Reviving Plain Old Therapy:Promoting Mentalizing in Relationships

Exploring Parallels in Psychotherapy and Parenting

Reviving Plain Old Therapy:Promoting Mentalizing in Relationships

Exploring Parallels in Psychotherapy and Parenting

Jon G. Allen, Ph.D.

Senior Staff Psychologist, The Menninger ClinicProfessor of Psychiatry, Baylor College of Medicine

Jon G. Allen, Ph.D.

Senior Staff Psychologist, The Menninger ClinicProfessor of Psychiatry, Baylor College of Medicine

Goals

I: Describe commonalities among different therapies

II: Draw parallels between therapy and parenting;each informs the other

III: Explain how “mentalizing” and “attachment” inform therapy and parenting

IV: Support common sense with science

Goals

I: Describe commonalities among different therapies

II: Draw parallels between therapy and parenting;each informs the other

III: Explain how “mentalizing” and “attachment” inform therapy and parenting

IV: Support common sense with science

The commonsensical essence of psychotherapy—and other healing relationships

John Bowlby: the role of the psychotherapist is “to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.” [A Secure Base]

Jon Allen: “The mind can be a scary place.”Patient: “Yes, and you wouldn’t want to go in there alone!”

Outline

I: Therapy brands versus common factors

II: Mentalizing in relationships

III: Attachment in relationships

Outline

I: Therapy brands versus common factors

II: Mentalizing in relationships

III: Attachment in relationships

Part I:

Therapy brands versus common factors

Part I:

Therapy brands versus common factors

Psychotherapy Brands

CPPADEP

TPP

TFPMBT

DBT

CBT

IPT

CFPDIT

SIT

EMDR

MBCBT

EFT

ERP RLX

PE

PCT

My non-brand of psychotherapy

CPPADEP

TPP

TFPMBT

DBT

CBT

IPT

CFPDIT

SIT

EMDR

MBCBT

EFT

ERP RLX

PE

PCT

POT

Much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than those that distinguish them from each other.

—Jerome Frank (1961): Persuasion and healing

There are about 150 evidence-based therapies, with treatment manuals for each; no therapist could possibly learn all of them, or even many of them

Evidence-based therapies are designed for specific disorders, and most psychotherapists are generalists (like general practitioners in medicine)

Most patients have more than one disorder so, in principle, would need many different evidence-based therapies

In practice, generalist psychotherapists combine elements of different approaches, and flexibility is essential

Despite their seeming differences, evicence-based therapies are generally equivalent in their effectiveness

Why we need plain old therapy

Determinants of Psychotherapy Outcome*

Patient characteristics (e.g., severity and duration of illness, social support, capacity for trust)

Patient-therapist relationship (e.g., empathy and therapeutic alliance)Therapist characteristics (e.g., experience, expertise, gender)Treatment method (e.g., CBT, DBT, psychodynamic)

*Discussion: parallels to “outcomes” of parenting?child characteristics, parent-child relationship, parent characteristics, parenting method/style

Therapist’s contribution to the relationship (Carl Rogers)

Empathytherapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view; requires empathic resonance (gut feelings), ability to communicate empathy, and receipt of empathy by the client

Positive Regardacceptance, respect, prizing of the client, non-possessive warmth, caring for the client as a separate person

Congruence (authenticity, genuineness)being open and honest, transparent, being oneself; requires mindful self-awareness and self-acceptance on the part of the therapist

These three facets are highly interrelated

Discussion: Parallels to parents’ contribution to the relationship?

Therapeutic Alliance

Extensive research shows that a positive therapeutic alliance is associated with a better therapy outcome, regardless of the type of treatment (brand name)

Two major components:• a trusting relationship• active collaborationRepair of ruptures in the alliance (e.g., disagreements about the

work, empathy failures, misunderstandings) relates to a positive outcome. Fluctuations in the alliance as well as ruptures are very common in therapy.

Empathy is highly related to the therapeutic alliance.

Discussion: Parallels to parent-child alliance?

Part II:

Mentalizing in relationships

Part II:

Mentalizing in relationships

Defining mentalizing

• attending to mental states in self and others• holding mind in mind• mindfulness of mind• understanding misunderstanding• seeing oneself from the outside and others from

the inside

The territory of mentalizing

othersothers

feelingsfeelingsthoughtsthoughts

selfself

empathyempathy

In advocating mentalization-based treatment we claim no innovation. On the contrary, mentalization-based treatment is the least novel therapeutic approach imaginable. —Allen & Fonagy, Handbook of Mentalization-Based Treatment

Parallel? Mentalizing a fundamental common factor in parenting and the least novel idea about parenting imaginable.

