Transcription
All right, well, I want to welcome everybody here this evening, uh, for the webinar. Um, we're very pleased to have Carla Sharp with us to speak on the topic of mentalizing. Before we introduce Carla, I just want to let you know a little bit about the Sash Bear Foundation and about this presentation tonight. I'm Doreen Hyndman. I'm the Executive Administrator for the Family Connections Program in Canada, as it's delivered through the Sash Bear Foundation. And the Sashbear Foundation is an organization that was formed to promote education and reduce stigma around the topics of borderline personality disorder and suicidality. And we offer the Family Connections Program free of charge throughout the country, as well as offering various other services, including these expert presentations.
So, this evening's presentation is a webinar. That means that all of you are currently muted and your cameras are turned off. And so, if you need to step away at any time, you're perfectly welcome to. You can pop questions into the chat, and those questions will come to those of us managing the, the webinar. And also, there's a Q&A feature. If you have access to that on your computer screen, you can put questions into the Q&A, and Dr. Sharp will answer a few questions for us at the end, as we have time.
So, um, I just wanted to remind you, the Sashbear Foundation, you can find more information about us at our website, www.sashbear.org, through social media. And as a registered charitable organization in Canada, we do always accept donations for our work, uh, through the Canada Helps website. So, at this point, I would like to turn it over to Lynn, who's the co-founder and president of the Sashbear Foundation, so that she can introduce our guest speaker tonight.
Thank you, Doreen. We're very excited to have Dr. uh, Sharp tonight with us. Dr. Carla Sharp is a professor of psychology at the University of Houston in Texas and conducts research into borderline personality disorder in children and adolescents. She has conducted several pioneer studies in this field and has published over 260 publications and journal articles and books. In 2016, she was the recipient of the Mid-Career Award for the North American Society of the Study of Personality Disorders. She was recently the recipient of the 2018 Award for Achievement in the Field of Severe Personality Disorder from the Personality Disorders Institute and Borderline Personality Disorder Resource Center. In 2013, I had the privilege to of being introduced to Carl, Dr. Carla Sharp, by Dr. Perry Hoffman at the North American Society for the Study of Personality Disorder conference. Since 2016, we have been supporting and embracing the Global Alliance for Prevention and Early Intervention for BPD, a position paper submitted by Carla Sharp, Andrew Shannon, and Perry Hoffman. At many conferences on BPD throughout the world, we connected with Dr. Sharp throughout the years. Here you can see a picture taken in Tel Aviv at a conference in November 2016 with, uh, Dr. Perry Hoffman, Dr. Dr. Shannon, and Doctor Blessed Gary. And last but not least, in 2019, Sashbear helped to organize the ISSPD Congress Family Day in Vancouver, and we were privileged to have Dr. Sharp deliver the Family Day closing and remarks. It was very impactful and provided hope to the families that attended the event. Tonight, Dr. Sharp will present on mentalizing. Research shows that our capacity to mentalize helps foster mutually rewarding relationships with others. In this talk, Dr. Sharp will introduce participants to the con, the concept of mentalizing and how it can be utilized to improve the quality of relationships with loved ones. Without further ado, here is Dr. Carla Sharp.
Lynn, thank you so much for introducing me, and I am so privileged to be able to speak, uh, with you and all of the participants in this webinar tonight. I just want to thank Sashbear Foundation for all the amazing work that you've been doing, not only in fact in Family Connections but also in advocacy. Um, you're making a big impact, and I'm just really pleased to be here tonight and share, um, some of the ideas that we've been working on with you. I am going to show you my screen, and I will trust that you will tell me if anything goes wrong in the sharing. All right, that looks good. And I just want to take a second to, um, I want to take a second to share the sound. I think we're good to go. And, um, so I am going to speak with you, uh, tonight about mentalizing, the construct of mentalizing, and what it is and how to do it. And to start us off, I'm going to show you a little video, um, explaining the construct of theory of mind.
Theory of mind and mentalizing, two constructs that can be used interchangeably. Mentalizing is slightly broader than theory of mind, but I think the video will help introduce this, uh, construct to you. You're going to have a tea party with Play-Doh. I'm going to serve myself. No. Well, you've probably discovered that however smart your three-year-old is, she doesn't seem able to put herself in someone else's mental shoes, to imagine how they think and what they believe. Perhaps you thought your parenting skills were to blame, but scientists suggest that understanding other minds is a skill that may not be fully developed until a child is about four. To learn how children's social skills evolve between about three and four, researchers use something called a false belief test. What do you think's in this box? Looks fairly obvious, doesn't it? Crayons. But let me show you. I filled it full of candles. All right. Now, I close it up again. While you and I have been having this conversation, Snoopy has been down here asleep. He doesn't know what we've talked about. But let's bring him into the conversation. Now, I have another question for you. What do you think Snoopy will say if I ask him what's in this box? Crayons, obviously. What else could anybody possibly say? Well, watch this three-year-old. What do you think is inside this box? Okay, let's open it up and see. Now, you can ask the child what appears to be a very simple question about that. What did you think was inside the box when you first saw it? They say, "Oh, I always thought that there were candles in this box." Then you can ask them about someone else. So you can ask them about Snoopy. Snoopy's been sitting here. He hasn't seen this box. He's never seen us open it up. What does Snoopy think is inside this box? Cowboys. Children say the same thing. Snoopy will think there are candles inside this box. What that indicates is that the children's view of how minds work, it's very, very different from the view that you and I would have. Yes, did you see it? In the mind of the three-year-old, everyone sees the world much the same way. There's no difference between what I think and believe and what everyone else, including Snoopy, thinks and believes. It is, in a sense, a naive and innocent view of the world, a kind of mental Eden. And then about four comes the fall from grace. What now? If you take a four-year-old, quite typically, the four-year-old will tell you that as a matter of fact, he thought there were crayons in the box, and then he found out that there were candles in the box. You can ask him about Snoopy, and he'll say, "Oh, no, Snoopy will think that there are crayons in this box." Great. Why would he think that? Because it's a clam box. That's right. And that's gonna make you think they're grounds. What's really in the box? Candles. And then you get the five-year-olds who are just utterly blase and think that this is such an obvious thing, it's silly even to ask the question. What that shows is that by the time children are four and five, they have a view of the mind that looks much more like our view of the mind. They understand that things can be tricky and deceptive, that you can change your mind, that things aren't always the way that they seem, and that gives them a very different vision of how the mind works and how people work. Remember, we're sharing this. Oh, I need that. And then it's my turn. Children who pass the false belief test now understand that other people can have different beliefs, even mistaken beliefs. Some scientists suggest that this test is further evidence of innate brain circuits specialized for reading other people's minds. They call it a theory of mind mechanism.
