Adelaide Minding the Person

7/27/2019 Adelaide Minding the Person

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Minding the person the clinicalapplication of mentalisationbased treatment in patients and

families

Prof Anthony W BatemanAAIMH Conference 2008

Adelaide, South Australia


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20062004


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Therapist stance


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Therapist Stance

Not-Knowing

Neither therapist nor patient experiences interactions other thanimpressionistically

Identify difference I can see how you get to that but when I thinkabout it it occurs to me that he may have been pre-occupied withsomething rather than ignoring you.

Acceptance of different perspectives Active questioning Eschew your need to understand do not feel under obligation to

understand the non-understandable.

Monitor you own mistakes Model honesty and courage via acknowledgement of your own mistakes

o Currento Future

Suggest that mistakes offer opportunities to re-visit to learn more aboutcontexts, experiences, and feelings


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Essential to the Stance Keep it current what the patient feels right now

Start by empathising finding a way of stating

that you genuinely understand distress Explore in the relational realm not just the intra-

psychic

Lower arousal by bringing it to the person of thetherapist

What have I done?

Stick to mentalizing aim in somewhat doggedmanner

Quickly step back if patient seems to lose control


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Therapist Stance

Explicit Mentalization Not directly concerned with content but with helping the

patient to generate multiple perspectives on the fly

to free himself up from being stuck in the realityof one view

(primary representations and psychic equivalence) to experience an array of mental states (secondary

representations) and

to recognize them as such (meta-representation).

Explication draws attention back to implicitrepresentationsfeelings for example

use language to bolster engagement on the implicit level ofmentalization

highlight the experience of feeling felt (mentalized affectivity)


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MBT Family also knownas SMART

LONDON-AFC HOUSTON-BAYLOR

Pasco Fearon Laurel WilliamsMary Target J ackie McGregorPeter Fonagy J ohn Sargeant

Stephen Butler Efrain BleibergPeter Fuggle


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MBT-FT Assumptions Mentalizing is powerfully effected by family

influences

Mentalizing is impaired acutely anddevelopmentally under conditions of stress

Problems with mentalizing may reduce families

capacities to repair relationships and findsolutions to relational problems

MBT-FT aims to improve general family-wide

mentalizing skills and target specific mentalizingdifficulties implicated in an identified relationalproblem


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Basic Clinical Model

Key proposition: emotional and behaviouralproblems are essentially relational in nature

Consideration, interpretation and appraisal ofmental states (in self and other) essential forhealthy relationships

Families and individuals vary in their capacity to

mentalize for a multitude of reasons (e.g. earlyexperience, genetics, current stressors)

Problems with mentalizing create distressing and

stressful family interactions which furtherundermine mentalizationThese interactions give rise to relational problems

that undermine family coping, creativity andresilience


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Cycles of inhibition of mentalizing in a family

Powerful emotion

Poor mentalising

Inability to understandor even pay attention

to feelings of others

Others seem

incomprehensible

Try to control or

change others

Frightening, undermining,frustrating, distressing or

coercive interactions

Loss of certaintythat thoughts are

not real


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Vicious Cycles of Mentalizing Problems

Within the Family

Powerful emotion

Poor mentalising

Inability to understand

or even pay attention


Others seem

incomprehensible

Frightening, undermining,frustrating, distressing orcoercive interactions

Try to control orchange others oroneself

Person 1

Powerful emotion

Poor mentalising

Inability to understandor even pay attention


Others seem

incomprehensible

Try to control or

change others oroneself

Frightening, undermining,frustrating, distressing or

coercive interactions

Person 2


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Treatment to promote mentalizing: the MBT-

FT protocol Objectives:

To help families shift from coercive, non-mentalizingcycles (impasses) to mentalizing discussions that canpromote trust, security and attachment

To promote parents sense ofcompetence in generaland, in particular, help them to help their children developmentalizing skills and attitudes

