An evaluation of the
HUB Program: A
mentalisation based
therapy for BPD
Dr Jennifer Perrin
Trainee Clinical Psychologist
NHS Grampian
S
Outline
S What is mentalisation and MBT?
S What’s the evidence for MBT?
S Brief History and introduction to the HUB program
S Aims of the study
S Study Protocol
What is mentalization ?
- Many ways to define it..
- To be able to hold someone else’s mind in your mind
- To implicitly and explicitly interpret the actions of
oneself and others as meaningful on the bases of
intentional mental states.
- Develops as part of of our attachment relationships.
Why is mentalizing important?
S It influences our understanding of others and ourselves
S Allows us to interpret intentions and meaning to human
behaviour.
Borderline Personality Disorder
S Thought to develop through a complex relationship between
genetics and adverse childhood events.
S Traditional view: genetic factors interact with experiences of
early adverse events to cause emotional dysregulation and
impulsivity, which in turn could lead to dysfunctional
behaviours such as self-harm and psychosocial conflicts and
deficits.
BPD: attachment theory
S Based on attachment theories put forward by Bowlby and
Winnicott.
S BPD development: attachment system is disorganized in
BPD resulting in the disorganization the individual’s selfstructure. This disrupted attachment system inhibits the
development of mentalisation.
S Disruption often due to childhood abuse or other
psychological trauma.
Disruption of mentalisation
S 4 hypothesized routes:
S 1) the child as a defense inhibits this process to protect themselves
from the abuse
S 2) early stress experienced by the child has an impact on the
arousal system, which is observed as inhibition in the orbitofrontal
cortex (the area of the brain thought to be involved in metalizing)
.
S 3) the trauma arouses the attachment system leading the child to
search for attachment security may lead to further abuse if the
perpetrator is an attachment figure.
S 4) the child in attempt to cope with the abuse may try to identify
with the abuser and as a result may internalize the intent of the
abuser, which can lead to feelings of self-hate.
BPD and mentalising
S Reported that between 40-71% on inpatients with BPD have
suffered from childhood abuse or neglect (Lieb et al 2004;
Zanarini et al, 1997; Ogata et al, 1990; Shearer et al, 1990).
MBT interventions
S Developed by Bateman and Fonagy
S Manualised intervention
S Original structure: Assessment – MBT-I – MBT (group plus
individual therapy).
S
MBT-I is 12 sessions covering such topics emotions and emotion
regulation, importance of attachment, mentalisation
S
MBT group = a training ground for mentalisation.
Therapist’s stance
Yes
S Not knowing
S Active questioning (curiosity)
S Continually questioning both the
patient’s and your own mental
state
S It’s ok to be wrong!
NO
MBT principles
S Keep it simple!
S Focused on affect
S Focused on the patients mind
S Keep it related to current events
S De-emphasize unconscious concerns
MBT interventions
Supportive/empathic
Clarification, elaboration, challenge
Basic metalizing: affect and affect focus
Mentalizing the relationship
Evidence for MBT
S Original RCT by Bateman and Fonagy (2008)
S Compared MBT with structured clinical management
S Those in the MBT group showed a faster decline in
symptom distress as well as suicide attempts and
hospitalization.
S Symptom Distress measured mainly by the SCL-90.
RCT 8-year follow-up
S Bateman and Fonagy followed-up the same patients from
the RCT for 8 years.
S Those in the MBT group had less suicide attempts, fewer
hospital admissions, and were taking less medications over
the 8 years since the intervention than the treatment as usual
group.
S Those in the MBT group were more likely to be employed
or in school in the years following treatment
Further studies of MBT
S Jorgensen and colleagues (2013) found that those receiving an
MBT intervention were more likely to achieve “recovery” and
were significantly less distressed by psychiatric symptoms than
patients receiving a supportive group intervention.
S Bales and colleagues (2012) also found that MBT was an effective
intervention and while reducing suicide, self-harm and care
consumption, it also increased interpersonal functioning.
