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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

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

slide2

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]

content
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

mentalization based therapy
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
what is mentalization
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.

schematic model of bpd
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

mbt developmental model of bpd
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
goals
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
essential features of the program
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
a summary of the evidence
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
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

mbt de viersprong
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?

study population
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

prospective naturalistic study design
Prospective naturalistic study design

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

results treatment engagement
Results: Treatment engagement

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)
results symptomatic functioning scl90 bdi eq 5d
Results Symptomatic functioning (SCL90, BDI, EQ-5D)

Effectsizes 0.75 – 1.79

Bales et al, 2009; Submitted – do not quote

results social and interpersonal functioning iip oq
Results Social and interpersonal functioning (IIP, OQ)

Effectsizes 1.17 – 1.56

Bales et al, 2009; Submitted – do not quote

slide19

Domain personality pathology

SIPP: Verheul et al, 2008

Effectsizes 1.08 – 1.58 large – very large

conclusions
Conclusions

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)

slide22
(Methodological) limitations

Working mechanisms; mentalization

Low N and missing values

Causality

mbt research
MBT Research
  • 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
slide24

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

slide25

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

8 year follow up uk
8 year follow-up UK
  • 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

zanarini rating scale for bpd mean sd
Zanarini Rating Scale for BPD : mean (SD)

8 year follow-up 2008 Bateman & Fonagy

suicide attempts mean sd
Suicide attempts : mean (SD)

8 year follow-up 2008 Bateman & Fonagy

global assessment of function
Global Assessment of Function

8 year follow-up 2008 Bateman & Fonagy

vocational status
Vocational status

8 year follow-up 2008 Bateman & Fonagy

conclusions from long term follow up
Conclusions from long term follow-up
  • 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

mbt research32
MBT Research
  • 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
slide33

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

cost effectiveness
Cost-effectiveness
  • 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
content36
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

slide37

Treatment Outcome Studies UK

Implementation of Outpatient

Mentalization Based Therapy for

Borderline Personality Disorder

Bateman & Fonagy (2009)

slide38

Design of Intensive out-patient MBT RCT

  • 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)

therapy
MBT - weekly

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?)

preliminary conclusions iop
(Preliminary) Conclusions IOP
  • 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
IOP in the Netherlands
  • Course explicit mentalizing (CEM; 8-10 sessions)
  • Two times group psychotherapy, 75 min per week
  • One individual contact per week
  • Maximum duration 18 months
slide42
RCT
  • IOP vs day hospital treatment
  • Explosive ASPD is excluded
  • Pilot randomisation
  • N=20
  • >70% cooperation
content43
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

background aim
Background & Aim

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?

study population 1
Study population (1)

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
Measurement Substance Abuse

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)
study population continued
Study population (continued)

39 eligible patients

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

24 PATIENTS with CIDI-SAM results

results prevalence substance abuse
Results: Prevalence substance abuse

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

2. Cannabis 58% (N = 14)

3. Cocaine 42% (N = 10)

slide50
Hypothesis from literature:

Prevalence liftetime substance abuse 50-70%

MBT population:

Prevalence 79%

Explorative analysis:

Association with treatment outcome?

treatment outcome results explorative longitudinal analyses
Treatment outcome resultsExplorative longitudinal analyses

Interaction

Time x Lifetime

substance abuse?

interaction time lifetime substance abuse
Interaction time * Lifetime substance abuse
  • 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!
new comparison subgroups
N = 5 no lifetime substance 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)

interaction time substance abuse start treatment
Interaction time * substance abuse start treatment
  • Pattern:
  • No significant interaction effect
  • Improvement substance abusers start treatment (n=13) resembles improvement non abusers start treatment (n=11)
interaction time substance abuse summary
Interaction Time * Substance abuse: 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
limitations
Limitations
  • Small N
  • Retrospective measurement substance abuse (recall bias)
  • Broader range of addictive problems
  • Substance abuse outcome data not yet available
conclusions57
Conclusions
  • Very high prevalence (79%) lifetime substance abuse diagnosis among MBT patients
  • Significant improvement possible for DD patients (severe BPD and substance abuse)
bpd and addiction hannah
BPD and addiction: Hannah
  • 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
BPD and addiction: Henry
  • 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’
new developments mbt dd
New Developments: MBT-DD
  • 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
content61
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

mbt for caregivers mbt c
MBT for caregivers: MBT-C
  • 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)
plan mbt c
Plan MBT-C
  • 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
content64
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

other new mbt developments
Other New MBT Developments
  • 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)
conclusions66
Conclusions
  • 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
ad