To practice mentalizing in the specific areas in which

mentalizing has become inhibited

To initiate virtuous cycles within the family, with peers,and in school which reinforce mentalizing, communication

and mutually supportive solutions to problems


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Similarities with other therapies PsychodynamicDrawing attention to, encouraging recognition of,

unacknowledged feelings, inner experiences, conflictingfeelings and repetitive patterns of behaviour

No transference interpretation of unconscious conflict Here-and-now psychological content in relationship context

CBT

Thought processes are mediators between experience andbehaviourNo reference to cognitive errors, distortions, negative automatic

thoughts, attentional biases or schemas

Family therapy Focuses on how thoughts and feelings affect behaviour within

relationships Systemic in seeing problems as inherently relational and

encouraging curiosity about other peoples thoughts andfeelings (cf. circular questioning) Fully articulated to the family, directive and psychoeducational


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Core mentalizing interventions Overarching principal is to take and encourage the

familial inquisitive stanceby collaborating in thedevelopment of a mentalizing formulations

Identifying, highlighting and praising examples ofpositive mentalizing

Sharing curiosity about mental states Pause and search tracking mental state

changes as they occur during interactions

Identifying and labeling hidden feeling states

Identifying and working with typical non-

mentalizing impassesTherapists use of self


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Pilot Study of MBT-FT at Baylor

and Anna Freud Centre AFC sample

33 families recruited65% of index child gender is male

Average age was 11.7, SD=3.0, range: 6-17

39% male and 35% female caregiver blackand ethnic minority

38% of women married or cohabiting

60% of men and 62% of women haveuniversity education

Compared to UK Consortium of Child andAdolescent Mental Health Service outomes


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Parent rated pre-post strength and difficultiesscores (SDQ)

P


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Value added pre-post SDQ scores

2.3

5.7

0.8

2.2

1.5

3.9

0.0

1.0

2.0

3.0

4.0

5.0

6.0

CORC comparison (n=225) SMART (n=33)

Using the youthinmind formula to calculate the added value of specialistintervention over 6 m. relative to change without treatment

Value added = 2.3 + 0.8*T1Total + 0.2*T1Impact 0.3*T1Emotion T2Total

Value added= 3.9 (95% CI: 2.3, 5.7) Effect size= .80


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Creating a peaceful schoollearning environment

Stuart W. Twemlow, Peter Fonagy,

Eric M. Vernberg, J ennifer A. Mize,Edward J . Dill, Todd D. Little,

J ohn A. Sargent


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Assumptions, Aims and Adjuncts

The whole school community contributesto bullying-related dysfunction

Peaceful collaboration with othersrequires prioritizing their subjectivestates, thus placing limits upon the urge

to violently control the behaviour of lesspowerful members of the group


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Assumptions, Aims and Adjuncts

CAPSLE aims constantly to focus on the mentalstates of all those involved in the power dynamicsof interpersonal violence (the bystander as well

as the bully and the victim) through:a positive climate campaign to draw attention to the

subjective experiences of bully, victim, and bystander

a classroom management plan that requires teachersto elaborate the thoughts and feelings associated withacts of aggression in the classroom

a defensive martial arts program based on mindfulness

peer or adult mentorship that create additionalopportunities for reflective interpersonal interaction

reflection time which offers opportunities for the classto consider shared immediate past experience together


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Increasing Mentalization Should Reduce

Violence: The Peaceful Schools Project9 schools randomly assigned to

CAPSLESchool Psychiatric Consultation

Treatment as usualoProgrammes as usual

Design3 year study

2 years of formal manualized intervention3rd year test of generalisation


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10 Schools, including 2,712Children, Stratified and Cluster

