø smiling - soothing n Affectional bond: expectation of being offered care

11 Attachment Styles Our attachment to others can be described as: 1. Secure 2. Insecure -Ambivalent (sometimes called anxious) 3. Insecure Distanced (sometimes called avoidant) 4. Disorganised

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

13 Relational Aspects of Mentalization n Overlap between neural locations of mentalizing self and other may be linked to intersubjective origin of sense of self Ø We find our mind initially in the minds of our parents and later other attachment figures thinking about us Ø The parent s capacity to mirror effectively her child s internal state is at the heart of affect regulation Ø 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 Ø Failure to find the constitutional self in the other has potential to profoundly distort the self representation (exaggerated mirroring of child s anxietyè aggravates anxiety rather than soothe) Ø The same applies to child with inadequate sense of independent self within therapeutic relationship

14 What goes wrong for mentalizing and attachment?

15 Attachment Disorganisation in Disrupted Early Relationships DISTRESS/FEAR Adverse Exposure Emotional to threat Experience Activation of attachment Proximity seeking The hyperactivation of the attachment system

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

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

18 Imbalance of mentalization generates problems Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, Implicit- Automatic- Non -conscious- Immediate. Mental interior cue focused Cognitive agent:attitude propositions Imitative frontoparietal mirror neurone system Impulsive, quick assumptions about others thoughts and feelings not reflected on or tested, cruelty Unnatural certainty about ideas Anything that is thought is REAL Intolerance of alternative ways of seeing things. Hypersensitive to others Moods, what others say. Fears disappearing BPD BPD Lack of conviction about own ideas Seeking external reassurance Overwhelming emptiness, Seeking intense experiences BPD BPD Does not genuinely appreciate others perspective. Pseudo-mentalizing, Interpersonal conflict cos hard to consider/reflect on impact of self on others Hyper-vigilant, judging by appearance. Evidence for attitudes and other internal states hasto come from outside Overwhelming dysregulated emotions, Not balanced by cognition come To dominate behavior. Lack of contextualizing of feelings leads to catastrophyzing Rigid assertion of self, controlling others thoughts and feelings. Explicit- Controlled Conscious Reflective Mental exterior cue focused Affective self:affect state propositions Belief-desire MPFC/ACC inhibitory system

19 Prementalizing Modes of Subjectivity n Psychic equivalence: Ø Mind-world isomorphism; mental reality = outer reality; internal has power of external Ø Intolerance of alternative perspectives èconcrete understanding Ø Reflects domination of self:affect state thinking with limited internal focus n Pretend mode: Ø Ideas form no bridge between inner and outer reality; mental world decoupled from external reality Ø dissociation of thought, hyper-mentalizing or pseudo-mentalizing Ø Reflects explicit mentalizing being dominated by implicit, inadequate internal focus, poor belief-desire reasoning and vulnerabilty to fusion with others n Teleological stance: Ø A focus on understanding actions in terms of their physical as opposed to mental constraints Ø Cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other. Ø Extreme exterior focus, momentary loss of controlled mentalizing Ø Misuse of mentalization for teleological ends (harming others) becomes possible because of lack of implicit as well as explicit mentalizing

20 Prementalizing Modes n Psychic equivalence: Ø Child will be mis-seen Ø Misattributions likely and difficult (if not impossible for the infant or child) to challenge Ø He knew (infant aged 8 weeks suffered fractured ribs) I was just about to go out for a fag when he started crying n n Ø In Lighthouse MBT-P we call this the Projecting Beam Pretend mode: Ø Care for the infant may correspond broadly to his needs but likely to be misattuned and child s experience will be a mixture of having needs met while not being accurately, markedly mirrored; can often result in frustration triggering psychic equivalence then resulting in compliance in the infant over time Ø Baby who sleeps hours every day, never cries, but gains weight, slow meeting milestones, mother appears bland but looks normal and affectionate (social worker observation) Ø dissociation of thought, hyper-mentalizing or pseudo-mentalizing and vulnerability to fusion with others Ø can be present in Factitious and Induced Illness Teleological stance: An infant may well be seen as responsible for mental state of parent is invariably in a precarious posi+on. I know she hates me, she can t bear to look at me He threw his carrots on the floor, he threw the plate. I was just so angry with him I just had to put him in the hallway, and walk away to calm down. At it felt like the worst thing he could possibly have done and now looking back I think, Oh he just threw his carrots on the floor. In that moment the rejec@on of the carrots felt like the rejec@on of all my love and all the good I try to do. It was like he was one more person in my life telling me that whatever I do is not good enough.

