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Eating Ones Words: Part III.

Mentalisation-BasedPsychotherapy for AnorexiaNervosaAn Outline for aTreatment and Training Manual

Finn Skarderud1,2*1Faculty of Health and Social Studies, Lillehammer University College,Norway2

Centre 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

INTRODUCTION

The aim of this paper is to propose an outline forpsychotherapeutic approaches to anorexia nervosa,and to introduce a model on mentalisation (Allen& Fonagy, 2006) as an intellectual framework for

developing therapeutic techniques for this disorder.

There is a general agreement that working withanorexia nervosa may be challenging. Ambivalenceabout recovery is a central feature. Patientswith anorexia rarely seek treatment on theirown initiative (Rosenvinge & Kuhlefelt-Klusmeier,2000), the motivation to change is low and/orunstable (Geller, Williams, & Srikameswaran, 2001),approximately one-half of the patients drop out oftreatment (Vandereycken and Pierloot, 1983) and ina review Fairburn (2005) states that treatment

European Eating Disorders ReviewEur. Eat. Disorders Rev. 15, 323339 (2007)

* Correspondence to: Prof. Finn Skarderud, MD, Institute foreating disorders, Kirkeveien 64 B, N-0364 Oslo, Norway.Tel: 47-918-19-990. Fax: 47 22025700.E-mail: [email protected]

Copyright# 2007 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.817


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outcome is generally poor. Despite research effortsthere is a striking paucity of empirical evidencesupporting any method of treatment for anorexianervosa (Woodside, 2005).

This is the third and final part of three companion

papers, Eating ones words I, II and III. The seriesaims at furthering the understanding of the specificpsychopathology of anorexia nervosa, based onresearch (Part I, Skarderud, 2007a), apply anddevelop relevant theory (Part II, Skarderud,2007b) and outline psychotherapy on this empiricaland theoretical basis (Part III). The recommen-dations for therapy follow the principle thatpsychotherapeutic interventions should be tailoreddirectly to psychopathological processes.

Part I reports from an interview study based onqualitative research methods. The study demon-strates how bodily sensations and qualities like

hunger, size, weight and shape are physical entitiesthat represent mental states. The overall finding isthe isomorphism between inner and outer reality,mind and body. The patients demonstrate acloseness, a more or less immediate connectionbetween physical and psychological realities; forexample restrictive control of food representspsychological self-control. The as if of mentalrepresentation is turned into an is. Most personswith anorexia nervosa experience this corporealityas an obsessional and ruthless reality which isdifficult to escape from. This concretisation ofmental life is interpreted as impaired reflective

function and mentalisation, and is proposed as acentral psychopathological feature in anorexianervosa.

Reflective function is the broader concept andrefers to the psychological processes underlying thecapacity to make mental representations. Thisconcept 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 ones own state,desires, and goals in mind as one addresses onesown experience, and keeping anothers state,

desires, and goals in mind as one interprets his orher behaviour (Coates, 2006 p. xv).

Part II develops further theoretical concepts todiscuss the empirical findings and to describeimpairment of reflective function in anorexianervosa. When psychic reality is poorly integrated,the body may take on an excessively central role forthe continuity of the sense of self, literally being abody of evidence. Not being able to feel themselvesfrom within, the patients are forced to experience

the self from without. Anorexia nervosa is describedas a disorder of self- and affect regulation, and theconcretistic symptoms essentially serve the functionof maintaining the cohesion and stability of atenuous sense of self.

The idea that severe eating disorders are essen-tially self disorders has emerged gradually asclinicians and researchers have recognised the needto revise earlier conceptual models because ofserious limitations in their ability to explain theclinical features of the eating disorders and to deviseeffective therapies (Taylor, Bagby and Parker, 1997).Already the pioneer in eating disorders, Bruch(1962) stated that the core problem lies in a deficientsense of self and involves a wide range of deficits inconceptual developments, body image and aware-ness and individuation.

Finally, this Part III, building on research results

and theory in the preceding texts, and on clinicalexperience, deals exclusively with the psychother-apy of anorexia. The first section of the paperdescribes the model on mentalisation. The secondsection applies these conceptual tools to describemore precisely the difficulties, limitations andhindrances to psychotherapy with anorexia ner-vosa. And, based on these descriptions, the thirdsection will outline some basic approaches andgoals in therapy. Psychotherapeutic enterprise withindividuals with compromised mentalising capacityshould be an activity that is specifically focused on therehabilitation of this function. In the history of

interpreting anorexia there are numerous descrip-tions of the possible symbolic meanings of symp-toms. This text will try to move interest from thewhat is symbolised to how symbolised, frominterpretation ofmeaning to enhancement of func-tion.

A MENTALISING THEORETICALAND THERAPEUTIC PERSPECTIVE

Mentalisation

The concept mentalisation originates from Frenchpsychoanalysis (Lecours & Bouchard, 1997; Luquet,1987; Marty, 1990) in the late 1960s, but diversifiedin the early 1990s when Baron-Cohen (1995), Frithand Frith (2003) and others applied it to neurobio-logical based deficits in autism and schizophrenia,and, concomitantly, Fonagy, Target and colleagues(Fonagy & Target, 1996, 1997; Fonagy, Gergely,Jurist, & Target, 2002) applied it to developmentalpsychopathology in the context of attachment

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relationships gone awry. This text leans on works inthe latter tradition (Allen & Fonagy, 2006). AnthonyBateman has together with Peter Fonagy been apioneer in translating theoretical principles intotherapeutic principles (Bateman & Fonagy, 2004).

The scientific and clinical staffs at The MenningerClinic in Texas, USA, are also important contribu-tors, with Jon G. Allen (Allen, 2001, 2003, 2006) as aprominent professional.

The model is based on developmental psychologyand contemporary psychoanalysis, and, not least,with a strong ambition to integrate recent develop-ments in neuroscience. The model also includesrevised versions of attachment theory. OriginallyBowlby (1969) described the human biological urgeto search for a secure base of attachments forsurvival and development. Attachment is seen as aninnate biological instinct to ensure protections and

reproduction through physical proximity to care-giver. Attachment is a context for the developmentof the social brain. Basic polarities for attachmenttheory are approachavoidance, security inse-curity, attachmentloss (Holmes, 2001).

On the basis of empirical observations andtheoretical elaboration, Fonagy and Target devel-oped (1996, 1997) the argument that the capacityto understand interpersonal behaviour in termsof mental states is a key determinant of self-organisation and affect regulation, and that it isacquired in the context of early attachment rela-tionships. It posits that a sense of self develops from

observing oneself being perceived by others asthinking or feeling. By internalising perceptionsmade by others about himor herself, the infantlearns that its mind does not mirror the world; itsmind interprets the world. This capacity is referredto as mentalisation, meaning the capacity to knowthat one has an agentive mind and to recognise thepresence and importance of mental states in others(Gunderson, 2004). Secure attachment promotesmentalising capacity, while insecure attachmentand trauma can undermine it.

Today this body of thought is reliably anchored inempirical studies of great robustness, demonstrat-

ing attachment patterns as a predictor for mentalhealth, the connections between secure/insecureattachment and mentalisation and the role ofmentalisation in regulating affects and negotiatingrelationships. And the works of Fonagy and colla-borators also show that this mentalising capacityprovides a critical link in the transmission ofattachment security across generations. Mothersand fathers who scored high on this dimensiontended to have children who were secure. Insight is

not only good for you but it is even better for yourchildren (Coates, 2006 p. xvixvii).

