Agenda 8:00-8:30: Recap of Day 1 8.30-10:00: Developmental theory - - PDF document
Day 2 Assessment, diagnosis and treatment of personality problems in youth Carla Sharp, Ph.D. csharp2@uh.edu Agenda 8:00-8:30: Recap of Day 1 8.30-10:00: Developmental theory 10:00-10:30: Break and refreshments 10:30-11:30: Examples from
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1970s 1990s/2000 1990s/onwards 1980s/1990s Mental elaboration/ symbolization Theory of mind Theory of mind/ mentalizing Mentalizing Mentalizing 1990s/onwards
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20 40 60 80 100 120 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Number of Publications Year
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focused attention or intention
conscious)
attention, intention and effort
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Wife: My darling, did you remember to pick up the dry cleaning? Husband: Oh no. I forgot. I’m sorry. Wife (feeling annoyed and thinking that he did not really want to do it in the first place): Oh no! I need the black dress for tonight’s work function. I wish you told me that you weren’t going to pick it up and I would have made an effort to pick it up myself. Husband: I just told you I forgot. I meant to pick it up. I’m really sorry. Wife (remembering the last time her husband forgot to pick up one of the children from soccer practice): When I asked you, you looked like you didn’t really want to do it. I could have easily swung by to pick it up if you’d been honest about it. I’d much rather you don’t commit to help out if you don’t think you can follow through. At least then I know I need to get it done myself. Wife: My darling, did you remember to pick up the dry cleaning? Husband: Oh no. I forgot. I’m sorry. Wife (feeling annoyed thinking that he did not really want to do it in the first place): Oh no! I need the black dress for tonight’s work function. I’ll make a plan…. but listen, can I talk to you about a broader issue this relates to? Husband: Sure. What’s up? Wife (remembering the last time her husband forgot to pick up one of the children from soccer practice): I know I might be completely off base here, but when you forget to do something like pick up the dry cleaning after we agreed you’d do it, it makes me feel that I or our family is not a priority. It might just be some insecurity on my part, but our relationship is important to me and I want to get your perspective on this.
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Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” She would like to be friends with me” “We could be good friends” “He was going to call me last night” “We had it all figured out last time we talked” “She is upset”
13 Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” “I think she wants to be friends with me” She would like to be friends with me” “We could be good friends” “He was going to call me last night” “We had it all figured out last time we talked” “She is upset” Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” “I think she wants to be friends with me” She would like to be friends with me” I wonder if she would like to be friends with me” “We could be good friends” “He was going to call me last night” “We had it all figured out last time we talked” “She is upset”
14 Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” “I think she wants to be friends with me” She would like to be friends with me” I wonder if she would like to be friends with me” “We could be good friends” “I believe we could be good friends” “He was going to call me last night” “We had it all figured out last time we talked” “She is upset” Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” “I think she wants to be friends with me” She would like to be friends with me” I wonder if she would like to be friends with me” “We could be good friends” “I believe we could be good friends” “He was going to call me last night” “I thought he was going to call me last night” “We had it all figured out last time we talked” “She is upset”
15 Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” “I think she wants to be friends with me” She would like to be friends with me” I wonder if she would like to be friends with me” “We could be good friends” “I believe we could be good friends” “He was going to call me last night” “I thought he was going to call me last night” “We had it all figured out last time we talked” “I was under the impression that we figured it all out last time we talked”. “She is upset” Non-representational thinking M-reprentations/metacognitive thinking “She wants to be friends with me” “I think she wants to be friends with me” She would like to be friends with me” I wonder if she would like to be friends with me” “We could be good friends” “I believe we could be good friends” “He was going to call me last night” “I thought he was going to call me last night” “We had it all figured out last time we talked” “I was under the impression that we figured it all out last time we talked”. “She is upset” “She seems to be feeling upset”
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Wife: My darling, did you remember to pick up the dry cleaning? Husband: Oh no. I forgot. I’m sorry. Wife (feeling annoyed and thinking that he did not really want to do it in the first place): Oh no! I need the black dress for tonight’s work function. I wish you told me that you weren’t going to pick it up and I would have made an effort to pick it up myself. Husband: I just told you I forgot. I meant to pick it up. I’m really sorry. Wife (remembering the last time her husband forgot to pick up one of the children from soccer practice): When I asked you, you looked like you didn’t really want to do it. I could have easily swung by to pick it up if you’d been honest about it. I’d much rather you don’t commit to help out if you don’t think you can follow through. At least then I know I need to get it done myself.
