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Mentalization-based Treatment for borderline personality disorder:
A summary of the evidence, new evidence & recent developments in different dosages and
treatment population
Dawn Bales, Helene Andrea, Maaike Smits, Joost Hutsebaut Psychotherapeutic Center de Viersprong,
Viersprong Institute for Studies on Personality Disorders (VISPD)
The Netherlands
Dedicated to Ab van Wezep †
Borderline Congres – Berlin, July 2th 2010
Research teamDe Viersprong – Roel Verheul, Dawn Bales, Maaike Smits, Helene Andrea,
Joost Hutsebaut, Katharina Koch, Fieke v/d MeerErasmus University Rotterdam – Reinier Timman, Jan van Busschbach
Tilburg University – Marieke Spreeuwenberg
&
MBT Staff(De Viersprong, Bergen op Zoom, The Netherlands)
Internet:
www.vispd.nl / presentations
Email [email protected]
Does MBT work?
A summary of the evidence
Dawn Bales
Content Mentalization-Based Treatment (MBT)
A summary of the evidence & new evidence
Does MBT work? Are the effects lasting? What does it cost? Does MBT work in another dosage? Does MBT work for another population?
• Double diagnosed patients• Adolescents
New developments
Mentalization-based Treatment
Psychoanalytically oriented; based on attachment theory Developed in the UK by Bateman & Fonagy Evidence-based DH and IOP treatment for patients with
severe BPD Maximum duration of 18 months Focus: increasing patient’s capacity to mentalize
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
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 functioning
To prevent reliance on prolonged hospital stays
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
Does MBT work?MBT De Viersprong
•First study manualized DH MBT outside UK
• Research question: What is the applicability and treatment outcome of day hospital Mentalization Based Treatment for severe BPD patients in the Netherlands?
• Naturalistic setting N=45 severe borderline patients with high comorbidity on both axis I and II
Bales et al., submitted, 2010
Example patient Because of anonimisity reasons, this information has been deleted
Treatment outcome 0-18 months UK & NL
Effectsize NL 1.26
Submitted for publicaton – do not quote
Treatment outcome 0-18 months UK & NL
Effectsize NL 1.23
Submitted for publicaton – do not quote
Treatment outcome 0-18 months UK & NL
Effectsize NL 1.36
Submitted for publicaton – do not quote
Treatment outcome 0-18 months UK & NL
Submitted for publicaton – do not quote
Effectsizes 1.23– 1.74
very large
SIPP: Verheul et al, 2008
Results Personality pathology
Results and conclusion DH MBT
Low dropout rate (n=4; 8.9%) despite limited exclusion criteria
Significant improvement on all outcome measures with effect sizes ranging from large to very large
Not only symptomatic improvement but also improvement in interpersonal and personality functioning
Results comparable to results of Bateman & Fonagy (1999)
Bales et al., submitted, 2010
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
Are the effects lasting?
18 month Follow-up UK 2001:
MBT patients maintained and even showed additional improvement of symptomatic and clinical gains during 18 months follow-up
18 month Follow-up Netherlands
Preliminary results analyzed June 2010
N= 61
Highly comorbid borderline patients
18 month follow-up UK and NL
Preliminary results 2010 – do not quote
18 month follow-up UK and NL
Preliminary results 2010 – do not quote
18 month follow-up UK and NLEffectsize NL
18-36 months
1.49
Preliminary results 2010 – do not quote
18 month follow-up UK and NL
Preliminary results 2010 – do not quote
18 month follow-up UK and NL
Cutoff BPDSI
Effectsize NL
18-36 months
1.98
Preliminary results 2010 – do not quote
Effectsizes 1.15-2.14
very large
SIPP: Verheul et al, 2008
Results Personality pathology
18-36 months
Conclusions 18 month FU NL
Results comparable to results of Bateman & Fonagy (1999):
Continuing decline in depression, symptom distress, minimal acts of suicide attempts and self harm throughout follow-up period
Also: continuing improvement in personality functioning and specific borderline symptoms
Preliminary results 2010 – do not quote
Patient example: follow-up
Are the effects lasting?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
Bateman & Fonagy (2008) Am J Psychiatry
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
Bateman & Fonagy (2008) Am J Psychiatry
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
Bateman & Fonagy (2008) Am J Psychiatry
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
Bateman & Fonagy (2008) Am J Psychiatry
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
Bateman & Fonagy (2008) Am J Psychiatry
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
Matched samples: Matched samples:
Patient characteristics and treatment outcome for Patient characteristics and treatment outcome for MBT versus MBT versus
3 other psychotherapeutic treatment settings3 other psychotherapeutic treatment settings
Helene Andrea
Background
UK results: MBT superior to standard psychiatric care(Bateman & Fonagy 1999, 2001, 2008)
As yet no direct comparison between MBT andother psychotherapeutic programs
Study aim: What is the effectiveness of day hospital MBT when Study aim: What is the effectiveness of day hospital MBT when compared to other psychotherapeutic treatment settings?compared to other psychotherapeutic treatment settings?