In summary, mentalisation has been empiricallylinked to important findings in development, bothin neuroscience and clinical psychology; in the

understanding of psychopathology; and in theconceptualisation of treatment efficacy both inchildren and adults. What we have here is some-thing of a conceptual revolution, one that is stillunderway (Coates, 2006 p. xvii).

The concept may for some appear to have adehumanising and technical ring to it, and shouldbe humanised. We must keep in mind that themental states perceived and the processes ofperception are suffused with emotion; hence,mentalising is a form of emotional knowing (Allen,2006). Mentalising is the normal ability to ascribeintentions and meaning to human behaviour, to

understand unwritten rules, and shapes ourunderstanding of others and ourselves. Hence, itis central to human communication and relation-ships. It can be described as being able to see oneselffrom the outside and other persons from the inside.There is an ethical aspect to this: The better oneunderstands other peoples behaviour, the harder itbecomes to treat a person as a thing.

Mentalisation is about mind-mindedness, hav-ing mind in mind. Related concepts are empathy,emotional intelligence, psychological minded-ness, metacognition, insight, observing ego,mindfulness, interpretation and reflection. Men-

talising involves both a self-reflective and aninterpersonal component that ideally provides theindividual with a well-developed capacity todistinguish inner from outer reality, physicalexperience from mind and intrapersonal mentaland emotional processes from interpersonal com-munications. Hence, the anorectic concretisation ofemotional life can be described as one of morepossible presentations of impaired mentalisation.

Mentalisation means to be able to understandones misunderstandings. Impaired mentalisationmay cause confusion and misunderstandings,acting on false assumptions. Being misunderstood

is highly aversive. It may generate powerful emo-tions that result in coercion, withdrawal, hostility,over-protectiveness or rejectionand symptomincrease (Bateman & Fonagy, 2004). The psychiatricpatient with impaired mentalisation, for example aperson with anorexia, will often experience thevicious circle: Impaired mentalisation creates mis-understandings and ruptures in relations, and aninsecure world becomes even more insecure. Suchstress, fear and affective arousal will further impair

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the mentalising capacity. And, hence, the anorecticwithdrawal and way of behaving may appear as anisland of control and predictability.

Mentalisation-Based Therapy for Borderline

Personality Disorder

The scientific tradition on mentalisation aspires todevelop a new intellectual framework for psy-chotherapy (Fonagy, 2006a). Based on develop-mental studies of psychopathology, the ambition isto identify psychological and neural mechanismsunderlying disturbance, and, consequently, employtherapeutic techniques specifically designed toaddress a developmental dysfunction.

Psychotherapy provides an opportunity forintensive practice in mentalising. The therapeuticrelationship is an attachment bond, and one impor-

tant aspect of psychotherapy is that it activatesattachment systems. An effective psychotherapeuticrelationship is the best analogue of a secure base inattachment that fosters mentalising. Not only doespsychotherapy entail mentalising in the sense ofexploring thoughts, feelings, hopes, wishes, dreamsand the like, but also psychotherapy provides theopportunity to experience and learn from failures inmentalising, such as occur in transference enact-ments.

So far, the main work has been done withborderline personality disorder. A mentalisation-based format for psychotherapy for borderline

personality disorder, MBT, was developed andmanualised, and has been shown to be effective in arandomised controlled clinical trial (Bateman &Fonagy, 1999). In that study, MBT was provided in aday-hospital setting for 18 months and was con-trasted with usual psychiatric care. MBT showedeffective results in diminishing hospitalisations,medication usage and suicidal and self-injuriousbehaviours. In addition, it also showed significantbenefits in symptoms of depression and anxiety,and in social and interpersonal function. Particu-larly impressive was that patients continued toimprove during an 18-month period of follow up

(Bateman & Fonagy, 2001; Gunderson, 2004).In advocating mentalisation-based treatment

there is no claim of innovation. On the contrary,mentalisation-based treatment is the least noveltherapeutic approach imaginable; it addresses thebedrock capacity to apprehend mind as such. . . .Nonetheless, fostering the capacity to mentalisemight be our most profound therapeutic endeavour:cultivating a fully functioning mind is a highaspiration indeed (Allen & Fonagy, 2006 p. xix).

Most psychotherapies probably promote mentalis-ing capacities. The activity of mentalising is the coreof psychotherapy, as it is of childrearing and ethics.It underpins clinical understanding, the therapeuticrelationship and therapeutic change. And it is an old

assumption that much of the effectiveness ofdifferent forms of psychotherapy may be due tothose features that are common rather than thosethat distinguish them from each other (Frank, 1961).But, the specific aspect of mentalisation-based therapy isthe systematic focus on the enhancement of mentalisingitself. In that sense, mentalisation can function as asuperior concept guiding clinical work, and with theemphasis on both cognitive and emotional processesbridge psycho-educative, cognitive and psychoanalyticaltechniques. But different from traditional cognitivetherapy working with own thoughts, the mentalis-ing approach also focuses on the feelings and

thoughts of others.A mentalising approach can be seen as simplify-ing the basic steps in psychotherapeutic encounters,either in individual, group or marital and familytreatment contexts; not at least in milieu therapy.Promoting a mentalising attitude means an inqui-sitive, playful, curious and open-minded style indialogues, with a focus on minding the mind. Amentalising attitude focuses on promoting theattentiveness to the activity of mentalising. AndAllen (2006) proposes that the better term ismentalising, and not mentalisation, emphasisingthe activity.

Minding Anorexia Nervosa

Today, there is no correspondingly well-developedmentalisation-based model for psychotherapy foranorexia nervosa. And a model for the psycho-pathology and therapy for borderline personalitydisorder cannot, of course, be directly applied toother kinds of disorders. But as there are importantdifferences, there are also striking similarities in themodes of experiencing psychic reality in borderlinepersonality disorder and eating disorders. Andthere is also a documented comorbidity of these two

disorders (Rosenvinge, Martinussen, & stensen,2000; Skodol, Oldham, Hyler, Kellman, Doidge, &Davies, 1993).

Mentalisation is operationalised for scientificresearch as reflective function. Reflective-functioning manual (Fonagy, Target, Steele, &Steele, 1998) is developed to measure reflectivefunction based on the Adult Attachment Interview,AAI (Main & Goldwyn, 1995). In a studyfrom Cassel Hospital in the United Kingdom 82


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non-psychotic psychiatric patients were groupedaccording to Axis I diagnoses depression, anxiety,substance use and eating disorders; and Axis IIdiagnoses borderline personality disorder, anti-social or paranoid disorder, other personality dis-

orders and no Axis II. The eating disorderedpatients scored lowest on reflective functiontogether with the patients diagnosed as borderlinepersonality disorders (Fonagy et al., 1996).

Not least to promote therapists beliefs in theirown competence, it is appropriate to deconstructparts of the myth that anorexia nervosa is such aparticular phenomenon. From the perspective ofsupervision and training, it is important to helptherapists to learn about the particularities con-nected to this disorder. Such specific competence isrelevant in itself, but just as important is thatcompetence may function as a door-opener to the

demystification of the disorder. When one under-stands what is special, it is easier to recognise whatis common. And recognising common aspects mayenhance professional self-confidence. Anorexianervosa is still an enigma, but it is important todeconstruct the myth of anorexia as extremelydifficult to comprehend and treat. The reference tocommon traits in psychological functioning inanorexia nervosa and, for example borderlinepersonality disorder, to think transdiagnostically,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 amongstother theoretical and empirical concepts constitut-ing a base for tailored therapeutic activity. But it isimportant to emphasise that, with respect to thepsychopathology of anorexia nervosa, the traditionof mentalising is far from satisfactorily elaborated.Not least, this refers to the need to develop modelsconcerning embodiment; the embodied mind andthe minded body. There are many dimensions ofhuman embodiment, but here it applies specificallyto the role of the body in the development of mind,both in normal development and in differentpsychopathologies.

