Mentalization-based Group Therapy Research Articles

On the relationship between group analysis and mentalization-based group therapy

In this article we describe and reflect upon the roots of mentalization-based group therapy (MBT-G) and its relationship to group analysis. The original setting for MBT was psychotherapeutic day hospitals that were strongly influenced by group analytic thinking. The challenges from an increasing number of borderline patients initiated theoretical and therapeutic innovations that separated MBT-G from traditional group analysis who responded differently, e.g. by strengthening its ties to object-relational theories that emphasized innate destructive drives. Since then, the dialogue between the two approaches have been meagre in the UK, but more constructive in e.g. Norway and Germany. We argue that MBT-G needs group analytic competence with respect to basic group dynamics, and that group analysis needs revitalization by the theory of mentalizing. We call for dialogues between the two approaches. The authors belong to both camps and speak with reference to experiences in Norway, United Kingdom, Denmark and Germany.

Narrative Identity within Mentalization-Based Group Therapy for Adolescents: A Feasibility Study.

Borderline personality disorder (BPD) is characterized by severe disturbances related to understanding oneself and other people and can be reliably detected and treated in adolescence. In this feasibility study, we aimed to focus on the features of, and changes in, narrative identity throughout the course of Mentalization-Based Treatment in Groups (MBT-G) for adolescents with BPD. Six female patients (M = 15.2, SD = 0.75) joined between 16 and 31 (M = 23.83) MBT g sessions. The narrated events within each session across sessions were coded for themes of agency and communion and the narrated reactions were coded for personality functioning. The patients and their parents also completed several self-report measures before and after therapy. Themes of diminished agency and communion were identified, with communion as the dominating theme. When comparing the patients' first five sessions with their last five sessions, there was an increase in themes related to agency and decreased in communion. The narrated reactions were dominated by themes related to thwarted self-functioning and primarily identity, although intimacy was also present. Patients improved in terms of self-reported functioning and internalizing and externalizing behavior before and after end of treatment. The importance of narration in BPD (group) therapy is discussed alongside clinical implications.

Pseudomentalization as a Challenge for Therapists of Group Psychotherapy With Drug Addicted Patients.

One of the main challenges in group therapy with drug-addicted patients is collective pseudomentalization, i.e., a group discourse consisting of words and clichés that are decoupled from any inner emotional life and are poorly related to external reality. In this study, we aimed to explore the phenomenology of pseudomentalization and how it was addressed by the therapist in an outpatient group for drug-addicted patients. The group was composed of seven members, and the transcripts of eight audio-recorded sessions (one per month) were rated and studied. The interventions of the therapist were measured with the mentalization-based group therapy (MBT-G) adherence and quality scale by independent raters. Two sessions, one with the highest and one with the lowest adherence, were selected, and the clinical sequences of pseudomentalization were analyzed in a comparative way. The findings revealed that pseudomentalization does occur as a collective phenomenon, akin to “basic assumptions” of Wilfred Bion, which we reconceptualized in this study. Any pseudomentalization seemed to be reinforced by the therapist when she was presenting frequent and long interventions, when abstaining from the management of group boundaries, when providing questions focused more on content than on the mental states of the group members, and when not focusing on emotions. However, the ultimate source of collective pseudomentalization seemed to be the fear of the group members of being overwhelmed by painful emotions, mental confusion, and a loss of identity. The findings also indicated that the principles of MBT-G may be a good antidote to pseudomentalization.

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.

Mentalization-Based Group Therapy for Adolescents with Avoidant Personality Disorder: Adaptations and Findings from a Practice-Based Pilot Evaluation

ABSTRACTAvoidant personality disorder (AVPD) is amongst the most severe personality disorders (PDs) and associated with a marked reduction in social functioning. However, AVPD research is sparse and little is known about treatment efficacy. In adolescents with AVPD even less is known about the disorder, and no studies have investigated the effect of psychotherapeutic treatment for this group. In this study, we present a new group-oriented treatment approach, Mentalization-Based Treatment for Avoidant Adolescents (MBT-AA), based on Mentalization-Based Treatment (MBT) principles and with elements from positive psychotherapy. Furthermore, we report on findings from a small MBT-AA case example and show that the treatment program reduces avoidant personality pathology, internalizing pathology and increases mentalization. We discuss the results and the potential empowering aspects of this new approach.