Wife: My darling, did you remember to pick up the dry cleaning? Husband: Oh no. I forgot. I’m sorry. Wife (feeling annoyed thinking that he did not really want to do it in the first place): Oh no! I need the black dress for tonight’s work function. I’ll make a plan…. but listen, can I talk to you about a broader issue this relates to? Husband: Sure. What’s up? Wife (remembering the last time her husband forgot to pick up one of the children from soccer practice): I know I might be completely off base here, but when you forget to do something like pick up the dry cleaning after we agreed you’d do it, it makes me feel that I or our family is not a priority. It might just be some insecurity on my part, but our relationship is important to me and I want to get your perspective on this.
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Implicit- Automatic- Non -conscious- Immediate. Explicit-controlled Conscious Reflective Mental interior cue focused Mental exterior cue focused Cognitive agent:attitude propositions Affective self:affect state propositions Other Self
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perspectives
her
views extended by others’
implicit mentalizing and controlled/deliberate mentalizing as the situation demands. A mother, arriving tired at home after a full day of work, finds her 8-year daughter has not completed her homework as previously agreed upon. The mother puts down her bag, sighs and looks at her daughter, who is sitting in front of the television watching a favorite show. “What?” says her daughter. Mom responds by saying, “You know what”. Her daughter appears baffled. Mom sighs again and reminds her daughter in a somewhat exasperated tone that they agreed at school drop-off that the 8-year old would complete her homework at after-school care. Her daughter explains that she forgot, and mom says, “Well, that’s not good enough. Go sit down now and do your homework while I start dinner. No buts! Now! Go sit down.” The daughter becomes distressed and says that she wants to finish her show. Mom becomes more exasperated and says, “I don’t want to be saddled with your homework after dinner. Do it now! Or no more television for you for the rest of the week.” By now, the daughter is crying and runs off to her room. Sharp, Shohet, Givon, & Penner, under review
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A mother, arriving tired at home after a full day of work, finds her 8-year daughter has not completed her homework as previously agreed upon. She finds her daughter sitting on the couch watching a favorite TV
your show for a moment as I have something important to talk you about.” Her daughter says, “Yes,” and turns to her mom. Her mom, making eye contact, says, “I can see you are busy watching your favorite show, but I realize that your homework is still not done, and we will need time to go over it together. What about we look at it together to see what still needs to be done, and then we can decide how to fit it all in around dinner?” Sarah grudgingly agrees (partly because her show has not been completely switched off and she is agreeing to come up with a plan to get the homework done and not necessarily having to do the homework right now). “Ah!” says her mom. “Look at this!” Your teacher has asked you to do more exercises in fractions. What do you think about that?” Sarah then says that it’s easy to do that. Her mom says, “Will you show me how you do it?” By now, Sarah is somewhat excited about showing her mom how fractions work, and she begins to work on her homework. After the first problem is completed her mom says, “Excellent work – I like how you first think through the problem and then write down your answer.” Sarah smiles and starts on the next problem. Her mom then says, “It’s close to dinner time, do you want to continue on with the fractions while I make dinner and then watch your show after dinner? Or do you want to wait till after dinner to do your homework?” Because Sarah is excited by the positive feedback and the thought of completing her homework, she elects to carry on with homework while her mom cooks dinner.
Sharp, Shohet, Givon, & Penner, under review
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to social orientation.
have goals.
thinking: the use of observable physical reality to make inferences about goal-directed nature of actions, e.g. Sees bottle of milk Drink bottle of milk.
effect.
caregiver’s emotional reactions to gauge her own affective reactions.
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unobservable mental states, but cannot actively reflect on mental states of others.
Sister cries Comforts sister
Autobiographical memory emerges
in decoupling the mind from reality, but pretend games feels very real and child can get lost in magical thinking.
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passing the false belief task.
reality.
explicit/controlled mentalizing capacity: can verbally reason and interpret behavior and intentions behind behavior.
mental states.
language.
