ArticleLiterature Review

Mentalization-based treatment and its evidence-base status: A systematic literature review

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Abstract

Purpose This study reviewed the evidence‐base status of mentalization‐based treatment (MBT), its quality, strengths, and limitations. The aim was to pave the way for further MBT research. Method An electronic database and reference lists search identified MBT outcome papers, and these were systematically reviewed. The quality of the studies and the risk of bias were determined using two validated checklist tools. Results Twenty‐three studies were included in the review. This included nine randomized controlled trials, seven uncontrolled pre‐ and post‐effectiveness studies, three retrospective cohort studies, two uncontrolled randomized trials, and two case studies. The methodological quality of almost half of the papers was assessed as fair (43%), followed by good (34%), poor (17%), and excellent (4%) ratings. Nevertheless, the review identified risk of confounding bias across the majority of studies (60%) and fidelity to treatment was poorly reported in almost half of the studies (47%). Most of the studies focused on borderline personality disorder (BPD), showing positive clinical outcomes for this population but the evidence‐base for other presentations was still developing. The treatment of adolescents who self‐harm and at‐risk mothers in substance abuse treatment showed particularly promising results, as these are client groups that have previously shown limited positive response to psychological interventions. Conclusions Mentalization‐based treatment is a potentially effective method across a wide range of clinical presentations but further research should focus on increasing the quality and the quantity of the MBT evidence outside the treatment of BPD. Practitioner points • MBT can be a particularly effective intervention for the treatment of adults with a diagnosis of BPD and of adolescents who self‐harm and mothers enrolled in substance abuse treatments. • MBT can be an effective intervention for depression and eating disorders but the evidence is currently limited. • Professionals supporting mothers of children at risk may benefit from receiving training in the principles of MBT.

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... Also, in MBT the therapist applies a more curious and empathetic approach and the focus is on mentalization, which contrasts with the original PDT where the therapist is more confrontational and the focus is on resolving unconscious conflicts [5,6,16,17]. Systematic reviews of clinical trials support the efficacy of MBT, including group therapy, in treating EUPD and other PDs [18,19]. The patients included in these studies often had several comorbid PDs [16,20,21]. ...
... Furthermore, similar to other PDT or psychotherapy studies, MBT has been investigated in a number of effectiveness studies. These found that MBT can be successfully implemented in clinical practice despite heterogeneous patient samples and the presence of more difficult cases, which are sometimes excluded from clinical trials [18,19]. ...
... Manualized PDT and MBT treatments have been found to be effective in clinical efficacy and effectiveness studies [10][11][12][13][14]18,19]. However, patients with PD do not in general receive this treatment, but rather more traditional and nonmanualized approaches of PDT combined with MBT [8,14,[22][23][24]. ...
Article
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Objectives: Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combine a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patient groups with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning. Methods: The design was a naturalistic, prospective cohort study. A total sample of 75 consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention. Results: Fifty-six percent (n= 42) of the patients completed treatment. Among completers, improvement was observed on the SCL-90-R Global Severity Index (mean change= -0.45, 95% CI=(-0.72)-(-0.19), Cohen’s d=-0.55), Positive Symptom Distress Index (mean change=-0.40, 95%CI=(-0.63)-(-0.17), Cohen’s d=-0.56) and Positive Symptoms Total (mean change=-10.70, 95%CI=(-17.31)-(-4.09), Cohen’s d=-0.52). Secondary outcome measures also improved: IIP-total (mean change=-0.50, 95%CI=(-0.74)-(-0.25), Cohen’s d=-0.66), GAF-Functioning (mean change=8.79, 95%CI=6.32-11.27, Cohen’s d=1.15) and GAF-Symptoms (mean change=10.67, 95%CI=8.09-13.25, Cohen’s d=1.34). Conclusions: Patients completing mentalization-oriented PDT group therapy improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that PDT spanning several years may be unrealistic for many patients with PD.
... Previous meta-analyses and systematic reviews in the scope of therapies for treating BPD yielded mixed evidence for mentalization-based treatment in reducing selfharm (Jørgensen et al., 2021;Malda-Castillo et al., 2019;Storebø et al., 2020;Vogt & Norman, 2019). However, no current meta-analysis and systematic review focuses specifically on the application of MBT(-A) for treating self-harm. ...
... MBT(-A) demonstrated effectiveness in reducing selfharm, BPD symptoms and depression in adolescents and adults, with rather large treatment effects (ranging from g = −1.1 to g = −0.82). These findings are in line with previous systematic reviews ( Malda-Castillo et al., 2019;Vogt & Norman, 2019), providing preliminary evidence of MBT(-A)'s effectiveness across studies of different methodological rigor. Although these findings seem promising, MBT(-A) did not prove to be a more efficacious treatment than control interventions, questioning its implication for clinical practice. ...
Article
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Introduction Mentalization‐based therapy (MBT) and its adapted version for adolescents (MBT‐A) are repeatedly highlighted as promising treatments for reducing self‐harm, particularly in borderline personality disorder (BPD). Despite the availability of publications providing evidence of their efficacy in reducing self‐harm, recent meta‐analyses have yielded mixed results. To inform best‐practice clinical decision‐making, we conducted a systematic review and meta‐analysis. We aimed to disentangle findings for both adolescents and adults on the efficacy of MBT(‐A) in reducing self‐harm (primary outcome) and symptoms of BPD and depression (secondary outcomes). Methods Web of Science, Scopus, Embase, PubMed/Medline, and Cochrane Review Database were searched for eligible studies published until September 2022. In total, 14 studies were identified, comprising 612 participants from nine MBT studies (six pre–post, three RCTs) and five MBT‐A studies (two pre–post, three RCTs). Aggregated effect sizes were estimated using random‐effects models. Meta‐regressions were conducted to assess the effect of moderator variables (treatment duration, drop‐out rates, and age) on effect sizes. Results Overall, both MBT and MBT‐A demonstrated promising effects in reducing self‐harm ( g = −0.82, 95% CI −1.15 to −0.50), borderline personality disorder ( g = −1.08, 95% CI −1.38 to −0.77), and depression ( g = −1.1, 95% CI −1.52 to −0.68) symptoms. However, when compared to control interventions (TAU, SCM), MBT(‐A) did not prove to be more efficacious, with the exception of MBT showing superior effects on BPD symptoms in adults ( g = −0.56, 95% CI −0.88 to −0.24). Conclusion Although the pre–post evaluations seem promising, this analysis, including RCTs, showed no superiority of MBT(‐A) to control conditions, so that prioritizing the application of MBT (‐A) for the treatment of self‐harm is not supported. Possible explanations and further implications are discussed.
... MBT views NSSI as a result of poor mentalization amidst emotionally challenging situations. Mentalization, a core component of MBT, is a skill developed through healthy attachment and interactions with caregivers during childhood that enables an individual to regulate emotions by reflecting on one's own thoughts and feelings and putting oneself in others' shoes to better understand or "mentalize" thoughts and feelings of the self and others (Malda-Castillo et al., 2018). Without this ability, individuals may feel overwhelmed and impulsively engage in NSSI amidst emotional distress. ...
... A systematic review of 23 studies assessing the effectiveness of MBT found some support for decreasing overall self-harm among adults with BPD (Malda-Castillo et al., 2018). At the time, only one study had assessed the use of MBT for adolescents (MBT-A) who self-harm. ...
Chapter
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Internationally, at least 1 in 5 adolescents and 1 in 16 children ages 12 and under report having engaged in nonsuicidal self-injury (NSSI) at some point in their life. Common methods of NSSI include self-cutting, burning, biting, hitting, carving (words or symbols into skin), and severely scratching. The reasons for self-injury vary from person to person and often change over time, but individuals self-injure most frequently to regulate or manage their emotions. There are several risk factors for engaging in NSSI. This chapter begins with a discussion about the variability of prevalence rates of NSSI among children and adolescents as well as a detailed review of common risk factors for engaging in the behavior. It then focuses on screening for NSSI and offers a step-by-step approach to completing a brief, yet thorough, risk assessment of self-injury, with special focus on the therapist’s role in wound care and assessment. This chapter ends with an overview of common treatment approaches for addressing NSSI and their evidence base. Here, modalities that target emotion dysregulation and those that target differential reinforcement of alternative behaviors as the mechanisms of change are delineated, and a brief discussion of digital interventions for NSSI and considerations for treatment choice are offered.KeywordsNonsuicidal self-injurySelf-harmNSSIPediatricsAdolescentsRisk assessmentSelf-injury assessmentSuicide preventionEvidence-based treatment
... The process of adaptation of MBT to target children and adolescents has focused on interventions that promote parental mentalizing (Etezady & Davis, 2012;Ordway et al., 2014;Suchman et el., 2016) and address adolescent symptomatology like self-harm, conduct disorder, and personality disorders (Rossouw & Fonagy, 2012;Taubner et al., 2019). Recent systematic reviews detect a gap in research suggesting that interventions with children aged 6-12 are underdeveloped (Malda-Castillo et al., 2018;Midgley et al., 2021). ...