SCEPTRE: Direct comparison MBT and- Outpatient, day hospital and inpatient psychotherapy - Matched-control design
Matched control study: Patient sample
SCEPTRE:
N=923 patients with personality pathology
Referred to psychotherapy in the Netherlands
N=214 BPD patients
N=39 MBT N=175 other treatment setting
Assignment not random -> Selection biasAssignment not random -> Selection bias
Correction for selection bias(baseline group differences)
Propensity score A sophisticated co-variance analysis Combines several
co-variates in 1 score
If successful “Imitation” of random
assignment Applicable in
non-randomised studies
MBT (n=39) vs. SCEPTRE (n=175): Baseline differences
Severity personalitypathology (SIPP):- Identity integration- Relational functioning- Responsibility- Self control- Social concordance
Personality disorders (SIDP-IV interview):- Number cluster C PDs- Number PDNOS- Number BPD criteria
Psychiatric symptoms (SCL) Quality of life (EQ-5D) Social rol (OQ-45)
Treatment history(outpatient / day hospital / inpatient)
Sexe Age Educational level Living situation (partner y/n) Care responsibility for
children
Combined in 1 score = Propensity ScoreCombined in 1 score = Propensity Score
MBT: for 31% PS too high (= too severe) -> Matching not possibleMBT: for 31% PS too high (= too severe) -> Matching not possible
0,0 0,2 0,4 0,6 0,8 1,0
Propensity Score
0
10
20
30
40
50
60
Fre
quen
cy
Mean = 0,1241811Std. Dev. = 0,13505588N = 175
SCEPTRE
0,00 0,20 0,40 0,60 0,80 1,00
Propensity Score
0
10
20
30
40
50
60
Fre
quen
cy
Mean = 0,4427772Std. Dev. = 0,29641958N = 39
MBT
MBT versus SCEPTRE before matching
Matches for n=21 MBT:
N=21 SCEPTRE
Setting Mean Teatment
Duration
Inpatient(47%)
11.7 Months(sd 8.7)
Day hospital
(29%)
10.2 months(sd 6.6)
Outpatient
(24%)
24.2 months(sd 15.5)
Effectiveness analysis
For the MBT and SCEPTRE matches(hence, without the “more severe MBT-patients”)
Mixed model Between effect: Group comparison Within effect: Time dependency Main outcome: GSI change score (SCL)
- Change score = Time of follow-up measurement – Baseline- Negative score = improvement
(Preliminary) effectiveness results
In favor of effectiveness MBTIn favor of effectiveness MBT
Conclusions
Treatment groups31% of MBT patients could not be matched;A considerable amount of MBT patients are likely
excluded from other psychotherapeutic treatments
Treatment outcome (Preliminary) evidence in favour of MBT when
compared to other psychotherapeutic treatments In line with results of Bateman &
Fonagy (1999, 2001, 2008)
Limitations
N is relatively small;
Several relevant severity variables are missing;e.g. substance use disorders, GAF, self-harm, suicidality
Relatively large amount of missings in the MBT group;
Different treatment setting and durations- subgroup analysis
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
What does MBT cost?
Does MBT work in other dosages?- Intensive Outpatient MBT
- Patients with substance use disorders
Maaike Smits
Total Annual Health Care Utilization Costs
Cost-effectiveness Bateman & Fonagy, UK 2003
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
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
Design of intensive out-patient MBT randomized controlled trial
RCT IOP-MBT vs. SCM groups (N = 134)
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) Am J Psychiatry
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 (2009) Am J Psychiatry
Percent of Sample Who Had Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months
0
20
40
60
80
100
Per
cen
t w
ith
In
cid
ent
Baseline Six Months TwelveMonths
EighteenMonths
SCM MBT
n.s.p<.02
p<.0002
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Percent who had made life threatening suicide attempt
0
20
40
60
80
Per
cen
t w
ho
att
emp
t
Baseline Six Months TwelveMonths
EighteenMonths
SCM MBT
n.s.
n.s.
n.s.
