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From the Experts
 DOI: 10.1176/appi.pn.2014.4a6
Of Supermentalization, Pleasing Others, and Anorexia: The Case of E.L.
Psychiatric News
Volume 49 Number 7 page 1

At the time of presentation, E.L. was a 20-year-old college sophomore with an 18-month onset of preoccupation with her diet, weight, and the shape of her thighs and hips, which she believed to be “obscenely fat and disgusting to look at.” She was 5’10” tall and weighed 97 pounds. Her chief complaint was, “I hate my body, and I hate myself.”

Since infancy, E.L. was the focus of her mother’s fierce determination for her academic success. The mother’s primary goal was that E.L. attend a prestigious Ivy League university, a campaign that she pursued with intensity. E.L.’s assignments were absolute obedience to maternal commands and perfection in their execution. Her reward for success was escape from her mother’s persistent physical and psychological brutality for noncompliance. Unlike her peers, E.L. was not permitted to go to parties, have friends over to her house, have a cell phone, or use her laptop computer for any purpose other than schoolwork.

Accepted via “early decision” to the university of her mother’s choice, E.L. was unprepared for the social experiences in college. Tall and physically attractive, as well as having tenacious work habits, E.L. aroused the competitive enmity of her female roommates. Perennially monitoring others for their approval, E.L. correctly perceived that her roommates didn’t like her, and she tried to do everything possible to please them and to fit in.

E.L.: “Nothing I did could make them like me. All they would comment on was how skinny I looked and how little I was eating. I had no choice but to stuff myself to make them happy. By the end of my three months of college, I had gained over 25 pounds.”

When her mother saw her daughter on the Thanksgiving holiday for the first time since E.L. had left for college, she was enraged:

E.L.’s Mother: “What have you done to yourself? You’re as fat as a pig. I thought that you went to college to become a doctor, not to waste all your time stuffing your ugly mouth. What will my friends think when they see you?”

Over the ensuing 18 months, E.L. progressively lost 40 pounds. At the time of presentation, she met DSM criteria for anorexia nervosa, obsessive-compulsive disorder, and social anxiety disorder. On a medical leave of absence from college, her treatment consisted of twice-a-week psychotherapy and an SSRI antidepressant.

Although numerous issues in E.L.’s case merit emphasis—including the likely personality disorder of her mother (Yudofsky SC, 2005)—the confluence of two phenomena has been pivotal in understanding her psychopathology and directing treatment: her superior capacity “to mentalize,” a condition that I have termed “supermentalization” (Yudofsky SC, 2015) and her pervasive need to “overplease” others.

“Mentalization” refers to a person’s ability to understand the current mental state of oneself and others during interactions and relationships. A simple way of defining the term is “keeping mind in mind (Allen JG, Fonagy P, Bateman, AW, 2008, p.3).” Mentalization enables a person to be aware of the mental state of another person, while simultaneously being conscious of his or her own psychological reactions to that person’s state of mind and behaviors. People with certain psychiatric disorders have difficulty mentalizing in ways categorized as follows:

“Hypomentalization” refers to people who attend primarily to what is going on in their own minds, with little or no attention to what is going on in the minds of others with whom they interact (Crespi B, Badcock C, 2008). They tend to think and respond to others in concrete ways and have difficulty seeing things from other people’s points of view.

“Hypermentalization” is excessive, inaccurate mentalizing (Sharp C, Pane H, Venta A, et al., 2011) and occurs when a person becomes oversensitive to and overvigilant of what is going on in the minds of others. Hypermentalization involves distortions and misinterpretations of the mental states of others, which leads to feeling insecure or unsafe.

“Supermentalization” is a term that I have coined to describe people, who, at rare and exceptional levels, not only accurately keep the minds of themselves and others in mind but also the feelings of themselves and others in their minds and feelings. They have sharpened perceptions and awareness, are attentive listeners, and are careful, systematic observers. These individuals are highly cognizant of the behavioral and emotional patterns of others and notice when these patterns change. Supermentalizers carefully monitor others’ body language, speech patterns, and mental associations. When they detect changes from the normal patterns, they are excellent at figuring out what has brought about these changes. They pick up a great deal from their interactions with others, far more than most people without their special abilities. A lot of what supermentalizers perceive from unsuspecting others leaves them anxious and uncomfortable. Unless they are using their skills constructively as professionals, most supermentalizers tell me that they would be better off not knowing what they pick up from unwitting others.

Supermentalizers do not limit their special perceptive capacities to what others are thinking or feeling about them, but also sense what others are feeling and thinking in general. This applies to human suffering. Supermentalizers, therefore, tend to be empathic and compassionate. As such, they are often at the forefront of recognizing and taking action to help others, even in circumstances that endanger their own safety and well-being. Many also tend to be deeply affected emotionally by what they perceive and thus may require the support and protection of others.

Because supermentalizers are so finely attuned to the wishes and wants of others and have such refined empathic facility, many have problems with “overpleasing” others. However, people arrive at “overpleasing” others by many routes, including those who have low self-esteem and histories of trauma and/or impaired attachments. Because E.L. is a supermentalizer and was abused as a child and adolescent by her mother, she was doubly vulnerable to over-pleasing others.

Currently, E.L.’s parents are divorced, and she chose to reside with her father with limited contact with her mother. After 18 months of excused absence from college and psychodyamically oriented psychotherapy in Houston, E.L. has returned to college. Her weight has been in a safe range and stable for over a year, she is flourishing academically and continues in twice weekly psychotherapy with a local psychiatrist. She also has a boyfriend who is a graduate student at her university. Neither her father nor I have any idea about whether E.L.’s mother would approve of him. E. L. says, “I couldn’t care less what my mother thinks.” ■

References:

1) Yudofsky, SC: Fatal Flaws: Navigating Destructive Relationships With People With Disorders of Personality and Character. American Psychiatric Publishing, 2005

2) Yudofsky, SC: Fatal Pauses: Getting Unstuck Through the Power of No and the Power of Go. American Psychiatric Publishing, 2014

3) Crespi B, Badcock C: Psychosis and Autism as Diametrical Disorders of the Social Brain. Behavioral and Brain Sciences 31(3):241-320, 2008

4) Allen JG, Fonagy, P, Bateman, AW: Mentalizing in Clinical Practice. American Psychiatric Publishing, 2008

5) Sharp C, Pane H, Venta A, et al.: Theory of Mind and Emotion Regulation Difficulties in Adolescents With Borderline Traits. Journal of the American Academy of Child and Adolescent Psychiatry 50:563-573, 2011

Stuart C. Yudofsky, M.D., is the Distinguished Service Professor and Chair of the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He also holds the Drs. Beth K. and Stuart C. Yudofsky Presidential Chair in Neuropsychiatry, is chair of the Department of Psychiatry at Methodist Hospital, and editor of the Journal of Neuropsychiatry and Clinical Neurosciences. He is the author of Fatal Pauses: Getting Unstuck Through the Power of No and the Power of Go. APA members may preorder the book at discount from American Psychiatric Publishing here.

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