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When an individual’s mentalising falters or fails, they revert to more primitive modes of thinking, including teleological thinking, psychic equivalence, and pretend mode (Bleiberg, 2013). This section outlines the various observable forms of non- mentalising developed and described by Bateman and Fonagy (2004, 2006).

Concrete mentalising refers to lack of ability to understand mental states beyond

concrete terms. When in this state, individuals may misrepresent their own or others’ minds as less complex and less differentiated (Baker, Silk, Westen, Nigg, & Lohr, 1992). Individuals functioning in concrete mode struggle to see alternative perspectives, and feel that their heightened reactions indicate the seriousness of a given situation. An indication of concrete thinking is when a person is not able to grasp the relationship between thoughts, feelings and actions in self or others. This may be demonstrated by an inability to see one’s impact on others and a difficulty in seeing how one thing leads to another (Bleiberg et al., 2012). Concrete thinking limits a person’s ability to cope with reality, as it limits ability to appraise reality. A hallmark of concrete mentalising is the absence of flexibility and the overuse of generalisations. In adolescents with eating disorders, examples include constant blame or self-blame, and statements such as: ‘I am fat’; ‘If I don’t exercise I will get fat’; ‘She always makes me eat too much’; ‘She never understands’. The main forms of concrete thinking are psychic equivalence and

teleological thinking.

Psychic equivalence is a state of mind in which internal state is equated with external reality; that is, where thoughts or feelings are experienced as facts. Psychic equivalence mode is characterised by difficulties in differentiating or regulating emotions. Instead, the individual is stuck in the immediate here and now of basic emotions, and may attempt to regulate inner states through various forms of

externalisation, projection, projective identification and self-harm (Fonagy et al., 2002). Skårderud (2007a) articulated how this is observed in patients with eating disorders. He describes how in patients with AN, bodily sensations and qualities such as hunger, size, weight and shape—physical signs—represent mental state. Skårderud described this as a concretisation of mental states; that is, inner emotional states such as low self-esteem, insecurity, confused identity, affect dysregulation and ambivalence are expressed through the body. In his qualitative study, Skårderud (2007a, 2007b, 2007c) found that patients with eating disorders described a clear connection between their physical and psychological realities. An example of this is when restrictive control of food represents psychological self-control. Another example is when an adolescent with AN thinks and feels that she is fat. This thought is experienced as a fact, and brings about behaviours as if the fact were true, such as efforts to lose weight even though the individual is already extremely underweight. Skårderud pointed out that this phenomenon may be key in understanding body image disturbance in patients with AN, as body image disturbance is contextually determined by affective state. Most often when experiencing a negative state, an anorexic young person will describe ‘feeling fat’, and therefore equates this to being fat.

The eating disorders literature supports this notion, with evidence pointing to a connection between emotional regulation difficulties, body image concerns and disordered eating in adolescents in community and eating disorder samples. For example, AN and BN have been related to negative affect, alexithymia, suppressed emotion and poor emotional awareness (Cochrane et al., 1993; Geller et al., 2000; Hughes & Gullone, 2011; Legenbauer et al., 2008; Markey & Vander Wal, 2007). In relation to emotion regulation and body image, greater use of avoidance strategies and appearance fixing or checking, and less use of positive acceptance strategies were found

to be associated with increased body dissatisfaction, eating disorder symptoms, and lower self-esteem and social support in an eating disorders sample (Cash, Santos, & Williams, 2005).

A clinical example of psychic equivalence is a 16-year-old with AN and comorbid complex Post Traumatic Stress Disorder (with a known history of physical and emotional trauma) who regularly talked about a belief that she was ‘foul, disgusting and toxic’, because she felt ‘foul, disgusting and toxic’. This young girl produced graphic art depicting a disfigured, decayed self oozing foul substances. She also equated her ‘feeling fat’ as being fat (even when extremely underweight). Another example is when eating disorder patients interpret a decrease in their prescribed meal plan as proof that they are ‘fat’.

