Hunger: Mentalization-based Treatments for Eating Disorders

By Paul Robinson, Finn Skårderud and Bente Sommerfeldt

This work presents the adaptation of mentalization-based therapy for use in Eating Disorders (MBT-ED). The book starts with a presentation of the theoretical concept of mentalization and describes eating disorders from this perspective. This is followed by a discussion of the place of MBT-ED in eating disorders practice. MBT is first presented as the original model for borderline personality disorder, and then the model is further developed to address specific symptoms found in eating disorders, such as body image disturbance, restriction and purging. The original MBT model consists of outpatient treatment combined with individual and group psychotherapy, and psychoeducation in groups. The book then looks at supervision and training, and how an eating disorders team can develop a mentalizing focus. It goes on to describe the training required for practitioners to deliver individual and group MBT-ED and to supervise therapy. Lastly, it examines the implementation of the approach in different clinical settings, including inpatient services, and how management can be involved in negotiating barriers and taking advantage of enablers in the system.

The authors have conducted a pilot randomized controlled trial and qualitative research in MBT-ED and have extensive experience in providing and supervising this novel therapy. MBT-ED is one of the few therapies for eating disorders that links theory of mind, and attachment and psychodynamic therapies and as such will be of great theoretical interest to a wide variety of clinicians and researchers.

• Language: English
• Publisher: Springer
• Release date: Nov 3, 2018
• ISBN: 9783319951218

Paul Robinson

Dr Paul Robinson works in the Department of Aeronautics at Imperial College London, UK. He is widely renowned for his expertise on the failure mechanics of composite materials.

Book preview

© Springer International Publishing AG, part of Springer Nature 2019

Paul Robinson, Finn Skårderud and Bente SommerfeldtHungerhttps://doi.org/10.1007/978-3-319-95121-8_1

1. Introduction: Minding the Body

Mentalizing and Eating Disorders

Paul Robinson¹ , Finn Skårderud², ³ and Bente Sommerfeldt²

(1)

Nutrition Science Group, Division of Medicine, University College London, London, UK

(2)

Institute for Eating Disorders, Oslo, Norway

(3)

Norwegian School of Sports Sciences, Oslo, Norway

1.1 The Title of the Book

We have chosen Hunger as the title of this book, hunger in both its concrete and metaphorical meanings. It may refer to physical hunger, as it may refer to unfulfilled desires and needs. As a metaphor originally based in physiology, it may refer to the hunger for meaning, rest, control, security, response, respect or attachment. Hungry hearts is a well-known metaphor for love. In eating disorders we experience all this, and it is a central part of the pathology of eating disorders how concrete and metaphor collapse in bewildering ways. Mental and relational phenomena are experienced via bodily behaviour and bodily sensations. The person with an eating disorder may experience emotional distress as the feeling of getting fatter. The bingeing person may have gained the insight that filling oneself with food is a tool to get away from oneself, to calm down or to seek time-out and oblivion. And the restrictive person’s self-starvation is an attempt to gain control and mastery in life. But they lose control over the desire to establish control.

This is an essential aspect of eating disorders. We can call it concretism . We borrow from a film title in 2003 by Sofia Coppola Lost in Translation, about an American in Tokyo. We propose that the eating-disordered patient is lost in translation. She or he is stuck in the isomorphism of body and mind, concrete and metaphor. In the context of this book, concretization represents a form of impaired mentalizing and will often function as a limitation for traditional psychotherapeutic work.

1.2 The Potential Severity of Eating Disorders

A therapeutic treatment will be effective to the extent that it is able to enhance the patient’s psychological, physiological and social capacities without generating too many iatrogenic effects. Treatments of eating disorders need to be improved. The challenges are obvious. Some of the challenges come from the persons with eating disorders, and not least from serious somatic disturbances and impaired social relations, and some come from therapists and treatment systems. Severe eating disorders may last for decades, cause patients to retreat from normal social and family activity and destroy and break up families, and anorexia is the psychiatric disorder with the highest standardized mortality (Arcelus et al. 2011).