Randomized

19 Eligible Elementary Schools,Including 6,522 K-5th Grade Children

10 Elementary Schools Elected ToParticipate, Including 2,712 Children

1 School(178 Children)Withdrew FromTreatment as

Usual

Condition

675 Children

Treatment as Usual

In 3 Schools

824 Children

SPC

In 3 Schools

1,035 Children

CAPSLE

In 3 Schools

Only 3rd-5th Grade ChildrenCompleted Research Instruments

SPC Children

Participating296 in Year 1283 in Year 2323 in Year 3

CAPSLE Children

Participating391 in Year 1356 in Year 2395 in Year 3

Treatment as Usual

Children Participating271 in Year 1221 in Year 2217 in Year 3


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Key Results of The Peaceful Schools

Project: Peer Nomination SPC vs TAU

Increase in helpful bystanding (p


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Mean Proportions of Observed

Disruptive Behaviors Over Two Yearsof Active Intervention

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Time 1 Time 2

ControlCAPSLE

SPC

Tests of simple effects between 1st and 2nd year of intervention

CAPSLE: t(106) = 5.21, p < .001, d=.94 (95% CI: -1.0, 2.9)SPC: t(106) = .50, p > .05TAU: t(106) = .13, p > .05


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Mean Proportions of Observed Off-task

Behaviors Over Two Years of ActiveIntervention

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

Time 1 Time 2

Control

CAPSLE

SPC

Tests of simple effects between 1st and 2nd year of intervention

CAPSLE: t(106) = 8.26, p < .001, Cohens d=1.61 (95% CI: -.38, 3.6)SPC: t(106) = 1.19, p > .05TAU: t(106) = .14, p > .05


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Minding the baby

Arietta Slade, PhD,

Lois Sadler, PhD, APRN, PNPLinda Mayes, MD,

A Collaboration:

Yale Child Study Center Yale University School of Nursing Fair Haven Community Health Center


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Theory-based Intervention

Social cognition plays a crucial role in protectingagainst the effects of trauma

A Reflective Parenting Program Enhancing a mothers capacity to understand her own

as well as the babys mental states: feelings, thoughts,

desires, and intentions that underlie behavior Other theoretical emphases Human ecology/transition to parenthood

Build maternal self efficacyDevelopmentally (teen-friendly) and culturally

sensitive


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Sample of Families An urban at-risk population - with

emotional/physical trauma and muchpoverty

Minding the Baby Mothers

Women between 14 and 25First pregnancy

No active drug use at time of pregnancydiagnosis

No serious or terminal medical illness


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Characteristics of our Families

Enrolled 49 intervention, & 25 control Moms

(60 babies so far) 3 LBW, 4 preterm

Mothers average age 19.5 years (range=14-25)

Ethnicity: 66% Latina, 24% African-American,10% white & mixed heritage

Marital status: 12% married, 60% cohabiting,

28% single with no FOB involvement Multigenerational family violence patterns


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The Setting and Plan of Visits

Recruitment of mothers during pregnancyfrom prenatal care groups run by nurse

midwives- consent process Initial engagement and assessment phase

Weekly home visits through one yearTransition visit at one year

Bi weekly visits during second year Graduation at two years

h i fl i i h


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What is a Reflective Parenting Approach?

Strategies to give voice to the babys experience(both physical and emotional).

Strategies to give voice to the mothers

experience of herself as a parent. Strategies to bring alive mothers positive

feelings for the child.

Strategies to develop the mothers capacities toreflect and contemplate. Help mother to learn words and ideas to express ideas about own

lifebefore she can think about how the baby experiences her. A reality tohow she feels; then how the baby might feel. Using own experience of themother to demonstrateit seems to me that you are.then how does this fitinto the babys life/experience/feelings

Strategies to develop mothers sense ofcompetence

Wh i R fl i P i A h?


