Mentalization-based Treatment for borderline personality disorder: A summary of the evidence, new...

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 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

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

Effectsize NL 1.23

Effectsize NL 1.36

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

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

Highly comorbid borderline patients

18 month follow-up UK and NL

Preliminary results 2010 – do not quote

18 month follow-up UK and NLEffectsize NL

18-36 months

Cutoff BPDSI

Effectsize NL

18-36 months

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

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

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

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

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

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

Mean = 0,1241811Std. Dev. = 0,13505588N = 175

SCEPTRE

0,00 0,20 0,40 0,60 0,80 1,00

Propensity Score

Mean = 0,4427772Std. Dev. = 0,29641958N = 39

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

10.2 months(sd 6.6)

Outpatient

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

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

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

Percent of Sample Who Had Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months

Baseline Six Months TwelveMonths

EighteenMonths

SCM MBT

n.s.p<.02

p<.0002

Percent who had made life threatening suicide attempt

EighteenMonths

SCM MBT

p<.0004

Percent of who seriously self harmed

EighteenMonths

SCM MBTn.s. p <.08

Average Beck Depression Scores

6 months prior totreatment

6 months 12 months End of treatment 18months

ressio

SCM MBT

Average Interpersonal Problems Scores

6 months prior totreatment

6 months 12 months End of treatment18 months

SCM MBT

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 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

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)

(N = 19)

Results: Prevalence substance disorders

No substance

Diagnosis

21%(N = 5)

diagnosis

(N = 3)

diagnoses

(N = 5)

diagnoses

(N = 7)

diagnoses

(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

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.

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)

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)

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)

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

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

Drop Out %

Historic data 2006-2008

Not yet published – do not quote

Outcome Monitoring: symptom index

Brief Symptom inventory

Start treatment End Treatment

Not yet published – do not quote

Outcome Monitoring: level of personality problems

Start behandeling Einde behandeling

SIPP Self control

SIPP Identity Integration

SIPP Social concordance

SIPP Relational capacities

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)

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

MBT-CMBFT

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)

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

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

dawn.bales@deviersprong.nl

maaike.smits@deviersprong.nl

helene.andrea@deviersprong.nl

joost.hutsebaut@deviersprong.nl

Mentalization-based Treatment for borderline personality disorder: A summary of the evidence, new...

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