Transcript for
Mentalisation and parent-child therapy

Runtime 00:27:43
Released 28/10/19

Narrator [00:00:02] Welcome to the Emerging Minds podcast.

Dom Kleinig [00:00:08] You’re with Dom Kleinig and today I’m speaking with Perth-based psychologist Dr Matthew Ruggiero, about mentalising and mentalisation base therapy. Matthew has worked in private practice for nine years and also lectures at Curtin University. His clinical work is focussed on working with children, adolescents and adults when things seem to be persistently going wrong in their relationships with others. He’s also a mental isation based therapy supervisor who consults in health and statutory settings. In this episode, Matt and I discuss the concept of mentalising as a developed skill that we all use. And how supporting its development can strengthen the resilience of relationships and contexts which put pressure on parents and children.

[00:00:46] Welcome Matt, thank you for coming and meeting us here. It’s been a long day for you I know. We are here at Emerging Minds and you’ve come all the way from WA. Maybe you can tell me a little bit just about yourself. Just to start with and your professional history a little bit?

Dr Matthew Ruggiero [00:01:03] I’m a psychologist. I did my training at Curtin University and went on and did a Master of Counselling Psychology and a PhD with that as well. And broadly speaking, most of my work has been developmentally focussed. So in the organisational work that I’ve done and private work that I’ve done and the lecturing that I do as well, my kind of bent or slant is related to developmental processes and the implications of those for treatment.

Dom Kleinig [00:01:43] I’ve got you here today under the pretext of talking about mentalising and mentalising based therapy. So I wonder if you can give us a little bit of a definition of firstly, I guess what mentalising is and maybe disambiguate that we’ve learnt mindfulness and reflection and reflective practice, that sort of thing.

Dr Matthew Ruggiero [00:02:03] Yep. It’s a it’s a good question because mentalising often gets used to sort of sort of catchall term for those reflective processes empathy, psychological mindedness, affect consciousness, all of those sorts of times mindfulness. And actually it has a very specific definition. So mentalising is a normal human ability to think about intention. So if you think about behaviour in the world will act and we act with others in the social world. Actually our ability to react well together and sort of to engage in teamwork together, depends on our capacity to make some sense of why we’re doing what we’re doing, why other people do what they’re doing. And mostly we don’t have to think about that. It’s something that instinctively comes to us. If we’ve had a decent enough upbringing and a decent enough experience of having the people around us during our upbringing to make what’s happening in our minds and in their minds fairly clear. So mentalising is this ordinary sense of trying to think about what’s happening in people’s minds to try and make sense of their actions. And the reason it turns out to be quite important is because one way of thinking about quite a lot of psychopathology and certainly personality pathology, is as a sort of communication breakdown, an inability to flexibly and curiously make sense of what goes on behind behaviour when we’re together. So I hope that contextualizes it a bit. And the reason I would say that it needs to be distinguished from those other concepts is because unhelpfully probably, it kind of captures all of those concepts, all of those concepts are in a way a sort of little bit of what it means to mentalise. So empathy, for example, is other focussed. It’s about me trying to tune in to you and what’s going on for you and tends to be more about how the other person’s feeling, mentalising captures that. But it’s also interested in what’s going on in my own mind, what’s going on in me as I’m with you. And and not just in feeling, but in thinking or how our needs might be impacting us or our longs or wishes or desires. So it sort of captures a lot. But if you wanted to strip it all down, it’s really about trying to think about why we’re acting the way we are and what sits behind that.

Dom Kleinig [00:04:53] That sounds like a very fundamental process in that way.

Dr Matthew Ruggiero [00:04:57] Well the creators of mentalising and MBT would say it’s a fundamental process and I would tend to agree with them. And maybe one of the reasons why I see it as being fundamental is because it’s such a critical developmental capacity. Another way that it gets talked about is in terms of theory of mind. Being able to think about what’s in someone else’s mind, which is something that normally emerges around four or five years old. And actually it’s really essential in the years leading up to that, that we have good experiences of having adults do that, sort of wondering and thinking and and labelling of the mental states that we as children have.

Dom Kleinig [00:05:36] Can I just. We’re just doing a little bit about us here at Emerging Minds. I think one of the things that we tried to put out into the world is a picture of the whole child. I think some of the things you’ve talked about of having a caregiver who can say what’s going on, give you some insight into yourself and into the world around you. And having people around you who can do that for you as a child and you are developing. Can you just tell us about how maybe mentalising fits into a picture of the whole child and I guess a child’s ecology?

