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Mentalization-based Therapy: A summary of the evidence and new developments. Dawn Bales, Helene Andrea, Ab Hesselink Psychotherapeutic Center de Viersprong, Viersprong Institute for Studies on Personality Disorders (VISPD) The Netherlands

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Mentalization based therapy a summary of the evidence and new developments l.jpg

Mentalization-based Therapy: A summary of the evidence and new developments

Dawn Bales, Helene Andrea, Ab Hesselink Psychotherapeutic Center de Viersprong, Viersprong Institute for Studies on Personality Disorders (VISPD)

The Netherlands

WPA: International Congress – Florence, april 4, 2009


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Research team

De Viersprong – Roel Verheul, Maaike Smits, Fieke vd Meer, Nicole v Beek

Erasmus University Rotterdam – Sten Willemsen, Jan van Busschach

Tilburg University – Marieke Spreeuwenberg

&

MBT Staff

(De Viersprong, Bergen op Zoom, The Netherlands)

Internet:

www.vispd.nl / presentations

Email [email protected]


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Content

Mentalization-Based Treatment (MBT)

A summary of the evidence

Does MBT work?

Are the effects lasting?

Wat does it cost?

New Developments and future plans

Does MBT work in another dosage?

Does MBT work for addiction problems?

MBT for caregivers

Other new developments


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Mentalization-based Therapy

  • Psychoanalytically oriented; based on attachment theory

  • Developed in the UK by Bateman & Fonagy

  • Evidence-based treatment for patients with severe BPD

  • Maximum duration of 18 months

  • Focus: increasing patient’s capacity to mentalize


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What is mentalization?

Making sense of the actions of oneself and others

on the basis of intentional mental states, such as

desires, feelings, and beliefs.

It involves the recognition that what is in the

mind is in the mind and reflects knowledge

of one’s own and others’ mental states

as mental states.


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Schematic Model of BPD

Retrieval of negative

affect laden memories

and cognitions

Constitutional

factors

Activating (provoking)

risk factors

Hyper-activation

of the attachment

system

BPD: Pre-mentalistic subjectivity

Trauma/

Stress

Poor affect

regulation

Inhibition of judgements of

social trustworthiness,

paranoid thoughts and

mentalizing failure

Early attachment

environment

Formation risk

factors

Vulnerability risk

factors


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MBT developmental model of BPD

  • Constitutionally vulnerable

  • Insecure attachment

  • Inhibited capacity to mentalize

  • Symptoms and interpersonal problems

  • Focus MBT: enhancing mentalization within the context of attachment relationship


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Goals

  • To engage the patient in treatment

  • To reduce general psychiatric symptoms, particularly depression and anxiety

  • To decrease the number of self-destructive acts and suicide attempts

  • To improve social and interpersonal function

  • To prevent reliance on prolonged hospital stays


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Essential features of the program

  • Highly structured

  • Consistent and reliable

  • Intensive

  • Theoretically coherent: all aspects aimed at enhancing mentalizing capacity

  • Flexible

  • Relationship focus

  • Outreaching

  • Individualized treatment plan

  • Individualized follow-up


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A summary of the evidence

  • Does MBT work?

    • RCT Day-hospital (1999 UK)

    • Partial Replication Study (2009 NL)

  • Are the effects lasting?

    • 18 month Follow-up (2001 UK, 2009 NL)

    • Long term follow-up (2008 UK)

  • Cost-effectiveness (2003 UK)

  • Does MBT work in another dosage?

    • RCT IOP (2009 UK)

    • Future plans


Introduction mbt effectiveness united kingdom l.jpg

RCT:Day hospital MBT versus TAU for BPD patients

Results

MBT patients showed significant improvement in all outcome measures (Depressive symptoms, suicidal and self-mutilatory acts, reduced inpatient days, better social and interpersonal function)

TAU patients showed limited change or deterioration over the same period

Conclusion

MBT superior to standard psychiatric care

IntroductionMBT-effectiveness United Kingdom

Bateman & Fonagy, American Journal Psychiatry 1999; 2001; 2008


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MBT De Viersprong

  • First MBT setting outside UK

  • Naturalistic setting (instead of RCT)

    Research question:

    What is the treatment outcome

    for severe BPD patients

    after 18 months of day hospital Mentalization Based Treatment

    in the Netherlands?


