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 team
De Viersprong – Roel Verheul, Dawn Bales, Maaike Smits, Helene Andrea,
Joost Hutsebaut, Katharina Koch, Fieke v/d Meer
Erasmus 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 maaike.smits@deviersprong.nl
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








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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
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(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
Depression (BDI)
45
40
Effectsize
NL 1.26
36 36.3
35
30
27
26.7
25
25.3
20.6
20.5
20
14.6
15
10
5
0
UK (n=19)
Start
NL (n=45)
6 months
12 months
18 months
Submitted for publicaton – do not quote
Treatment outcome 0-18 months UK & NL
Symptom distress (SCL-90)
3
Effectsize
NL 1.23
2.8
2.6
2.4
2.2
2.5
2.4
2.2
2.1
2
1.73
1.8
1.6
1.6
1.37
1.4
1.2
1
0.79
0.8
0.6
0.4
UK (n=19)
Start
NL (n=45)
6 months
12 months
18 months
Submitted for publicaton – do not quote
Treatment outcome 0-18 months UK & NL
Interpersonal problems (IIP)
3.4
3.2
Effectsize
NL 1.36
3.05
3
2.8
2.6
2.4
2.42
2.38
2.2
2
1.86
1.8
1.6
1.4
UK (n=19)
NL (n=45)
Start
18 months
Submitted for publicaton – do not quote
Treatment outcome 0-18 months UK & NL
% of patients commiting parasuicidal behavior
(past 6 months)
94.7%
100%
90%
80%
79.0%
70%
60%
51.00%
50%
40%
37.0%
32.0%
30%
19.0%
20%
6.0%
5.3%
10%
0%
UK (n=19)
NL (n=45)
Self harm start
Self harm 18 months
Suicide attempts start
Suicide attempts 18 months
Submitted for publicaton – do not quote
Results Personality pathology
Self control
5.00***
Identity integration
4.51***
5
3.96**
6 months
12
months
18
months
Responsibility
Mean score SIPP
identity integration
Mean score SIPP
Self control
6
5.5
5
4.5
4 3.73
3.5
3
start
4.30***
4.5
3.5
3
2.96
2.5
start
3.17*
6
months
12
months
18
months
Relational functioning
4
3.64
5
3.78
3.5
3
start
Mean score SIPP
Social concordance
4.13***
3.75***
4
4.76***
6 months
12 months
Social- concordance
7
6.5
5
4.40***
4.5
4.00**
4
3.5
3.56
3.40
3
start
6 months
5.93***
6
5.5
18 months
Mean score SIPP
Relational functioning
Mean score SIPP
Responsibility
5
4.5
4.88
5.16*
5.43***
SIPP: Verheul et al, 2008
Effectsizes 1.23– 1.74
4.5
4
start
12
months
6 months
12 months 18 months
very large
18
months
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
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(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
Mean score Beck Depression Inventory
Depression (BDI)
25
22.1
20
19
16.5
15
13.7
13.3
11.9
11
10
8.3
5
0
UK (n=22)
18 months
24 months
NL (n=61)
30 months
Preliminary results 2010 – do not quote
36 months
18 month follow-up UK and NL
Symptom distress (SCL-90)
2.2
2.1
2
Mean score SCL-90
1.8
1.6
1.6
1.4
1.2
1.1
1.1
1
0.9
0.8
0.8
0.7
0.6
0.5
0.4
UK (n=22)
18 months
24 months
NL (n=61)
30 months
Preliminary results 2010 – do not quote
36 months
18 month follow-up UK and NL
Effectsize NL
Mean score IIP
Interpersonal problems (IIP)
2.8
2.6
2.4
2.2
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
18-36 months
1.49
2.5
2.1
1.9
1.5
UK (n=22)
18 months
NL (n=61)
36 months
Preliminary results 2010 – do not quote
18 month follow-up UK and NL
% of patients commiting parasuicidal behavior
(past 6 months)
50%
40%
30%
20%
18.2%
18.2%
10%
5.9%
0.0%
0%
UK
NL
18 months
Preliminary results 2010 – do not quote
36 months
18 month follow-up UK and NL
Borderline Symptoms
18-36 months
25
Mean score BPDSI
Effectsize NL
1.98
20
18.35
Cutoff BPDSI
15
10
5
0
18 months
Preliminary results 2010 – do not quote
8.93
36 months
6
5.8
5.6
5.4
5.2
5 4.86
4.8
4.6
4.4
4.2
4
start
Selfcontrol
Results Personality pathology
5.54
5.88
5.2
6 months
18-36 months
12 months
18 months
Responsibility
5.4
5.2
5.26
5.03
5
5
4.8
4.6
4.4
4.2 3.98
4
3.8
3.6
start
4.8
4.25
6 months
12 months
18 months
4.8
4.57
4.6
4,53
4.4
4.4
start
4.53
Relational Functioning
4.8
4.8
4.6
Identity integration
6 months
12 months
18 months
4.2
4.8
4.25
4.08
4
3.8
Social concordance
6.4
6.2
6.04
6
5.8
3.6
start
12 months
18 months
6.23
5.85
SIPP: Verheul et al, 2008
5.66
Effectsizes 1.15-2.14
5.6
5.4
start
6 months
6 months
12 months
18 months
very large
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 TAU
Significance
(n = 22)
(n=15)
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)
Bateman & Fonagy (2008) Am J Psychiatry
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)
Bateman & Fonagy (2008) Am J Psychiatry
χ2 = 6.5
df = 1
p = .02
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
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(2010 NL)