p<.0004
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Percent of who seriously self harmed
0
20
40
60
80
Per
cen
t W
ho
Sel
f-H
arm
Baseline Six Months TwelveMonths
EighteenMonths
SCM MBTn.s. p <.08
p<.05
p<.05
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Average Beck Depression Scores
10
15
20
25
30
35
6 months prior totreatment
6 months 12 months End of treatment 18months
Mean
Dep
ressio
n (
BD
I) s
co
res
SCM MBT
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Average Interpersonal Problems Scores
1
1.2
1.4
1.6
1.8
2
2.2
2.4
6 months prior totreatment
6 months 12 months End of treatment18 months
Mean
To
tal
Inte
rpers
on
al
Pro
ble
ms (
IIP
) sco
res
SCM MBT
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Conclusions Both groups showed improvement over 18 months
BUT DIFFERENT RATES OF CHANGE
MBT-OP was superior to SCM-OP – differences started to emerge after 6 months suicide attempts and severe incidents of self harm self-reported measures of psychiatric symptoms and
social adjustment
Rate of improvement in both groups was higher than spontaneous remission of symptoms of BPD estimated from follow-along studies
Results support emphasis on highly structured treatment approaches
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
IOP in the Netherlands
Two times group psychotherapy, 75 min per week
One individual contact per week
Maximum duration 18 months
RCT IOP versus Day hospital treatment Minimal a priori exclusion criteria
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
Substance abuse among MBT patients : Prevalence and relation to treatment outcome
57%-67% BPD patients addiction problems -> MBT? Worse treatment prognosis
What is the prevalence of substance abuse among
MBT-patients?
Additional explorative analysis:Is substance abuse related to MBT treatment outcome?
N= 39 Substance abuse measuremunt:CIDI N=24
Substance use disorders study, Bales et al. (manuscript 2010)
CIDI-SAM
Abuse / dependence
Total population
(N = 24)
79.2%
(N = 19)
Results: Prevalence substance disorders
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)
Mean = 2.8 diagnosis
Median = 2 diagnosis
Substance use disorders study, Bales et al. (manuscript 2010)
Interaction time * Lifetime substance abuse
Pattern for 50% of the outcome measures:
SCL-90, BDI, OQ Symptom distress, OQ interpersonal relations,
OQ social concordance, SIPP identity integration and
Quality of life.
Substance use disorders study, Bales et al. (manuscript 2010)
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)
Substance use disorders study, Bales et al. (manuscript 2010)
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)
Substance use disorders study, Bales et al. (manuscript 2010)
SummaryLifetime substance abuse: 19 lifetime-abusers versus 5 non lifetime- abusers Tendency towards stronger improvement for
small group without lifetime substance abuse
Substance abuse start treatment: 13 abusers versus 11 non abusers No difference in improvement over time
(Preliminary) Conclusions Very high prevalence (79%) lifetime substance abuse
diagnosis among MBT patients Significant improvement possible for DD patients
(severe BPD and substance use disorders)
Substance use disorders study, Bales et al. (manuscript 2010)
BPD and addiction: Patient examples
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 5 days a week day-hospital (PH) outpatient treatment
Including system-oriented interventions Research
A summary of the evidence 1. Does MBT work?
RCT Day-hospital vs TAU (1999 UK, 20.. NL) Partial Replication Study (2010 NL)
2. Are the effects lasting? 18 month Follow-up (2001 UK, 2011 NL) Long term follow-up (2009 UK)
3. MBT vs. other psychotherapy? (2010 ? NL)
4. What does MBT cost? (2003 UK, 2011? NL)
5. Does MBT work in another dosage? RCT IOP (2009 UK) Start RCT Dosis (2010 NL)
6. Does MBT work for another population? • Double diagnosed patients• Adolescents
Mentalization-based Treatment for severe personality
disorders in adolescents
Joost Hutsebaut
PDs in adolescence: some facts
PDs are underdiagnosed in adolescence
Adolescents with PDs suffer even more than adults with PDs
Adolescents with PDs cost society annually € 14479,- (Feenstra et al., in prep)
There are no treatment guidelines/evidence based treatments for (severe) PDs in adolescents
Innovative/experimental treatment program: MBT-A
What? A treatment program aiming to improve mentalizing capacities in adolescents and their parents
For whom? For adolescents suffering from severe borderline PDs (and their families)
Based on: Mentalization-based treatment (Bateman and Fonagy)
MBT-A versus MBT: double innovation
Adaptation of an adult model for adolescents Developmentally specific (Multi)systemic approach
Adaptation of an outpatient model to an inpatient setting Pedagogics in line with MBT (limit setting) Dosage of intensity of attachment
Described in an unpublished manual
Developmental aspects of mentalizing in adolescence
Adolescence has a double impact on the ability to mentalize
Impact of developmental changes (biological, emotional, cognitive, social,…) on the ability to mentalize
• Cognitive development enhances abilities to mentalize about others by enhancing the ability to take different perspectives, think in a more abstract way etc
Impact of developmental tasks on the ability to mentalize• The need to ‘separate’ from parents reduces the ability to mentalize (at
some times) about parents (and vice versa)
(Multi-)systemic perspective
Adolescents often are closely connected to their family of origin and experience attachment reactions of their parents
• Reactions of parents are often antecedents of failure in mentalizing (and v.v.)
