Psychotherapy for Borderline Personality Disorder

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Mentalisation and eating disorders
Professor Finn Skårderud Lillehammer University
College Ullevål University Hospital, Oslo
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Mentalising A new word for an ancient concept

• Implicitly and explicitly interpreting the
  actions of oneself and other as meaningful on the
  basis of intentional mental states (e.g. desires,
  needs, feelings, beliefs, reasons)
• Fonagy et al.

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Conclusion in advance

• The concept of mentalisation is utterly relevant
  and useful in the clinical field of eating
  disorders
• And, through the bodily concreteness of symptoms,
  eating disorders illustrate precisely some
  essential features in the concept of mentalisation

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The concept of mentalising as a fulcrum for
contemporary theory and research
evolutionary biology
neurobiology
MENTALISING
attachment
theory of mind
Bateman Fonagy
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Embodied mind
Objective (world)
Intersubjective (mind of others)
Subjective (own mind)
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Embodied mind
Objective (world)
Intersubjective (mind of others)
Subjective (embodied mind)
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Embodied mindMinded body
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A culture bound syndrome
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A culture bound syndrome

• Rapid societal changes
• The most stable state is the state of instability
  
• Culture chaos syndromes
• Politics of identity
• Gordon, R., Katzman, M. Nasser. M (Eds.).
  Eating disorders and cultures in transition 2001

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Opaqueness of feelings

• Applied on eating disorders when mentalisation
  is impaired, and when psychic reality is poorly
  integrated, the body may take on an excessively
  central role for the continuity of the sense of
  self. Not being able to feel themselves from
  within, they are forced to experience the self
  from without

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Therapy

• There is a striking paucity of empirical
  evidence supporting any method of treatment
  this leaves 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.
• D.B. Woodside, International Journal of Eating
  Disorders, 2005

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The challenges of eating disorders

• Patients lack of insight into illness
• Patients lack of motivation for change
• Physiological symptoms of undernourisment and
  malnutrition
• Psychological symptoms of undernourisment and
  malnutrition
• Anorexia nervosa is the psychiatric disorder with
  highest mortality
• Therapists lack of understanding of the
  phenomena

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Hazards

• Few symptoms can create stronger reactions in
  therapists than anorexia nervosa and severe
  eating disorders
• High risk for drop-outs and disrupted therapeutic
  relations
• Overreactions, like aggression or rejection, due
  to intense emotional reactions in the therapists
• Iatrogenic effects

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Disorders of the self

• Impaired mentalising

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Reflective function
The Cassel hospital study (Fonagy et al., 1996)
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To describe

• The phenomenology of eating disorders
• Psychopathology
• Self- and affect dysregulation
• Symptoms as repair and compensation
• Concreteness of symptoms

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Affects

• are not properly regulated and properly tolerated
• are not properly identified, differentiated and
  expressed

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Symptoms as restorative

• Examples
• The illusion of control
• Activity and feeling of emptiness
• Construction of an identity, being unique
• Oblivion
• Intimacy

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Concreteness of symptoms

• Related concepts
• Operative thinking (Marty de MUzan, 1963
  McDougall, 1989)
• Concretisation (Atwood Stolorow, 1984)
• Concretism (Buhl, 2002)
• Concrete attitude (Joseph, 1989)
• Concretised metaphors (Enckell, 2002 Skårderud,
  2006)
• Psychic equivalence mode (Fonagy et al., 2002)

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Concreteness of symptoms

• Inner life is presented in a concrete way as
  behaviour and bodily and physical qualities
• Inner reality outer reality
• As if of mental representation turns to is
• Presentations not re-presentations
• In a mentalisation context Impaired
  mentalisation and psychic equivalence mode

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The plate of control

• The idea of mixing different types of food
  scares me. The sight of too many types of food on
  my plate, and the idea of them mixed together in
  my stomach induce in me a sense of chaos.
• I have to have control of my plate to have
  control in my life.
• I gradually understood that taking control over
  food was a way to take control over my
  overwhelming worries, my restlessness, all my
  anxieties about myself and simply my need to be
  somebody.
• Elisabeth, 26

