Mentalising and eating disorders

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Mentalising and eating disorders
Professor Finn Skårderud Lillehammer University
College Oslo University Hospital
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Eating disorders as disorders of the self
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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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Reflective function
The Cassel hospital study (Fonagy et al., 1996)
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Examples from Reading the Mind in the Eyes
(Baron-Cohen et al., 2001)
surprised
Sure about something
joking
happy
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Examples from Reading the Mind in the Eyes
(Baron-Cohen et al., 2001)
friendly
sad
worried
surprised
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www.autismresearchcentre.com/tests
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Hilde Bruch revisited and revised

• 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
• (Skårderud, F, 2009. Bruch revisited and revised.
  European Eating Disorders Review, 17, 83-88)

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Modes of psychic reality

• Psychic equivalence
• Mind-world isomorphism mental reality outer
  reality
• Intolerance of alternative perspectives
• Self-related negative cognitions and emotions are
  too real
• The very hearth of severe eating disorders and
  self harm

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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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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
• 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.
• Eating disorders and self harm precisely
  illustrates this

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Opaqueness of feelings

• Applied on eating disorders and self harm 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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(No Transcript)
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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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Mentalisation-based therapy

• Stimulating the attentiveness to mind
• Tailoring treatment to the actual
  pscychopathology and impairment of mentalising
• Practising mentalising in an attachment bond

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Therapeutic stance

• Not-knowing stance
• Active
• Open-minded To be a role-model
• Avoid absolute certainty
• Accept different perspectives
• Check out your understanding
• Regulate intensity in therapeutic relation

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Interventions

• Simple sound-bite
• Focus on patients mind (not on behaviour)
• Relate to current event or activity
• Here-and now
• Affect focused (love, desire, hurt, catastrophe,
  excitement)

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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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Embodied mentalisation

• Focus on identifying, differientiating,
  tolerating and expressing affects
• Explicit focus on embodiment of affects
• Focus on the translations between affects and
  bodily behaviour and sensations
• Translate back from body to tolerated affects

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The Oslo Psychotherapy project

• Format is combined therapy
• Weekly group therapy
• Weekly individual therapy
• Dietist
• Psychoeducation in group
• Mentalising, misunderstandings, affects,
  nutrition, body awareness, cognitive deficits
• Network of supervision workshops
• Educational programs in Scandinavian languages
  and also English
• Cooperation with Peter Fonagy and Anthony
  Bateman, London
• Currently working on Mentalisation-based
  treatment for eating disorders Practical guide