Mentalization-based Therapy: A summary of the evidence and new developments

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.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 Retrieval of negative affect laden memories and cognitions Constitutional factors Activating (provoking) risk factors Hyper-activation of the attachment system BPD: Pre-mentalistic subjectivity Trauma/ Stress Poor affect regulation Inhibition of judgements of social trustworthiness, paranoid thoughts and mentalizing failure Early attachment environment Formation risk factors Vulnerability risk factors

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 IntroductionMBT-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 BPDn=2 refusedn=1 early dropout 40 PATIENTS INCLUDED

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

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=406 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. Domain personality pathology SIPP: Verheul et al, 2008 Effectsizes 1.08 – 1.58 large – very large

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) 8 year follow-up 2008 Bateman & Fonagy

28. Suicide attempts : mean (SD) 8 year follow-up 2008 Bateman & Fonagy

29. Global Assessment of Function 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. Design of Intensive out-patient MBT RCT • 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 IOP vs. SCM Bateman & Fonagy (2009)

39. 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 Therapy 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: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 BPDn=2 refusedn=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. Results: Prevalence substance abuse 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?