Mentalization-based Treatment Research Articles

Pedagogical stance in mentalization-based treatment.

BackgroundA common aspect of evidence‐based treatments for people with borderline personality disorder (BPD) is pedagogical interventions and formats. In mentalization‐based treatment (MBT) the introductory course has a clear pedagogical format, but a pedagogical stance is not otherwise defined.MethodsTreatment integrity was quantitatively assessed in a sample of 346 individual MBT sessions. Nine group sessions and 24 individual MBT sessions were qualitatively subjected to interpretative phenomenological analysis (IPA).ResultsThe dominating intervention type was MBT Item 16—therapist checking own understanding (31% of the interventions). IPA unveiled the following: (1) a pervasive, but hidden/implicit psychopedagogical agenda, (2) psychopedagogical content seemed precious for the patients, and (3) four tentative strategies for pedagogical interventions in MBT (a) independent reasoning; (b) epistemic trust; (c) mental flexibility; and (d) application of verified insights, knowledge, or strategies.ConclusionDevelopment and clarification of the pedagogical stance in MBT could further improve the quality of therapists' interventions.

Interpersonal Psychotherapy and Mentalizing-Synergies in Clinical Practice.

Interpersonal psychotherapy (IPT) is an evidence-supported, relationally focused treatment for people living with depression and other psychiatric disorders in the context of stressful life events. Mentalizing, also relationally focused, promotes the ability to perceive, understand, and interpret human behavior in terms of intentional mental states of others or oneself, in order to support social leaning. IPT and mentalization-based treatments (MBT) both seek to improve interpersonal effectiveness, albeit with different emphases in the therapeutic process, with IPT promoting interpersonal problem solving and MBT promoting understanding of the obstacles to this outcome. In this article, the authors propose that the central intentions of IPT and mentalizing are essentially linked and complementary; understanding others and oneself in relationships facilitates interpersonal problem resolution and symptomatic recovery and enhances resilience. The clinical synergies of IPT and mentalizing are elaborated and illustrated through a case example of treatment for a socially isolated woman with depression and interpersonal sensitivities.

The mind-in-mind study: A pilot randomised controlled trial that compared modified mentalisation based treatment with supportive clinical management for patients with eating disorders without borderline personality disorder.

Mentalisation-based treatment (MBT) aims to improve reflective functioning. There is a growing evidence base outlining positive clinical outcomes for the use of MBT in eating disorder patients with co-morbid borderline personality disorder (BPD). The use of MBT has not been studied for eating disorder patients without BPD. This pilot study is an exploratory randomised controlled trial in which outcomes from MBT are compared with standard clinical management in a cohort of patients diagnosed with an eating disorder but not BPD. The main objectives were two-fold-to explore the use of MBT as a therapeutic modality and to test the acceptability and feasibility of the protocol design. Thirty-two participants were randomised to receive either MBT or standard treatment during an inpatient eating disorders program. All patients enrolled in the study were diagnosed with an eating disorder but did not meet DSM-5 criteria for BPD. On admission patients were categorised as very underweight (BMI 15.0-16.4kg/m2 ), underweight (BMI 16.5-18.4kg/m2 ) or healthy weight range (BMI ≥ 18.5-24.9kg/m2 ). Upon discharge participants were further categorised as weight restored (BMI ≥ 18.5kg/m2 ) or non-weight restored (BMI < 18.5kg/m2 ). The primary outcome was the subscale score on the Reflective Functioning Questionnaire (RFQ-8). Secondary outcomes were subscale scores on the Eating Disorder Examination Questionnaire and the Depression, Anxiety and Stress Scale (DASS)-21. Participants were assessed at baseline and on discharge. Statistical significance was determined using repeated measurements analysis of variance (ANOVA). Both groups experienced improvements in eating disorder symptoms and measures of psychological well-being. Participants within the MBT group exhibited greater improvements in reflective capacity as defined by the RFQ-8 however these benefits appeared to be limited to patients who achieved weight restoration at discharge. The eligibility criteria-which excluded comorbid BPD-led to challenges in recruitment which limited the power of the study analysis. As participants with a range of different eating disorder diagnoses were included this led to complexities in estimating the treatment effect within a defined cohort. Although the small sample size must be noted as a limitation-the finding that weight restoration appears to be associated with improvements in reflective capacity in MBT would be worth exploring in a subsequent larger study. Modification of eligibility criteria and recruitment from a defined cohort may increase the efficiency of a future study.

Trauma and Outcomes of Mentalization-Based Therapy for Individuals With Borderline Personality Disorder.

Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP). All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment. Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP. Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.

Hypermentalizing and Borderline Personality Disorder: A Meta-Analytic Review.