Dr Matthew Ruggiero [00:06:11] I think that one of the key ways it plays into thinking about the child as a whole, developmentally speaking, is in through the process of marked mirroring, which I can explain fairly quickly. If you think about any of the feelings that you’re able to distinguish, you know, if I was to say to you, how do you know when you’re angry? How do you know when you’re sad? And how are you able to work out that you’re one and not the other? Actually, that’s a very difficult question to answer in any real way, because most of us don’t sit there thinking about our feelings explicitly and thinking, what is this feeling? Oh, I guess it’s probably anger. It’s definitely not sadness. We just sort of know and we kind of take for granted that we just know. And actually, it’s really important that we’re able to just know because being able to just know means that we can respond quite quickly to the things that are going on around about us. And we can respond in a way that’s sort of about what’s going on for us. If you’re sad, you need from your environment different responses to when you’re angry, for example. So the way we learn to distinguish our internal states and there’s way more than just those two is through this process of marked mirroring. What happens is that babies and young children don’t have words, don’t have nice concepts in mind to be able to distinguish. But actually by having adults around who can recognise states, who can respond to them, not in an intellectual way, but in a way that’s sort of about what’s going on. So when the baby is screaming and desperate and frantic phone for some comfort, a mother or father who is able to read that. And most parents, the vast majority, can very naturally. Why not just say ‘there, there’, they’ll respond to sort of in a physical embodied way, and become the sadness or the distress would be plastered across the parent’s face. And so we call that mirroring because it’s like the parent is holding up a mirror to the child saying, ‘look, this is what you’re feeling. And I get it, I see it. And it’s not too much for me, and I’m coming to aid in response’.

[00:08:30] But the second quality is marking, that’s important. And that is that when the baby is highly distressed, that actually the parent isn’t equally distressed. It’s not a perfect mirror. The parent isn’t thrown to pieces in the way that the baby is feeling all to pieces. The parent takes the feeling and gives a sort of caricature response. And again, this is all totally natural and instinctual and part of how we continue as a species. And so the parent responds in a sort of exaggerated way. And so ‘oh there, there, there’, and this is very comforting. And this process repeated over and over again, reflects good parenting and is the foundational way that the child is then able to take in a sense of this is the experience that I’m having. It has a name, it has parameters that aren’t overwhelming. I know that because I’m with someone who’s not overtaken by these. And over time, the baby or the child is able to draw on their own sense of what it is that’s going on inside. It is a very, very nuanced fine process that happens over a long period of time. But is basically the early precursor to mentalising, to being able to distinguish that there are things that are happening inside, that they can be very powerful, that they evoke needs and that we act in response to them.

Dom Kleinig [00:10:01] Thank you for that explanation that’s really good and detailed way of putting it. And I found myself as you were explaining it, mirroring your enthusiasm for the content of what you’re talking about. My eyebrows were raising.

Dr Matthew Ruggiero [00:10:14] It happens naturally you are drawn.

Dom Kleinig [00:10:16] Yeah. Yeah. It felt very natural.

Dr Matthew Ruggiero [00:10:19] And it’s probably worth saying in terms of pathology, because I know that we often work with the few for whom things fall apart rather than those who happily go about doing the job of parenting and child rearing. And it all goes well. But the reason why knowing about this process is important is for precisely that reason. When it doesn’t happen effectively, actually, it throws things, it can throw things out substantially for a child. When the child’s experience is that they’re not able to have their states seen accurately or responded to consistently, contingently it’s what we call it. It creates problems down the line in terms of that child’s ability to first of all contain their states, down regulate them when they’re too big. And second of all, to be able to read states accurately in other people and then respond to them. So in the worst cases, in the most problematic cases, you have the experience of the personality disorders that start emerging in early adolescence, where actually the experience that the person suffering has of the world is that I know exactly what’s going to happen in a social interaction. I know exactly what I can expect and it will play out that way. And that means that there’s very little ability to take in new information or to learn from social engagement.

Dom Kleinig [00:11:52] It becomes quite fixed or rigid.

Dr Matthew Ruggiero [00:11:54] Yeah. When in fact, we need to be able to take in new information, we need to be able to work out in a way each time we’re interacting with someone new. We need to be able to work out how trustworthy is this person and how much do I need to take in something that they’re giving me? How much do I need to be able to respond to what they are giving me? As if that if that process is gone awry, then either it results in too much trust for the wrong people. And you can for that sort of thing, bring to mind people who are quite naive, who might be easily taken into awful relationships, violent relationships and that sort of thing. You can also have the opposite kind of profound mistrust and inability to distinguish gentleness in your eyes or relaxed posture, and perceive a sense that actually talking to you, Dom. You look like you’re the kind of person who’s gonna be open to me and who’s gonna give me something useful. If I’m not open to seeing that, if the implicit kind of set of beliefs that I bring to this are that you, you’re going to be mistrustful, you’re gonna hurt me, you’re gonna misunderstand me. That actually destabilizes social relationships in a way that’s very hard to, to repair.

