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Mentalization-based Therapy: A summary of the evidence and
new developments
Dawn Bales, Helene Andrea, Ab Hesselink Psychotherapeutic Center de Viersprong,
Viersprong Institute for Studies on Personality Disorders (VISPD)
The Netherlands
WPA: International Congress – Florence, april 4, 2009
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Research teamDe Viersprong – Roel Verheul, Maaike Smits, 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]
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Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost?
New Developments and future plans Does MBT work in another dosage? Does MBT work for addiction problems? MBT for caregivers Other new developments
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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
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What is mentalization?
Making sense of the actions of oneself and others on the basis of intentional mental states, such as desires, feelings, and beliefs.
It involves the recognition that what is in the mind is in the mind and reflects knowledge of one’s own and others’ mental states as mental states.
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Schematic Model of BPD
Constitutional factors
Hyper-activation of the attachment
system
Trauma/Stress
Early attachmentenvironment
Retrieval of negativeaffect laden memories
and cognitions
Inhibition of judgements of social trustworthiness, paranoid thoughts and
mentalizing failure
BPD: Pre-mentalistic subjectivity
Vulnerability risk factors
Activating (provoking) risk factors
Formation risk factors
Poor affectregulation
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MBT developmental model of BPD
Constitutionally vulnerable Insecure attachment
Inhibited capacity to mentalize Symptoms and interpersonal problems
Focus MBT: enhancing mentalization within the context of attachment relationship
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Goals
To engage the patient in treatmentTo reduce general psychiatric symptoms,
particularly depression and anxietyTo decrease the number of self-destructive
acts and suicide attemptsTo improve social and interpersonal functionTo prevent reliance on prolonged
hospital stays
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Essential features of the programHighly structuredConsistent and reliable IntensiveTheoretically coherent: all aspects aimed at
enhancing mentalizing capacityFlexibleRelationship focusOutreachingIndividualized treatment planIndividualized follow-up
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A summary of the evidence
Does MBT work? RCT Day-hospital (1999 UK) Partial Replication Study (2009 NL)
Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2008 UK)
Cost-effectiveness (2003 UK)
Does MBT work in another dosage? RCT IOP (2009 UK) Future plans
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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
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MBT De Viersprong
• First MBT setting outside UK
• Naturalistic setting (instead of RCT)
Research question:
What is the treatment outcome
for severe BPD patients
after 18 months of day hospital Mentalization Based Treatment
in the Netherlands?
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Study population
45 patients referred
to MBT(Aug.’04 – Apr. ’08)
Excluded:n=2 no DSM-IV BPDn=2 refusedn=1 early dropout
40 PATIENTS
INCLUDED
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Demographic and clinical characteristics study population (N= 40)
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%
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Prospective naturalistic study design
Measurements: start treatment, 6, 12, and 18 months
Continuous outcomes: GEE (SPSS)- correction for missing values- age and sexe as covariates- effect sizes corrected for data dependency
Categorical outcomes: univariate statistics
Baseline n=406 months n=31; 12 months n=19; 18 months n=16
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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)
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Results Symptomatic functioning (SCL90, BDI, EQ-5D)
Effectsizes 0.75 – 1.79
Bales et al, 2009; Submitted – do not quote
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Results Social and interpersonal functioning (IIP, OQ)
Effectsizes 1.17 – 1.56
Bales et al, 2009; Submitted – do not quote
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Effectsizes 1.08 – 1.58 large – very large
SIPP: Verheul et al, 2008
Domain personality pathology
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Results care consumption domain
n=17 (81%)n=19 (68%)
n=7 (25%)
n=13 (62%)
n=6 (21%)
n=0
0
4
8
12
16
20
Inpatientadmissions
(n=28)
Additionaltreatments
(n=28)
Psychotropicmedication
(n=21)
Measurement (months)
N p
ati
en
ts
Start
18 months
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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)
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(Methodological) limitations
Working mechanisms; mentalization
Low N and missing values
Causality
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MBT Research
Does MBT work? RCT Day-hospital (1999 UK) Partial Replication Study (2008 NL)
Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2008 UK)