... Another finding related to the research in this area is that most of it covers broader populations compared to MBT studies for adults, which typically focus on diagnostic groups (Malda-Castillo et al., 2018). Hofmann and Hayes (2019) argue that it might be an expression of diagnosis categories being less clinically meaningful for children and emphasize that mentalizing capacity and biopsychosocial processes are more relevant foci for research. ...
Article
It is well documented how adverse childhood experiences can inhibit child development and mentalizing ability and lead to high risk of developmental psychopathology. Mentalization-based treatment (MBT) has been established as an effective approach to treatment for a long range of psychopathologies with both in- and outpatient treatment, yet the evidence base for effective clinical interventions that can help guide professionals working in residential care on how to support the development of neglected and traumatized children is underdeveloped. This article demonstrates a mentalization-based approach to understanding and working with children in residential care, and offers practical models and tools as well as considerations on implementation that are beneficial and easy to apply, demonstrated through cases. The STORM model and “Obtaining Skills” screening tool may be helpful models for professionals addressing mentalization in children while working in challenging environments such as with traumatized and neglected children.
... Mentalization is an umbrella term that has evolved out of the psychoanalytic and psychodynamic psychotherapy tradition and is broadly "defined as the ability to understand feelings, cognitions, intentions and meaning in oneself and others" (Robinson, Skårderud, & Sommerfeldt, 2019, p. 1). Mentalization has subsequently been validated in studies of human development, neuroscience, and psychology as a form of metacognition or "thinking about thinking" of oneself and others (Bateman & Fonagy, 2013;Malda-Castillo, Browne, & Perez-Algorta, 2019;Ridenour, Knauss, & Hamm, 2019). The concept is now explicitly embedded in contemporary treatment models such as mentalization-based therapy for children (Muller & Midgley, 2015). ...
... Mentalization-based treatment for personality disorder has the most robust evidence for its effectiveness (Malda-Castillo et al., 2019). However, recent reviews can only conclude that results are promising and recommend the urgent need for methodologically sound and sufficiently powered studies to investigate both effectiveness and efficacy (Volkert, Hauschild, & Taubner, 2019). ...
Preprint
Professional popular musicians are at increased risk of psychological distress, substance use problems, and suicide, yet little evidence is available on effective psychotherapeutic practices to address these issues. This scoping review aims to understand how professional popular musicians perceive, engage with, and respond to mental health interventions. Four databases were searched, garnering a total of 310 articles. Of these, six met inclusion criteria. Four thematic categories were explored: (1) amenability of professional popular musicians to particular therapeutic approaches; (2) attribution of treatment outcomes to tailored approaches; (3) professional popular musicians’ perceived barriers to treatment; and (4) recommendations for treatment approaches. The scoping review supports the importance of considering the characteristics of professional popular musicians as a distinct group with unique well-being needs, challenges, and strengths. There is a clear preference for tailored, affordable, and accessible approaches that consider the uniquities of musicianship and the need to explore the role of nonclinical support, such as friends, family, and industry peers.
... Mentalization is an umbrella term that has evolved out of the psychoanalytic and psychodynamic psychotherapy tradition and is broadly "defined as the ability to understand feelings, cognitions, intentions and meaning in oneself and others" (Robinson, Skårderud, & Sommerfeldt, 2019, p. 1). Mentalization has subsequently been validated in studies of human development, neuroscience, and psychology as a form of metacognition or "thinking about thinking" of oneself and others (Bateman & Fonagy, 2013;Malda-Castillo, Browne, & Perez-Algorta, 2019;Ridenour, Knauss, & Hamm, 2019). The concept is now explicitly embedded in contemporary treatment models such as mentalization-based therapy for children (Muller & Midgley, 2015). ...
... Mentalization-based treatment for personality disorder has the most robust evidence for its effectiveness (Malda-Castillo et al., 2019). However, recent reviews can only conclude that results are promising and recommend the urgent need for methodologically sound and sufficiently powered studies to investigate both effectiveness and efficacy (Volkert, Hauschild, & Taubner, 2019). ...
Preprint
Children who are exposed to trauma often develop difficulties with reflective functioning, affect, and emotion regulation. These problems are thought to arise from and are reflective of disruptions in the process of mentalization, or the human capacity to interpret and reflect upon the thoughts, feelings, wishes, and intentions of oneself and others. This scoping review sought to describe the empirical support for focusing on mentalization processes in psychotherapy for children who have been exposed to trauma. Two independent researchers searched electronic databases, Psychology and Behavioral Sciences Collection, MEDLINE, PsycARTICLES, PsycINFO, and Cochrane. Search terms child, trauma, mentalization and mentalization-based therapy were applied. A total of 425 studies were screened against the inclusion criteria, to include 18 studies comprising quasi-experimental, cross-sectional, naturalistic, case-control, and case studies. In all, 3 themes were identified across the articles: (a) trauma and mentalization, (b) measurement of mentalization, and (c) charting recovery. The literature suggests the role of mentalization treatment in the remission of symptoms for internalizing and externalizing disorders and shaping mentalization deficits over time. Mentalization focused treatments may also improve reflective functioning, emotional regulation capacity and the quality of attachment. The implementation of a child mentalization-based model as a preventative intervention may contribute to increased positive outcomes for vulnerable children. This scoping review presents an overview of the evidence for program developers, mental health services, family support services and those in independent practice that wish to adopt a mentalization approach in child psychotherapy. Future systematic reviews are needed to support this evidence.
... Difficulty mentalizing can compromise the evaluation of risk and assumed trust in web-based communications [13] and might therefore represent a valuable target for interventions aimed at reducing risk in YP who have already been exposed to TASA. Indeed, difficulties in mentalizing processes have been linked to greater vulnerability to a range of mental health problems that are common among TASA survivors, including depression, anxiety, eating disorders, and shame [14,15]. ...
... A recent systematic review [14] has highlighted mentalization-based therapy (MBT), a therapeutic approach that specifically aims to improve mentalizing capacity and consequently affect regulation and psychological distress, as a promising treatment approach across a wide range of clinical presentations, including groups that have previously shown a limited response to psychological therapy (eg, adolescents who self-harm). The efficacy of MBT has been more extensively trialed in adult mental health; however, a growing evidence base is emerging for the efficacy of MBT in YP. ...
Article
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Background: No evidence-based support has been offered to young people (YP) who have experienced technology-assisted sexual abuse (TASA). Interventions aimed at improving mentalization (the ability to understand the mental states of oneself and others) are increasingly being applied to treat YP with various clinical issues. Digital technology use among YP is now common. A digital intervention aimed at improving mentalization in YP who have experienced TASA may reduce the risk of revictimization and future harm and make YP more resilient and able to manage distress that might result from TASA experiences. Objective: In this paper, we describe a protocol for determining the feasibility of the i-Minds trial and the acceptability, safety, and usability of the digital intervention (the i-Minds app) and explore how to best integrate i-Minds into existing routine care pathways. Methods: This is a mixed methods nonrandomized study aimed to determine the feasibility, acceptability, safety, and usability of the intervention. Participants aged between 12 and 18 years who report distress associated with TASA exposure will be recruited from the United Kingdom from the National Health Service (NHS) Trust Child and Adolescent Mental Health Services, sexual assault referral centers, and a web-based e-therapy provider. All participants will receive the i-Minds app for 6 weeks. Coproduced with YP and a range of stakeholders, the i-Minds app focuses on 4 main topics: mentalization, TASA and its impact, emotional and mental health, and trauma. A daily prompt will encourage YP to use the app, which is designed to be used in a stand-alone manner alongside routine care. We will follow participants up after the intervention and conduct interviews with stakeholders to explore the acceptability of the app and trial procedures and identify areas for improvement. Informed by the normalization process theory, we will examine barriers and enablers relevant to the future integration of the intervention into existing care pathways, including traditional clinic-based NHS and NHS e-therapy providers. Results: This study was approved by the Research Ethics Board of Scotland. We expect data to be collected from up to 60 YP. We expect to conduct approximately 20 qualitative interviews with participants and 20 health care professionals who referred YP to the study. The results of this study have been submitted for publication. Conclusions: This study will provide preliminary evidence on the feasibility of recruiting YP to a trial of this nature and on the acceptability, safety, and usability of the i-Minds app, including how to best integrate it into existing routine care. The findings will inform the decision to proceed with a powered efficacy trial. Trial registration: International Standard Randomised Controlled Trial Number Registry (ISRCTN) ISRCTN43130832; https://www.isrctn.com/ISRCTN43130832. International registered report identifier (irrid): DERR1-10.2196/40539.
