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Eating one's words: part iii. mentalisation-based psychotherapy for anorexia nervosa-an outline for a treatment and training manual

European Eating Disorders ReviewEur. Eat. Disorders Rev. 15, 323–339 (2007) Eating One’s Words: Part III.
Mentalisation-BasedPsychotherapy for AnorexiaNervosa—An Outline for aTreatment and Training Manual 1Faculty of Health and Social Studies, Lillehammer University College,Norway2Centre for Child and Adolescent Mental Health, Eastern and SouthernNorway, Oslo, Norway This paper presents a new outline for psychotherapy with per-sons with anorexia nervosa. ‘Model on mentalisation’ is theintellectual 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 capacityto 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 anddescribed as a central psychopathological feature in anorexia ner-vosa. Psychotherapeutic enterprise with individuals with com-promised mentalising capacity should be an activity that isspecifically focused on the rehabilitation of this function, withspecial 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 developedinto manuals as a basis for therapy, training and research.
Copyright # 2007 John Wiley & Sons, Ltd and Eating DisordersAssociation.
Keywords: anorexia nervosa; embodiment; mentalisation; psychotherapy; psychoanalysis 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/orunstable (Geller, Williams, & Srikameswaran, 2001), * Correspondence to: Prof. Finn Ska˚rderud, MD, Institute for approximately one-half of the patients drop out of eating disorders, Kirkeveien 64 B, N-0364 Oslo, Norway.
treatment (Vandereycken and Pierloot, 1983) and in Tel: þ47-918-19-990. Fax: þ47 22025700.
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.817 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 of maintaining the cohesion and stability of a This is the third and final part of three companion 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, Ska˚rderud, 2007a), apply and to revise earlier conceptual models because of develop relevant theory (Part II, Ska˚rderud, 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- 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- 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 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, and can be defined as ‘keeping one’s own state, desires, and goals in mind as one addresses one’s 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) Mentalisation-Based Psychotherapy for Anorexia Nervosa 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- thing of a conceptual revolution, one that is still The model is based on developmental psychology 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 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) 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 therapeuticrelationship and therapeutic change. And it is an old Mentalisation-Based Therapy for Borderline assumption that much of the effectiveness of 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 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 attentiveness to the activity of mentalising. And Allen (2006) proposes that the better term is borderline personality disorder. A mentalisation- mentalising, and not mentalisation, emphasising based format for psychotherapy for borderline personality disorder, MBT, was developed andmanualised, and has been shown to be effective in a 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, mentalisation-based treatment is the least novel Mentalisation is operationalised for scientific therapeutic approach imaginable; it addresses the 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) Mentalisation-Based Psychotherapy for Anorexia Nervosa 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 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 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.
Today, there is a risk of isolation of professionalmilieus working with anorexia nervosa.
Mentalising may serve a function as one amongst 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 to the role of the body in the development of mind,both in normal development and in different 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) 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 also been shown that ‘patient factors’ such asmotivation 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 (Ska˚rderud, 2007c). This maybe expressed in high compliance towards people— 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 conceived as pseudo-compliance. Actually, there is noworking 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 theirown illness. The body functions metaphorically Self- and affect regulation. Patients with anorexia (Ska˚rderud, 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- tion in therapeutic processes is the possiblerestorative 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- entation, and this may help us to realise why he or she may be so difficult to engage in therapeutic apathy, reduced power of concentration and 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) Mentalisation-Based Psychotherapy for Anorexia Nervosa whose mentalising capacities are not yet fully Therapists’ impaired mentalising. The concept of mentalisation is relevant not only to describepatients, but also their helpers. The capacity ofmentalisation is contextual; it is far from an either-or 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 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 called ‘therapist factors’, together represent greathazards in terms of harmful effects on the Therapists’ lack of insight into illness. Some therapists 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 basic premise in psychodynamic therapy thatthere are related processes coming into beingbetween 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 U¨bertragung (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 (Ska˚rderud, 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 be illustrated with clinical examples, demonstrating Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 15, 323–339 (2007) both psychological function and how this may be examples, all referring to one or more of the patients 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 (Ska˚rderud, 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 what exists out there must invariably also exist inthe 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.
The ‘as if’ of the representational mind is turned toan ‘is’.
Part I gives examples of how the anorectic patients 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).
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 Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 15, 323–339 (2007) Mentalisation-Based Psychotherapy for Anorexia Nervosa 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 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 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 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- 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 made, and no real understanding is experienced’(p. 70). Ideas do not form a satisfactory bridgebetween inner and outer reality and affects do not 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) 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 see, is that it is too distinct. Bodily practices ofanorexia can be read as statements of both problemsand solutions, of ‘pros’ and ‘cons’ (Serpell, Treasure, 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 frequent difficulties with establishing such in work Confusion can be unravelled by reducing the 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.