All right, so we saw in that video the difference between a three-year-old who is thinking that what's in his mind matches reality, and the four-year-old who realizes that what's in her mind doesn't necessarily match reality. And that's really the core meaning of mentalizing or theory of mind: the capacity to reflect on one's own thoughts and feelings and those of others, to predict and understand behavior, to understand that what might be in my mind about your behavior may not be how you see that behavior, or may not even reflect the reality of what occurred. That what is in our minds is really just a representation, a, a an imagination of what might be really going on. And in order to verify whether that representation is real or true, all we can do is be curious about that. But we cannot assume that what is in our mind is the truth or does reflect what really, um, happened. And it reflects the idea that people can change their minds. I can change my mind because what is in our mind is just a representation of reality and not reality itself. It means that we can change our minds. We can change our view on things. We can change our perspective on things. We are not caught or locked into a particular perspective or a representation of what is going on. That can be renegotiated. That meaning of what we are thinking or our replica of [Music] reality can be changed or adjusted or negotiated. It means that things are not always as they seem. Things are not always as I think they are. Uh, to know whether things are the way I think they are, I need to explore and be curious about whether that's actually the case. I can't merely assume that it, that what is in my mind is an exact replica of what is really going on. Um, so it promotes uncertainty and curiosity. It puts us in a position of seeking clarification, and it really means that we place ourselves in a position of not knowing, a not-knowing stance, a curious, not-knowing stance about other people's minds. And so the official working definition of mentalizing is that it is a form of imaginative mental activity. So what we're doing when we're mentalizing, we're imagining what someone else might be thinking. We're not sure, but we're thinking, we're hypothesizing about what might be going on. We're perceiving and interpreting human behavior in terms of intentional mental states. We assume when we mentalize that there is meaning behind someone's intentions, but we don't know what that meaning is, and we want to inquire. We want to be curious about what the meaning might be. And so mentalizing is an umbrella concept that encompasses a lot of different types of mentalizing, and I'm going to introduce that to you now. And this looks more complicated than what it is. It's really a cube that gives us all of the different types of mentalizing. There's explicit and implicit mentalizing along this axis, self-other mentalizing along this red axis, cognitive and affective mentalizing along, along the green axis, and then here, um, internal and external mentalizing. And so we can place someone's mentalizing on this dimension, on these dimensions, and we can say, "Oh, it looks like she's busy with affective mentalizing, and the X means that she's using external features of the face to engage in this affective mentalizing, and it's more focused on other mentalizing than on self-mentalizing, and according to that access, it lies more on the explicit side of things." So I'm going to explain to you now what all of these different types of mentalizing really means. We'll start off with explicit and implicit mentalizing. And implicit mentalizing is shooting from the hip. You're in a situation, it's, it just happens automatically. You're not really consciously trying to understand or read someone else's mind. It just happens by itself. So perceived, it's emotional resonance, it's empathy, it's non-conscious, it's procedural, it happens by itself, it's non-verbal, it's non-reflective, it's fast, requires little effort, um, and focused attention or intention, and it's facilitated by arousal. Explicit mentalizing is interpreted, explained. You take the perspective. You consciously trying to think or unpack what might be going on. It can usually be verbalized, and it's reflective. It's therefore slower and sequential. It requires your attention, and it's inhibited by arousal. And so to give you an example, we can imagine a scenario where a wife is saying to her husband, "My darling, did you remember to pick up the dry cleaning?" And the husband says, "Oh no, I forgot. I'm sorry." And the wife, feeling annoyed and thinking that he did not really want to do it in the first place, says, "Oh no, I need the black dress for tonight's work function. I wish you told me that you weren't going to pick it up, and I would have made an effort to pick it up myself." The husband says, "Well, I just told you I forgot. I meant to pick it up. I'm really sorry." The wife, remembering the last time that her husband forgot to pick up one of the children from the soccer practice, says, "When I asked you, you looked like you didn't really want to do it. I could have easily swung by to pick it up if you'd been honest about it. I'd much rather you don't commit to help out if you don't think you can follow through. At least then I know I need to get it done myself." And so here you can see a lot of automatic mentalizing taking place. She's not really stopping to think of other options or other perspectives or alternatives of what may have happened that her husband forgot to pick up the dry cleaning. Um, we can compare it with this example here. "My darling, did you remember to pick up the dry cleaning?" "Oh no, I forgot. I'm sorry." The wife, again, feeling annoyed because she thought that he didn't really want to do it in the first place, um, says, "Oh no, I need the black dress for tonight's work function. I'll make a plan. But listen, can I talk to you about a broader issue that this relates to?" The husband then says, "Sure, what's up?" And she's remembering the last time that he forgot to pick up the children from soccer practice. And so she says, "I know I might be completely off base, but when you forget to do something like pick up the dry cleaning after we agreed you do it, it makes me feel that I or our family is not a priority. It might just be some insecurity on my part, but our relationship is important to me, and I want to get your perspective on this." And so this is an example then of explicit mentalizing, where she is actually stopping to think, "Well, what's going on with me right now? I'm feeling annoyed about this being the second time now that he forgets, or third or fourth time that he forgets, and I'm not sure if this is me or you, but I want to bring this to your attention. I want to try and interpret this. I don't know what to make of this, but can we talk about this?" So that's an example then of explicit mentalizing.