... MBT is an evidence-based treatment for patients with (severe) BPD (Daubney and Bateman 2015;Volkert, Hauschild, and Taubner 2019). MBT has been found to result in significant reductions in BPD features (Jørgensen et al. 2013;Löf et al. 2018), self-harm and suicidality (Bateman and Fonagy 2013a;Kvarstein et al. 2015;Löf et al. 2018;Rossouw and Fonagy 2012), general psychiatric symptoms (Jørgensen et al. 2013;Kvarstein et al. 2015;Löf et al. 2018), improvement in general functioning (Jørgensen et al. 2013) and social functioning (Bateman et al. 2016;Jørgensen et al. 2013;Malda-Castillo, Browne, and Perez-Algorta 2018;Vogt and Norman 2019;Volkert, Hauschild, and Taubner 2019). MBT appears to be more effective than traditional psychodynamic group therapy as BPD severity level increases (Kvarstein et al. 2019). ...
Article
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Background Mentalization‐based treatment (MBT) is an evidence based treatment for patients diagnosed with borderline personality disorder (BPD). Although MBT is effective, on average, for individuals with BPD, there are large individual differences in treatment outcomes. Research on predictors of the treatment effect of MBT, such as intelligence, is needed to determine which treatment is most effective for which ‘category’ of BPD patients, providing more knowledge about optimal indications. Objective The study aimed to investigate whether intelligence is associated with MBT outcomes in patients with BPD and exploratively studying the difference between two variants of MBT. Methods and Procedures A pre‐post intervention design was used to examine the effects of MBT on BPD severity. Personal and social recovery were measured as secondary outcome measures. The association between intelligence and the degree of recovery was examined. Results No significant correlation was found between intelligence level and treatment efficacy. In addition, a negative correlation between IQ and personal and social recovery was found, indicating that, as IQ increased, the level of recovery decreased. Secondary subanalyses showed the treatment effect of MBT was large and significant in reducing BPD symptoms (Cohen's d = 1.5) and that there was no significant difference between the 2‐day MBT and 3‐day MBT programmes in terms of a decrease in BPD severity. However, a significant medium positive correlational relationship was found between intelligence and a decrease in BPD severity level for the 3‐day MBT, which was not found for the 2‐day MBT programme. This indicates that in the 3‐day MBT programme, the higher the IQ, the higher the decrease in BPD severity level. Conclusions and Implications This study is the first to examine the association between intelligence and the outcome of MBT in BPD patients. It shows that patients with a wide range of intelligence (72–124) can equally benefit from MBT and that effectiveness of MBT was not influenced negatively by lower intelligence. Secondary subanalyses showed that this was particularly evident when the intervention was delivered within the context of a 2‐day MBT programme. Nevertheless, further randomized studies are required to ascertain the relationship between IQ and treatment effectiveness, as well as other predictors of MBT outcomes.
... The program demonstrated potential, with staff continuing to employ its tools three years later. Mentalization-based methods offer cost-effective strategies individuals with Borderline Personality Disorder, Eating Disorders, or Depression [58]. In contrast, the school environment offers a unique platform for interventions targeting young individuals without a formal diagnosis. ...
Article
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Mentalization-based interventions (MBIs) have been increasingly applied in school settings to support the social-emotional development and mental health of children and adolescents. This systematic review aimed to synthesize the evidence on the effectiveness of MBIs implemented in educational contexts for students aged 6–18 years. A comprehensive search was conducted in PsychInfo, MEDLINE, EMBASE, Web of Science, and ERIC databases from inception to October 2023. The search strategy combined terms related to mentalization, school-based interventions, and the target age group. The review protocol was registered with PROSPERO (CRD42022302757). Inclusion criteria included peer-reviewed publications in English, studies published between 1980 and 2023, interventions based on mentalization principles, and a primary focus on children aged 6 to 18 years. Exclusion criteria involved non-mentalization based interventions and research outside the 6–18 age range. The risk of bias was assessed using the Quality Assessment Tools from the National Institutes of Health (NIH). Data were synthesized narratively due to the heterogeneity of study designs and outcomes. Of the 5,250 articles screened, 21 studies met the inclusion criteria, comprising over 7,500 participants. The reviewed interventions targeted various aspects of mentalizing, such as emotion-understanding, empathy, perspective-taking, and Theory of Mind. Significant improvements were found in social-cognitive abilities, emotion regulation, and mental health outcomes, including reductions in disruptive behaviours. Interventions that combined mentalizing training for both students and teachers showed promising results. However, the long-term sustainability of these benefits remains unclear. Limitations of the reviewed studies include the lack of control groups, small sample sizes, and variations in outcome measures. The findings highlight the potential of MBIs as a promising approach to fostering socio-emotional competence, positive behaviour, and well-being in school-aged children. Future research should aim to establish the active components and optimal delivery of these interventions through well-designed randomized controlled trials with larger, more diverse samples and extended follow-up periods. The integration of MBIs within educational systems holds promise for promoting resilience and positive mental health outcomes in young people. Embedding MBIs within school curriculums and evaluating cost-effectiveness are important next steps to guide widespread implementation.
... Until recently, the research literature for MBT had consisted solely of studies using a quantitative methodology. Two systematic reviews have summarized and reviewed the quantitative evidence base to date (Malda-Castillo et al., 2018;Vogt and Norman, 2019) and have demonstrated the effectiveness of MBT in achieving positive clinical outcomes for clients. However, few studies within the literature have investigated the proposed mechanism of change of MBT, that of increased mentalizing capacity. ...
Article
Purpose Mentalization-based treatment (MBT) is a psychotherapeutic approach that aims to increase mentalizing capacity. The purpose of this meta-ethnography was to synthesize the available qualitative literature on MBT to allow for a more thorough understanding of the lived experience of those who have undergone this therapy. Design/methodology/approach A systematic search of seven databases was carried out. The Critical Appraisal Skills Programme was used to appraise the papers suitable for inclusion. The data were synthesized using a meta-ethnographic approach in which the second-order constructs from each paper were translated and reinterpreted creating a line of argument synthesis. Findings A total of 11 studies were included in the meta-ethnography. Three overarching themes were identified within the included papers which outlined that participant experience of MBT consisted of three different developmental stages. Navigating the therapeutic process describes the participant’s experience of the therapeutic process of MBT. The processes of change in MBT outlined participant reports of mechanisms of change experienced in MBT. Mentalizing self and others described the experience of generalizing new knowledge and skills to the world outside of therapy and unveiled the impact that engaging in MBT had on participants. Originality/value This meta-ethnography offers new insights into how clients experience MBT as a therapeutic process and offers suggestions for implementation in clinical practice as well as areas of focus for research of this therapeutic approach.
... For example, the current data seem to suggest that, together with the recommended psychological and pharmacological treatments for OCD (such as cognitivebehavioural therapy and certain selective serotonin reuptake inhibitors; Nezgovorova et al., 2022), individuals with OCS may benefit from mentalizationfocused interventions. Consistently, interventions focusing on mentalization have shown positive results in patients with impaired top-down control associated with CT, such as individuals with borderline personality disorder and eating disorders, and can be integrated with other forms of psychotherapeutic interventions (Malda-Castillo et al., 2019;Robinson et al., 2016;Volkert et al., 2019). Furthermore, mentalization-based treatments seem to be also effective in children exposed to trauma, resulting in a promising preventive therapy for highrisk psychopathology children (Oehlman Forbes et al., 2021). ...
