Mentalizing in Child Therapy

Guidelines for Clinical Practitioners

Marcel G. J. Schmeets, Annelies J. E. Verheugt-Pleiter, Jolien Zevalkink, Marcel G. J. Schmeets, Annelies J. E. Verheugt-Pleiter, Jolien Zevalkink

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429916250
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Mentalization-based child therapy, previously known as developmental therapy, is the latest branch on the psychoanalytic tree of knowledge. It comprises a number of techniques that address deficiencies in specific areas of psychological development. It aims to treat children whose development has come to a standstill. A combination of data from psychoanalysis, infant research, attachment research, and neurobiology was of decisive significance in reaching this point. It is becoming clear that neurobiological processes can be understood very well on the basis of psychoanalytic frameworks. These new insights into peoples mental functioning also serve to foster collaboration, resulting in an integration of the more relationship-oriented and the more competence oriented treatments. This book aims to fill a growing need in mental health care for children and young people to recieve an integrated treatment.

CHAPTER ONE


Introduction

Marcel G. J. Schmeets, Annelies J. E. Verheugt-Pleiter and Jolien Zevalkink

Psychoanalysis has always been in a process of development, and mentalization-based child therapy—previously known as developmental therapy—for the treatment of children whose development has come to a standstill is the latest branch on this tree of knowledge (Bateman & Fonagy, 2004; Hurry, 1998a). A combination of data from psychoanalysis, infant research, attachment research, and neurobiology was of decisive significance in reaching this point. It is becoming clear that neurobiological processes can be understood very well on the basis of psychoanalytic frameworks (Kaplan-Solms & Solms, 2000). These new insights into people’s mental functioning also serve to foster collaboration, resulting in an integration of the more relationship-oriented and the more competence-oriented treatments. This book aims to fill a growing need in mental health care for children and young people for an integrated treatment—that is, one using several different modes of treatment simultaneously when the problems are complex. Treating complex problems in children with new psychoanalytic techniques is expected to add a new dimension to the practice of treatment, one that is interesting to cognitive behavioural therapists and psychoanalytically schooled psychotherapists alike. One step further, mental health care for children and adolescents may well draw benefits from the achievements of psychoanalysis, thus embedding psychoanalysis more firmly in the field of mental health care. To achieve this, not only will the various forms of psychotherapy need to be integrated, but the therapists as well (Bateman & Fonagy, 2004; Bleiberg, 2001).

The theory with respect to mentalization can be seen as a psychoanalytic model within developmental psychopathology. The field of work of developmental psychopathology focuses on the interaction between normal and atypical development: it emphasizes the use of a developmental framework in understanding psychological adaptation (Cicchetti & Cohen, 1995). Various theoretical models exist in this field. For their further development, theoretical models need feedback from both researchers and therapists who work with the children targeted in the model. Researchers may be able to demonstrate some relationships posited by the theory, although this may be more difficult in other parts of the model. Therapists may also find that some constructs are not workable in clinical practice. All these experiences can further refine the model. At the same time, a good theory ought to be a practical theory. The theoretical framework was formulated on the basis of extensive empirical attachment research (Bateman & Fonagy, 2004; Fonagy, 2001a). In this line of thinking, the present book can also not be regarded as an end point in itself. It describes a point in time in the development of therapeutic possibilities that can be achieved with mentalization-based child therapy.

In this chapter, starting from this theoretical framework, we focus on children who have difficulty to sense intuitively what they, and others, express in their actions. Essential mental processes do not operate properly in these children. More specifically, they are unable to see themselves and others as creatures with inner intentions. This means that they do not have a coherent inner world, and they are often driven by what happens to cross their path. We see these problems—as do Bateman and Fonagy (2004)—primarily as a disorder in the perception of the self as an active agent. Classical psychoanalytic therapy gives interpretations and suggestions about conflicts between wishes, fantasies, and reality, but this is only possible if a child is able to perceive these. In children with a serious disorder, the mental processes necessary for this are underdeveloped (Hurry, 1998a). We have come to refer to setting in motion the blocked mental processes as mentalization-based child therapy, on analogy with mentalization-based treatment for adults (Bateman & Fonagy, 2004). Mentalization-based child therapy comprises a number of techniques that address deficiencies in specific areas of psychological development (Cluckers, 1986; Hellendoorn, Groothoff, Mostert, & Harinck, 1992; Thoomes-Vreugdenhil, 2000; Verhofstadt-Denève, 1988). In terms of DSM-IV, such children are often diagnosed as having a Pervasive Development Disorder (PDD, PDD-NOS), Asperger’s syndrome, or Disruptive Disorders such as attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant behavioural disorder (ODD), or conduct disorder (CD). In these children, the most important objective of treatment is to encourage the emergence of a coherent self, a sense of agency, and a capacity to postpone, modulate, and regulate emotional reactions (Tyson, 2005).

