Empathy, Attachment, and Mentalization

同理心、依戀、與心智化

Jou, Lih-Chih 周勵志

新光醫院精神科 台灣向日葵全人關懷協會

886-2-25921411 886-928354381

joupsyc@gmail.com

http://catalog.digitalarchives.tw/item/00/32/98/11.html

Affect Regulation & Memory Reconsolidation

情感調節與記憶重塑

“what good therapists do with their patients is analogous to what successful parents do

with their children”. 好治療師對他們病人所做的類似於成功的父母

對他們孩子所做的。

Holmes J, The search for the secure base: Attachment theory and psychotherapy.

New York: Brunner-Routledge 2001, p. xi

母嬰互動、心理治療

Mother-infant Interaction 母嬰互動

• 1/3 of the time are correctly • another 1/3 of the occasions appropriate

corrected • The successful repair of misattunements may be

crucial for the infant’s normal development. Lewis JM Am J Psychiatry; 2000, 157:1375-8

Mother-infant Interaction 母嬰互動

• 成功修復 successful repair turns despair into positive emotions.

Tronick EZ, Gianino A, 1986

• 當無能修復時 When not successful repair －begin to feel helpless (without mastery) －turn away from relationships & focus on self-regulation. －a negative affective core to the sense of self Lewis JM Am J Psychiatry; 2000, 157:1375-8

Infant Imitation嬰兒模仿

• 20 minutes (Kugiumtzakis,1985; Reissland,1988)

42 minutes (Meltzoff & Moore, 1983)

• Mouth opening (Heimann & Schaller, 1985; Legerstee, 1991)

Lip pursing, eye blinking (Kugiumtzakis,1985)

Head movements, cheek movements (Fontaine,

1984)

Hand Gestures (Meltzoff & Moore, 1989)

• Vocal sounds such as /m/, /a/, and /ang/

as early as 40 minutes after birth (Kugiumtzakis,1993)

Discrimination & Imitation of Facial Expression

面部表情的區別與模仿

• Human neonates (average age, 36 hours) discriminated three facial expressions (happy, sad, and surprised) posed by a live model

Field TM, et al Science 1982, 218: 179-181

Instinct Behavior本 能行為

1. 先天上已定型的行為模式（fixed action

pattern；FAP）

2. 與生俱來的，由基因所掌控，是一組序列性的行為

3. 通常由簡單的刺激引起發，例如：

1) 人類的眨眼

2) 打噴嚏和唾液的分泌及嬰兒的微笑等

Social Cognition 2009; 27:949-961

人際同步增進親和

Mirroring the Affects of the Child 鏡映孩童情感

. . . the precursor of the mirror is the mother’s face.

Winnicott DW, 1971, p. 111

Problematic Mirroring 有問題的鏡映

•看見vs.看穿

• If the mother’s face is unresponsive, then a mirror is a thing to be looked at but not looked into.

Winnicott DW, 1971, p. 113

Overlap of activation between reorienting, empathy & theory of mind

Decety J, Lamm C, Neuroscientist 2007, 13:580-593

鏡像神經元

• 1992年義大利神經科學家Giacomo Rizzolatti和他的研究生一起研究小猴腦部的運作，當小猴伸出手拿東西的時候，腦部的premotor cortex就會運作，因為premotor cortex負責計劃和行動。

• 在一次試驗中，研究生在小猴面前吃冰淇淋，意外發現小猴腦部 "鏡像神經元" 的存在： 小猴看著研究生吃冰淇淋，身體雖然沒有任何動作，但是腦中的premotor cortex卻開始運作，好似他是吃冰淇淋的人。

模仿先於辨識 嬰兒大腦中的鏡像神經元是自我和他人交互作用而成。

Brain Structure & Empathy (I)

• A “theory of mind” system or network that is widely distributed and made up of interactive nodes, probably in the medial prefrontal regions, the superior temporal sulcus, the inferior frontal region, and the cerebellum.

Frith CD, Frith U Science 1999; 286:1692–1695

The primary motor & premotor cortices also used to directly simulate another person's (or animal's) observed actions. Image from "The Brain from Top to Bottom" online brain encyclopedia

Brain Structure & Empathy (II)

• Mirror neurons (I)

I. Ventral premotor cortex,

II. First identified in monkey studies, respond

when a primate observes certain hand

movements performed by another primate

or by a human or when the animal performs

the same movements itself.

Gabbard, Glen O Am J Psychiatry 2005; 162:648-55

Brain Structure & Empathy (III)

• Mirror neurons (II)

III. Encoding object-oriented actions, whether

they are performed or observed.

IV. May have a crucial role in goal detection

and therefore in action understanding.

