Attachment, Mentalization, and Trauma-Magnavita

A group of us shrink types visit Austen Riggs an eminent psychiatric hospital located in West Stockbridge, MA to attend their Friday night lecture series. After a lovely dinner at the Red Lion Inn across the street from the bucolic Riggs campus we were delighted to hear Peter Fonagy lecture on mentalization, a concept that he has articulated and on which he has based an approach to psychotherapy which has shown efficacy with severe personality disorders. Of course as you might expect Fonagy is a master at conceptualizing theoretical constructs, describing technical interventions, and carrying out research which he combines rather seamlessly. The concept of mentalization refers to having a theory of mind both self and other which is essential for interpersonal relationships and self-coherence. Fonagy draws from attachment theory to ground his work as well as psychodynamics. I found myself thinking that mentalization is akin to psychological mindedness and observing ego, which are parts of what I think he means by mentalization. His therapeutic approach strives to enhance mentalization in patients and he and Mary Target have developed a manualized treatment for this which is evidence-based. In fact, I was honored to have them collaborate with me in my Handbook of Personality Disorders for which they wrote a chapter. Upon introduction, Peter told me the volume is prominently featured on his bottom shelf in his office. I teased him about it being on the bottom shelf and he was very good natured in return.

Basically I think most everything we do as psychotherapists and medical docs comes down to attachment styles so I am in total agreement with Fonagy about the basis of Bowlby and Ainsworth’s attachment paradigm. He also showed some interesting studies he conducted using PET scans and showing differential activation of brain structures comparing borderline to normal subjects. One of my good friends muttered phrenology which inspired some interesting discussion amongst us.

I always try to understand at what level of the unified system a particular theory-method set is operating and clearly placed mentalization in the intrapsychic-biological  and interpersonal-dyadic domain. Mentalization occurs in a relational configuration and essentially structures the developing infants mind probably by strengthening connections in related brain regions especially between the frontal cortext and limbic system but certainly more complex connections are occuring. 

The concept of trauma is essential for any theory of psychopathology and is well established as the common pathway to many forms of psychopathology. Trauma not only causes distress but disrupts the attachment system and if not repaired creates ongoing issues that can derail development. I thought it was interesting that Fonagy believes, as I have seen in my clinical practice, that neglect is really a malignant form of trauma. At least when someone is overtly abused they exist to the other but when neglected they are insignificant which has many serious implications.

I suspect that all experienced therapists are activating mentalization systems in the brain through sophisticated self-other methods of restructuring which is basically internalizing objects or formulating schemata. One could say that the interpersonal processes are captured in intrapsychic structures in an iterative process. If you get a chance Fonagy is certainly worth listening to or reading about.