Keynote from SiRCC 2018 by Dr Michael Smith

1. ACEs, capacity and mentalisation in practice
Dr Michael Smith,
Associate Medical Director,
Mental Health & Addictions,
NHS Greater Glasgow & Clyde

3. 1. What are ACEs?
2. What do ACEs do?
3. Capabilities and ACEs
4. Mentalizing trauma & adversity
5. Next steps

4. “still face” experiment

8. ACEs…
• are common
ACE= 0,
54%
ACE= 1,
23%
ACE= 2-3,
15%
ACE= 4+,
8%

9. ACEs…
• are common
• are harmful
• Lifetime smoking reduces longevity by
10-12 years
• 6+ ACEs reduces longevity by 20 years

10. 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

11. ACEs…
• are common
• are harmful
• are not the same as
poverty
Poverty &
inequality
ACEs

12. 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

13. ACEs…
• are common
• are harmful
• are not the same as
poverty
• extend beyond the
household
• can be overcome

15. Beebe et al, Attachment & Human Development 2010 3-141

16. http://circleofsecurity.net/

17. “toxic” stress

19. Glasgow, Raymond Depardon, 1980

21. “them” or “us”?
Pre-ACE
“What’s wrong with
you?”
Blame
Shame
Punishment
ACE-informed
“What happened to
you?”
Acceptance
Curiosity
Empathy

22. What do ACEs mean?

24. 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?

25. 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

26. 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”

27. 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”

28. 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”

29. 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”

30. 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”

31. capabilities
affiliation
play
bodily
integrity
senses,
imagination
& thought
control over
one’s
environment
nature
health
emotions

32. ACEs impair capabilities
play
senses,
imagination
& thought
nature
practical
reason

33. ACEs in practice: mentalizing

34. the premise...
• Internal states (emotions, thoughts etc) are opaque.
• We make inferences about them...
• but often get it wrong

35. 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”.

36. 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

37. 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

38. 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”

39. 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.

40. 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

41. • We are already mentalizing
• Mentalizing is highly interactive
• Mentalizing is not warmth & sympathy
• Mentalizing is hard work

42. aspects of mentalizing
• Contemplation, reflection
• Taking other perspectives
• Genuine interest
• Realistic scepticism
• Forgiveness
• Predictability
• Accepting things can be “opaque”

43. mentalizing is difficult for services

44. 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

45. 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?”

46. some techniques
• Not knowing
• Identify differences
• Accept different perspectives
• Active questioning
• Model honesty
• Stay alongside the patient
• Rewind

47. 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