Conexiones intra e interdisciplinares

T he term ‘client’ also implies an equitable financial contract, obscuring the inherent power differential between patient and health professional______________________________________

Borderline Personality Disorder and certain variants of ED, namely Bulimia (BN), Binge Eating Disorder (BED) and Anorexia (AN) (binge-purge type), have been termed ‘multi-impulsive disorders’ (Lacey & Evans, 1986). This may explain the high rates of comorbidity between ED and BPD (Rosenvinge et al., 2000). However, studies are beginning to suggest that another mediating variable may be operating in BPD and ED. mentalization. Evidence indicates that RF is lower in BPD and ED than in other psychiatric disorders (Fonagy et al., 1996), and that it may be acting as a mediator in the intergenerational transmission of psychopathology in BPD (Fonagy et al., submitted) and ED (Ward et al., 2001). The concrete style of thinking displayed in the narratives of both ED and BPD clients certainly suggests a common lack of a mentalizing stance (Skârderud, 2007a).

Identifying the core processes driving BPD or ED impulsive behaviours will be key to designing effective therapeutic interventions. Mentalization Based Therapy (MBT) has already shown promising results in BPD (Bateman & Fonagy, 1999), and Skârderud (2007) suggests it has much potential to help people with ED also. However, further quantitative research into mentalization in BPD or ED is hampered by difficulties with measurement. Traditionally, an RF rating scale has been applied to transcripts from the Adult Attachment Interview (Main & Goldwyn, 1994) to determine a person’s mentalization ability (Fonagy et al., 1998). This is a lengthy and time-consuming process, and therefore a brief, self-report measure of mentalization is urgently needed. To that end Peter Fonagy developed the new 46-item Reflective Function Questionnaire (RFQ) (Appendix 1).

This study sought to validate the new measure in non-clinical and clinical populations. The clinical sample comprised individuals with a diagnosis of ED or BPD. The study’s second aim was to investigate the common processes behind ED and BPD that may explain their high comorbidity. A selection of the measures used in the validation study was analysed to explore how RF mediates impulsivity and the subsequent development of ED or BPD.

MENTALIZATION

Bateman and Fonagy (2004) define mentalization ‘as the mental process by which an individual implicitly and explicitly interprets the actions of himself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs and reasons’ (p.xxi). Choi-Kain and Gunderson (2008) draw out three dimensions of mentalizing in Bateman and Fonagy’s (2004) definition. The first is related to mode of functioning (implicit-explicit), the second related to objects (self-other) and the third related to aspects of the content and process of mentalizing (cognitive-affective). Attending to mental states in oneself and others is at the heart of mentalizing (Fonagy et al., 2002). Bateman and Fonagy (2004) suggest that the capacity to think about mental states as separate from, yet potentially causing, actions is a developmental achievement attained in the context of secure attachment relationships. Mentalization implies an ability to see ‘yourself from the outside and others from the inside’ (Allen et al., 2008, p3), and as such is an imaginative skill that recognises oneself and others as ‘intentional’ agents (Dennett, 1987).

Historical context

The psychoanalytic origins of the term mentalization are diverse. While Freud himself never used the term, his discussion of primary and secondary process (1900/1976) illustrates how non-mental phenomena are turned into something mental. French psychoanalysis has used the term for over 40 years (Bouchard et a/., 2008) particularly stressing the gradual and often uneven process whereby somatic drive energies are transformed into symbolic mental representations. By being able to think through something, rather than acting, individuals are able to contain their impulsivity and tolerate frustration. Bion’s notion of the container applies here to thought itself: ‘a capacity for tolerating frustration thus enables the psyche to develop thought as a means by which the frustration that is tolerated is itself made more tolerable’ (1962, p307 cited in Allen et al., 2008). Mentalization differs from classical psychoanalytic theory in its emphasis on relational, rather than merely intrapsychic processes. Owing much to the British Object Relations School, mentalizing ability is said to develop in the context of secure attachment relationships where the mother’s mirroring of the infant’s communications facilitates their nascent agentive self (Winnicott, 1971).

Critique of mentalization theory

In light of the similarities between mentalization theory and existing psychoanalytic theory, it is arguable that mentalization is merely ‘old wine in new bottles’ (Allen, 2006) and therefore offers little to the study of developmental psychopathology. Even amongst its proponents, it has been criticised for being ungainly (Holmes, 2006) and too broad and multi­ faceted to be a marker for specific forms of psychopathology (Choi-Kain & Gunderson, 2008). The present author would argue it does offer much however. Mentalization theory coherently integrates new findings in

cognitive neuroscience, social cognition and attachment research. Its empirical grounding presents testable hypotheses and hence offers many opportunities for investigating causal mechanisms. Mentalization theory therefore avoids criticisms often waged against the psychoanalytic community, which largely eschews deductive reasoning in favour of hermeneutics. Indeed, it seems many agree with its utility, as the explosion of interest in mentalization testifies. Allen et al. (2008) describes mentalization research as having expanded in three waves over the last 20 years: Firstly through studies in Theory of Mind and mentalizing impairments in autism; secondly through Fonagy and colleagues' work on attachment and trauma-related developmental psychopathology of BPD; and thirdly, through attempts to apply mentalization to a broader range of disorders, treatment modalities and theoretical approaches.

Development of the self

Fonagy’s (1991) theory of mentalization was originally developed to explain how BPD develops. However, interest from clinicians working with other disorders of the self, such as eating disorders (Skârderud, 2007b), shows its application is widening. Fonagy (2003) suggests that ‘we may, in fact, see all disorders as different kinds of mentalization failures that have in common the mind misperceiving and misrepresenting the status of its own contents and its own functions’ (p.272). Mentalization underlies affect regulation, impulse control, self-monitoring, and the experience of self­ agency, each of which is deemed to be a crucial building block of the self (Fonagy & Target, 1997). Being able to understand others’ actions and one’s own as intentional, creates a sense of continuity in the self, and therefore coherence.

More than a decade’s work developing mentalization theory by Fonagy and his team is perhaps most cogently summarised in two seminal texts: Affect Regulation, Mentalization and the Development of the Self (Fonagy et al., 2002) and Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment (Bateman & Fonagy, 2004). It is primarily from these two key books that the following sketch of his theory is drawn.

At the heart of mentalization lies attachment. Those infants whose attachment needs are regularly and appropriately met develop a subjective experience of security and perceive their caregiver as providing a secure base (Bowlby, 1988). The infant’s internal working model of relationships builds on these early caregiver experiences. Secure infants have positive templates for relationships, feeling secure exploring their environment because they have internalised a model of an available and nurturing object they can rely on to be there on their return. Infants whose attachment needs were not appropriately responded to internalise a neglectful, unavailable object. Their internal working models are insecure and do not lead to exploratory behaviour.

Contingent, marked mirroring by a caregiver in the context of secure attachment relationships is crucial to the development of mentalization, affect regulation, impulse control and a secure self-concept (Gergely & Watson, 1996). Building upon the theory of Winnicott (1971) and Kohut (1971) Fonagy suggests that the mother’s attuned response to the infant’s cries and movements facilitates his17 developing sense of agency through self-perceived omnipotence. This starts a process where three pre- mentalistic modes of experiencing are bound together.

17 The male pronoun has been chosen for clarity. The female pronoun has been chosen