Adolescent Mentalization Based Therapy - Royal … Mentalization Based Therapy Dr Louise Duffy,...

Adolescent Mentalization

Based Therapy

Dr Louise Duffy, Consultant Clinical Psychologist

Dr Helen Griffiths, Consultant Clinical Psychologist

NHS Lothian CAMHS / University of Edinburgh

RCP in Scotland Child and Adolescent Faculty Conference.

Nov 2016

With thanks to Anna Freud Centre and UCL for use of some of their

material/slides

What we’ll cover • What mentalization is

• Markers of mentalizing

• Theory of development of mentalizing

• Mentalizing and the adolescent brain

• Application of mentalization

– As a therapy: MBT, MBT-A

• Evidence

• In Lothian CAMHS

– As a general approach:

• Mentalizing stance

• Video clips

• Exercise – using a mentalizing approach to role-play a

discussion with a young person you are finding particularly

challenging.

• Forewarning:

There is nothing new in Mentalizing

What is mentalization?

• A form of imaginative mental activity about

others or oneself

• Perceiving and interpreting behaviour – our own

and others’ – in terms of intentional mental

states (e.g. feelings, beliefs, desires, fears,

hopes)

• When you think about what you are feeling or

wonder what someone else might be thinking or

feeling you are mentalizing. Allen 2005

What is mentalization?

• A ‘bedrock neurodevelopmental capacity’ that is:

• Located primarily in the prefrontal cortex

• Fostered (or rekindled) in the experience of relationship with a

– trusted other, in which one has an iterative experience of

– being accurately mentalized (I find my mind in your mind.)

• Easily overwhelmed by powerful stress/arousal/attachment

What is mentalization?

• When you think about what you are feeling or wonder what

someone else might be thinking or feeling you are mentalizing.

• Having mind in mind

• Seeing ourselves from the outside and others from the inside

• Understanding misunderstanding

• Those psychological skills that allow us to spontaneously and

largely in an intuitive manner make sense of the actions of

oneself and others by reference to mental states such as

beliefs, desires and feelings. Peter Fonagy (2004)

What is mentalization?

• Mentalizing shapes our understanding of self and others.

• Good relationships are based on an ability to understand each other, and ourselves, fairly well. Problems with mentalizing can create difficulties in relationships as people will become unhappy if you’re not aware of their needs and feelings or you misinterpret why they are behaving in certain ways.

The MBT Approach

• The MBT approach is based on a view that a core

problem for many patients, especially those with BPD, is

their vulnerability to a loss of mentalizing.

• This vulnerability becomes associated with interpersonal

sensitivity which triggers dysregulated emotions and

impulsivity

• Mentalization based treatment hopes to address this

vulnerability and in this therapy the aim is on improving

the young person (and families’) mentalizing ability

• The therapy is relational focussed and the therapist is

seen as an active participant and a contributor to

emotional impact on the patient.

Mentalizing as an

Integrative framework

Cognitive Behaviourism: The value of understanding the relationship between my thoughts and feelings

and my behaviour.

Systems Theory: The value of understanding the relationship between

the thoughts and feelings of family members and their behaviours, and the

impact of these on each other.

Psychodynamic: The value of understanding the nature of resistance

to therapy, and the dynamics here-and-now in the therapeutic

relationship.

BIOLOGICAL, SOCIAL and ECOLOGICAL: The value of understanding the impact of context upon mental states: development, deprivation, opportunity, hunger, fear...

COMMON LANGUAGE

MIND BRAIN

When emotion is high....

....mentalizing is in danger

Curiosity I know that I don’t

KNOW what you

must think, boss,

but I can wonder

what that is…

How must it feel

to be you right

now, boss?

Why do I keep

getting into

trouble over my

rabbit habit…?

Is there something

about me and

rabbits that stems

from my childhood, I

wonder…?

Awareness of the impact on others:

Too vigorous,

and

Stuff’ll get spilt

The Opacity of other minds

Perspective-taking

Capacity to Trust

Narrative Continuity

START

X

X

X

How does the capacity for mentalization develop? The caregiver’s emotionally attuned responses to the infant’s states becomes a source of information to the infant about his internal states Theory of Self Development Thinking arises in the context of the relationship with another. The caregiver thinks of the infant as agentive and through this the agentive sense of self is acquired Safe, playful interaction with the caregiver leads to the integration of primitive models of experiencing internal reality (Fonagy & Bateman)

The development of mentalizing

Learning About My Mind, Your

Mind (My mother thinks) I think, therefore I am

Mirroring

Contingent

Marked

Mind in mind

Sam-I-am

Mirroring sadness

Unmarked mirroring Marked mirroring

But the mothers capacity to make sense of the baby’s state is

highly influenced by…….

How she feels about

herself as a mother

How supported she is in

her relationships

How her mother felt

about her as an

infant

What happens when it goes wrong?