So, the difference between implicit and explicit mentalizing. Looking at this example, we would think that implicit mentalizing is therefore bad because it's sort of shooting from the hip and not really thinking before you say something or doing something. And we might think that explicit mentalizing is good. But it's not really the case. So let's look at this example. You wake up in the middle of the night from a noise downstairs. As you tiptoe into the living room, you see that the window has been broken and a stranger is busy rummaging through your drawers. When the stranger turns around towards you, you notice that he's carrying a knife. When you're in this situation, you really do want to shoot from the hip, and you don't want to be reflective. You don't want to say, "Excuse me, sir, I notice that you're in my living room and you're rummaging through my drawers. What might be going on? Can we have a conversation about this?" That would be explicit mentalizing. But this is a situation where you don't want to engage in explicit mentalizing. You do just want to let your body, your flight or fight, take over, and you want to call 9-1-1 or run up the stairs and make yourself safe. So the point here is that implicit or explicit mentalizing is neither good nor bad. It's context-specific, and whether which one of the two we're engaging in must fit the context. If you're at work and your boss is telling you off about something that you did wrong, that is not the moment to be shooting from the hip and engaging in implicit mentalizing. That is the time to take a deep breath and engage in explicit mentalizing so that you can try and figure out what's going on, what is the impact of what your boss is saying to you in the moment, so that you can think to yourself, "What is the best way of handling it and really finding out what's what's really going on here?" So it's, it's about the fit with the context. It's not that the one is good or bad in itself.
What about cognitive and affective mentalizing? So cognitive mentalizing really refers to thinking language that we add to the way we talk and interpret and look at the world. Leslie was the researcher who first introduced this idea of meta-representations. And he basically just analyzed a sentence like, "I'm being mean on purpose." Instead of saying, "I'm being mean on purpose," "I believe you think that I'm being mean on purpose." So you can see by adding those thinking language, the meta-representations, we are changing the meaning of the sentence to be more tentative, to be more curious. Let's have a look at these, uh, examples. "She wants to be friends with me." By just adding, "I think she wants to be friends with me," we are moving that sentence, "She wants to be friends with me," from a certain preposition to something that is a little bit more uncertain. That opens up the possibility for communication and for connection. "I think she wants to be friends with me. I'm not sure, but I think she wants to be friends with me." "She would like to be friends with me." "I wonder if she would like to be friends with me." "We could be good friends." "I believe we could be good friends." "He was going to call me last night." "I thought he was going to call me last night." "We had it all figured out last time we talked." "I was under the impression that we had it all figured out last time we talked." "She's upset." "Sorry, I'm thinking or I'm wondering if she is upset." So you can see by adding the thinking language, we turn the sentence into a representational sentence. We give a cue or we signal that we're not talking about reality. "She would like to be friends with me" sounds like reality, but if I say, "I wonder," it spins reality and it says, "Well, whether she's going to be friends or not with me, something that's in my mind. I don't know if it's really true. I don't know if it matches reality." So you can see again, coming back to that original concept of theory of mind, we are able by to then tag it as representational, that what is in my mind doesn't necessarily match perfectly onto reality.
Affective mentalizing, compared to cognitive mentalizing, is something much more automatic. And I'm going to show you this video to illustrate what we mean with affective mentalism. Babies this young are extremely responsive to the emotions and the reactivity and the social interaction that they get from the world around them. This is something that we started studying 30, 40 years ago when people didn't think that infants could engage in social interaction. And the still-face experiment. What the mother did was she sits down and she's playing with her baby, who's about a year of age, and she gives a greeting to the baby. The baby gives a greeting back to her. Yeah. This baby starts pointing at different places in the world, and the mother's trying to engage her and play with her. They're working to coordinate their emotions and their intentions, what they want to do in the world. And that's really what the baby is used to. And then we ask the mother to not respond to the baby. The baby very quickly picks up on this, and then she uses all of her abilities to try and get the mother back. She smiles at the mother, she points because she's used to the mother looking where she points. [Music] The baby puts both hands up in front of her and says, "What's happening here?" She makes that screechy sound at the mother like, "Come on, why aren't we doing this?" Even in this two minutes when they don't get the normal reaction, they react with negative emotions. They turn away. They feel the stress of it. They actually may lose control of their posture because of the stress that they're experiencing. [Music] "I'm here, and what are you doing?" Oh, yes. Oh, would it be girl? It's a little like the good, the bad, and the ugly. The good is that normal stuff that goes on that we all do with our kids. The bad is, well, he's just finishing up the, uh, it's saying that when, when there is trauma, actually, that is the, the sort of most significant disruption of affect of mentalizing. And I'm just gonna quit there. And something bad happens, but the infant can overcome it. After all, when you stop the still face, the mother and the baby start to play again. The ugly is when you don't give the child any chance to get back to the good. There's no reparation, and they're stuck in that really ugly situation.
