Mentalization based therapy for Eating Disorders: MBT-ED Dr Paul Robinson St Ann’s Hospital, London Eating Disorders Unit University College London MSc in Eating Disorders and Clinical Nutrition [email protected]

Professor Finn Skårderud, who should have been giving this workshop!

MBT-ED in the NOURISHED study •  4 year RCT of MBT (iMBT 5 sessions, MBT IT + GT) vs SSCM (Specialist Supportive Clinical Management) •  In patients with –  Eating disorders (BMI>15) –  Symptoms of BPD

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Treatment for 1 year, assessed up to 18 months Last assessment due in June Results in September Robinson, P H et al (2014) The NOURISHED study protocol. BMC Psychiatry

MBT concepts (revision) •  Therapist stance –  –  –  –  – 

Not knowing Curiosity Mentalizing Monitoring mistakes Active questioning

•  Prementalistic modes –  –  –  – 

Psychic equivalence Teleological mode Pretend mode Detachment?

•  Methods –  Reassurance, support, empathy –  Clarification –  Challenge and elaboration –  Stimulate mentalization –  Affect focus –  Stop, stand, rewind, explore –  Using transference and countertransference

Eating Disorder symptoms in MBT-ED

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Body image, weight, eating Restriction Overeating Compensatory behaviours Physical risk

Breaks in mentalizing •  Various causes. Eg: Therapist too challenging, pushing for change too quickly •  Possible ways to recover: give ground, admit mistake, ask patient for guidance, re-run conversation, use humour (with care!) •  If not dealt with can lead to substantial barrier to communication

Video 1 •  Milly (an actor) is interviewed by Dr Robinson •  She is portraying a patient of an Eating Disorders Service with symptoms of bulimia, vomiting, laxative abuse and weight loss. •  In this clip, the therapist induces a break in mentalizing and tries to recover from it using stop and stand and re-running the conversation

Role play 1 •  Please work with your neighbour •  The therapist has caused a break in mentalizing by suggesting that the patient might eat more. •  Try and recover from the situation and regain the interest of the patient. •  Swap roles after 5 minutes

Detachment, psychic equivalence, pretend mode •  Patient may become detached from reality as a result of weight loss, food and weight preoccupations, bingeing and vomiting •  Psychic equivalence is common: “I feel fat so I am fat”, “I feel good about losing weight so I am good.” •  Pretend mode: In the detached state, patient may appear to be cooperating with therapy, but lacks emotional engagement

Video 2 •  Milly is told that she has lost weight •  She cannot understand why feeling good is not accepted •  The therapist challenges her feeling good •  She responds by losing her euphoria

Workshop 2 •  Work with your neighbour •  Therapist lets the patient know she has lost weight •  Patient responds by being very happy and dismissive of concerns •  Therapist tries to regain the sense of concern about deterioration/chance of admission •  Swap roles after 5 minutes

Bulimic symptoms as episodic phenomena •  In MBT a self harm episode is analysed as an event with antecedents and consequences •  Most ED symptoms are construed as long term eg low weight, bulimia, etc •  However, changes in weight, bulimia etc can be treated in the same way as self harm using MBT

Video 3 •  Milly was doing very well until last Sunday when she stopped having regular meals and resumed bingeing and vomiting •  The therapists uses Stop and Stand, Rewind and Explore to identify what happened to lead to a change in symptoms •  Especially to identify where mentalizing broke down

Questions •  What’s the evidence that MBT-ED is effective in EDs? •  How should risk be managed in MBT-ED? •  Is there any further training for MBT-ED? •  Who can provide and supervise MBT-ED?

•  Robinson, Paul (2014) Mentalization Based Therapy of Non-Suicidal Self-Injury and Eating Disorders. Muehlenkamp, Claes. Non-suicidal Self-Injury in Eating Disorders. Springer 2014