Let us redefine: Maybe the case of anorexianervosa and eating disorders may represent thephenomenological ground for such elaboration. Aperson with anorexia will most often be a personwith difficulties in interpreting and regulating theirown affects, in interpreting other peoples emotions,but not least in perceiving and interpreting theirown corporeality. Bruch (1962) observed thatanorexic patients manifest difficulties in accuratelyperceiving or cognitively interpreting stimuli aris-

ing in their bodies, such as hunger and satiety, andalso fatigue and weakness as the physiological signsof malnutrition. The person with anorexia can be aperson who is obsessively preoccupied with bodilyqualities and sensations most of the 24 hours of the

day, and at the same time has distorted experiencesof their own physical body. Hence, anorexianervosa can be described as embodiment goneawry, therefore elucidating developmental pro-cesses, and as such contributing to widening thescope of the mentalising-model.

The challenge for the therapist is to become abetter mentaliser. This challenge increases whenmentalising non-mentalising and impaired menta-lising. But one can also redefine this, and state thatpsychopathology itself, as in anorexia nervosa, mayhelp us in this effort. Psychopathology compro-mises mentalising, and scientific knowledge devel-

ops descriptions that can guide the psychother-apeutic approach and focus.It is stated here that more of the basic principles

applied in the treatment model for borderlinepersonality disorder are utterly relevant for work-ing with anorexia nervosa; since they refer to thefundamental capacity of mentalising as such. Butfurther developments are also necessary. Hence,anorexia nervosa can contribute to widening thescope of mentalisation-based treatment and psy-chotherapy.

LIMITATIONS TO THERAPY

It is a main thesis in this paper that the describedcentral aspects of the psychopathology of anorexianervosa are not adequately understood and takenaccount of in many therapeutic encounters. Inpractical terms this means insufficient assessmentsor over-estimating the patients mentalising capa-cities. The patients intellectual skills may confusetherapists.

Therapeutic Alliance

Uncertain motivation for recovery is a relevant topicfor many patients and health workers may lackmotivation to work with them. Few symptoms cancreate stronger reactions in therapists than anorexianervosa and few require more forbearance.

After approximately a half century of psychother-apy research, one of the most consistent findings isthat the quality of the therapeutic alliance is themost robust predictor of treatment success. Thisfinding has been evident across a wide range of


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treatment modalities. A related finding is that pooroutcome cases show greater evidence of negativeinterpersonal process, that is hostile and complexinteractions between therapist and patient thangood outcome cases (Safran & Muran, 2000). It has

also been shown that patient factors such asmotivation make the greatest contribution to thetherapeutic alliance (Horvath & Symonds, 1991).Many clinicians find it difficult to establish healthyworking alliances with their patients with anorexianervosa. Let us address this problem from twoperspectives, theirs and ours. The dual perspect-ive is: how to understand patients, and how tounderstand therapists negative reactions.

Patient factorsAnorexia nervosa often represents great therapeuticchallenges, not least due to the impaired mentalisa-

tion and more precisely the concretisation ofemotional life.

Patients lack of insight into illness. One limitationin therapy is the patients lack of insight into theirown illness. The body functions metaphorically(Skarderud, 2007a, 2007b), but this symbolic com-munication via the body is not experienced asmetaphors by the anorectic patients, but rather asconcrete reality. It is the bodily reality here-and-now, a harsh reality difficult to escape for thepatient. Representations become presentations.

Restorative function of symptoms. Another limita-tion in therapeutic processes is the possiblerestorative function of symptoms. The symptomsare destructive, but at the same time they mayfunction for self-cohesion and affect regulation; andtherefore may be subjectively experienced asconstructive. This contributes to unstable or absentmotivation for recovery. The patient may seem to betrapped in the concreteness of mindbody repres-entation, and this may help us to realise why he orshe may be so difficult to engage in therapeuticrelations.

Alexithymia. Impaired mentalisation in anorexianervosa will often be expressed, or rather notexpressed, as incapacity to give verbal accounts ofones inner states. Bruch (1962) observed thatpatients with anorexia experience their emotionsin a bewildering way and are often unable todescribe them. Such disconnections between phys-iological and subjective feeling components ofemotion are commonly termed as alexithymia.The concept originates from Greek and literally

means no-words-for-feelings. And the concreteway of functioning mentally may represent paucityor absence of verbal accompaniment, often con-tributing to frustrating and non-productive silencesin the therapeutic situation.

Pseudo-compliance. Patients with anorexia aredescribed as outer-directed (Buhl, 2002), in thesense that low self-esteem induces a high sensitivityfor attention, tokens of esteem, praise and com-parison and great interest in compensating lowself-esteem through performances, achievements,skillsand a sensitivity and a drive for satisfyingother peoples needs (Skarderud, 2007c). This maybe expressed in high compliance towards people and therapists. The clever child also tends to aspireto be the clever patient. Using a Winnicottian term,the false self is at work (Winnicott, 1975).

From the therapists perspective this may beconceived aspseudo-compliance. Actually, there is noworking alliance, but mainly an ambiguous form ofpoliteness; saying yes, meaning both yes and no.

Self- and affect regulation. Patients with anorexiaoften present themselves via their lacking capacityto tolerate, modulate or synthesise affects, expressedboth through their affective and cognitive either-or,all-or-nothing. In clinical terms therapists mayexperience oscillations between restrictive silenceand outburst of both positive and negative affects;for example excitement, enthusiasm, fear, rage and

shame.

Physiology and psychology of hunger. In addition,as therapists we are often confronted with physio-logical symptoms of under-nourishment and mal-nutrition, like tiredness and exhaustion. And thereare thepsychologicalsymptoms of malnutrition. Thesomatic states will in themselves often contribute todysfunctional psychic phenomena, such asemotional instability, low spirits, irritability,apathy, reduced power of concentration andmemory, compulsive behaviour and rituals and,logically enough, increased preoccupation with

food rituals, often with fear of binge eating. Thisis what we call the psychology of hunger, wherepsychic symptoms are secondary to the state ofnutrition. In a causality model for eating disorders,the psychology of hunger functions as a maintain-ing factor. This makes recovery difficult.

Impaired mentalising by age. And, not least,treating anorexia nervosa often means workingwith adolescents; immature by definition and


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whose mentalising capacities are not yet fullydeveloped.

Therapist factorsA possible negative contribution to therapeutic

enterprises does not concern the patients, but thetherapists; and our difficulties with being ableto understand the very nature of these disorders.A lack of understanding can lead to a lack ofcommitment and patience, to moralising statementsand coercive behaviour; or worse provoked toaggression and rejection. And this may bereinforced by self-starvation inducing cliniciansrational fear of somatic complications and death.Anorexia nervosa is a psychiatric disorder with arather high mortality rate (Nielsen, 2001). Butrational fear does not necessarily lead to rationalreactions. Filled with such frustrations, therapists

may elicit potentially treatment-destructive inter-ventions.

Therapists lack of insight into illness. Some therapistsseem to be more prepared to endure aggressiveoutbursts, verbal attacks, acting-out and overtlydestructive behaviour, for example from personsdiagnosed with borderline personality disorder,better than the silence, isolation and restriction ofthe anorectic.