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Study population

45 patients referred

to MBT(Aug.’04 – Apr. ’08)

Excluded:n=2 no DSM-IV BPDn=2 refusedn=1 early dropout

40 PATIENTS

INCLUDED



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Prospective naturalistic study design (N= 40)

Measurements: start treatment, 6, 12, and 18 months

Continuous outcomes: GEE (SPSS)- correction for missing values- age and sexe as covariates- effect sizes corrected for data dependency

Categorical outcomes: univariate statistics

Baseline n=406 months n=31; 12 months n=19; 18 months n=16


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Results: Treatment engagement (N= 40)

Low dropout rate (n=5; 12.5%)

  • n=3 dropouts

  • n=2 push-outs

  • Average treatment length: 15.1 months(sd 4.2 months; range 4-18 months)


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Results Symptomatic functioning (SCL90, BDI, EQ-5D) (N= 40)

Effectsizes 0.75 – 1.79

Bales et al, 2009; Submitted – do not quote


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Results Social and interpersonal functioning (IIP, OQ) (N= 40)

Effectsizes 1.17 – 1.56

Bales et al, 2009; Submitted – do not quote


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Domain personality pathology (N= 40)

SIPP: Verheul et al, 2008

Effectsizes 1.08 – 1.58 large – very large



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Conclusions (N= 40)

Significant improvement on all outcome measures with effect sizes ranging from large to very large

Low drop-out rate despite limited exclusion criteria

Results similar to results of Bateman & Fonagy (1999)


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(Methodological) limitations (N= 40)

Working mechanisms; mentalization

Low N and missing values

Causality


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MBT Research (N= 40)

  • Does MBT work?

    • RCT Day-hospital (1999 UK)

    • Partial Replication Study (2008 NL)

  • Are the effects lasting?

    • 18 month Follow-up (2001 UK, 2009 NL)

    • Long term follow-up (2008 UK)

  • Cost-effectiveness (2003, UK)

  • Does MBT work in another dosage?

    • RCT IOP (2009, UK)

    • Future plans


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Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial hospitalization: An 18 month Follow-up

Bateman & Fonagy, American Journal of Psychiatry (2001)

Summary follow-up trial:

MBT patients maintained and even showed additional improvement of symptomatic and clinical gains during 18 months follow-up


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8-Year follow-up of Patients treated for Borderline Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

Bateman & Fonagy 2008

American Journal of Psychiatry


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8 year follow-up UK Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

  • Study: the effect of MBT-PH vs. TAU

    • N=41 patients from original trial

    • 8 years after entry in to RCT, 5 years after all MBT treatment was complete

  • Method:

    • interviews (research psychologists blind to original group allocation)

    • structured review medical notes

8 year follow-up 2008 Bateman & Fonagy


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Zanarini Rating Scale for BPD Personality Disorder: Mentalization-Based Treatment versus Treatment as usual : mean (SD)

8 year follow-up 2008 Bateman & Fonagy


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Suicide attempts : mean (SD) Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

8 year follow-up 2008 Bateman & Fonagy


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Global Assessment of Function Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

8 year follow-up 2008 Bateman & Fonagy


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Vocational status Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

8 year follow-up 2008 Bateman & Fonagy


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Conclusions from long term follow-up Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

  • MBT-PH group continued to do well 5 years after all MBT treatment had ceased

  • TAU did badly within services despite significant input

  • TAU is not necessarily ineffective in its components but package or organization is not facilitating possible natural recovery

  • BUT

    • Small sample, allegiance effects (despite attempts being made to blind the data collection) limit the conclusions.

    • GAF scores continue to indicate deficits. Suggests less focus during treatment on symptomatic problems greater concentration on improving general social adaptation

8 year follow-up 2008 Bateman & Fonagy


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MBT Research Personality Disorder: Mentalization-Based Treatment versus Treatment as usual

  • Does MBT work?

    • RCT Day-hospital (1999 UK)

    • Partial Replication Study (2008 NL)

  • Are the effects lasting?

    • 18 month Follow-up (2001 UK, 2009 NL)

    • Long term follow-up (2008 UK)

  • Wat does it cost? (2003, UK)

  • Does MBT work in another dosage?

    • RCT IOP (2009, UK)

    • Future plans


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Health Service Utilization Costs for Borderline personality Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Bateman & Fonagy (2003)

American Journal of Psychiatry


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Total Annual Health Care Utilization Costs Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care


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Cost-effectiveness Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Significantly lower cost during treatment compared to 6-month pretreatment costs for both MBT and General Care Group

  • During FU period: annual cost of MBT 1/5 of anual General Care costs


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Content Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Mentalization-Based Treatment (MBT)

A summary of the evidence

Does MBT work?