• Parents have lost their ability to mentalize about their child
• Parents and children are absorbed in unmentalizing interactions (excessive control, closing their eyes for problems)
Adolescents are embedded in multiple systems influencing them (school, peer group, neighborhood, justice)
Adaptations to the original model
(By far) Most aspects remain unchanged Treatment principles: highly structured, coherent,
consistent, focus on affect, focus on relationships, focus on here and now, outreaching,…
Clinical processes: group and individual therapy, signal plan, treatment evaluations, treatment goals,…
(MBT is a very adolescent-friendly model)
Adaptations to the original MBT-model
Some aspects (probably) remain unchanged, but deserve special attention Therapeutic attitude:
• open, transparant
• playful, use of humor
• flexible concerning the therapeutic frame
• casual, ‘real’
Interventions: • affect-focused (what do I feel)
• identity-focused (what do I feel)
• maybe less focused on mentalizing about others
Adaptations to the original MBT-model
Some aspects are new Including Mentalization-based Family Therapy
(MBFT) (trial version)
Including developmental tasks in the treatment plan
• An important goal is also to resume a healthy developmental trajectory
• Including an analysis of mental states interfering with specific developmental tasks
• Including a phasing of developmental tasks
Outcome monitoring: drop out
42,9
8,69
0
5
10
15
20
25
30
35
40
45
50
Drop Out %
Historic data 2006-2008
MBT-A
Not yet published – do not quote
Outcome Monitoring: symptom index
Brief Symptom inventory
0,8
1
1,2
1,4
1,6
1,8
Start treatment End Treatment
MBT-A
KPA
Not yet published – do not quote
Outcome Monitoring: level of personality problems
2
3
4
5
6
Start behandeling Einde behandeling
SIPP Self control
MBT-A
KPA2
2,53
3,54
4,5
Start behandeling Einde behandeling
SIPP Identity Integration
4,5
5
5,5
6
6,5
Start behandeling Einde behandeling
SIPP Social concordance
3
3,5
4
4,5
Start behandeling Einde behandeling
SIPP Relational capacities
2
2,5
3
3,5
4
4,5
5
Start behandeling Einde behandeling
SIPP Responsability
Not yet published –
Do not quote
Implementation was not a success over the whole line… (not at all, in fact…)
Two major negative consequences Extreme levels of arousal in the patient groups Leading to much acting out, crises, high stress
Extreme burden for staff (mainly nurses) Leading to temporarily high illness and drop
out of staff members
Causes of implementation problems
Related to institution Traditional therapeutic community for neurotic patients MBT-A arose from the ‘ashes’ of such a TC program MBT-A arose from conflicts between team members of this TC
Related to the start of the program Staff was not selected, but personnel was re-trained Group had to adapt to a new program
Related to team Existing split between nurses and psychotherapists Team members with highly similar personality profile Abscence of experience in MBT at the start
Causes of implementation problems
Related to training Basic training without continuous monitoring/supervision
Related to adolescent population Strong peer bonding against staff Parents blaming the therapists/institution
Related to inpatient setting Too much (attachment, peer bonding) leading to high
arousal Extremely difficult to maintain a consistent and coherent
apporach, leading to unreliability
Preliminary conclusions MBT is a promising approach for the treatment of severely
personality disordered adolescents It not only reduces symptoms, but also improves core components
of personality functioning
MBT does not need huge adaptations for adolescents, with exception of the addition of MBFT and attention for developmental tasks
Implementation of MBT is a difficult process (more general: implementation of a new treatment model in a complex population is difficult)
An inpatient setting might be possible for milder PD adolescents, but is riskful for low level BPD (i.p. with strong antisocial traits)
Future developments
Reorganisation of the program: Intensive outpatient instead of inpatient Restricted age range (16-18) Developing an adapted version of MBFT
• Integrated within MBT-a (one-team model)• CEM for parents including focus on parental
skills
Development of a quality monitoring system
Content
Mentalization-Based Treatment (MBT)
A summary of the evidence & new evidence
New Developments MBT-Double diagnosis (MBT-DD) MBT-Caregivers (MBT-C) MBFT MBT quality assurance and improvement system Other new developments
New developments:- MBT Caregivers
- MBFT
MBT quality assurance and improvement system
Other new developments
Dawn Bales
MBT UnitMBT QA/QI
Supervisor team 2
Day-HospitalGroup 1
Day-HospitalGroup 2
Pre-Treatment
CEMCEM-ACEM-C
- children-- adolesc.
