I'm Owen Muir. I am a psychiatrist. This article is adapted from 2017, when I was completing my Fellowship in Child and Adolescent Psychiatry at the NYU School of Medicine. Still, I was already a Supervisor in Mentalization Based Treatment through the Anna Freud Centre after 4 Years of rigorous and expensive additional training in that evidence-based modality as it applied to borderline and antisocial personality disorders. I was also trained in the approach to youth. In this article, I do my best o explain what this modality is and how it helped me understand working with those suffering from severe suicidal ideation. I understand more now, of course, but I think the lessons I learned before I had tools like neuromodulation hold up well enough.
I worked in a Children’s State Hospital
My days are spent doing a bunch of different things, which is true for people who are child psychiatrists. Virtually all child psychiatrists are also adult psychiatrists. And (at the time) I worked in the City of New York public psychiatry system. I also worked—and still do— in private practice in Brooklyn.
I've worked in a number of emergency rooms. I have two academic appointments at various hospitals and work at the State Hospital in Rockland County. It is a State Hospital for Children, where my job—this year—is to create a mentalizing milieu for what is, essentially, the ICU of attachment disorders.
It's a state hospital for people under 18. State hospitals are the hospitals of last resort in America. You go to acute care hospitals first. When they can't “fix you” and get you out safely, and you're going to be there for a long time, which insurance companies hate, they transfer you to the state.
This is true for adults; this is true for kids. State hospitals are where we used to house many of the people who are now in jails. Creedmoor State Hospital, for example. It is out in Queens County and had 40,000 residents at its peak. Pilgrim State Hospital, further out in Long Island, had 60,000 people. And in Rockland, they had about 8,000 people.
It is where they shoot Orange is the New Black. And then Kennedy deinstitutionalized the hospital system, and all those patients were discharged, and now the prison population has risen by about those numbers.
And there are some forensic state hospitals where you go if you're both
A. someone who's committed a crime
B. are (criminally) mentally ill—and sometimes, you used “the insanity defense.”
You'll end up in, in Kirby State, for example, which is part of Manhattan State. One could end up there for a very long time.
But the thought is, for state hospitals, these are people who are medication resistant. The standard treatments haven't worked. We need to give them more medication and get them somewhere where they can get that for longer. And that's a fine thought1 for adults, and it's probably true2, but for kids, it's not that.
Kids are not responding to the medications because they have illnesses that aren't treated by medications, by and large3. So my job, when I'm at state, is to understand. I also take away medications if I can. Those kids often have borderline personality disorder. No one will diagnose them with that until I get there—but that's what they have.
What Is Mentalizing?
Mentalization—or its active form, mentalizing— the term is it describes this fundamental thing people have— the ability to figure out what's going on for someone else. It is based on what might be going on inside their minds. It includes curiosity about what is in ourselves. If you're walking down the street and see a woman running after a man, grab him, spin him around, smack him in the face? You're probably thinking, wow, she must be mad at him. Also: He's probably really upset about this.
“I wonder if I should do something to stop it?!”
You're thinking all these things that make inferences about their internal states. They could just be filming a movie. I walked into that on the street in Williamsburg the other day. I thought they were having some conversation. Oh! There's a camera here, and I'm walking in the middle of the scene. Sorry.
That's what we're doing all the time. We're trying to figure out what's going on for us, inside of us, why we're acting the way we're acting, and why other people might be acting the way they're acting. And I say might because curiosity and not knowing is a core feature of good mentalizing.
If you know why someone else is doing something, you're not mentalizing. You'd have a pretty good idea. You'd have an odds-on chance, but if you are Certain… you're not mentalizing. That's a concept that came out of research on attachment disorders by Peter Fonagy at UCL, Anna Freud, and his colleagues.
This inquiry started when they invented video cameras. This is how psychotherapy research exploded. Before video cameras, research on psychotherapy was, at best, people thinking deep thoughts and writing them down. They followed this by pretending they were true. A lot of people are still psychoanalysts to this day. I was in class in fellowship, and I had to listen to someone say: “We don't know how we're going to resolve the Oedipal Complex in children who have gay parents.”
