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ACEs, capacity and mentalisation in practice

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Keynote from SiRCC 2018 by Dr Michael Smith

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ACEs, capacity and mentalisation in practice

  1. 1. ACEs, capacity and mentalisation in practice Dr Michael Smith, Associate Medical Director, Mental Health & Addictions, NHS Greater Glasgow & Clyde
  2. 2. 1. What are ACEs? 2. What do ACEs do? 3. Capabilities and ACEs 4. Mentalizing trauma & adversity 5. Next steps
  3. 3. “still face” experiment
  4. 4. ACEs… • are common ACE= 0, 54% ACE= 1, 23% ACE= 2-3, 15% ACE= 4+, 8%
  5. 5. ACEs… • are common • are harmful • Lifetime smoking reduces longevity by 10-12 years • 6+ ACEs reduces longevity by 20 years
  6. 6. ACEs… • are common • are harmful 4xincreased risk of Depression with 4 or more ACEs 32xincreased risk of an STI with 4 or more ACEs 2.3xincreased risk of unemployment with 4 or more ACEs 5xincreased risk of Mother <18y with 4 or more ACEs 10xincreased risk of hitting someone in last month with 4 or more ACEs 3xincreased risk of attending A&E in last year with 4 or more ACEs 12xincreased risk of suicide with 4 or more ACEs
  7. 7. ACEs… • are common • are harmful • are not the same as poverty Poverty & inequality ACEs
  8. 8. ACEs… • are common • are harmful • are not the same as poverty • extend beyond the household • Bereavement • Bullying • Discrimination • Witnessing violence • Neighbourhood safety • Frequent money problems • Food insecurity • Homelessness • Prolonged parental absence • Parents always arguing • No good friends
  9. 9. ACEs… • are common • are harmful • are not the same as poverty • extend beyond the household • can be overcome
  10. 10. Beebe et al, Attachment & Human Development 2010 3-141
  11. 11. http://circleofsecurity.net/
  12. 12. “toxic” stress
  13. 13. Glasgow, Raymond Depardon, 1980
  14. 14. “them” or “us”? Pre-ACE “What’s wrong with you?” Blame Shame Punishment ACE-informed “What happened to you?” Acceptance Curiosity Empathy
  15. 15. What do ACEs mean?
  16. 16. Nussbaum's central capabilities • a theory of social justice, based on ideas about human dignity • "What are people actually able to do and to be?“ • which genuine opportunities are open to people?
  17. 17. 1. Life 2. Health 3. Bodily integrity 4. Senses, imagination and thought 5. Emotions 6. Practical reason 7. Affiliation 8. Other species 9. Play 10. Control over one’s environment
  18. 18. 1. Life 2. Health 3. Bodily integrity 4. Senses, imagination and thought 5. Emotions 6. Practical reason 7. Affiliation 8. Other species 9. Play 10. Control over one’s environment “… to be secure against violent assault, including sexual assault and domestic violence”
  19. 19. 1. Life 2. Health 3. Bodily integrity 4. Senses, imagination and thought 5. Emotions 6. Practical reason 7. Affiliation 8. Other species 9. Play 10. Control over one’s environment “To be able to love, to grieve, to experience longing, gratitude, and justified anger”
  20. 20. 1. Life 2. Health 3. Bodily integrity 4. Senses, imagination and thought 5. Emotions 6. Practical reason 7. Affiliation 8. Other species 9. Play 10. Control over one’s environment “… to imagine, think, and reason in a truly human way, including literacy, numeracy, science & creative arts”
  21. 21. 1. Life 2. Health 3. Bodily integrity 4. Senses, imagination and thought 5. Emotions 6. Practical reason 7. Affiliation 8. Other species 9. Play 10. Control over one’s environment “The right to political expression, participation and choices”
  22. 22. 1. Life 2. Health 3. Bodily integrity 4. Senses, imagination and thought 5. Emotions 6. Practical reason 7. Affiliation 8. Other species 9. Play 10. Control over one’s environment “… being able to live with and toward others… to engage in various forms of social interaction; to be able to imagine the situation of another”
  23. 23. capabilities affiliation play bodily integrity senses, imagination & thought control over one’s environment nature health emotions
  24. 24. ACEs impair capabilities play senses, imagination & thought nature practical reason
  25. 25. ACEs in practice: mentalizing
  26. 26. the premise... • Internal states (emotions, thoughts etc) are opaque. • We make inferences about them... • but often get it wrong
  27. 27. a mentalizing failure A mother was watching her 5-year old daughter play. The child had taken a stethoscope out of her mother’s doctor bag and was playing with it. As she put the stethoscope to her ears, her mother thought proudly “she seems interested in medicine. Maybe she will grow up and become a doctor like me”.
  28. 28. After a time, the little girl put the listening end of the stethoscope up to her mouth and exclaimed “Welcome to MacDonald’s. May I take your order?” Kornfeld, The Wise Heart
  29. 29. interpretations Secure attachment “...this young fellow feels he needs a hug before he goes to sleep – so she slides up a little closer to him and gives him a big hug – and ahh strokes his head... gets him ready for sleep and she kisses him good-night – and leaves the room.” George & West, Attachment & Human Development 3, 1, 2001
  30. 30. Dismissing attachment “The son is reaching for the mom and the mom is not really reaching back for some reason. And I’m not sure if it’s a cultural or just if it’s personal but she’s wearing slippers. I’m not a slipper person but some people are. Um, so maybe just the floor is cold”
  31. 31. Preoccupied attachment You know like if I was to draw a picture on her face you know I’d probably have a smile on it but the child I think would be – just the first reaction you know the child’s upset for some reason – sick. Also reminds me of when my husband was sick too. Yeah. Um I’d definitely see that this is being my husband and you know this being me because that was really frustrating with him being unable to communicate – I didn’t feel there was anything I could do – I couldn’t understand what he wanted, there was no way to find out what he wanted.
  32. 32. mentalizing means… • Holding mind in mind • Attending to mental states in self and others • Understanding misunderstandings • Seeing yourself from the outside and others from the inside Mentalizing in Clinical Practice Allen, Fonagy, Bateman
  33. 33. • We are already mentalizing • Mentalizing is highly interactive • Mentalizing is not warmth & sympathy • Mentalizing is hard work
  34. 34. aspects of mentalizing • Contemplation, reflection • Taking other perspectives • Genuine interest • Realistic scepticism • Forgiveness • Predictability • Accepting things can be “opaque”
  35. 35. mentalizing is difficult for services
  36. 36. not mentalizing • Excessive detail, excluding thoughts and feelings (fillers) • Focus on external factors • Focus on labels • Focus on physical characteristics or stereotypes • Preoccupation with rules, “shoulds” and “should nots” • Denial of involvement in a problem • Being certain about other peoples’ thoughts and feelings
  37. 37. temporary failures of mentalization • “She does my head in. I can’t think once she starts on me.” • “You hate me!” • “Are you trying to drive me crazy?”
  38. 38. some techniques • Not knowing • Identify differences • Accept different perspectives • Active questioning • Model honesty • Stay alongside the patient • Rewind
  39. 39. Summary: ACE memes • Childhood experiences have lifelong effects • Bodily changes are adaptation, not pathology • Behaviour is communication • Distress is contagious • Services find attachment very difficult – “Blame shame and punishment” is everywhere • Secondary responses often worse than the primary causes • This can be undone – but later is always harder • We need to start with ourselves

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