Mentalization Based Treatment: past, present, and future - BIGSPD

Mentalization Based
Treatment: past, present,
and future
Prof Anthony Bateman
BIGSPD Conference
Manchester 2012

Halliwick Unit

Meet some Mentalizing Mafia
n Menninger Clinic/Baylor Medical College (The USA branch)
Ø Dr Jon Allen
Ø Dr Lane Strathearn
Ø Dr Brooks King-Casas
Ø Dr Read Montague
n Yale Child Study Centre
Ø Prof Linda Mayes
Ø Dr Carla Sharp
Ø Dr Efrain Bleiberg
Ø Professor Flynn O’Malley
Ø Professor Nancy Suchman

And further recent recruits
• Cindy Decoste
• Ulla Kahn
• Morten Kjolbe
• Benedicte Lowyck
• Marjukka Pajulo
• Robert Green
• Dave Carlyle
Ø Dawn Bales
Ø Dr Mirjam Kalland
Ø John Gunderson
• Trudie Rossouw
• Bart Vandeneede
• Annelies Verheught-Pleiter
• Rudi Vermote
• Joleien Zevalkink
• Bjorn Philips
• Lois Choi-Kain
• Brandon Unruh
And Rose Palmer and Fran Fonagy for help with the preparation of this presentation.
Ø Professor Finn Skårderud
Ø Professor Sigmund Karterud

NEW!
IMPROVED!
Washes brains
whiter!
Some Free Publicity
2012
American Psychiatric Publishing, Inc
JUST RELASED!
Longer than all
previous
versions!

What is
Mentalizing?

What is mentalizing?
Mentalizing is a form of imaginative
mental activity about others or oneself,
namely, perceiving and interpreting
human behaviour in terms of
intentional mental states (e.g. needs,
desires, feelings, beliefs, goals,
purposes, and reasons).

CBT: The value of understanding
the relationship between
my thoughts and feelings and
my behaviour.
PSYCHODYNAMIC: The value of
Understanding the nature of resistance
to therapy, and the dynamics of
here-and-now in the therapeutic
relationship.
Mentalizing
as an
Integrative
framework
SYSTEMIC: The value of
understanding the relationship
between the thoughts and
feelings of family members and
their behaviours, and the impact
of these on each other.
COMMON LANGUAGE
SOCIAL ECOLOGICAL: The value
of understanding the impact of
context upon mental states;
deprivation, hunger, fear, etc...

Forewarning
In advocating mentalization-based treatment we
claim no innovation. On the contrary,
mentalization-based treatment is the least novel
therapeutic approach imaginable: it addresses
the bedrock human capacity to apprehend mind
as such. Holding mind in mind is as ancient as
human relatedness and self-awareness.
Chichester: J. Wiley, 2006
—Allen & Fonagy (2006) Preface.
MBT is a technique
NOT a new theology!

Mentalizing at the World Cup: How does Robert Green
feel after letting in the USA goal?
Upset
Angry
Disappointed Frustrated

The simple idea behind MBT-BPD
n Failure of mentalization in attachment associated
contexts is key aspect of BPD psychopathology
n An individual with BPD is vulnerable to the
collapse of subjectivity associated with
Ø intolerable mental pain
Ø amplified experience of negative emotions
Ø cognitive dyscontrol
n A psychotherapeutic approach focusing on
sensitively and gently expanding and clarifying
the patient’s representations of mental states
serves to reduce impulsivity and improves sense
of subjective well-being.

Mentalizing Profile of Prototypical BPD patient
Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.
Implicit-
Automatic-
Non -conscious-
Immediate.
Mental
interior
cue
focused
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
BPD
amygdala, basal ganglia,
ventromedial prefrontal
cortex (VMPFC),
lateral temporal cortex (LTC)
and the dorsal anterior
cingulate cortex (dACC)
medial frontoparietal
network activated
Associated with several areas
of prefrontal cortex
BPD
frontoparietal mirror-neuron
system
lateral and medial prefrontal cortex
(LPFC & MPFC), lateral and medial
parietal cortex (LPAC & MPAC),
medial temporal lobe (MTL),rostral
anterior cingulate cortex (rACC)
BPD
recruits lateral fronto-temporal
network
BPD
Associated with inferior prefrontal
gyrus
the medial prefrontal cortex,
ACC, and the precuneus
Explicit-
Controlled
Conscious
Reflective
Mental
exterior
cue
focused
Affective
self:affect state
propositions
Belief-desire
MPFC/ACC
inhibitory
system