You don't have to because there is no such thing. It's made up. So having gay parents?— there's nothing to resolve. There is no Oedipal Complex. Those are things people thought. They did a lot of thinking. People have been thinking about thinking for a long time. But all of it was made up.
Some of it is useful. The developed models and some of them are useful. It doesn't mean they're true. When we developed video cameras? Suddenly, you could watch what happens with people and take it apart, frame by frame. John Gottman is a great example of this. His couples therapy research is based on thousands of hours of carefully examined videotape by underpaid graduate students watching microexpressions lasting milliseconds between these couples, caught on video.
You couldn't do that before you had a video camera. Fonagy’s work is the same. You couldn't look at attachment theory before you had a video camera. You couldn't look at how enough one-year-olds reacted to their mom leaving a room and coming back before you had a camera. And once they had a camera, they could research how human relationships mechanistically work.
You could... to see what it was like when a mother was interacting with a child, when that mother was X, Y, or Z, and the child was this style or that style. And that research grew into this concept of mentalization and Fonagy's idea:
We learn how to understand our internal states thanks to these early interactions with our parents.
You look at your kid, and your kid has some emotion. The parent sees their child crying. They visually respond to their fact, mirroring the emotion, then do it slightly more exaggeratedly. And that's called a marked response. That marked response is how we learn that someone else is understanding our emotions.
That's where mentalization starts—before you can even talk. When my delightful son Trent is dancing the wiggle worm dance, he's learning to understand that we are different people, emotions exist, and how I respond. I respond to the smiling he's doing by smiling even bigger. So this is core to being human—your emotion gets reflected and slightly exaggerated to clue you in it’s been understood on its way back to you.
The Strange Situation Paradigm
Without careful, videotaped, coded research, we would never have figured this out. The attachment style we have at age one is the attachment style we have forever. What do you look like at one year old? It predicts how you look at 21 and beyond in the face of stressors. There's a classic experiment by Mary Ainsworth where there's a one-year-old child in a room, Mom leaves, a stranger in the room, the kid flips out, and Mom comes back.
What happens when Mom comes back? And the kid either goes and hugs her and is okay and goes and plays with toys again, avoids her, looks uninterested, goes up to her, cries, clings on, doesn't let go, and then kids who do some bizarre combination of those things. And there we have secure, avoidant, anxious, and disorganized attachment.
And those are the kids, one, who have borderline personality disorder. Look, trauma can intervene, and life experiences can intervene. Many things lead to attachment disorders, but the concepts behind mentalization-based treatment are based on the understanding that early experiences influence us.
Freud was right about that. And that ability to be curious about what's going on for someone else or yourself gets you better. That is what makes you well. So we have all these other treatments, and John Gunderson will say, Look, it's all just engaging the frontal lobe. That's what we're doing. But mentalization is some Jedi shit.
How did I end up as someone who treated probably 70% or so outpatients with borderline personality disorder at that time? And why am I so interested in kids? I didn't want to be a psychiatrist. I didn't want to go to medical school. I wanted to be a recording engineer. My cousin gave me a 4 track when I was 16, and it was all over from there….
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This is sarcasm
prior to accelerated neuromodulation like SAINT and Acacia Clinics and MDMA and Psychedelic Medicine, etc.
In 2023, I agree with this statement, but I also add the asterisk that neuromodulation will likely be helpful.
>All models are wrong, some are useful. My point about the lack of utility of that question in the children of gay parents is that wondering how we're gonna solve fictional problems isn't a good use of time.
Ok, I understand. I grew up in a household with a lot of sexual tension and as a young boy it was very confusing and terrifying. In unwinding it for myself, I have found the Oedipal model useful. YMMV
>There is no Oedipal Complex.<
Do you mean in the case of “gay parents” or in general?