Eating One's Words: Part III. Mentalisation-Based Psychotherapy for Anorexia Nervosa-An Outline for a Treatment and Training Manual
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European Eating Disorders Review
Eur. Eat. Disorders Rev. 15, 323–339 (2007)
Eating One’s Words: Part III.
Mentalisation-Based
Psychotherapy for Anorexia
Nervosa—An Outline for a
Treatment and Training Manual
Finn Skårderud 1,2*
1
Faculty of Health and Social Studies, Lillehammer University College,
Norway
2
Centre for Child and Adolescent Mental Health, Eastern and Southern
Norway, Oslo, Norway
This paper presents a new outline for psychotherapy with per-
sons with anorexia nervosa. ‘Model on mentalisation’ is the
intellectual and empirical framework for this contribution. Men-
talisation is defined as the ability to understand feelings, cogni-
tions, intentions and meaning in oneself and in others. The capacity
to understand oneself and others is a key determinant of self-
organisation and affect regulation, and is acquired in early attach-
ment relationships. Impaired mentalisation is documented and
described as a central psychopathological feature in anorexia ner-
vosa. Psychotherapeutic enterprise with individuals with com-
promised mentalising capacity should be an activity that is
specifically focused on the rehabilitation of this function, with
special emphasis on how the body is representing mental states.
The paper describes psychotherapeutic goals, stances and tech-
niques. It is intended that this outline will be further developed
into manuals as a basis for therapy, training and research.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders
Association.
Keywords: anorexia nervosa; embodiment; mentalisation; psychotherapy; psychoanalysis
INTRODUCTION developing therapeutic techniques for this disorder.
There is a general agreement that working with
The aim of this paper is to propose an outline for anorexia nervosa may be challenging. Ambivalence
psychotherapeutic approaches to anorexia nervosa, about recovery is a central feature. Patients
and to introduce a ‘model on mentalisation’ (Allen with anorexia rarely seek treatment on their
& Fonagy, 2006) as an intellectual framework for own initiative (Rosenvinge & Kuhlefelt-Klusmeier,
2000), the motivation to change is low and/or
unstable (Geller, Williams, & Srikameswaran, 2001),
* Correspondence to: Prof. Finn Skårderud, MD, Institute for approximately one-half of the patients drop out of
eating disorders, Kirkeveien 64 B, N-0364 Oslo, Norway.
Tel: þ47-918-19-990. Fax: þ47 22025700. treatment (Vandereycken and Pierloot, 1983) and in
E-mail: finns@online.no a review Fairburn (2005) states that treatment
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.817324 F. Skårderud
outcome is generally poor. Despite research efforts the self from without. Anorexia nervosa is described
there is a striking paucity of empirical evidence as a disorder of self- and affect regulation, and the
supporting any method of treatment for anorexia concretistic symptoms essentially serve the function
nervosa (Woodside, 2005). of maintaining the cohesion and stability of a
This is the third and final part of three companion tenuous sense of self.
papers, ‘Eating one’s words I, II and III’. The series The idea that severe eating disorders are essen-
aims at furthering the understanding of the specific tially self disorders has emerged gradually as
psychopathology of anorexia nervosa, based on clinicians and researchers have recognised the need
research (Part I, Skårderud, 2007a), apply and to revise earlier conceptual models because of
develop relevant theory (Part II, Skårderud, serious limitations in their ability to explain the
2007b) and outline psychotherapy on this empirical clinical features of the eating disorders and to devise
and theoretical basis (Part III). The recommen- effective therapies (Taylor, Bagby and Parker, 1997).
dations for therapy follow the principle that Already the pioneer in eating disorders, Bruch
psychotherapeutic interventions should be tailored (1962) stated that the core problem lies in a deficient
directly to psychopathological processes. sense of self and involves a wide range of deficits in
Part I reports from an interview study based on conceptual developments, body image and aware-
qualitative research methods. The study demon- ness and individuation.
strates how bodily sensations and qualities like Finally, this Part III, building on research results
hunger, size, weight and shape are physical entities and theory in the preceding texts, and on clinical
that represent mental states. The overall finding is experience, deals exclusively with the psychother-
the isomorphism between inner and outer reality, apy of anorexia. The first section of the paper
mind and body. The patients demonstrate a describes the ‘model on mentalisation’. The second
closeness, a more or less immediate connection section applies these conceptual tools to describe
between physical and psychological realities; for more precisely the difficulties, limitations and
example restrictive control of food represents hindrances to psychotherapy with anorexia ner-
psychological self-control. The ‘as if’ of mental vosa. And, based on these descriptions, the third
representation is turned into an ‘is’. Most persons section will outline some basic approaches and
with anorexia nervosa experience this corporeality goals in therapy. Psychotherapeutic enterprise with
as an obsessional and ruthless reality which is individuals with compromised mentalising capacity
difficult to escape from. This concretisation of should be an activity that is specifically focused on the
mental life is interpreted as impaired ‘reflective rehabilitation of this function. In the history of
function’ and ‘mentalisation, and is proposed as a interpreting anorexia there are numerous descrip-
central psychopathological feature in anorexia tions of the possible symbolic meanings of symp-
nervosa. toms. This text will try to move interest from the
‘Reflective function’ is the broader concept and ‘what is symbolised’ to ‘how symbolised’, from
refers to the psychological processes underlying the interpretation of meaning to enhancement of func-
capacity to make mental representations. This tion.
concept has been described both in the psycho-
analytic (Fonagy, 1989, 1991) and cognitive (e.g.
Morton & Frith, 1995) psychology literatures.