Are the effects lasting?

Wat does it cost?

New Developments and future plans

Does MBT work in another dosage?

Does MBT work for addiction problems?

MBT for caregivers

Other new developments


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Treatment Outcome Studies UK Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Implementation of Outpatient

Mentalization Based Therapy for

Borderline Personality Disorder

Bateman & Fonagy (2009)


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Design of Intensive out-patient MBT RCT Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Referrals for IOP-MBT and SCM groups

  • Random allocation (minimisation for age, gender, antisocial PD)

  • Individual (50 mins) + Group (1.5 hrs) weekly for 18 months

  • Assessments at admission, 6 months, 12 months, 18 months

  • Medication followed protocol

IOP vs. SCM Bateman & Fonagy (2009)


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MBT - weekly Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Support and structure

Challenge

Basic mentalizing

Interpretive mentalizing

Mentalizing the transference

Medication review

Crisis management

SCM - weekly

Support and structure

Challenge

Advocacy

Social support work

Problem solving

Medication review

Crisis management

Therapy

IOP vs. SCM Bateman & Fonagy (2008?)


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(Preliminary) Conclusions IOP Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • MBT-IOP is surprisingly effective

  • The sample was less disturbed than the partial hospital sample

  • Most of the MBT subjects but also some of the SCM subjects lost their diagnosis

  • Relatively few of the SCM patients improved in terms of subjective measures

  • The MBT patients more reliably improved

  • Even when improved, remains quite high scoring on pathology scales

IOP vs. SCM Bateman & Fonagy (2009)


Iop in the netherlands l.jpg
IOP in the Netherlands Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Course explicit mentalizing (CEM; 8-10 sessions)

  • Two times group psychotherapy, 75 min per week

  • One individual contact per week

  • Maximum duration 18 months


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RCT Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • IOP vs day hospital treatment

  • Explosive ASPD is excluded

  • Pilot randomisation

  • N=20

  • >70% cooperation


Content43 l.jpg
Content Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Mentalization-Based Treatment (MBT)

A summary of the evidence

Does MBT work?

Are the effects lasting?

Wat does it cost?

New Developments and future plans

Does MBT work in another dosage?

Does MBT work for addiction problems?

MBT for caregivers

Other new developments


Substance abuse among mbt patients prevalence and relation to treatment outcome l.jpg

Substance abuse among Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric CareMBT patients:Prevalence and relation to treatment outcome


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Background & Aim Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Literature:

  • 57%-67% BPD patients addiction problems -> MBT?

  • Combination BPD & addiction -> treatment prognosis worse

    Study objective:

    What is the prevalence of DSM-IV substance

    abuse among MBT-patients?

    Additional explorative analysis:

    Is substance abuse related to MBT treatment outcome?


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Study population (1) Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

45 patients referred

to MBT(Aug.’04 – Apr. ’08)

Excluded:n=2 no DSM-IV BPDn=2 refusedn=1 early dropout

n=1 no follow-up measurements

39 PATIENTS

INCLUDED


Measurement substance abuse l.jpg
Measurement Substance Abuse Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Composite International Diagnostic Interview (CIDI)

Lifetime auto-version 2.1

Substance Abuse Module (CIDI-SAM):

  • Alcohol dependence or abuse (section J)

  • Drugs / medication / other substance abuse or dependence (section L)


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Study population Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care(continued)

39 eligible patients

No CIDI available:n=6 refused n=9 untraceable (not in treatment anymore)

24 PATIENTS with CIDI-SAM results


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Results: Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric CarePrevalence substance abuse

Specific prevalences: 1. Alcohol 67% (N = 16)

2. Cannabis 58% (N = 14)

3. Cocaine 42% (N = 10)


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Hypothesis from literature: Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Prevalence liftetime substance abuse 50-70%

MBT population:

Prevalence 79%

Explorative analysis:

Association with treatment outcome?


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Treatment outcome results Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric CareExplorative longitudinal analyses

Interaction

Time x Lifetime

substance abuse?


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Interaction time * Lifetime substance abuse Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Pattern for 50% of the outcome measurements:

  • Improvement for substance abusers and non-abusers

  • Stronger improvement for no lifetime substance abuse

  • However, only n=5 no lifetime substance abuse!


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N = 5 no lifetime Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Caresubstance abuse

N = 19 lifetime substance abuse

Diagnosis starttreatment?