Treatment vectors in re-establishing mentalizing
in borderline personality disorder
Implicit-
Automatic
Mental
interior
focused
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
Impression Controlled driven
Emotional Autonomy
sensitivity
Inference Appearance
Certainty Doubt of of cognition emotion
Explicit-
Controlled
Mental
exterior
focused
Affective
self:affect state
propositions
Belief-desire
MPFC/ACC
inhibitory
system

Is there evidence
that individuals
with borderline
PD have
mentalization
problems?

Trust in Borderline Personality Disorder
King-Casas, Sharp, Lomax-Bream, Lohrenz, Fonagy, & Montague (2008) Science,
321, 806-810.
n Studying social behavior in task that involves
Ø Live interaction with unknown but real person
Ø Engages mesocorticolimbic dopaminergic reward
circuit
n Total patients screened è assessed è scanned:
Ø BPD: 1,060 è 224 è 62
Ø Mood control: 622 è 235 è 22
Ø Normal control: 877 è 398 è 116

$20
Disordered Social Exchange?
healthy
investor
X 3
BPD
trustee

*King-Casas et al, in Science, 321,
806-810
Average Repayment:
repay everything
repay investment (33%)
repay nothing

Investor Sent
MU sent / MU available
44 non-psychiatric investors
55 non-psychiatric investors
Trustee Repaid
MU sent / MU available
44 non-psychiatric trustees
55 BPD trustees
60%
50%
40%
30%
20%
10%
60%
50%
40%
30%
20%
10%
*King-Casas et al, in Science, 321, 806-810
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
rounds

Traumatic attachment history associated with
affect dysregulation crucial in inhibiting
mentalization in the face of stress
n Arousal/stress inhibits controlled (‘reflective’)
mentalization
n This leads to automatic mentalizing dominated by
reflexive (unreflective) assumptions regarding self
and others under stress, which may not be obvious
in low stress conditions
n Reemergence of non-mentalizing modes
Luyten, P., Mayes, L. C., Fonagy, P., & Van Houdenhove, B. (2010). The interpersonal regulation of stress: A
developmental framework. Manuscript submitted for publication.
Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and
treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355-1381.
Fonagy, P., Luyten, P., Bateman, A., Gergely, G., Strathearn, L., Target, M., et al. (2010). Attachment and
personality pathology. In J. F. Clarkin, P. Fonagy & G. O. Gabbard (Eds.), Psychodynamic psychotherapy for
personality disorders. A clinical handbook (pp. 37-87). Washington, DC: American Psychiatric Publishing.

Dimensions of mentalization: implicit/automatic
vs explicit/controlled in Othello
Controlled
That Why, handkerchief how now, ho! from which whence I so ariseth loved this? and gave thee
Thou Are we gavest turn'd Turks, to Cassio. and to ourselves do that
By Which heaven, heaven I saw hath forbid my handkerchief the Ottomites? in's hand.
For Christian shame, put by this barbarous brawl:
Controlled Automatic
Love
Spurned/
Automatic

Dimensions of mentalization: implicit/automatic
vs explicit/controlled in Othello
Controlled Controlled
That handkerchief which I so loved and gave thee
Thou Lateral gavest to Cassio.
By heaven, temporal Lateral I saw PFC Amygdala
my handkerchief Medial Ventromedial PFC PFC
in's hand.
cortex
Controlled Automatic
Automatic Automatic
Arousal

Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychological understanding drops and is
rapidly replaced by confusion about mental
states under high arousal
Controlled Controlled
That handkerchief which I so loved and gave thee
Thou gavest to Cassio.
By heaven, I saw my handkerchief in's hand.
Controlled Automatic
Automatic Automatic
Arousal

BPD and Minnesota longitudinal study
(Carlson, Egeland, & Sroufe, 2009)
n Early predictors borderline personality symptoms at age 28:
Ø Attachment disorganisation
Ø maternal hostility and boundary dissolution .42***
o (42 months)
Ø family life stress .29***
o (3-42 months)
n Adolescent predictors (12 years)
Ø attentional disturbance,
Ø emotional instability,
Ø behavioral instability, and
Ø relational disturbance.
n Process analyses suggest mediating effect of self-representation on relation
between attachment disorganisation on borderline symptoms.