Anorexia nervosa represents a particular challenging case. In a special issue on anorexia in the leading scientific journal International Journal of Eating Disorders, a seminal figure in eating disorders and founder of cognitive behavioural therapy for eating disorders, Chris Fairburn (2005), provokes the clinical and scientific field by stating that, until more effective treatments for anorexia are developed, it is waste of time and money to set up randomized controlled studies. In the same issue of the journal, Woodside (2005: S 41) comments on a series of comprehensive overviews on therapy and therapeutic organization that there are more questions than answers and that there are more weaknesses than strengths in our understanding of the treatment of individuals with anorexia nervosa. There is a striking paucity of empirical evidence supporting any method of treatment, leaving clinicians, patients, and their families in the awkward position of relying on ‘best guess’ and ‘clinical experience’ when attempting to choose a treatment for the affected individual.

This is written more than 10 years ago, but it is hard to find current evidence for an improvement of the situation. The current state of the art is slightly better for bulimia and binge eating disorder, although therapeutic efficiency should not be overrated (Clinton 2010; Gowers et al. 2007). Hence, there is an obvious need to develop treatment programmes, train and supervise therapists and evaluate these in clinical trials.

A major challenge in the work with eating disorders is the problem of establishing good working alliances. Many do not seek treatment on their own initiative, the motivation to change is generally low and/or unstable and despite the impression of improving quality of available treatments for eating disorders, research data demonstrate a high number of patients dropping out of therapy (Campbell 2009; Robinson et al. 2016). Mentalization-based treatments, MBT, have a specific focus on establishing healthy working alliances and preventing dropout. See more about MBT as relational psychotherapy later in this chapter.

In this book we focus not only on characteristics of the patients and disorders but also on our own emotional reactions as therapists. Emotions are contagious and so are mentalizing and impaired mentalizing. Few symptoms create stronger reactions in the therapist than those in eating disorders, particularly anorexia nervosa, and few conditions require more forbearance and self-questioning. Working with patients with severe eating disorders tends to compromise the therapist’s reflective mode and mentalizing, with the risk of enactments and overreactions due to intense emotional reactions. A lack of understanding can lead to a lack of commitment and patience—or worse, to aggression and rejection. Eating disorders are challenging for mental health practitioners in both clinical and intellectual terms.

Treatment should be tailored.

We will here briefly describe mentalizing as a concept and tradition and also our major understandings of the nature of severe eating disorders. We hope to enrich the understanding of eating disorders by presenting updated theory. Not least we want to convince the reader why the implementation of mentalizing in the field of eating disorders is highly relevant and hopefully clinically useful. Within this intellectual framework, there is solid evidence to describe eating disorders as severe forms of impaired mentalizing . To make therapy really therapeutic, we are convinced that an understanding of the processes underpinning psychopathology will inform treatment innovation, which in turn can be the subject of empirical investigation. Treatment should be tailored.

1.3 What Is Mentalizing?

Mentalizing is a form of emotional knowing. The processes of perception are suffused with emotions. Body and brain, which strictly is part of the body, mature during development. A central part of this maturing is how experiences turn into mind. And we grow mentally via meetings with others. Physical encounters and relational experiences develop into internal representations, to a world of assumptions. Physical becomes mental. That gives us the unique possibility of using our minds to reflect upon our own minds and others’ minds. Instead of acting on strong emotions and impulses, we may use our minds to reflect and hopefully seek realistic, healthy and friendly modes of behaviour.

Mentalizing is the normal ability to ascribe intentions and meaning to human behaviour, to understand unwritten rules. It involves both a self-reflective and an interpersonal component that ideally provides the individual with a well-developed capacity to distinguish inner from outer reality, physical experience from mind and intrapersonal mental and emotional processes from interpersonal communications. Mentalizing can be described as being able to see oneself from the outside and other persons from the inside. It is a major social competence, central to human communication and relationships. Mentalizing fosters the regulation of feelings.

