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

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 team De Viersprong – Roel Verheul, Helene Andrea, Fieke vd Meer, Nicole v Beek Erasmus University Rotterdam – Sten Willemsen, Jan van Busschach Tilburg University – Marieke Spreeuwenberg & MBT Staff (De Viersprong, Bergen op Zoom, The Netherlands) Internet: www.vispd.nlwww.vispd.nl / presentations Email maaike.smits@deviersprong.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 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 function To prevent reliance on prolonged hospital stays

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 Introduction MBT-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 BPD n=2 refused n=1 early dropout n=1 no follow-up measurements 39 PATIENTS INCLUDED Bales et al., submitted, 2009

Clinical characteristics Study population (N=40) MeanSd Age31.77.5 N% Female sex2870% At least one Axis-I diagnosis3895% More than one Axis-I diagnosis3280% Anxiety Disorders1743% Mood disorders1435% Eating disorders1333% Substance abuse & dependency start treatment2666% PTSD513% More than 1 comorbid axis II diagnosis2870% Paranoïd personality disorder923% Avoidant personality disorder923% Dependant personality disorder615% Histrionic personality disorder410% Antisocial personality disorder38% Bales et al., submitted, 2009

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) Bales et al., submitted, 2009

Results Symptomatic functioning (SCL90, BDI, EQ-5D) Effectsizes 0.75 – 1.79 Bales et al., submitted, 2009

Results Social and interpersonal functioning (IIP, OQ) Effectsizes 1.17 – 1.56 Bales et al., submitted, 2009

Effectsizes 1.08 – 1.58 large – very large SIPP: Verheul et al, 2008 Results Personality pathology

Results care consumption Bales et al., submitted, 2009

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) Bales et al., submitted, 2009

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)χ 2 = 16.5 p=.000004 Total mean (SD)5.5 (5.2)15.1 (5.3)F 1,35 = 29.7 p=.000004 Affect mean (SD)1.6 (2.0)3.7 (2.0)F 1,35 = 9.7p=.004 Cognitive mean (SD)1.1 (1.4)2.5 (2.0)F 1,35 = 6.9 p=.02 Impulsivity mean (SD)1.6 (1.8)4.1 (2.3)F 1,35 = 13.9 p=.001 Interpersonal mean (SD) 1.5 (1.7)4.7 (2.3)F 1,35 = 23.2p=.00003 8 year follow-up 2008 Bateman & Fonagy

Suicide attempts : mean (SD) MBT-PHTAUSignificance 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

Global Assessment of Function MBT-PHTAUSignificance 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

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

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)

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 MBT patients: Substance abuse among 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 substance abuse 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 BPD n=2 refused n=1 early dropout n=1 no follow-up measurements 39 PATIENTS INCLUDED Substance use disorders study, Bales et al. (manuscript 2009)

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 Substance use disorders study, Bales et al. (manuscript 2009)

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: Prevalence 79% Explorative analysis: Association with treatment outcome? Substance use disorders study, Bales et al. (manuscript 2009)

Treatment outcome results - Explorative longitudinal analyses Interaction Time x Lifetime substance abuse? Substance use disorders study, Bales et al. (manuscript 2009)

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. Substance use disorders study, Bales et al. (manuscript 2009)

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! Substance use disorders study, Bales et al. (manuscript 2009)

New comparison subgroups N = 5 no lifetime substance abuse N = 19 lifetime substance abuse Substance use disorders study, Bales et al. (manuscript 2009)

New comparison subgroups N = 5 no lifetime substance abuse N = 19 lifetime substance abuse Diagnosis start treatment? Yes: N = 13 No: N = 6 Substance use disorders study, Bales et al. (manuscript 2009)

New comparison subgroups N = 5 no lifetime substance abuse N = 19 lifetime substance abuse Diagnosis start treatment? Yes: N = 13 No: N = 6 Diagnosis start treatment Diagnosis start treatment Yes: N = 13 No: N = 11 (n = 5 + n = 6) Substance use disorders study, Bales et al. (manuscript 2009)

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) 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 time No 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)

New Developments: MBT-DD MBT-PH and IOP: parallel low-frequent outpatient 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

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

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

Other new MBT Developments Adolescents (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 dawn.bales@deviersprong.nl maaike.smits@deviersprong.nl

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.

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