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Mentalization in the Context of Advanced Cancer

Updated: Mar 27


Introduction

Mentalization was originally conceived by psychoanalytic thinkers (Freud, 1911; Klein, 1945; Bion, 1962; Winnicott, 1962; Marty, 1968) to emphasize a qualitative change from the concrete or physical to mental representation of internal processes. Fonagy and Target (1997) incorporated the concept of ‘the theory of mind’ (Dennett, 1987) as well as the work of cognitive developmentalist such as Baron-Cohen et al. (1988; 2000) to expand on the psychoanalytic notion of mentalization (Fonagy et al. 1998); which entailed the idea that developmental origins of our capacity to attribute causal mental states to others is an evolutionary adaptation that enables us to predict others’ behavior (Bateman and Fonagy, 2004). Contrary to cognitive developmental theorists, Fonagy and Target (1997) do not view this capacity as an isolated one based on biological processes, but rather a developmental achievement arguably facilitated by secure attachment (Fonagy, 1991, 1997). The idea that the sense of self develops in the mind of the other is also embedded in the Fonagy and Target’s (1997) formulation of mentalization, which is why they propose that the developing child’s attempt at meaning making of others’ actions is a precursor of labeling and finding meaning of the child’s own psychological experiences. Consequently, this ability is considered to constitute the capacity for affect regulation, impulse control, self-monitoring, and the experience of self-agency, and ultimately, the organization of the self (Fonagy and Target, 1997, p.2).

Fonagy et al (1998) operationalized this capacity to interpret one’s own and others’ behavior in terms of underlying mental states (Bateman and Fonagy, 2004) through their development of Reflective Functioning (RF) Scale which offers a quantifying model of a form of narrative analysis derived from a discourse analytic approach. Since the development of the RF scale, reflective functioning as a term has been used interchangeably with mentalization and corresponds to an awareness that experiences give rise to certain beliefs and emotions and vice versa, and that one’s own developmental history is associated with certain feelings and attitudes within attachment contexts.

The RF scale (Fonagy et al. 1998) consists of eleven levels ranging from negative (-1) to exceptional (9) RF. Negative, absent, cliché or self-serving mental states qualify as low levels of RF, i.e. below RF 5. Ordinary mentalizing is rated at a mean score of RF 5, while more sophisticated narratives deserve higher levels of RF. Ordinary to high levels of RF are identifiable by characterizing the narrative through any of the 22 codes which correspond to four categories: 1) awareness of the nature of mental states, 2) explicit effort to tease out mental states, 3) recognizing developmental aspects of mental states and 4) recognizing mental states of the interviewer (Fonagy et al., 1998). The person whose level of RF is measured is not expected to articulate these theoretically, but they are expected to demonstrate it in the way they interpret events within their attachment relationships (Bateman and Fonagy, 2004, p. 74). The level of one’s RF is then reflected in the extent to which they are able to go beyond the observable phenomena to give an account of their own or other’s actions in terms of beliefs, desires, and plans and so on. Therefore, initially RF (Fonagy et al., 1998) was only scored on interviews such as Adult Attachment Interview (Main et al., 2003), Child Attachment Interview (Schmueli-Goetz et al. 2008; Target et al. 2003) and the Object Relations Inventory (Diamond et al, 1991).

One of the issues related to RF as a research tool is that it requires time-intensive and supervised reliability training. When this is combined with the requirements of training for and administering of the above mentioned Attachment Interviews it becomes a very expensive and time consuming process and not very accessible for many clinicians who might benefit greatly from such a valuable clinical and research tool.

Recently, Fonagy & Bateman (2012, p. 53) highlighted those efforts to score RF on psychotherapy transcripts (Karlsson & Kermott 2006; Szecsody 2008) and also proposed that a comprehensive assessment of mentalization needs to be based on at least one and preferably two to three detailed clinical interviews (p. 54). These need to review the patient’s attachment history, with particular attention to past and current relationships. They pointed out to the importance of these interviews including clear demand questions, explicitly probing for mentalization in the context of past and current attachment relationships as well as with regard to the context and the way patients experience their symptoms and complaints.

