A drama based group intervention for adolescents to improve menta

Antioch University AURA - Antioch University Repository and Archive Student & Alumni Scholarship, including Dissertations & Theses Dissertations & Theses 2020 A Drama-Based Group Intervention for Adolescents to Improve Mentalization Michael S. Goddard Follow this and additional works at: https://aura.edu/etds Part of the Clinical Psychology Commons A Drama-Based Group Intervention for Adolescents to Improve Mentalization by Michael S. Antioch University New England, 2018 DISSERTATION Submitted in partial fulfillment for the degree of Doctor of Psychology in the Department of Clinical Psychology at Antioch University New England, 2020 Keene, New Hampshire ii Department of Clinical Psychology DISSERTATION COMMITTEE PAGE The undersigned have examined the dissertation entitled: A DRAMA-BASED GROUP INTERVENTION FOR ADOLESCENTS TO IMPROVE MENTALIZATION presented on July 15, 2020 by Michael S. Goddard Candidate for the degree of Doctor of Psychology and hereby certify that it is accepted*.

Dissertation Committee Chairperson: Theodore Ellenhorn, PhD, ABPP Dissertation Committee members: Vince Pignatiello, PsyD Megan Turchetti, PsyD Accepted by the Department of Clinical Psychology Chairperson Vincent Pignatiello, PsyD 7/15/2020 iii Dedication I dedicate this research project to my former students from Vladimirovtsi, Bulgaria. iv Acknowledgements The completion of this dissertation was made possible through the support of friends, family, and mentors who supported me with their curiosity, interest, and inspiration. To the friends I have made at Antioch, our Sunday night groups were without a doubt the most meaningful experiences of my graduate studies. You taught me the truest meaning of friendship I have known.

To my family, spread out across the globe, you have been a source of support when I needed you throughout my training. I would not have embarked on this journey without you. To Ted, my advisor, you have offered guidance and a willing ear when the stresses of being a doctoral student felt like too much. You have been one of the most impactful teachers I have had in my life.

You brought the complex world of psychoanalysis alive for me and stirred in me a life-long interest in the more ambiguous, complex, and ineffable aspects of what makes us psychological beings. In addition, a very special thank you to other mentors I have had the pleasure of working with. Vince, you put up with me for two years of ProSem, three years of supervision, and more classes than I can count. I have joked with my classmates on more than one occasion that I feel as though I am graduating from the University of Vince.

I would add that it has been an inspiring institution in which to learn. Megan, your dedication, compassion, and expertise have impacted me tremendously. Finally, to all the young people I have had the pleasure to work with in therapy. It is you who have made all of this worthwhile and have taught me the most about being an empathic and creative therapist.

v Table of Contents Dedication.3 Mentalization and the Self .3 Mentalization and Attachment .5 Psychic Equivalence and Pretend Mode .7 Marked-affect Mirroring .9 The Components of Mentalization.11 Mentalization-Based Treatment and Children .14 Why Mentalization: A Rationale .17 A Remark on Manualized Treatment Approaches .17 Mentalization as a Common Factor .21 Focusing on Group Treatment .22 Mentalization-Based Group Therapy .28 Drama and Therapy.29 Therapy with Preadolescents .40 Structure of the Group .45 Approach of the Therapist .49 The Not-Knowing Stance .51 Working with Emotions .52 Working with the Relational Environment .53 The Format of a Session .55 Starting the Session .61 Limitations and Future Directions .64 1 Abstract This dissertation is an innovative intervention design to improve mentalization in preadolescents. The intervention presented is conducted in a group format and using techniques drawn from drama-based therapy. I have provided a brief literature review on mentalization, and relevant topics in group treatment and drama therapy. I have outlined key concepts from mentalization theory including: (a) the development of the self, (b) its relationship to attachment, (c) psychic equivalence and pretend mode functioning, (d) marked-affect mirroring, (e) the various facets of mentalization, and (f) mentalization treatment with children.

After outlining these concepts, I discuss psychodynamic group treatment, mentalization-based group therapy, and the mechanism of change in group treatment from a neurobiologically informed perspective. From there I discuss concepts from play and drama therapy relevant to work with preadolescents. The topics covered in the literature review are used as a basis for an mentalization-based intervention appropriate for preadolescents. The argument is made that drama therapy is an appropriate vehicle through which this age group can be engaged as they are often regarded as too old for the typical toys of play therapy, but not yet ready for an adult approach to group treatment.

Following the literature review, an intervention design is proposed. The proposal offers guidance on the structure of the group intervention, approach taken by the therapist, and the format of a typical session. Finally, limitations, future directions, and reflections on conducting this research are discussed. This dissertation is available in open access at AURA, http://aura./ and Ohio Link ETD Center, https://etd.

Keywords: mentalization, group therapy, drama therapy, preadolescence 2 A Drama-Based Group Intervention for Adolescents to Improve Mentalization The aim of this dissertation was to propose an innovative group intervention for working with preadolescent children using the concept of mentalization as an organizing principle and dramatic play techniques as the primary vehicle of intervention. Mentalization, or reflective functioning, is the ability to reflect on one’s own and others’ emotional states. It is a capacity that is refined over the course of healthy development, in the context of attuned relationships, and is needed for effective self-regulation and social interaction (Fonagy et al. Deficits in mentalizing capacity underlie seemingly disparate interpersonal and intrapersonal difficulties.

