MENTALIZING FAILURES IN ATTACHMENT TRAUMA 依恋创伤中的心智化失败

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1 MENTALIZING FAILURES IN ATTACHMENT TRAUMA 依恋创伤中的心智化失败
Jon G. Allen, Ph.D.

2 Thesis 论点 The experience of being left psychologically alone in unbearable emotional states is potentially traumatic owing in part to the absence of mentalizing and the experience of being psychologically invisible in these states. Treatment entails creating a secure attachment context by means of mentalizing in which previously unbearable emotional states can be experienced, expressed, reflected upon, and understood—and thus rendered meaningful and bearable. 心理上被独自留在无法承受的情绪状态中，这种体验可能是创伤性的，部分原因在于缺乏心智化和在这些状态下心理上未被看到的体验。治疗需要通过心智化来创造安全的依恋情境，在治疗中可以体验、表达、反思和理解那些先前难以承受的情绪状态，从而使其变得有意义和可以忍受。 2

3 Core Concepts 核心概念 Trauma: Lasting adverse impact of stressful events
创伤：压力事件带来的持续不利影响 Two senses of attachment trauma 依恋创伤的两种意义 traumatic events in attachment relationships (child & adult) 依恋关系中的创伤事件（儿童和成人） impact: undermines capacity for attachment and mentalizing 影响：破坏依恋和心智化的能力 Evident in disorganized attachment in infancy (e.g., frightened, dissociative behavior, extremely contradictory interactions) 在婴儿时期的紊乱型依恋（例如，受惊吓的，解离的行为，极其矛盾的互动）中很明显 Types of attachment trauma 依恋创伤的类型 physical abuse 身体虐待 sexual abuse 性虐待 antipathy (rejection, harsh criticism) 憎恶（拒绝，严厉的批评） psychological abuse (cruelty, terrorizing, humiliating) 心理虐待（残忍，恐吓，侮辱） physical neglect 身体的忽略 psychological neglect 心理的忽略 witnessing domestic violence 目睹家庭暴力 3

4 1）provokes extreme, repeated stress 引发极端的、反复的压力
Triple liability associated with attachment trauma in childhood 与儿童时期依恋创伤相关的三重不利因素 1）provokes extreme, repeated stress 引发极端的、反复的压力 2）undermines the development of the capacity to regulate distress (via insecure attachment, impaired mentalizing) 破坏调节痛苦的能力的发展（通过不安全的依恋，损害心智化） 3）compromises the development of epistemic trust: 干扰认知信任的发展： Epistemic trust, trust in another person’s knowledge, mediates openness to social influence, inside and outside therapy. Epistemic trust is promoted by mentalizing in therapy. The therapist must become a credible source of personal (social) knowledge for the patient (see Fonagy & Allison; Allen & Fonagy).认知信任，信任他人的知识，在治疗中以及在治疗之外调节对社会影响的开放度。通过治疗中的心智化促进认知信任。治疗师必须成为病人个人（社会）知识的可靠来源（参见福纳吉＆艾利森；艾伦＆福纳吉）。 4

5 Attachment Trauma: Fright without Solution 依恋创伤：没有解决方案的恐惧
BALANCE平衡 relatedness (effective dependence) 关联性（有效的依赖） self-definition (autonomy) 自我定义 （自治） secure attachment/ psychological security 安全型依恋/心理安全 excessive dependency 过度依赖 diminished autonomy 自治性降低 Ambivalent 矛盾型 diminished relatedness 关联性降低 excessive autonomy 过度自治 Avoidant 回避型 diminished relatedness 关联性降低 diminished autonomy 自治性降低 Disorganized 紊乱型 5

6 Non-mentalizing in the intergenerational transmission of attachment trauma (begets non-mentalizing) 依恋创伤的代际传递中的非心智化（会带来非心智化） parental attachment insecurity ↔ impaired parental mentalizing capacity 父母的不安全依恋↔父母的心智化能力受损 infant affective dysregulation 婴儿情感失调 non-mentalizing parent-infant interactions 非心智化的父母 - 婴儿互动 infant attachment disorganization 婴儿的紊乱型依恋（无组织） impaired mentalizing capacity in childhood 童年时期心智化能力受损 6