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Contact; looking babies in the eyes; speaking tobabies; listening to what they are telling the mother

Strategies such as speaking for the baby - useful for

issues of discipline, spoiling, cryingTalking about the babys behavior and intentions

underlying his behavior. Shes not hitting, grabbing,

biting, breaking the remote on purpose because shesbad and is trying to hurt you, but because of hercuriosity and need to explore and touch

Using teachable momentsto point outdevelopmental changes and refer those back to thebabies intentions, emotions etc. Oh look at how

interested she is in grabbing my earringsshe wantsto see and touch them


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Encouraging mothers expression of feelings (inparticular as they underlie her impulses) the feelingsshe is having when she turns away from or ignoresthe baby

Attend to mothers desire to be a good mother; giveself credit and look for strengths within own life andbehaviors

Have parent imitate what the child is doingto help toget into the childs experience, then link with fun and

games for parent and child (parent may not rememberhaving fun or playtime as child)


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Case Example

Amanda

17 years old, living with FOB and paternal family(dysfunctional family system)

Long history of parental substance abuse,neglect, DCF placement, violent parental death

Own health/social problems include malnutrition

during pregnancy, depression, conflict with FOBabout having and raising infant, chronic povertyand food insufficiency


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Amanda in Pregnancy

Overall RF Score: 3

While some awareness of own emotionalexperience, primary experience is ofblocking feelings, finding themoverwhelming, and being unable toregulate them when they do erupt.

I didnt want the baby. I felt like I was tooyoung. I just kinda blocked it out until Iended up in the hospital.


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Amanda 27 months later Overall RF Score: 6 (J ust short of Marked RF)

Less emphasis on confusion and helplessness thanin earlier interview. Negative affect, but regulated.

She is very aware of her babys thoughts andfeelings, and very interested in responding to these,even though she sometimes finds this taxing and

frustrating Highly attuned to the dynamic aspects of mental

states, especially in relation to her child

Particularly conscious of the intergenerationaleffects of her mothers way of regulating affects andrelationships upon her parenting

Still afraid to speak

Reflective Comments from Mothers about


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Reflective Comments from Mothers aboutMTB

When you are

aware about

yourself, its easier

to be aware of your

child

They changed my

framework ofthinking about my

daughter. They

helped me to think

things out and tothink about her

personality when I

talk to her.

They help you to help you,


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MBT-BPD

Anthony Bateman

Peter Fonagy

Rory Bolton

Karen OShaugnessy


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Interventions: Spectrum

Supportive/empathic

Mostinvo

lved

Clarification, elaboration, challenge

Basic mentalizing and affect focus

Leastin

volved

Interpretive mentalizing

Mentalizing the transference

Interventions:


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Interventions:

Supportive & empathic Identifying and exploring positive mentalizing

judicious praise you have really managed to understand what

went on between you Examine how it feels to others when such mentalizing occurs

how do you think they felt about it when you explained it to them

Explore how it feels to self when an emotional situation ismentalized how did working that out make you feel

Identifying non-mentalizing fil lers Fillers: typical non-mentalizing thinking or speaking, trite

explanations Highlight these and explore lack of practical success associated

with them

Interventions:


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Interventions:

Basic Mentalizing Stop, Re-wind, Explore

Lets go back and see what happened just then. At first you

seemed to understand what was going on but then Lets try to trace exactly how that came about Hang-on, before we move off lets just re-wind and see if we can

understand something in all this.

Labeling with qualification (I wonder ifstatements) Explore manifest feeling but identify consequential experience

Although you are obviously dismissive of them I wonder if thatleaves you feeling a bit left out?

I wonder if there are some resentments that make it hard for youto allow yourself to listen to rules. Lets think about why the rulesare there?

I wonder if you are not sure if its OK to show your feelings toother people?

Interventions:


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Interventions:

Interpretive Mentalizing Transference tracers always currentLinking statements and generalization

o That seems to be the same as before and it may be thato So often when something like this happens you begin to feel

desperate and that they dont like you

Identifying patternso It seems that whenever you feel hurt you hit out or shout at

people and that gets you into trouble. May be we need toconsider what happens otherwise.

