Anna Freud Centre, London Department of Clinical...
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“The concept of epistemic trust: Can it help integrate attachment theory and psychoanalysis.” Peter Fonagy OBE PhD FBA FMedSci FAcSS The Anna Freud Centre, London Department of Clinical, Educational & Health Psychology, University College London [email protected] San Francisco Center for Psychoanalysis: Haskell Norman Prize Event
Transcript of Anna Freud Centre, London Department of Clinical...
“The concept of epistemic trust: Can it
help integrate attachment theory and
psychoanalysis.”
Peter Fonagy OBE PhD FBA FMedSci FAcSS
The Anna Freud Centre, London
Department of Clinical, Educational & Health Psychology, University College London
San Francisco Center for Psychoanalysis: Haskell Norman Prize Event
The things I feel proud of
(just showing off, not relevant so
you don’t need to listen!)
Some of the Mentalizing Family
UCL/AFC/Tavistock
Prof George Gergely
Professor Pasco Fearon
Professor Mary Target
Prof Anthony Bateman
University of Leuven
Dr Patrick Luyten
Dr Liz Allison
Professor Alessandra Lemma
Professor Eia Asen
& UCL/AFC
Dr Trudie Rossouw
Dr Dickon Bevington
More Family Members (The USA branch)
Menninger Clinic/Baylor Medical College/U Laval/Harvard (The
USA branch)
Dr Jon Allen
Dr Lane Strathearn
Dr Karin Ensink
Dr Read Montague
Yale Child Study Centre UCL & Catholic University, Santiago
Prof Linda Mayes
Dr Carla Sharp
Dr Efrain Bleiberg
Nicolas Lorenzini
Professor Lois Choi-Kain
Dr Elisabeth Newlin
And European adopted to the ‘Family’
Dawn Bales
Dr Mirjam Kalland
And Nicolas Lorenzini, Chloe Campbell, Liz Allison and Rose Palmer
for help with the preparation of this presentation.
Professor Finn Skårderud
Professor Sigmund Karterud
•Cindy Decoste
•Catherine Freeman
•Ulla Kahn
•Ilan Diamant
•Morten Kjolbe
•Benedicte Lowyck
•Tobi Nolte
•Marjukka Pajulo
•Svenja Taubner
•Bart Vandeneede
•Annelies Verheught-Pleiter
•Rudi Vermote
•Joleien Zevalkink
•Bjorn Philips
•Peter Fuggle
The journey from attachment to
communication
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).
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Source: Google Ngram Viewer
Google’s Ngram Viewer shows the
percentage a word is present in a
corpus of 5.2 million books published
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Some Free Publicity
2016
Oxford University Press, PLC
RECENTLY
RELEASED! NEW!
SLIGHTLY
IMPROVED!
Washes brains
whiter!
Longer than the
previous
version!
But hurry!
Only 2,000 copies
left!
Let the boy
dream Ivan,
He is a born
dilettante!
You will never
amount to anything
if you hold a ball
like that!
I want to write my
PhD on the “Use
of low signal-to-
noise ratio stimuli
for highlighting the
functional
differences
between the two
cerebral
hemispheres”.
You look smug now but you will lose your hair just like
Dad
Criticisms of attachment theory
From psychoanalysis: “mechanistic”
“reductionistic”
“no real metapsychology”
“broad classifications that lose the
subtlety and detail of the original material”
Fonagy & Target, 2007; Röttger-Rössler, 2014; Otto, 2011)
WEIRD: Western, Educated,
Industrialised, Rich & Democratic
From anthropology: “culturally blind”
“socially oblivious”
“misses different family configurations, e.g.,
alloparenting”
“empirically based on WEIRD people”
John Bowlby’s disagreements with psychoanalysis 1. Emphasis on internal phantasy at the expense of the environment and
experiences
2. Rigid dogmatism in psychoanalysis, at odds with scientific creativity
3. Metapsychology is speculative and not open to empirical verification
4. Lack of experimental observation to underpin psychoanalytic theorising
Holmes, 1993; Hoffman 2009; Stern, 2013; Luyten et al., 2006
Two psychoanalyses today
Scepticism concerning the
empirical approach to clarifying
and examining the validity of
psychoanalytic ideas has certainly
continued almost unabated within
the clinical psychoanalytic tradition
The academic position, a more positive
approach towards systematic enquiry and
empirical research
Psychoanalysis & Attachment: Areas of integration
• Emergence of relational and relation-ship focused emphasis.