Cost-effectiveness (2003, UK)
Does MBT work in another dosage? RCT IOP (2009, UK) Future plans
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Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial hospitalization:
An 18 month Follow-upBateman & 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
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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
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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
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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
8 year follow-up 2008 Bateman & Fonagy
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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
8 year follow-up 2008 Bateman & Fonagy
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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
8 year follow-up 2008 Bateman & Fonagy
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Vocational status
8 year follow-up 2008 Bateman & Fonagy
0
10
20
30
40
50
60
70
80
Baseline Mid-Treatment
EndTreatment
3 year FU 5 year FU 8 year FU
Pe
rce
nt
in E
mp
loy
me
nt
MBT-PH TAU
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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
8 year follow-up 2008 Bateman & Fonagy
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MBT Research
Does MBT work? RCT Day-hospital (1999 UK) Partial Replication Study (2008 NL)
Are the effects lasting? 18 month Follow-up (2001 UK, 2009 NL) Long term follow-up (2008 UK)
Wat does it cost? (2003, UK)
Does MBT work in another dosage? RCT IOP (2009, UK) Future plans
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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
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44
.96
7
52
.56
3
27
.30
3
30
.97
6
3.1
83 1
5.4
90
0
10.000
20.000
30.000
40.000
50.000
60.000
6 monthsbefore
treatment
18 months oftreatment
18 monthsfollow-up
period
MBT
TAU
Total Annual Health Care Utilization Costs
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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
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Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost?
New Developments and future plans Does MBT work in another dosage? Does MBT work for addiction problems? MBT for caregivers Other new developments
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Treatment Outcome Studies UK
Implementation of Outpatient
Mentalization Based Therapy for
Borderline Personality Disorder
Bateman & Fonagy (2009)
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Referrals for IOP-MBT and SCM groups
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
Design of Intensive out-patient MBT RCT
IOP vs. SCM Bateman & Fonagy (2009)
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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 (2008?)
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(Preliminary) Conclusions IOP
MBT-IOP is surprisingly effective
The sample was less disturbed than the partial hospital sample
Most of the MBT subjects but also some of the SCM subjects lost their diagnosis
Relatively few of the SCM patients improved in terms of subjective measures
The MBT patients more reliably improved
Even when improved, remains quite high scoring on pathology scales
IOP vs. SCM Bateman & Fonagy (2009)
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IOP in the Netherlands
Course explicit mentalizing (CEM; 8-10 sessions)
Two times group psychotherapy, 75 min per week
One individual contact per week
Maximum duration 18 months
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RCT
IOP vs day hospital treatmentExplosive ASPD is excludedPilot randomisationN=20>70% cooperation
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Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost?
New Developments and future plans Does MBT work in another dosage? Does MBT work for addiction problems? MBT for caregivers Other new developments
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Substance abuse among Substance abuse among MBT patients:MBT patients:
Prevalence and relation to treatment outcome
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Background & AimLiterature: 57%-67% BPD patients addiction problems -> MBT? Combination BPD & addiction -> treatment prognosis
worse
Study objective:Study objective:What is the prevalence of DSM-IV substanceabuse among MBT-patients?
Additional explorative analysis:Is substance abuse related to MBT treatment outcome?
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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
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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)
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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
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CIDI-SAM
Abuse / dependence
Total population(N = 24)
79.2%(N = 19)
Results: Prevalence substance abusePrevalence substance abuse
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)
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Hypothesis from literature: Prevalence liftetime substance abuse 50-70%
MBT population:MBT population:Prevalence 79%Prevalence 79%
Explorative analysis:Association with treatment outcome?
