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 team De Viersprong – Roel Verheul, Dawn Bales, Maaike Smits, Helene Andrea, Joost Hutsebaut, Katharina Koch, Fieke v/d Meer Erasmus University Rotterdam – Reinier Timman, Jan van Busschbach Tilburg University – Marieke Spreeuwenberg & MBT Staff (De Viersprong, Bergen op Zoom, The Netherlands) Internet: / presentations

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

Treatment outcome 0-18 months UK & NL Effectsize NL 1.23 Submitted for publicaton – do not quote

Treatment outcome 0-18 months UK & NL Effectsize NL 1.36 Submitted for publicaton – do not quote

Treatment outcome 0-18 months UK & NL Submitted for publicaton – do not quote

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

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

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 N= 61 Highly comorbid borderline patients

18 month follow-up UK and NL Preliminary results 2010 – do not quote

18 month follow-up UK and NL Preliminary results 2010 – do not quote

18 month follow-up UK and NL Effectsize NL months 1.49 Preliminary results 2010 – do not quote

18 month follow-up UK and NL Preliminary results 2010 – do not quote

18 month follow-up UK and NL Cutoff BPDSI Effectsize NL months 1.98 Preliminary results 2010 – do not quote

Effectsizes very large SIPP: Verheul et al, 2008 Results Personality pathology 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 Preliminary results 2010 – do not quote

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)χ 2 = 16.5 p= Total mean (SD)5.5 (5.2)15.1 (5.3)F 1,35 = 29.7 p= 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= Bateman & Fonagy (2008) Am J Psychiatry

Suicide attempts : mean (SD) MBT-PHTAUSignificance Total N mean (SD).05 (0.9)0.52 (.48)U = 73 Z= 3.9 p = Any attempt N (%) 5 (23)14 (74)χ2 = 8.7 df- =1 P =.003 Bateman & Fonagy (2008) Am J Psychiatry

Global Assessment of Function MBT-PHTAUSignificance Mean (SD)58.3 (10.5)51.8 (5.7)F1,35 = 5.4 p=.03 Number (%) > (45.5)2 (10.5)χ2 = 6.5 df = 1 p =.02 Bateman & Fonagy (2008) Am J Psychiatry

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 Bateman & Fonagy (2008) Am J Psychiatry

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

Matched samples: Patient characteristics and treatment outcome for MBT versus 3 other psychotherapeutic treatment settings Matched samples: Patient characteristics and treatment outcome for MBT versus 3 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 and other psychotherapeutic programs Study aim: What is the effectiveness of day hospital MBT when compared to other psychotherapeutic treatment settings? Study aim: What is the effectiveness of day hospital MBT when 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 MBTN=175 other treatment setting Assignment 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 personality pathology (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 Score

MBT: for 31% PS too high (= too severe) -> Matching not possible MBT versus SCEPTRE before matching

Matches for n=21 MBT: N=21 SCEPTRE SettingMean Teatment Duration Inpatient (47%) 11.7 Months (sd 8.7) Day hospital (29%) 10.2 months (sd 6.6) Outpatient (24%) 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 MBT

Conclusions Treatment groups 31% 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

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

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

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

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 IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

Percent of Sample Who Had Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months n.s. p<.02 p<.0002 IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

Percent who had made life threatening suicide attempt n.s. p<.0004 IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

Percent of who seriously self harmed n.s. p <.08 p<.05 IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

Average Beck Depression Scores IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

Average Interpersonal Problems Scores IOP vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

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 vs. SCM Bateman & Fonagy (2009) Am J Psychiatry

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

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

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) 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 Substance use disorders study, Bales et al. (manuscript 2010)

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 2010)

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 2010)

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 2010)

Summary Lifetime 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) Substance use disorders study, Bales et al. (manuscript 2010)

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

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

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 Not yet published – do not quote

Outcome Monitoring: symptom index Not yet published – do not quote

Outcome Monitoring: level of personality problems 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) A summary of the evidence & new evidence 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 Unit MBT QA/QI Supervisor team 2 Day- Hospital Group 1 Day- Hospital Group 2 Pre- Treatment CEM CEM-A CEM-C - children -- adolesc. Post- treatment IOP 1 MBT-C MBFT IOP 2 MBT-C MBFT IOP 3 MBT-C MBFT MBT-A MBT-A Supervisor team 3 Supervisor 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) A summary of the evidence & new evidence 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 and To increase the amount of BPD patients receiving evidence-based (cost)effective BPD treatment.

In company MBT Training 2x half dayTeammanager/ project leader Kick offTeamOptional 2-day basic trainingTeam 3rd day basictrainingTeam Training on-the-job 5 days3 therapists First day extra trainingTeam Second day extra trainingTeam TeamsupervisionTeam Individual supervision ; 8x 1 x p 6 weeks All therapists Individual supervision : 6 x 1 x p 2 months ST

Training MBT Nr.Phase training Result Implementa tion. MBT Result program 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+  -; endedsplitting,, reorganisation 5.Finished+  -Small, vulnerable team, working on recovery 6.FinishedendedImplementation 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 Etten-Leur

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 Supervisory Adherence Measure Therapist Adherence Measure Implementatio n program MBT Expert/consultant MBT Expertisecenter Manualized SupervisorPatiënt

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