The excluded therapist. Health workers experien-cing rejection is well-known in clinical work withanorexia nervosa; and enduring rejection is difficult.The anorectic persons withdrawal into the realm ofthe concrete is perceived also as a withdrawal fromrelationships and as an exclusion of the clinician.The shame-based denial by the patient, claiming notto be worthy of any help or anything good(Skarderud, 2007c), may similarly be experiencedas a provoking disruption of attachment.

Therapeutic freedom. The drama of soma, threat ofdeath and the anorectic no restricts the therapists

freedom of movement. Anorectic behaviour isutterly seductive in the way it directs attention andfocus from emotions and the persons subjectiveexperiences to physical entities like gram, kilo andcalories. In this way anorexia nervosa is conta-gious. And it may be contagious in the sense thatclinicians in the therapeutic relationships reproducepatients rejective style of attachment, with highrisks for drop-outs and disrupted therapeuticrelations.

Therapists impaired mentalising. The concept ofmentalisation is relevant not only to describepatients, but also their helpers. The capacity ofmentalisation is contextual; it is far from an either-orcapacity. In some situations we all mentalise badly,

in the sense of being able to understand the othersposition. Mentalisation is reduced in situations ofaffective arousal and in intensive attachmentrelations, like threat of separation, relieving attach-ment traumas. Hence, impaired mentalisation iscontextual. And the severely ill anorectic patientmay also in some contexts appear to be a goodmentaliser. Therefore, she or he confuses us.

And when confused, the therapist may feelfrustrated and provoked, and mentalising isimpaired.

To sum up, the very nature of the psychopathol-ogy of anorexia nervosa, here called patient

factors, and clinicians being intellectually andemotionally challenged by these disorders, herecalled therapist factors, together represent greathazards in terms of harmful effects on thetherapeutic alliance.

Impaired mentalisation and psychic modes ofreality. In the following paragraphs there willfollow elaborations of the hindrances and com-plications already described, with conceptualreference to the model on mentalising. It is abasic premise in psychodynamic therapy thatthere are related processes coming into beingbetween the infant and caregivers, and later

between patient and therapist. Former and actualrelationships are reciprocal metaphors, and theGreek meta-phoros is etymologically very close toFreuds original German concept of transference,Ubertragung (Enckell, 2002). History becomes amodel to understand the contemporary, and thecontemporary becomes a model to understandhistory. And where therapeutic alliances areestablished, where new attachment bonds areformed and activate former bonds, new possibi-lities for development and change appear. Half acentury ago Alexander (1952) established theconcept of corrective emotional experience.

The outline of therapy presented here is in thismanner theoretically founded in models of devel-opmental psychology. In the further presentationthere will be an emphasis, with explicit reference tothe tradition of mentalising, on psychic modes ofreality that can be experienced and described inanorexia nervosa. There will also be an emphasis oncorporealities; how different modes of realitiesinvolve bodily experiences. The presentation willbe illustrated with clinical examples, demonstrating


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both psychological function and how this may beexpressed in therapeutic relations.

Psychic equivalencePsychic equivalence as a construct means equating the

internal with the external world (Fonagy, 2006b;Fonagy et al., 2002), and refers precisely to theempirical findings described in the first paper in thisseries of three (Skarderud, 2007a). Psychic equival-ence covers one central aspect of the phenomenologicalessence of embodiment in severe anorexia nervosa.Psychic equivalence refers to an interesting, butproblematic mindworld isomorphism. What existsin the mind must exist in the external world, andwhat exists out there must invariably also exist inthe mind.

Possible clinical expressions relevant for treat-

ment. Psychic equivalence in anorexia nervosa isabout carnal thoughts and emotions. Part I presentsa number of examples of equivalence between bodyand mind in anorexia nervosa, and the process ofequating goes both ways: What is thought and felt,is also perceived as physical reality. And bodilyperceptions represent emotional realities. Thepatient experiencing lack of control in her life,can also have an experience of bodily expansion,getting bigger and fatter. Hence, psychic equival-ence is relevant for the understanding of the bodyimage disturbance in anorexia nervosa. It is aclinical experience, not yet satisfactorily described

in research literature, that body image disturbanceis contextually dependent on affective state; mostprominent 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 patientsascribe numerous possible meanings to symptoms.Hence, there is richness in what being symbolised,but poverty in how to symbolise. The psychic painfor the patient is that he or she is trapped in thisharsh corporeality here-and-now; and does notsatisfactorily mentalise how his or her body func-tions as a metaphorical source for emotional life,

and vice versa.For the therapist the mode of psychic equivalence

may contribute to confusion: inner states areconcretely presented in a bodily way. Commonpsychological states are low self-esteem, insecurityand confused identity, affect disregulation andambivalence. These may concretely be lived out asambiguous and contradictory messages, and lit-erally confusing us. The patient in inner conflictwith herself, plays out these conflicts. Here are some

examples, all referring to one or more of the patientsinterviewed in Part I:

She tries to be somebody by becoming nobody. She

is the one who is most hardworking to be clever and

most ill. She is very interested in food, but does not

eat it. She tries to improve her self-esteem by

destroying herself. She sacrifices herself to save

herself. She behaves like a small child, and as a

mother for her parents. She is the self-obliterating

child governing the whole family. She is the most

obedient protesting most violently. She is con-

forming and different. She longs for help, and

despises her helpers.

Psychic equivalence may for the therapistrepresent a frustrating difficulty to engage thepatient and establish a fruitful working alliance. The

patients fear of not being in psychological controlcan lead to controlling behaviour, like checking,double-checking and including controlling thetherapist. A general feeling of distrust is expressedas distrust towards scales, amounts of food but alsothe trustworthiness of the therapist. Insecureidentity generates the patients tendency to com-pare themself with others, concerning concreteachievements and bodily qualities. The therapistworking with anorexia and eating disorders shouldbe aware that ones own body is being assessed andjudged; and this may impair therapeutic relation-ships, particularly in initial phases. Hence, the

therapeutic relationship and interchange, and otherrelationships, are also concretised and psychologi-cally equated.

Teleological stanceTeleological stance is introduced as a concept todeepen the understanding of such physicalisation oflife and relationships. As a child normally develops,it gradually acquires an understanding of fiveincreasingly complex levels of agency of the self:physical, social, teleological, intentional and repres-entational (Fonagy et al., 2002; Gergely, 2001).

Teleological stance refers to a developmental levelwhere expectations concerning agency of the selfand the agency of the other are present, but these areformulated in terms restricted to the physical world.There is a focus on understanding actions in termsof their physical as opposed to mental outcomes; Idont believe before I see it. Patients have problemsaccepting anything other than a modification in therealm of the physical as a true index of theintentions of the other.


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Possible clinical expressions relevant for treat-ment. In the world of psychiatric disorders anorexianervosa and eating disorders represent a specialcase, in the sense that in the biographies of thepatients one can find an initial active wish for

change. The persons want to change themselves, inself-esteem and social acceptance, and such changesare sought to be fulfilled by physically changingtheir bodies. Hence, teleological stance may be auseful concept to describe and understand theconcretisation of ambitions for self-improvement inanorexia nervosa.

Teleological stance is also relevant to under-standing relationships in general, and therapeuticrelationships in particular, like battles about agree-ments, appointments, contracts, time, money andattention. If the therapist really cares, he or she isexpected to show this benign disposition and

motivations to helpful in concrete manners; likeavailability on the telephone, extra sessions atweekends, physical touching, holding and actsbeyond rules. Hence, this may contribute toviolations of therapeutic boundaries (Bateman &Fonagy, 2004).