21 Cycles of inhibition of mentalizing Powerful emotion Frightening, undermining, frustrating, distressing or coercive interactions Poor mentalising Loss of certainty that thoughts are not real Try to control or change others Inability to understand or even pay attention to feelings of others Others seem incomprehensible

22 Vicious Cycles of Mentalizing Problems within the Family/Parent-child Powerful emotion Powerful emotion Frightening, undermining, frustrating, distressing or coercive interactions Poor mentalising Frightening, undermining, frustrating, distressing or coercive interactions Poor mentalising Person 1 Inability to understand or even pay attention to feelings of others Person 2 Inability to understand or even pay attention to feelings of others Try to control or change others or oneself Others seem incomprehensible Try to control or change others or oneself Others seem incomprehensible

23 Mentalizing failures in trauma traumatizer terrorizing mindblind T AFRAID, terrified, overwhelmed, helpless, out of control + ALONE, abandoned, neglected, unloved, without needed comforting and making sense + unmentalized R A U M traumatized A

24 Developmental impact of attachment trauma secure attachment attachment trauma optimal arousal mentalizing hyperarousal impaired mentalizing

25 Attachment class and BPD features: Coefficient for Preoccupied Attachment Coefficient for Dismising Attachment Preoccupied attachment Sexual risk taking (Slope=1.79, SE=0.81, p<.03) Parent rated aggression (Slope=1.17, SE=0.57, p<0.04) Dismissing attachment Age 13 (n=217) Age 15 (n=201) Age 17 (n=172) Hostile behavior (Slope=0.09, SE=0.10, n.s.) Age 13 (n=217) Age 15 (n=201) Age 17 (n=172) Preoccupied attachment predicts increased sexual risk taking and aggressive behaviors over the course of adolescence, as well as steeper rates of growth in these behaviors Given that these behaviors reflect impulsivity, deficits in self-regulation (core features of BPD)è preoccupied attachment may be related to the development of BPD. Observed in several other studies. 0 Sexual risk taking Parent rated aggression Hostile behavior Kobak, Zajac & Smith, C. (2009)

26 Choi-Kain et al. (2009) Self-Reported Attachment Styles and BPD Mean score Commmunity Controls (n=64) MDD (n=64) BPD (n=109) Secure Preoccupied Fearful Dismissing

27 Disorganized attachment (D) n Behavior lacks an observable goal n Look fearful n Behavior is bizarre n May try to leave after the reunion or freeze

28 Among these studies, earlier ones show stronger correlations between BPD and disorganisation (around 0.8). Subsequent studies showed a somewhat weaker association ( ) Levy, 2005 BPD and disorganised attachment A disorganised attachment pattern is noticeable in the unstable relationships BPD patients usually have Holmes, 2004; De Zulueta, 2006; Barone, 2003 Zero order partial correlations between BPD and disorganised attachment in clinical population: 0.44 for adolescents and 0.48 for adults (p 0.001) Westen et al., 2006 In a sample of 140 BPD subjects, 40% presented disorganised attachment Barone, Fossatu & Gulducci, 2011 In a review of 13 studies, the percentage of BPD patients presenting disorganised attachment has been estimated between 32.2% and 89%. This percentage raised to 100% among BPD patients with history of trauma. Agrawal et al., 2004

29 Attachment and cognitive functioning: the development of competence in logical reasoning secure insecure disorganised Source: Jacobson et al Age

30 Circle of Security Marvin, Cooper, Hoffman & Powell (2002) n Child s Exploratory System and Needs Ø The child can move off and explore, if he believes and expects that the attachment figure will be available if, or when, needed n Attachment System Ø The child needs the attachment figure to be available to protect, comfort, delight, and organize his feelings when he becomes overwhelmed

31 Cooper, Hoffman, Marvin &Powell, 2000

32 Impact of Empathic Failure n Whatever she fails to recognize in him he is likely to fail to recognize in himself. In this way, it is postulated, major parts of a child s developing personality can become split off from, that is, out of communication with, those parts of his personality that his mother recognizes and responds to, which in some cases include features of personality that she is attributing to him wrongly. Bowlby (1988) p.132

33 The journey from attachment to communication

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

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

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

37 1: Baseline control group No object-directed attitude demonstration Simple Object Request by Experimenter A Subjects: n= 20 Age: 18-month-olds

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

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

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

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

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

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

47 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

48 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 Corriveau, Harris, Meins et al., Child Dev,, 80, Avoidant Secure Anxious Resistant Disorganised Attachment Classification at 18 months

49 Conclusions from attachment and epistemic trust studies n Security of attachment èfeeling recognizedè increases likelihood of trust in the source of communication when it is reasonably credible Ø Also empowers confidence in own experience and belief (empowers judgment) n Avoidance leads to epistemic mistrust while anxious attachment generates overreliance on views of attachment figure n Disorganized attachment èmisattunement è mistrust of both attachment figure and stranger