• When the parent misperceives the baby’s inner state, the

mirroring would not accurately reflect the baby’s feelings

e.g. when the parent is frightened by a baby’s distress,

what the baby would see and experience is the fear in

the parent, and hence the experience that they would

take into themselves is the experience of: Inner distress

which frightens the other and hence lead to an inner

experience of ‘I am frightening’

Adolescent neurodevelopment

• Brain continues to develop throughout

adolescence into early 20s

• Prefrontal cortex – dramatic changes in

adolescence

• Decline in volume of grey matter

corresponding to synaptic pruning

• ……mentalizing located primarily in

prefrontal cortex

Developmentally, Adolescents are particularly prone to stress-arousal, and low mentalizing

A Developmental trajectory, with high frequency fluctuations:

Mentalization is fragile “Programmed for overwhelm”

Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J. (2015).

Therapeutic Interventions for Suicide Attempts and Self-Harm in

Adolescents: Systematic Review and Meta-Analysis. Journal of the

American Academy of Child & Adolescent Psychiatry., 54(2), 97-107.e2.

MBT outcomes

• Bateman & Fonagy (1999, 2001, 2003): MBT

superior than TAU including at follow-up – MBT: 18-month period with weekly individual and group

sessions, crisis planning and integrated psychiatric care

– Suicidality, diagnostic status, medication, global functioning,

vocational status

• Roussow & Fonagy (2012): MBT superior than

TAU for adolescents who self-harm – MBT: 12 month period with weekly individual MBT-A sessions

and monthly mentalization-based family therapy (MBT-F)

– Self harm behaviour, depression, borderline traits, attachment avoidance, mentalization

Clinical trials register (adolescents)

• Mentalization-Based Therapy to Prevent Suicidal

Behavior in Adolescents With Bipolar Disorder

(Miklowitz, LA)

– Individual and family therapy

• MBT in Groups for Adolescents With BPD or

Subthreshold BPD Versus TAU - the M-GAB

Randomized Controlled Trial (M-GAB) (Emma

Beck, Denmark)

– Case formulation, MBT-I, MBT-G, MBT-P

• Group-based Mentalization Therapy for

Adolescents (NHS Lothian)

– Up to 24 sessions group-based MBT

MBT in Lothian CAMHS

• Different training route – pre MBT-A

• Focus on group therapy

• Tier IV – AMBIT trained

• Early intervention

• Adapted manual, originally developed for adults with

BPD, for adolescents presenting with self harm,

experience of emotional distress and relational

difficulties (i.e at risk of developing BPD)

MBT Skills Training

Small grants to support supervision and further

training:

MBT-AI group

manual: Duffy,

Duffy, Griffiths,

Happer

Initial clinical evaluation • 3 groups: 29 female adolescents, mean age

15.6 years (SD= 1.5)

• Median no sessions attended = 7

• Acceptable to young people

• Pre-post change on a number of variables

showing small-to-medium effect sizes e.g.

reflective function, crisis presentations, emotion

regulation strategies

• RF accounted for variance in outcomes for self-

harm, emotional distress, interpersonal

problems, internal dysfunctional emotion reg

strategies

Lothian MBT RCT

Pilot RCT comparing MBT-A to TAU to determine:

– Effectiveness of recruitment strategies

– Compliance with protocol/procedures

– Trends towards reduced self harm

– Result will inform a future definitive RCT and give an

indication for the potential for wider service

implementation.

Mentalizing ourselves in our work

• We get stressed / upset / anxious / angry

ourselves

• ……..and lose the capacity to mentalize

• ……and when that happens it significantly

affects others’ capacity to mentalize

• This can happen when we are with patients

Fuggle, P., Bevington D., Duffy,

F., Cracknell, L (2016): The

AMBIT approach: working with

hard to reach youth

Griffiths, H., Noble, A., Duffy,

F., Schwannauer, M (2016):

Outcome and service

utilisation in an AMBIT-

Trained Tier IV CAMH

service

Mentalizing

stance

Inquisitive

Terminating

Non-mentalizing

Holding the balance(s)

Highlighting

mentalizing

Video clip

• https://youtu.be/vhPOC-z-3aw

Dickon & girl – exploring argument – example of therapist

stance. 3.19

• Exercise: Spot elements of the stance in this clip

• Client's part played by actor.

Watch the clip and try to spot the elements of the stance that you

notice in this clip.

Feel free to criticise the therapist, too

Video clip

the therapist's mentalizing stance has been

likened to flying as it is described by the

character Buzz Lightyear in the film Toy

Story: "it's just falling... with attitude". The

critical elements of maintaining

inquisitiveness, are to retain awareness of

the extent of one's not-knowing, readiness to

take responsibility for getting it wrong, and

commitment not to get it wrong again in the

same way.

• https://www.youtube.com/watch?v=nyEmI

mJ7ODo

Dickon explaining posture 1.34

THANK YOU FOR LISTENING!

Helen.Griffiths@ed.ac.uk

Helen.Griffiths@nhslothian.scot.nhs.uk

Louise.Duffy@nhslothian.scot.nhs.uk

Video clip

• https://www.youtube.com/watch?v=IzBHD

SnR2jk

Anthony – empathic validation 7.13