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self-concept
self-hypotheses
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Constitutional Factors Early Caregiving Context Stress/Arousal
relationships
Pre-mentalizing modes
Attachment disruptions
pain and emptiness
Poor self-other differentiation Impairments in integration of cognition and affect Low threshold for attachment activation and controlled mental deactivation Fonagy & Luyten, 2009 Hypersensitivity to mental states
Distal Factors Proximal Factors BPD: Core Features
Constitutional Factors Early Caregiving Context Stress/Arousal
relationships
Pre-mentalizing modes
Attachment disruptions
pain and emptiness
Poor self-other differentiation Impairments in integration of cognition and affect Hypersensitivity to mental states Low threshold for attachment activation and controlled mental deactivation Fonagy & Luyten, 2009
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Psychic equivalence: – Mind-world isomorphism; mental reality = outer reality; internal has power of external – Intolerance of alternative perspectives – Reflects domination of self:affect state thinking with limited internal focus – Because I think it, it is true. – What is in my mind, is out there in nature. – My perspective reflects reality. Pretend mode: – Ideas form no bridge between inner and outer reality; mental world decoupled from external reality – “dissociation” of thought, pseudo-mentalizing – Reflects explicit mentalizing being dominated by implicit, inadequate internal focus, poor belief-desire reasoning and vulnerability to fusion with others – Using mental state words, but lacks coherence and authenticity. Teleological stance: – A focus on understanding actions in terms of their physical as opposed to mental constraints – Cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the
– Extreme exterior focus – Misuse of mentalization for teleological ends (harming others) becomes possible because of lack of implicit as well as explicit mentalizing; the end justifies the means – Absent mind; quick fix thinking
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N = 228, 57.9% female SS, CERQ, PAI-BOR Kim, Sharp, & Carbonne (2013). PD:TRT
Vanwoerden, Kalpakci, & Sharp (2015). Comprehensive Psychiatry
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N = 133; 64.7% female; 24.1% Black; 40.6% Hispanic SS, INQ, YSR
Venta, Mellick, Schatte & Sharp (2014) JSCP
Kalpakci, Venta, & Sharp (2014) BPDED
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Crowell et al. (2009), D&P
author emerges
the caregiver-child dyad
by functionally mature limbic regions during adolescence (imbalance of limbic relative to prefrontal control), compared to children, in whom these systems are both still developing, and adults, in whom they fully mature
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The person….
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
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interaction with the caregiver:
– If the parent is:
accurately
– Then this:
a reflective self
partial exclusivity.
figure, – it can be more challenging to maintain mentalization in the context of an attachment relationship (e.g. the relationship with the therapist) (Gunderson,
1996).
and/or biological predisposition
will never learn to function psychologically in the context of interpersonal relationships.
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– Neither therapist nor patient experiences interactions other than impressionistically – Differentiate self from other – Acceptance of different perspectives – Active questioning – Eschew your need to understand – do not feel under obligation to understand the non-understandable. – Not the expert
– Model honesty and courage via acknowledgement of your own mistakes
– Suggest that mistakes offer opportunities to re-visit to learn more about contexts, experiences, and feelings
– Inquiring – Respectful – Curious – Tentative – Mentalizing out loud: making hypotheses explicit – Sharing hunches
– Try to be clever – Complicated, long interventions – Psychobabble – Theory-based assumptions – Certainty – Attribute patient’s experience to a general pattern rather than specific detail – Long silence, non-contingency – Transference to explore unconscious repetitions of the past
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– Searches actively for examples (or episodes) of good mentalization – Enlarges upon them
– Stay with the mind – Respectful – No skill building!
– Communicate the intention to understand – Feel the intention to understand
mind if I….? “
may have been pre-occupied with something rather than ignoring you”
happens at home?”
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Less Mentalizing More Mentalizing
Empathize, support, and validate Explore, clarify, and expand Challenge Mentalizing the relationship Basic (practice) mentalizing
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Mentalizing stance Video/audio clips
– The patient – The patient’s history – The patient’s relational context – The meaning of the reason for referral – The patient’s coping strategies – The patient’s mentalizing abilities
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Background Information. When you were referred to this service you reported a two year history of feeling depressed and harming yourself. At times you have felt so depressed that life did not feel worth
father's drinking and his recent violent relationship with his girlfriend all played a role to make you
entered into a relationship in which you allowed someone to treat you in a disrespectful manner, almost as if you were being punished. All of this made you feel terrible about yourself. Personality Style. You are a very brave young person who has coped with a lot in your life. You were also very brave to speak to me about your feelings and stuff that happened in your life. You are kind and caring to others and you have been a very reliable friend to your friends. It is sad to notice how you cannot see your own beautiful qualities and how you constantly expect people to dislike you. This can make you feel so anxious in social situations that you tend to withdraw yourself, but the problem with this way of coping is that it does not allow others to be close to you and in that way it reinforces you view that they do not like you. You also told me that in your relationships things can be up and down at times. You explained that you have a desire to be close to people but as soon as you are close to them, you feel ripped apart by anxieties that they will let you down or reject you. This, you said, can make you feel so anxious that you can feel as if you are on a rollercoaster emotionally with large mood swings. From our discussions I had the impression that sometimes when you have strong feelings inside you, you cope with it by either cutting yourself or by switching your emotions off until you feel empty. Is that what happens to you?