Article
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Objective Obsessive and compulsive symptoms (OCS) are cross-cutting psychopathological manifestations frequently detected in a variety of clinical and non-clinical samples. It has been suggested that impaired mentalization abilities and traumatic experiences during childhood may be relevant etiopathogenetic factors in the development of OCS. The purpose of the current study was to cross-sectionally assess these variables in a non-clinical sample, testing the mediational role of mentalization abilities in the association between childhood trauma (CT) and OCS. Method 667 participants (488 females; mean age= 29.76 ± 11.87 years; age range: 18-80) answered a survey including the Childhood Trauma Questionnaire, the Mentalization Questionnaire and the Obsession-Compulsion subscale of the Brief Symptom Inventory. Results The mediation model was significant for the total effect (p< .001), showing that CT was positively associated with OCS (95% CI: .006; .019) and that this association was mediated by reduced levels of mentalization capacity (95% CI: .003; .009). Such results were significant controlling for potential sociodemographic and clinical confounding variables. Conclusions The findings contribute to elucidate the complex relationships between CT, mentalization capacity, and OCS, supporting the possibility that mentalization impairments, arising from CT, may affect top-down control mechanisms thus contributing to the development of OCS.
... 30 Mentalisation-based therapy is commonly used to treat borderline personality disorder and self-harm, among other mental health issues. 31 Mentalisation-based therapy typically involves discussion with a therapist to explore mentalising, whereas MIT emphasises guided imagery practices to enhance self-understanding and other-understanding, focusing on ecological connection, interconnectedness with the world, and mindfulness training. 24 MIT has become a well-established psychological support intervention programme for caregivers with dementia over the last few years. ...
Article
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Introduction Dementia is a growing public health concern, and providing long-term care for individuals affected by this condition is challenging for their family caregivers. While researchers have explored various intervention options to provide psychological support for dementia caregivers, mentalising imagery therapy (MIT) has gained significant recognition as an effective programme. Despite its significance and effectiveness, there is a lack of comprehensive scoping reviews of MIT in dementia caregiving. Thus, conducting such a review can provide valuable insights into the status and outcomes of MIT, identify gaps in existing research and provide recommendations for a more effective clinical practice. Methods and analysis This study proposes a scoping review conducted according to the Joanna Briggs Institute, Arksey and O’Malley’s methodological framework, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension. PubMed, Web of Science, Embase, Scopus, CINAHL and PsycINFO databases will be searched while grey literature will be retrieved via Google Scholar. Covidence will be used to manage the literature selection process and remove duplicate publications. Two researchers will independently screen the literature according to the inclusion criteria, with any discrepancies resolved through discussions with a third researcher. Data will be presented in a structured tabular format, with a narrative synthesis providing an overview of the findings on the identified research gaps and the effectiveness of MIT in the field of dementia caregiving. Ethics and dissemination In a scoping review, no ethical approval is necessary. The results will be published in a peer-reviewed journal. Trial registration number The scoping review protocol has been registered with Open Science Framework ( https://doi.org/10.17605/OSF.IO/FHRG8 ).
... That moderate to high mentalizing-certainty about mental states mitigates the effect of CSA on relationship satisfaction provides a sufficient goal for intervention. This is cause for optimism, as intervention programs to enhance mentalizing capacity can indeed increase individuals' robust mentalizing (Malda-Castillo et al., 2019), especially among patients with traumatic history (Smits et al., 2022). Professionals working with CSA survivors may thus benefit from using therapeutic interventions enhancing mentalization on self and others (Ensink et al., 2017), both in individual and within couple therapy (MacIntosh, 2013b;MacIntosh et al., 2019). ...
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Background: Childhood sexual abuse (CSA) is a significant risk factor with consistently demonstrated negative implications for satisfaction with adult romantic relationships. Yet, research on risk and protective factors in this context is scarce, particularly among well-functioning adults. Objective: Addressing this gap, the present study focused on the potential mediating and moderating roles of mentalizing or reflective functioning, i.e., the capacity to understand oneself and others in terms of intentional mental states. We investigated whether impairments in mentalizing underlie the association between CSA and relationship satisfaction and whether robust mentalizing can buffer the CSA-relationship satisfaction link. Method: A sample of 667 individuals engaged in a meaningful romantic relationship was drawn from a larger sample obtained in an online convenience survey. A mediation and moderation model was examined using PROCESS. Results: The results confirmed our integrative model—the association between CSA and satisfaction with romantic relationships was mediated by impairments in mentalizing (uncertainty about mental states) and was simultaneously moderated by robust mentalizing (certainty about mental states). These effects were shown even when controlling for age, gender, education, and psychopathological symptoms. Conclusions: These findings highlight the importance of mentalizing, a key transdiagnostic factor. Reduced mentalizing is a risk factor for harmful impact of CSA on romantic relationships, while greater mentalizing abilities can be a significant resilience factor protecting CSA survivors. This study supports the potential contribution of mentalization-based interventions with survivors of CSA at risk for dissatisfaction with romantic relationships.
... Bateman & Fonagy, 2012). The treatment programmes of mentalization-based therapy (MBT) is considered evidencebased for a range of mental disorders (Malda-Castillo et al., 2018). ...
Article
This paper is the first to present a model for mentalization-based supervision of professionals working with environmental therapy. Mentalization-based supervision should be based on a mentalizing stance and theory aligned with the current mentalizing perspective, that is, the theory of attachment, mentalization and should aim at establishing ‘we-mode’ and epistemic trust. This paper offers a practical guide, models, and templates that are easy to apply and beneficial for the supervisor to underpin the mentalizing stance and focus on mentalizing processes during complex supervision sessions with groups of supervisees. The approach and method of supervision are demonstrated through a clinical case, and the supervision process is illustrated via templates to aid the reader who is a supervisor for groups in this field. The article is based on current theory and research on mentalization and on the clinical practice of supervision in psychiatric inpatient treatment and residential care.
... Depressive symptoms, anxiety symptoms, and personality functioning all improved at followup. This is consistent with the extensive literature documenting that MBT interventions improve affective and personality disorder symptoms (Malda-Castillo et al., 2019). The present study suggests that a relatively short MBT parenting intervention might have mental health benefits. ...
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This paper reports follow-up findings for an Mentalization based treatment (MBT) parenting intervention delivered to a community mental health sample. Parents completed the 12-week version of the Lighthouse Parenting Program (LPP) and were evaluated on parenting practices, parent-child relationships, parental mental health indicators, and child problem behaviour levels. We evaluated the extent to which improvements in mentalizing at follow-up mediated changes in parenting, parental adjustment, mental health, and child outcomes. Results included a reduction in parental coercive behaviours and child problems, improved parent-child relationship, and better parental psychological adjustment and mental health. Improvement in self-focused mentalizing were observed. Self-focused mentalizing mediated the changes in most outcomes from baseline to 3-month follow-up. These results provide strong preliminary evidence that the LPP improves parent and child outcomes.
... Awareness of such maladaptive neural recalibration following early maltreatment may prove helpful in clinical settings. It may aid the timely recognition of potential barriers to successful rapport-building during treatment, help clinicians reflect on how to best address process difficulties when they arise, and promote the identification and prioritisation of treatment targets (for which evidence-based interventions already exist), such as emotion dysregulation (Moltrecht et al., 2021), excessive rumination (Watkins and Roberts, 2020), memory processing difficulties (Barry et al., 2019;Hitchcock et al., 2017), poor social skills (Merrill et al., 2017) and mentalising (Byrne et al., 2020;Malda-Castillo et al., 2019). ...