Mentalizing is the most fundamental common factor among psychotherapeutic treatments…perforce, clinicians mentalize in conducting psychotherapies and also engage their patients in doing so. —Allen, Fonagy, & Bateman, Mentalizing in Clinical Practice

Mentalizing as a common factor in therapies

A remarkable convergence: Mindfulness of Mind

Mentalizing MindfulnessMF of

Mind

Developmental Psychopathology

psychoanalysis attachment

Buddhism

philosophy spirituality

ways of contending with suffering

Mindful attentiveness: a foundation for effective mentalizing

making inferences about mental states

reflecting on the meaning of mental states

constructing biographical and autobiographical narrative

mentalizing

nonjudgmental attitude; acceptance, compassion, curiosity

awareness of mental states as representational*

*Don’t believe everything you think

overlap

bare attention, present-centered

attentiveness to mental states in self & othersmindfulness

The Mentalizing Stance (mentalizing mindfully)

Psychological aspects inquisitive, curious, playful, open-minded “not knowing”

Ethical aspects good will and compassion acceptance and forgiveness respect for autonomy love

Parallel? A stance for parenting?

Strong emotions fear anger shame infatuation

Defensiveness

Indifference

Factors that interfere with mentalizing

Part III:

Attachment in relationships

Part III:

Attachment in relationships

Attachment is our most potent way to regulate distress

Experimental situation Satisfied marital couples brought into lab; wife hooked up to receive

shocks. Conditions varied: holding husband’s hand, stranger’s hand, or no one’s hand. Multiple brain areas scanned.

ResultLowest levels of brain activation associated with holding hand of husband; highest levels with holding no hand.

ConclusionAttachment is the most potent and efficient means of emotion regulation. Outsource your emotion regulation and give your brain a break.

—“Lending a Hand” Jim Coan, University of Virginia

Every person throughout life confronts two fundamental psychological developmental challenges:

(a) to establish and maintain reciprocal, meaningful, and personally satisfying interpersonal relationships, and

(b) to establish and maintain a coherent, realistic, differentiated, integrated, essentially positive sense of self.

—Sidney Blatt (2008): Polarities of experience

Compare Immanuel Kant’s “two great moral forces”(a) Love (relatedness, coming closer)(b) Respect (autonomy, keeping distance)

Two Polarities of development:Relatedness and self-definition (autonomy)

Circle of security in secure attachment

exploring

seeking comfort

safe haven

secure

base psychological securityavoidant

attachment

ambivalent attachment

relatedness (effective

dependency)

self-definition

(autonomy)

secure attachment/

psychological security

BALANCE

excessive dependency

diminished autonomy

ambivalent attachment

diminished relatedness

excessive autonomyavoidant

attachment

Development of secure attachment and mentalizing

parental security of attachment ↔ parental mentalizing capacity

child secure attachment (comfort seeking)

mentalizing interactions with child

enhanced mentalizing capacity in childhood

Parallel contributions to mentalizing: Meeting of minds in relationships

The essence of psychotherapy—and parenting?

John Bowlby: the role of the psychotherapist [parent?] is “to provide the patient [child?] with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.” [A Secure Base]

Conclusions, with parenting also in mind

In practice, the patient’s and therapist’s characteristics, their relationship, the alliance they establish, and the method of therapy cannot be disentangled; they all act in concert.

To the extent that they can be disentangled in research, the relationship and alliance carry more weight than the specific treatment techniques or method (brand name).

Rogers believed that the relationship is the therapy, but this begs the question: What are the patient and therapist doing while they are relating? We need to figure out the key problems and find the best methods of working on them.

Secure attachment, which requires and promotes mentalizing, provides a compelling developmental model for the psychotherapy relationship and alliance, especially as it balances the needs for relatedness and autonomy. Increasing the capacity for mentalizing and attachment security is a potentially important outcome of psychotherapy. Mentalizing is the foundation of relationships.

Menninger Blog Posts: SayNoToStigma.com

Is psychotherapy going to POT? (July 21, 2010)Can we cultivate more potent POT? (August 9, 2010)POT: What’s new in plain old therapy? (February 7, 2013)

Books:

Allen, J.G. Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy. Washington, DC: American Psychiatric Publishing, 2013.Allen, J.G. Mentalizing in the development and treatment of attachment trauma. London: Karnac.