Dom Kleinig [00:13:19] So for someone who might be working with a family or with a child, then maybe there’s this context where they don’t have a way of understanding people’s intentions as clearly as someone who has that developmental experience of being held in mind and being seen clearly. What are some of the things that MBT can offer to them to support those families and to engage them?

Dr Matthew Ruggiero [00:13:47] Well, I think the answer to that question actually isn’t just about MBT. Increasingly, it’s about what we’re starting to see in the literature that underpins most of the treatments that end up working. MBT isn’t the only one that is effective, it just sort of is the most explicitly focussed on mentalising. But the things that seem to be important first and foremost that practitioners treat the people they are seeing as self-determining agents, that they’re interested not in insisting that there’s a problem to begin with and challenging that there’s something to change. But actually trying to see the world through the eyes of the family or the child or the person that they are with. And it’s not about paying lip service invalidating, but it’s actually showing that if you’ve come to see the world in this way, there must be some way in which that’s a valuable way for you to be seeing things. And it’s modelling that actually I don’t see things that way straight away. Because I’ve had a different set of experiences and I need your help to put it all together to be able to imagine exactly how things are for you. So it is validating, but it’s not about just what often gets thought of as empathy. You know, ‘there there, oh that sounds terrible’. It’s not that kind of empathy. It’s about trying to actually build a picture of exactly how this looks. And then it’s engaging the patient agency, i.e. not providing all the answers as though a therapist somehow has all the answers, but trying to work together to work out how we are going to look at this as a problem. How are we going to look at where you want to get to, and how we can navigate that as a partnership? And what becomes important there is that the therapist has a coherent, structured way of thinking. So this is where it’s important to have a theoretical model or a treatment model that you’re confident in being able to to draw upon to put the pieces together. So, for example, in MBT, if we’re thinking about mentalising, we might sit together and I could say, ‘look, there’s a way of thinking about what we’re talking about. That has to do with this thing called mentalising’. And you can sort of map it out together and see whether that fits the the person’s sense of what goes on for them. And if it does, then you’ve got a structured way of thinking about what matters.

Dom Kleinig [00:16:34] How are you using that in those contexts and what does it look like in some of the people that you’re that you’re seeing, children or parents?

Dr Matthew Ruggiero [00:16:41] Yeah, I think although I relish the opportunity to do MBT formally with people, more often than not, the work that I’m doing is sort of MBT light. And I think around the world actually more people are engaging in a sort of mentalising, informed treatment approach than actually doing the formal thing that the Anna Freud Centre has specified in the mentalisation based treatment, which is a roughly twelve to eighteen month process of engaging in an introductory psycho education group followed by weekly group and individual therapy. So it’s a very specified process and there’s a lot of adaptation going on because of how intense that is. For example, child protection services just simply wouldn’t be referring people if I was to say to them that in every case I needed 18 months of group plus individual therapy every week.

[00:17:40] So it becomes this interesting thing of trying to work out what’s needed and what’s the most efficient way that we might be able to go about doing that without compromising on the fidelity of what I’m trying to do. And really to simplify that, it’s exactly what I’m talking about. So I’ll initially engage in a period of trying to understand how whomever I’m with sees the difficulty that has brought them to see me. And we engage in something that’s quite central in MBT and that’s a period of formulation. And most treatments have a way of formulating, but it differs a little bit in MBT in that the goal is not for the therapist to develop a kind of expert conceptualisation of the problem through whatever theoretical lens they have. The goal of formulation in MBT is to model sitting together and placing the patient’s mind in the middle and trying to think about it together and make sense of it together. And although a therapist might come with a sort of a structured way of thinking about the patient’s mind, so you might write a paragraph or two about what you think brought them to see you and how you understand it in mentalising terms. Actually the point of it is not getting it right. In fact, the opposite. The point is to be able to work together to update the way I think about things so that we can both buy into the way we’re seeing this.