Efficacy of Mentalization-based group therapy for adolescents: the results of a pilot randomised controlled trial

BackgroundMentalization Based Therapy (MBT) has yielded promising outcomes for reducing self-harm, although to date only one study has reported MBT’s effectiveness for adolescents (Rossouw and Fonagy, J Am Acad Child Adolesc Psychiatry 51:1304–1313, 2012) wherein the treatment protocol consisted of an intensive programme of individual and family therapy. We sought to investigate an adaptation of the adult MBT introductory manual in a group format for adolescents.MethodsThe present study is a randomised controlled single blind feasibility trial that aims to (1) adapt the original explicit MBT introductory group manual for an adolescent population (MBT-Ai) and to (2) assess the feasibility of a trial of MBT-Ai through examination of consent rates, attendance, attrition and self-harm. Repeated measures ANOVAs were conducted to examine change over time in independent and dependent variables between groups, and multi level models (MLM) were conducted to examine key predictors in relation to change over time with self-report self-harm and emergency department presentation for harm as the primary outcome variables.ResultsFifty-three young people consented to participate and were randomised to MBT-Ai + TAU or TAU alone. Five participants withdrew from the trial. Trial procedures seemed appropriate and safe, with acceptable group attendance. Self-reported self-harm and emergency department presentation for self-harm significantly decreased over time in both groups, though there were no between group differences. Social anxiety, emotion regulation, and borderline traits also significantly decreased over time in both groups. Mentalization emerged as a significant predictor of change over time in self reported self harm and hospital presentation for self-harm.ConclusionsIt was feasible to carry out an RCT of MBT-Ai for adolescents already attending NHS CAMHS who have recently self-harmed. Our data gave signals that suggested a relatively brief group-based MBT-Ai intervention may be a promising intervention with potential for service implementation. Future research should consider the appropriate format, dosage and intensity of MBT for the adolescent population.Trial registrationNCT02771691; Trial Registration Date: 25/04/2016.

Case formulations in mentalization-based group therapy.

Ideally, the assessment phase of patients who are referred to mentalization-based treatment (MBT) should conclude with a mentalization- based case formulation. The structure and content of such case formulations are described. Their aim are: i) to enhance treatment alliance and ii) to provide some structure to the treatment process through suggesting privileged themes related to emotions, relational patterns and mentalizing. MBT is a conjoint kind of psychotherapy, integrating individual and group therapies. Case formulations has belonged to the tradition of individual psychotherapy, while being mostly ignored by group therapists. The question is: are case formulations also relevant for group psychotherapy? How can they be properly introduced while not disturbing the group processes? The theme is discussed through a clinical vignette that illuminates typical therapeutic challenges in dynamic group psychotherapy with borderline patients. The author concludes with some suggestions for clinical structure, process and research.

Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy.

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance,” especially in initial sessions. It is also recommendable to strengthen patient to patient relations.

Efficacy of Mentalization-Based Group Therapy for Adolescents: A Pilot Randomised Controlled Trial

Background: Suicide is the leading cause of death in adolescents. Furthermore, up to one quarter of adolescents who self-harm will repeat self-harm within one year, highlighting the need for evidence-based prevention and treatment services. Mentalization Based Therapy (MBT) has yielded promising outcomes for individuals who self-harm, however to date only one study has examined MBT in adolescents, wherein the treatment protocol consisted of individual and family therapy. Currently, there has been no development or examination of MBT-A in a group format for adolescents.
 Methods/Design: The present study is a randomised controlled single blind feasibility trial that aims to (1) adapt the original explicit MBT introductory group manual for an adolescent population (MBT-Ai) and to (2) assess the feasibility of MBT-Ai through examination of consent rates, attendance, attrition and self-harm. Participants are adolescents presenting to Child and Adolescent Mental Health Services (CAMHS) with self-harming behaviors within the last 6 months. Young people will be randomised to a 12-week MBT-Ai group plus treatment as usual (TAU) or TAU alone. Participants will be assessed at baseline and at 12-, 24- and 36-weeks post-baseline.
 Discussion: This paper describes the development of a treatment manual and the protocol of a randomised controlled feasibility trial of MBT-Ai aimed at treating adolescents who self-harm. Further investigation of a full-scale trial will be necessary to instill benefits if pilot results suggest efficacy.
 Trial registration: NCT02771691