7 “Trauma” broadly construed “创伤”的宽泛定义
+ ALONE absence of experience of being mentalized feeling abandoned neglected, unloved, invisible 孤单 缺乏心智化的体验 被抛弃、被忽视、不被爱的感觉，隐形的感觉 AFRAID unbearable emotional states 害怕 无法忍受的情绪状态 IMPAIRED MENTALIZING CAPACITY 心智化能力 受损 7

8 Filling the transmission gap: disorganized attachment
填补传递的空档：紊乱型依恋（无组织） Mary Main Initially identified disorganized infant attachment with maltreatment and then more broadly identified frightening or frightened parental behavior (e.g., associated with parents’ history of trauma or loss). 玛丽·梅因 首次识别出婴儿的紊乱型依恋与虐待的关联，然后更广泛地识别出和令人害怕的或被吓坏了的父母的行为的关联（例如，与父母的创伤或丧失历史相关）。 Karlyn Lyons-Ruth Paralleling Main’s frightening-frightened pattern, identified hostile-helpless behaviors as well as a broader pattern of disrupted emotional communication, for example, negative-intrusive behavior, role confusion (e.g., seeking reassurance from the infant), withdrawal, contradictory behaviors (e.g., verbal encouragement to come close coupled with physical distancing), and disorientation (e.g., dissociative states). Disrupted communication predicts disorganization even in the absence of frightening behavior. 卡林·莱昂-鲁斯 和梅因的令人害怕-吓坏了的模式平行，识别出敌对-无助行为也是一种更广泛的会打断情绪沟通的模式，例如，负面-侵入性的行为，角色混乱（例如，向婴儿寻求安慰），退缩，矛盾行为（例如， 言语上鼓励靠近，但身体上远离），和迷失方向（例如，解离状态）。即使没有令人害怕的行为，沟通的干扰也会导致紊乱型依恋。 Arietta Slade Poor maternal mentalizing in the Parent Development Interview indicated by obliviousness to child’s feelings, malevolent attributions, lack of self-awareness of feelings. Poor mentalizing in the interview is associated with disrupted emotional communication in interactions as well as disorganized attachment in infants. 阿莉埃塔·斯莱德 在父母发展访谈中心智化表现不佳的母亲，无视孩子的感受，恶意归因，缺乏对情感的自我觉察。访谈中心智化不良与互动中的情绪沟通干扰以及婴儿的紊乱型依恋有关。

9 Levels of stress in the transmission gap: Tronick
传递空档中的压力水平：特罗尼克 Still Face (Google: Tronick, YouTube, Still Face to see video) Brief separation-reunion experience (e.g., 3, 6, 9 months): after period of free interactive play, mother remains expressionless for 3 minutes, then resumes interaction. An experimental model of emotional neglect. Infants make efforts to engage mother, avert their gaze, show signs of emotional distress and physiological stress, lowered positive emotion, increased negative emotion; ultimately withdraw; can be difficult to re-engage 静止的脸（搜索：特罗尼克，《静止的脸》视频） 短暂的分离 – 重聚的体验（例如，3个月，6个月，9个月）：在一段自由的互动玩耍之后，母亲保持面无表情3分钟，然后恢复互动。情感忽略的实验模型。婴儿努力吸引母亲参与，移开他们的视线，体现出情绪困扰和生理压力的迹象，积极情绪降低，消极情绪增加；最终退缩；可能很难重新参与 Simulated depression Infants are less socially engaged, more distress and more disengaged than in the still-face paradigm; also less engaged with objects 模拟的抑郁症 与静止的脸范式相比，婴儿更少参与社交活动，更多的痛苦和更多的不参与; 也更少与客体互动