Pretend modeIn a developmental perspective pre-tend represents for the child an alternative mode ofexperiencing reality. It is a decoupling of internalfrom external reality (Fonagy, 2006b; Fonagy et al.,2002). Actually the child is playing and playingwith reality (Winnicott, 1971). In a clinical perspect-

ive with adolescents and adults this refers todissociation between internal state and outsideworld. In psychotherapeutic work, words withreference to inner states are commonly used withthe expectation on the part of the therapist that thesewill have a real impact on the patient. But while thepatient is in pretend mode, the words may beunderstood, but do not have such real impact. AsBateman and Fonagy (2004) write about therapywith borderline patients: Therapy can go on forweeks, months, sometimes even years, in thepretend mode of psychic reality, where internalstates are discussed at length, sometimes with

excessive detail and complexity yet no progress ismade, and no real understanding is experienced(p. 70). Ideas do not form a satisfactory bridgebetween inner and outer reality and affects do notaccompany thoughts.

Possible clinical expressions relevant for treatment. Aclinical feature, not at least in anorexia nervosa, maybe feelings of emptiness, meaninglessness anddissociation in the wake of trauma. In the thera-

peutic relationship this may lead to endlessinconsequential talk of thoughts and feelings, andwill be experienced as tiresome by the therapist. Thedialogues may appear as relevant, given the topicsof emotions and thoughts, but with minor effects.

This representspseudo-mentalising. Pretend mode asa concept is a useful tool to widen the under-standing of ineffective therapy. The alexithymicpatient may lack words for inner life, while thepatient in pretend mode has words, but they are notyet their own.

The described outer-directedness, with thepatient trying to interpret and satisfy other peoplesneeds (Buhl, 2002), may lead to hyper-mentalising.The combination of pseudo- and hyper-mentalisingmay contribute even more to the confusiondescribed above.

Pretend modeas not being in contact with

may also be relevant if furthering the understandingof the nature of body image distortion in anorexianervosa. One of the patients interviewed in Part I,Maria, spoke of her body. When underweight shedescribed a satisfactory firmness of her body abovethe waist. Then I become more distinct to myself.But she did have a radically different experiencewith her thighs and legs, particularly thighs. Sheused words like numb, fatty, liquid and withoutborders. And when she was scared or stressed, shefelt this even worse; it is as they live their own lives,beyond my control, and sometimes they are in theother part of the room.

The statement here is that there is a parallelsituation in the way of experiencing/not experien-cing bodily states and experiencing/not experien-cing emotional states. Neither the pretend mode norpsychic equivalence have the full quality of internalreality. Pretend mode is too unreal, while psychicequivalence is too real. In normal development thechild integrates these two modes to arrive at areflective mode, or mentalisation, in which thoughtsand feelings can be experienced as representations.Inner and outer reality are seen as linked, butseparate, and no longer have to be either equated ordissociated from each other (Bateman & Fonagy,

2004 p. 70).

THERAPY

A therapeutic treatment will be effective to the extentthat it is able to enhance the patients psychological,physiological and social capacities without generat-ing too many iatrogenic effects. Iatrogenic effects arehopefully reduced if intensity and therapeutic


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approach is carefully titrated to patient capacities(Bateman & Fonagy, 2006). Based on what ispresented in Parts I and II and about obstacles toand possible complications in therapy, this sectionwill outline some very basic goals and tasks in

psychotherapy to further such titration in the workwith anorexia nervosa. The text will not deal withorganisational aspects of treatment services.

A fundamental assumption is entering theconcrete; to point to the expediency of enteringthe phenomenological world presented by thepatient; an acceptance and understanding of thepatients way of mental functioning. The psycho-analyst Josephs (1989) writes that an alternative togetting the patient to enter the realm of the symbolic(the therapists world), is the therapist insteadentering the realm of the concrete (the patientsworld). Afterall, the patient is usually looking for an

ally (p. 495).

Therapeutic Alliance

This is a vital insight for building healthy thera-peutic alliances. A necessary primary focus is theestablishment of a working relationship betweenpatient and therapist; given the robust scientificknowledge about the predictive value for goodoutcome of the therapeutic alliance and given thefrequent difficulties with establishing such in workwith anorexia nervosa.

There is a growing body of neurological evidence

for the importance of secure attachment formentalising capacity (Slade, Belsky, Aber, & Phelps,1999; van Ijzendoorn, Moran, Belsky, Pederson,Bakermans-Kranenburg, & Kneppers, 2000). Inse-curity, affective arousal and attachment traumasimpair mentalisation, while a secure base representsopen-mindedness. Activating attachment systemsis facilitating change. What is the therapeuticalliance if not an attachment bond? Hence, aworking alliance can in itself be considered asbeneficial for enhancing mentalisation. And theother way round: serious relational ruptures mayfor the patient function as being (re)traumatised.

The presented model of psychopathologyrepresents an intellectual basis for the developmentof the therapeutic alliance. A theoretical model ofpsychopathology is always as a simplification,using a set of conceptual metaphors. A model canbe most helpful to organise the confusing phenom-enology presented by the patients, as describedabove. And, hence, it can help us to better under-stand and tolerate such confusing appearances. Amodel of mentalisation when working with anor-

exia nervosa can be helpful for the therapist as abuffer against affect arousal. The therapists men-talising the patients impaired mentalisation maymake it easier to empathise with the patient, like thepatient, and enhance his or hers negative capa-

bility, that is the capacity to tolerate and doubt andto stay with the material (Holmes, 2001).1

Psychic equivalence as a construct is mosthelpful to deconstruct confusion. The same goesfor concretised metaphor, extensively presented inParts I and II, referring to the same phenomena withother terms (Enckell, 2002). Bodily sensations andqualities metaphorically represent mental states.The anorectic body can be read as a text (Ricoeur,1977). The equation of inner and outer reality makesit possible to decipher symptoms and bodilybehaviour as distinct expressions of emotionalstates. 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 mayrefer to loss of control, vulnerability, distrust, senseof ineffectiveness and being overwhelmed by affectsand contradictory demands. And they refer toattempted solutions, as strategies for control,protection, reduction, effectiveness, purity andradical simplification.

Confusion can be unravelled by reducing thecomplex to the simple, but confusion can also becreated by reducing complexity into something that

is too simple, that is bodymind isomorphism.Confusing bodily practices in anorexia nervosa canbe read as confusion itself is the message. Whattherapists need to see, is that the confused state isnot ours, but the patients. These disorders com-municate distinctly about being indistinct; theyspeak precisely about the patients sense of vague-ness, insecurity, ambivalence, paralysing ambiguityand affective dysregulation. The patients body andbehaviour may be interpreted as messages aboutbeing emotionally malnourished. They do not havewhat they need to feel safe. And the body talksabout that dilemma.

Mentalising the patient, and being able to seebeyond bodily practices and symptoms, most oftenreveal the anorectic persons anxiety, fear and anincapacity to handle ones own affects. It is a wrongassertion to see the patient as strong with a firmwill. Symptoms are driven not by strength, but by a

1 The term negative capability stems originally from the poetKeats, referring to his prescription for approaching poetry(Holmes, 2001).


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sense of weakness, fright and despair. Hence, thetherapeutic focus on securing, assuring and makingsafe is important. The patients fear and anxiety isconcretised as fear about food, weight, etc., and thetherapists genuine interest in even details may be

reassuring and beneficial for the working alliance.One shows interest in what engages the patientmost, although using this to bridge the concretepreoccupancies with affects. And since fear mostoften is a key feature, demonstrating ones knowl-edge about eating disorders as such, may becomforting. Mentalising the patients impairedmentalising capacity also reveals that recoverymost probably will demand time. Hence, patienceand slow progress is necessary when working withpersons who are severely ill with anorexia.Therapeutic impatience will often be harmful forthe alliance.