So you saw really the effect of mentalizing, um, when the mother is not engaged in the still face. And most of affective mentalizing is non-verbal. It's synchrony and touch, connecting with someone in a non-verbal way. It's often unconscious and implicit, but can be made conscious if we look at that, for instance, on video. What about self-other mentalizing? So if we come back to that example of the wife and the husband and the dry cleaning that wasn't picked up, you can clearly see that the wife is busy really thinking about what's going on in her own mind, and it's difficult for her to mentalize what's going on in the mind of her husband. She doesn't really give a chance or an option for what might have happened on this occasion for him to to have forgotten. Instead, she jumps to conclusions about his intentions, and that this is part of a broader pattern of behavior. Now, she, of course, may have a lot of data from before to suggest that there is something wrong here, and that there is something wrong in the intentions of her husband. The question in mentalizing is, what purpose does it serve for her to jump to those conclusions in the moment? Will it help the couple resolve or feel close to each other or have a close relationship if she jumps to conclusions, even if there is good data to suggest that he deserves it? In this example, where, um, she is now engaging in reflective mentalizing or explicit mentalizing, she's much more able to sort of take his perspective into account in trying to figure out, well, what really did happen here, and and how does my reaction connect to what's going on for you? And then finally, external and internal mentalizing. So you saw a very nice example here where the, um, mother, her still face becomes a blank, um, slate, and the baby has no clue. There's no cues coming back to the baby about what his mom is thinking or feeling. And so that means that the baby has to only rely on the internal features of, of, of her mind. Of course, the baby is still too small to be able to imagine. Doesn't, baby doesn't have the representational or metacognitive capacity to imagine what his mom is thinking. So the reliance on the internal features of the, of, of the mom is sort of falling flat and not being, um, successful. So when we think about mentalizing, we can really put people on this, on these four dimensions: implicit, explicit, and interior, exterior, and cognitive, affective, and self, and other.
So what guides us in whether we are going to mentalize or not? First of all, um, mentalization capacity is guided by our capacity, and that capacity both has biological roots as well as learned roots. Research has shown that some people are better mentalizers than others. Um, it turns out that women are slightly better mentalizers than men. And mentalizing also comes about by by learning. We often talk about in our work about early childhood or the early environment being a laboratory where a child can be learning the serve and return, the serve and return, the ping pong, um, and thereby learn to mentalize. So mentalizing comes about by with an interaction of those two things, um, happening. But mentalizing also comes about by goals and values. As I said earlier, if the wife has no interest in having a good relationship with her husband, she may not feel motivated to really stop and think about that particular incident with the dry cleaning. She may say, "You know, I don't care. I don't want to solve this. I don't want to repair the rupture. I am just going to think about you in one way, and what I think is the truth, and I'm not going to try and negotiate a shared meaning between the two of us." And therefore, we talk about the deep objective. What is your deep objective in your relationships? If your deep objective is to have a rewarding, fulfilling relationship, then there is motivation to stop and slow down the interaction, to engage in explicit mentalizing when, when it's asked for.
So why is family mentalizing important? Because it scaffolds personality development. And, um, I don't know, uh, if you guys saw the movie Inside Out. I think it's a really good movie for understanding how personality develops. Um, and, uh, I do understand that they, uh, the team was advised by someone who did understand emotion memory, uh, processes quite well in, in the brain. And this is just the four emotions that, uh, this main character, Riley, or five emotions that she tends to feel. And here is what I want to draw your attention to: the pillars of her personality. And you'll see that these are particular domains of function, and the family domain, and the hockey domain, and the fun, fun domain over there. And what happens with Riley when she moves from one city to another is, and there's also a traumatic event that happens there, these pillars that's, that scaffolds her personality start to get gray and they start to fall away. And it is really through bringing representation back, helping her thinking and remembering good times, not the reality of this situation, but the representation of a reality, that she builds back the pillars of her, um, uh, of her personality function. And here you can see towards the end of the movie, she actually has much more differentiated pillars that start to grow. Much more color is coming back into her personality. So really, how we scaffold personality function in our children's lives is by drawing on their representational function, by helping them think through replicas of reality, that there are multiple ways of interpreting reality, that we are not caught or stuck in one way of seeing the world.