Movie for the Assessment of Social Cognition
(MASC) (Dziobek et al 2006)
Picture 1: Cliff is the first to arrive at Sandra’s house for the dinner party.
He and Sandra seem to enjoy themselves when Cliff is telling about his
vacation in Sweden

Movie for the Assessment of Social Cognition
(MASC) (Dziobek et al 2006)
Picture 2: When Michael arrives, he dominates the conversation,
directing his speech to Sandra alone

Movie for the Assessment of Social Cognition
(MASC) (Dziobek et al 2006)
Picture 3: Slightly annoyed by Michael’s bragging story, Sandra shortly looks in
Cliff’s direction and then asks Michael: ‘‘Tell me, have you ever been to Sweden?’’
Question: Why is Sandra asking this?

Movie for the Assessment of Social Cognition
(MASC) (Dziobek et al 2006)
n Example correct answers:
Ø To change to the topic that Cliff talked about before so
that he gets involved again
Ø To redirect the conversation to Cliff
Ø To integrate Cliff
n Example incorrect answers:
Ø To hear if Michael also has something interesting to say
about Sweden
Ø To see which of the two guys has a cooler story to tell
Ø She is very suspicious of Michael and thinks he is
making up stories because he is the kind of person who
tries to deal with his inadequacy by making up stories. So
she wants to see if Michael’s story corroborates Cliff’s

Impaired abilities in social cognition compared to
healthy controls in their recognition of emotions,
thoughts, and intentions on the MASC.
40
35
30
25
20
15
10
5
0
n.s.
“Reading the mind
in the eyes”sum
score
p

What is
mentalization
based treatment
for individuals
with borderline
PD?

So what should the therapist aim do?
n Care taken not to assume the presence of
social cognitive capacities that cannot be
relied on
n Empathy with experience of disrupted
subjectivity
Ø Psychic equivalence è ego-destructive shame
Ø Pretend mode è sense of disintegration
Ø Teleological mode è the urgency to cause
observable change
n Constant awareness of the potential for
iatrogenic harm
Ø Over-activating the attachment system è
reduces the capacity for mentalization

Implication for the phenomenology
of borderline personality disorder
n Patients with BPD feel vulnerable to losing a sense
of self in interpersonal interchange because they
cannot adequately inhibit the alternative state of
mind which is imposed on them through social
contagion.
n Perhaps the apparent determination to ‘change
and control’ the mind of others characteristic of
BPD patients should be best seen as a defensive
reaction, defending the integrity of the self within
attachment contexts.
Ø without such control, they might feel excessively
vulnerable to losing their sense of separateness and
individuality.

Shared
characteristics of
evidence based
therapies for BPD
likely to enhance
the organization
of mental states?

MBT
DBT
CBT
SFT
TFP

Psychotherapy for BPD
n A range of structured treatment programmes for
BPD shown to be effective in studies
Ø DBT
Ø TFP
Ø SFT
Ø CBT
Ø SPT
Ø DDP
Ø CAT
Ø GPM
Ø MBT
n Do they work for
the reasons the
developers suggest?

Mentalizing Elements of BPD
Therapies (1)
n Extensive effort to maintain engagement in treatment
(validation in conjunction with emphasis on need to
address therapy interfering behaviours) è
acceptance and recognition
n Include a model of pathology that is explained to the
patient è increased cognitive coherence (early phase)
n Active therapist stance: Explicit intent to validate and
demonstrate empathy, generate strong attachment
relationship è foundation of alliance (epistemic trust)
n Focus on emotion processing and connection between
action and feeling (suicide feeling == abandonment
feelings) è restore cognitive representation of
emotion

Who specifically
benefits from
MBT-BPD?
Or should all patients
be offered SCM/
GPM

Design of intensive out-patient MBT
randomized controlled trial.
n Referrals for Intensive Outpatient
(IOP-MBT) and Structured Clinical
Management (SCM) groups
n Random allocation (minimisation for
age, gender, antisocial PD)
n Individual (50 mins) + Group (1.5 hrs)
sessions weekly for 18 months
n Assessments at admission, 6
months, 12 months, 18 months
n Medication followed protocol