The eventual teleological function of anorexicpatients requires the therapist to ensure that theydo what they say they will do. Motivation of others isjudged by outcome. Promises must be kept withinthe agreed time. Whilst a neurotic patient may acceptthat a therapist has forgotten something and acceptan apology or the offer of an alternative explanation,the teleologically functioning patient may believethat the therapist has forgotten because he or shedoes not like the patient or wants to punish her orhim (Bateman & Fonagy, 2004). The apparently smallerror may be conceived as a serious violation.

Mentalisation-Based Treatmentof Anorexia Nervosa

Introducing a mentalisation-based treatment app-roach to anorexia nervosa means that the mainpriority is not content, butfunction. The main aim ofpsychotherapy with anorexia nervosa is not prim-arily to achieve specific insights into oneself orones past, however interesting or intellectuallysatisfying these may be, but rather to develop thefunction for minding oneself and others; and todistinguish between bodily sensations and mentalrepresentations; to identify feelings, thoughts and

impulses, for example put them into words; and ingeneral assist the capacity of symbolising,

The possible meanings of symptoms in anorexiamay be many, not one and only (Nordb, Espeset,Gulliksen, Skarderud, & Holte, 2006). Of course, theinvestigation 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 arein focus. Content is important, but there is a basic focus

on the process of mind-mindedness itself. The furtherpresentation leans partly on some of the guidelinesdescribed by Bateman and Fonagy in their manualPsychotherapy for borderline personality disorder(2004). But these are also expanded with therapeutic

approaches more specific to anorexia nervosa.

A Mentalising Stance

A main goal of psychotherapy is to enhancementalising. Bateman and Fonagy (2004) definethe mentalising stance as an ability on thetherapists part to question continually what mentalstates both within the patient and within themselvescan explain what is happening. This represents aninquisitive stance, exploring triggers for feelings,identifying small changes in mental states, high-lighting patients and therapists differences in

perceptions of the same events, bringing awarenessto the intricacies of the relationship between actionand meaning and placing affect into a causal chainof concurrent mental experience, etc.

Here-and-now

This refers to working with current mental states.The main focus should be on the present state andhow it remains influenced by events of the pastrather than on the past itself. Past experiences are ofcourse utterly relevant, but they need to beemotionally linked to the present situation, bridgingnarratives and affects.

Marked Mirroring

Staying mentally close with the patient is akin to thecaregivers mirroring response, providing the infantwith feedback on his or her emotional state to enabledevelopmental progress. The task of the therapist isto represent accurately the feeling state of thepatient and its accompanying internal representa-tions. In addition, the therapist must be able todistinguish between his own experiences and thoseof the patient and be able to demonstrate thisdistinction to the patientmarking (Bateman &

Fonagy, 2004 p. 210). Marked mirroringfirst tomirror the patients emotional state, and then tointentionally mark a discrepancy, compels patientand therapist to examine their internal statesfurther. The difference makes a difference.

Active Approach

Hence, this represents an active approach, activelyusing language to ask, comment and propose


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alternative views. But it is important to stress thatthis is based in a not-knowing position. Ideas areideas, thinking out loud, with the intention ofincreasing the ecology of possible views. They arenot interpretations, as in classical psychoanalysis.

An active approach deliberately relates to thealexithymia often experienced as a significant clinicaltrait in persons with anorexia, see above. For thepatient experiencing feelings of sadness and empti-ness such activity may represent vitality. But ofcourse, the level of activity must be adapted to thefunction of the patients. It is a frequent experience insuccessful psychotherapy with anorexia nervosa thatit us useful, or rather necessary, for the therapist tolean 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

outer-directed patient, non-responsiveness may beexperienced as threatening; feeling responsible forthe wellbeing of the therapist. For the shamefulpatient silence may stimulate negative shamefeelings. Hence, therapeutic activity can be reliev-ing. On the other hand, too much activity on thetherapists behalf may be experienced as invadingand threatening.

Minding the Functions of Symptoms

As described above, the patients with anorexianervosa most regularly experience both the pros

and cons of symptoms, experiencing the anorecticway of living as both a problem and a solution. Amentalising approach to anorexia stimulates theopen investigation of different functions and mean-ings of symptoms. Such an approach, opening upfor the dialogue not at least about the possiblepositive aspects of the disorder, may be experiencedas liberating for the patient. The therapist marksthat it is allowed to present ambivalences, doubts,hesitations and resistance. Creating such an atmos-phere of open inquiry is most often beneficial for thetherapeutic alliance, not at least because thetherapist demonstrates that he or she is one who

understands the complexity of the disorder.Such a therapeutic approach is based on the

therapists role as an expert, from a knowing position.But the way of investigating is done with theinquisitive stance, from a not-knowing position.

Psycho-Education

A mentalisation-based approach to anorexia ner-vosa bridges psychotherapy and psycho-education,

altering between being an expert in the sense offactual knowledge and an expert in the sense ofopen inquiry, between knowing and not-knowing.For patients the competent therapist sharing his orher knowledge about different aspects of the

disorder, including the model of psychopathology,will hopefully be experienced as an interested andtrustworthy person. The utility of psycho-educationcan in general be partially explained by the idea thatinformation and understanding gives the patientsthe opportunity to move from the traditional role ofpassively accepting treatment to becoming activeagents in the treatment process (Corey, 2000;Haslam-Hopwood, Allen, Stein, & Bleiberg, 2006).

Negotiating Non-Negotiables

A particular challenge of working with anorexia

nervosa is the inevitability of non-negotiables in thetreatment. The major non-negotiable is that thepatient has to eat more and more healthily simply tosurvive. Many iatrogenic effects are consequencesof too harsh and authoritarian ways of presentingsuch basic non-negotiables, and introducing morenon-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 andsomatic situation? (Duesund & Skarderud, 2003).Moralistic and threatening approaches will oftenproduce fear, protest and a war-like situation, and

reduce therapeutic possibilities.The non-negotiables need to be redefined: they arealso an excellent opportunity to demonstrate thementalising ambition to understand different andopposite views, and to negotiate non-negotiables.Much may have been achieved if the patient ismoved from a no to any weight gain to accepting aminimal increase over months. The latter representsa yes, although a small one. From that position itmay be possible to negotiate the frames and limits.How to deal with non-negotiables is at the veryheart of treating anorexia, and must be given carefulconsideration. For the therapist this represents a key

situation to demonstrateboth firmness and flexibility,not either-or. Again there is the striking similaritywith parents relation to children.

Stimulating Affective Consciousness

There is a gap between the primary affectiveexperience and its symbolic representation. Amentalisation-based psychotherapy actively triesto bridge gaps. Technically, this means an active


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focus on experienced affects, and to elaborate theseboth in details and contextually.

The point of departure may be a concretesituation, for example the patients increasedvomiting combined with a stressful situation during

recent days. A spectrum of mentalising interven-tions regarding affective states may be like this: (1) asupportive and emphatic approach is basic in theseries of interventions. (2) The affect is identified notonly by the behaviour; there will be simple andsystematic clarifying and naming of feelings. (3)Then one explores the contexts of the emotions; thatis the current emotional and interpersonal context.(4) And so forth, widening the exploration contextto broader interpersonal contexts, as recurrentthemes in the patients life and (5) eventuallyexplore the actual emotions in the patienttherapistcontext, that is mentalising the transference. With

impaired mentalisation, transference is experiencedas real, accurate and current and needs to beaccepted as such in the treatment, and not as adisplacement and repetition of the past.