In normal development, in order for a child to develop a mentaliz-ing self-organization, it is of great importance for the child to explore the mental state of a sensitive caregiver. In the caregiver’s mind, the child finds a picture of himself¹ as a being motivated by thoughts, feelings, and intentions. This refers not only to acquiring the capacity to read another person’s mind, but also the integrative role played by such a capacity in a person’s self-organization (Fonagy, Gergely, Jurist, & Target, 2002). A child who understands more about what might motivate others and can show some empathy for his own motives will have greater flexibility in thinking and will be able to learn from incorrect assessments. This gives the child a fantastic resource to use in social life, in dealing with stress, and in building up a sense of self that will give direction to the child’s actions. In many children this process has come to a standstill in certain areas because they did not feel they were seen, heard, or understood in their primary attachment relationship. These children have built up little in the way of an inner world, or they have a chaotic inner world that has internalized, for example, an overpowering, aggressive person, or a rejecting, depressive person. This can lead to rigid, controlling behaviour or to withdrawn, avoidant behaviour.

As we see it, mentalization-based child therapy leans heavily on systematic observation of the mentalizing techniques used in the course of a therapy. The current book reports on a project in which these observations were carried out: the initial stages of six treatments were followed intensively, and the observing therapists wrote down interventions they had noted in each observed therapeutic session. The result is a unique data collection that has formed the basis for this manual. We have given the six children, who will often be quoted in this book, the following names: “Paul” (9 yrs), “Geert” (8 yrs), “Maartje” (7 yrs), “Ivo” (11 yrs), “Xander” (9 yrs), and “Eduard” (10 yrs). Observing treatments in their initial stages has had its disadvantages. For instance, in the middle stages of therapy, children might have exhibited different types of negative reactions from those included in the current observational system. In line with an earlier retrospective study of the predictors of results in child therapy (Fonagy & Target, 1996b), the children in our group also seemed to profit most from psychoanalytic treatment of a high frequency—an understandable result when we consider the seriousness of the disorder in personality development. In our ambulatory setting, we have therefore opted for fairly intensive treatment, with a frequency of two sessions per week. In the six cases described in this book, a higher frequency was not feasible in view of the parents’ limited tolerance and the logistics problems in these families. The optimum frequency remains a point of discussion. If the frequency is high—that is, five sessions a week—the attachment system becomes activated to such a degree that anxiety can also mount. If the frequency is too low, the attachment system is not activated enough, yielding too little leverage for change. So far, our conclusion has been that two or three sessions a week is best.