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Hilde Bruch(1904-84)

• Descriptions
• Deficient sense of self
• Wide range of deficits in conceptual
  developments, body image and awareness, and
  individuation
• Cognitive and perceptual disorder, interoceptive
  confusion
• Alexithymia
• Theory Parents misinterpreation and mislabeling
  of the childs emotional states
• Consequences for psychotherapy Not giving
  insight but enhancing awareness of feelings and
  impulses

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• To these patients, receiving interpretations
  represents in a painful way a re-experience of
  being told what to feel and think, confirming
  their sense of inadequacy and thus interfering
  with the development of a true self-awareness and
  trust in their own psychological abilities
• (Bruch, 1985)

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Modes of psychic reality
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Modes of psychic reality

• Psychic equivalence
• Mind-world isomorphism mental reality outer
  reality
• Associated with insufficiently marked mirroring
• Intolerance of alternative perspectives
• Self-related negative cognitions are too real
• The very hearth of severe anorexia nervosa

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Psychic equivalence in anorexia nervosa

• Specific body metaphors
• Emptiness/fullness
• Purity
• Spatiality
• Heaviness/lightness
• Solidity
• Removal

• Compound body metaphors
• Control
• Vulnerability/protection
• Self-worth
• (Skårderud, 2007)

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• Emptiness/fullness
• Sol I am so confused. It is simply too much for
  me. I have to reduce. I am completely filled up.
  In some way or another I do have to empty myself.
  (She refers to her frequent vomiting and misuse
  of large doses of laxatives.)
• Purity
• Emily My anorexia was there when everything
  else seemed unpredictable, excessive, in a
  frantic state. Its austerity, its plain,
  straightforward and concrete nature infused the
  unsure with something safe - it served as a
  channel to something more basic, minimalist,
  uncluttered, pure.
• Spatiality
• Ingrid It is difficult enough as it is. How big
  can I be? It is not about fat, it is about how
  much of me? How can I stand it if it becomes even
  more of me?

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• Heaviness/lightness
• Karen I feel sad. And when I am sad, I feel
  burdened and heavy and then comes the urge to
  lose weight.
• Solidity
• Maria When I dont have access (to bones and
  skeleton), when there is something between what I
  feel when I touch myself and my inside, then I
  get scared. I dont like it. Things are blurred.
• Removal
• Hanna When I was in hospital, admitted because
  of my extremely low weight, I remembered thinking
  that this is good. The old, chaotic, unhappy me
  is gone, and this is a new opportunity. Now I am
  down to bedrock. And this time I will be another
  person.

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• Control
• Emily I think my anorexia helped to restore
  some order and direction to my life, and return
  to something more wholesome when my environment
  seemed overwhelming with endless choices. It
  assisted me in having not to choose. It was like
  a static, uncluttered refuge within me.
• Vulnerability/protection
• Sol in an otherwise limitless world, I was
  sure of my limit. In a world of empty stomachs
  and laxatives after the bouts of vomiting, I was
  certain, that boundary was quite certain, and the
  others had no choice, they had to respect the
  limit I laid down.
• Self-worth
• Else This has been a bad day. I am a lazy
  person, I have done nothing extra. I dont feel I
  deserve to eat anything today.