Bateman and Fonagy (2006) emphasise thatnon-mentalising interpretations should be usedwith care. Interpretations, in the classical psycho-analytical sense, may be too advanced, referring toconcrete mode of functioning; being without anypositive effect. Or they may be experiencednegatively. As Bruch (1985) stated: To thesepatients, receiving interpretations . . . representsin a painful way a re-experience of being told what

to feel and think, confirming their sense ofinadequacy and thus interfering with the develop-ment of a true self-awareness and trust in their ownpsychological abilities (p. 14). The patient mayrespond with pseudo-compliance, the hallmark ofthe anorectic functioning, or, if threatened enough,may simply bolt from treatment.

Minding the Body

The focus on the patient minding their own body isalso of specific relevance to psychotherapy withanorexia nervosa. The concept body is demon-

strably inadequate. It is problematic insofar as itimplies a discrete phenomenon that is capable ofbeing investigated apart from other aspects of ourexistence to which it is intrinsically related. We maylose sight of the fact that the body is never isolated inits activity, but always already engaged with theworld. Hence, we make a shift from body toembodiment, where the embodiment refers to ananti-Cartesian and existential position in which thebody is the subjective source or intersubjective

ground of experience; awayof living or inhabitingthe world through ones acculturated body (Weiss& Fern Haber, 1999, p. xiv). Studies under the rubricof embodiment are not about the body per se. Theyare about personal, psychological and cultural

experiences as these can be understood from thestandpoint of bodily being-in-the-world (Csordas,1999).

Anorectic embodiment has several differentaspects. One aspect refers to culture. Culture, inthe sense of common and normative reflection,whether it be in the form of religion, philosophy,moral, biological science or the aesthetics ofcontemporary consumer culture, objectifies thehuman body. Flesh is symbolically loaded; likebeing thin may symbolise control and psychologicalstrength in our affluent, contemporary Westernculture (Skarderud & Nasser, 2007). The body is

metaphorised in the sense that physical qualitiesmetaphorically represent non-physical qualities.This object status is part of our culture and becomesclearly evident when we refer to the body assomething to be investigated in, trained, slimmed,in order to serve other purposes. Collective normsand ideals about good and bad, beautiful and ugly,adapted by the individual, and in particular theinsecure, sensitise the human body in a psycho-logical sense.

In anorexia this is complicated by a second aspect;the immediate and analogous connection betweeninner and outer reality. Physical qualities refer to

social and emotional qualities, and vice versa; andfor the person with anorexia there may be anon-negotiable link here-and-now between fatand weak (psychic equivalence). A third aspect isthe possible dissociative experience of ones bodilysensations (pretend mode). Bruch (1962) describedpatients difficulties in accurately perceiving orinterpreting stimuli arising in their bodies.

Hence, anorectic embodiment is a complex andpossibly confusing picture. At the same time theremay be a culturally driven unduly negative focus onexterior, combined with incapacity of makingdistance to this dissatisfaction, and at the same

time experiencing impaired awareness of onesbodily sensations. The body is emotionally andcognitively experienced more via glances, on theweighing scales, in the mirror, measuring circum-ferences of limbs, counting skin folds on thestomach and via fantasies about being looked atby others, than by feeling ones own lived body(Merleau-Ponty, 1962). Anorectic corporeality may atthe same time be experiencing ones body as too real andtoo unrealand too disgusting.


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Mentalising the body means to stimulate thepatient to investigate concretely the experienceswith body and food, and connect them with emo-tional, cognitive and relational experiences, with theaim to transfer them into a language reflecting upon

them both as physical reality and as metaphor. Thepatient is lost in translationor lost in repres-entation. A patient may be desperately afraid of fat,and she is also generally afraid; of what? Can theseexperiences of fright be linked?

This refers specifically to the concepts psychicequivalence and concretised metaphors. In theperspective of therapeutic alliance, this is to meetthe patient where the patient is. In clinical workwith anorexia nervosa one learns how the feelingsare bound up with concrete experiences. Thedialogues about emotions can be experienced bythe therapist as non-committal, empty and exhaust-

ing. But the dialogues dealing with the non-negotiables of treatment, like proposals of increasedfood intake and weight increase, can become veryemotional. This may be seen as a limitation forpsychotherapeutic work, but also as a possibility.Meeting the patient in the concrete is also apossibility for reaching out and thus bringingemotional experiences into the dialogue.

The aim of psychotherapy is enhanced mentalisa-tion, and in this context this refers to separatingbody from body, that is sensation from representa-tion, flesh from affect. This represents ade-concretisation, opening up the closed psychologi-

cal experience of equivalence of realities. In thelanguage of body metaphors, psychotherapy isre-metaphorisation (Carveth, 1984); an exercise inbecoming conscious and self-critical in our employ-ment of the metaphors we liveand eatby.

It is important to stress that the use of concretisedmetaphors 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, sincelanguage is lifting the experience above the physicalrealm. This is important to stress, since metaphoris a popular concept in some schools of psychother-

apy. Bateman and Fonagy (2004) warn against theextensive use of metaphors in therapy, althoughreferring to borderline personality disorder. Lin-guistic metaphors presuppose an ability to usemental representations, and rather than heighten-ing the underlying meaning of the discourse, use ofmetaphor is more likely to induce bewildermentand incomprehension (p. 213).

In practical terms, entering the concrete can haveseveral practical meanings. Imagine this scene:

Under the therapists couch one can see theweighing scale. Let this be a statement for reflectionand discussion: It may be useful that the therapist isalso the person who is responsible for the regularweighing and actively taking part in monitoring the

eating programme. This is usually a very challen-ging situation for the patient, and therefore asuitable arena for the therapist to demonstrate his/her empathic presence.

Psychotherapy will be helped by concomitantphysiotherapy, programmes for activity, bodilyawareness or body psychotherapy. Duesund andSkarderud (2003) describe the possible benefits ofadapted physical activity as a supplement to thepsychotherapeutic dialogues. Social interaction inactivities can move negative attention from theobjectivated anorectic body to a more profound andsubjective experience of ones own body. This is

intentionally using the bodylike movement,social interactions, physical and psychologicalchallenges (the lived body)with the intention toforget the body (the anorectic objectified body).Forget in this context actually means turningattention from the anorectic objectified bodytowards the lived body. Thien, Thomas, Martin,and Birmingham (2000) also describe how agrounded use of physical activity and bodilyapproaches may be beneficial to the therapeuticrelationship. This points to unutilised possibilitiesin psychotherapeutic enterprises collaborating withtraditions such as physiotherapy, body-oriented

psychotherapy and adapted physical activity (Due-sund & Skarderud, 2003).Experiences from different kinds of activities and

different perceptions of ones body in differentcontexts are an utmost relevant topic in thementalising psychotherapeutic dialogue.

Repairing Ruptures in Therapeutic Alliance

The hindrances in psychotherapy with anorexianervosa are described above. In psychotherapy

research a consensus is emerging around tworelated issues: That strains in the alliance areinevitable, and that one of the most importanttherapeutic skills consists of dealing therapeuticallywith this type of negative process and repairingruptures in the therapeutic alliance (Safran &Muran, 2000). In this context this may mean toinvestigate common and in detail misunderstand-ings, different views and possible alternative viewsand behaviours with regard to concrete events.