I'm going to show you another video that tries and expresses this idea of the role of adults in helping children develop a healthy personality, but also just protecting them against psychopathology of all sorts: depression, anxiety, substance use, and personality disorder. So let's just look at this [Music] video. [Music] Science tells us that the experiences we have in the first years of our lives actually affect the physical architecture of the developing brain. This means that brains aren't just born, they're also built over time based on our experiences. Just as a house needs a sturdy foundation to support the walls and roof, a brain needs a good base to support all future development. Positive interactions between young children and their caregivers literally build the architecture of the developing brain. Building a sturdy foundation in the earliest years provides a good base for a lifetime of good mental function and better overall health. So just how is a solid brain foundation built and maintained in a developing child? One way is through what brain experts call serve and return interactions. Imagine a tennis match between a caregiver and a child, but instead of hitting a ball back and forth across a net, various forms of communication pass between the two, from eye contact to touch, from singing to simple games like peekaboo. These interactions, repeated throughout a young person's developing years, are the bricks that build a healthy foundation for all future development. But another kind of childhood experience shapes brain development too, and that's stress. Good kinds of stress, like meeting new people or studying for a test, are healthy for development because they prepare kids to cope with future challenges. Another kind of stress, called toxic stress, is bad for brain development. If a child is exposed to serious ongoing hardships like abuse and neglect, and he has no other caregiver in his life to provide support, the basic structures of his developing brain may be damaged. Without a sturdy foundation to properly support future development, he is at risk for a lifetime of health problems, development issues, even addiction. It's possible to fix some of the damage of toxic stress later on, but it's easier, more effective, and less expensive to build solid brain architecture in the first place. [Music] One of the things that sturdy brain architecture supports is the development of basic emotional and social skills. An important group of skills which scientists call executive function and self-regulation can be thought of like air traffic control in the child's mental airspace. Think of a young child's brain as the control tower at a busy airport. All those planes landing and taking off, and all of the support systems on the ground simultaneously demand the controller's attention to avoid a crash. It's the same with a young child learning to pay attention, plan ahead, and remember and follow lots of rules, like all of us. Kids have to react to things happening in the world around them while also dealing with worries, temptations, and obligations on their minds. As these demands for attention pile up, air traffic control helps a child regulate the flow of information, prioritize tasks, and above all, find ways to manage stress and avoid mental collisions along the way. Having this ability is a necessity for positive and level mental health. Developing effective air traffic control, overcoming toxic stress, and building solid brain architecture are things kids can't do on their own. And since strong societies are made up of healthy, contributing individuals, it's up to us as a community to make sure all young people have the kinds of nurturing experiences they need for positive development. To build better futures, we need to build better brains. [Music]
So, what this video does not talk about, um, is that the majority of individuals who develop borderline personality disorder and other forms of personality disorder do not experience abuse and all of the things that were talked about in this video. So the toxic stress does not come about by things that we would usually associate with a difficult upbringing. The toxic stress comes about through a very, very sensitive temperament that these children are born with. I have stood out for me for a forever that, uh, I'm talking to a mom with a child who has BPD who told me that it's like her child just has one layer of skin. Putting away asking her to put away a pair of shoes has feels to her as invalidating as a significant toxic stress event might feel. And so I think this is what we've missed for a long time in understanding the development of personality pathology is that the things that we would consider toxic stress, um, as a person who is not particularly emotionally sensitive, would feel like toxic stress for someone who is emotionally sensitive. And so for individuals like this, um, we have to slow down the interaction. And we cannot underestimate the extent to which we have to slow down the interaction. And I wish this was a two-way, uh, street tonight so that I can ask you about your experiences. Certainly, my experience as a, as a full-time working mom is that it's difficult to slow down. So even for, for me, who is a, who is a mental health professional who's working in this area, I have to use all of my skills every single day to slow down with my children because I know if I don't do that, and I have a child with a sensitive temperament, I could be inadvertently, unbeknownst to me, causing a, causing a toxic stress environment.
So how do we slow down the interaction? And we've been using a based approach, um, where we really believe that the sky is the limit for all children, even children who have a sensitive and, and emotionally sensitive temperament. And so I want to, uh, give you an example. This, uh, this little vignette to introduce the concepts to you. A mother arriving tired at home after a full day of work finds her eight-year-old daughter has not completed her homework as previously agreed upon. The mother puts down her bag, sighs, and looks at her daughter who's sitting in front of the television watching her favorite show. Her daughter says, "What?" to her mom. And the mom responds by saying, "You know what?" Her daughter appears baffled. Mom sighs again and reminds her daughter in a somewhat exasperated tone that they agreed at school drop-off that the eight-year-old would complete her homework at after-school care. Her daughter explains that she forgot. And mom says, "Well, that's not good enough. Go sit down now and go do your homework while I start dinner. No buts. Now go sit down." The daughter becomes distressed and says that she wants to finish a show. Mom becomes more exasperated and says, "I don't want to be saddled with your homework after dinner. Do it now, or no more television for you for the rest of the week." By now, the daughter is crying and she runs off to her room. And so what happened in this example is a perfectly normal response by a mom who is tired, coming home from work. There was an agreement to get the homework done. It wasn't done, and mom is understandably frustrated. With us, the question again, like the example we talked about with the husband and the wife and the dry cleaning, is what is mom to be? What is she going to gain by not slowing down in this moment, by not trying to mentalize her daughter in this moment? Um, and so, uh, the mentalizing approach that we have been, uh, working with, really, uh, introduces these five basic elements into an interaction that helps a parent or a family member. This is not just a parent-child technique. This is a technique that we can use with our spouses, with our friends, and whenever we feel the arousal level going up, when things get hot, and we want to slow it down, and we want to be able to switch into an explicit mentalizing mode. Why do we want to do that? Because our deep objective is to have a good relationship. We can use these steps to try and slow down the, the, um, the interaction. The first one is that we're going to have to focus. We're going to have to get both parties to focus on what we're talking about. In the example that I just gave, the mom is not really, she's talking to the, to the daughter while the TV is going on. The daughter is sort of listening with one ear. She's watching her pre, uh, show. She's not really paying attention to what mama's mom wasn't even here. Now suddenly mom is coming to the room. What is she saying? First of all, we need to focus. Then we have to provide meaning or request meaning. That means that we have to ask, "What is going on? What happened?" In the example with the mom previously, she immediately jumped to ex, conclusions. You know what? You should know what. Remember, the daughter is in a different place at that very moment. She is busy watching her favorite show. So mom is coming in and says, "You know what?" The daughter is feeling baffled, like, "What does my mom mean? I'm busy watching the show." What is she talking about? Mom and daughter are in two different places. So first, we have to provide meaning. We have to describe what's going on and all ask what might be going on. Once we've done that, we can expand. We can use our imagination, our mentalizing capacity, and we can think about how are we going to solve this problem? We are now having to be creative. You have one perspective on this. I have another perspective on this. Where are we going to meet each other halfway? So we have to use our problem-solving, our expanding capacity, our imagination to think, "What are the possible solutions here?" We then can reward the behavior by saying, "Kudos to, uh, to how it was handled in whichever way we want to choose to do that." And then finally, regulating behavior means that we return to the issue again, and we try and come up with what we've learned from this experience.
