03/07/18 MINDING THE BODY � Mentalising and eating disorders Professor Finn Skårderud finns@online.no Kaunas June 2018 The embodied mind Some Free Publicity Psychotherapy Brands JUST RELASED! NEW! CBT IMPROVED! PE DBT MBT EMDR TFP EFT Much longer than all DIT ADEP CFP previous SIT CPP Washes minds versions! whiter! ERP RLX MBCBT TPP IPT PCT 2012 American Psychiatric Publishing, Inc 1
03/07/18 Mentalising as a common factor in My brand of psychotherapy (Jon Allen) therapy CBT PE DBT MBT EMDR TFP EFT Mentalising as a common language DIT POT ADEP CFP SIT CPP ERP RLX MBCBT TPP IPT PCT What is MBT? Models of psychotherapy • Always combina;on treatment • The drug metaphor (Wampold) • Individual therapy • MBT is rela%onal psychotherapy • Group therapy • Therapist competences are the capaci;es to engage and regulate in the mee;ngs • Psychoeduca;on in groups in beginning of therapy • HOW TO REACH THOSE HARD TO REACH • Use of texts • Complex cases – Case formula;ons – Crisis plans Goals The aims • To promote mentalising about oneself • To promote mentalising about others • To promote mentalising of relationships • To promote mentalising about the body and the embodied mind • To promote our mentalising 2
03/07/18 Mentalising � A new word for an ancient concept Implicity and explicity intepreting the actions of oneself and other as meaningful on the basis of intentional mental states (e.g desires, needs, feelings, beliefs & reasons). (Fonagy, Gergely, Jurist & Target, 2002) Further definitions and scope READING THE MIND IN THE EYES Guilt? • To see ourselves from the outside and others from the inside Fear? • Understanding misunderstandings • Having mind in mind • Past, present, future Seductive ? • Introspection for subjective self construction – know yourself as others know you, but also know your The eye region can signal specific social information, such as guilt, fear or flirtatiousness and a study found that abused children could not read these expressions which subjective self might predispose to certain PDs. Examp Exa mples s fro rom m the Reading the Mi Mind in the Eye Eyes s (Ba (Baro ron-C -Cohen et al., Exa Examp mples s fro rom m the Reading the Mi Mind in the Eye Eyes s (Ba (Baro ron-C -Cohen et al., 2001) ) 2001) 2001) friendly sad surprised sure about something joking happy worried surprised 3
03/07/18 Some features of good Si Simp mple test st of mi mind-mi -mindedness ss mentalising 1. Is curious/inquisitive about own and other people ’ s perspectives Joki Jo king-A -A Flust stere red-B -B ( ‘ safe uncertainty ’ – Mason) 2. Being flexible – not stuck in one point of view 3. Can be playful – using humour to engage (vs. avoid) 4. Can solve problems using give and take between different people ’ s views 5. Can differentiate one ’ s own experience from that of others 6. Conveys ‘ ownership ’ of own behaviour 7. Uses ‘ grounded imagination ’ Desi sire re-C -C Convi vince ced-D -D 20 Mentalising History of the concept can be seen as essential for • Freud and Bindung sense of self • French psychoanalysis and psychosomatic disorders constructive social interactions (Lecours & Bouchard, 1997; Luquet, 1987). mutuality of relationships • Autism spectrum disorers and mind-blindness sense of personal security (Baron-Cohen 1995; Frith, 2003) … SO mentalising is a core psychological process worthy of focus • Fonagy and attachment in treatment. The concept of mentalising as a fulcrum for Why mentalisation–based therapy contemporary theory and research for eating disorders? neurobiology evolutionary biology Treatment should be tailored to the MENTALISING actual psychopathology theory of mind attachment Bateman & Fonagy 4
03/07/18 Hilde Bruch � Eating disorders as disorders of the 1904 - 1984 self A conceptual model Eating disorders as self disorders Hilde Bruch revisited and revised To describe The phenomenology of eating disorders • Descriptions: • The embodiment of self- and affect dysregulation • Deficient sense of self • Symptoms as repair and compensation • Wide range of deficits in conceptual developments, • i.e. Lacking or unstable motivation for change body image and awareness, and individuation • Concreteness of symptoms • Cognitive and perceptual disorder, interoceptive confusion • Alexithymia The body as self- and affect regulation Eating disorder behaviour – Compensation and oblivion – Self-harm – Exercise – Intoxication – Sex – Work 2 9 5