It is of great clinical relevance that mentalizing promotes affect regulation. But the capacities of mentalizing are also important for identity, for knowing oneself and not least for experiencing a sense of agency. Mentalizing is also important for real intersubjectivity and healthy relationships with others, to feeling felt. Impaired mentalizing often leads to loneliness. Good mentalizing is the flexibility of the mind and in relationships.

Mentalizing is the immune system of the mind.

Mentalizing means to be able to understand one’s misunderstandings. Impaired mentalizing may cause confusion and misunderstandings, acting on false assumptions. Being misunderstood is highly aversive. It may generate powerful emotions that result in coercion, withdrawal, hostility, overprotectiveness or rejection and symptom increase. The psychiatric patient with impaired mentalizing, for example, a person with an eating disorder, will often experience a vicious cycle: impaired mentalizing creates misunderstandings and ruptures in relationships, and an insecure world becomes even more insecure. Such stress, fear and affective arousal will further impair mentalizing capacity. And, hence, anorectic withdrawal and ways of behaving may appear like an island of control and predictability (Skårderud and Fonagy 2012).

Mentalizing represents a new paradigm by integrating knowledge from different realms, such as evolution, developmental psychology, attachment, theory of mind and neuroscience. Mentalizing is a model for understanding human behaviour in general and psychopathology in particular, and it is used—as demonstrated in this book—to inform the application of psychotherapy.

The concept of mentalization, popularized in the last 25 years by Peter Fonagy and collaborators (Fonagy 1991; Fonagy et al. 2002; Bateman and Fonagy 2016), describes the way humans make sense of their social world by imagining the mental states, e.g. beliefs, emotions, motives, desires and needs, that underpin behaviours in interpersonal interactions (Choi-Kain and Gunderson 2008). As stated above, mentalizing refers to minding the minds of both oneself and others. It is a rather new concept for well-known phenomena. Its originality lies in the ambition to integrate knowledge from different realms, putting man together again. Mentalizing represents the ambition to integrate body and mind, attachment and brain, past and present, and developmental psychology as a guide for therapy, and not least a psychotherapeutic search for subjectivity combined with manualized and evidence-based practice.

Fonagy and colleagues have elaborated a theory of how the capacity to mentalize develops in early childhood and how deviations from this normal developmental path may result in severe forms of psychopathology. Hence, central concepts both in the development of mentalizing competences and in clinical encounters may be safe/unsafe and secure/insecure. This will be further developed in Chap. 4 in relation to therapeutic stances and interventions.

Box 1.1 Definitions of Mentalizing

Mind-mindedness

Being interested in one’s own mind and others’ minds

To see others from the inside and yourself from the outside

To understand misunderstandings

(Bateman and Fonagy 2016).

1.4 Eating Disorders as Self-Disorders

In the diagnostic manuals, eating disorders refer to a set of symptoms. These presentations are central in the clinical phenomenology of these disorders. In this context, we also focus on symptoms as manifestations of underlying psyche. In the language of mentalizing, eating disorders are understood as manifestations of underlying deficits in self-regulation and affect regulation. When psychic reality is poorly integrated, the body may take on an excessively central role for the continuity of the sense of self, literally being a body of evidence (Skårderud and Fonagy 2012). Body serves as mind. And this introduces the tyranny of metrics. Concretistic symptoms essentially serve the function of maintaining the cohesion and stability of a tenuous sense of self. This formulation suggests that problems in the integration of psychic reality, such as disturbances in the sense of self or the body-mind continuum, may also have been present in the presymptomatic phase. Thus, this represents early manifestations of a disorder of self which may be associated with disturbed attachment in childhood, before eating and body were ever a problem.

Body serves as mind. And it is the tyranny of metrics.