In their recent book, Bateman and Fonagy (2012) re-defined mentalization as a multi-dimensional construct that is not a static unitary skill or trait but rather a dynamic capacity that is influenced by stress and arousal, particularly in the context of specific attachment relationships (Allen et al., 2008). Based on these dimensions, they anchored RF in the realm of psychological concepts related to mentalization such as alexithymia (Bagby et al., 1994), mindfulness (Brown & Ryan, 2003), empathy (Lawrence et al, 2004) and psychological mindedness (Shill & Lumley, 2002) amongst others (p. 55), which made the concept of RF arguably more accessible to a wider audience.

Mentalization is a point of growing interest among psychotherapy researchers as a possible mediating factor in outcome studies. Several methods in psychotherapy research began to reveal the role of RF or mentalization in the mechanism of therapeutic change. These studies aim at identifying the techniques that foster mentalization among patients, and link these processes to improvements in behavior, symptoms, and emotional resiliency (Fertuck and Mergenthaler et al. 2012, p. 2 ). The clinical implications of mentalization in the context of advanced cancer, however, are rarely discussed.

In a randomized clinical trial measuring the effectiveness of a new psychotherapeutic approach ‘Managing Cancer and Living Meaningfully’ (CALM) (Hales, Lo & Rodin, 2010; Nissim, Gagliese & Rodin, 2009) to alleviate death related anxiety and depression among patients with metastatic cancer (n=100?) the intervention group (n=50?) receives short term (3 – 6 session) psychotherapy, whereas the control group (n=50?) receives standard medical care. CALM therapy sessions typically focus on four main domains. These can be summarized as communication with health care providers to achieve optimal cancer care and symptom control, adjustment in the sense of self and significant relationships, sense of meaning and mortality-related concerns and lastly, advance care planning.

It can be argued that the general tasks of the first CALM session are in line with the type of qualitative interview suggested by Bateman and Fonagy (2012, p. 53) to measure mentalization. First sessions of CALM RCT uniformly focus on the patient’s story and the context of their illness, attachment history and their reflections surrounding their anticipated death. Moreover, the therapists who are taking part in CALM RCT are instructed to introduce the above mentioned domains in a way which demand mentalization and to create space for reflection about these highly emotionally charged areas. In addition, we argue that acknowledging the certainty one’s own death corresponds to the context of “loss” which is considered to be one of the main triggers of the attachment system (Bowlby, 1980). Therefore, we postulate that these characteristics render first sessions of CALM RCT particularly suitable for assessing mentalization in advanced cancer patients.

Based on these assumptions, in the current study we explored the research question of how different levels of mentalization or RF manifest behaviorally in patients with advanced cancer with a qualitative approach.

Method

Procedure and sampling

Managing Cancer and Living Meaningfully (CALM) is a randomized controlled study for advanced cancer patients, conducted at Princess Margaret Hospital (PMH), a large urban cancer center in Toronto, Canada. The aim of the study is to reduce death related anxiety and depression and to facilitate better coping with disease related difficulties. Eligibility criteria consists of being 18 years of age and older, fluent in English and having received a diagnosis of advanced cancer with an expected survival of greater than six months. Eligible participants were identified through referrals to psychosocial services at PMH. Those who were interested in individual psychotherapy to assist in coping with their cancer experience were randomized to take part in the CALM study or to receive standard medical care. The study received approval from the University Health Network Ethics Board, and all participants provided informed consent.

The CALM therapists have been trained and supervised by the clinician investigators (Gary Rodin and Sarah Hales) who developed the intervention. Treatment integrity and therapeutic competence continues to be fostered through weekly group supervisions.

The data in the current study comprises of the first CALM psychotherapy session transcripts which were audio-recorded during the phase III of CALM RCT. All sessions cover three out of four CALM domains. These are communication with health care providers, adjustment in the sense of self and significant relationships, sense of meaning and mortality-related concerns. The fourth domain, the advanced care planning, was not mentioned in these sessions, as it may be too early to do so.

One of the CALM study coordinators (Judy Jung) assigned nine first session CALM audio-recordings for our qualitative study based on the principles of purposive sampling (Silverman, 2001). She chose those patients’ first sessions which appeared to be representations of both good and poor mentalizing.

Analysis

The audio-recordings of the first CALM psychotherapy sessions were consecutively transcribed by a group of volunteers who were trained by the researcher (EA).