‘Mentalisation’ is an aspect of reflective function, A MENTALISING THEORETICAL
and can be defined as ‘keeping one’s own state, AND THERAPEUTIC PERSPECTIVE
desires, and goals in mind as one addresses one’s
Mentalisation
own experience, and keeping another’s state,
desires, and goals in mind as one interprets his or The concept mentalisation originates from French
her behaviour’ (Coates, 2006 p. xv). psychoanalysis (Lecours & Bouchard, 1997; Luquet,
Part II develops further theoretical concepts to 1987; Marty, 1990) in the late 1960s, but diversified
discuss the empirical findings and to describe in the early 1990s when Baron-Cohen (1995), Frith
impairment of reflective function in anorexia and Frith (2003) and others applied it to neurobio-
nervosa. When psychic reality is poorly integrated, logical based deficits in autism and schizophrenia,
the body may take on an excessively central role for and, concomitantly, Fonagy, Target and colleagues
the continuity of the sense of self, literally being a (Fonagy & Target, 1996, 1997; Fonagy, Gergely,
body of evidence. Not being able to feel themselves Jurist, & Target, 2002) applied it to developmental
from within, the patients are forced to experience psychopathology in the context of attachment
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/ervMentalisation-Based Psychotherapy for Anorexia Nervosa 325
relationships gone awry. This text leans on works in not only good for you but it is even better for your
the latter tradition (Allen & Fonagy, 2006). Anthony children’ (Coates, 2006 p. xvi–xvii).
Bateman has together with Peter Fonagy been a In summary, mentalisation has been empirically
pioneer in translating theoretical principles into linked to important findings in development, both
therapeutic principles (Bateman & Fonagy, 2004). in neuroscience and clinical psychology; in the
The scientific and clinical staffs at The Menninger understanding of psychopathology; and in the
Clinic in Texas, USA, are also important contribu- conceptualisation of treatment efficacy both in
tors, with Jon G. Allen (Allen, 2001, 2003, 2006) as a children and adults. ‘What we have here is some-
prominent professional. thing of a conceptual revolution, one that is still
The model is based on developmental psychology underway’ (Coates, 2006 p. xvii).
and contemporary psychoanalysis, and, not least, The concept may for some appear to have a
with a strong ambition to integrate recent develop- dehumanising and technical ring to it, and should
ments in neuroscience. The model also includes be humanised. We must keep in mind that the
revised versions of ‘attachment theory’. Originally mental states perceived and the processes of
Bowlby (1969) described the human biological urge perception are suffused with emotion; hence,
to search for a secure base of attachments for mentalising is a form of emotional knowing (Allen,
survival and development. Attachment is seen as an 2006). Mentalising is the normal ability to ascribe
innate biological instinct to ensure protections and intentions and meaning to human behaviour, to
reproduction through physical proximity to care- understand ‘unwritten rules’, and shapes our
giver. Attachment is a context for the development understanding of others and ourselves. Hence, it
of the social brain. Basic polarities for attachment is central to human communication and relation-
theory are approach—avoidance, security—inse- ships. It can be described as being able to see oneself
curity, attachment—loss (Holmes, 2001). from the outside and other persons from the inside.
On the basis of empirical observations and There is an ethical aspect to this: The better one
theoretical elaboration, Fonagy and Target devel- understands other people’s behaviour, the harder it
oped (1996, 1997) the argument that the capacity becomes to treat a person as a thing.
to understand interpersonal behaviour in terms Mentalisation is about ‘mind-mindedness’, hav-
of mental states is a key determinant of self- ing mind in mind. Related concepts are ‘empathy’,
organisation and affect regulation, and that it is ‘emotional intelligence’, ‘psychological minded-
acquired in the context of early attachment rela- ness’, ‘metacognition’, ‘insight’, ‘observing ego’,
tionships. It posits that a sense of self develops from ‘mindfulness’, ‘interpretation’ and ‘reflection’. Men-
observing oneself being perceived by others as talising involves both a self-reflective and an
thinking or feeling. By internalising perceptions interpersonal component that ideally provides the
made by others about him—or herself, the infant individual with a well-developed capacity to
learns that its mind does not mirror the world; its distinguish inner from outer reality, physical
mind interprets the world. This capacity is referred experience from mind and intrapersonal mental
to as mentalisation, meaning the capacity to know and emotional processes from interpersonal com-
that one has an agentive mind and to recognise the munications. Hence, the anorectic concretisation of
presence and importance of mental states in others emotional life can be described as one of more
(Gunderson, 2004). Secure attachment promotes possible presentations of impaired mentalisation.
mentalising capacity, while insecure attachment Mentalisation means to be able to understand
and trauma can undermine it. one’s misunderstandings. Impaired mentalisation
Today this body of thought is reliably anchored in may cause confusion and misunderstandings,
empirical studies of great robustness, demonstrat- acting on false assumptions. Being misunderstood
ing attachment patterns as a predictor for mental is highly aversive. It may generate powerful emo-
health, the connections between secure/insecure tions that result in coercion, withdrawal, hostility,
attachment and mentalisation and the role of over-protectiveness or rejection—and symptom
mentalisation in regulating affects and negotiating increase (Bateman & Fonagy, 2004). The psychiatric
relationships. And the works of Fonagy and colla- patient with impaired mentalisation, for example a
borators also show that this mentalising capacity person with anorexia, will often experience the
provides a critical link in the transmission of vicious circle: Impaired mentalisation creates mis-
attachment security across generations. Mothers understandings and ruptures in relations, and an
and fathers who scored high on this dimension insecure world becomes even more insecure. Such
tended to have children who were secure. ‘Insight is stress, fear and affective arousal will further impair
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/erv326 F. Skårderud
the mentalising capacity. And, hence, the anorectic Most psychotherapies probably promote mentalis-
withdrawal and way of behaving may appear as an ing capacities. The activity of mentalising is the core
island of control and predictability. of psychotherapy, as it is of childrearing and ethics.