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 describedabove. 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- Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 15, 323–339 (2007) Mentalisation-Based Psychotherapy for Anorexia Nervosa 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 patientmost, although using this to bridge the concrete preoccupancies with affects. And since fear mostoften 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- 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 acceptthat a therapist has forgotten something and accept 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, bridgingnarratives and affects.
Mentalisation-Based Treatmentof Anorexia Nervosa 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, Ska˚rderud, & Holte, 2006). Of course, the further. The difference makes a difference.
investigation of meaning is highly relevant andimportant in the specific therapeutic relationship.
But, it is the investigation as such, the activity, thecuriosity, 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) 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 graduallygives more of the initiative to the patient.
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- waran, 2006) that is, why should not patients beallowed some sort of physical activities, as long asthese activities are adapted to the nutritional and somatic situation? (Duesund & Ska˚rderud, 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 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 theinquisitive stance, from a not-knowing position.
There is a gap between the primary affective 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) Mentalisation-Based Psychotherapy for Anorexia Nervosa focus on experienced affects, and to elaborate these ground of experience; ‘a way of living or inhabiting the world through one’s acculturated body’ (Weiss & Fern Haber, 1999, p. xiv). Studies under the rubric situation, for example the patient’s increased of embodiment are not about the body per se. They vomiting combined with a stressful situation during are about personal, psychological and cultural recent days. A spectrum of mentalising interven- experiences as these can be understood from the tions regarding affective states may be like this: (1) a standpoint of bodily being-in-the-world (Csordas, supportive and emphatic approach is basic in the series of interventions. (2) The affect is identified not Anorectic embodiment has several different only by the behaviour; there will be simple and aspects. One aspect refers to culture. Culture, in systematic clarifying and naming of feelings. (3) the sense of common and normative reflection, Then one explores the contexts of the emotions; that whether it be in the form of religion, philosophy, is the current emotional and interpersonal context.
moral, biological science or the aesthetics of (4) And so forth, widening the exploration context contemporary consumer culture, objectifies the to broader interpersonal contexts, as recurrent human body. Flesh is symbolically loaded; like themes in the patient’s life and (5) eventually being thin may symbolise control and psychological explore the actual emotions in the patient–therapist strength in our affluent, contemporary Western context, that is mentalising the transference. With culture (Ska˚rderud & Nasser, 2007). The body is impaired mentalisation, transference is experienced metaphorised in the sense that physical qualities as real, accurate and current and needs to be metaphorically represent non-physical qualities.
accepted as such in the treatment, and not as a This object status is part of our culture and becomes displacement and repetition of the past.
clearly evident when we refer to the body as something to be investigated in, trained, slimmed, non-mentalising interpretations should be used in order to serve other purposes. Collective norms with care. Interpretations, in the classical psycho- and ideals about good and bad, beautiful and ugly, analytical sense, may be too advanced, referring to adapted by the individual, and in particular the concrete mode of functioning; being without any insecure, sensitise the human body in a psycho- positive effect. Or they may be experienced negatively. As Bruch (1985) stated: ‘To these In anorexia this is complicated by a second aspect; patients, ‘receiving interpretations’ . . . represents the immediate and analogous connection between in a painful way a re-experience of being told what inner and outer reality. Physical qualities refer to to feel and think, confirming their sense of social and emotional qualities, and vice versa; and inadequacy and thus interfering with the develop- for the person with anorexia there may be a ment of a true self-awareness and trust in their own non-negotiable link here-and-now between fat psychological abilities’ (p. 14). The patient may and weak (psychic equivalence). A third aspect is respond with pseudo-compliance, the hallmark of the possible dissociative experience of one’s bodily the anorectic functioning, or, if threatened enough, sensations (pretend mode). Bruch (1962) described patients’ difficulties in accurately perceiving orinterpreting stimuli arising in their bodies.