Cochrane Review of treatment
for BDP (2013)
S Most research done on Dialect Behaviour Therapy (DBT)
S MBT interventions are effective at treating core symptoms
of BPD
S Core finding = More research is needed!!!!
The HUB Program
S Originated in Aberdeen out of necessity to offer treatment
for BPD and the closure of the therapeutic community.
S The HUB combined aspects of the therapeutic community
and MBT, which was at the time emerging as an effective
treatment.
S Unique as it is a group only approach.
HUB set up
S Once a week for 24 weeks
S Full day from 10 until 3
S Morning group is psychoeducation, then lunch and an
afternoon group MBT
Morning Schedule
Psycho
education
1
2
3
4
5
SCID
6
7
8
9
10
11
MBT skills
12
13
14
15
16
17
18
19
20
21
22
23
24
The Study
S Aim: A pilot investigation into the effectiveness of the HUB
program.
S Main question: Does completing the HUB program
decrease within-participant psychological distress?
S Secondary questions: Are there within-participant changes
in relationship style or relationship problems after
completing the HUB program? What is the subjective
experience of the HUB?
Study Design
S Mixed method within-participant design
S Includes both qualitative and quantitative measures
S Interviews will take place pre-HUB and then post-HUB
S Looking to recruit 10-15 patients
Study/HUB flow chart
Referral made to psychotherapy
Patients sent SCL-90 to complete and information on HUB Program
Sending back = opting in
1 on 1 appointment with clinician: eligibility, CTQ and PDQ4
Suitable for HUB = formulation session
Pre-Hub group session - recruitment
Includes:
AAP
Pre-HUB interview IIP
SAS-SR
Includes:
AAP
IIP
SAS-SR
SCL-90
Interview
HUB program
Week 23 – post HUB interview
The Symptom Checklist (SCL90)
S Routine measure
S Self-report questionnaire scored on a five-point scale (0-4)
assessing rate of symptom occurrence over the last 7 days.
S Subscales include: somatization, obsessive-compulsive,
interpersonal sensitivity, depression, anxiety, hostility,
phobic anxiety, paranoid ideation, psychoticism.
S Mean score = Global Severity Index
Childhood Trauma
Questionnaire (CTQ)
S Self-report questionnaire where
you are asked to rate the truth of
each statement from never true to
very often true.
S CTQ covers emotional, physical
and sexual abuse as well as
emotional and physical neglect.
Personality Diagnostic
Questionnaire (PDQ-4)
S Routine measure
S 99 true/false questions that
produce scores for the 10
different diagnoses.
S Score of 50 or greater =
increased likelihood of a
personality disorder.
Adult Attachment Projective
(AAP)
S Adult Attachment Projective
S Shown 8 pictures and asked
to tell a story
S Responses allows
classification into 4
attachment styles
Inventory of Interpersonal
Problems (IIP)
S 32 questions
S examines what types of interpersonal problems an
individual may be experiencing and the levels of distress
associated with these problems
S Used by Bateman and Fonagy in their RCT of MBT
Social Adjustment Scale (SAS)
S Examines interpersonal relationships, whether any friction
exists in these relationships, feelings and satisfaction at work
and what if any social and leisure activities are undertaken
with any family members.
S Again used by Bateman and Fonagy in their RCT
Qualitative Interview
S Asks participants about their subjective experience of the
HUB program.
S Will include questions such as:
S
What did you like about the program?
S
What is the main thing you are taking away from your time in the
HUB group?
S
If you could make any changes to the program what would they
be?
Planned analyses
S Quantitative:
S
Paired t-tests between pre and post scores on the SCL-90, IIP and
SAS
S
Are there significant decreases?
S
Correlations between attachment styles and outcome measures
S Qualitative:
S
Thematic analysis to highlight common themes among responses
Potential Outcomes
S Provide the basis for a larger scale RCT of the HUB
program.
S Potential to refine the program based on responses from the
interviews.
S Add to the evidence base on treatment for BPD.
S THANK YOU AND ANY QUESTIONS????