In our six cases, parent guidance, which we always carry out parallel to child therapies, proved to be more intensive and of a different nature than when it accompanies regular psychoanalytic child therapy. On the one hand, this has to do with problems that the parents have. They are often people whose thinking is highly concrete and who spend little time reflecting on their children’s intentions. If parents become better able to untangle complicated family interactions with the help of the parent counsellor, this is of great therapeutic value for them. They begin to feel more competent, and their ties with their children improve. On the other hand, it is also of great value for the treatment of the child. If parents gain a better picture of their children’s thoughts or intentions—not only those of the child who is in therapy, but of their other children or the child’s friends as well—then this helps them to deal with this and to coach their children better. If the situation at home becomes more reflective, then there is a greater chance that the mentalizing ability of the child will show improvement. We are in favour of an “integration of therapists”, by which we mean that parent supervisor and child psychotherapist need to work together so that both of them can keep their focus on mentalization. Sometimes other care workers are also involved, or perhaps the child’s teacher. Retaining a consistent focus on mentalization therefore demands consultation on a regular basis. Just as in the adult variant of mentalization-based treatment, practice has shown that therapist peer review meetings are a necessary and permanent aspect of such treatment. It is easy for schisms to occur between therapists, and they require mutual attunement. The better integrated the therapists, the safer the climate becomes for parents and children. There is a great deal to be said for the use of a family therapy such as Short-term Mentalization and Relational Therapy (SMART) (Fearon et al., 2006), where parents and children work together to acquire a picture of each other’s mental situation and learn some perspective on how much you can know about another person. If there has been no treatment as yet, from the point of view of stepped care, such a form is preferable. But if several care workers are already involved, we prefer to work with children and parents separately, because then we can focus in greater detail on building up the sense of self in both of them. Often, these are children and parents with a negative self-image, who need the exclusiveness of a relationship with a therapist in order to build up their sense of self by means of mentalizing interventions. By exclusiveness we do not mean intimacy. It has been our experience that empathy and proximity must be offered cautiously. The objective is certainly not to provide the affection that the child and the parent are lacking: this would show a complete misperception of the major damage caused by intensely emotionally charged interactions that require very specific repair work.

In carrying out the project, our goal was to develop a joint framework of concepts formulated on the basis of clinical empiricism. In the future we want to take this one step further. In writing this text, one of our objectives is to perform scientific research. The text describes techniques intended to promote specific aspects of a child’s development. We hope very soon to be able to conduct scientific research to measure the effectiveness of this mentalization-based psychotherapy. On another front, the guidelines provided here aim to fill the need of practitioners to gain more insight into modified psychoanalytic treatment methods. In this light, the book can also be used as a textbook for training courses.

The structure of the volume is as follows. Chapter 2 describes the theories on which mentalization-based child therapy is based. The concepts involved and the theoretical framework are discussed at length. At the back of the book there is a glossary for easy reference, giving the meanings of the constructs described. Chapter 3 describes the group of children we work with and the diagnostic process. The description of the group is still largely based on theoretical considerations and diagnostic criteria that were formulated on this basis. These criteria can be operationalized with diagnostic instruments. Chapter 4 covers treatment strategy and guidelines in carrying out mentalization-based child therapy. This chapter sketches backgrounds and therapeutic frameworks to the treatment and concludes by formulating a few basic principles underlying this form of treatment. Chapter 5 describes the specific characteristics of guidance for parents with children in mentalization-based child therapy. Chapter 6 describes the procedure followed and the methods used to obtain the data that form the basis for this text. Chapters 7, 8, and 9 contain the empirically observed and identified mentalization-based child therapy techniques, classified into three groups: attention regulation, affect regulation, and mentalization (Bateman, 2002). These observation categories are useful when discussing the therapy during peer review meetings, for training purposes, and as a process measure in effect study. They offer a perspective on the practice of mentalization-based child therapy. These categories also form the basis for critical reflection and future adaptations. For ease of identification, the categories have been summarized and tabulated in Appendix A, and each has been provided with a short label. Chapter 10 summarizes issues that may come up in carrying out the treatment. The chapter discusses matters such as becoming acquainted, the therapeutic setting, and the various stages in the course of a treatment. Finally, in Chapter 11, research questions are formulated that point the way for future research and also show what aspects should be included in setting up research on the effectiveness of mentalization-based child therapy.

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¹ For grammatical simplicity and comprehensibility the feminine pronoun has been used throughout the book for otherwise unidentified caregivers and therapists, and the masculine pronoun for children in general.

CHAPTER TWO


Theoretical concepts

Marcel G. J. Schmeets

This chapter takes a closer look at the concept of mentalization and the way in which this ability comes into being. The quality of the mother-child relationship seems to play a crucial role in this respect. In the process of learning to make representations, it is important that the child is given space by another person—for example, the mother—between the direct primary experience of the affect and being able to think about the affect. At this juncture, the capacity of the mother to make her own representations is decisive for the extent to which the child “learns” this ability from her. Intrapsychic processes in the mother are formative for the degree to which a child learns to mentalize. Traumatic experiences that are unmentalized in the mother will lead to blind (unmentalized) spots in the child. They are part of the information stored on a daily basis that helps to shape the structure of the brain, leading to personality traits and possibly also to psychopathology.

Introduction

Mentalization means the—often nonconscious—ability, when interacting with others, to continually make the assumption that, like yourself, others too have an internal world, with their own feelings, thoughts, and desires (Fonagy, Gergely, et al., 2002). The ability to mentalize is typically human. Mentalization presumes intentional-ity and second-order representation. The ability to mentalize might be something that needs to be acquired in the course of the development. It resembles the concept of Theory of Mind because both theorize about the possibility of reflecting on thoughts and feelings. It differs in that the concept of mentalizing includes relationship dynamics (e.g. Allen, 2006). Cognitive psychology assumes that a Theory of Mind (Baron-Cohen, 1991; Leslie, 1987; ) is an emergent process—that is to say, it comes about by itself. The psychoanalytic view of how the ability to mentalize develops starts from the assumption that not only is the basis laid during the child’s early years, but this ability is shaped in and by an affective relationship with the caregiver. The quality of the intimate affective relationship between parent and child is very decisive for developing the ability to mentalize, and being able to mentalize has, in turn, a great impact on a child’s ability to regulate himself. In order to develop a mentalizing self-organization, exploration of the mental state of the sensitive caregiver is of great importance. The child constructs a hypothetical representation of the caregiver’s or mother’s mind to explain her behaviour towards him. In the mother’s mind, the child finds a picture of himself as motivated by thoughts, feelings, and intentions. Mentalization includes not only this mind-reading ability, but also the integrative role played by this capacity in the organization of the self (Fonagy, Gergely, et al., 2002).

The capacity to mentalize can also be stimulated in a psychotherapeutic relationship. Mentalization-based child therapy used to be called developmental therapy or psychoanalytic developmental therapy. It initially emerged from classical child analysis (Schmeets, 2003). Child psychoanalysts soon spoke of adaptations to the classical technique to encourage the child’s mental growth so that classical psychoanalytic interventions could also do their therapeutic function (Bion, 1962, 1967b; Winnicott, 1971). Recent developments in infant research have lent support to the idea that mental functions, including thinking and feeling, develop in an affective relationship, and that an affective relationship later in life can bring about changes in these mental functions. The essential human mental functions are nowadays summarized under the term “mentalization” (Fonagy, Gergely, et al., 2002). Deficiencies in the ability to mentalize are thought to be capable of change in a methodically manipulated, affectively charged relationship with a psychoanalyst or a psychotherapist (Bateman & Fonagy, 2006). In seriously disturbed children the mental processes necessary for this are blocked or underdeveloped (Hurry, 1998b). Setting the mental processes into motion is termed “mentalization-based psychotherapy”. Mentalization-based child therapy consists of a number of techniques aimed at deficiencies and shortcomings in specific areas of psychological development. This chapter attempts to clarify the theoretical concepts and developmental phases that play a role in this form of treatment.

Developmental tasks of the infant

Fonagy, Gergely, and colleagues (2002)—building on the work of others—have formulated a theoretical model that states that in normal development an infant goes through five levels of “agency of self” of increasing complexity: physical, social, teleological, intentional, and representational. The experience of a child’s own body—combining proprioceptive and sensory data—forms the basis for the self. The degree of predictability, or lack of contingency, in the infant’s experiences contributes to the distinction between self and not-self. From birth, babies interact with the caregivers in their environment. The infant gradually gains an awareness that his physical actions have an effect on the behaviour and the emotions of the significant caregiver. This contributes to the development of the self as a “social agent”.

Infant research has shown that in the first months of life a baby actively seeks interaction with his caregiver (Beebe & Lachmann, 1988). The facial expression of one of them is indicative for the facial expression the ot...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Series Foreword
• About the Editors and Contributors
• Foreword
• Chapter One Introduction
• Chapter Two Theoretical concepts
• Chapter Three Assessment of mentalizing problems in children
• Chapter Four Treatment strategy
• Chapter Five Helping parents to promote mentalization
• Chapter Six Observation method
• Chapter Seven Intervention techniques: attention regulation
• Chapter Eight Intervention techniques: affect regulation
• Chapter Nine Intervention techniques: mentalization
• Chapter Ten Treatment in practice
• Chapter Eleven Research strategy
• Appendix A Intervention techniques
• Appendix B Glossary
• References
• Index