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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
WPA: International Congress – Florence, april 4, 2009
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
 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
 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?
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
Constitutional
factors
Poor affect
regulation
Activating (provoking)
risk factors
Trauma/
Stress
Early attachment
environment
Vulnerability risk
factors
Retrieval of negative
affect laden memories
and cognitions
Hyper-activation
of the attachment
system
BPD: Prementalistic
subjectivity
Inhibition of judgements of
social trustworthiness,
paranoid thoughts and
mentalizing failure
Formation risk
factors
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
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
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
 Does MBT work?
 RCT Day-hospital
(1999 UK)
 Partial Replication Study (2009 NL)
 Are the effects lasting?


18 month Follow-up
Long term follow-up
 Cost-effectiveness
(2001 UK, 2009 NL)
(2008 UK)
(2003 UK)
 Does MBT work in another dosage?


RCT IOP
Future plans
(2009 UK)
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
Bateman & Fonagy, American Journal Psychiatry 1999; 2001; 2008
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
45 patients referred
to MBT
(Aug.’04 – Apr. ’08)
Excluded:
n=2 no DSM-IV BPD
n=2 refused
n=1 early dropout
40 PATIENTS
INCLUDED
Demographic and clinical characteristics study population (N= 40)
Clinical characteristics Study population
(N=40)
Mean
Sd
31.7
7.5
N
%
Female sex
28
70%
At least one Axis-I diagnosis
38
95%
More than one Axis-I diagnosis
32
80%
Anxiety Disorders
17
43%
Mood disorders
14
35%
Eating disorders
13
33%
Substance abuse & dependency start treatment
26
66%
PTSD
5
13%
More than 1 comorbid axis II diagnosis
28
70%
Paranoïd personality disorder
9
23%
Avoidant personality disorder
9
23%
Dependant personality disorder
6
15%
Histrionic personality disorder
4
10%
Antisocial personality disorder
3
8%
Age
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=40
6 months n=31; 12 months n=19; 18 months n=16
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)
3
2.8
2.6
2.4
2.2
2
1.8
1.62
1.51
1.6
1.4
1.2
1
MBT Netherland
0.8
MBT UK
0.6
start
6 months
Depression
30
25.2
1.30*
0.87***
12 months
18 months
Mean score BDI
Mean score GSI
Symptom distress
25
23.6
20
19.3*
15
14.2***
10
5
0
start
6 months
12 months
Mean score EQ
Quality of life
1
0.9
0.8
0.7
0.51
0.6
0.5
0.4
0.3
0.2
0.1
0
start
Effectsizes 0.75 – 1.79
0.67**
0.57
6 months
0.63**
12 months
18 months
Bales et al, 2009; Submitted – do not quote
18 months
Results Social and interpersonal functioning (IIP, OQ)
Dissatisfaction in Interpersonal
Relationships
Interpersonal Problems
Mean score IIP
3.2
2.98
3
2.85**
2.8
2.68**
2.6
2.4
2.45***
2.2
2
start
6 months
12 months
26
Mean score OQ
Interpersoonlijke relaties
3.4
24
23.3
22
22.3
20
17.7***
18
16
16.5***
14
12
10
start
18 months
6 months
12 months
Dissatisfaction in social role
20
Mean score OQ
Social role
18
Effectsizes 1.17 – 1.56
16.94
16.71
16
14
11.83**
12
11.81***
10
start
6 months
12 months
18 months
Bales et al, 2009; Submitted – do not quote
18 months
Selfcontrol
Domain personality pathology
5
5.5
Identity Integration
5.05***
5
4.58***
4.5
4.16**
3.77
4
3.5
3
start
6 months
12 months
18 months
Mean score SIPP
Identiteitsintegratie
Mean score SIPP
Zelfcontrole
6
4.5
3.87*
4
3.5
4.08***
3.40*
3.11
3
2.5
start
6 months
12 months
18 months
Responsibility
4.87***
4.5
5
3.96
4
3.71
3.5
3
start
6 months
12 months
18 months
Social Condordance
7
Mean score SIPP
Sociale Concordantie
Relational Functioning
4.49***
Mean score SIPP
Relationeell Functioneren
Mean score SIPP
Verantwoordelijkheid
5
4.38***
4.5
4.19***
4
3.54
3.78*
3.5
3
start
6 months
12 months
6.5
5.93***
6
5.56***
5.5
5.00
5.32*
Effectsizes 1.08 – 1.58
large – very large
5
4.5
4
start
SIPP: Verheul et al, 2008
6 months
12 months
18 months
18 months
Results care consumption domain
n=19 (68%)
20
n=17 (81%)
N patients
16
n=13 (62%)
12
8
4
Start
n=7 (25%)
18 months
n=6 (21%)
n=0
0
Inpatient
admissions
(n=28)
Additional
treatments
(n=28)
Measurement (months)
Psychotropic
medication
(n=21)
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)
(Methodological) limitations
 Working mechanisms; mentalization
 Low N and missing values
 Causality
MBT Research
 Does MBT work?


RCT Day-hospital
Partial Replication Study
(1999 UK)
(2008 NL)
 Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2009 NL)
(2008 UK)
 Cost-effectiveness
(2003, UK)
 Does MBT work in another dosage?


