1. 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

2. Research team De Viersprong – Roel Verheul, Maaike Smits, 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 helene.andrea@deviersprong.nl

3. 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

4. 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

5. 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.

6. Schematic Model of BPD Constitutional factors Hyper-activation of the attachment system Trauma/ Stress Early attachment environment Retrieval of negative affect 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 affect regulation

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. Study population 45 patients referred to MBT ( Aug.’04 – Apr. ’08) Excluded: n=2 no DSM-IV BPD n=2 refused n=1 early dropout 40 PATIENTS INCLUDED

14. Demographic and clinical characteristics study population (N= 40) 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%

15. 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=40 6 months n=31; 12 months n=19; 18 months n=16

16. 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)

17. Results Symptomatic functioning (SCL90, BDI, EQ-5D) Effectsizes 0.75 – 1.79 Bales et al, 2009; Submitted – do not quote

18. Results Social and interpersonal functioning (IIP, OQ) Effectsizes 1.17 – 1.56 Bales et al, 2009; Submitted – do not quote

19. Effectsizes 1.08 – 1.58 large – very large SIPP: Verheul et al, 2008 Domain personality pathology

20. Results care consumption domain

21. 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)

22. (Methodological) limitations Working mechanisms; mentalization Low N and missing values Causality

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Vocational status 8 year follow-up 2008 Bateman & Fonagy

31. 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

32. 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

33. 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

34. Total Annual Health Care Utilization Costs

35. 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

36. 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

37. Treatment Outcome Studies UK Implementation of Outpatient Mentalization Based Therapy for Borderline Personality Disorder Bateman & Fonagy (2009)

38. 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)

39. 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?)

40. (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)

41. 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

42. RCT IOP vs day hospital treatment Explosive ASPD is excluded Pilot randomisation N=20 >70% cooperation

43. 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

44. Substance abuse among MBT patients: Substance abuse among MBT patients: Prevalence and relation to treatment outcome

45. Background & Aim Literature: 57%-67% BPD patients addiction problems -> MBT? Combination BPD & addiction -> treatment prognosis worse Study objective: What is the prevalence of DSM-IV substance abuse among MBT-patients? Additional explorative analysis: Is substance abuse related to MBT treatment outcome?

46. 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

47. 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)

48. 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

49. CIDI-SAM Abuse / dependence Total population (N = 24) 79.2% (N = 19) Prevalence substance abuse Results: Prevalence 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)

50. Hypothesis from literature: Prevalence liftetime substance abuse 50-70% MBT population: Prevalence 79% Explorative analysis: Association with treatment outcome?

51. Treatment outcome results Explorative longitudinal analyses Interaction Time x Lifetime substance abuse?

52. Interaction time * Lifetime substance abuse 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!

53. 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)

54. 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)

55. 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 improvement over time No difference improvement over time

56. Limitations Small N Retrospective measurement substance abuse (recall bias) Broader range of addictive problems Substance abuse outcome data not yet available

57. Conclusions Very high prevalence (79%) lifetime substance abuse diagnosis among MBT patients Significant improvement possible for DD patients (severe BPD and substance abuse)

58. BPD and addiction: Hannah 22 years old female Axis 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’

59. BPD and addiction: Henry 46 years old Axis I: polysubstance dependence (cocaine and alcohol); sexual dysfunction; depression Axis II: borderline personality disorder; narcissistic personality disorder, avoidant personality disorder Fired from work because of drug dependence Divorced, two children Detoxification before start MBT Able to follow a day program without drugs Some social structure (volunteer, children visits, etc) No users as friends, not in ‘drugscene’

60. 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

61. 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

62. 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)

63. 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

64. 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

65. 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)

66. 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

67. www.vispd.nl/presentations dawn.bales@deviersprong.nl helene.andrea@deviersprong.nlelene.andrea@deviersprong.nl ab.hesselink@deviersprong.nl