Yes: N = 13

No: N = 6

New comparison subgroups

Diagnosis start treatmentYes: N = 13

No: N = 11 (n = 5 + n = 6)


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Interaction time * substance abuse Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Carestart treatment

  • Pattern:

  • No significant interaction effect

  • Improvement substance abusers start treatment (n=13) resembles improvement non abusers start treatment (n=11)


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Interaction Time * Substance abuse: Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care Summary

Lifetime substance abuse:

  • N = 19 yes, N = 5 no

  • Tendency towards stronger improvement forsmall group without lifetime substance abuse

    Substance abuse start treatment:

  • N = 13 yes, N = 11 no

  • No difference improvement over time


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Limitations Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Small N

  • Retrospective measurement substance abuse (recall bias)

  • Broader range of addictive problems

  • Substance abuse outcome data not yet available


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Conclusions Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Very high prevalence (79%) lifetime substance abuse diagnosis among MBT patients

  • Significant improvement possible for DD patients (severe BPD and substance abuse)


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BPD and addiction: Hannah Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • 22 years old female

  • Axis I: polysubstance dependence (cannabis, cocaïne, XTC, speed); ADHD; post-traumatic stress disorder; sexual dysfunction

  • Axis II: borderline personality disorder; histrionic personality disorder, paranoid features

  • Low-level borderline/psychotic personality organisation (Kernberg)

  • Unable to follow a whole day-program without drugs

  • Completely integrated in ‘drugscene’


Bpd and addiction henry l.jpg
BPD and addiction: Henry Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • 46 years old

  • Axis I: polysubstance dependence (cocaine and alcohol); sexual dysfunction; depression

  • Axis II: borderline personality disorder; narcissistic personality disorder, avoidant personality disorder

  • Fired from work because of drug dependence

  • Divorced, two children

  • Detoxification before start MBT

  • Able to follow a day program without drugs

  • Some social structure (volunteer, children visits, etc)

  • No users as friends, not in ‘drugscene’


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New Developments: MBT-DD Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • MBT-PH and IOP: parallel low-frequent out-patient contact in addiction-center

  • Plan: integrated MBT- DD treatment

  • Program:

    • inpatient detox

    • day-hospital (PH)

    • outpatient treatment

  • Including system-oriented interventions


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Content Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Mentalization-Based Treatment (MBT)

A summary of the evidence

Does MBT work?

Are the effects lasting?

Wat does it cost?

New Developments and future plans

Does MBT work in another dosage?

Does MBT work for addiction problems?

MBT for caregivers

Other new developments


Mbt for caregivers mbt c l.jpg
MBT for caregivers: MBT-C Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • A mentalizing parental program for high-risk parents and their children

  • Goal: promoting reflective parenting by enhancing the caregiver’s mentalizing with respect to him/herself and the child

  • Population: caregivers with severe BPD and their children up to seven years

  • The interventions on caregiver-child interactions are based on principles from Minding the baby (Slade)


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Plan MBT-C Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Program:

    • Course explicit mentalizing (8-10 sessions)

    • Course explicit mentalizing for caregivers (6-8 sessions)

    • IOP MBT (1 gpt and 1 individual session)

    • Interventions on caregiver-child interaction: home-visitations and routine videotaping of mother-child interactions

  • Research:

    • MBT-C versus TAU

    • Hypothesis: enhancing the caregiver’s mentalizing capacity results in less psychopathology in the children


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Content Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

Mentalization-Based Treatment (MBT)

A summary of the evidence

Does MBT work?

Are the effects lasting?

Wat does it cost?

New Developments and future plans

Does MBT work in another dosage?

Does MBT work for addiction problems?

MBT for caregivers

Other new developments


Other new mbt developments l.jpg
Other New MBT Developments Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • Adolescents (MBT-a, Viersprong, NL)

  • Antisocial and BPD (Bateman, 2008; Viersprong, NL)

  • Families (MBFT), (Viersprong, NL)

  • Severe eating disorders (GGZ-MB, NL)

  • Severe psychosomatic disorders (Eikenboom, NL)

  • Children/parents (MBKT, NPi, NL)


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Conclusions Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

  • A summary of the evidence

    • MBT does work for severe borderline patients

    • The effects are lasting

    • MBT shows considerable cost savings after treatment

    • MBT-IOP also seems effective

    • MBT is also promising for addiction

  • Internationally many new developments


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www.vispd.nl/presentations Disorder Patients Treated with Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care

[email protected]

[email protected]

[email protected]


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