• Increasing interest in the child’s social environment.
Contemporary psychoanalysis is more pluralistic
• The intrapsychic (representational) aspect of attachment theory: expectations and perceptions of the self and others.
• Mechanism of intergenerational transmission of attachment.
• Fosters defenses against incompatible stimuli.
• This representational level allowed for the development of the AAI
The Internal Working Model (IWM)
• People are fundamentally driven by relationships and the primary need for them (Fairbairn, 1952; 1963).
• Representations of self and others are building blocks of development.
• Normal development implies the integration and differentiation of those representations.
• Psychopathology is then an impairment in integration and differentiation.
• Attachment and object relation theories share a decline of the interest in sexuality.
Object relations theory
Epstein, 2010; Brown, 2010; Aron, 2011; Bowlby 1973; Greenberg, 1983; Blatt, 1974, 1997; Kernberg, 2005; Fonagy, 2008; Zamanian, 2011
Attachment and relational psychoanalysis
Both regard emotional problems as the result as interference with an innate potential for interrelatedness.
Patterns of relation are crucial for diagnosis and treatment.
Both see dynamic transactions between people as the primary context for theory building and analytic technique.
Attachment and intersubjectivity are motivational systems.
There exist subtle aspects of interpersonal interaction in the creation of identity and also in therapeutic change.
A systemic perspective in which the subject and object have interchanging roles.
Emphasis on the dyadic nature of affect representations.
The dynamics of recognition and otherness that grow out of a transactional understanding of relationships.
Central role of reality in development
Contemporary psychoanalysis: The emergence of an interpersonal perspective
• “The Relational School”
– Based on the work of Harry Stack Sullivan (1892-1949)
Not a single theory, but metatheories where human relationships have a superordinate role
Stephen Mitchell Thomas Ogden Irwin Hoffman
Attachment theory, like relational theory, is a two-person theory of conflict and
defense, which sees defensive mechanisms as arising from the conflict between
the infant’s needs and caregiver’s responses (Lyons-Ruth, 1999; 2003)
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!
Rethinking the centrality of attachment in developmental psychopathology
(Aries, 1973; Stone, 1977)
Different social environment
are likely to trigger different
attachment styles as more
adaptive
Infanticide in 19th C Milan was
30-40% (Marten, 2010)
Attachment not universal: Historically childhood is a
state of enduring murderous abuse and brutality
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
Attachment is not everything…but it is
• Early attachment has limited predictive power
– Later unfolding of genetic endowment (Fearon, 2013)
– Attachment styles change in adaptation to genes and
environment (Roisman, 2007; Pinquart, 2013)
Sexuality and aggression
Social relatedness
Communication
• Attachment provides a secure base from which to explore the internal world
• It is the basis and most important context for the emergence of mentalization
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
Gergely, 2007; 2012; Csibra, 2009; 2011; Fonagy, 2014; in press.
Attachment relationships provide the sufficient conditions for epistemic trust
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
From attachment to
communication: via socio-biology
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
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
How do young humans learn to use the bewildering array
of tools that surround them efficiently?
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
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
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. turn-taking contingent reactivity, eye contact)
Ostensive cues have in common
Person recognized as a self
Paid special attention to (noticed as an agent)
ET=
Epistemic
Trust
Innate Sensitivity to Contingency
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
Subjects : 4 groups of 18-month-olds Stimuli: Two unfamiliar objects
Experimental illustration of ostensive cues
Gergely, Egyed et al. (2013)
1: Baseline – control group
Simple Object Request by Experimenter A
Subjects: n= 20 Age: 18-month-olds
No object-directed attitude demonstration
Ostensive Communicative Demonstration
Other
person
Requester: OTHER person (Condition 1)
Non-Ostensive (Non-Communicative) Demonstration
Other
person
Requester: OTHER person (Condition 2)
Condition 4: Non-Ostensive (Non-Communicative)
Same
person
Demonstration Requester: SAME person
Epistemic trust and mother – infant
attachment
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?
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?’’
A 50:50 animal from Corriveau et al.