RCT IOP
Future plans
(2009, UK)
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
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
 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)
MBT-PH TAU
Significance
(n = 22)
(n=15)
Positive criteria n (%)
3 (13.6)
13 (86.7)
Total mean (SD)
5.5 (5.2)
15.1 (5.3) F1,35 = 29.7 p=.000004
Affect mean (SD)
1.6 (2.0)
3.7 (2.0)
F1,35 = 9.7p=.004
Cognitive mean (SD)
1.1 (1.4)
2.5 (2.0)
F1,35 = 6.9 p=.02
Impulsivity mean (SD) 1.6 (1.8)
4.1 (2.3)
F1,35 = 13.9 p=.001
Interpersonal mean
(SD)
4.7 (2.3)
F1,35 = 23.2p=.00003
1.5 (1.7)
8 year follow-up 2008 Bateman & Fonagy
χ2 = 16.5 p=.000004
Suicide attempts : mean (SD)
MBT-PH TAU
Significance
Total N
mean (SD)
.05 (0.9)
0.52 (.48) U = 73
Z= 3.9
p = .00004
Any attempt N
(%)
5 (23)
14 (74)
8 year follow-up 2008 Bateman & Fonagy
χ2 = 8.7
df- =1
P =.003
Global Assessment of Function
MBT-PH TAU
Mean (SD)
58.3 (10.5)
Number (%) > 10 (45.5)
60
Significance
51.8 (5.7) F1,35 = 5.4 p=.03
2 (10.5)
8 year follow-up 2008 Bateman & Fonagy
χ2 = 6.5
df = 1
p = .02
Vocational status
MBT-PH
TAU
Percent in Employment
80
70
60
50
40
30
20
10
0
Baseline
MidTreatment
End
Treatment
3 year FU
8 year follow-up 2008 Bateman & Fonagy
5 year FU
8 year FU
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 Research
 Does MBT work?


RCT Day-hospital
Partial Replication Study
(1999 UK)
(2008 NL)
 Are the effects lasting?


18 month Follow-up
Long term follow-up
 Wat does it cost?
(2001 UK, 2009 NL)
(2008 UK)
(2003, UK)
 Does MBT work in another dosage?


RCT IOP
Future plans
(2009, UK)
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
Total Annual Health Care Utilization Costs
MBT
60.000
TAU
15.490
3.183
10.000
30.976
20.000
27.303
30.000
52.563
40.000
44.967
50.000
0
6 months
before
treatment
18 months of
treatment
18 months
follow-up
period
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
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
Treatment Outcome Studies UK
Implementation of Outpatient
Mentalization Based Therapy for
Borderline Personality Disorder
Bateman & Fonagy (2009)
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
IOP vs. SCM Bateman & Fonagy (2008?)
SCM - weekly
 Support and structure
 Challenge
 Advocacy
 Social support work
 Problem solving
 Medication review
 Crisis management
(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
 Course explicit mentalizing (CEM; 8-10 sessions)
 Two times group psychotherapy, 75 min per week
 One individual contact per week
 Maximum duration 18 months
RCT
IOP vs day hospital treatment
Explosive ASPD is excluded
Pilot randomisation
N=20
>70% cooperation
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
Substance abuse among
MBT patients:
Prevalence and relation to
treatment outcome
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)
45 patients referred
to MBT
(Aug.’04 – Apr. ’08)
Excluded:
n=2 no DSM-IV BPD
n=2 refused
n=1 early dropout
n=1 no follow-up
measurements
39 PATIENTS
INCLUDED
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)
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
CIDI-SAM
Abuse /
dependence
Total
population
79.2%
(N = 19)
(N = 24)
Specific prevalences:
No substance
Diagnosis
21%
1
diagnosis
13%
2
diagnoses
21%
3-5
diagnoses
29%
6-7
diagnoses
17%
1. Alcohol 67% (N = 16)
2. Cannabis 58% (N = 14)
3. Cocaine 42% (N = 10)
(N = 5)
(N = 3)
(N = 5)
(N = 7)
(N = 4)
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
Depression
30
Mean score BDI
25.2
23.6
25
20
19.3*
15
14.2***
10
5
0
start
6 months
12 months
18 months
Depression (BDI)
30
27,3
25,0
25
22,9
Score
20
19,1
17,3
14,9
15
16,9
substance
abuse (n=19)
10
5,8
5
0
0
6
12
Measurement (months)
no substance
abuse (n=5)
18
Interaction
Time x Lifetime
substance abuse?
Interaction time * Lifetime substance abuse
Depression (BDI)
30
27,3
25,0
25
22,9
Score
20
19,1
17,3
14,9
15
16,9
no substance
abuse (n=5)
substance
abuse (n=19)
10
5,8
5
0
0
6
12
18
Measurement (months)
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 start
treatment?
 Yes: N = 13
 No: N = 6
Diagnosis start treatment
Yes: N = 13
No: N = 11 (n = 5 + n = 6)
Interaction time * substance abuse start treatment
Score
Problems interpersonal relations (OQ)
30
25
20
15
10
5
0
no (n=11)
yes (n=13)
0
Pattern:
6
12
18
Measurement (months)
- No significant interaction effect
- Improvement substance abusers start treatment (n=13)
resembles improvement non abusers start treatment (n=11)
Interaction Time * Substance abuse:
Summary
Lifetime substance abuse:
 N = 19 yes, N = 5 no
 Tendency towards stronger improvement for
small group without lifetime substance abuse
Substance abuse start treatment:
 N = 13 yes, N = 11 no
 No difference improvement over time
Limitations
Small N
Retrospective measurement substance
abuse (recall bias)
Broader range of addictive problems
Substance abuse outcome data not yet
available
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
 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
 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
 MBT-PH and IOP: parallel low-frequent outpatient contact in addiction-center
 Plan: integrated MBT- DD treatment
 Program:
 inpatient detox
 day-hospital (PH)
 outpatient treatment
 Including system-oriented interventions
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
 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
 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: homevisitations 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
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
 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)
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
www.vispd.nl/presentations
[email protected]
[email protected]
[email protected]

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