It underpins clinical understanding, the therapeutic
relationship and therapeutic change. And it is an old
Mentalisation-Based Therapy for Borderline
assumption that much of the effectiveness of
Personality Disorder
different forms of psychotherapy may be due to
The scientific tradition on mentalisation aspires to those features that are common rather than those
develop a new intellectual framework for psy- that distinguish them from each other (Frank, 1961).
chotherapy (Fonagy, 2006a). Based on develop- But, the specific aspect of mentalisation-based therapy is
mental studies of psychopathology, the ambition is the systematic focus on the enhancement of mentalising
to identify psychological and neural mechanisms itself. In that sense, mentalisation can function as a
underlying disturbance, and, consequently, employ superior concept guiding clinical work, and with the
therapeutic techniques specifically designed to emphasis on both cognitive and emotional processes
address a developmental dysfunction. bridge psycho-educative, cognitive and psychoanalytical
Psychotherapy provides an opportunity for techniques. But different from traditional cognitive
intensive practice in mentalising. The therapeutic therapy working with own thoughts, the mentalis-
relationship is an attachment bond, and one impor- ing approach also focuses on the feelings and
tant aspect of psychotherapy is that it activates thoughts of others.
attachment systems. An effective psychotherapeutic A mentalising approach can be seen as simplify-
relationship is the best analogue of a secure base in ing the basic steps in psychotherapeutic encounters,
attachment that fosters mentalising. Not only does either in individual, group or marital and family
psychotherapy entail mentalising in the sense of treatment contexts; not at least in milieu therapy.
exploring thoughts, feelings, hopes, wishes, dreams Promoting a mentalising attitude means an inqui-
and the like, but also psychotherapy provides the sitive, playful, curious and open-minded style in
opportunity to experience and learn from failures in dialogues, with a focus on minding the mind. A
mentalising, such as occur in transference enact- mentalising attitude focuses on promoting the
ments. attentiveness to the activity of mentalising. And
So far, the main work has been done with Allen (2006) proposes that the better term is
borderline personality disorder. A mentalisation- mentalising, and not mentalisation, emphasising
based format for psychotherapy for borderline the activity.
personality disorder, MBT, was developed and
manualised, and has been shown to be effective in a
Minding Anorexia Nervosa
randomised controlled clinical trial (Bateman &
Fonagy, 1999). In that study, MBT was provided in a Today, there is no correspondingly well-developed
day-hospital setting for 18 months and was con- mentalisation-based model for psychotherapy for
trasted with usual psychiatric care. MBT showed anorexia nervosa. And a model for the psycho-
effective results in diminishing hospitalisations, pathology and therapy for borderline personality
medication usage and suicidal and self-injurious disorder cannot, of course, be directly applied to
behaviours. In addition, it also showed significant other kinds of disorders. But as there are important
benefits in symptoms of depression and anxiety, differences, there are also striking similarities in the
and in social and interpersonal function. Particu- modes of experiencing psychic reality in borderline
larly impressive was that patients continued to personality disorder and eating disorders. And
improve during an 18-month period of follow up there is also a documented comorbidity of these two
(Bateman & Fonagy, 2001; Gunderson, 2004). disorders (Rosenvinge, Martinussen, & Østensen,
In advocating mentalisation-based treatment 2000; Skodol, Oldham, Hyler, Kellman, Doidge, &
there is no claim of innovation. ‘On the contrary, Davies, 1993).
mentalisation-based treatment is the least novel Mentalisation is operationalised for scientific
therapeutic approach imaginable; it addresses the research as ‘reflective function’. ‘Reflective-
bedrock capacity to apprehend mind as such. . . . functioning manual’ (Fonagy, Target, Steele, &
Nonetheless, fostering the capacity to mentalise Steele, 1998) is developed to measure reflective
might be our most profound therapeutic endeavour: function based on the ‘Adult Attachment Interview,
cultivating a fully functioning mind is a high AAI’ (Main & Goldwyn, 1995). In a study
aspiration indeed’ (Allen & Fonagy, 2006 p. xix). from Cassel Hospital in the United Kingdom 82
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/ervMentalisation-Based Psychotherapy for Anorexia Nervosa 327
non-psychotic psychiatric patients were grouped ing in their bodies, such as hunger and satiety, and
according to Axis I diagnoses depression, anxiety, also fatigue and weakness as the physiological signs
substance use and eating disorders; and Axis II of malnutrition. The person with anorexia can be a
diagnoses borderline personality disorder, anti- person who is obsessively preoccupied with bodily
social or paranoid disorder, other personality dis- qualities and sensations most of the 24 hours of the
orders and no Axis II. The eating disordered day, and at the same time has distorted experiences
patients scored lowest on reflective function of their own physical body. Hence, anorexia
together with the patients diagnosed as borderline nervosa can be described as embodiment gone
personality disorders (Fonagy et al., 1996). awry, therefore elucidating developmental pro-
Not least to promote therapists’ beliefs in their cesses, and as such contributing to widening the
own competence, it is appropriate to deconstruct scope of the mentalising-model.
parts of the myth that anorexia nervosa is such a The challenge for the therapist is to become a
particular phenomenon. From the perspective of better mentaliser. This challenge increases when
supervision and training, it is important to help mentalising non-mentalising and impaired menta-
therapists to learn about the particularities con- lising. But one can also redefine this, and state that
nected to this disorder. Such specific competence is psychopathology itself, as in anorexia nervosa, may
relevant in itself, but just as important is that help us in this effort. Psychopathology compro-
competence may function as a door-opener to the mises mentalising, and scientific knowledge devel-
demystification of the disorder. When one under- ops descriptions that can guide the psychother-
stands what is special, it is easier to recognise what apeutic approach and focus.
is common. And recognising common aspects may It is stated here that more of the basic principles
enhance professional self-confidence. Anorexia applied in the treatment model for borderline
nervosa is still an enigma, but it is important to personality disorder are utterly relevant for work-
deconstruct the myth of anorexia as extremely ing with anorexia nervosa; since they refer to the
difficult to comprehend and treat. The reference to fundamental capacity of mentalising as such. But
common traits in psychological functioning in further developments are also necessary. Hence,
anorexia nervosa and, for example borderline anorexia nervosa can contribute to widening the
personality disorder, to think transdiagnostically, scope of mentalisation-based treatment and psy-
may contribute to openness, interest and curiosity. chotherapy.
Today, there is a risk of isolation of professional
milieus working with anorexia nervosa.