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When we spoke about you switching your emotions off, I thought about it afterwards and I thought that although I can see that it feels as if this coping style helps you at the time, I did wonder whether it does not also make you feel disconnected from what you or other people feel and whether it is then not difficult to understand what is going and I wondered if it may be at times like this that you feel action is the only thing available to you – and whether it may be at these times that you have a tendency to harm yourself. What do you think about that? In listening to the way you spoke about yourself, I felt myself feeling very sad about the constant negative ways in which you see yourself. I was also struck by how you seem to relate to other people in a self sacrificing manner and how at times you allow them to take advantage of you. Perhaps in therapy we can work on all these aspects and help you to develop a desire to look after yourself and to allow others to look after you rather than hurt you. You are a lovely person and you deserve more than what you currently allow yourself to have. Treatment Plan. We propose to offer you a treatment in which we suggest a combination of individual therapy once a week and family therapy once or twice a month delivered by the community team.
Sharp & Rossouw (in press)
Trigger factors that you and I identified are times when you feel rejected, humiliated, or bad about yourself. As we have discussed, these feelings do not just arrive out of the blue; they are likely to have been triggered in a close relationship. When you have those feelings you tend to rush into an action to take the feelings away. When you feel like that again, I would like you to use the COPING SKILLS APP. STOP AND PAUSE. Try focusing on your breathing or on one of your senses. Then try and reflect – what are you feeling? What happened before you had the feeling? Did something happen between you and someone else? Can you try and pause before you make an assumption about what they are feeling and thinking. Remember we cannot see into someone else’s mind and we can make mistakes when we make assumptions about what they feel. Sometimes we are so overwhelmed with our own feelings, we assume others feel it to. Signed: Patient Signed: Parent Signed: Therapist Sharp & Rossouw (in press)
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Sharp & Rossouw (in press)
Don’t blame her and don’t blame yourself. Just try to understand what she felt before she wanted to harm herself and help her to speak about the feelings and the events leading up to the feelings. If the events involved you, listen and try to understand her perspective without becoming defensive. You don’t have to hold the same perspective, but it is important that you validate her perspective. If there was a misunderstanding between you that you contributed to, own up to it. You are not here to win battles, but to restore the connection between you. If she is very aroused, speaking too much is not helpful. Just be kind and supportive, and say things like: “I am not angry with you, I am here to help you and keep you safe. Something has made you so upset. I don’t know what it is and if it is something I have done, I am sorry. I really want to understand. Talk when you are ready, but until then, I will just be with you to keep you safe.” If she wants to hurt herself, you could say: “I really don’t want you to hurt yourself. You deserve so much
If she is suicidal, you could say: “Killing yourself is not an option. I love you and do not want you to kill
you safe. Let’s try to think of something that will help right now. Will distraction help—maybe going for a walk or watching TV?” If all else fails, call the clinic, or if it is after hours, you may have to take her to the emergency department.
Sharp & Rossouw (in press)
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Sharp & Rossouw (in press)
Sharp & Rossouw (in press)
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Therapist: Welcome. I am glad you came; from what your mom said on the phone, it sounded as if it was difficult for you to come. So, that tells me you must have been quite brave to come. Patient: [silent, looking down] Therapist: Is it okay to be here? Patient: It’s awkward to talk to people. Therapist: I understand that, especially now, because I am still a stranger to you. If you think, at any stage, that I say something that makes you feel that I don’t understand, please tell me. Would you mind just giving me an idea of what happened and how you came to be here? Patient: I had problems at school... [silence] Therapist: I am sorry to hear that; what happened? Patient: I was bullied by some kids, and I’m worried about the exams. I’m scared of what people think of me. Therapist: Tell me more. Patient: I’m worried that I will do badly on the exams and that the teacher will be angry. Therapist: Do you have a horrible teacher? Patient: She sometimes takes marks off just to make me feel bad so that I work harder. Therapist: Gosh, how does that make you feel? Patient: It upsets me, and then I feel angry, and I think I didn’t work hard enough. Therapist: It sounds to me that when the teacher does that, you get cross with yourself, but she is the one who is doing something wrong, not you, so why should you get cross with yourself? Patient: I always get cross with myself. Therapist: Do you think you just feel cross, or do you feel other things, too? Patient: I think I feel sad. Therapist: What do you think is making you sad? Patient: I try so hard. Therapist: Yes, I understand that. And when she takes marks off like that, do you feel as if she does not notice how hard you try? Patient: Yes. [cries] Therapist: I wonder if that feels quite cruel to you. Patient: Yes. Therapist: Is she just a horrible, cruel woman? Why do you think she does that? Patient: She says she does it to help me, to motivate me to work harder. Therapist: But that isn’t the way it makes you feel, is it? It sounds to me like you feel that nothing you do is good enough. Patient: Yes. Therapist: Do you think she knows how you suffer? Patient: No, I think she thinks it is a game. Therapist: If people play games with my feelings, I sometimes get angry. Patient: I am very bad with anger. Therapist: Tell me more...