Gabbard, Glen O Am J Psychiatry 2005; 162(4):648-55

Brain Areas Associated with Mentalizing

• Perceiving social and emotional cues fusiform gyrus (identifying individuals, e.g., by face) superior temporal sulcus (perceiving agency and

intention) temporal pole (interpreting social scenarios) amygdala (detecting emotion, especially threat)

• Resonating emotionally mirror neurons (activated by performing and observing

actions and by feeling and observing emotions)

• Mentalizing emotion and interpersonal interactions medial prefrontal cortex anterior cingulate cortex

“mentalizing region”

同理心

• Poses a paradox, may be used for both helpful and hurtful purposes

Decety J, Moriguchi Y BioPsychoSocial Medicine 2007, 1:22 doi:10.1186

http://www.speechmark.net/assets_cm/xml/book_covers/0035558W.jpg

Definition 定義

• Perceive the internal frame of reference內在參考架構 of another with accuracy and with the emotional components & meanings

• Without ever losing the “as if” condition. Carl Rogers, 1959

• The capacity to think & feel 思考與感受oneself into the inner life of another person. Heinz Kohut, 1984

Component組成

(a) an affective response情感反應 to another person, which often, but not always, entails sharing that person’s emotional state;

(b) a cognitive capacity認知能力 to take the perspective of the other person;

(c) some regulatory mechanisms 調節機制that keep track of the origins of self and other-feelings

Decety J, Jackson P Behav Cogn Neurosci Rev 2004; 3:71-100

Processes Involved in Empathy

• Identification認同 • Incorporation併入 • Reverberation回響: cognition and affect • Detachment隔絕: flexibility Reik T, 1949

聽完病人的傷痛……

•跟著一起去跳樓

－同情 sympathy

•擦乾眼淚，鼓勵向前行

－同理 empathy

同情心vs.同理心

同理心 同情心

一起感覺 替他感覺

注意力在對方 注意力在傾聽者(自己)

注重於「你覺得如何……」 注重於「我覺得如何……」

表達「我瞭解和接受你有這些感覺，對你真的是如此」

表達「我瞭解了，我把這些感覺接受為我的感覺，對我也真的是如此」

辨別及接受對方的感覺為何 我所感覺到的感覺應該就是他的感覺

瞭解~讓對方擁有自己的感覺 投射~認為他該與我有相同的感覺，是主觀的

cogprints.org/1042/0/preston_de_waal.html

Choi-Kain LW, Gunderson JG Am J Psychiatry. 2008 Sep;165(9):1127-35

www.geocities.com/.../meadows/3786/wolf.html

The wolf is a highly social animal, generally living within the same pack for most, if not all, of its life. Survival depends very much upon the pack.

依附(一)

a. Social mammals are fundamentally incapable of maintaining basic neurophysiologic homeostasis on their own.

b. Attachment system is not only an organizing feature of basic neurophysiologic function but the central organizing system in the brain of higher mammals.

Field 1985; Hofer 1984; kraemer 1992; Reite & Capitanio 1985; Amini 1996

依附(二)

c. Human behaviors pertaining to relationships may not readily influenced by the more advanced cognitive structures.

Field 1985; Hofer 1984; kraemer 1992; Reite & Capitanio 1985; Amini 1996

d. Affective attunement, ……are permanently encoded in memory in some fashion.

Amini 1996

Psychiatry1996; 59:213-39

Affect, Memory, Attachment (I)

Affect： Survival & reproductive fitness (Darwin1872)

a. Brainstem：neurotransmitter system, autonomic function, motor nuclei for facial nerve

b. Limbic system：endocrine system, learning & memory system, social/emotional behaviors.

c. Neocortex：complex cognitive tasks, experiential awareness

Amini F et al Psychiatry1996;59(3):213-39

依附(三)

• Mother and her infant interact creates the child's first internal representation

－another person －an interaction －a relationship. • Critical for the subsequent psychological

development of the child. • The interaction goes both ways. Kandel ER

Am J Psychaitry 1999; 156:505-524

依附(四)

• The development of these internal representations can only be induced during certain early and critical periods in the infant's life.

• During these critical periods, and only during these periods, the infant (and its developing brain) must interact with a responsive environment (an "average expectable" environment, to use Heinz Hartmann's term)

Kandel ER Am J Psychaitry 1999; 156:505-524

Mind & Brain

• Windows in time early childhood (15 months to 4 years), late childhood (6-10 years), puberty mid-adolescence Ornitz, E M Developmental aspects of neurophysiology. In Child and Adolescent Psychiatry: A Comprehensive Textbook (2nd ed), 1996

依附(五)

• Evolutionarily significant

• Clearly enhances the infant's chances for survival

• Allowing the immature brain to use the parents' mature functions to organize its own life processes.

• Infant's attachment mechanism is mirrored in the parents' emotionally sensitive responses to the infant's signals.