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Modes of psychic reality

• Pretend mode
• Ideas form no bridge between inner and outer
  reality mental world decoupled from external
  reality affects that do not acompany thoughts
• Associated with non-contingent mirroring
• Linked with emptiness, meaninglessness and
  dissociation in the wake of trauma
• In therapy endless inconsequential talk of
  thoughts and feelings
• Combined with the patients overcompensations in
  skills and social relations, this may confuse
  therapists

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Modes of psychic reality

• Teleological stance
• Expectations concerning the agency of the other
  are present but these are formulated in terms
  restricted to the physical world
• Patients cannot accept anything other than a
  modification in the realm of the physical as a
  true index of the intentions of the other.
• One core topic in eating disorders control
  may be experienced as patients trying to control
  therapists

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• But he said to them Unless I see the nail marks
  in his hands and put my finger where the nails
  were, and put my hand into his side, I will not
  believe it.
• John 20 25

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Treatment implications
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Limitations in psychotherapy

• Patients contribution
• Impaired mentalisation, with emphasis on psychic
  equivalence as a mode of psychic reality
• Lacking insight into illness as if turned to
  is reality here-and-now.
• Lack of motivation for change symptoms are
  partly restorative
• Paucity or absence of verbal accompaniment
• The drama of soma and the treat of death
• Often adolescents, mentalising capacities not yet
  developed
• Psychological symptoms of malnutrition

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Limitations in psychotherapy - a reminder

• Therapists contribution
• Lack of understanding
• Provoked and scared
• Affective arousal leads to therapists impaired
  mentalisation

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Therapeutic alliance

• Alliance is supported by
• A model of the psychopathology provides a buffer
  against overwhelming affect for patient and
  clinician
• Mentalising the impaired mentalisation of
  patients a realistic view of their reflective
  function
• Active approach, demonstrating separated minds,
  open-mindedness and curiosity

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Therapeutic alliance

• Alliance is supported by
• The inquisitive stance and mentalising stance
  (Bateman Fonagy)
• Regulating intensity of attachment relationship
  and complexity of mentalisation
• Entering the concrete

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• A basic method in psychotherapeutic work with
  eating disorders is to investigate concretely the
  experiences with body and food, not
  interpretations but descriptions, and connect
  them to emotional, cognitive and relational
  experiences, with the aim to transfer them into a
  language reflecting upon them both as physical
  reality and as metaphor.

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• an alternative to getting the patient to enter
  the realm of the symbolic (the therapist's
  world), is the therapist instead entering the
  realm of the concrete (the patient's world).
  After all, the patient is usually looking for an
  ally.
• (Joseph, 1989)

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Mentalising interventions Spectrum
Supportive/empathic
Most involved
Clarification and elaboration
Basic mentalizing

• Interpretive mentalizing

Mentalizing the transference
Least involved
Bateman Fonagy
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Clinical pathway for interventions
Identify the affect not simply the behaviour
Explore the emotional context
Process not content
Define the current interpersonal context outside
Examine the broad interpersonal theme in treatment
Explore the specific (transference) context
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Applied on eating disordersLost in translation

• Focus on identifying, differientiating,
  tolerating and expressing affects
• Focus on the translations psychic equivalence
  - between affects and bodily behaviour and
  sensations
• Translate back from body to tolerated affects
• Mentalising stance as a way to develop sense of
  self

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• To these patients, receiving interpretations
  represents in a painful way a re-experience of
  being told what to feel and think, confirming
  their sense of inadequacy and thus interfering
  with the development of a true self-awareness and
  trust in their own psychological abilities
• (Bruch, 1985)

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MBT for eating disorders

• Oslo University Hospital, Ullevål

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Oslo projectMinding the body MBT for eating
disorders

• Combination treatment
• Group therapy
• Individual therapy
• Psycho-education

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Mentalising and eating disorders

• Skårderud, F. (2007). Eating ones words. Part I.
  Concretised metaphors and reflective function
  in anorexia nervosa. An interview study. European
  Eating Disorders Review, 15, 163-174.
• Skårderud, F. (2007). Eating ones words. Part
  II. The embodied mind and reflective function in
  anorexia nervosa. Theory. European Eating
  Disorders Review, 15, 243-252.
• Skårderud, F. (2007). Eating ones words. Part
  III. Mentalisation-based psychotherapy for
  anorexia nervosa. An outline for a treatment and
  training manual. European Eating Disorders
  Review, 15, 323-339.