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CONCLUSION

Patients who suffer from anorexia are hetero-geneous in terms of background, clinical features,comorbidity and personality functioning, but it isstated here that impaired reflective function most

often, in severe cases, is central in the psycho-pathology. Of course, psychotherapy has to bereinvented in every new case. But it is possible todefine some basic principles. The aim of this paperhas been to outline such principles, with specificreference to described deficits in reflective function.Linking up to a current tradition this is described asmentalisation-based treatment.

All therapy requires mentalising, while mentali-sation-based treatment and psychotherapy entailsexplicit attention to mentalising in the therapeuticprocess both in individual, groups and familycontexts (Allen & Fonagy, 2006). The future

challenge will be to further qualitative and quan-titative research on the psychopathology in anorexianervosa and eating disorders; and to developoutlines into treatment manuals as basis for therapy,training and scientific research. Introducing amentalisation-based approach for anorexia nervosais not least meant to be helpful to reduce iatrogeniceffects. Mentalisingholding mind in mindis akey challenge for both therapists and patients.

ACKNOWLEDGEMENTS

Thanks to Anthony Bateman and Peter Fonagy, fortheir works, inspiration and comments to this work.The research work behind this paper is financiallysupported by The Norwegian Research Fund.

REFERENCES

Allen, J. G. (2001). Traumatic relationships and serious mentaldisorders. West Sussex: John Wiley & Sons, Ltd.

Allen, J. G. (2003). Mentalizing. Bulletin of The MenningerClinic 67, 87108.

Allen, J. G. (2006). Mentalizing in practice. In J. G. Allen &

P. Fonagy (Eds.),Handbook of mentalization-based treat-ment (pp. 330). West Sussex: John Wiley & Sons, Ltd.

Allen, J. G., & Fonagy, P. (Eds.). (2006). Handbook ofmentalization-based treatment. West Sussex: John Wiley& Sons, Ltd.

Alexander, F. (1952). Psychosomatic medicine. London:G. Allen & Unwin.

Baron-Cohen, S. (1995).Mindblindness: An essay on autismand theory of mind. Cambridge, MA: MIT Press.

Bateman, A. , & Fonagy, P. (1999). The effectivenessof partial hospitalization in the treatment of border-

line personality disorder. A randomised controlledtrial. The American Journal of Psychiatry, 156, 15631569.

Bateman, A. , & Fonagy, P. (2001). Treatment of border-line personality disorder with psychoanalyticallyoriented partial hospitalisation. An 18-month fol-

low-up.The American Journal of Psychiatry,158, 3642.Bateman, A. , & Fonagy, P. (2004). Psychotherapy forborderline personality disorder: Mentalization-based treat-ment. Oxford, England: Oxford University Press.

Bateman, A. , & Fonagy, P. (2006). Mentalizing andborderline personality disorder. In J. G. Allen & P.Fonagy (Eds.),Handbook of mentalization-based treatment(pp. 185200). West Sussex: John Wiley & Sons, Ltd.

Bowlby, J. (1969).Attachment and loss, Vol. 1: Attachment.London: Hogarth Press and Institute of Psycho-Analysis.

Bruch, H. (1962). Perceptual and conceptual disturbancesin anorexia nervosa. Psychosomatic Medicine, 24, 187194.

Bruch, H. (1985). Four decades of eating disorders. InD. M. Garner & P. E. Garfinkel (Eds.), Handbook of

psychotherapy for anorexia nervosa and bulimia (pp.7.18). New York: Guilford Press.Buhl, C. (2002). Eating disorders as manifestations of

developmental disorders: Language and capacity forabstract thinking in psychotherapy for eating dis-orders. European Eating Disorders Review, 10, 138145.

Carveth, D. L. (1984). The analysts metaphors.Psycho-analysis and Contemporary Thought,7, 491560.

Coates, S. W. (2006). Foreword. In J. G. Allen & P. Fonagy(Eds.), Handbook of mentalization-based treatment (pp.xvxvii). West Sussex: John Wiley & Sons, Ltd.

Corey, G. (2000).Theory and practice of group counselling(5th ed.). Stamford, CT: Brooks/Cole.

Csordas, T. J. (1999). Introduction: The body as repres-

entation and being-in-the-world. In T. J. Csordas (Ed.),Embodiment and experience. The existential ground ofculture and self(pp. 126). Cambridge, UK: CambridgeUniversity Press.

Duesund, L. , & Skarderud, F. (2003). Use the body andforget the body. Treating anorexia nervosa withadapted physical activity. Clinical Child Psychologyand Psychiatry,8, 5372.

Enckell, H. (2002). Metaphor and the psychodynamic func-tions of the mind. Doctoral dissertation. Kuopio, Finland:Kuopion Yliopisto.

Fairburn, C. G. (2005). Evidence-based treatment of anor-exia nervosa. International Journal of Eating Disorders,37, S26S30.

Fonagy, P. (1989). On tolerating mental states: Theory of

mind in borderline patients.Bulletin of the Anna FreudCentre,12, 91115.

Fonagy, P. (1991). Thinking about thinking: Some clinicaland theoretical considerations in the treatment of the

borderline patient. International Journal of Psycho-Analysis,72, 118.

Fonagy, P. (2006a). Developmental roots of mentalisation.Presentation at the conference Widening the scope of men-talisation, London June/July 2006.

Fonagy, P. (2006b). The mentalization-focused approachto social development.In J. G. Allen & P. Fonagy (Eds.),


DOI: 10.1002/erv



16/17


17/17

Skarderud, F. (2007c). Shame and pride in anorexianervosa: A qualitative descriptive study.European Eat-ing Disorders Review,15, 8197. DOI: 10.1002/erv.774

Skarderud, F., & Nasser, M. (2007). (Re)figuring identities.My body is what I am. In M. Nasser, K. Baistow, & J.Treasure (Eds.),The female body in mind. When the body

speaks the mind. The interface between the female body andmental health (pp. 1727). London/New York: Brunner-Routledge.

Slade, A. , Belsky, J. , Aber, L. , & Phelps, J. L. (1999).Mothers representation of their relationships withtheir toddlers: Links to adult attachment andobserved mothering. Developmental Psychology, 35,611619.

Taylor, G. J. , Bagby, R. M. , & Parker, J. D. A. (1997).Disorders of affect regulation. Alexithymia in medical andpsychiatric illness. Cambridge and New York: Cam-

bridge University Press.Thien, V. , Thomas, A. , Martin, D. , & Birmingham, C. L.

(2000). Pilot study of a graded exercise program for the

treatment of anorexia nervosa. International Journal ofEating Disorders,28, 101106.

Vandereycken, W. , & Pierloot, R. (1983). Drop-out duringin-patient treatment of anorexia nervosa. British Journalof Medical Psychology,56, 145156.

van Ijzendoorn, M. H. , Moran, G. , Belsky,J. , Pederson, D.

, Bakermans-Kranenburg, M. J. , & Kneppers, K.(2000). The similarity of siblings attachments to theirmothers.Child Development,71, 10861098.

Weiss, G. , & Haber, H. F. (1999). Introduction. In G.Weiss & H. F. Haber (Eds.),Perspectives on embodiment.The intersections of nature and culture(pp. xiixvii). NewYork and London: Routledge.

Winnicott, D. W. (1971). Playing and reality. London:Routledge.

Winnicott, D. W. (1975). Collected papers. Through pediatricsto psychoanalysis. London: Tavistock.

Woodside, D. B. (2005). Commentary: Treatment of anor-exia nervosa: More questions than answers.International

Journal of Eating Disorders,37, S41S42.



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