Data analysis consisted of two steps.The first step of data analysis was executed by using the qualitative software program RQDA. This was to identify emerging themes in the transcripts in a general inductive approach (Thomas, 2003) which draws upon the tradition of grounded theory (Strauss and Corbin, 1990). The inductive approach is a systematic procedure for analyzing qualitative data where the analysis is not restricted by limitations imposed by structured methodologies (Thomas, 2003, p. 2). Adopting this type of approach enabled the researcher to establish common themes and patterns in the way the participants spoke during the first CALM psychotherapy sessions and to develop a coding frame that is not necessarily in line with a particular theoretical stance.

Emerging themes were developed by studying the transcripts repeatedly by the researcher. Transcripts were also read horizontally which involved grouping segments of text by theme. Towards the end of the analysis of the sixth transcript no new themes emerged, which suggested that major themes had been identified. All nine transcripts were analyzed to ensure saturation of themes (Thomas, 2006). Coding was conducted by one researcher (EA) and then reviewed by another member of the research team (CL).

The second step in data analysis comprised of rating the passages that were identified to reflect the emerging themes for RF (Fonagy et al. 1998). The researcher (EA) is a reliable and experienced RF coder (r=.87) who was trained at Anna Freud Centre.

The passages were rated in a way that each participants’ responses were rated separately for each CALM domain. The responses within each CALM domain contained multiple passages, which were scored separately and an aggregate score was given for each domain. In line with the original formulation of RF coding principles, weight of the overall RF score in these interviews were carried by those passages where the therapist asked questions that are clearly ‘demanding’ mentalization. For example:

“You have been through a lot and a lot of questions about how things have been handled, and who to trust. How, should you stand back and assert yourself, how have you been managing that?” (Therapist’s question, Patient #1)

“What was it like for you? To get that news?” (Therapist’s question, Patient #2)

“So, emotionally, how do you think you have gone through it all?” (Therapist’s question, Patient #3)

“Do you feel that your body has failed you?” (Therapist’s question, Patient #4)

“What was it like, growing up in your home?” (Therapist’s question, Patient #5)

The remaining passages where reflective functioning was not demanded were taken into consideration when calculating the overall score, only if they qualify for high RF ratings (i.e. 5 and above.

Results

Sample

Nine first session psychotherapy interviews that were audio-recorded during CALM RCT’s phase III between April 2012 and November 2012 were analyzed. Four of the sessions were conducted with male patients and all remaining participants were female. The types of advanced cancer the participants had were diverse and included breast, pancreas, lung, prostate, leiomyosarcoma, bladder and cervical cancers. The sessions were conducted by four experienced master’s level oncology social workers who received intensive training by two psychiatrists (Gary Rodin and Sarah Hales) who are also the principal investigators of the CALM study. The sessions ranged from 45 to 95 minutes in length. The patients’ age varied from 45 to 68 years (Mean=54.8). Based on the second step of data analysis, we were able to identify that five of the participants have ordinary to high RF (RF 5 and higher). The rest have low RF, ranging from RF3 to RF1.

Findings

Two contrasting groups of themes emerged through the first step of data analysis. The second step of data analysis revealed parallels between these themes and the participants’ RF levels.

The first group of themes is characterized by: 1) Accepting 2) The ability to talk about death 3) People recruiting 4) Maintaining double awareness. The second group of themes is defined as: 1) Fault finding 2) Compartmentalizing 3) Isolating 4) Magical thinking.

During the second step of data analysis, we identified that those participants’ interviews who have ordinary to high levels of RF encompass more themes that fall within the first group than the second group, and vice versa. In the following section, we will demonstrate this more in detail. In order to point out the links between the RF scores and the groups of themes, we used the main RF categories that are illustrations of negative and moderate to high RF (Fonagy et al. 1998) for simplicity. The categories will be discussed in relation to the actual passages below.

1) Accepting vs. Fault-finding

One of the defining characteristics of the participants’ narratives who are highly mentalizing was their ability to ‘accept’. This does not mean that they were content with everything. It rather means that they were able to face both their own and others’ anger, sadness, disappointments, failures and so on, without the need to deny or avoid their or others’ negative feelings to be able to deal with the situation. They spoke about their negative feelings that emerged in relation to their health care providers, loved ones or having cancer in a way that reflected both awareness of their discomfort and owning up of their feelings without necessarily having to make the others bad to be able to establish an internal equilibrium. For example: (Please note that in the following examples, the therapist’s comments will be marked by bold letters and those sentences that are reflective according to RF scale (Fonagy et al. 1998) will be underlined.)