Mentalising may serve a function as one amongst
LIMITATIONS TO THERAPY
other theoretical and empirical concepts constitut-
ing a base for tailored therapeutic activity. But it is It is a main thesis in this paper that the described
important to emphasise that, with respect to the central aspects of the psychopathology of anorexia
psychopathology of anorexia nervosa, the tradition nervosa are not adequately understood and taken
of mentalising is far from satisfactorily elaborated. account of in many therapeutic encounters. In
Not least, this refers to the need to develop models practical terms this means insufficient assessments
concerning embodiment; ‘the embodied mind’ and or over-estimating the patients’ mentalising capa-
‘the minded body’. There are many dimensions of cities. The patient’s intellectual skills may confuse
human embodiment, but here it applies specifically therapists.
to the role of the body in the development of mind,
both in normal development and in different
Therapeutic Alliance
psychopathologies.
Let us redefine: Maybe the case of anorexia Uncertain motivation for recovery is a relevant topic
nervosa and eating disorders may represent the for many patients and health workers may lack
phenomenological ground for such elaboration. A motivation to work with them. Few symptoms can
person with anorexia will most often be a person create stronger reactions in therapists than anorexia
with difficulties in interpreting and regulating their nervosa and few require more forbearance.
own affects, in interpreting other peoples emotions, After approximately a half century of psychother-
but not least in perceiving and interpreting their apy research, one of the most consistent findings is
own corporeality. Bruch (1962) observed that that the quality of the therapeutic alliance is the
anorexic patients manifest difficulties in accurately most robust predictor of treatment success. This
perceiving or cognitively interpreting stimuli aris- finding has been evident across a wide range of
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/erv328 F. Skårderud
treatment modalities. A related finding is that poor means ‘no-words-for-feelings’. And the concrete
outcome cases show greater evidence of negative way of functioning mentally may represent paucity
interpersonal process, that is hostile and complex or absence of verbal accompaniment, often con-
interactions between therapist and patient than tributing to frustrating and non-productive silences
good outcome cases (Safran & Muran, 2000). It has in the therapeutic situation.
also been shown that ‘patient factors’ such as
motivation make the greatest contribution to the Pseudo-compliance. Patients with anorexia are
therapeutic alliance (Horvath & Symonds, 1991). described as ‘outer-directed’ (Buhl, 2002), in the
Many clinicians find it difficult to establish healthy sense that low self-esteem induces a high sensitivity
working alliances with their patients with anorexia for attention, tokens of esteem, praise and com-
nervosa. Let us address this problem from two parison and great interest in compensating low
perspectives, ‘theirs’ and ‘ours’. The dual perspect- self-esteem through performances, achievements,
ive is: how to understand patients, and how to skills—and a sensitivity and a drive for satisfying
understand therapists’ negative reactions. other peoples’ needs (Skårderud, 2007c). This may
be expressed in high compliance towards people—
Patient factors and therapists. ‘The clever child’ also tends to aspire
Anorexia nervosa often represents great therapeutic to be ‘the clever patient’. Using a Winnicottian term,
challenges, not least due to the impaired mentalisa- the ‘false self’ is at work (Winnicott, 1975).
tion and more precisely the concretisation of From the therapist’s perspective this may be
emotional life. conceived as pseudo-compliance. Actually, there is no
working alliance, but mainly an ambiguous form of
Patients’ lack of insight into illness. One limitation politeness; saying ‘yes’, meaning both ‘yes’ and ‘no’.
in therapy is the patient’s lack of insight into their
own illness. The body functions metaphorically Self- and affect regulation. Patients with anorexia
(Skårderud, 2007a, 2007b), but this symbolic com- often present themselves via their lacking capacity
munication via the body is not experienced as to tolerate, modulate or synthesise affects, expressed
metaphors by the anorectic patients, but rather as both through their affective and cognitive either-or,
concrete reality. It is the bodily reality here- all-or-nothing. In clinical terms therapists may
and-now, a harsh reality difficult to escape for the experience oscillations between restrictive silence
patient. Representations become presentations. and outburst of both positive and negative affects;
for example excitement, enthusiasm, fear, rage and
Restorative function of symptoms. Another limita- shame.
tion in therapeutic processes is the possible
restorative function of symptoms. The symptoms Physiology and psychology of hunger. In addition,
are destructive, but at the same time they may as therapists we are often confronted with physio-
function for self-cohesion and affect regulation; and logical symptoms of under-nourishment and mal-
therefore may be subjectively experienced as nutrition, like tiredness and exhaustion. And there
constructive. This contributes to unstable or absent are the psychological symptoms of malnutrition. The
motivation for recovery. The patient may seem to be somatic states will in themselves often contribute to
trapped in the concreteness of mind–body repres- dysfunctional psychic phenomena, such as
entation, and this may help us to realise why he or emotional instability, low spirits, irritability,
she may be so difficult to engage in therapeutic apathy, reduced power of concentration and
relations. memory, compulsive behaviour and rituals and,
logically enough, increased preoccupation with
Alexithymia. Impaired mentalisation in anorexia food rituals, often with fear of binge eating. This
nervosa will often be expressed, or rather not is what we call ‘the psychology of hunger’, where
expressed, as incapacity to give verbal accounts of psychic symptoms are secondary to the state of
one’s inner states. Bruch (1962) observed that nutrition. In a causality model for eating disorders,
patients with anorexia experience their emotions the psychology of hunger functions as a ‘maintain-
in a bewildering way and are often unable to ing factor’. This makes recovery difficult.
describe them. Such disconnections between phys-
iological and subjective feeling components of Impaired mentalising—by age. And, not least,
emotion are commonly termed as ‘alexithymia’. treating anorexia nervosa often means working
The concept originates from Greek and literally with adolescents; immature by definition and
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/ervMentalisation-Based Psychotherapy for Anorexia Nervosa 329
whose mentalising capacities are not yet fully Therapists’ impaired mentalising. The concept of
developed. mentalisation is relevant not only to describe
patients, but also their helpers. The capacity of
mentalisation is contextual; it is far from an either-or
Therapist factors
capacity. In some situations we all mentalise badly,
A possible negative contribution to therapeutic
in the sense of being able to understand the others’
enterprises does not concern the patients, but the
position. Mentalisation is reduced in situations of
therapists; and our difficulties with being able
affective arousal and in intensive attachment
to understand the very nature of these disorders.