A hypermentalizing impairment, or tendency to overattribute mental states to others, has been identified among individuals with borderline personality disorder. However, associations between hypermentalizing and other disorders call into question the specificity of this impairment to borderline personality disorder. This study aimed to evaluate the relative strength of the association between hypermentalizing and borderline personality disorder compared with other disorders and to assess the impact of moderators on the relationship between hypermentalizing and psychopathology. The authors conducted a meta-analysis of 36 studies (N=4,188 people) to investigate the relative strength of the association between hypermentalizing and borderline personality disorder, compared with other disorders, and to assess the impact of moderators on this relationship. The Movie for the Assessment of Social Cognition, an ecologically valid experimental instrument, was used to measure hypermentalizing. Results indicated support for an association between psychopathology and hypermentalizing (r=0.24, 95% confidence interval [CI]=0.17 to 0.31), but the association was not significantly stronger for borderline personality disorder (r=0.26, 95% CI=0.12 to 0.39) than for other disorders (r=0.24, 95% CI=0.14 to 0.33). Neither age nor gender significantly moderated the association between psychopathology and hypermentalizing. Hypermentalizing may be related to psychopathology in general rather than borderline personality disorder in particular. The findings are discussed in view of the possibility that features of borderline personality disorder associated with other psychopathology may explain the overall association between psychopathology and hypermentalizing. Clinical implications for mentalization-based treatment and concerns that the measurement used for hypermentalization may be too narrow and not representative of variations in functioning across cultures and race-ethnicity also are discussed.

Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis.

A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD). To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely. We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition. Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, P = 0.006; psychosocial functioning: SMD -0.51, P = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, P < 0.0007; suicide-related outcomes: risk ratio 0.10, P < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, P < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, P = 0.03; suicide-related outcomes: SMD -0.96, P = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, P = 0.002). There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode".

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Art therapy for children following adverse childhood experiences: An intervention development study

The aim of this study was to complete the planning stage of intervention development for ACTIVATE-C (ACTIVe Art ThErapy for Children in the community), a complex intervention that supports art therapists to improve outcomes for children struggling with social, emotional and mental health difficulties following Adverse Childhood Experiences. The Person-Based Approach to intervention planning was used to identify barriers, facilitators and suggested solutions and ensure that ACTIVATE-C is not just acceptable and usable but also engaging and persuasive. The study included seven art therapists, trained in mentalization-based therapy, with more than three years’ experience practising with children and/or providing clinical supervision. Ten stakeholder workshops resulted in changes to the intervention plan: a written manual became a Digital Health Intervention (DHI), including underlying clinical guiding principles, protocols and training to support art therapists adopt a mentalization-based active stance; intervention materials were clarified; icons and a treatment pathway were added; creative input from therapist and child was highlighted; psychoeducation for children was digitally integrated. The key output of this research is an acceptable planned DHI called ACTIVATE-C, targeting actions required by art therapists to improve outcomes for children who have had Adverse Childhood Experiences. ACTIVATE-C is now ready for optimization.

Mentalization-Based Treatment for a Physician With Borderline Personality Disorder.

Mentalization-Based Treatment for a Physician With Borderline Personality Disorder.

TBM-Crise : intervention hospitalière brève basée sur la mentalisation

Contexte Notre équipe travaille dans une unité hospitalière psychiatrique de crise aux Hôpitaux universitaires de Genève (Suisse). Nous y accueillons pour 7 jours des personnes en situation de crise qui présentent des idées ou un comportement suicidaire. Comme facteurs précipitant la crise suicidaire, ces personnes traversent des évènements de vie s’accompagnant d’intenses difficultés interpersonnelles et menaçant l’image qu’ils ont d’eux-mêmes. Il y a dans notre population clinique environ 35 % de patients souffrant de trouble de personnalité limite (TPL). Chez ces patients, les crises à répétition et les comportements suicidaires engendrent des ruptures relationnelles et thérapeutiques fréquentes et dommageables. Notre objectif est de développer une approche spécifique à cette problématique clinique. Intervention Nous avons développé une intervention psychologique brève focalisée sur la mentalisation en 4 temps : accueil, mentalisation affective des éléments de crise, formulation de la problématique, travail sur la sortie et la suite de soins ambulatoires. Cette intervention est adaptée à une équipe médicosoignantes. Du point de vue de la thérapie basée sur la mentalisation (TBM), la phase d’accueil est principalement consacrée à un mirroring et à une régulation affective afin de réduire l’intensité de la désorganisation psychique. Il s’agit ensuite d’activer la capacité à mentaliser, à savoir la curiosité au sujet des états mentaux, au travers d’un travail sur la narrative de crise avec un focus affectif. Nous travaillons ensuite à construire avec les personnes une formulation de sa problématique dans laquelle elle a peut assumer un rôle. Il s’agit de les rendre « agents » de leurs crises. Alors nous pouvons terminer l’intervention en travaillant tant la séparation qu’une projection dans le futur immédiat. Le but est alors de prolonger le travail psychologique entamé au niveau d’un réseau ambulatoire. Cette dernière phase voit se réactiver le système d’attachement et réapparaître les difficultés jusque-là extérieures à l’espace thérapeutique. Implications cliniques La TBM est efficace pour le TPL notamment sur la réduction des gestes suicidaires et du nombre d’hospitalisations. Nous avons ajusté son dispositif théorique et clinique pour des individus hospitalisés en raison d’une crise suicidaire et qui présentent des profils psychopathologiques divers et comorbides. La TBM permet l’adaptation et l’évaluation d’outils psychothérapeutiques empiriquement fondés à différents contextes cliniques, mais aussi à différentes populations cliniques.