“…I do everything right, I go through their therapy, I do everything, I do this and then my tumor doubles, it’s like “thanks a lot little tumor!” (chuckle). You know, …, I really have this proprietary feeling about my tumor, like it’s mine. I’ve seen it on the screen, they’ve showed it to me and stuff, but you know, it’s more like, it’s really weird, but it’s like I care about it. It’s part of me, and it is part of me, it is a yucky part of me, but it’s part of you, it’s part of me, so umm, you know, I resent it and yet I’m kind of caring about it (laughing)(b). It’s very weird, right, I don’t know why? It’s just very weird (d).And I don’t cry a lot, I’ve cried very little through this whole thing, and maybe I should cry more, but I just yeah, I might cry now, and very little have I shed a tear through this whole thing.” (Patient #4)

In terms of RF, the passage contains category b) the explicit effort to tease out mental states d) mental states in relation to the interviewer. With the category (b) we emphasize a statement here that is unusual and arguably refreshing. The freshness of recall (Fonagy et al. 1998, p. 22) is conveyed by the dysfluenc of the participant’s words and her own surprise to her statement. Moreover, her acknowledgement of the unusual nature of her statement implies that she is simultaneously aware how the other person may be impacted by her words, hence category (d).

The existence of two different categories qualifies it for ‘sophisticated’. However, direct discourse has been used in the same passage, therefore RF6 is more suitable.

This ‘accepting’ approach is highly contrasted by the ‘fault-finding’ attitude of the patients who are more likely to fall within the second group:

“That was by the way what your department told us to do. Alright. We actually came here last September.You spoke to someone? Spoke to someone can’t remember who. We were told it’s best to let them [children] know what is going on, rather than to hide it and surprise them later. Right. We followed that advice. Has that been ok? Well, we’ll see, I mean I was told, for instance, at this stage in her life my daughter should hate me, in a normal way. Yet she is all over me, because she doesn’t want to lose me. She may not hit that stage and then I am gone. I don’t know. Or she may replace me with the first boyfriend she can find. I don’t know what is going to happen. That’s my wife’s to worry about.” (self-serving)(Patient #1)

This passage, although not prompted by a ‘demand’ question, reflects a type of low mentalization which is categorized as ‘self-serving’ (usually marked as RF1). The categories for low levels of RF are usually not indicated in the narrative as the ones for high levels of RF, but here we will do so for clarity. Fonagy et al. (1998) postulate that this self-serving distortion reflects the tendency of the mind to reinforce and confirms judgments already arrived at, leading to a selective retrieval of memories and their over-confidence in such (p. 33). This passage reflects this patient’s holding the medical authorities responsible for his metastasized illness. In his need to convince himself of his position, he gives a rather ‘self-serving’ and almost ‘bizarre’ (another category, marked by RF -1) answer to the therapist’s rather benign prompt. Therefore this passage deserves the rating of RF 0.

2) The ability to talk about death vs. Compartmentalizing

Those participants’ who were able to talk about their feelings, worries, preconceptions and plans about their own death were marked with higher degrees of RF:

“Yeah absolutely, well I think I know when I talk about get-you know getting my name of the deed for my house, like stuff like that, mhm, the-my way I presented it to my wife is if this goes south, mhm, well then we can’t wait, she says ‘well why can’t we see how it goes’, I said ‘no’. We can’t because by then there-it will be too late or could be too late you don’t know, mhm. Right, so we can’t wait till then, mhm, right and with me I think the difference with her and I is, she denying that possibility where I already accepted it and I have moved passed it and I am fighting for it not to happen.” (b)(Patient #7)

The underlined passage in this sentence indicates b) an explicit effort to tease out mental states (of both self and other). The speaker’s explicit recognition of difference in perception of the situation merits RF5. The following passage is also within the same category, but it reflects a different way of ‘talking’ about death:

I don’t know how. I sometimes wonder, like I’m very close to my kids. They often will come into bed with me at night or I’ll go and lie with each of them and we can talk about anything. I do ask them very prying questions. Sometimes I think it bothers them. I don’t ask them like are you worrying mommy’s dying? I don’t even know, should I ask them something like that? Should I say to them, are you worried mommy’s dying? Or do you worry about mommy? Or how is it to have me as a mother, with cancer? I don’t even know what to ask. Maybe you do have some advice to tell me, what to ask my kids.” (a) (Patient #9)

In this passage, there is a depiction of category a) awareness of the nature of mental states in terms of RF. The participant shows explicit awareness about her ‘opaqueness’ (Fonagy et al. 1998, p.19) or ‘limitation of insight’ (p. 20) into how to handle the idea of her own death with her children and therefore qualifies for RF5.