The idea that severe eating disorders are essentially self-disorders has emerged gradually as clinicians and researchers have recognized the need to revise earlier conceptual models because of serious limitations in their ability to explain the clinical features of these disorders and to devise effective therapies (Taylor et al. 1997; Skårderud 2007). Moreover, there is a distinct trend emphasizing the role of emotions and not only distorted cognitions; see, e.g. Fox (2009). The pioneer in eating disorders, Hilde Bruch (1962), stated that the core problem lies in a deficient sense of self and involves a wide range of deficits in conceptual developments, body image and individuation (Skårderud 2013). It is our conviction that these underlying deficiencies should be the central focus for psychotherapy. A psychotherapeutic enterprise with individuals with compromised mentalizing capacity should be an activity that is specifically focused on the rehabilitation of this function and in eating disorders with special emphasis on how the body is representing mental states.

In Chap. 2 we will present examples of how eating disorders can be described and explained in the terminology of mentalizing.

1.5 Mentalization-Based Therapies for Eating Disorders

We already do it. All forms of psychotherapy foster mentalizing. The specific aspect of mentalization-based therapy is the systematic focus on the enhancement of these competences. In therapeutic enterprises it is highly relevant to ask: What is a human being? And not least: What is a suffering human being? We need a good language for bad experiences. In every treatment tradition, there is a model of humanity. Such a model, or vision, with its ideas and ideologies, can be more or less explicit. In MBT there is an explicit model of man as a relational being. The mentalizing approach has roots in psychodynamic psychotherapy and more specifically a relational or intersubjective tradition (Bateman and Fonagy 2016). In practical terms that implies a belief that mentalizing, symptom reduction and clinical improvement are best encouraged via a therapeutic relationship that lasts for a while (Allen and Fonagy 2006).

There is specific emphasis on the therapeutic encounter itself: that the cooperation works and that meetings are experienced as safe enough so the patient can be challenged in beliefs and behaviour. Mentalization-based therapy has a systematic and explicit focus on how to work with the therapeutic relationship . Psychotherapy provides an excellent opportunity to experience and learn from failures in mentalizing, such as those that occur in the therapeutic encounters, and repair ruptures in bonds, such as those that occur in enactments here and now. An effective therapeutic relationship is considered as a good analogy to secure attachment. When the relationship is experienced as a secure base , there are probably better possibilities to explore feelings, thoughts, hopes, needs, demands and dreams. With roots in attachment theory, and informed by both clinical experience and neuroscience, the therapeutic meeting is understood as activating the attachment system. Optimal activation harnesses brain processes partially to remove the dominance of constraints on the present from the past and creates the possibility of rethinking and reconfiguring intersubjective networks (Fonagy and Bateman 2006). In this model, therapy is an attachment bond, and therapists’ stance and interventions serve the function of developing this bond. Mentalizing is stimulated in and about the therapeutic relationship. And therapeutic interventions to address anxiety, motivation, ambivalence and symptoms are best furthered in a relationship with safe enough persons who reduce the sense of aloneness and who actively contribute in co-constructing new narratives about self and others.

1.6 The Art of Meeting

We can have different paradigms for treatment. For psychotherapy, we can state that there is something we can term a medical model of psychotherapy. The patient, based on assessment and diagnosis, is served a dose of sessions with techniques and prescribed interventions, as if it were a drug, hence, the drug metaphor (Wampold and Imel 2015). Public services often work within such an ideological and administrative framework. MBT is not independent of such a model, but proper mentalization-based therapy is, as stated, far more based in the relational model of psychotherapy. We have stated that therapy should be tailored. That means to the particular pathologies, but this is even more relevant to the concrete patient. A relational model of psychotherapy is more a person-centred than a disorder-centred approach.

MBT is a person-centred more than a disorder-centred approach.

This is highly relevant for eating disorders since establishing sound working alliances often is a problem, particularly with anorexia nervosa. In MBT there is explicit focus on the quality of the meeting. Persons with severe eating disorders are often hard to reach in the various clinical settings, and hence, the mentalizing tradition is asking how to reach those hard to reach. Important qualifications for the therapist are relational competences.