10 Levels of stress in the transmission gap: Tronick
传递空档中的压力水平：特罗尼克 Symptomatic depression Mothers: less positive social play, more looking away, more angry and intrusive, less positive affect. Infants: less social play, less focus on objects, less attention to mother, more protest, become more passive and depressed; respond in a way that mirrors mother’s lack of engagement and decreased range of affect 症状性抑郁症 母亲：社交玩耍不太积极，更多的看向别处，更多的愤怒和侵入，更少的积极情感。 婴儿：减少社交玩耍，减少对客体的关注，减少对母亲的关注，抗议增多，变得更加被动和有挫折；以一种映照出母亲缺乏参与度的方式作出反应，情感的范畴缩小。 Trauma No single event but rather prolonged interactive failure and negative emotion; less repair and thus less movement continually from negative to positive emotion. Neglect is more compromising than abuse. Trauma exceeds the infant’s resources for coping, in contrast to the 30:70 ratio that promotes resilience. 创伤 不是单一的事件，而是长期的互动失败和负面情绪；较少修复，从而较少从负面到积极情绪的连续运动。忽略比虐待更有伤害。创伤超过了婴儿的应对资源，而30:70的比例则促进韧性。

11 毕比：4月龄时的母亲行为预测12月龄时紊乱的依恋
Beebe: Maternal behavior at 4 months predicting disorganized attachment at 12 months 毕比：4月龄时的母亲行为预测12月龄时紊乱的依恋 gazed away from their infant’s face more often and unpredictably 更频繁和不可预测地把视线从婴儿的脸上转开 loomed into the infant’s face more often and unpredictably 更频繁和不可预测地迫近婴儿的脸 did not respond to their infant’s self-touch with complementary affectionate touch 不以互补的带着情感的触摸来回应婴儿的自我触摸 showed less variable emotional responsiveness, that is, relatively rigid, closed-up facial expressions 较少表现出有变化的情绪反应，即相对僵硬、封闭的面部表情 were less likely to follow the infant’s shifts between positive and negative emotions, for example, less able to “emotionally ‘enter’ and ‘go with’ infant facial and vocal distress” 不太能够跟随婴儿在积极和消极情绪之间的转变，例如，不能“带着情绪地‘进入’和‘伴随’婴儿面部和 声音中的痛苦” showed discordant emotional responses, responded to their infant’s distress with surprise or positive emotion. Discordant responses are indicative of denial of the infant’s emotional distress, attempting to ride negative into positive, e.g., “Don’t be that way” or “No fussing, no fussing, you should be very happy” 表现出不和谐的情绪反应，以惊讶或积极情绪回应婴儿的痛苦。不和谐的反应提示出对婴儿情绪痛苦的否认，试图以积极的情绪覆盖消极的情绪，例如“不要那样”或“别难过，别难过，你应该非常高兴”

12 毕比：4月龄时的婴儿行为预测12月龄时紊乱的依恋
Beebe: infant behavior at 4 months predicting disorganized attachment at 12 months 毕比：4月龄时的婴儿行为预测12月龄时紊乱的依恋 high levels of emotional distress (facial and vocal) 程度强烈的情绪痛苦（面部和声音） discordant responses, e.g., one infant joined sweet maternal smiles with smiles of his own, but meanwhile he whimpered as his mother pushed his head back and roughly smacked his hands together 不和谐的反应，例如，一个婴儿微笑着呼应了母亲的甜蜜微笑，但同时他呜咽着，因为他的母亲把头往后推，太过毛躁地让他双手击掌 behavior erratic and unstable, moment-to-moment, potentially making it more difficult for mothers to mentalize 行为易变、不稳定，时刻刻刻都是如此，可能导致母亲更难心智化 low levels of self-soothing, emotion-regulating self-touch 低水平的自我安抚性质、情绪调节性质的自我触摸 Mentalizing commentary: “I’m so upset and you’re not helping me. I’m smiling at you and whimpering; don’t you see I want you to love me? When I’m upset, you smile or close up or look away. You make me feel worse. I feel confused about what I feel and about what you feel. I can’t predict you. I don’t know what is going on. What am I supposed to do? I feel helpless to affect you. I feel helpless to help myself. I feel frantic.” 心智化的评论：“我很难过，你没有帮助我。我对你微笑又呜咽；你看不到我希望让你爱我吗？当我心烦意乱时，你会微笑或封闭或移开视线。你让我感觉更糟。我对自己的感受和你的感受是什么感到困惑。我无法预测你。我不知道发生了什么事。我应该做些什么？我感到没有办法影响你。我感到没有办法帮助自己。我感到很疯狂。”