Those transcripts which were characterized by poor mentalization avoidance of reflection about the participants’ own death was prominent:

Has he actually given you a sense of time? What has he told you? He said in December, he said to me a year and a half to three. He said probably not more than four. Or it probably won’t get to four. I’m guessing two. How are, how are you? I mean I guess one of the things is you don’t know exactly until I guess getting that type of information. Well again, I was pretty much told this right from the beginning. The fact that it’s now happening, is no surprise, it’s unfortunate.”(disavowal) (Patient #1).

The absence of mentalizing in this passage is different from the example on poor mentalizing in the previous theme. Here, instead of a self-serving or negative attitude, the person talks factually about his impending death, without any referral of mental states language despite the ‘demand’ question from the therapist. This passage where repudiation of a reflective stance is not coupled with hostility is marked as ‘disavowal of RF’ (Fonagy et al. 1998, p. 31) and qualifies for RF1.

3) People recruiting vs. Isolating

There was a clear distinction between two groups of transcripts in terms of how the participants viewed others. While the first group was more likely to ‘recruit people’ for friendship, help, counseling and other forms of support, the second group was reluctant to do so. The difference in attitudes is clearly reflected in the following passages. The passage belongs to a participant in the highly mentalizing group:

“…(3 secs) yeah, after my husband died [speaking about husband’s suicide] you know, umm … (3 secs) most of my friends were couples, oh yeah, and it’s sort of got away, you are the odd woman, so umm, eventually I joined a group called the [name] society which is umm an east end sort of beach area yeah, mainly a lot of people and uhh I eventually got up my courage and caught them and joined them and that has been absolutely wonderful. I’ve made, I’ve got so many friends from that mhm and then they’re all single women, okay, and a few men and couples, but only a couple, okay,couple of people I’ve actually met in a group, it’s, it’s mainly women, there are a few men, okay, but umm, it’s not to meet men, it’s socializing. (d) Socializing. Yeah and so I have terrific friends in there…Great.” (Patient #6)

In this passage, the reflection is in the last sentence, where the participant explicitly acknowledges d) mental states in relation to the interviewer. She is not assuming that the other person knows what she is talking about and makes a clarification as to what kind of a society it is that she belongs to. Although it is a naïve reflection, it merits RF4-5.

The following two passages reflect the reluctance of those participants in reaching out to others. These participants’ narratives were defined as poorly mentalizing:

“…between her [wife] and [name of daughter], they are my rocks, right, ok, so yeah yeah you know so I just I was fighting alone, umm men, men don’t… (2 secs). They have nothing, empathy, ok we just don’t ok, ok and umm everybody knows about it, but I don’t think people really want to know about it, about the details, they want to know if I’m feeling okay (chuckling) yes, ok, and how did the treatments go and yeah but to get into the emotional yeah, you know, not a chance (chuckling) and that’s that’s men in general, so that’s nothing new…” (self-serving) (Patient #8)

The sociological nature of the passage above, that men don’t know how to offer support, is one of the hallmarks of ‘disavowal’ of RF (Fonagy et al. 1998, p. 31). Even though the speaker seems to be mentalizing, the reasons for human behavior is defined in concrete terms rather than mental state language. Therefore the passage is marked RF1.

4) Maintaining double awareness vs. Magical thinking

Double awareness in the context of advanced cancer is characterized by the ability to tolerate one’s impending death without losing hope and without relinquishing the possibility that life can be meaningful (Rodin & Zimmerman, 2008, p. 188). The following two passages reflect this dichotomy in a poignant way:

“…I have no idea, okay, to be honest, okay, I haven’t – I have not thought it, okay, okay, so I mean, I guess ultimately, yeah, it would be umm (silence 3 seconds) to me a (silence 3 seconds) I am not afraid to die okay, it is going to happen sooner or later, mhm right mhm. I like to think I am pretty grounded, okay, when it comes to that, mhm, umm, but obviously I don’t want it to be now, I would like it to be later, mhm. But I guess, (a) you know, I am sure it would be beneficial to sort of accept the possibility at some point, mhm but umm (2 seconds), mhm (silence 3 seconds) or maybe I already have and that’s how I can go forward with the other.” (b) (Patient #7)

