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