The Therapies (Bateman & Fonagy, 2009,
Am. J. Psychiat. and in press)
n MBT - weekly
Ø Support and structure
Ø Challenge
Ø Basic mentalizing
Ø Affective mentalizing
Ø Mentalizing the
relationship
Ø Medication review
Ø Crisis management
n SCM - weekly
Ø Support and structure
Ø Challenge
Ø Advocacy
Ø Social support work
Ø Problem solving
Ø Medication review
Ø Crisis management

Consort Diagram – IOP Study:
Patient Recruitment Flow-Chart
71 patients allocated to MBT-OP
6 attended < 6 months
13 attended 6-12 months
52 completed treatment
71 included in analyses
168 patients screened for eligibility
134 randomized
34 patients excluded:
10 did not attend interview
12 declined participation
5 did not meet inclusion criteria
4 met exclusion criteria
3 were uncontactable
63 patients allocated to SCM-OP
10 attended < 6 months
6 attended 6-12 months
47 completed treatment
63 included in analyses

Outcomes
n Primary outcome
Ø proportion of each group without severe parasuicidal
behavior as indicated by a) suicide attempt; b) lifethreatening
self-harm; and c) hospital admission
Ø formal research confirmed records
n Secondary outcomes (assessed at baseline, and at 6monthly
intervals until the end of treatment at 18 months)
Ø independently rated Global Assessment of
Functioning (GAF) scores at beginning and end of
treatments
Ø self-reported psychiatric symptoms and social and
interpersonal function

Percent with Incident
Percent with Clinical Episode (Attempted
Suicide, Self-harmed, or were Hospitalized
in Last Six Months)
120
100
80
60
40
20
0
n.s.
SCM MBT
p

Independently rated functioning (GAF)
Mean GAF score
65
60
55
50
45
40
35
MBT SCM
some difficulty in social
or occupational functioning
serious impairment in social or
occupational functioning
6 months prior to treatment End of treatment 18 months
moderate difficulty
in social functioning
Difference between slopes 2.61 (95% CI: 1.33, 3.89), p

Odds of a self-harming in MBT by therapist
Therapist x Time interaction: p

Moderating effect of Narcissistic PD
Coefficient of difference between slopes=-.14 (-.21, -0.08), p

Antisocial problems and clinical outcome
Coefficient of difference between slopes=-.14 (-.21, -0.08), p

Mean SCL-90 scores
MBT patients who remained with clinical
problems: SCL-90 subscale scores
2.2
2
1.8
1.6
1.4
1.2
1
Somatic
Obsessional
No clinical change (n=19) Significant change (n=52)
Interpersonal
Depression
Anxiety
Hostility
Phobia
Psychoticism
Paranoia

Percent
Nineteen patients were not free of self-
harm, suicide or hospitalization after 18-
months of MBT. Who were they?
90
80
70
60
50
40
30
20
10
0
No clinical change Significant change
Eating Disorder
(p

Replication
With an
Adolescent
Sample

Design of trial of adolescent self-harm
trial.
n Referrals to community mental heath
centre for severe self harm identifying all
referrals including
n Random allocation (minimization for age,
gender, SES)
n Individual (50 mins) sessions weekly and
Family (1.5 hrs) monthly for 12 months
n Assessments at admission, 6 months, 12
months, 18 months (not yet analyzed)
n Medication followed protocol

Sample characteristics of Self Harm And
Mentalization Trial (Rossouw et al., in prep)
Characteristics at Baseline Routine Care MBT
Female, n/N (%) 87.50% 82.5%
Age, mean (SD) 14.8 (1.2) 15.4 (1.3)
Chronicity of Self harming
less than 3 months 40% 40%
3-5 months ago 10% 17.5%
6-11 months ago 15% 5%
1-2 years ago 27.5% 30%
over 2 years ago 7.5% 7.5%

Sample characteristics of Self Harm And
Mentalization Trial (Rossouw et al., in prep)
Characteristics at Baseline Routine Care MBT
Childhood Interview for DSM-
IV BPD:(%) 70% 75%
Possible BPD (inc. threshold) 78% 90
Borderline personality features 3.3 (0.08) 3.2(0.08)
Percent depressed on MFQ 70% 77%