A Comparison of the Effectiveness of Mentalization-Based Therapy (MBT) and Affect Phobia Therapy (APT) in Reducing Depressive Symptoms in Women with Borderline Personality Disorder

Aim: The present study aimed to determine the effectiveness of Mentalization-based therapy (MBT) in comparison with Affect Phobia Therapy (APT) in reducing depressive symptoms in women with borderline personality disorders. Methods: The study had a quasi-experimental method with a pretest-posttest design and follow-up with a control group. The statistical population consisted of 120 women with borderline personality disorder symptoms who visited counseling centers in Qom from August and October 2020. After screening with the Goldberg Depression Questionnaire (1971) and interviews according to DSM-5 criteria, 60 women were selected by purposive sampling and were randomly assigned to two experimental groups and a control group (20 per group). The first experimental group received mentalization-based therapy by Batman and Funagi (2016), and the second experimental group received affect phobia therapy by McCullough in eight 90-minute sessions, one session per week, and the control group was placed on a waiting list. Data were analyzed using repeated-measures analysis of variance (ANOVA). Results: The results indicated the effects of mentalization-based therapy intervention (F=18.41, P=0.001) with an effect size of 0.36, and affect phobia therapy intervention (F=20.35, P=0.001) with an effect size of 0.38 on women's depression, and the stability of the effects at the follow-up stage. Conclusion: The affect phobia therapy along with medication can be used for patients with depression.

The role of attachment in sexualised polydrug use among LGBT+ male Chemsex users and the impact on Neuropsychology: Clinical implications for the use of Mentalisation Based Therapy (MBT)

The role of attachment in sexualised polydrug use among LGBT+ male Chemsex users and the impact on Neuropsychology: Clinical implications for the use of Mentalisation Based Therapy (MBT)

Mentaliser les conflits en thérapie de groupe : détruire et survivre, au service de la cohésion

La prévalence élevée des troubles de la personnalité et l’impact important de ces troubles sur le fonctionnement des individus atteints en font un enjeu majeur et incontournable des soins en santé mentale. Plusieurs traitements de psychothérapie ont démontré jusqu’à maintenant des bénéfices significatifs dans l’amélioration des difficultés liées à ces troubles. La thérapie basée sur la mentalisation (TBM), qui utilise la psychothérapie de groupe, est l’un des traitements reconnus comme efficaces. La modalité de groupe basée sur la mentalisation (TBM-G) présente toutefois des défis pour les psychothérapeutes. L’efficacité même de l’intervention de groupe repose, selon les auteurs, sur la capacité à stimuler la mentalisation, utiliser la dynamique de groupe, encourager la cohésion et permettre l’expérience d’une réappropriation réparatrice de situations conflictuelles, qui, à leur avis, sont sous-utilisées dans ce type de processus thérapeutique. Le présent article s’attarde, en ce sens, à des pistes d’interventions pour favoriser des attitudes mentalisantes dans un groupe de thérapie. Plus spécifiquement, nous tentons de réviser comment l’attention portée à ce qui se produit dans l’ici et maintenant, l’identification et la résolution du « détruit/trouvé » et le développement de métacognitions se veulent des techniques qui stimulent la cohésion et potentialisent le processus thérapeutique.

A rapid evidence assessment of psychological treatment approaches for stalking behaviour

PurposeThis paper aims to provide practitioners with a brief but comprehensive review of the current evidence base for psychological treatment approaches used in the UK that may be useful for stalking therapies.Design/methodology/approachA rapid evidence assessment was conducted on papers (post the UK Protection from Harassment Act, 1997) that discuss treatments of stalking (with or without a conviction) and associated offences/disorders. Therapies reviewed were Acceptance and Commitment Therapy, Cognitive Analytic Therapy, Cognitive Behavioural Therapy, Dialectical Behaviour Therapy and Schema Therapy. Searches for Mentalization-Based Therapy and Psychodynamic Therapy in relation to stalking were also performed but yielded no results that met inclusion criteria.FindingsThere is currently a severely limited evidence base for the efficacy of the psychological treatment of stalking behaviours. Some interventions show promise although a multifaceted, formulation-based approach is likely to be required.Practical implicationsFuture research would benefit from robust studies focused on stalking with long-term efficacy follow-ups.Originality/valueTo the best of the authors’ knowledge, this is the first rapid evidence review of psychological treatments that directly address stalking behaviour.