The teleological stance refers to an understanding of the organisation of the self and others that is restricted to the physical world. This involves a focus on

understanding actions in terms of physical rather than mental outcomes. In teleological mode, only overt physical actions are accepted as true indications of feelings and intentions. Needs and emotions are expressed with actions rather than thoughts or words. Examples of this mode in adolescents with eating disorders are behaviours such as restricting, bingeing or purging, compulsive exercise, or treatment refusal as a response to distress. The adolescents attempt to change their internal experience via an external mode, such as weight loss, restricting, bingeing or purging. Some adolescents with eating disorders also deliberately self-harm (via cutting, burning, head banging, etc.) as a means of expressing inner distress. Sometimes patient behaviours will escalate in response to an apprehended sense that clinical staff or family members consider that they are ‘recovering’. An escalation of symptoms can be seen as a signal that the young person is afraid that people will think that they are recovered (no longer experiencing

distress) unless they see a physical demonstration of their distress. Sometimes patients will increase binge-purge behaviour when distressed, or when feeling alone or

‘abandoned’. Individuals functioning in teleological mode may also have difficulty accepting a change in the intentions of another person unless they see a physical sign.

Pseudomentalising is linked with pretend mode functioning. This describes a state of mind where the experience and expression of mental states is disconnected from reality. In pretend mode, the individual is able to symbolise her own inner states, and can distinguish internal from external reality, but only when the inner and the outer worlds are completely separated (Fonagy et al., 2002). Being unable to symbolise or accurately sense what they really feel, patients functioning in pretend mode often have problems identifying, expressing and regulating affect. A person operating in pretend mode may also experience feelings of emptiness that arise from the poor connection between representations of inner states and the basic emotions present (Fonagy et al., 2002). This may be experienced in a therapeutic relationship, in which a therapist and a patient may have lengthy discussions around inner states and behaviour, but if the patient is functioning in pretend mode, the words will have no impact (Bateman & Fonagy, 2004).

Common forms of pseudomentalising include intrusive mentalising and

hypermentalising. Intrusive mentalising comes about when an individual does not

acknowledge the separateness or opaqueness of minds. It is often characterised by a certainty about the thoughts and feelings of others. Intrusive mentalising is commonly observed in family dynamics, for example, when parents incorrectly ascribe mental states to their children’s behaviour without any attempt to try to understand what a child is actually feeling. This can be seen in family therapy sessions when either an

without taking the time to stop and test their assumption. An example of this is parents who insist that their child’s eating disorder behaviours are manipulations or attention seeking. For example, a 15-year-old girl suffered from AN with extreme compulsive exercise so severe that she continued to pace even when she had macerated blisters on her feet from pacing 16 hours a day. Her parents reported that they believed their daughter was deliberately continuing this behaviour in order to ‘punish’ them and that she did not have a mental illness at all.

Hypermentalising is a form of pseudomentalising that involves an individual being excessively concerned with trying to understand what people think and feel without a connection to the true state of the person in question. It is characterised by excessive explanations without the presence of real affect, or by limited connections with reality. At first, such individuals may appear to have exceptional mentalising abilities, but appear to find it difficult to relate to the feeling that underpins their mentalising efforts (Allen et al., 2008). Because they do not connect with real feelings or emotional experiences, such individuals can misuse their cognitive capacity in self- serving ways, such as getting others to care or have compassion for them, or to control or coerce others (Fonagy et al., 2012). Adolescents with eating disorders can sometimes present with intense focus and concern about what is in the mind of their parents or their therapist, and this can sometimes be expressed as caretaking or role reversal. In

addition, adolescents with eating disorders may be excessively concerned with

monitoring the thoughts and feelings of other patients, which can lead to a competitive dynamic, or concern about the wellbeing of others to the detriment of their own.

Sometimes parents of adolescents with eating disorders can present with

hypermentalising, particularly those who present as highly intellectual in their approach. Such parents may participate in what appear to be insightful conversations about their

experience with their child, but then demonstrate no change in the way that they respond or interact with their child.

The misuse of mentalising can occur when someone has an accurate

understanding of another’s mental state, but exploit this understanding for their own gain. This type of mentalising can sometimes be seen in group or inpatient settings, when an adolescent with an eating disorder may sabotage a peer’s attempt to avoid weight gain in order to help manage their own fears of weight gain. This can be seen in a dynamic of comparison and competition in an inpatient treatment setting.