A high-quality mentalization-based group therapy session

A previous study of a MBT group displayed that the therapists failed to establish the group as a training ground for mentalizing. In this study we present a detailed and long transcript of a sequence in a successful MBT group. The therapists’ interventions were rated according to the mentalization-based group therapy adherence and quality scale, performed by the Norwegian MBT Quality Laboratory. The therapists displayed a high adherence to the MBT-G manual and the patients became collectively engaged in exploring and reflecting upon crucial borderline dynamics. The interventions that seemed most important for unfolding of the sequence are carefully spelled out. They have a metacognitive flavour, but are elsewise simple and straight forward. There seems to be nothing essentially new in this MBT-G approach, if one asks for specific ingredients. However, the therapeutic stance is consequently geared towards exploration of mental states, guided by a certain theory. One might say that it represents a more modern mixture of ingredients that are well known in different research and group therapy camps.

A comparative study of a mentalization-based versus a psychodynamic group therapy session

Aims: The purpose of this study was to explore how mentalization-based group therapy (MBT-G) for patients with borderline personality disorder may be both different and similar to a more traditional psychodynamic group psychotherapy approach. Material and methods: The study is a comparative case-study examining a supposedly representative clinical example of MBT-G and a supposedly representative clinical example of a psychodynamic group (PDG). Both groups were composed mainly of patients with borderline personality disorder. The study used a mixed methodological approach with quantitative research methods, including MBT-G Adherence and Quality Scale and Reflective Functioning Scale (RF-scale), and qualitative content analysis. Results: 1) The MBT-G therapists focused consistently on mental states and emotions. This was reflected both in a significantly higher intervention frequency, and in a higher proportion of theoretically assumed mentalizing-promoting interventions. 2) We observed an increase in mentalizing (defined as RF) among some patients in the MBT-G group. In the PDG session, RF development were less systematic, and had lesser impact. 3) Interventions with ‘demand’ characteristics might play an important role in developing a mentalizing group discourse. 4) In both groups, therapists and patients actively structured the sessions, but the MBT-G session more explicitly engaged in ‘meta’ discussions about it, i.e. discussing whether a topic should or should not be put on the agenda. Conclusion: Despite similarities between the approaches, differences in choice of therapeutic focus and consistency suggest that the two methods engage patients in different therapy processes. The results warrant studies that include more sessions in order to validate or falsify the resulting hypotheses.

First empirical evaluation of outcomes for mentalization-based group therapy for adolescents with BPD.

Adolescent borderline personality disorder (BPD) is a devastating disorder, and it is essential to identify and treat the disorder in its early course. A total of 34 female Danish adolescents between 15 and 18 years old participated in 1 year of structured mentalization-based group therapy. Twenty-five adolescents completed the study, of which the majority (23) displayed improvement regarding borderline symptoms, depression, self-harm, peer-attachment, parent-attachment, mentalizing, and general psychopathology. Enhanced trust in peers and parents in combination with improved mentalizing capacity was associated with greater decline in borderline symptoms, thereby pointing to a candidate mechanism responsible for the efficacy of the treatment. The current study provides a promising rationale for the further development and evaluation of group-format mentalization-based treatment for adolescents with borderline traits. (PsycINFO Database Record

The design of the MBT-G adherence and quality scale.

