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

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

Erasmus University Rotterdam – Sten Willemsen, Jan van BusschachTilburg University – Marieke Spreeuwenberg

&

MBT Staff(De Viersprong, Bergen op Zoom, The Netherlands)

Internet:

www.vispd.nl / presentations

Email [email protected]

http://www.vispd.nl/

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

Hyper-activation of the attachment

system

Trauma/Stress

Early attachmentenvironment

Retrieval of negativeaffect laden memories

and cognitions

Inhibition of judgements of social trustworthiness, paranoid thoughts and

mentalizing failure

BPD: Pre-mentalistic subjectivity

Vulnerability risk factors

Activating (provoking) risk factors

Formation risk factors

Poor affectregulation

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 treatmentTo reduce general psychiatric symptoms,

particularly depression and anxietyTo decrease the number of self-destructive

acts and suicide attemptsTo improve social and interpersonal functionTo prevent reliance on prolonged

hospital stays

Essential features of the programHighly structuredConsistent and reliable IntensiveTheoretically coherent: all aspects aimed at

enhancing mentalizing capacityFlexibleRelationship focusOutreachingIndividualized treatment planIndividualized 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 (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

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

• 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 BPDn=2 refusedn=1 early dropout

40 PATIENTS

INCLUDED

Demographic and clinical characteristics study population (N= 40)

Clinical characteristics Study population (N=40) Mean Sd

Age 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%

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

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)

Effectsizes 0.75 – 1.79

Bales et al, 2009; Submitted – do not quote

Results Social and interpersonal functioning (IIP, OQ)

Effectsizes 1.17 – 1.56

Bales et al, 2009; Submitted – do not quote

Effectsizes 1.08 – 1.58 large – very large

SIPP: Verheul et al, 2008

Domain personality pathology

Results care consumption domain

n=17 (81%)n=19 (68%)

n=7 (25%)

n=13 (62%)

n=6 (21%)

n=0

0

4

8

12

16

20

Inpatientadmissions

(n=28)

Additionaltreatments

(n=28)

Psychotropicmedication

(n=21)

Measurement (months)

N p

ati

en

ts

Start

18 months

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



Cost-effectiveness (2003, UK)

Does MBT work in another dosage? RCT IOP (2009, UK) Future plans

Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial hospitalization:

An 18 month Follow-upBateman & 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 (n = 22)

TAU (n=15)

Significance

Positive criteria n (%) 3 (13.6) 13 (86.7) χ2 = 16.5 p=.000004

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)

1.5 (1.7) 4.7 (2.3) F1,35 = 23.2p=.00003


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) χ2 = 8.7

df- =1

P =.003


Global Assessment of Function

MBT-PH TAU Significance

Mean (SD) 58.3 (10.5) 51.8 (5.7)

F1,35 = 5.4 p=.03

Number (%) > 60

10 (45.5) 2 (10.5) χ2 = 6.5

df = 1

p = .02


Vocational status


0

10

20

30

40

50

60

70

80

Baseline Mid-Treatment

EndTreatment

3 year FU 5 year FU 8 year FU

Pe

rce

nt

in E

mp

loy

me

nt

MBT-PH TAU

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


MBT Research



Wat does it cost? (2003, UK)

Does MBT work in another dosage? RCT IOP (2009, UK) Future plans

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

44

.96

7

52

.56

3

27

.30

3

30

.97

6

3.1

83 1

5.4

90

0

10.000

20.000

30.000

40.000

50.000

60.000

6 monthsbefore

treatment

18 months oftreatment

18 monthsfollow-up

period

MBT

TAU

Total Annual Health Care Utilization Costs

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




Treatment Outcome Studies UK

Implementation of Outpatient

Mentalization Based Therapy for

Borderline Personality Disorder

Bateman & Fonagy (2009)

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

Design of Intensive out-patient MBT RCT

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

IOP vs. SCM Bateman & Fonagy (2008?)

(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 treatmentExplosive ASPD is excludedPilot randomisationN=20>70% cooperation

Content




Substance abuse among Substance abuse among MBT patients:MBT patients:

Prevalence and relation to treatment outcome

Background & AimLiterature: 57%-67% BPD patients addiction problems -> MBT? Combination BPD & addiction -> treatment prognosis

worse

Study objective:Study objective:What is the prevalence of DSM-IV substanceabuse 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 BPDn=2 refusedn=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

CIDI-SAM

Abuse / dependence

Total population(N = 24)

79.2%(N = 19)

Results: Prevalence substance abusePrevalence substance abuse

No substance

Diagnosis

21%(N = 5)

1

diagnosis

13%(N = 3)

2

diagnoses

21% (N = 5)

3-5

diagnoses

29% (N = 7)

6-7

diagnoses

17%(N = 4)

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

2. Cannabis 58% (N = 14)

3. Cocaine 42% (N = 10)

Hypothesis from literature: Prevalence liftetime substance abuse 50-70%

MBT population:MBT population:Prevalence 79%Prevalence 79%

Explorative analysis:Association with treatment outcome?

Treatment outcome resultsExplorative longitudinal analyses

Depression (BDI)

27,3

19,1

14,9

5,8

25,022,9

17,3 16,9

0

5

10

15

20

25

30

0 6 12 18


Sco

re

no substanceabuse (n=5)

substanceabuse (n=19)

Interaction Time x Lifetimesubstance abuse?

Interaction time * Lifetime substance abuse

Pattern for 50% of the outcome measurements: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!However, only n=5 no lifetime substance abuse!

Depression (BDI)

27,3

19,1

14,9

5,8

25,022,9

17,3 16,9

0

5

10

15

20

25

30

0 6 12 18


Sco

re

no substanceabuse (n=5)

substanceabuse (n=19)

New comparison subgroups N = 5 no lifetime

substance abuse N = 19 lifetime

substance abuse

Diagnosis starttreatment?

Yes: N = 13 No: N = 6

Diagnosis start treatmentDiagnosis start treatmentYes: N = 13

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

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)

Problems interpersonal relations (OQ)

0

5

1015

20

25

30

0 6 12 18


Scor

e no (n=11)

yes (n=13)

Interaction Time * Substance abuse:Interaction Time * Substance abuse: Summary

Lifetime substance abuse:N = 19 yes, N = 5 noTendency towards stronger improvement for

small group without lifetime substance abuse

Substance abuse start treatment:N = 13 yes, N = 11 no No difference improvement over timeNo 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: Hannah22 years old femaleAxis 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: Henry46 years oldAxis I: polysubstance dependence (cocaine

and alcohol); sexual dysfunction; depressionAxis II: borderline personality disorder;

narcissistic personality disorder, avoidant personality disorder

Fired from work because of drug dependence Divorced, two childrenDetoxification before start MBTAble to follow a day program without drugsSome social structure (volunteer, children

visits, etc)No users as friends, not in ‘drugscene’

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

Content




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: 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

Content




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]

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mentalization-based therapy: a summary of the evidence and new developments

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