This passage is another example of ‘sophisticated’ RF in the sense that there are two different categories of reflection in one passage. The participant first a) acknowledges the nature of mental states which is explicit in his difficulty in being sure of how he feels or thinks about the idea of his impending death. On the other hand, the second part of the sentence that is an example of b) explicit effort to tease out mental states, is marked by the spontaneity of his thinking where the thinking conveys a quality of ‘freshness’ (Fonagy et al., 1998, p. 22) and therefore merits a rating of RF7.

What was it like for you when you were told? Ummm (3 seconds)(exhale) it’s, it’s kind of strange I guess, it was a (inaudible) of disbelief, (a) mhm, you know how could this possibly be me yeah umm… (3 seconds). But I was surprised at myself, I took it very calmly, ummm…(3 seconds). I, my biggest difficulty was my son who was wildly optimistic about things (b) you know? Umm, looking things up on the internet, you know, it’s only a 25% chance that it’s malignant and what that sort of thing and of course it turned out to be malignant, and umm (3 seconds). I-I didn’t want to dampen his, yeah, feelings but (exhale) I-I knew myself I-I was in trouble you know, but (3 seconds) (exhale) I guess, still I have moments of disbelief because I’ve always been pretty healthy, right, umm, you know, it suddenly hits you, well, how could this possibly happen to me? Yeah. I have to confess … umm (3 seconds) and I still feel, I mean, I have days…(3 seconds) when I feel down, yeah, you know, I-I-I feel kind of scared of what’s gonna happen, yeah, and other days, when I think, well, okay, the chemo appears to be working. My doctor says that my liver function is good, my tumor marker is going down, mmmm, things (inaudible) all black…(3 seconds) you know, so, it … and there! I think, I’m slightly more than I wouldn’t say positive, but optimistic slightly, okay okay, than negative, (a) you seem like a realist, yeah I think I am, okay, yeah, okay.” (Patient #6)

The way the participant acknowledges the dichotomy of her thinking by her b) explicit effort to tease out mental states needs to be credited with high RF. In this instance, she was able to define that the real difficulty for her in this situation is to stay true to her instincts while not dampen her son’s hopes. She also demonstrates a) awareness of the nature of mental states in two incidents throughout the passage where she conveys her ‘recognition of limitation on insight’ (Fonagy et al. 1998, p. 20). The presence of more than one category of reflection also qualifies this passage with RF7.

These narratives are contrasted by those which reflect a lack of realistic expectation of the participant’s prognosis of their illness. We coined them as ‘magical thinking’ as they in a way imply the idea that their acceptance of the possibility of death might actually cause it to happen:

“I don’t think I’m going to die tomorrow, you know, things might be a little bit different. I’m not thinking about any of the mortality at this point. I’m not thinking. I just obviously want the clinical trial drugs to work so they can shrink it and I can move on with my life. You know I`m thinking of this, I think more of the critical illness than anything else. I’m not even entertaining the fact. I have to think past that. I think I’ll deal with that when and if they tell me, but…” (self-serving) (Patient #5)

We think that it is important to begin by acknowledging that ‘self-serving’ statements are defenses of the self when the situation is experienced as a straining one on the psyche. So the participant’s self-serving statement in this case appears to be an expectation of a wish to be true, rather than an accurate reflection of the actual state of her illness or her thinking. This passage therefore is credited with RF1.

What kills me is I’m probably going to drop dead a week before they have this thing ready. It’s, there’s so much going on. Oh, we’re five years away, this far. They really are five years away. They’re working on these vaccines that are going to knock off multiple cancers. Every day as part of this group I get emails about all the research that’s going on. I mean there are lots of trials for these things, Level 1 trials or Level 2. My doctor says that’s too experimental for me right now. It is for me too, because I am not that sick. Why would I do anything crazy? At some point I am going to want to join one of these trials. I don’t know that they are here or there all here. Some maybe, maybe there’s better ones in New York or Cleveland. Who knows?” (self-serving) (Patient #1)

Like the one before, the mental state attributions in this passage are self-justifying for the same reasons. They promote the selective availability of information that confirms the judgements already arrived at by the participant as a form of defense against the dread of thinking of dying.

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