[00:19:18] So in a way, it’s mentalising together right from the start. It’s trying to think about what what is occurring in the mind of the person to result in their problems. And it models the respecting, the nature of minds in that minds are opaque, that even the best theoretical models and treatment models only offer hypotheses, general ways of putting things together. It is very anxiety provoking to work out how do we sit here and put your parenting or a child who has experienced horrible things in their past? How do how do we find a way to talk about that together in a way that brings us together? It’s a very fraught process. I don’t know about any other therapist, but it’s an anxiety-provoking process every time for me. And the urge, well, the various urges that I’ve seen in me and in my supervises are to get very good at explaining. And that provides a little bit of sort of distance if I’ve got the explanation. Then it’s all worked out. I don’t have to be so anxious about it. If they disagree with me, then they’ve just got it wrong. So having an explanation can be a bit like needing to settle my own anxiety about this. Being interpretive is another way that we can manage our own anxieties. And all of these are at least at the start of therapy, non mentalising in the sense that the therapist is essentially insisting that they have the inside scoop on how to put this person’s mind together. And even if they’re right, in MBT, it would be said that even if you’re absolutely right, that actually provides no use to the person who has difficulty putting their own mind together. Even if the therapist is totally accurate in the hypotheses that they have. If the patient can’t do something with those hypotheses, they’re meaningless.

[00:21:27] So the first thing that I think is useful for me in therapy is trying to come up with a shared sense of why we’re here, of how we’re going to see it as a patterned problem and what we’re going to try and work on together. And as part of that, I don’t know if I’m getting too detailed here, but as part of that, I want to try and specify not just what happens that goes wrong, but actually what we think sits behind that together. Actually, what sits behind the way these behaviours map out in your relationships. How do you end up seeing things that means you respond in that way? Or that at the end of a process means you become very aggressive or that you engage in self-injurious behaviour of some sort. Once we’ve got that mapped out, then it’s not the behaviour that we’re trying to change with a mentalising focus. It’s building the person’s ability to self mentalise, to be able to make sense of what’s going on for them and for others at the times when historically they lose that ability. So the benefit of that approach with the sorts of people I’m seeing who have experienced complex trauma, for whom trust comes very slowly. Vigilance is meal of the day. That early process is respectful. And the goal of it is to try and establish some basis of trust where even if it’s only tenuous. There will be times when actually I might be able to say or do something that is going to be useful to you. Then we can work on whatever treatment you’re doing. You can work on some skills development, or you can engage in some thought monitoring, or you can offer interpretations or you can do whatever it is you do in your treatment of choice. But actually, then it’s going to be meaningful because the person’s capacity to take in something new from the social environment is going to be at least minimally switched on.

Dom Kleinig [00:23:44] I want to ask you a question that probably takes you out of any realm of expertise, but it relates to us here at Emerging Minds and just thinking of the broader context for people. The social environment they maybe go back to. What what do you think the utility of ideas of mental ising and even from MBT are at a public health kind of level, if it exists at all? Is there something in at a policy level that these ideas can be of use to policymakers or people who are trying to improve the life of children and children’s mental health at that broader level?

Dr Matthew Ruggiero [00:24:24] Frankly, I think that behaviour is important, but we need to help people to see beyond it. That no child or adolescent or adult wakes up in the morning determined to do bad or to do wrong. But actually often behaviour gets perceived or labelled in that kind of a way. The point of mental izing is that behaviour has a point. It’s driven by something. It’s motivated by something that’s happening underneath. And it is so much easier just to react to behaviour rather than to engage in an effortful process of trying to understand it. Particularly, I’m thinking of kids who are engaging quite problematic behaviours, it’s particularly difficult for loud, obnoxious, frightening behaviours to respond by in some way for any adult, including clinicians, including teachers, including parents, including people in any sort of regard. It’s really difficult sometimes to engage in a thoughtful process of trying to understand the point or the motivation of a behaviour. And this might be the sort of attraction of behaviourally focussed treatment and intervention and reinforcement planning, and all that sort of thing. Which there’s no I have no problem with any of that, except that in order for long term psychological change to occur for children, they need help to develop the capacity to mentalise, to think about what goes on inside them and inside others. And we don’t learn that by simply being given star charts or by being educated about how we ought to behave.

[00:26:19] All of that is good. And so I don’t want to be seen to be sort of splitting here and saying some interventions about and some aren’t. But actually, we need to try and foster the development of this skill in children. And it’s something that they require modelled in relation to them and their loudest behaviours in order to to draw out and and build that capacity. So maybe that’s what I would change to actually try and make some sense of kids rather than just educating them.

Dom Kleinig [00:26:50] Make sense of them instead of educating them. I like that.

Dr Matthew Ruggiero [00:26:53] Well as well as educating them.

Dom Kleinig [00:26:55] Maybe that’s a good place to draw a line under the interview. Thank you so much for giving us an insight into your work and your understanding of mentalalising. Really appreciated that.

Dr Matthew Ruggiero [00:27:08] Thanks.

Narrator [00:27:10] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.

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