Few group psychotherapy studies focus on therapists' interventions, and instruments that can measure group psychotherapy treatment fidelity are scarce. The aim of the present study was to evaluate the reliability of the Mentalization-based Group Therapy Adherence and Quality Scale (MBT-G-AQS), which is a 19-item scale developed to measure adherence and quality in mentalization-based group therapy (MBT-G). Eight MBT groups and eight psychodynamic groups (a total of 16 videotaped therapy sessions) were rated independently by five raters. All groups were long-term, outpatient psychotherapy groups with 1.5 hours weekly sessions. Data were analysed by a Generalizability Study (G-study and D-study). The generalizability models included analyses of reliability for different numbers of raters. The global (overall) ratings for adherence and quality showed high to excellent reliability for all numbers of raters (the reliability by use of five raters was 0.97 for adherence and 0.96 for quality). The mean reliability for all 19 items for a single rater was 0.57 (item range 0.26-0.86) for adherence, and 0.62 (item range 0.26-0.83) for quality. The reliability for two raters obtained mean absolute G-coefficients on 0.71 (item range 0.41-0.92 for the different items) for adherence and 0.76 (item range 0.42-0.91) for quality. With all five raters the mean absolute G-coefficient for adherence was 0.86 (item range 0.63-0.97) and 0.88 for quality (item range 0.64-0.96). The study demonstrates high reliability of ratings of MBT-G-AQS. In models differentiating between different numbers of raters, reliability was particularly high when including several raters, but was also acceptable for two raters. For practical purposes, the MBT-G-AQS can be used for training, supervision and psychotherapy research.

Comments on Karterud’s ‘On Structure and Leadership in Mentalization-based Group Therapy and Group Analysis’, June 2015

Comments on Karterud’s ‘On Structure and Leadership in Mentalization-based Group Therapy and Group Analysis’, June 2015

A Response to ‘On Structure and Leadership in Mentalization-based Group Therapy and Group Analysis’ by Sigmund Karterud

A Response to ‘On Structure and Leadership in Mentalization-based Group Therapy and Group Analysis’ by Sigmund Karterud

On Structure and Leadership in Mentalization-based Group Therapy and Group Analysis

Mentalization-based group therapy (MBT-G) has its roots in group analytic psychotherapy. Modifications were made in order to suit the needs of more disturbed personality disordered patients, and to avoid the chaotic and destructive processes often encountered in groups dominated by these patients. In this article I outline the kind of leadership, structure and authority that MBT proscribes and discuss these principles in comparison with group analysis. I also comment upon a study of a MBT group that failed to establish a good mentalizing culture, with reference to Bion’s concept of ‘attack on linking’. This study reminds us that strong professional support and competent supervision is necessary in order to achieve sound communicational ideals, when the group is composed of members who easily resort to prementalistic modes of thinking.

A Qualitative Study of a Mentalization-based Group for Borderline Patients

In this article we present a video-based explorative study of three consecutive mentalization-based group therapy (MBT-G) sessions at a Norwegian Mental Health Centre. MBT-G has its roots in group analytic psychotherapy, but is modified to avoid the chaotic and destructive processes often encountered in groups consisting of severely personality disordered patients. Among the most notable differences from the Foulkesian group analytic approach are the therapists handling of authority and a ‘not-knowing stance’ (as opposed to an interpretative stance). Contrary to our expectations we found the typical chaotic borderline group processes that MBT-G was designed to avoid. An in-depth examination of the data, employing qualitative Thematic Analysis, revealed that the therapists failed to establish themselves as authoritative leaders of the group and misconstrued the ‘not-knowing stance’. We present transcripts of some typical sequences and discuss their clinical and therapeutic implications.

Mentalisierungsgestützte Gruppenpsychotherapie

Mentalization-based-treatment (MBT) has currently proven to be one of the most efficient treatments for patients with (borderline-)personality disorders in a dyadic as well as a group therapy setting. The underlying new theoretical and technical features of MBT-interventions are demonstrated. Furthermore, differences and similarities between MBT and other analytic group therapies are discussed with regard to the therapeutic stance as well as the affect-orientated intervention styles. Finally, prototypic therapeutic interventions that inhibit or enable mentalizing capacities are discussed. In the therapeutic context it is important that interventions which inhibit mentalization should be avoided. The concept of Mentalization-based group therapy should also be integrated in the curricula of group therapy training institutes. It has been shown that role-play is very effective in teaching MBT interventions.