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Treatment outcome resultsExplorative longitudinal analyses
Depression (BDI)
27,3
19,1
14,9
5,8
25,022,9
17,3 16,9
0
5
10
15
20
25
30
0 6 12 18
Measurement (months)
Sco
re
no substanceabuse (n=5)
substanceabuse (n=19)
Interaction Time x Lifetimesubstance abuse?
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Interaction time * Lifetime substance abuse
Pattern for 50% of the outcome measurements:Pattern for 50% of the outcome measurements:
- Improvement for substance abusers and non-abusers
- Stronger improvement for no lifetime substance abuse
However, only n=5 no lifetime substance abuse!However, only n=5 no lifetime substance abuse!
Depression (BDI)
27,3
19,1
14,9
5,8
25,022,9
17,3 16,9
0
5
10
15
20
25
30
0 6 12 18
Measurement (months)
Sco
re
no substanceabuse (n=5)
substanceabuse (n=19)
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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)
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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)
Problems interpersonal relations (OQ)
0
5
1015
20
25
30
0 6 12 18
Measurement (months)
Scor
e no (n=11)
yes (n=13)
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Interaction Time * Substance abuse:Interaction Time * Substance abuse: Summary
Lifetime substance abuse:N = 19 yes, N = 5 noTendency towards stronger improvement for
small group without lifetime substance abuse
Substance abuse start treatment:N = 13 yes, N = 11 no No difference improvement over timeNo difference improvement over time
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Limitations
Small N
Retrospective measurement substance abuse (recall bias)
Broader range of addictive problems
Substance abuse outcome data not yet available
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Conclusions
Very high prevalence (79%) lifetime substance abuse diagnosis among MBT patients
Significant improvement possible for DD patients (severe BPD and substance abuse)
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BPD and addiction: Hannah22 years old femaleAxis I: polysubstance dependence (cannabis,
cocaïne, XTC, speed); ADHD; post-traumatic stress disorder; sexual dysfunction
Axis II: borderline personality disorder; histrionic personality disorder, paranoid features
Low-level borderline/psychotic personality organisation (Kernberg)
Unable to follow a whole day-program without drugs
Completely integrated in ‘drugscene’
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BPD and addiction: Henry46 years oldAxis I: polysubstance dependence (cocaine
and alcohol); sexual dysfunction; depressionAxis II: borderline personality disorder;
narcissistic personality disorder, avoidant personality disorder
Fired from work because of drug dependence Divorced, two childrenDetoxification before start MBTAble to follow a day program without drugsSome social structure (volunteer, children
visits, etc)No users as friends, not in ‘drugscene’
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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 day-hospital (PH) outpatient treatment
Including system-oriented interventions
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Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost?
New Developments and future plans Does MBT work in another dosage? Does MBT work for addiction problems? MBT for caregivers Other new developments
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MBT for caregivers: MBT-C A mentalizing parental program for high-risk parents
and their children
Goal: promoting reflective parenting by enhancing the caregiver’s mentalizing with respect to him/herself and the child
Population: caregivers with severe BPD and their children up to seven years
The interventions on caregiver-child interactions are based on principles from Minding the baby (Slade)
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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 mother-child interactions
Research: MBT-C versus TAU Hypothesis: enhancing the caregiver’s
mentalizing capacity results in less psychopathology in the children
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Content
Mentalization-Based Treatment (MBT)
A summary of the evidence Does MBT work? Are the effects lasting? Wat does it cost?
New Developments and future plans Does MBT work in another dosage? Does MBT work for addiction problems? MBT for caregivers Other new developments
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Other New MBT Developments Adolescents (MBT-a, Viersprong, NL)
Antisocial and BPD (Bateman, 2008; Viersprong, NL)
Families (MBFT), (Viersprong, NL)
Severe eating disorders (GGZ-MB, NL)
Severe psychosomatic disorders (Eikenboom, NL)
Children/parents (MBKT, NPi, NL)
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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