The mentalizing model has roots in psychodynamic traditions, as we already have stated, but with the emphasis on both cognitive and emotional processes this young tradition bridges psychoeducative, cognitive and psychoanalytical traditions. Mentalization-based therapy (MBT) was originally developed for borderline personality disorder (BPD) (Bateman and Fonagy 2016). The pivotal question is in what way should the therapeutic approaches originally developed for emotionally unstable patients be modified to be optimal for persons with different subtypes of eating disorders? As well as important differences, there are also striking similarities in the modes of experiencing psychic reality in borderline personality disorder and eating disorders. This will be further addressed in Chap. 2 where we discuss impairments of mentalizing in eating disorders. It seems to us clinically pertinent to give attention to the particular psychopathological aspects of eating disorders from the perspective of mentalizing. It is tempting to state that severe forms of eating disorders represent their own phenotype of self-regulation and affect regulation.

In the original model for MBT for borderline personality disorders, there is a basic assumption that developing mentalizing competences through the therapeutic discourse in itself will have a positive effect on affect regulation and hence on symptom reduction (Bateman and Fonagy 2016). This is different in MBT-ED. Because of the possibly severe somatic consequences of symptomatic behaviour, there is a need to also have a specific focus on symptom reduction.

The explicit ambition of MBT-ED is the double focus : at the same time being able to work constructively with symptoms and also to foster curiosity about the meetings of minds. Patients are stuck in their view of psychological and corporeal reality, and by encouraging curiosity through therapeutic activity, one aims to enrich reflective functioning.

1.7 Therapists’ Minds

The model of mentalizing is not only about them but also about us. In the contexts of great therapeutic challenges, like severe eating disorders, ours, the therapists’ reflective function, may collapse. Well-known examples from everyday clinical work show how, e.g. fear, frustration or anger among therapists can produce tunnel vision with a one-sided focus on somatic and bodily traits, like weight, blood tests, etc. In this way, severe eating disorders can be seen as contagious with both patients and clinicians having an overemphasized attention on bodily traits and less on what is going on in the mind. Or it may be the other way. We might be become too focused on mind and mental processes and ignore serious somatic threats. It is as if we are infected by patients’ cognitive and affective style of either-or, all-or-nothing. There is not least a practical but also an ethical aspect to this: patients can get worse through treatment.

Allow us to be critical and in particular self-critical. The contagion of concretism in eating disorders, as an expression of impaired mentalizing and low reflective function, may drain the creativity and vitality of those close to the patients. That may be family members and partners but also the clinicians and academics working in this arena. Clinicians’ problems understanding severe eating disorders represent hazards in terms of possible harmful effects on mentalizing capacities in the therapist and the treatment systems. As stated above, this may be expressed by disrupted therapeutic relationships, as well as by overreactions due to intense emotional reactions in the therapists. Hence, we need models to understand and prevent collapse in our own clarity of thinking, curiosity, open-mindedness and professional behaviour. Mentalizing as an intellectual framework can be helpful to organize the confusing and challenging phenomenology presented by the patients. And, hence, it can help us to better tolerate such phenomenology. The therapist’s mentalizing the patient’s impaired mentalizing may make it easier to empathize with the patient and enhance one’s negative capability, i.e. the capacity to tolerate and doubt and to stay with the material (Holmes 2001).

1.8 Common Factors in Therapy

The interest in mentalizing as part of treatment is about more than new theoretical models. We believe it also is about a tradition that is experienced as integrative and inclusive. Structures and clinical stances invite therapists from different traditions to reflect upon and modify their own practices. It is our experience from teaching, training and implementing that colleagues experience mentalizing models as a supplement to and a further development of established practices. That includes therapists working within the frames of psychodynamic, cognitive and systemic models. Hence, the mentalizing approach is not only for MBT therapists.

Mentalizing as the common factor in psychotherapy.

