Mentalization-based Therapy: A summary of the evidence and new developments Dawn Bales, Maaike Smits...

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)

Internet:

www.vispd.nl / presentations

Email [email protected]

http://www.vispd.nl/

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

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




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


Clinical characteristics Study population (N=40) Mean Sd

Age 31.7 7.5

N %

Female sex 28 70%

At least one Axis-I diagnosis 38 95%

More than one Axis-I diagnosis 32 80%

Anxiety Disorders 17 43%

Mood disorders 14 35%

Eating disorders 13 33%

Substance abuse & dependency start treatment 26 66%

PTSD 5 13%

More than 1 comorbid axis II diagnosis 28 70%

Paranoïd personality disorder 9 23%

Avoidant personality disorder 9 23%

Dependant personality disorder 6 15%

Histrionic personality disorder 4 10%

Antisocial personality disorder 3 8%


Results: Treatment engagement

Low dropout rate (n=5; 12.5%)

n=3 dropouts n=2 push-outs

Average treatment length: 15.1 months (sd 4.2 months; range 4-18 months)


Results Symptomatic functioning (SCL90, BDI, EQ-5D)

Effectsizes 0.75 – 1.79


Results Social and interpersonal functioning (IIP, OQ)

Effectsizes 1.17 – 1.56


Effectsizes 1.08 – 1.58 large – very large

SIPP: Verheul et al, 2008

Results Personality pathology

Results care consumption


Conclusions

Significant improvement on all outcome measures with effect sizes ranging from large to very large

Low drop-out rate despite limited exclusion criteria

Results similar to results of Bateman & Fonagy (1999)


Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial hospitalization: An 18 month Follow-up

Bateman & Fonagy, American Journal of Psychiatry (2001)

Summary follow-up trial:

MBT patients maintained and even showed additional improvement of symptomatic and clinical gains during 18 months follow-up

18 month follow-up 2001 Bateman & Fonagy

8-Year follow-up of Patients treated for Borderline Personality Disorder:

Mentalization-Based Treatment versus Treatment as usual

Bateman & Fonagy 2008

American Journal of Psychiatry

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

8 year follow-up 2008 Bateman & Fonagy

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


Health Service Utilization Costs for Borderline personality Disorder Patients Treated with Psychoanalytically Oriented

Partial Hospitalization Versus General Psychiatric Care

Bateman & Fonagy (2003)

American Journal of Psychiatry

Total Annual Health Care Utilization Costs

Cost-effectiveness Bateman & Fonagy, UK 2003

Cost-effectiveness

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

Treatment Outcome Studies UK

Implementation of Outpatient

Mentalization Based Therapy for

Borderline Personality Disorder

Bateman & Fonagy, in press; Am. J. Psychiat.

Outcome of mentalization-based and supportive psychotherapy in BPD-patients. Preliminary data

from a randomized trial

Jørgensen, CR., Kjølbye, M., Freund, C. & Bøye, R.

Clinic for Personality Disorders, Aarhus University Hospital, Risskov, Denmark

(manuscript 2009)

IOP in the Netherlands

Two times group psychotherapy, 75 min per week

One individual contact per week

Maximum duration 18 months

RCT

IOP vs day hospital treatment

Minimal a priori exclusion criteria

Substance abuse among Substance abuse among MBT patients:MBT patients:

Prevalence and relation to treatment outcome

Background & Aim

Literature: 57%-67% BPD patients addiction problems -> MBT? Combination BPD & addiction -> treatment prognosis

worse

Study objective:What is the prevalence of substanceabuse among MBT-patients?

Additional explorative analysis:Is substance abuse related to MBT treatment outcome?

Substance use disorders study, Bales et al. (manuscript 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


Measurement Substance Abuse

Composite International Diagnostic Interview (CIDI)

Lifetime auto-version 2.1

Substance Abuse Module (CIDI-SAM): Alcohol dependence or abuse (section J) Drugs / medication / other substance abuse

or dependence (section L)

Study population (continued)

39 eligible patients

No CIDI available:n=6 refused n=9 untraceable (not in treatment anymore)

24 PATIENTS with

CIDI-SAM results


CIDI-SAM

Abuse / dependence

Total population

(N = 24)

79.2%

(N = 19)

Results: Prevalence substance disorders

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)Specific prevalences:

1. Alcohol 67% (N = 16)

2. Cannabis 58% (N = 14)

3. Cocaine 42% (N = 10)

Mean = 2.8 diagnosis

Median = 2 diagnosis

Hypothesis from literature: Prevalence liftetime substance abuse 50-70%

MBT population:MBT population:Prevalence 79%Prevalence 79%

Explorative analysis:Association with treatment outcome?


Treatment outcome results - Explorative longitudinal analyses

Interaction Time x Lifetimesubstance abuse?


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.


Results Improvement for substance abusers and non-

abusers

Stronger improvement for no lifetime substance abuse

Average effect size of 0.61 for the difference between non abusers and abusers at 18 months.

(range 0.26 – 1.08)

However, only n=5 no lifetime substance abuse!However, only n=5 no lifetime substance abuse!


New comparison subgroups N = 5 no lifetime

substance abuse N = 19 lifetime

substance abuse


New comparison subgroups N = 5 no lifetime

substance abuse N = 19 lifetime

substance abuse

Diagnosis starttreatment?

Yes: N = 13 No: N = 6


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)


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


Limitations

Small N

Retrospective measurement substance abuse

Broader range of addictive problems

Substance abuse outcome data not yet available


Conclusions

Very high prevalence (79%) lifetime substance abuse diagnosis among MBT patients

Significant improvement possible for DD patients (severe BPD and substance use disorders)


Content




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




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)

Plan MBT-C

Program: Course explicit mentalizing (8-10 sessions) Course explicit mentalizing for caregivers (6-8

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




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




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

Internationally many new developments

www.vispd.nl/presentations

[email protected]

[email protected]

Mentalization-based Therapy: A summary of the evidence and new developments Dawn Bales, Maaike Smits...

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