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Resting-state functional connectivity (rsFC) has the potential to shed light on how childhood abuse and neglect relates to negative psychiatric outcomes. However, a comprehensive review of the impact of childhood maltreatment on the brain's resting state functional organization has not yet been undertaken. We systematically searched rsFC studies in children and youth exposed to maltreatment. Nineteen studies (total n = 3079) met our inclusion criteria. Two consistent findings were observed. Childhood maltreatment was linked to reduced connectivity between the anterior insula and dorsal anterior cingulate cortex, and with widespread heightened amygdala connectivity with key structures in the salience, default mode, and prefrontal regulatory networks. Other brain regions showing altered connectivity included the ventral anterior cingulate cortex, dorsolateral prefrontal cortex, and hippocampus. These patterns of altered functional connectivity associated with maltreatment exposure were independent of symptoms, yet comparable to those seen in individuals with overt clinical disorder. Summative findings indicate that rsFC alterations associated with maltreatment experience are related to poor cognitive and social functioning and are prognostic of future symptoms. In conclusion, maltreatment is associated with altered rsFC in emotional reactivity, regulation, learning, and salience detection brain circuits. This indicates patterns of recalibration of putative mechanisms implicated in maladaptive developmental outcomes.
... Cela résulterait en un système d'attachement hypersensible dans les contextes interpersonnels et au développement d'une capacité affaiblie à se représenter ses propres états mentaux ainsi que ceux des autres. Comme pour la thérapie focalisée sur le transfert, cette seconde conceptualisation a donné lieu au développement puis à la validation d'une autre forme de psychothérapie : la Thérapie Basée sur la Mentalisation (ou TBM) [46]. À la même période, Marsha Linehan, thérapeute comportementaliste, publie un article fondateur sur l'utilisation d'une nouvelle thérapie cognitivo-comportementale -la thérapie comportementale dialectique -dans le TPB [5]. ...
Article
Borderline personality disorder (BPD) is a common disorder in general and clinical populations and is related to potentially severe medical and socio-professional consequences. Treatment of BPD is based on evidence-based psychotherapies (such as Dialectical Behavioral Therapy, Mentalization-Based Therapy, Schema-Focused Therapy or Transference Focused Psychotherapy), which have been shown effective but are poorly available in France. Pharmacological treatments, which are more easily available, are not effective in treating symptoms of the disorder but can be useful in management of comorbidities. In this context, recently called "generalist" models have been developed, which every well-trained psychiatrist can implement in their daily practice, combining practical elements from evidence-based psychotherapies and elements of pharmacological management of symptoms and comorbidities. The purpose of this article is to present one of these models, the Good Psychiatric Management (GPM) and its basic principles and its applications, and to provide one of the first French-speaking resources about this model. In addition, beyond the practical elements proposed by the GPM, we discuss the deeper question that it raises, namely the question of a pragmatic integration of different theoretical and clinical models. Indeed, the treatment of BPD patients is at the junction of different conceptualizations of mental pathology (psychopathological, neurobiological) and different modalities of practice (psychotherapy, biological psychiatry). In a French context, that sometimes separates these two models, and in our opinion GPM constitutes an example of clinical collaboration which shows the interest of the combined role of psychiatrist-psychotherapist.
... They also mentioned therapy based on mentalization for adolescents as a promising therapy type. The same conclusion was reported by Malda-Castillo et al. (2019), who noted that although that type of therapy had produced promising results in some studies, there is so far no scientific evidence that would allow it to be considered a treatment of choice. ...
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The scientific literature in recent years and the new research paradigms for suicidal behavior indicate that clinical treatment should focus on the reasons a person is considering suicide and why they would prefer to die rather than live. Suffering, desperation, and an inability to find meaning in life transcend diagnostic categories and are linked to the presence of any manifestation of suicidal behavior. This calls for a perspective that understands the need for specific approaches, beyond particular diagnoses or what is required for other possible psychological problems. In the adult population, the psychotherapies with the most empirical support for their efficacy are cognitive behavioral therapy and dialectical behavioral therapy for people diagnosed with borderline personality disorder, particularly women. In adolescents, dialectical behavioral therapy has the highest level of recommendation. The short intervention with the best empirical support in response to suicidal crises is safety planning. We indicate the common components needed for effective psychotherapies, such as the importance of comprehensive evaluations, the therapeutic alliance, the family component, and emotional regulation skills, among others. We consider the professional implications and reflect on the need for specific training for therapists.
... Mentalizing is a concept that has origins in psychodynamic theory, attachment theory and cognitive psychology [5,43,[48][49][50]. The concept of parental mentalizing provides a well-established theory and mode of relationship-focused intervention (Mentalization-Based Treatment) that is accessible across disciplines [51][52][53][54]. Evidence suggests that parental mentalizing is a central process in the intergenerational transmission of attachment patterns [55,56], with poor parental mentalizing predictive of children's insecure [57] and disorganised attachment [58]. ...
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Mother-Baby Nurture is an innovative group program that focusses on strengthening the mother-infant relationship through enhancing reflective capacity within mothers and their infants. We describe the unique combination of the features that are central to this program and present comparisons with other early parenting interventions. Infancy is a unique period of acute developmental vulnerability and dependence on a care-giver. As the caregiver is the critical regulator between infant and their environment, disturbances in the caregiver-infant relationship have heightened potential to interfere in the infant's developmental trajectory and lifelong wellbeing. Mother-Baby Nurture is a 10-week targeted group program that is currently being implemented in Western Australia, for infants and their mothers experiencing relational or emotional distress. This program provides an emotionally containing space for a mother and her infant to explore mental states. We foster curiosity in the thoughts, feelings, and behaviour (of the baby, the mother, and others), as well as reflection on attachment relationships (past and present). This therapeutic approach shares common ground with parent-infant psychotherapy and mentalization-based treatment, and is informed by attachment theory and the neurobiological science of infant development.
... Mentalization-based therapies developed out of psychodynamic, psychoanalytic, and attachment theory-based therapeutic traditions, and were first described in the 1990's as an approach to treating Borderline Personality Disorder (BPD; Bateman & Fonagy, 2016). Since that time, mentalization deficits have been implicated in many psychological presentations, including depression, eating disorders, self-harm, substance abuse, and trauma (Malda-Castillo, et al. 2019;Stein & Allen, 2007); and the implementation of mentalization-based treatment has broadened. Regardless of the population being treated, the primary aim of mentalization-based treatment is to strengthen one's ability to reflect upon their own affective states, thoughts, and desires, as well as the affective states, thoughts, and desires of others (Conway et. ...
Article
Phoebe Shepard’s (2022) hybrid case study of "Chloe' describes a young woman struggling with a constellation of difficulties rooted in the relational trauma of her childhood. Shepard’s treatment approach with Chloe is anchored in Courtois and Ford’s (2013) Sequenced, Relationship-Based Approach to treating complex trauma. Within the structure provided by Courtois and Ford’s model, Shepard integrated techniques from a wide array of treatment perspectives including Cognitive Behavioral Therapy (CBT), Sensorimotor Psychotherapy (SP), and Accelerated Experiential Dynamic Psychotherapy (AEDP). Despite pulling from such seemingly disparate sources, Shepard presents a cohesive treatment anchored in a focus on the healing potential of the therapeutic relationship. In the approximately two years that she worked with Chloe, this emphasis on safety and connectedness yielded deeply meaningful and clinically significant change. In this commentary I hope to simultaneously honor the deeply reflective and compassionate approach taken by Shepard and to present a simplified guiding conceptualization of Chloe’s presentation and treatment—one rooted in "mentalization." Mentalization, sometimes summarized as "thinking about thinking," is the process of thinking about one’s self from the outside in and thinking about others from the inside out—considering the thoughts, feelings, and needs underlying our own and others’ behavior. I propose that many of Chloe’s difficulties can be viewed through a lens of mentalization lapses, and much of the beautiful and transformative work Shepard accomplished with this client may have been driven by improvements in Chloe’s capacity to mentalize. By simplifying what is an undoubtedly complicated clinical presentation—rich with history, multilayered interpersonal dynamics, transient self-states, and overlapping symptom profiles—I hope to present the perspective that treating complex trauma need not be quite so complex.
... For reviews focusing on the efficacy/effectiveness of MBT see [64,102]. Two original studies are of interest concerning MBT and suicide prevention. In the first, patients with Borderline Personality Disorder (BPD) showed higher reduction in self-harming behaviors and suicide attempts when treated with MBT than with TAU [2]. ...
... Aus diesen Befunden leitet sich der zentrale Stellenwert der Mentalisierungsfähigkeit für die Psychotherapie ab, dessen Bedeutung inzwischen auch über die psychodynamische Psychotherapie hinaus anerkannt wird. Die Wirksamkeit einer mentalisierungsbasierten Therapie (MBT) bei verschiedenen Störungsbildern konnte inzwischen hinreichend nachgewiesen werden (Malda-Castillo et al. 2019). Die Reduzierung von Mentalisierungsdefiziten wurde von Luyten et al. (2020, s. 4) als ‚common factor in treatment' bezeichnet und somit als ein zentraler, umfassender Faktor im therapeutischen Veränderungsprozess charakterisiert. ...