Hence, anorectic embodiment is a complex and possibly confusing picture. At the same time there The focus on the patient minding their own body is may be a culturally driven unduly negative focus on also of specific relevance to psychotherapy with exterior, combined with incapacity of making anorexia nervosa. The concept ‘body’ is demon- distance to this dissatisfaction, and at the same strably inadequate. It is problematic insofar as it time experiencing impaired awareness of one’s implies a discrete phenomenon that is capable of bodily sensations. The body is emotionally and being investigated apart from other aspects of our cognitively experienced more via glances, on the existence to which it is intrinsically related. We may weighing scales, in the mirror, measuring circum- lose sight of the fact that the body is never isolated in ferences of limbs, counting skin folds on the its activity, but always already engaged with the stomach and via fantasies about being looked at world. Hence, we make a shift from ‘body’ to by others, than by feeling one’s own ‘lived body’ ‘embodiment’, where the embodiment refers to an (Merleau-Ponty, 1962). Anorectic corporeality may at anti-Cartesian and existential position in which the the same time be experiencing one’s body as too real and body is the subjective source or intersubjective Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 15, 323–339 (2007) Mentalising the body means to stimulate the Under the therapist’s couch one can see the patient to investigate concretely the experiences weighing scale. Let this be a statement for reflection with body and food, and connect them with emo- and discussion: It may be useful that the therapist is tional, cognitive and relational experiences, with the also the person who is responsible for the regular aim to transfer them into a language reflecting upon weighing and actively taking part in monitoring the them both as physical reality and as metaphor. The eating programme. This is usually a very challen- patient is ‘lost in translation’—or ‘lost in repres- ging situation for the patient, and therefore a entation’. A patient may be desperately afraid of fat, suitable arena for the therapist to demonstrate his/ and she is also generally afraid; of what? Can these Psychotherapy will be helped by concomitant This refers specifically to the concepts psychic physiotherapy, programmes for activity, bodily equivalence and concretised metaphors. In the awareness or body psychotherapy. Duesund and perspective of therapeutic alliance, this is to meet Ska˚rderud (2003) describe the possible benefits of the patient where the patient is. In clinical work adapted physical activity as a supplement to the with anorexia nervosa one learns how the feelings psychotherapeutic dialogues. Social interaction in are bound up with concrete experiences. The activities can move negative attention from the dialogues about emotions can be experienced by objectivated anorectic body to a more profound and the therapist as non-committal, empty and exhaust- subjective experience of one’s own body. This is ing. But the dialogues dealing with the non- intentionally using the body—like movement, negotiables of treatment, like proposals of increased social interactions, physical and psychological food intake and weight increase, can become very challenges (the lived body)—with the intention to emotional. This may be seen as a limitation for ‘forget the body’ (the anorectic objectified body).
psychotherapeutic work, but also as a possibility.
Forget in this context actually means turning Meeting the patient in the concrete is also a attention from the anorectic objectified body possibility for reaching out and thus bringing towards the lived body. Thien, Thomas, Martin, emotional experiences into the dialogue.
and Birmingham (2000) also describe how a The aim of psychotherapy is enhanced mentalisa- grounded use of physical activity and bodily tion, and in this context this refers to separating approaches may be beneficial to the therapeutic body from body, that is sensation from representa- relationship. This points to unutilised possibilities in psychotherapeutic enterprises collaborating with de-concretisation, opening up the closed psychologi- traditions such as physiotherapy, body-oriented cal experience of equivalence of realities. In the psychotherapy and adapted physical activity (Due- language of body metaphors, psychotherapy is re-metaphorisation (Carveth, 1984); an exercise in Experiences from different kinds of activities and becoming conscious and self-critical in our employ- different perceptions of one’s body in different ment of the metaphors we live—and eat—by.
contexts are an utmost relevant topic in the It is important to stress that the use of concretised mentalising psychotherapeutic dialogue.
metaphors as a concept refers to the absence ofconscious language about the metaphorical func-tion of bodily qualities. Hence, they are categori-cally different from linguistic metaphors, since Repairing Ruptures in Therapeutic Alliance language is lifting the experience above the physicalrealm. This is important to stress, since ‘metaphor’ The hindrances in psychotherapy with anorexia is a popular concept in some schools of psychother- nervosa are described above. In psychotherapy apy. Bateman and Fonagy (2004) warn against the research a consensus is emerging around two extensive use of metaphors in therapy, although related issues: That strains in the alliance are referring to borderline personality disorder. Lin- inevitable, and that one of the most important guistic metaphors presuppose an ability to use therapeutic skills consists of dealing therapeutically mental representations, and ‘rather than heighten- with this type of negative process and repairing ing the underlying meaning of the discourse, use of ruptures in the therapeutic alliance (Safran & metaphor is more likely to induce bewilderment Muran, 2000). In this context this may mean to investigate common and in detail misunderstand- In practical terms, ‘entering the concrete’ can have ings, different views and possible alternative views several practical meanings. Imagine this scene: and behaviours with regard to concrete events.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
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