50 Social Cues that Create Epistemic Trust n Attachment to person who responded sensitively in early development is special condition for generating epistemic trust ècognitive advantage of security è including neural development (Van Ijzendoorn et al.) n Generally any communication marked by recognition of the listener as intentional agent will increase epistemic trust and likelihood of communication being coded as Ø Relevant Ø Generalizable Ø To be retained in memory as relevant n OSTENSIVE CUES TRIGGER EPISTEMIC TRUST WHICH TRIGGERS A SPECIAL KIND OF ATTENTION TO KNOWLEDGE RELEVANT TO ME

51 Parents with borderline personality disorder and social vulnerability

52 Borderline Personality Disorder Emotion Dysregulation Self-Concept Social Interaction

53 Mentalizing Positive Emotions in Borderline Personality Psychopathology and Psychotherapy: A randomized phase-based multiple-baseline study Tine Harpøth, Mickey Kongerslev, Anthony Bateman & Erik Simonsen Psychiatric Research Unit, Region of Zealand, Denmark n The broaden and build theory proposes that positive emotions - independently of negative emotions - help people build lasting resources. n Enhancing positive emotions through psychological interventions may increase resilience. n Specific intervention mentalizing positive emotions n Outcomes: General psychopathology; personality disorders and BPD pathology; Differential emotions; Resilience (Ego-resilience scale (ER-89) and Perseverance and passion for long-term goals (GRIT-S); Life Satisfaction Satisfaction with Life Scale (SWLS);Therapeutic alliance (patient-rated) Working Alliance Inventory (WAI)

54 Reported Social Cognitions in BPD n I depend on others a lot n I can t manage when people don t respond to me n I am an outsider n I am different from others (shame) n Others will reject me n I do not deserve being part of the group (guilt) n I am ugly (self-contempt- self disgust)

55 Rejection-sensitivity (anxiously expect, readily perceive, over reaction) in different patient populations Stäbler et al., 2011

56 Rejection Sensitivity in acute and remitted BPD patients cognitive RS RSQ-Score (0-30) RSQ-Score HC acute BPD affective RS remitted BPD HC HC N=75 acute BPD acute BPD remitted BPD remitted BPD N=77 N=15 RSQ-Score HC acute BPD remitted BPD Bungert et al. BPDED, 2015

57 UCLA Loneliness Scale (n=40 female BPD; 40 HC)

58 Figure 1. Graph of social judgement scores for each of six dimensions. Nicol K, Pope M, Sprengelmeyer R, Young AW, Hall J (2013) Social Judgement in Borderline Personality Disorder. PLoS ONE 8(11): e doi: /journal.pone

59 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 Direction of bias Untrustworthy as Trustworthy

60 Trust in Borderline Personality Disorder King-Casas, Sharp, Lomax-Bream, Lohrenz, Fonagy, & Montague (2008) Science, 321, n Studying social behavior in task that involves Ø Live interaction with unknown but real person Ø Engages mesocorticolimbic dopaminergic reward circuit n Total patients screened è assessed è scanned: Ø BPD: 1,060 è 224 è 62 Ø Mood control: 622 è 235 è 22 Ø Normal control: 877 è 398 è 116

61 A dynamic version of the Trust game (10 rounds) BPD: The absence of Basic Trust $20 X 3 Investor Trustee Camerer & Weigelt, (Econometrica, 1988) Berg, Dickhaut & McCabe (Games and Economic Behavior, 1995)

62 Average Repayment: repay everything repay investment (33%) repay nothing

63 60% 50% Investor Sent MU sent / MU available 36 non-psychiatric investors 42 BPD investors 40% 30% 20% 10% % 50% Trustee Repaid MU sent / MU available 36 non-psychiatric trustees 42 BPD trustees 40% 30% 20% 10% rounds

64 Effects of inclusion on subsequent interaction

65 Reaction to Small Investments z = 0 anterior insula x = 0 anterior cingulate cortex (ACC) Sanfey et al, TICS, 2006 response to unfair offers in an Ultimatum Game (take it or leave it) (I <.25) minus (I >.5); p <.004, uncorrected, n = 36 trustees

66 A Neural Signature of Borderlineness in Trust Task

67 Cyberball

68 Did you feel ostracized? BPD patients significantly more often feel ostracized under inclusion and uncontrollable conditions Staebler et al., 2011; Domsalla, Lis, Bohus et al., 2013

69 Social perception: fmri (Domsalla, Lis, Bohus et al., SCAN, 2013) BPD patients showed a stronger engagement of the dorsal anterior cingulate and medial prefrontal cortex particularly in inclusion conditions = HYPERMENTALIZING