Article
Objectives: Psychosomatic rehabilitation clinics represent an important branch of care with good treatment results in Germany. So far, however, it is largely unclear which processes underlie the treatment successes. In the partial evaluations of the Hersfeld catamnesis study presented here, recourse is made to the construct of mentalizing ability, which has become very important in recent psychotherapy research. Methods: The mentalization ability of a large sample (N = 559) was assessed with the help of the Mentalization Questionnaire (MZQ), and psychological and somatic complaints were assessed with HEALTH-PSB scale from HEALTH-49 at three points in time, namely at admission, at discharge and in a 6-month catamnesis. Results: Both the total score of the MZQ and all subscores show significant reductions in mentalization deficits in the small effect size range, the HEALTH-PSB in the high effect size range and the catamnesis in the medium effect size range. A regression analysis shows that the reduction in mentalization deficits has a high predictive power for symptom improvement. Conclusions: The results indicate that the construct of mentalization ability is a central target variable in psychosomatic rehabilitation.
... Bateman and Fonagy developed a treatment approach that focusses on enhancing the ability to mentalize, mentalization-based treatment (MBT) (Bateman & Fonagy, 2016). It has already been shown empirically that patients' mentalizing capacity can be improved by MBT interventions (Malda-Castillo et al., 2019;Möller et al., 2017;Rossouw & Fonagy, 2012). Psychodynamic approaches, which have a focus on "insight" and on emotional processes associated with relationships, might also be effective in this regard. ...
Article
Objective: Improvement in patients' mentalizing capacities is considered a possible mechanism of change in psychotherapy. This improvement might take place via mentalization-enhancing interventions (MEIs) performed by psychotherapists. The study aimed to explore the use of MEIs in two evidence-based psychotherapeutic treatments for patients with anorexia nervosa (enhanced cognitive-behavior therapy, focal psychodynamic therapy) and their association with the patients' capacity to mentalize in sessions ("in-session reflective functioning" / in-session RF). Additionally, it was explored, if the amount of MEIs used could either predict change in in-session RF or outcome (end of treatment, one year follow-up). Method: 84 audiotapes from psychotherapy sessions of 28 patients of the ANTOP-study (three sessions per patient) were transcribed and rated with both the MEI Rating Scale and the In-Session RF Scale by trained raters. Results: MEIs were applied in both treatments. A moderate correlation between the amount of MEIs and patients' in-session RF as well as its change over the course of treatment was found, but no relation to change in BMI or eating disorder symptoms. Conclusion: A greater use of MEIs was related to patients' in-session-mentalizing. However, there seems to be no simple relation between RF as shown in sessions and symptom change.
... It theoretically follows that reduced uncertainty about mental states may help adolescents reduce self-harm. A recent systematic review highlights MBT as a potentially effective therapeutic approach across a range of clinical presentations, including youth self-harm (Malda-Castillo et al., 2019). Our results tentatively suggest that involving parents, in particular female caregivers, in a supportive or co-therapist position in MBT work, may be beneficial. ...
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Youth self-harm is associated with poor health outcomes and attempted and completed suicide. Associations exist between self-harm and expressed emotion (EE), attachment insecurity, and reflective functioning (RF), but these associations are poorly understood. This study evaluates a mediation model in which perceived caregiver EE (pEE) exerts an indirect effect on youth self-harm through attachment insecurity and RF uncertainty. 461 participants aged 16-24 years completed an online survey. Statistical analyses revealed significant direct effects of pEE on attachment insecurity, and of RF uncertainty on self-harm; however, some direct effects were specific to pEE from female caregivers, and attachment insecurity in youth relationships with female caregivers. A significant direct effect of pEE on self-harm was found for pEE from male caregivers only. Significant indirect effects of pEE on self-harm through attachment anxiety and RF uncertainty were found only in relation to female caregivers. The findings encourage family-, attachment-, and mentalization-based approaches to preventing and treating youth self-harm, with a recommendation that caregivers are given adequate support, education, and skills-based training following youth disclosures of self-harm. Supplementary information: The online version contains supplementary material available at 10.1007/s12144-022-03614-w.
... Their work of how processes of affect regulation and mirroring can either foster the development of the self or cause pathologies when failing led to a specific treatment approach, namely mentalization-based treatment [92]. Mentalization-based treatment has shown to be effective in individual as well as in group settings for diverse indications, borderline personality disorder in particular [93]. According to Bateman et al. [94], group therapy is a very suitable setting for patients to practice mentalizing within multiple relationships in a safer space than their regular social environment. ...
Article
In interaction with their mother, infants not only learn how human relationships work, but – on an even more basic level – the continuous bidirectional, interactive regulation between mother and infant shapes the infant’s socioemotional development. Coordinated interactions alternate with uncoordinated ones, the latter resulting in momentary ruptures during this dyadic exchange. Usually, these are quickly repaired. The mother’s capacity for engaging with her infant in a sensitive and appropriate manner is crucial for successful socioemotional development. On a transgenerational level, a mother will draw on her own relational experiences – embodied as implicit memory – when interacting with her baby. Thus, comprehensive and effective treatment of maternal postpartum disorders that often impair the mother’s interactive skills and capacity for maternal bonding is of great importance. One aim of modern mother-infant treatment is to target dysfunctional interactive patterns, often with the help of video feedback and microanalysis of behavioral observations. In this paper, after giving an overview of affective regulation in mother-infant dyads and the role of maternal factors and postpartum mental health, we describe relationship-focused approaches to mother-infant treatment. Our focus lies on video feedback and body-oriented interventions. We also explore classical as well as contemporary theoretical underpinnings in mother-infant research and how psychoanalytic concepts like containment and mentalization not only enrich approaches to mother-infant treatment but also adult treatment in general. We conclude that working with and expanding one’s own implicit relational knowledge is central for the therapeutic process and can be initiated by video-based interventions or by genuinely experiencing and reflecting on interactions in dyads and groups.
... For reviews focusing on the efficacy/effectiveness of MBT see [64,102]. Two original studies are of interest concerning MBT and suicide prevention. In the first, patients with Borderline Personality Disorder (BPD) showed higher reduction in self-harming behaviors and suicide attempts when treated with MBT than with TAU [2]. ...
... Le programme STEP s'inscrit notamment dans les cadres théoriques de la mentalisation et des approches sensibles aux traumas. La mentalisation est un cadre conceptuel contemporain en psychologie développementale et clinique sur lequel sont fondées de nombreuses interventions psychologiques bénéficiant de données probantes (Malda-Castillo et al., 2019). La mentalisation réfère à une habileté imaginative préconsciente consistant à interpréter les comportements comme le reflet d'états mentaux sous-jacents, tels que des émotions, des motivations et des croyances. ...
... The underlying mechanisms and the precise role of ToM in the etiology, diagnosis, and treatment of these mental disorders are also still poorly understood. Some existing treatment programs, such as mentalization-based therapy or metacognitive training, emphasize ToM treatment as a core component (Moritz et al., 2014;Malda-Castillo et al., 2019). This Research Topic promotes our understanding on the specific nature of ToM in individuals with borderline personality disorder, autism spectrum disorder and schizophrenia. ...
... Indeed, one recent study (86) found that for individuals with borderline personality disorder, high levels of hypermentalizing pretreatment were associated with improved interpersonal functioning. Furthermore, evidence supports the efficacy of MBT in the treatment of borderline personality disorder among adults and adolescents, and preliminary support has been found for its use in other disorders, such as eating disorders, depression, and self-harm (87,88). Although no evidence was found in the current study to support the specificity of hypermentalizing to borderline personality disorder, challenges in the organization of psychopathology introduce two additional questions warranting further research. ...
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Objective: 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. Methods: 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: 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. Conclusions: 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.
... MBT is a manualized treatment protocol first developed by Anthony Bateman and Peter Fonagy (12) to treat patients with borderline personality disorders. MBT has been further adapted for other mental disorders in which mentalizing deficits may be part of what underlies or maintains the difficulties (e.g., eating, anxiety, depressive, and psychotic disorders) and for various settings, ages, and target groups (13)(14)(15). During the past 20 years, MBT has also been adapted for parents, children, youths, and families (16). ...