relations, like threat of separation, relieving attach-
A lack of understanding can lead to a lack of
ment traumas. Hence, impaired mentalisation is
commitment and patience, to moralising statements
contextual. And the severely ill anorectic patient
and coercive behaviour; or worse—provoked to
may also in some contexts appear to be a good
aggression and rejection. And this may be
mentaliser. Therefore, she or he confuses us.
reinforced by self-starvation inducing clinicians’
And when confused, the therapist may feel
rational fear of somatic complications and death.
frustrated and provoked, and mentalising is
Anorexia nervosa is a psychiatric disorder with a
impaired.
rather high mortality rate (Nielsen, 2001). But
To sum up, the very nature of the psychopathol-
rational fear does not necessarily lead to rational
ogy of anorexia nervosa, here called ‘patient
reactions. Filled with such frustrations, therapists
factors’, and clinicians being intellectually and
may elicit potentially treatment-destructive inter-
emotionally challenged by these disorders, here
ventions.
called ‘therapist factors’, together represent great
hazards in terms of harmful effects on the
Therapists’ lack of insight into illness. Some therapists therapeutic alliance.
seem to be more prepared to endure aggressive Impaired mentalisation and psychic modes of
outbursts, verbal attacks, acting-out and overtly reality. In the following paragraphs there will
destructive behaviour, for example from persons follow elaborations of the hindrances and com-
diagnosed with borderline personality disorder, plications already described, with conceptual
better than the silence, isolation and restriction of reference to the model on mentalising. It is a
the anorectic. basic premise in psychodynamic therapy that
there are related processes coming into being
between the infant and caregivers, and later
The excluded therapist. Health workers experien-
between patient and therapist. Former and actual
cing rejection is well-known in clinical work with
relationships are reciprocal metaphors, and the
anorexia nervosa; and enduring rejection is difficult.
Greek meta-phoros is etymologically very close to
The anorectic person’s withdrawal into the ‘realm of
Freud’s original German concept of transference,
the concrete’ is perceived also as a withdrawal from
Übertragung (Enckell, 2002). History becomes a
relationships and as an exclusion of the clinician.
model to understand the contemporary, and the
The shame-based denial by the patient, claiming not
contemporary becomes a model to understand
to be worthy of any help or anything good
history. And where therapeutic alliances are
(Skårderud, 2007c), may similarly be experienced
established, where new attachment bonds are
as a provoking disruption of attachment.
formed and activate former bonds, new possibi-
lities for development and change appear. Half a
Therapeutic freedom. The drama of soma, threat of century ago Alexander (1952) established the
death and the anorectic ‘no’ restricts the therapist’s concept of ‘corrective emotional experience’.
freedom of movement. Anorectic behaviour is The outline of therapy presented here is in this
utterly seductive in the way it directs attention and manner theoretically founded in models of devel-
focus from emotions and the person’s subjective opmental psychology. In the further presentation
experiences to physical entities like gram, kilo and there will be an emphasis, with explicit reference to
calories. In this way anorexia nervosa is ‘conta- the tradition of mentalising, on psychic modes of
gious’. And it may be contagious in the sense that reality that can be experienced and described in
clinicians in the therapeutic relationships reproduce anorexia nervosa. There will also be an emphasis on
patients’ rejective style of attachment, with high corporealities; how different modes of realities
risks for drop-outs and disrupted therapeutic involve bodily experiences. The presentation will
relations. be illustrated with clinical examples, demonstrating
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/erv330 F. Skårderud
both psychological function and how this may be examples, all referring to one or more of the patients
expressed in therapeutic relations. interviewed in Part I:
Psychic equivalence She tries to be somebody by becoming nobody. She
Psychic equivalence as a construct means equating the is the one who is most hardworking to be clever and
internal with the external world (Fonagy, 2006b; most ill. She is very interested in food, but does not
Fonagy et al., 2002), and refers precisely to the eat it. She tries to improve her self-esteem by
empirical findings described in the first paper in this destroying herself. She sacrifices herself to save
series of three (Skårderud, 2007a). Psychic equival- herself. She behaves like a small child, and as a
ence covers one central aspect of the phenomenological mother for her parents. She is the self-obliterating
essence of embodiment in severe anorexia nervosa. child governing the whole family. She is the most
Psychic equivalence refers to an interesting, but obedient protesting most violently. She is con-
problematic mind–world isomorphism. What exists
forming and different. She longs for help, and
in the mind must exist in the external world, and
despises her helpers.
what exists out there must invariably also exist in
the mind. Psychic equivalence may for the therapist
represent a frustrating difficulty to engage the
Possible clinical expressions relevant for treat- patient and establish a fruitful working alliance. The
ment. Psychic equivalence in anorexia nervosa is patient’s fear of not being in psychological control
about carnal thoughts and emotions. Part I presents can lead to controlling behaviour, like checking,
a number of examples of equivalence between body double-checking and including controlling the
and mind in anorexia nervosa, and the process of therapist. A general feeling of distrust is expressed
equating goes both ways: What is thought and felt, as distrust towards scales, amounts of food but also
is also perceived as physical reality. And bodily the trustworthiness of the therapist. Insecure
perceptions represent emotional realities. The identity generates the patient’s tendency to com-
patient experiencing lack of control in her life, pare themself with others, concerning concrete
can also have an experience of bodily expansion, achievements and bodily qualities. The therapist
getting bigger and fatter. Hence, psychic equival- working with anorexia and eating disorders should
ence is relevant for the understanding of the ‘body be aware that one’s own body is being assessed and
image disturbance’ in anorexia nervosa. It is a judged; and this may impair therapeutic relation-
clinical experience, not yet satisfactorily described ships, particularly in initial phases. Hence, the
in research literature, that body image disturbance therapeutic relationship and interchange, and other
is contextually dependent on affective state; most relationships, are also concretised and psychologi-
prominent when there is negative affective arousal. cally equated.