Allen et al. (2008) propose that promoting mentalizing can be seen as the effective common factor in psychotherapeutic treatments.

1.9 Curiosity, the Not-Knowing Stance and Transparency

The essence of a mentalizing approach is the stance of curiosity and not knowing. That implies a genuine interest in the other and encourages the other to explore himself or herself and their relationships. By being authentically curious, we are hoping to encourage curiosity in our patients, to promote reflection and healthy doubt. Let us call this curiosity by proxy.

Curiosity by proxy.

There is an ethical side to this. The more interested we are in a person, the more difficult it is to treat this person as a thing, an object or an instrument. Moreover, therapists trying to see ourselves from the outside also provides an ethical perspective.

A mentalizing stance also means being transparent. We open up. We share ideas; we speak openly about ourselves and the patients and not least about the actual meeting. By doing this, we are role models for how minds work and work together. It also introduces the possibility that we might be able to negotiate the relationship between therapist and patient, for example, regulating intensity. We also demonstrate that we keep few secrets from our patients, hence, trying to make a more equal relationship. This may be seen in contrast to the traditionally non-disclosing analyst, although this stereotype has been challenged (Greenberg 1995). Moreover, as transparent MBT clinicians, we also give responses to our patients, like parents give responses to their infants. Silence and a therapeutic still face will often frustrate patients and lead to further impairments of mentalizing just as it causes major distress to infants (Tronick 2018). We do believe that being responsive in this way may promote secure attachment in the therapeutic relationship. In MBT we often say go current, in the sense of wanting to develop what is going on here and now with you and me.

1.10 Epistemic Trust

A rather recent theoretical development in our thinking about mentalizing and therapeutic change is the concept of epistemic trust . Briefly, we propose that efficient psychotherapy is a pedagogical situation. In pedagogical encounters we learn to ride a bicycle, to understand mathematics, to eat spaghetti and to reflect more freely about our minds, i.e. recover from impaired mentalizing. But we absolutely need to trust those we will learn from. So it is in the therapeutic relationship. Are we as therapists trustworthy enough? And how can we become so?

Via this construct we emphasize the social and emotional significance of the trust we place in the information about the social world that we receive from another person (Bateman and Fonagy 2016). In other words, what needs to be open for change to occur? The concept relates to the postulate that mentalizing might be the common factor across different forms of effective psychotherapy. Mentalizing in therapy is a generic way of establishing epistemic trust, meaning trust in the authenticity and personal relevance of interpersonally transmitted information, between the patient and the therapist in ways that help the patient to relinquish the rigidity that characterizes many individuals with enduring personality pathology and in this case severe and enduring eating disorders (Fonagy and Allison 2014).

Are we therapists trustworthy enough? And how can we improve?

The relearning of flexibility allows the patient to go on to learn, socially, from new experiences and achieve change in their understanding of their social relationships and their own actions and behaviours. As Peter Fonagy and Elizabeth Allison state (2014: 372), the very experience of having our subjectivity understood—of being mentalized—is a necessary trigger for us to be able to receive and learn from the social knowledge that has the potential to change our perception of ourselves and the social world.

In practical terms, what does epistemic trust mean concerning the therapist’s way of being and acting? Epistemic trust is a useful concept to remind us that when we trust a teacher, it is easier to learn. A securely attached child is more likely to treat the caregiver as a reliable source of knowledge, and this trust is likely to generalize to other people in a position to learn from (Bateman and Fonagy 2016). Not least, it is a useful construct to remind us therapists about all the epistemic mistrust we meet. The people we meet, the patients, may imagine the motives of our communications to be malign. They will be hostile to new information, and might come across as rigid and stubborn, and new information is met with deep suspicion. Their epistemic trust has been undermined by earlier experiences, and the channel, prepared by evolution for the acquisition of relevant information, is partially blocked. For example, a person with a history of trauma has little reason to trust and will reject information that is inconsistent with their beliefs. Precluding themselves from social learning in this way will present as a reluctance to change.