Article
Family members mentalize when they try to understand each other’s behavior on the basis of intentional mental states. This article aims to introduce and briefly describe how the concept of mentalization can provide a useful framework for clinicians to understand psychopathology of children, youths, and families. The authors further out- line how mentalization-based techniques and interven- tions can be applied to build epistemic trust and to reestablish mentalizing in families by presenting clinical vignettes of initial sessions from various clinical settings in the United Kingdom and Germany. The article concludes with a brief summary about the current evidence for mentalization-based interventions with children, adoles- cents, and families and provides an outlook for future clinical and research work.
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Psychodynamic theory and therapy is widely misunderstood by students, clinicians, and researchers at all levels of the mental health profession. This is an unfortunate consequence of bias and misinformation, which run rampant in academic and clinical environments alike. Despite the publication of numerous empirical research volumes and evidence-based treatment manuals over the past two decades, many students and professionals persist in their belief that the modality is ineffective and obsolete. After identifying several sources of bias and misinformation, Psychodynamic Theory, Therapy, and Research: A Reintroduction presents a detailed overview of key developments in theory and technique. Readers will then be introduced to the clinical, developmental, and neurobiological domains of evidence which establish the validity of psychodynamic models and the efficacy of psychodynamic therapies. Each chapter also provides topical reading lists for those who wish to explore the literature in more depth. *Paperback and hardcover available for purchase, please message for pricing and shipping*
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Background Early-life stressful experiences are associated with increased risk of adverse psychological outcomes in later life. However, much less is known about associations between early-life positive experiences, such as participation in cognitively stimulating activities, and late-life mental health. We investigated whether greater engagement in cognitively stimulating activities in early life is associated with lower risk of depression and anxiety in late life. Methods We surveyed former participants of the St. Louis Baby Tooth study, between 22 June 2021 and 25 March 2022 to collect information on participants' current depression/anxiety symptoms and their early-life activities ( N = 2187 responded). A composite activity score was created to represent the early-life activity level by averaging the frequency of self-reported participation in common cognitively stimulating activities in participants' early life (age 6, 12, 18), each rated on a 1 (least frequent) to 5 (most frequent) point scale. Depression/anxiety symptoms were measured by Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Screener (GAD-7). We used logistic regressions to estimate odds ratios (OR) and 95% confidence intervals (CI) of outcome risk associated with frequency of early-life activity. Results Each one-point increase in the early-life composite cognitive activity score was associated with an OR of 0.54 (95% CI 0.38–0.77) for late-life depression and an OR of 0.94 (95% CI 0.61–1.43) for late-life anxiety, adjusting for age, sex, race, parental education, childhood family structure, and socioeconomic status. Conclusions More frequent participation in cognitively stimulating activities during early life was associated with reduced risk of late-life depression.
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The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we contribute to that literature by analyzing the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how experiences of testimonial injustice within BPD can prevent patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder.
Thesis
This study aimed to provide a model for constructing a relationship of childhood abuse and avoidant and ambivalent attachment styles with the diagnosis of borderline personality disorder with the mediating role of uncertainty of mental state and maladaptive emotional regulation. In this study, the basic method as well as the descriptive correlation method were used. The statistical population of this study included all students of Islamic Azad University, Research Sciences Branch of Tehran. Sampling method in this study was available and voluntary sampling and a total of 1026 students (404 men and 622 women, undergraduate (717), master (277) and doctoral (32) who wish The mean and standard deviation of the study participants was 29.03 ± 8.72. Data from this study using childhood abuse (CTQ) by Bernstein et al. (2003), normative and abbreviated version of attachment styles (ASQ), Hazen & Shaver (1987), Fonagy et al.'s RFQ questionnaire (2016), normative version. The Cognitive Emotion Regulation Questionnaire (CERQ-S),Personality Assessment Inventory-Borderline Scale (PAI-BOR), and the Murray (2007) subscale of the Borderline Personality Disorder Characteristics were used. The research hypotheses were analyzed using path analysis and regression methods. Showed a very good fit (RMSEA = 0.043). All indirect pathways, childhood abuse variables, uncertainty about mental state, and maladaptive emotional regulation were significant. In total, this model explains 51% of the symptoms of borderline personality disorder among students. Another result of this research is its capacity to be used in the field of mental health from childhood to adulthood and to modify and improve the current lifestyle of individuals.
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This scoping review explores research conducted between 2008 to 2019, that aims to understand the conceptual use of mentalization(M) and reflective functioning (RF) and explore possibilities for interventions that promote these skills. The review utilized the descriptors “reflective functioning OR mentalizing OR mentalization AND intervention”. Reviewed papers were written in English, Portuguese or Spanish, and covered several research areas. The analysis considered several categories, including aims, study design, participants, type of intervention, intervention assessments and outcomes. Thirty-four papers were considered, most of them using a quantitative approach and addressed to adults and parents/caregivers-infants. The present review highlights the need to develop specific assessments procedures to evaluate RF and M, as well as studies that consider the Brazilia n context. The study also emphasizes the need for theoretical systematization of M and RF concepts, considering they are frequently used as synonyms.
Article
This study assessed the effect of a mentalisation-based therapy (MBT) treatment programme on the utilisation of Western Australian public hospitals for mental health presentations over an 18-month period. Hospital data included the number of visits to the emergency department (ED), the number of inpatient admissions to hospital and length of stay of the admissions. Participants included 76 adolescents aged 13-17 years old, who presented with borderline personality disorder (BPD) traits. The Touchstone treatment programme is a time-limited intensive programme that utilises MBT in the context of a therapeutic community. Hospital data for the participants were collected and analysed from three time points; 6 months prior to attending the programme, during the 6-month programme (active treatment) and 6 months after the programme. Results found a statistically significant decrease in hospital utilisation from pre to post programme, with a decline in ED visits, inpatient admissions and admission length of stay. This study presents promising preliminary evidence for the effectiveness of an intensive MBT programme as an intervention for adolescents with BPD features and has significant implications for the public health system in terms of providing effective community-based treatment for this difficult to treat population as well as reducing pressure on tertiary care.
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Mentalization is a complex and multifaceted trans-theoretical and trans-diagnostic construct that has found increasing application in the clinical context. This research aimed at deepening the psychometric properties of the Multidimensional Mentalizing Questionnaire (MMQ), a 33-item theoretically based self-report questionnaire allowing for a comprehensive assessment of mentalizing, by integrating factor analysis and network analysis approaches. A sample of 1640 participants (M age = 33 years; SD = 13.28) was involved in the research. The six-factor structure was confirmed for the MMQ, and both the total and the subdimensions demonstrated good reliability. The network analysis has further enriched these results, showing the central role of the items attributable to Emotional Dysregulation or Reflexivity in influencing the network as well as the contribution of aspects related to Relational Discomfort in managing the flow of communication flow. Such findings may have useful clinical implications and emphasize the usefulness of the MMQ in both research and clinical practice.
Article
»I see her differently now« – A mentalization-based therapy with an adolescent with a borderline and antisocial personality The present study was devoted to the question of how much space relevant thematic areas occupied in a successful MBT with an adolescent with a borderline as well as antisocial personality and how the patient’s mentalizing in those areas developed over the course of therapy. For this purpose, six therapy sessions from the initial, middle, and final phases of an MBT were se­lected and patient statements assigned to different thematic areas as well as to the corresponding mentalization level. A descriptive analysis of changes in statement frequencies per theme and of mentalization levels over the course of therapy indicated the great therapeutic significance of working on relationship issues. The results suggest that both the patient’s borderline and antisocial symptomatology improved through the primary treatment focus on mentalizing significant relationships.