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Empathize, support, and validate Explore, clarify, and expand Challenge Mentalizing the relationship Basic (practice) mentalizing
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This is an example of a session with Peter, a 15-year-old boy who was referred with a history of cutting himself, taking overdoses, and having great difficulty managing relationships at school. Peter also had a strong history of violent outbursts and impulsive behavior, and on one
as unpredictable when he was growing up, surrounded by volatile relationships and inconsistent boundaries, which had left him with very little ability to manage his own feelings, and hence he frequently fell back on concrete ways of trying to reassure himself of his safety and concrete ways of managing his feelings.
Sharp & Rossouw (in press)
feelings and trigger factors
interpretations, keep interpretations simple and non-threatening, stay emotionally attuned, and avoid silences
Sharp & Rossouw (in press)
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Peter: I broke up with Michelle. You remember that I wanted to see her last Friday, and she said she was
thought I’m not having this; I may as well end it with her rather than wait around for her. Therapist: What did you feel on Friday? Peter: I sent her a text Saturday and said, “If you don’t call me by 5 o’clock, it’s over.” I used to think that she wasn’t answering her phone because it was broken, but, funnily enough, just after I sent the text, she texted straight back saying, “I am sorry, but I am a happy person, and you are always moaning, and it brings me down.” So, I thought, okay, whatever, and just left it. Therapist: Gosh, you must have felt very hurt. Peter: No, I tried to convince myself that I felt nothing. I just don’t understand; I was always happy when I was with her. I don’t see how she could say that I am always moaning. The only thing I moaned about was that she just never answered her phone. Any boyfriend would want that, right? Therapist: So, when she didn’t answer her phone, what did that feel like? Peter: It felt as if she didn’t care. Jenny [another ex-girlfriend] always answered her phone, and that is how I knew she cared. Therapist: And when you felt that she didn’t care, how did that make you feel? Peter: Anxious, and then I would phone her non-stop, and I would text and leave messages. It’s not right to ignore me like this.
Therapist: So, the more she didn’t answer, the more anxious you would get. Peter: Sometimes I would call her 20 times, and she would ignore me. I know why. Therapist: And when you were anxious, what thoughts did you have, and what were you anxious about? Peter: I think that she’s met someone else. And I sort of saw it coming, so Friday evening, when I went dancing, I flirted with people and then I met this new girl. She’s not really new; she is a sort of a friend. So, I thought that I’d like to take her out, so I pretended to be drunk, and then I told her that I would like to take her out. I thought that if I pretended to be drunk and she said no, then I would just say the next day that I was drunk and that I don’t remember anything. Then I won’t have to feel
Saturday, when I dumped Michelle, I already had the other one lined up, so I didn’t really care about Michelle anymore [pretend]. Now life has moved on and this weekend I will go out with her for the first time. And this week I felt really happy. This girl is really special. We have so much in common; she is pretty… Therapist: Can I just slow things down a bit to try and catch up?
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Peter: Yes, it is a bit fast, isn’t it? I always do that—I always have one in reserve. The minute I see trouble coming, I get one in reserve. Therapist: It seems to me that all of this action about phoning her so many times and getting another girl in reserve are ways in which you try to manage a terribly anxious feeling inside you. Peter: Yes, but now I don’t feel it because the new girl answers her phone all the time, so I know she likes me. Therapist: You said that when Michelle didn’t answer her phone, you got anxious. Is that all you felt, or did you have other feelings, too? Peter: I felt anxious that she was seeing another guy and then I phoned again and again. Therapist: If I thought that someone I like was seeing someone else, it would make me feel angry. Peter: Yes, I felt like I could smash my phone up. I wanted to break her door down. Therapist: So, part of phoning her so many times was also an angry thing. Peter: Yes, I suppose it was a bit smothering; maybe that is why she said that I was
55 Less Mentalizing More Mentalizing
Empathize, support, and validate Explore, clarify, and expand Challenge Mentalizing the relationship Basic (practice) mentalizing
Sharp & Rossouw (in press)
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Empathize, support, and validate Explore, clarify, and expand Challenge Mentalizing the relationship Basic (practice) mentalizing
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