70 Virtual Reality Group Interaction Paradigm

71 VR Group Interaction Paradigm Inclusion Become acquainted Appraisal Reappraisal Social Cooperation Exclusion

72 Social expectations before and after feedback Do you expect that people will invite you?

73 Social expectations before and after feedback Would you like to invite others? % HC BPD Inklusion Inclusion Exklusion Exclusion

74 Results n Social inclusion in the VRGIP Ø Has little influence on people with BPD Ø Increases suspicion Ø BPD become less co-operative than under exclusion conditions

75 Summary n Start from a position of distrust n Assume you are to be disadvantaged and seen as an outsider n Sensitivity to unfairness n Interprete social cues as being an outsider n Positive social cues aversive and increase suspicion n Feel impoverished and become either mean or over-generous in social interaction

76 Implications for treatment

77 The Natural Pedagogy Model of PD Social Dysfunction Communication Failures Epistemic Mistrust Imperviousness to Social Influence History of Adversity Loss of Balanced Mentalizing Loss of Interest in Social Communication Insecure/ Disorganized Attachments Failure of Ostension High Epistemic Vigilance or Hypervigilance Limits on Social Learning Processes Emotion Dysregulation Social Disruption Compromised Social Network

78 Which enables Successful navigation of social world Mentalizing Learning about others This lays the founda+ons for Learning channel opens (selec6vely) Caregiver s mentalizing of the infant acts as the prototypical ostensive cue Self-control & selflearning Epistemic trust Sensitive caregiving Learning about the world Secure attachment

79 In all 3 cases, the individual struggles to learn effec+vely about either self or world Epistemic hypervigilance Learning channel is closed, indiscriminately open or both by turns Ostensive cues are not processed, were absent or misleading Mentalizing difficul6es Epistemic dilemma Absence of epistemic trust Neglect/ a;achment trauma Excessive credulity Problems understanding others Insecure/ disorganized abachment Problems naviga+ng social world

80 Video feedback Aims to improve the parent s: n nurturing n understanding of what their child s behaviour means n responses to cues and expressions of the child s feelings n behaviour so that it is not frightening to the child n mastery of their own feelings when nurturing the child.

81 Parental sensitivity and behaviour training Aims to help parent s: n understand their child s behaviour n improve their responsiveness to their child s needs n manage difficult behaviour.

82 Home visiting Includes observing the child (not using video) with their parents Aims: to help parent s improve their communication and relationship with their child by: n n n. using role modelling reinforcing positive interactions and parental empathy parental education on child development

83 Parental Stance n Not-Knowing Ø Curiosity and interest Ø Uncertainty Ø Testing out Ø Active questioning of one s assumptions Ø Asking others n Monitor you own misunderstandings Ø Surprise and re-appraisal Ø Errors offer opportunities to re-visit to learn more about contexts, experiences, and feelings leading to effective actions

84 A vicious cycle in BPD Increase of emotional arousal (including depression) Impaired social interaction Loss of personal resilience Activation of secondary attachment strategies mentalizing impairment Fonagy & Luyten, 2009; Northoff et al., 2006; Mennin et al., 2013; Lemma, Target & Fonagy, 2011

85 Vicious Cycles of Mentalizing Problems within the Family/Parent-child Powerful emotion Powerful emotion Frightening, undermining, frustrating, distressing or coercive interactions Poor mentalising Frightening, undermining, frustrating, distressing or coercive interactions Poor mentalising Person 1 Inability to understand or even pay attention to feelings of others Person 2 Inability to understand or even pay attention to feelings of others Try to control or change others or oneself Others seem incomprehensible Try to control or change others or oneself Others seem incomprehensible

86 Lighthouse Project (Gerry Byrne et al) n The lighthouse beams Ø illuminating beam (the mentalizing stance, wanting to know the child n Ø scanning beam (ready to notice, keeping an eye and an ear out for the child) and the safe harbour (snap judgements in which a child can be mis-seen) Secure and insecure attachment patterns are represented by the metaphors Ø Safe Harbour (secure), Ø Piracy and Battleships (insecure conflicted/ ambivalent), Ø Raft (avoidant) Ø Rocks Beneath the Surface (disorganized)

87 Lighthouse Project (Gerry Byrne et al) n The Wrecking Light acknowledges that in the parent s own childhood they may have suffered abuse, that is that an adult offered a false beam that signaled Safe Harbour but led to abuse and trauma. n Night Seas addresses the role of the unconscious in children s (and parents ) fears and anxieties and acknowledges the increased risk of loss of mentalization and of risk of harm to the child around bedtime and at night through increased stress and exhaustion in parents

88 Thank you for mentalizing! For further information Slides available at: