1. Changing Minds 2: how does psychotherapy change your mind?
Professor Gwen Adshead

2. General over view
What is wrong with the minds of people in mental distress?
Common themes: The Self and Others
Disorders of thought and mentalisation
Therapies that change mentalising
Acknowledgements: Professor Peter Fonagy, Professor Anthony Bateman, Professor Jon Allen, Dr Jay Sarkar, Dr Martin Humphrey.
Morris Nitsun: therapist and artist

3. Meditation on madness by Magritte

4. What’s wrong with people with mental distress?
Man is a social animal
Homo narrans: man is the story telling animal
To live with others in groups, people need to tell a coherent story of themselves
A story by which they recognise themselves across time
But which can change when the environment changes

5. To tell your story You need to be able to organise your thoughts
You need to be able to regulate your feelings and the degree to which you get stressed and aroused
You need to be able to regulate the distance between yourself and others
You need to be able to think about your mind and the minds of others

6. What’s wrong with people with mental distress ? What can’t they do?
Arousal regulation and self-soothing
Negative Affect regulation
Regulation of distance and closeness in interpersonal relationships: (attachment disorders)
Experience an integrated sense of self
Disorders of embodiment
Reality testing deficits
Thinking errors: jumping to conclusions, bias
Dysfunctional time relationships
Defects of mentalisation: thinking about other people’s minds

7. 3 in 1 or ‘Triune’ Brain (Maclean 1990)

8. 1 BRAIN, 3 MINDS and ONE SELF
COGNITION: Information as Knowledge
Capacity for conceptual information processing, reason, meaning-making and decision making.
EMOTION: Information as Subjective Feeling
Capacity for experiencing, identifying and articulation of feeling and affect, which adds motivational colouring to somatic and cognitive processing.
SOMATIC: Information as Behavioural Outputs
Processing through the body that involves physiological experiences that are associated with impulses, movement, postural changes, orienting and defensive responses, and ANS arousal.

10. HOW DO OUR BODIES (AUTOMATIC BRAIN) DEFEND US ?
Hyperaroused
Sympathetic
Danger
Fight- Flight response
Optimal Arousal
Ventral vagal
parasympathetic
Safety
“Social Engagement”
Exploratory behaviour
Freeze- submit
Helplessness
response
Life threat
Hypoaroused
Dorsal vagal
parasympathetic 10

11. Bottom-up processing

12. The Prefrontal Cortex: “Top-Down” Regulation
The foregoing focus on such subcortical structures as the amygdala only partly addresses the clinical phenomena associated with BPD. The regulatory functions of cortical structures must be taken into account as well. Our emphasis on the amygdala and HPA axis examines borderline object relations from a perspective described in the literature as “bottom up” (reflexive/automatic) regulation (Herpetz et al 2001 need other reference here).

13. Defences and disorder
There is a problem (defect) with the brain function in terms of arousal, attention, reality testing, threat perception, pain management
There is a problem with the psychological responses (defence) to the defect: meaning-making; self-other interpretations, secondary defences against stress
Erratic behaviour in response to immature defence

14. So the problems lie…
In how we ‘see’ the world : ourselves and others in it
Appraisals and interpretations of stress, loss and danger: especially bodily experience
Responses to those interpretations: defences, memory, time and image
The story we tell of our situation
What change we envisage as solution

15. Secure attachment and the development of the R Brain

16. Development of mentalising
A function of the attachment relationship between parent and child
Secure attachment promotes reflective function i.e. thinking about one’s own state of mind
Which extends over time to being able to conceive of others’ states of mind; and be curious
The intentional stance: related to group safety: is this person a predator?

17. Model of intergenerational transmission and developmental psychopathology
child attachment security
parental attachment security
parental mentalizing in relation to childhood attachment
child mentalizing
emotion regulation
psychosocial functioning
parental mentalizing of child
adapted from Sharp & Fonagy (2008) Social Development 17

18. The function of mentalising
To help regulate affects and arousal at times of stress
To help make and maintain social relationships in groups
To help support the coherence of Self narratives
“The story I tell now is not the story I told then”

19. Mentalising underpins the social mind
General self-other awareness and distinction
Empathy and perspective taking
Mindfulness
Theory of mind
The intentional stance: ‘reading’ other minds
Part of our mammalian heritage: is this person predator, prey or partner?
A neurobiological basis

20. Trauma disrupts reflective function
In childhood or in adulthood
Chronic fear experiences and/or failure of care
The experience of hostility from another and absence of soothing
Neglect in childhood
Begins antenatally: maternal stress affects gene expression in the neonate, which affects protein synthesis in stress regulation systems

21. Dysfunctional neural networks
Failure of top down regulation by orbito-frontal cortex (OFC)
Erratic function in the limbic system or hippocampal system
Disorganisation of neural networks linking OFC, amygdala and hippocampus via disruption of neurotransmitter function

22. If you can’t reflect… You can’t see yourself You can’t see others
You may become confused about what is real and what is not
You may be confused about where you and your body end and others begin
How do you see the world with no eyes? I see it feelingly….

24. What could help? Better affect and arousal regulation
Better understanding of stress and distress and how it affects us
Better awareness of Self and how I function and see the world
What am I not thinking about?
Could I change the way I see myself? Others?
Is there another way to think about this?

25. Professors Bateman & Fonagy

26. Mentalising Based Therapy
A conscious cognitive process of being aware of one’s own mind, and the minds of others
Based on attachment theory and evolutionary psychology: evidence of adaptive unconscious (Wilson, 2010)
Keeping mind in mind: appraisal of other’s intentions and experience
Implicit and explicit

27. Three impairments of mentalizing too little, too much, misuse
distorted mentalizing
nonmentalizing
mentalizing
concreteness, indifference, aversion
grounded imagination
imagination gone wild (paranoia)
With thanks to Jon Allen
Mindblindness and predator mode
hypermentalizing 27

29. Symptoms of mental disorders
Poor arousal regulation and embodiment: impulsivity, somatisation and acting out
Poor affect regulation: self-medication with substances, use of others to regulate mood
Poor interpersonal skills and mentalising:
alienate others, can’t use the social world, attacks on the social, oscillating attachment and rejection, attacks on vulnerability
Failure of reality testing : Intermittent psychotic states

30. So what happens in psychotherapy?
Restore or improve mentalising by
Challenging thinking errors and fixed dysfunctional beliefs
Reducing the tendency to act on distorted thoughts or feelings
Improving mood regulation and coping with painful emotions
Raising awareness of felt and thought experience and dysfunctional attachments
Changing time perspectives: what was then is not now

31. All Psychological therapies
Try to help people understand themselves better
Not avoid distress: reality testing
Help people understand how anxiety and distress distort thinking
And how negative thoughts drive mood
Reappraise fixed beliefs about themselves and others in relationships
Try to increase a sense of agency and hope

32. Problems
Psychotherapy takes time: weeks for minor problems, 18 months for complex problems
It may be painful and scary
It means trying something new
It may mean thinking something new
It takes trust in another person or persons
It can have unforeseen effects

34. Current therapies for mental distress
CBT ( individual and group)
DBT ( ditto)
MBT (Ditto)
SFT (ditto)
TFP
Mindfulness and ACT (either separately or part of DBT)
POT
OMG!
Acceptance and Commitment therapy

35. Do they work? Evidence that psychological therapies change the brain
Like any new learning does
New information affects the way that neural-transmitters are released or processed at neural synapses
What you learn affects the way your brain works, which affects the way your mind works

36. These brain scans, made by positron emission tomography, show post-treatment increases (orange) and decreases (blue) in regional glucose metabolism. The subjects were depressed patients who responded to cognitive behavior therapy (CBT) or paroxetine, a serotonin-reuptake-inhibitor drug. CBT resulted in metabolic decreases in frontal and parietal cortex, and increases in hippocampus; paroxetine had the opposite effects. Helen maybers’s group (From K. Goldapple et al., Arch Gen Psychiatry, 61:34–41, 2004.)

37. What do they have in common?
They support enhanced mentalising either explicitly or implicitly
If effective, they promote enhanced sense of agency and decrease negative behaviours
Changing perspective or narrative
The therapist needs to be consistent, patient, empathic, attuned
“I’m still the same person, I just think completely differently”

38. Attention to language ‘I just have to pick up the pieces and go on’
( you were in pieces)
‘After [she] died, I was shattered…. Completely shattered’

39. The therapist by Magritte

40. Blocks to therapy Engagement and expectations Ruptures in the alliance
Hostility, enmeshment and repetition of toxic attachments
Therapist’s feelings: conscious and unconscious, positive and negative
Therapist’s behaviours: payback, appeasement, rejection, helplessness

41. Engagement is important
Failure to complete treatment is common (e.g. ranging from 30-50%).
Failure to complete is associated with a worse outcome than if the individual had never been offered treatment.
So need to improve engagement: patient readiness and therapist preparedness