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: [email protected]
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
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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.
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Eur. Eat. Disorders Rev. 15, 323–339 (2007)
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