Imputed Log Mean Scores (SE)
Self harm scores for TAU (n=40) and
MBT (n=40) groups on the RSHI
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
TAU
MBT
p

Definite diagnosis of BPD using Zanarini
Adolescent Interview (cut-point at 5 criteria)
Imputed Proportional
Odds Ratios (SE)
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
TAU
MBT
Baseline 12 Months
Group differential rate of change: β=-1.035, 95% CI: -2.71, 0.63, t(159)=-1.21, p

Imputed Mean Scores (SE)
Borderline personality features scores
for TAU (n=40) and MBT (n=40) groups
3.6
3.4
3.2
3
2.8
2.6
2.4
2.2
2
TAU
MBT
Baseline 12 Months
Group differential rate of change: β=-0.361, 95% CI: -0.7, -0.03, p

Depression scores for TAU (n=40) and
MBT (n=40) groups on the MFQ
Imputed Log Mean Scores (SE)
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
TAU
MBT
Baseline 3 months 6 monts 9 months 12 months
Group differential rate of change: β=-0.046, 95% CI: -0.09, -0.01, t(159)=-2.25, p

Imputed Mean Scores (SE)
Mentalizing scores for treatment
groups
15.5
15
14.5
14
13.5
13
12.5
12
TAU
MBT
Baseline 12 Months
Group differential rate of change: β=1.49, 95% CI: 0, 2.98, t(159)=1.99, p

Total scores on the Adolescent Dissociative
Experiences Scale
Imputed Mean Scores (SE)
5
4.5
4
3.5
3
2.5
2
TAU
MBT
Baseline 12 Months
Group differential rate of change: β=-1.266, 95% CI: -2.58, 0.04, t(159)=-1.91, p

International
replication

Percent of who seriously self harmed:
Netherlands – UK comparison
(Bales et al., in press, J Pers. Disord.)
Percent Who Self-Harm
80
60
40
20
0
n.s.
SCM MBT-UK MBT-NL
p

Percent of sample hospitalized:
Netherlands – UK comparison (Bales
et al., in press)
Percent hospitalized
30
25
20
15
10
5
0
n.s.
SCM MBT-UK MBT-NL
p

Boston
Los Angeles
Connecticut
Bergen
London
RCTs and other research studies
Milan
Ulm
Adelaide
Turku
Stockholm
Huddinge
Oslo
Aarhus
Amsterdam
Brisbane
Christchurch
Melbourne

Finally

Is there a future for branded
treatments?
n Outcomes across DBT/TFP/SCM were “generally
equivalent” (Clarkin)
n Cognitive analytic therapy ‘v’ Good Clinical Care (GCC)
for adolescents with BPD or BPD traits - equally effective
with significant improvements across a range of clinical
outcome measures (Chanen)
n Mentalization based treatment (MBT) ‘v’ structured clinical
management (SCM) – both were effective treatments.
SCM was superior in the intial months at reducing selfharm.
n GPM ‘v’ DBT shows equal outcomes at end of treatment
and at follow-up (McMain)

Is there a future for branded
treatments?
n Zanarini, in a 10 year prospective follow-up study, found
that whilst substantial reduction in symptom severity is
achievable, good social and vocational function is more
difficult to attain with or without treatment.
n McMain et al: at two year follow-up patients with BPD still
show marked functional impairment despite wellorganised
treatment.
n Bateman and Fonagy found that, 8 years after
randomisation, patients still had functional impairment.
n Davidson and colleagues found at 6 year follow-up that
only one fifth of patients had showed improvement in
affective disturbance and their quality of life remained
poor.

Is there a future for branded
treatments?
Bateman, A (in press) Am J Psychiatry
n Yes but I think this will represent a failure in
mental health development and treatment
of personality disorder
n What do we need?
Ø A more coherent theory
Ø Translation of that theory into a packaged
treatment (not a mix and match system)
which….
Ø Can be delivered within mental health services
without extensive additional training

POT trial
n At assessment and 6 monthly all patients in PD
services
Ø SAPAS
Ø SCL-90
Ø IIP-PD
n Weekly
Ø PHQ-9
Ø SFQ
Ø Euroqol
Ø WAI
Ø Behavioural questionnaire

For further information
anthony@mullins.plus.com
Thank you for
mentalizing!
Slides available at:
http://www.ucl.ac.uk/psychoanalysis/unit-staff/staff.htm