So I want to come back to this example and now show how it could have gone had we be, had the mom been able to hold on to her five mentalizing components in the moment. A mother arriving tired at home after a full day of work finds her eight-year-old has not completed her homework as previously agreed upon. She finds her daughter sitting on the couch watching a favorite TV show. She quietly sits down next to her daughter, takes the remote control, and says, "Sarah, can I pause your show for a moment, as I have something important to talk to you about?" So she's focusing, she's focusing her daughter. She's pausing the show. She's sitting next to her, taking a deep breath, creating a quiet moment. Her daughter says, "Yes," and turns to her mom. Her mom, making eye contact, says, "I can see you are busy watching your favorite show, but I realize that your homework is still not done, and we will need time to go over it together. What about we look at it together to see what still needs to be done, and then we can decide how to fit it in around dinner?" So she's giving meaning to the situation. She's just describing what's going on. Um, she's, she could have requested meaning as well, you know, "What do you think is going on here?" But in this case, she is describing what's going on. Sarah grudgingly agrees, partly because the show has not been completely switched off, and she's agreeing to come up with a plan to get the homework done, and not necessarily having to do the homework right now. And the mom now shows excitement. She says, "Ah, look at this! Your teacher has asked you to do more exercise and fractions. What do you think about that?" So again, she's requesting meaning. She's creating a shared sense of meaning with Sarah, and she's exciting her about what's going on. Sarah then says that it's easy to do that. Her mom says, "Will you show me how to do it?" By now, Sarah is somewhat excited about showing her mom how fractions work, and she begins to work on her homework. After the first problem is completed, her mom uses the rewarding component of mentalizing and she says, "Excellent work. I like how you first think through the problem and then write down your answer." Sarah smiles and starts on the next problem. Her mom then says, "It's close to dinner time. Do you want to continue on with the fractions while I make your dinner, and then we watch, you watch your show after dinner, or do you want to wait till after then to do the homework?" Of course, I don't know that it will always work out this way, but then Sarah is excited about the positive feedback and the thought of completing her homework, and she likes to carry on her homework while her mom cooks dinner.
Now, if I was able and in the same room than you, I would ask you, you know, "What's the problem with taking this approach?" Of course, mom might be too tired. It is more time-consuming to slow down and use these, uh, mentalizing components in an interaction. The, the point here is, number one, that if we don't do this consistently, and we are losing touch with the mind of our family members, we are not able to connect with their minds. We are not able to see their perspective. They are not able to see our perspectives. And the time that you put in in slowing down at the front end, you win 10 times over at the back end. When I work with mothers preventatively, we talk about the importance of saving all the heartache and the pain if you can do this at the front end, rather than wanting or needing to repair things at the back end. The other thing that I want to say is that our research shows that you only have to do this six out of ten times. You don't have to do this ten out of ten times. In fact, sometimes losing your temper or losing it is fine if you can go back and use your mentalizing components to repair the rupture. So you don't have to do this ten out of ten times. You just have to do it, in old Winnicott terms, in a good enough way. Six out of ten is fine.
So, uh, all this is to say that, um, we often feel, especially with adolescents, that we are on the way to a terrible train wreck, um, especially if we have children who are emotionally sensitive, who have just one layer of skin, and we feel that we are, as they are slipping away, um, developmentally, it becomes harder and harder for us to, to believe that we can still connect with them using those mentalizing components. We can slow down the, the interaction, and we can reconnect. And, um, what looks like a train wreck is actually a great opportunity, uh, for the last time, uh, provide a safe base for them as they, the last time that your household is a laboratory for them as they, uh, enter into adulthood and have to, um, fly solo. So I'll stop there, and I said I'll talk to about for 45 minutes, and I'm about there, and I am happy to take some of your questions.
That's great. Thank you so much, Dr. Sharp. That was absolutely amazing, and definitely, I'm really glad you gave us permission to record this because I will certainly be watching it again to try and gain a better understanding of all of these new ideas. Um, we've had a number of really excellent and thoughtful questions come in. Um, so the first one that I just want to bring up is the idea that a lot of what you've talked about, and a lot of us who have dealt with family members who have BPD, is there's so much emphasis on these early childhood experiences. So this kind of leads us to two, two questions that impact us in our real life. One is, clinicians who make an assumption that there's been some childhood trauma and look for that as the as the reason for why our loved one may have a personality disorder. And then also, where does this leave us if so much of it has come from childhood experiences that's impacted, or or just the learning and the executive functioning piece? What can we do now that they're adults?