 6. Does MBT work for another population?
• Double diagnosed patients
• Adolescents
Matched samples:
Patient characteristics and treatment outcome for
MBT versus
3 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 and
other psychotherapeutic programs
 Study aim: What is the effectiveness of day hospital MBT
when 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 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 personality
pathology (SIPP):
- Identity integration
- Relational functioning
- Responsibility
- Self control
- Social concordance
 Psychiatric symptoms (SCL)
 Quality of life (EQ-5D)
 Social rol (OQ-45)
 Personality disorders
(SIDP-IV interview):
- Number cluster C PDs
- Number PDNOS
- Number BPD criteria





 Treatment history
(outpatient / day hospital / inpatient)
Sexe
Age
Educational level
Living situation (partner y/n)
Care responsibility for
children
Combined in 1 score = Propensity Score
MBT versus SCEPTRE before matching
MBT
60
60
50
50
40
40
Frequency
Frequency
SCEPTRE
30
30
20
20
10
10
Mean = 0,1241811
Std. Dev. =
0,13505588
N = 175
0
0,0
0,2
0,4
0,6
Propensity Score
0,8
1,0
Mean = 0,4427772
Std. Dev. =
0,29641958
N = 39
0
0,00
0,20
0,40
0,60
0,80
1,00
Propensity Score
MBT: for 31% PS too high (= too severe) -> Matching not possible
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 MBT
Conclusions
Treatment groups
 31% 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
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(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
15,490
10,000
3,183
20,000
TAU
30,976
30,000
MBT
27,303
40,000
44,967
50,000
52,563
60,000
0
6 months before treatment
18 months of treatment
18 months follow-up period
 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
Cost-effectiveness Bateman & Fonagy, UK 2003
A summary of the evidence
 1. Does MBT work?
 RCT Day-hospital vs TAU
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(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
SCM
Percent with Incident
100
MBT
n.s.
p<.02
80
p<.0002
60
40
20
0
Baseline
Six Months
Twelve
Months
Eighteen
Months
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Percent who had made life threatening suicide
attempt
SCM
Percent who attempt
80
MBT
n.s.
n.s.
60
n.s
.
40
20
p<.0004
0
Baseline
Six Months
Twelve
Months
Eighteen
Months
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Percent of who seriously self harmed
n.s.
SCM
p <.08
80
Percent Who Self-Harm
MBT
p<.05
60
p<.05
40
20
0
Baseline
Six Months
Twelve
Months
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Eighteen
Months
Average Beck Depression Scores
SCM
MBT
35
Mean Depression (BDI) scores
30
25
20
15
10
6 months prior to
treatment
6 months
12 months
End of treatment 18
months
IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry
Average Interpersonal Problems Scores
SCM
MBT
Mean Total Interpersonal Problems (IIP) scores
2.4
2.2
2
1.8
1.6
1.4
1.2
1
6 months prior to
treatment
6 months
12 months
End of treatment
18 months
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
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(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)
Results: Prevalence substance disorders
CIDI-SAM
Abuse /
dependence
Total
population
(N = 24)
79.2%
(N = 19)
Specific prevalences:
1.
Alcohol
67% (N = 16)
2. Cannabis
58% (N = 14)
3. Cocaine
42% (N = 10)
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)
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 start
treatment?
 Yes: N = 13
 No: N = 6
Diagnosis start treatment
Yes: 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)
Summary
Lifetime 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 outpatient 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
 Partial Replication Study
(1999 UK, 20.. NL)
(2010 NL)
 2. Are the effects lasting?
 18 month Follow-up
 Long term follow-up
(2001 UK, 2011 NL)
(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
 Start RCT Dosis
(2009 UK)
(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
50
45
42,9
40
35
30
25
20
15
8,69
10
Historic data 20062008
MBT-A
5
0
Drop Out %
Not yet published – do not quote
Outcome Monitoring: symptom index
Brief Symptom inventory
1,8
1,6
1,4
MBT-A
KPA
1,2
1
0,8
Start treatment
End Treatment
Not yet published – do not quote
Outcome Monitoring: level of personality problems
6
SIPP Self control
SIPP Identity Integration
5
4
MBT-A
3
KPA
2
Start behandeling
6,5
4,5
4
3,5
3
2,5
2
Start behandeling
Einde behandeling
SIPP Social concordance
Einde behandeling
SIPP Relational capacities
4,5
6
5,5
4
5
3,5
4,5
Start behandeling
Einde behandeling
3
Start behandeling
Einde behandeling
SIPP Responsability
5
Not yet published –
4,5
4
3,5
Do not quote
3
2,5
2
Start behandeling
Einde behandeling
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
QA/QI
MBT Unit
Supervisor team 1
DayHospital
Group 1
DayHospital
Group 2
Supervisor team 2
PrePostTreatment treatment
CEM
CEM-A
CEM-C
- children
-- adolesc.
Supervisor team 3
IOP 1
IOP 2
IOP 3
MBT-C
MBFT
MBT-C
MBFT
MBT-C
MBFT
MBT-A
MBT-A
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: homevisitations and routine videotaping of caregiverchild 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 and
 To increase the amount of BPD patients
receiving evidence-based (cost)effective
BPD treatment.
In company MBT Training
2x half day
Teammanager/
project leader
Kick off
Team
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 ST
p 2 months
Optional
Training MBT
Nr.
Phase
training
Result
Implementa
tion. MBT
Result Problem
program
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
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,
splitting,, reorganisation
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)
Manualized
Therapist
& program
Supervisor
Organization
Manualized
Supervisory
Adherence
Measure
Patiënt
Therapist
Adherence
Measure
Implementatio
n program
Manualized
MBT
Expert/consultant
MBT
Expertisecenter
Manualized
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.nl
www.vispd.nl/presentations
dawn.bales@deviersprong.nl
maaike.smits@deviersprong.nl
helene.andrea@deviersprong.nl
joost.hutsebaut@deviersprong.nl