The role of attachment in sexualised polydrug use among LGBT+ male Chemsex users and the impact on Neuropsychology: Clinical implications for the use of Mentalisation Based Therapy (MBT)

The role of attachment in sexualised polydrug use among LGBT+ male Chemsex users and the impact on Neuropsychology: Clinical implications for the use of Mentalisation Based Therapy (MBT)

The role of attachment in sexualised polydrug use among LGBT+ male Chemsex users and the impact on Neuropsychology: Clinical implications for the use of Mentalisation Based Therapy (MBT)

The role of attachment in sexualised polydrug use among LGBT+ male Chemsex users and the impact on Neuropsychology: Clinical implications for the use of Mentalisation Based Therapy (MBT)

Effectiveness of Psychological Treatments for Borderline Personality Disorder and Predictors of Treatment Outcomes: A Multivariate Multilevel Meta-Analysis of Data from All Design Types.

We examined the effectiveness of psychotherapies for adult Borderline Personality Disorder (BPD) in a multilevel meta-analysis, including all trial types (PROSPERO ID: CRD42020111351). We tested several predictors, including trial- and outcome type (continuous or dichotomous), setting, BPD symptom domain and mean age. We included 87 studies (N = 5881) from searches between 2013 and 2019 in four databases. We controlled for differing treatment lengths and a logarithmic relationship between treatment duration and effectiveness. Sensitivity analyses were conducted by excluding outliers and by prioritizing total scale scores when both subscale and total scores were reported. Schema Therapy, Mentalization-Based Treatment and reduced Dialectical Behavior Therapy were associated with higher effect sizes than average, and treatment-as-usual with lower effect sizes. General severity and affective instability showed the strongest improvement, dissociation, anger, impulsivity and suicidality/self-injury the least. Treatment effectiveness decreased as the age of participants increased. Dichotomous outcomes were associated to larger effects, and analyses based on last observation carried forward to smaller effects. Compared to the average, the highest reductions were found for certain specialized psychotherapies. All BPD domains improved, though not equally. These findings have a high generalizability. However, causal conclusions cannot be drawn, although the design type did not influence the results.

Expert clinicians’ prototypes of an adolescent treatment: Common and unique factors among four treatment models

Objective: To investigate (1) whether expert clinicians within psychodynamic therapy (PDT), mentalization-based treatment (MBT), cognitive-behavioral therapy (CBT), and interpersonal psychotherapy (IPT) agree on the essential adolescent psychotherapy processes using the Adolescent Psychotherapy Q-Set (APQ); (2) whether these four session prototypes can be empirically distinguished; and (3) whether mentalization is a shared component in expert clinicians’ conceptualizations of these four treatment models. Method: Thirty-nine raters with expertize in PDT, MBT, CBT, and IPT provided ratings of the 100 APQ items to characterize a prototypical session that adheres to the principles of their treatment model. A Q-factor analysis with varimax rotation was conducted. Results: Expert clinicians reached a high level of agreement on their respective session prototypes, which loaded onto five independent factors. The PDT session prototype straddled two different factors, suggesting more variability in PDT expert clinicians’ understanding of PDT process for adolescents than in the views of the expert clinicians representing the other treatment models. Mentalization process was shared among all four session prototypes; however, the correlation between the CBT and IPT session prototypes remained significant after controlling for the MBT session prototype. Conclusions: Researchers can now assess adherence to four adolescent treatments and identify change processes beyond these labels.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study.

Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

Lenses and Mirrors: Reflecting on Dyadic Psychotherapy, Supervision, and Research with Families Involved in the Child Welfare System

ABSTRACT Historically, services for families in the child welfare system have been behaviorally and externally focused, rather than attuning to what is happening on the inside for parents and children. Rarely do families have access to psychodynamic treatment provided by highly trained and well supported therapists. The Building Blocks program was developed at New Alternatives to Children, a child welfare agency, to provide mentalization-based psychodynamic treatment to families with children in foster care or at risk of being removed from the home. This paper presents data from a case of a mother and her infant daughter, observed through three lenses – clinical observation, research and supervision – sharpening our understanding of factors that facilitate trust, healing and attachment within both parent-child and therapeutic relationships. To empirically evaluate the Building Blocks program, families participate in assessments at baseline and after 12 sessions. We observed meaningful changes in this dyad’s verbal and nonverbal behaviors, based on Coding Interactive Behavior System, confirming the clinical observations. Finally, reflective supervision supported positive movement, and the use of video aided therapist mentalization. Integration of clinical training and research can provide a more comprehensive view of clinical work and allow families to be more fully seen and known.