03/07/18 Reflective function ‘ REFLECTIVE FUNCTIONING ’ SCALE The Cassel hospital study (Fonagy et al., 1996) 9 COMPLETE OR EXCEPTIONAL High Diagnoses 7 MARKED Axis I Depression Anxiety Substance Abuse Eating disorder to (n=72) (n=44) (n=37) (n=14) moderate RF 5 PLAIN or ORDINARY 3.8 (1.7) 3.5(1.8) 3.4(1.8) 2.8 (1.7)* 3 LOW Axis II No Axis II BPD(DSM) Antisocial or Paranoid Other (n=23) (n=22) (n=38) Low ABSENT but not REJECTED 4.3 (1.7)* 2.7 (1.6)*** 3.9 (1.8) 3.3 (1.7) 1 to negative RF -1 NEGATIVE Impaired mentalising: � Impaired mentalising 4 categories Contextually impaired • Context-spesific poor mentalising – E.g. conflict between partners Non-mentalising is variable and occurs in particular contexts – E.g. angry patients • Concrete mentalising Generalized lack of mentalizing – E.g. provoked therapists • Pseudo-mentalising More severly impaired Looks like mentalising, but missing essential features – Trauma • Misuse of mentalising – Neglect Others ’ minds understood and thought about, but used to hurt, manipulate, control or undermine – Non-congruent mirroring Attachment and eating disorders Learning About My Mind, Your Mind Mind in mind Contingent • Review of AAI–based research (Zachrisson & Marked Skårderud, 2010) Sam-I-am Mirroring • A vast majority of insecure patterns • No secure findings concerning subtypes, dismissive, preoccupied and disorganised 6
03/07/18 Opaqueness of feelings Cogito ergo sum I think, therefore I am Descartes Applied on eating disorders and self-harm; when ‘The baby looks at his mother’s face and finds himself there’ psychic reality is poorly integrated, the body may D. Winnicott take on an excessively central role for the continuity of the sense of self. Not being able to feel themselves from within, the person is forced to ‘You are thinking about me, therefore I am Fonagy ’ experience the self from without . ’ But he said to them: Unless I see the nail marks in his hands and put my finger where the nails were, and put my hand into his side, I will not believe it.” John 20: 25 7
03/07/18 The goal is to stimulate Therapeutic techniques and mentalising with our patients skills ..and our own mentalising. Adaption of the MBT model to eating disorders 43 Minding the body Hilde Bruch � A specific challenge in psychotherapy with 1904 - 1984 eating disorders is to stimulate and rehabilitate the mentalising of one’s own Teach thy tongue to say I do body’s role in mental life. not know and thou shalt progress. Maimonides 45 Hilde Bruch 1904-1984 • Mother of mentalising? To these patients, ‘receiving interpretations’ … represents • “ The constructive use of in a painful way a re-experience of being told what to ignorance ” feel and think, confirming their sense of inadequacy and • Curiosity thus interfering with the development of a true self- • To ask rather than to interpret awareness and trust in their own psychological abilities. • Enhance awareness of feelings and Hilde Bruch, 1985 impulses 8
03/07/18 The transparent therapist Mentalizing stance • Role-model for openness and honesty. Like parachutes • Role-model for how minds work. Comfor;ng for the Inquisitive stance pa;ent – not s;ll face! Accept different perspectives • ”Less ques;ons – more statements” Open-minded Curiosity • The pa;ent mind find himself or herself in the mind of Check out your understanding the therapist, minding the pa;ent and the rela;onship. Regulate intensity in the therapeutic Remember WinnicoV relations • Freedom for the therapist. Modelling safe insecurity THE TRANSPARENT THERAPIST • “Being clever is a sin” The dual track! • Challenges – Either-or, body OR mind – Fear, the threat of soma;c crisis – Mo;va;on – Engaging in rela;ons, not at least the therapeu;c rela;onships Ein Tummelplatz Sigmund Freud In English: Playing ground Humour and playfulness is in the manual 9
03/07/18 THANKS! 10
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