13 Clinical Example: depersonalization 临床实例：去人格化
History 背景 Women in her forties with extreme and pervasive trauma history: many types of abuse and neglect by father and abusive older brother; abuse continued into early adulthood 有着极端且广泛的创伤史的四十多岁的女性：遭受父亲和虐待人的哥哥的多种类型的虐待和忽略；虐待持续到成年早期 Central to all trauma was lack of feeling validated and understood 所有创伤的核心元素都是缺乏得到确认、被理解的感觉 Severe PTSD + and dissociation 严重的PTSD + 解离 Pervasive absorption in fantasy, living in a dream 严重沉浸在幻想中，生活在梦里 Dissociative detachment was primary problem: felt “spacy,” like robot, non-human, light as a feather that could blow away in the wind; worried she was making up her problems, which her husband reinforced 解离型的脱节是主要问题：感觉“空白感”，像机器人，非人类，轻如羽毛，可以被风吹走；担心自己的问题是自己编造出来的，而她丈夫强化了这一点 Nonsuicidal self-injury to make herself feel “real.” 非自杀性的自我伤害使她自己感觉“真实”。 13

14 Clinical Example, continued 临床实例，续
Therapy 治疗 Patient felt she was living in a dream and wanted to “wake up” 病人觉得她生活在梦中，想要“醒来” Positive experience of being able to express herself, felt understood, felt more stably real (illness as well as talents and professional achievements taken very seriously) 能够表达自己，感受到被理解，感觉更加稳定且真实（疾病、天赋以及专业成就得到认真看待）的积极体验 Took up the hobby of making pottery, helped her feel grounded. 有了制作陶器的爱好，帮助她感受到有了根基。 Toward end of therapy, used metaphor of being “plugged in” and “synced” instead of being in a dream world 接近治疗结束时，使用“插入”和“同步”的比喻，而不再是生活在梦境中 Couples therapy helped her husband take her illness more seriously instead of calling her an “airhead”; she felt validated and more connected to him; helped her sense of reality. 夫妻疗法帮助丈夫更严肃地对待她的病，而不是称她为“没脑子”；她感到得到确认，与他有了更多连接；帮助她的现实感。 Family work also led to some better sense of connection with husband 家庭工作也带来了一些与丈夫更好的连接感 Positive follow-up 积极的后续发展 14

15 References 参考文献 Allen JG (2013). Mentalizing in the development and treatment of attachment trauma. London: Karnac. Allen JG & Fonagy P (2014). Mentalizing in psychotherapy. In RE Hales et al. (Eds.). Textbook of Psychiatry: DSM-5 Edition. Washington, DC: American Psychiatric Publishing. Beebe B (2010). The origins of 12-month attachment: A microanalysis of 4-month mother-infant interaction. Attachment and human development, 12, Fonagy P & Allison E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51, Lyons-Ruth K & Jacobvitz D (2016). Attachment disorganization from infancy to adulthood: Neurobiological correlates, parenting contexts, and pathways to disorder. In J Cassidy & PR Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications. New York: Guilford. Main M & Hesse E (1990). Parents’ unresolved traumatic experience are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In MT Greenberg et al. (Eds.), Attachment in the preschool years: Theory, research, and intervention. Chicago: University of Chicago Press. Slade A et al. (2005),. Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment and Human Development, 7, Tronick, E (2007). The neurobehavioral and social-emotional development of infants and children. New York: Norton. 15