Mentalization-based Therapy: A summary of the evidence and new developments Dawn Bales, Maaike Smits Psychotherapeutic Center de Viersprong, Viersprong Institute for Studies on Personality Disorders (VISPD) The Netherlands ISSPD: International Congress - New York City 2009
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Mentalization-based Therapy: A summary of the evidence and new developments Dawn Bales, Maaike Smits Psychotherapeutic Center de Viersprong, Viersprong.
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Mentalization-based Therapy: A summary of the evidence and
new developments
Dawn Bales, Maaike Smits Psychotherapeutic Center de Viersprong, Viersprong Institute for Studies on Personality Disorders (VISPD)
The Netherlands
ISSPD: International Congress - New York City 2009
Research teamDe Viersprong – Roel Verheul, Helene Andrea, 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)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems?
New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD 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
Essential features of the program
Highly structuredConsistent and reliable IntensiveTheoretically coherent: all aspects aimed at enhancing
mentalizing capacityFlexibleRelationship focusOutreaching Individualized treatment plan Individualized follow-up
GoalsTo 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 function
To prevent reliance on prolonged hospital stays
Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems?
New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments
A summary of the evidence
Does MBT work? RCT Day-hospital (1999 UK, 20.. NL) Partial Replication Study (2009 NL)
Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2009 UK)
Cost-effectiveness (2003 UK, 2009 NL)
Does MBT work in another dosage? RCT IOP (2009 UK, 20.. DK) Start RCT Dosis (20.. NL)
Does MBT work for addiction problems? Study MBT for DD (2009 NL) Start RCT MBT-DD (20.. SWD)
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
Research question:
What is the treatment outcome for severe BPD
patients after 18 months of day hospital
Mentalization Based Treatment
in the Netherlands?
Bales et al., submitted, 2009
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
Bales et al., submitted, 2009
Clinical characteristics Study population (N=40) Mean Sd
Substance use disorders study, Bales et al. (manuscript 2009)
Interaction Time * Substance abuse:Interaction Time * Substance abuse: Summary
Lifetime substance abuse: N = 19 yes, N = 5 no Tendency towards stronger improvement for
small group without lifetime substance abuse
Substance abuse start treatment: N = 13 yes, N = 11 no No difference in improvement over timeNo difference in improvement over time
Substance use disorders study, Bales et al. (manuscript 2009)
Limitations
Small N
Retrospective measurement substance abuse
Broader range of addictive problems
Substance abuse outcome data not yet available
Substance use disorders study, Bales et al. (manuscript 2009)
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 2009)
Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems?
New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments
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
Mentalization Based Treatment for Dual Diagnosis Bjorn Philips, Karolinska Institute, Zweden Initiated in 2009
MAT for opiate dependence Regular visits to outpatient clinic for medication and
urine specimens Contact with physician, nurse and contact person Psychosocial support
MAT + MBTDD MBT complement to MAT MBT accordant to manual Weekly group session Weekly individual session 18 months of treatment
Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems?
New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments
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 seven 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)
sessions) IOP MBT (1 gpt and 1 individual session) 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 Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems?
New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments
MBT for BPD - ASPD
Bateman and Fonagy (2008): abnormalities in mentalizing are a significant problem in ASPD.
Intensity is iatrogenic
Target population: BPD ASPD history of severe physical agression midrange level of psychopathy
Program (1.5 year with FU) One group session every two weeks One individual session
Research
Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost? Does MBT work in another dosage? Does MBT work for addiction problems?
New Developments and future plans MBT DD MBT for caregivers MBT for BPD – ASPD Other new developments
Other new MBT DevelopmentsAdolescents (MBT-a, Viersprong, NL)
Families (MBFT), (Viersprong, NL)
MBT expertise center (UK & NL)
Children/parents (MBKT, NPi, NL)
Severe eating disorders (GGZ-MB, NL)
Severe psychosomatic disorders (Eikenboom, NL)
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
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