Kandel ER Am J Psychaitry 1999; 156:505-524

Core Functions 核心功能

• 安全避風港Safe haven provides a feeling of security (regulation of emotional distress)

• 安全堡壘Secure base fosters exploration of the outer world and the inner world, including exploring the mind (mentalizing)

Attachment Figures依附對象

• Provide protection, promote safe exploration of the environment and help the infant learn to regulate emotions in a pro-adaptive, effective way.

• 保護

安全地探索環境

情感調節 Hruby R, Hasto J, Minarik P Neuro Endocrinol Lett 2011;32:111-20

Internal Working Model 內在運作模式

• 對依附者所產生的感受、情緒、知覺會內化形成內在客體表徵，也會形成對自我、對他人、對環境的概念以及適應行為。

•內在運作模式的特質，主要取決於依附對象(Collins & Reads)。

陳秉華，1996

http://www.thedigeratilife.com/blog/buy-cheap-eyeglasses-online/

http://en.wikipedia.org/wiki/File:Attachment_Theory_Four_Category_Model.png

http://internal.psychology.illinois.edu/~rcfraley/attachment.htm

Role reversal角色逆轉

• The caregiver needs or expects the baby to be “entertaining,” to” be good,” or to be “ comforting, ” without sufficient sense of the baby’s own needs.

• When the child is cognitively and emotionally unprepared to reply on his own device, his internalized ego state will represent “the self that takes care of others.”

Pairs of Attachment Style 配對的依附型態

Caregiver照顧者 Infant嬰兒 Secure Secure

Dismissing Avoidant

Preoccupied Ambivalent/Preoccupied

Disorganized/Unresolved Disorganized/Unresolved＊

＊ Role reversal or aggressively directive & punitive at 6 Y/O

Theory of Mind: False Belief Test

https://sfari.org/image

Process of Mentalization 心智化歷程

• 心靈對等模式（psychic equivalence modes）：約兩歲半以前

• 假扮模式（pretend modes）：兩歲半左右起

• 反思模式（reflective modes）：大約六歲

Birth of the Agentive Self 主事自體的誕生

依附對象發現嬰兒心靈(主體性Subjectivity)

嬰兒心智狀態 的表徵

依附對象

核心心理自體

嬰兒內化照顧者的表徵以形成心理自體 Psychological self

內化

推論 嬰兒

Bateman & Fonagy, 2004

51

The Development of Affect Regulation

• Closeness of the infant to another human being who via contingent (mirroring) actions generates a symbolic representational system of mental states and assists in developing affect regulation and selective attention secure attachment

• For normal development the child needs to experience a mind that has his mind in mind

– Able to reflect on his intentions accurately

– Does not overwhelm him

– Not accessible to neglected children

Psychological

Self: 2nd Order

Representation

Physical Self: Primary

Representations

Representation

of self-state:

Internalization

of object’s image

Constitutional self

in state of arousal

Expression

Reflection

Resonance

Infant CAREGIVER

symbolic binding

of internal state

The Development of Regulated Affect …..Symbolization of Emotion

With apologies to Gergely & Watson (1996)

Reflective Parenting & Development of Mentalization

“小屁屁濕了嗎？”

“一個人站太久了嗎？”

“想要換尿布了喔?”

“想要抱抱嗎?”

• Having the person in mind. • Bridge the focus on physical reality &

internally directed attention. Fonagy P, Target M Dev Psychopathol 1997; 9:679-700

治療歷程概述

心智化 Mentalizing

依附 Attachment

Relation關係

•在治療中，只有透過自己與治療師間親近關係的體驗Experiencing close relation，才能得到幫助。

心理治療系統觀（一）

I. The interpersonal relationship between therapist and client is the tool for creating the needed change.

II. Initially the relations with the therapist will repeat the same patterns of interpersonal relations that caused the distress.

Peled & Geva：Brain Organization & Psychodynamics J. Psychother Pract Res 1999; 8:24-39

心理治療系統觀（二）

III. The skilled therapist identifies these patterns and reacts in a way that gradually changes the attitudes of the client toward similar future situations.

IV. Successively, this change continues both in

and outside of the therapeutic setting.

Peled & Geva：Brain Organization & Psychodynamics J Psychother Pract Res 1999; 8:24-39

Mentalized Affectivity

Elements of mentalized affectivity I. identifying II. modulating III. expressing

Development of Self 自體的發展

•鏡映 Mirroring

•理想化 Idealizing

•孿生 Twinship

＊治療關係的演進 作之親：父母－子女 作之師：老師－學生 作之友：夥伴、同儕

Transference Relationship

Past Relationships

Current Relationships outside the transference

Triangle of Insight adapted from Menniger,1958

Something More

• Intellectual

－Insight 洞察

• Experiential

－Doing 改變

－Being 存在

謝謝聆聽，

敬請指教！