Post-treatment
IOP 1
MBT-CMBFT
IOP 2
MBT-CMBFT
IOP 3
MBT-CMBFT
MBT-A
MBT-A
Supervisor team 3Supervisor team 1
Objectives of MBFT
Help families shift from non-mentalizing to mentalization-based discussions and interactions, building a basis of trust and attachment between children and parents.
Promote parents’sense of competence in helping their children develop the skill of mentalizing.
Practice the skills of mentalizing, communication and problem solving in the specific areas in which mentalizing has been inhibited.
Initiate activities and contexts within the family, with peers, in school, and in the community which reinforce mentalizing, communication skills and mutually supportive solutions to problems
MBT for caregivers: MBT-C A mentalizing parental program for high-risk parents
and their children
Population: caregivers with severe BPD and their children up to four years
Goal: promoting reflective parenting by enhancing the caregiver’s mentalizing with respect to him/herself, the child and the relationship
The interventions on caregiver-child interactions are based on principles from Minding the baby (Slade)
Plan MBT-C
Program: Course explicit mentalizing (8-10 group sessions) Course explicit mentalizing for caregivers (6-8 group
sessions) IOP MBT (1 group psychotherapy and 1 individual
session, with primary focus on their BPD) Interventions on caregiver-child interaction: home-
visitations and routine videotaping of caregiver-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 & new evidence
New Developments MBT-Double diagnosis (MBT-DD) MBFT MBT-Caregivers (MBT-C) MBT quality assurance and improvement system Other new developments
Borderline Task Force (NL)
Prominant researchers and clinicians from different evidence-based BPD treatment programs (MBT, TFP, SFT en DBT).
Mission:Jointly contributing to more (cost)effective BPD
treatment programs andTo increase the amount of BPD patients
receiving evidence-based (cost)effective BPD treatment.
In company MBT Training2x half day Teammanager
/project leader
Kick off Team Optional
2-day basic training Team
3rd day basictraining Team
Training on-the-job 5 days 3 therapists
First day extra training Team
Second day extra training Team
Teamsupervision Team
Individual supervision ; 8x 1 x p 6 weeks
All therapists
Individual supervision : 6 x 1 x p 2 months
ST
Training MBTNr. Phase
trainingResult
Implementation. MBT
Resultprogram
Problem
1. Finished - +_ Reorganisation, cut-backs, no evidence-based program
2. Finished - + Goal was to add certain components facilitating mentalizing
3. Finished + - +- splitting, reorganization, new start
4. Finished + -; ended splitting,, reorganisation
5. Finished + - Small, vulnerable team, working on recovery
6. Finished ended Implementation problems; problems in team, not enough expertise, adherence low, splitting
7. Middle phase
± Small, vulnerable team, no support from management
8. Finished ± Complex organization, low adherence,
Framework for MBT:Succes factors Multi System
Therapy (MST)? Evidence-based product
MST program development and support
Consultation, training and boostersessions
Quality assurance and improvement system
Research supporting QA/QI linkages with outcome
Components of QA/QI system
Training Manualized training, supervision on site, consultation and booster
training
Implementation measurement and reporting Therapist adherence measure, program adherence measure,
supervisor adherence measure and consultant adherence measure Outcome measurement
Organisational support Organisational manual Pre-implementation program development process, Ongoing organizational support
Quality assurance and Improvement System (MST model)
Organization
Therapist & program
Manualized Manualized
Supervisory Adherence Measure
Therapist Adherence Measure
Implementation program
MBT Expert/consultantMBT Expertisecenter
ManualizedManualized
Supervisor Patiënt
Other new MBT Developments
MBT for ASPD
Children/parents (MBKT, NPi, NL)
Eating disorders RCT MBT with eating disorders (UK) Phd on MBT with Severe eating disorders (GGZ-MB, NL)
Severe psychosomatic disorders (Eikenboom, NL)
Conclusions
A summary of the evidence MBT does work for severe borderline patients The effects are lasting MBT shows considerable health care cost savings
after treatment MBT-IOP also seems effective MBT is also promising for addiction and
adolescents
Internationally many new developments
www.deviersprong.nlwww.vispd.nl/presentations