50% pig : 50% bear If Mother names hybrid as pig
then stranger always names it
bear
A 50:50 animal from Corriveau et al.
50% cow : 50% horse If Mother names hybrid as
horse then stranger always
names it cow
A 75:25 animal from Corriveau et al.
75% rabbit : 25% squirrel Mother always names hybrid as squirrel
and stranger always names it rabbit
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
Proportion of Trials on Which Children Chose Their Mother for
Information by Attachment Group and by task P
erce
nt
Moth
ers
Cho
sen
Avoidant 0
Secure
20
40
60
80
Attachment Classification at 18 months
*
N=146
***
Resistant Disorganised
***
***
*** ***
***
Novel Object
50-50 Hybrid
75-25 Hybrid
Corriveau, Harris, Meins et al.,
Child Dev,, 80, 750-761.
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
Individuals differ in the extent they
are able to generate epistemic
trust
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
What you want
to communicate
What they are
interested in
OSTENSIVE
CUEING
EPISTEMIC
TRUST
Knowledge
experienced
as relevant &
generalizable
What you want
to communicate
What they are
interested in
Communicating without
ostensive cueing…
…will be experienced
as irrelevant
What you want
to communicate
What they are
interested in
KNOWLEDGE
TRANSFER BLOCKED
What you want
to communicate
What they are
interested in
When the speaker
uses ostensive cues…
…audience hear message
as relevant to them
What you want
to communicate
What they are
interested in
What you want to
communicate
What they are
interested in
What you want to
communicate
What they are
interested in
RAPID, EFFICIENT KNOWLEDGE TRANSFER
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
Therapist is greatest source of variance in
psychotherapy outcome (Wampold et al. 2016) O
dd
s o
f a
clin
ica
l e
pis
od
e in
MB
T b
y th
era
pis
t
Sensitive caregiving
Caregiver’s mentalizing of the infant acts as the
prototypical ostensive cue
Secure attachment
Epistemic trust
Learning channel opens (selectively)
Learning about self
Learning about the world
This lays the foundations for…
Learning from & about others
Which enables… Mentalizing
Successful navigation of social world
Epistemic trust and a history of
maltreatment
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
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 responsiveness to psychotherapeutic intervention
Neglect/ attachment
trauma
Ostensive cues are not processed, were absent
or misleading
Insecure/ disorganized attachment
Absence of epistemic
trust
Learning channel is closed, indiscriminately
open or both by turns
Epistemic hyper-
vigilance
Excessive credulity
Epistemic dilemma
Mentalizing difficulties
Problems in adapting to social world
Problems in learning from
others In all 3 cases, the individual struggles to learn effectively
about either self or world
Implications for understanding and treating personality disorders
Openness to the (social) environment is usually adaptive…
Openness to the (social) environment is usually adaptive…
Openness to the (social) environment is usually adaptive…
…but so is hypervigilance under certain circumstances
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 Epistemic Mistrust Teacher }
Approachable as
Unapproachable
Unapproachable as
Approachable
Trustworthy as
Untrustworthy
Untrustworthy as
Trustworthy
Judgment bias for approachability and trustworthiness of faces.
NS
NS
BPD
Control P<.001
P<.001
Direction of bias
Nicol et al., 2013 Plos One
Implications: The nature of psychopathology
• 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
Vulnerability
to psychopathology…
…can be buttressed by
foundations of
epistemic trust that
build resilience
Building a social network in childhood and adolescence
When the capacity to form bonds of trust is shaky and tends to break down…
…we lose our learning network and social expectations are not updated
Reconceptualising BPD: understanding not in terms of disease mechanisms…
…but as an absence of expected resilience or lack of epistemic trust…
Epistemic injustice and therapy
Epistemic injustice: the credibility of a person’s
testimony is questioned on the basis of the hearer’s
bias or suspicion.
In the therapeutic context in relation to BPD, the ascribed
manipulative and unreliable nature of patients can lead
therapists to hypermentalize their patients. As a result
they over-ascribe or inaccurately impute agency and
intentionality
This can create a self-reinforcing communicative
impasse: the epistemic hypervigilance of the patient is
compounded by the epistemic injustice of the therapist.
This can be guarded against by the maintenance of a
mentalizing stance on the part of the therapist, which is
further dependent on the therapist’s social environment.