Making transference hintso I can see that it might happen here if you feel that something I

say is hurtful

Indicating relevance to therapyoThat might interfere with us working together

Components of mentalizing the


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Components of mentalizing the

transference Validation of experience

Exploration in the current relationship Accepting and exploring enactment (therapist

contribution, therapists own distortions)

Collaboration in arriving at an understanding

Present an alternative perspective

Monitor the patients reaction

Explore the patients reaction to the new

understanding


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Trial 2:

Cohort of MBT Partial HospitalTreatment (18 months)

(Bales and Verheul, Holland)

Attempted Suicide: NNT (18 months)=2.4

Self-Mutilating: NNT (18 months)=2.3

General dysfunction: ES(18m)=1.9

Depression: ES (18m)=2.8


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Trial 3:

8 year follow up of patientstreated with MBT compared withTAU

(Bateman & Fonagy submitted)

Design of MBT Partial Hospital follow-up study


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g p p y

41 (22 MBT v 19 TAU) patients followed up 8years after they started treatment

Contact was made by letter, via their generalpractitioner, and by telephone.

Medical and psychiatric records were obtained

for all 41 patients and relevant informationextracted.

Patients interviewed by research psychologists

who remained blind to original group allocation. 5 patients (2 MBT/3TAU) refused interview

1 patient from TAU had died from suicide

Assessment at follow-up interview


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Assessment at follow up interview

Primary outcome

Zanarini Rating Scale for DSM-IV BPD (ZAN-

BPD)Global Assessment of Function (GAF)

Secondary outcomes

Number of self-harm and suicide attemptsNumber of emergency room visits

Length of hospitalization

Continuing out-patient psychiatric careUse of medication, psychological therapies, and

community support.

Vocational status

Zan-BPD (22 v 15) Means (SD)


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Zan BPD (22 v 15) Means (SD)

MBT-PH TAU Significance

Positive criteria

n (%)

3 (13.6) 13 (86.7) 2 = 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

Interpersonalmean (SD)

1.5 (1.7) 4.7 (2.3) F1,35 = 23.2p=.00003

Partial Hospital RCT: GAF Scores


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p

30

35

40

45

50

55

60

65

Baseline End

treatment

4 yrs FU 6 yrs FU 8 yrs FU

MeanG

AFScore

MBT-PH

TAU


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Conclusions from long term follow-up


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MBT-PH group continued to do well 5 years after allMBT treatment had ceased A strong correlate of improvement in the MBT-PH

group is vocational status ?cause or consequence 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. BUTSmall sample, allegiance effects (despite attempts

being made to blind the data collection) limit theconclusions.

GAF scores continue to indicate deficits. Suggestsless focus during treatment on symptomatic

problems greater concentration on improvinggeneral social adaptation.


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Design of Intensive out-patient MBT randomisedcontrolled trial


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controlled trial.

Referrals (n=71 & n=63 for IOP-MBTand SCM groups respectively)

Random allocation (minimisation forage, gender, antisocial PD)

Individual (50 mins) + Group (1.5 hrs)weekly for 18 months

Assessments at admission, 6months, 12 months, 18 months

Medication followed protocol

Suicide attempts in 6 month period


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Suicide attempts in 6 month period

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Baseline 6 months 12 months 18 months

Proportionsuicideattempt

ControlMBT

Limitations


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Limitations

Not all outcome data analysed

Outcome diagnostic data not yet available Small number of therapists

Conclusion


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In advocating mentalization-based treatment weclaim no innovation.

Mentalization-based treatment is the least novel

therapeutic approach imaginable: it addressesthe bedrock human capacity to apprehend mindas such.

Is all psychotherapy mentalization basedtreatment? No more than all therapy influencingbehaviour is behaviour therapy!

Nonetheless, fostering the capacity to mentalizemight be our most significant therapeuticendeavour: cultivating a fully functioning mind is ahigh aspiration indeed.


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Thank you formentalizing!

Adelaide Minding the Person

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