Well, I'll take your last question first. Uh, you know, I, that slide of the sky is the limit, I would like everybody to hold on to that idea. That, and with that, it is never too late. When we are working with adolescents, you know, they are already close to being adults, and a lot of these interactional patterns, for good or bad, have become entrenched. And so it is hard to undo them. But I want to, uh, tell parents on the call and, and family members that it's never too late to start slowing down in your interactions. Um, I have, uh, uh, when I work with my students, I tell them, "Start practicing those five components and, and that mentalizing stance with everybody. Just start practicing it, and you will see when you do it with loved ones, slowly but surely, the trust." Because what happens when, when we're not in that curious or mentalizing stance six out of ten times, is that trust, uh, erodes in the relationship. But if you continue to do this six out of ten times, slowly but surely, those connections come back, and you are beginning to build that trust relationship again. So I would say, as the sky is the limit, it is never too late. Don't think that you can't undo this, um, but, but be, be patient and, and just begin. Take every single interaction on its own merit so that you can begin to, to reverse, uh, those interactional patterns. Um, and then your first question, remind me of your, the first question, Doreen. Um, so a lot of, a lot of us, uh, kind of feel that the families are blamed for having created the personality disorder because so much of the, of the theory.
is about child childhood brain development, adverse childhood experiences, and in a lot of cases, then clinicians end up not wanting to treat because they think the family is the problem. They look for, they look for the trauma where there is not the trauma. You know, I would, um, try and use those same mentalizing skills with the clinician. Focus, focus, and give meaning or request meaning. "I get the sense that that you think there might be more going on here than what we are disclosing. Um, can you tell me more about that?" Um, and, uh, ask the clinician to expand. Um, when the clinician is is giving you something, reward for clinician and say, "Oh, well, that was really illuminating. Thank you. That makes a lot of sense to me."
So, I think it is, um, very frustrating for for parents, and, and I've, I hear this over and over again, um, when they are confronted with a stick stigma around this disorder. Um, I think Andrew Shannon was one of the first people, um, that, uh, helped me have a different perspective on this. You know, I never thought about clinicians perpetuating the stigma, and it was, you know, and Andrew told me, you know, Carla, if we don't, uh, name the disorder, if we don't treat it, um, because I was, I was scared myself of stigmatizing a young person by giving them the diagnosis of borderline personality disorder. And, and Andrew was the first that said, "What's, what's that's just like depression or anxiety. There's nothing different to with this. Let's not perpetuate the stigma, um, by thinking that it's special." And, and one of the ways that people think it's special is this idea that somehow the family has brought it about.
I would also, uh, share the data with the families. It is now conclusive that the majority of people with BPD do not have abuse in their backgrounds. The majority. And so, um, I think we have to get better at getting that data out to clinicians so that they understand that they are working on a very old, very old view of of how BPD comes about and how it's maintained.
That's great. Thank you. Um, another question that's on a completely different tack is around this idea of the the external expression. So, uh, this person is asking, are the facial expressions of people with mental health issues different from universal facial expressions? And if they are, then for, you know, for somebody who's in an interaction with that person, how would we then interpret the facial expressions in order to most effectively interact with them?
You know, this is a very good question. Um, there's, of course, a lot of studies that do it the other way around, that look at how good are people with BPD at understanding facial expressions. And this research has actually shown that people with personality disorder are often better at reading facial expressions than other people. They are not, to my knowledge, research that shows that have been published to show that people with BPD have, um, have different facial expressions. Um, you know, so I'd be curious to hear from the person who submitted the question what their experience has been. I'm guessing that this person has experienced family members who perhaps have a facial expression that is difficult to interpret, um, or that is contradictory to what turns out to be what's really going on. Perhaps, you know, laughing when there is sadness, or an angry expression when it's sadness, or a sad expression when when it's neutral.
So again, the beauty of the mentalizing stance is that if you have a not-knowing approach and a not-knowing stance, you can ask about it. You can say, "I notice that you are laughing, but at the same time, it feels like you're sad. I'm struggling to put those two together." That was a mentalizing approach to that problem, where we are just giving meaning, we're describing what we're seeing and saying, "I'm not sure what's going on. Can we talk about it?" Um, and, uh, ask the clinician to expand. Um, when the clinician is is giving you something, reward for clinician and say, "Oh, well, that was really illuminating. Thank you. That makes a lot of sense to me."
So, I think it is, um, very frustrating for for parents, and, and I've, I hear this over and over again, um, when they are confronted with a stick stigma around this disorder. Um, I think Andrew Shannon was one of the first people, um, that, uh, helped me have a different perspective on this. You know, I never thought about clinicians perpetuating the stigma, and it was, you know, and Andrew told me, you know, Carla, if we don't, uh, name the disorder, if we don't treat it, um, because I was, I was scared myself of stigmatizing a young person by giving them the diagnosis of borderline personality disorder. And, and Andrew was the first that said, "What's, what's that's just like depression or anxiety. There's nothing different to with this. Let's not perpetuate the stigma, um, by thinking that it's special." And, and one of the ways that people think it's special is this idea that somehow the family has brought it about.