The ‘as if’ of the representational mind is turned to
an ‘is’.
Part I gives examples of how the anorectic patients Teleological stance
ascribe numerous possible meanings to symptoms. ‘Teleological stance’ is introduced as a concept to
Hence, there is richness in what being symbolised, deepen the understanding of such physicalisation of
but poverty in how to symbolise. The psychic pain life and relationships. As a child normally develops,
for the patient is that he or she is trapped in this it gradually acquires an understanding of five
harsh corporeality here-and-now; and does not increasingly complex levels of agency of the self:
satisfactorily mentalise how his or her body func- physical, social, teleological, intentional and repres-
tions as a metaphorical source for emotional life, entational (Fonagy et al., 2002; Gergely, 2001).
and vice versa. Teleological stance refers to a developmental level
For the therapist the mode of psychic equivalence where expectations concerning agency of the self
may contribute to confusion: inner states are and the agency of the other are present, but these are
concretely presented in a bodily way. Common formulated in terms restricted to the physical world.
psychological states are low self-esteem, insecurity There is a focus on understanding actions in terms
and confused identity, affect disregulation and of their physical as opposed to mental outcomes; ‘I
ambivalence. These may concretely be lived out as don’t believe before I see it’. Patients have problems
ambiguous and contradictory messages, and lit- accepting anything other than a modification in the
erally confusing us. The patient in inner conflict realm of the physical as a true index of the
with herself, plays out these conflicts. Here are some intentions of the other.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/ervMentalisation-Based Psychotherapy for Anorexia Nervosa 331
Possible clinical expressions relevant for treat- peutic relationship this may lead to endless
ment. In the world of psychiatric disorders anorexia inconsequential talk of thoughts and feelings, and
nervosa and eating disorders represent a special will be experienced as tiresome by the therapist. The
case, in the sense that in the biographies of the dialogues may appear as relevant, given the topics
patients one can find an initial active wish for of emotions and thoughts, but with minor effects.
change. The persons want to change themselves, in This represents pseudo-mentalising. Pretend mode as
self-esteem and social acceptance, and such changes a concept is a useful tool to widen the under-
are sought to be fulfilled by physically changing standing of ineffective therapy. The alexithymic
their bodies. Hence, teleological stance may be a patient may lack words for inner life, while the
useful concept to describe and understand the patient in pretend mode has words, but they are not
concretisation of ambitions for self-improvement in yet their own.
anorexia nervosa. The described outer-directedness, with the
Teleological stance is also relevant to under- patient trying to interpret and satisfy other people’s
standing relationships in general, and therapeutic needs (Buhl, 2002), may lead to hyper-mentalising.
relationships in particular, like battles about agree- The combination of pseudo- and hyper-mentalising
ments, appointments, contracts, time, money and may contribute even more to the confusion
attention. If the therapist really cares, he or she is described above.
expected to show this benign disposition and Pretend mode—as ‘not being in contact with’—
motivations to helpful in concrete manners; like may also be relevant if furthering the understanding
availability on the telephone, extra sessions at of the nature of body image distortion in anorexia
weekends, physical touching, holding and acts nervosa. One of the patients interviewed in Part I,
‘beyond rules’. Hence, this may contribute to Maria, spoke of her body. When underweight she
violations of therapeutic boundaries (Bateman & described a satisfactory firmness of her body above
Fonagy, 2004). the waist. ‘Then I become more distinct to myself’.
But she did have a radically different experience
Pretend modeIn a developmental perspective ‘pre- with her thighs and legs, particularly thighs. She
tend’ represents for the child an alternative mode of used words like numb, fatty, liquid and without
experiencing reality. It is a decoupling of internal borders. And when she was scared or stressed, she
from external reality (Fonagy, 2006b; Fonagy et al., felt this even worse; ‘it is as they live their own lives,
2002). Actually the child is playing and ‘playing beyond my control, and sometimes they are in the
with reality’ (Winnicott, 1971). In a clinical perspect- other part of the room’.
ive with adolescents and adults this refers to The statement here is that there is a parallel
dissociation between internal state and outside situation in the way of experiencing/not experien-
world. In psychotherapeutic work, words with cing bodily states and experiencing/not experien-
reference to inner states are commonly used with cing emotional states. Neither the pretend mode nor
the expectation on the part of the therapist that these psychic equivalence have the full quality of internal
will have a real impact on the patient. But while the reality. Pretend mode is too unreal, while psychic
patient is in pretend mode, the words may be equivalence is too real. In normal development the
understood, but do not have such real impact. As child integrates these two modes to arrive at a
Bateman and Fonagy (2004) write about therapy reflective mode, or mentalisation, in which thoughts
with borderline patients: ‘‘Therapy’ can go on for and feelings can be experienced as representations.
weeks, months, sometimes even years, in the ‘Inner and outer reality are seen as linked, but
pretend mode of psychic reality, where internal separate, and no longer have to be either equated or
states are discussed at length, sometimes with dissociated from each other’ (Bateman & Fonagy,
excessive detail and complexity yet no progress is 2004 p. 70).
made, and no real understanding is experienced’
(p. 70). Ideas do not form a satisfactory bridge
between inner and outer reality and affects do not
accompany thoughts.
THERAPY
A therapeutic treatment will be effective to the extent
Possible clinical expressions relevant for treatment. A that it is able to enhance the patient’s psychological,
clinical feature, not at least in anorexia nervosa, may physiological and social capacities without generat-
be feelings of emptiness, meaninglessness and ing too many iatrogenic effects. Iatrogenic effects are
dissociation in the wake of trauma. In the thera- hopefully reduced if intensity and therapeutic
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/erv332 F. Skårderud
approach is carefully titrated to patient capacities exia nervosa can be helpful for the therapist as a
(Bateman & Fonagy, 2006). Based on what is buffer against affect arousal. The therapist’s men-
presented in Parts I and II and about obstacles to talising the patient’s impaired mentalisation may
and possible complications in therapy, this section make it easier to empathise with the patient, like the
will outline some very basic goals and tasks in patient, and enhance his or hers ‘negative capa-
psychotherapy to further such titration in the work bility’, that is the capacity to tolerate and doubt and
with anorexia nervosa. The text will not deal with to ‘stay with’ the material (Holmes, 2001).1
organisational aspects of treatment services. ‘Psychic equivalence’ as a construct is most
A fundamental assumption is ‘entering the helpful to deconstruct confusion. The same goes
concrete’; to point to the expediency of entering for ‘concretised metaphor’, extensively presented in
the phenomenological world presented by the Parts I and II, referring to the same phenomena with
patient; an acceptance and understanding of the other terms (Enckell, 2002). Bodily sensations and
patients’ way of mental functioning. The psycho- qualities metaphorically represent mental states.
analyst Josephs (1989) writes that ‘an alternative to The anorectic body can be ‘read’ as a text (Ricoeur,
getting the patient to enter the realm of the symbolic 1977). The equation of inner and outer reality makes
(the therapist’s world), is the therapist instead it possible to decipher symptoms and bodily
entering the realm of the concrete (the patient’s behaviour as distinct expressions of emotional
world). After all, the patient is usually looking for an states. The problem is, and what we often do not
ally’ (p. 495). see, is that it is too distinct. Bodily practices of
anorexia can be read as statements of both problems
and solutions, of ‘pros’ and ‘cons’ (Serpell, Treasure,
Therapeutic Alliance
Teasdale, & Sullivan, 1999). The anorectic body may
This is a vital insight for building healthy thera- refer to loss of control, vulnerability, distrust, sense
peutic alliances. A necessary primary focus is the of ineffectiveness and being overwhelmed by affects
establishment of a working relationship between and contradictory demands. And they refer to
patient and therapist; given the robust scientific attempted solutions, as strategies for control,
knowledge about the predictive value for good protection, reduction, effectiveness, purity and
outcome of the therapeutic alliance and given the radical simplification.
frequent difficulties with establishing such in work Confusion can be unravelled by reducing the
with anorexia nervosa. complex to the simple, but confusion can also be
There is a growing body of neurological evidence created by reducing complexity into something that
for the importance of secure attachment for is too simple, that is body–mind isomorphism.
mentalising capacity (Slade, Belsky, Aber, & Phelps, Confusing bodily practices in anorexia nervosa can
1999; van Ijzendoorn, Moran, Belsky, Pederson, be read as confusion itself is the message. What
Bakermans-Kranenburg, & Kneppers, 2000). Inse- therapists need to see, is that the confused state is
curity, affective arousal and attachment traumas not ours, but the patient’s. These disorders com-
impair mentalisation, while a secure base represents municate distinctly about being indistinct; they
open-mindedness. Activating attachment systems speak precisely about the patients’ sense of vague-
is facilitating change. What is the therapeutic ness, insecurity, ambivalence, paralysing ambiguity
alliance if not an attachment bond? Hence, a and affective dysregulation. The patient’s body and
working alliance can in itself be considered as behaviour may be interpreted as messages about
beneficial for enhancing mentalisation. And the being emotionally malnourished. They do not have
other way round: serious relational ruptures may what they need to feel safe. And the body ‘talks’
for the patient function as being (re)traumatised. about that dilemma.
The presented model of psychopathology Mentalising the patient, and being able to see
represents an intellectual basis for the development beyond bodily practices and symptoms, most often
of the therapeutic alliance. A theoretical model of reveal the anorectic person’s anxiety, fear and an
psychopathology is always as a simplification, incapacity to handle one’s own affects. It is a wrong
using a set of conceptual metaphors. A model can assertion to see the patient as ‘strong’ with a firm
be most helpful to organise the confusing phenom- will. Symptoms are driven not by strength, but by a
enology presented by the patients, as described
above. And, hence, it can help us to better under- 1
The term ‘negative capability’ stems originally from the poet
stand and tolerate such confusing appearances. A Keats, referring to his prescription for approaching poetry
model of mentalisation when working with anor- (Holmes, 2001).
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/ervMentalisation-Based Psychotherapy for Anorexia Nervosa 333
sense of weakness, fright and despair. Hence, the on the process of mind-mindedness itself. The further
therapeutic focus on securing, assuring and making presentation leans partly on some of the guidelines
safe is important. The patient’s fear and anxiety is described by Bateman and Fonagy in their manual
concretised as fear about food, weight, etc., and the ‘Psychotherapy for borderline personality disorder’
therapist’s genuine interest in even details may be (2004). But these are also expanded with therapeutic
reassuring and beneficial for the working alliance. approaches more specific to anorexia nervosa.
One shows interest in what engages the patient
most, although using this to bridge the concrete
A Mentalising Stance
preoccupancies with affects. And since fear most
often is a key feature, demonstrating one’s knowl- A main goal of psychotherapy is to enhance
edge about eating disorders as such, may be mentalising. Bateman and Fonagy (2004) define
comforting. Mentalising the patient’s impaired ‘the mentalising stance’ as an ability on the
mentalising capacity also reveals that recovery therapist’s part to question continually what mental
most probably will demand time. Hence, patience states both within the patient and within themselves
and slow progress is necessary when working with can explain what is happening. This represents an
persons who are severely ill with anorexia. inquisitive stance, exploring triggers for feelings,
Therapeutic impatience will often be harmful for identifying small changes in mental states, high-
the alliance. lighting patient’s and therapist’s differences in
The eventual teleological function of anorexic perceptions of the same events, bringing awareness
patients requires the therapist to ensure that they to the intricacies of the relationship between action
do what they say they will do. Motivation of others is and meaning and placing affect into a causal chain
judged by outcome. Promises must be kept within of concurrent mental experience, etc.
the agreed time. Whilst a neurotic patient may accept
that a therapist has forgotten something and accept Here-and-now
an apology or the offer of an alternative explanation,
This refers to working with current mental states.
the teleologically functioning patient may believe
The main focus should be on the present state and
that the therapist has forgotten because he or she
how it remains influenced by events of the past
does not like the patient or wants to punish her or
rather than on the past itself. Past experiences are of
him (Bateman & Fonagy, 2004). The apparently small
course utterly relevant, but they need to be
error may be conceived as a serious violation.
emotionally linked to the present situation, bridging
narratives and affects.
Mentalisation-Based Treatment
of Anorexia Nervosa Marked Mirroring
Introducing a mentalisation-based treatment app- Staying mentally close with the patient is akin to the
roach to anorexia nervosa means that the main caregiver’s mirroring response, providing the infant
priority is not content, but function. The main aim of with feedback on his or her emotional state to enable
psychotherapy with anorexia nervosa is not prim- developmental progress. The task of the therapist ‘is
arily to achieve specific ‘insights’ into oneself or to represent accurately the feeling state of the
one’s past, however interesting or intellectually patient and its accompanying internal representa-
satisfying these may be, but rather to develop the tions. In addition, the therapist must be able to
function for minding oneself and others; and to distinguish between his own experiences and those
distinguish between bodily sensations and mental of the patient and be able to demonstrate this
representations; to identify feelings, thoughts and distinction to the patient—marking’ (Bateman &
impulses, for example put them into words; and in Fonagy, 2004 p. 210). ‘Marked mirroring’—first to
general assist the capacity of symbolising, mirror the patients emotional state, and then to
The possible meanings of symptoms in anorexia intentionally mark a discrepancy, compels patient
may be many, not one and only (Nordbø, Espeset, and therapist to examine their internal states
Gulliksen, Skårderud, & Holte, 2006). Of course, the further. The difference makes a difference.
investigation of meaning is highly relevant and
important in the specific therapeutic relationship.
Active Approach
But, it is the investigation as such, the activity, the
curiosity, wondering and explorative mood which are Hence, this represents an active approach, actively
in focus. Content is important, but there is a basic focus using language to ask, comment and propose
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
DOI: 10.1002/erv334 F. Skårderud
alternative views. But it is important to stress that altering between being an expert in the sense of
this is based in a not-knowing position. Ideas are factual knowledge and an expert in the sense of
ideas, ‘thinking out loud’, with the intention of open inquiry, between knowing and not-knowing.
increasing the ecology of possible views. They are For patients the competent therapist sharing his or
not interpretations, as in classical psychoanalysis. her knowledge about different aspects of the
An active approach deliberately relates to the disorder, including the model of psychopathology,
alexithymia often experienced as a significant clinical will hopefully be experienced as an interested and
trait in persons with anorexia, see above. For the trustworthy person. The utility of psycho-education
patient experiencing feelings of sadness and empti- can in general be partially explained by the idea that
ness such activity may represent vitality. But of information and understanding gives the patients
course, the level of activity must be adapted to the the opportunity to move from the traditional role of
function of the patients. It is a frequent experience in passively accepting treatment to becoming active
successful psychotherapy with anorexia nervosa that agents in the treatment process (Corey, 2000;
it us useful, or rather necessary, for the therapist ‘to Haslam-Hopwood, Allen, Stein, & Bleiberg, 2006).
lean forward’ in initial phases, while one gradually
gives more of the initiative to the patient.
Negotiating Non-Negotiables
Regulating the activity and intensity of attach-
ment relationship is a key challenge. For the A particular challenge of working with anorexia
outer-directed patient, non-responsiveness may be nervosa is the inevitability of non-negotiables in the
experienced as threatening; feeling responsible for treatment. The major non-negotiable is that the
the wellbeing of the therapist. For the shameful patient has to eat more and more healthily simply to
patient silence may stimulate negative shame survive. Many iatrogenic effects are consequences
feelings. Hence, therapeutic activity can be reliev- of too harsh and authoritarian ways of presenting
ing. On the other hand, too much activity on the such basic non-negotiables, and introducing more
therapist’s behalf may be experienced as invading non-negotiables than necessary (Geller & Srikames-
and threatening. waran, 2006) that is, why should not patients be
allowed some sort of physical activities, as long as
these activities are adapted to the nutritional and
Minding the Functions of Symptoms
somatic situation? (Duesund & Skårderud, 2003).
As described above, the patients with anorexia Moralistic and threatening approaches will often
nervosa most regularly experience both the ‘pros’ produce fear, protest and a war-like situation, and
and ‘cons’ of symptoms, experiencing the anorectic reduce therapeutic possibilities.
way of living as both a problem and a solution. A The non-negotiables need to be redefined: they are
mentalising approach to anorexia stimulates the also an excellent opportunity to demonstrate the
open investigation of different functions and mean- mentalising ambition to understand different and
ings of symptoms. Such an approach, opening up opposite views, and to negotiate non-negotiables.
for the dialogue not at least about the possible Much may have been achieved if the patient is
positive aspects of the disorder, may be experienced moved from a ‘no’ to any weight gain to accepting a
as liberating for the patient. The therapist marks minimal increase over months. The latter represents
that it is allowed to present ambivalences, doubts, a ‘yes’, although a small one. From that position it
hesitations and resistance. Creating such an atmos- may be possible to negotiate the frames and limits.
phere of open inquiry is most often beneficial for the How to deal with non-negotiables is at the very
therapeutic alliance, not at least because the heart of treating anorexia, and must be given careful
therapist demonstrates that he or she is one who consideration. For the therapist this represents a key
understands the complexity of the disorder. situation to demonstrate both firmness and flexibility,
Such a therapeutic approach is based on the not either-or. Again there is the striking similarity
therapist’s role as an expert, from a knowing position. with parents’ relation to children.
But the way of investigating is done with the
inquisitive stance, from a not-knowing position.
Stimulating Affective Consciousness
There is a gap between the primary affective
Psycho-Education
experience and its symbolic representation. A
A mentalisation-based approach to anorexia ner- mentalisation-based psychotherapy actively tries
vosa bridges psychotherapy and psycho-education, to bridge gaps. Technically, this means an active
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 15, 323–339 (2007)
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