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Picture This: Mentalization-based Therapy to Treat Eating Disorders

Picture This: Mentalization Based Therapy to Treat Eating Disorders

There’s a new tool for individuals with eating disorders that can help them think in new ways about themselves, others and food. Called mentalization-based therapy, this newer subset of psychodynamic therapy focuses on attachment therapy using a technique developed by researchers Peter Fonagy and Anthony Bateman. Originally used to help patients with borderline personality disorder, mentalization-based therapy (MBT) can also help those with eating disorders, who have a similar tendency to lose their awareness of their own and others’ emotional states. Mentalization is used to pique curiosity about internal thought processes, and gain more insight into how others think and feel and what they intend. In MBT, the therapist helps patients grow more curious about themselves. At the same time, patients develop an attachment to the therapist that facilitates patients’ understanding of other relationships, as an insecure attachment style appears to underlie mentalization issues. Generally, there are two types of mentalization errors. In hypomentalization, most often associated with autism, individuals have little insight into their own or others’ ways of thinking. Most individuals with eating disorders make the opposite error. They are attuned to their own and other’s emotional states. They tend to overpersonalize interpretations of what caused someone else’s behavior and then fixate on it. For instance, if a teen’s best friend does not say “hi” in the hallway at school, most people might think the friend didn’t see her or she was focused on something else. Someone with a mentalization error more likely thinks the friend is angry with her. She will act as if the person is angry and avoid the friend or make comments about how she acted. Those behaviors may cause the friend to actually become angry and alienated. In MBT, the therapist works with the patient to develop alternative explanations and to consider that the other person’s behavior may not be about them at all. Internally, individuals with eating disorders have difficulty distinguishing between how they feel and what is factual. They may feel fat, which becomes truth for them, entirely separate from the actual condition of their bodies. These patients act as if they are fat by avoiding going to the beach, for instance, because they are ashamed of their body, or dieting, even though they do not need to lose weight. The ability to properly mentalize originates in early attachment relationships. Think of four scenarios for an infant.

  • Ideally, if a baby cries, the mother responds. She may not identify the reason correctly initially, but she keeps trying and will eventually fix the problem.
  • If, instead, the mother ignores the baby, the baby will cry louder and louder until he finally elicits a response. The child learns to be loud and demanding and develops anxiety: “Will she respond? When? Does she hear me?”
  • Alternatively, no one responds to crying. The baby learns it is futile to communicate its needs. The child develops avoidance characteristics and lack of trust.
  • Sometimes when the baby cries, the parent responds right away. Sometimes, she does not respond at all or responds after a long time. The baby does not know what will elicit a response. “Did I do it right this time? Should I do it again?” That chaotic response results in a child who finds it hard to trust himself or rely on his ability to know to when or to what others will respond. He develops a mentalization problem, which may manifest as borderline personality disorder or as an eating disorder.

Most patients who develop an eating disorder do so as the result of another problem, often related to insecure attachments. For others, an eating disorder becomes their primary relationship. Mentalization-based therapy creates a relationship with the therapist that becomes stronger than the relationship with food or with the eating disorder. When patients start attaching to the therapist, patients become more interested in what the therapist thinks, what the therapist means by a comment or intends through an action. The therapist asks the patient to explore possible interpretations. Ultimately, patients learn that they cannot actually know someone else’s mental state without asking and that, very often, it has nothing to do with what patients, said, did or who they are. Patients also become aware of when they are vulnerable to losing their ability to mentalize well. They identify triggers that create stress or anxiety for them. They learn to slow down and question their assumptions about “the facts” in these situations. By experiencing a trusted relationship, patients learn to rely on someone else. They then build the skills to take that trust outside therapy and apply it in other aspects of their lives. This allows patients to see themselves as worthy and move away from dependence on an eating disorder.

About the author

Nicole Garber, MD

Chief of Pediatric and Adolescent Eating Disorders @

Rosewood Centers for Eating Disorders

Web Site: /our-experts/

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