I would also, uh, share the data with the families. It is now conclusive that the majority of people with BPD do not have abuse in their backgrounds. The majority. And so, um, I think we have to get better at getting that data out to clinicians so that they understand that they are working on a very old, very old view of of how BPD comes about and how it's maintained.
That's great. Thank you. Um, another question that's on a completely different tack is around this idea of the the external expression. So, uh, this person is asking, are the facial expressions of people with mental health issues different from universal facial expressions? And if they are, then for, you know, for somebody who's in an interaction with that person, how would we then interpret the facial expressions in order to most effectively interact with them?
You know, this is a very good question. Um, there's, of course, a lot of studies that do it the other way around, that look at how good are people with BPD at understanding facial expressions. And this research has actually shown that people with personality disorder are often better at reading facial expressions than other people. They are not, to my knowledge, research that shows that have been published to show that people with BPD have, um, have different facial expressions. Um, you know, so I'd be curious to hear from the person who submitted the question what their experience has been. I'm guessing that this person has experienced family members who perhaps have a facial expression that is difficult to interpret, um, or that is contradictory to what turns out to be what's really going on. Perhaps, you know, laughing when there is sadness, or an angry expression when it's sadness, or a sad expression when when it's neutral.
So again, the beauty of the mentalizing stance is that if you have a not-knowing approach and a not-knowing stance, you can ask about it. You can say, "I notice that you are laughing, but at the same time, it feels like you're sad. I'm struggling to put those two together." That was a mentalizing approach to that problem, where we are just giving meaning, we're describing what we're seeing and saying, "I'm not sure what's going on. Can we talk about it?" Because there's a disconnect between what you're saying and what I'm seeing on your face, and I don't know what to make of it.
I would should add that for mentalizing to work, you really have to be not-knowing. You really have to have truly in your heart a sense that you know, you, you do, you are curious. You can't be kind of expecting something in your mind and then asking a socratic question that's really going to catch out the other person. You have to really embody that, "I don't know what's going on. I see something and it doesn't match with something else, and I can, can we talk about what's going on because I don't fully, I don't fully get it." I hope that helps.
Thank you so much. I, I certainly had helped me, and I hope it helped the person who asked the question. I see that we're almost at eight o'clock already, so I want to apologize to people whose questions we don't get to. I've had a lot of people ask questions about where do we find the research to back up statistics around personality disorders. And I would suggest that people go to the NEABPD website, which is borderlinepersonalitydisorder.org, and they maintain an archive and a library of a lot of research. So maybe I'll turn it to Kathleen. And Kathleen, maybe if you have one question that seems like it would be a good, a good wrap-up question that could help a lot of people before we close.
Or thanks, Doreen. Um, the question that I'd like to pose is kind of got a little scenario with it. Um, our loved one, um, is highly sensitive and has emotional dysregulation with his family. If and how he were to obtain, um, mentalization skills, would this help him in all of his relationships, or just specifically to the ones that he starts to learn the skills for?
All these relationships. Yes. And the reason is that this is a, it's an approach, it's an attitude to life where we free ourselves from a rigid position on other people's minds. And so, while I think, uh, the person who asked the question is onto something, these, our mentalizing goes awry most often in our attachment relationships because that's the hottest relationships. Those are the ones where our, our arousal levels, it's the most salient, it's the most important. So these are the ones where we can get derailed in our mentalization the quickest. However, I think these are also, once you, once you can master mentalization in your attachment relationships, which are the hardest to do, all other relationships will, uh, become easier because you are able to embody this, um, non-assuming approach to other people, um, rather than assume what people might be thinking. You would step back and say, you know what, I don't know, but I'm gonna try and find out because this relationship is important to me.
Okay. And would they obtain these skills from a regular, um, clinician that they're seeing, or family doctor, or a special organization like Sashbear? Where can they look for this? Like with DBT, it's not as readily available as it should be. We are in the mentalization-based world working to develop more accessible material. I'm working on a book that will be published by Guilford that will have a title like something like "Mentalizing Made Easy," that will give these steps in a really easy way. I do invite anybody who wants to have more information on this to to contact me. You guys are welcome to to post my email, csharp2@edu. People can contact me. The other place for mentalization, I would say the world's hub for mentalization-based therapy is the Anna Freud Centre in London. And so they have a lot of resources online for mentalization-based therapy, videos that people can watch and access. There are, of course, books as well. Again, people can contact me if they want information, more information on research for adolescent BPD, but also more information on mentalization-based approaches, and I'd be happy to share that.
Wonderful. Thank you so much, Carla. That's all. Doreen?
Okay, great. Uh, since we're past eight o'clock already, um, I want to thank you once again for having volunteered your time and your expertise to share all of this incredible knowledge with us. And I know certainly it's been very helpful to everyone who's been on the call. And I know that we'll have a lot of people re-watching the webinar. We will be posting it, and generally it takes a week or two for us to get them posted, but it will be linked on the Sashbear website on our resources page, and also as part of our Sashbear YouTube channel. So if people want to Google Sashbear in YouTube, you can subscribe to our YouTube channel, and that way you will get a notification when the the different webinars are posted there and the recordings are available. So, um, I want to thank everyone again for attending as well, and being such a great audience for Dr. Sharp's presentation. And so, uh, we hope that we will see you next week for our next presentation. And feel free to email fcprogram@sashbear.org if you have any further questions. Thanks, everybody. Have a good night.