For example, a middle schooler may be referred for psychological services because they are constantly disruptive in the classroom, while another child may be having frequent disagreements with classmates, and a third frequently becomes tearful and is difficult to soothe. Although the manifest symptoms in each case are quite different, each of the children in question are experiencing a deficit in their ability to mentalize effectively; they are limited in their ability to reflect on (a) their own behavior; (b) the impact their behavior is having on the people around them; and (c) the motivations, desires and intentions of the behaviors of others. As failures to mentalize at an age-appropriate level can be understood as a significant factor influencing a wide variety of challenging behaviors and psychopathologies, intentionally focusing on this capacity is a meaningful target for therapeutic intervention. While there exist effective treatment approaches using mentalization as a core concept (Allen & Fonagy, 2006), the intervention proposed here is unique in that it was designed to address the specific developmental concerns of middle school-aged children (approximately ages 10-13); and, the intervention is focused on work in groups to be implemented as a stand-alone 3 treatment or used in conjunction with individual and/or family therapy.

The rationale for focusing on an approach that is theoretically grounded in a concept that is therapeutically valuable to wide ranging symptom presentations, and already has an empirical support base as a group treatment (Karterud, 2016), is pragmatic. Many school, community mental health, and inpatient settings lack the financial and human resources to provide treatment focused on specific diagnostic categories, and many patients present with complex diagnostic pictures. Due to these factors, transdiagnostic treatment approaches are increasingly needed. The review of the literature to follow clarifies the theory and practice of mentalization as an approach to treatment and argues that improved mentalizing ability can be understood as a transdiagnostic and transtheoretical treatment goal.

The literature review then proceeds to discuss the benefits of group therapy and its role in treatment to improve mentalization. Finally, the review also explores the aims of arts-based therapies, including drama therapy, through the lens of mentalization, and discusses the particular therapeutic needs of preadolescent children. The aim of this review was to highlight the need and establish the theoretical foundation for a mentalization-based group treatment targeting preadolescent children. Mentalization Mentalization and the Self Mentalization is concerned with the development of both the representational self, the aspects of self inferred from the way our social environment reacts to us—the “me,” and the psychological, or agentive, self—the “I” (Fonagy et al.

According to Fonagy et al. (2002) the latter has received far less attention in both the fields of psychoanalytic and cognitive psychology due to the Cartesian assumption that we possess a reliable ability to accurately introspect on intentional states of mind. 4 The relative neglect by psychologists and psychoanalysts of the developmental processes that underpin the agentive self may be seen as a residue of the traditionally powerful Cartesian doctrine of first-person authority that claims direct and infallible introspective access to intentional mind states. (Fonagy et al.

3) The view from this Cartesian perspective has been that our ability to think and introspect is a given, is reliable, and is accurate. When Descartes wrote cogito, ergo sum, I think, therefore I am, it meant that the ability to doubt the existence of the self proves its existence. However, embedded in the phrase is an assumption that has had a great influence on many modern theories of mind and the development of the self—that consciousness of the self is an individual act that does not require the existence of other selves. Contemporary research from a wide range of fields, notably in neurobiology and infant development research (Beebe, 2006; Schore, 2003; Trevarthen et al., 2015), are pointing in quite a different direction; namely, we come into existence as psychological selves because early in life others envision us as selves with agency.

The roots of this view of self-development can be found in the perspectives of psychoanalysts such as Fairbairn (1952),Winnicott (1964), and Kohut (1977). In the Cartesian tradition, many developmental theorists have regarded mental agency as an innate modular capacity (Carruthers & Smith, 1996), in a similar vein to Chomsky’s language acquisition device (Chomsky, 1965; Palmer, 2000). Their argument is that the existence of certain human capabilities, such as language, can be explained as genetically endowed internal capacities that need only be activated by the environment. Mentalization challenges that notion and takes an alternate approach to the development of the psychological self.

According to Fonagy et al. (2002), the psychological self“ “is not a genetic given. It is a structure that evolves from infancy through childhood, and its development critically depends upon interaction with 5 more mature minds, who are both benign and reflective in their turn”“ (Fonagy et al. This insight, that the capacity to infer others’ and our own minds is a developmental process, beginning in infancy and continuing throughout the lifespan, has significant implications for the manner in which we approach therapy and its aims.

From the mentalization perspective, and the psychoanalytic theories from which it draws, the birth of the psychological self begins with the recognition and co-regulation of affective states, which occurs through interaction with primary object relationships. Children learn, from birth through 5 months, to represent affect through moment-by-moment nonverbal exchanges with caregivers (Beebe, 2006; Beebe & Lachmann, 2014; Fonagy et al. The development of self-representations is accompanied by object representations. Self and other representations are associated with feelings and different affective states (Kernberg, 1984) that provide the emotional coloring for the experience of self in interaction with significant others, which, in turn, informs the way we see ourselves in the world.

Interactions with caretakers and the environment become a part of the developing personality, long before autobiographical memory comes online. Preverbal experiences of self and other are remembered through bodily sensations, behaviors, and models of interaction (Ogden et al. The self comes into being through the interaction of neurophysiological processes and interpersonal experience (Fonagy, 1991; Fonagy et al. Mentalization and Attachment The theory of mentalization is closely related to and draws heavily from attachment theory (Bowlby, 1969, 1973, 1980, 1988).