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Introduction: In depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms, and a high rate of comorbid disorders. Personalised treatments targeting comorbidities as well as underlying transdiagnostic mechanisms and factors like early childhood maltreatment may lead to better outcomes. A modular-based psychotherapy (MoBa) approach provides a treatment model of independent and flexible therapy elements within a systematic treatment algorithm to combine and integrate existing evidence-based approaches. By optimally tailoring module selection and application to the specific needs of each patient, MoBa has great potential to improve the currently unsatisfying results of psychotherapy as a bridge between disorder-specific and personalised approaches. Methods and analysis: In a randomised controlled feasibility trial, N=70 outpatients with episodic or persistent major depression, comorbidity and childhood maltreatment are treated in 20 individual sessions with MoBa or standard cognitive–behavioural therapy for depression. The three modules of MoBa focus on deficits associated with early childhood maltreatment: the systems of negative valence, social processes and arousal. According to a specific questionnaire-based treatment algorithm, elements from cognitive behavioural analysis system of psychotherapy, mentalisation-based psychotherapy and/or mindfulness-based cognitive therapy are integrated for a personalised modular procedure. As a proof of concept, this trial will provide evidence for the feasibility and efficacy (post-treatment and 6-month follow-up) of a modular add-on approach for patients with depression, comorbidities and a history of childhood maltreatment. Crucial feasibility aspects include targeted psychopathological mechanisms, selection (treatment algorithm), sequence and application of modules, as well as training and supervision of the study therapists. Trial registration number DRKS00022093.
Chapter
Treatment approaches for borderline personality disorder (BPD) derive from a range of traditions and theoretical orientations, oftentimes considered to be competing or mutually exclusive. In this chapter we describe the major psychotherapy approaches for treating BPD and examine the evidence from both randomized controlled trials and meta-analyses. We summarize the evidence for the efficacy various treatments for BPD, outline similarities and differences among these treatments, and provide a big-picture perspective by integrating research findings and distilling principles. We encourage researchers and clinicians to begin examining treatments more broadly, including how elements of various approaches may be combined or sequenced to better help patients. In this vein, strategies for adapting and integrating various treatments are discussed.
Article
Objective: 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. Method: 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 15.0-16.4 kg/m2 ), underweight (BMI 16.5-18.4 kg/m2 ) or healthy weight range (BMI ≥ 18.5-24.9 kg/m2 ). Upon discharge participants were further categorised as weight restored (BMI ≥ 18.5 kg/m2 ) or non-weight restored (BMI < 18.5 kg/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). Results: 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. Conclusions: 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.
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This paper conducted a preliminary study of reviewing and exploring bias strategies using a framework of a different discipline: change management. The hypothesis here is: If the major problem of implicit bias strategies is that they do not translate into actual changes in behaviors, then it could be helpful to learn from studies that have contributed to successful change interventions such as reward management, social neuroscience, health behavioral change, and cognitive behavioral therapy. The result of this integrated approach is: (1) current bias strategies can be improved and new ones can be developed with insight from adjunct study fields in change management; (2) it could be more sustainable to invest in a holistic and proactive bias strategy approach that targets the social environment, eliminating the very condition under which biases arise; and (3) while implicit biases are automatic, future studies should invest more on strategies that empower people as “change agents” who can act proactively to regulate the very environment that gives rise to their biased thoughts and behaviors.
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Personality disorders (PDs) and substance use disorders (SUDs) have a long history of being recognized as intimately linked, sharing many common clinical features, and frequently co-occurring in individuals seeking treatment for 1 or the other disorder. Equally important, it has long been recognized that the presence of 1 disorder has a significant and negative impact on the prognosis of the other disorder. Individuals with concurrent PD and SUD typically have worse addiction severity and greater impairment in functioning. Clinicians’ inability or reluctance to accurately diagnose PDs in a timely manner in SUD patients may inadvertently have a negative impact on their recovery and clinical prognosis. Individuals with concurrent PD and SUD have been observed to present with greater severity of symptoms, to be more resistant to treatment, and have an increased risk of relapse. Unfortunately, despite the significant prevalence of concurrent PDs and SUDs, there is a scarcity of evidence-based treatment approaches for this population. Ideally, these individuals would be offered highly structured integrative care and evidence-based relapse prevention pharmacotherapy for addictive disorders, as there is very limited effective pharmacotherapy for PDs. This article explores the interface between SUDs and PDs, attempting to highlight the complex interaction of the respective disorders and how this might inform treatment choices, specifically the need for comprehensive approaches for patients suffering from PDs and addiction, a population who tend to be stigmatized and marginalized. Les troubles de la personnalité (TP) et les troubles liés à l’utilisation de substances (TUS) sont reconnus depuis longtemps comme étant intimement liés, partageant de nombreuses caractéristiques cliniques communes et coexistant fréquemment chez les personnes cherchant un traitement pour l’un ou l’autre trouble. Tout aussi important, il est reconnu depuis longtemps que la présence d’un trouble a un impact significatif et négatif sur le pronostic de l’autre trouble. Les personnes atteintes de TP et de TUS simultanées ont généralement une plus grande gravité de l’addiction et une plus grande altération du fonctionnement. L’incapacité ou la réticence des cliniciens à diagnostiquer avec précision les TP en temps opportun chez les patients souffrant de TUS peut avoir par inadvertance un impact négatif sur leur rétablissement et leur pronostic clinique. Il a été observé que les personnes atteintes de TP et de TUS simultanées présentaient des symptômes plus graves, étaient plus résistantes au traitement et avaient un risque accru de rechute. Malheureusement, malgré la prévalence importante des TP et des TUS concomitants, il existe une pénurie d’approches thérapeutiques fondées sur des traitements ayant fait leur preuves pour cette population. Idéalement, ces personnes se verraient offrir des soins intégrés hautement structurés et une pharmacothérapie de prévention des rechutes fondée sur des traitements ayant fait leur preuves pour les troubles de dépendance, car il existe très peu de pharmacothérapie efficace pour les troubles de la personnalité. Cet article explore l’interface entre les TUS et les TP, essayant de mettre en évidence l’interaction complexe des troubles respectifs et comment cela pourrait éclairer les choix de traitement, en particulier le besoin d’approches globales pour les patients souffrant de TP et d’addiction, une population qui a tendance à être stigmatisée et marginalisée.
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Background Day hospital mentalization-based treatment (MBT-DH) is a promising treatment for borderline personality disorder (BPD) but its evidence base is still limited. This multi-site randomized trial compared the efficacy of MBT-DH delivered by a newly set-up service v. specialist treatment as usual (S-TAU) tailored to the individual needs of patients, and offered by a well-established treatment service. Methods Two mental healthcare institutes in The Netherlands participated in the study. Patients who met DSM-IV criteria for BPD and had a score of ⩾20 on the borderline personality disorder severity index (BPDSI) were randomly allocated to MBT-DH ( N = 54) or S-TAU ( N = 41). The primary outcome variable was the total score on the BPDSI. Secondary outcome variables included symptom severity, quality of life, and interpersonal functioning. Data were collected at baseline and every 6 months until 18-month follow-up, and were analyzed using multilevel analyses based on intention-to-treat principles. Results Both treatments were associated with significant improvements in all outcome variables. MBT-DH was not superior to S-TAU on any outcome variable. MBT-DH was associated with higher acceptability in BPD patients compared v. S-TAU, reflected in significantly higher early drop-out rates in S-TAU (34%) v. MBT-DH (9%). Conclusions MBT-DH delivered by a newly set-up service is as effective as specialist TAU in The Netherlands in the treatment of BPD at 18-month follow-up. Further research is needed to investigate treatment outcomes in the longer term and the cost-effectiveness of these treatments.
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This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the beneficial and harmful effects of psychological therapies for people with borderline personality disorder (BPD).
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Aims: There is a scarcity of clinical trials on psychological treatments for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Mentalization-based treatment (MBT) have shown efficacy in several trials on BPD. The aim of the present study was to examine the feasibility and effectiveness of MBT for concurrent BPD and SUD. Methods: Patients (n = 46) with concurrent BPD and SUD were randomized either to MBT in combination with SUD treatment (n = 24) or to SUD treatment alone (n = 22). Outcome was measured after 18 months using objective data, as well as interview and self-report measures. Results: There was no significant difference between the groups on any outcome variable. No suicide attempts occurred in the MBT group in contrast to 4 suicide attempts that occurred in the control group - a difference that did not reach statistical significance (p = 0.06). A majority of the therapists did not show sufficient MBT adherence and quality. Conclusion: MBT for patients with concurrent BPD and SD does not appear to be harmful; on the other hand, it is possibly helpful in reducing the risk involved in suicide attempts.
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Objective To examine changes in personality disorders and symptomology and the relation between personality disorder variables and treatment outcomes in an adolescent sample during partial residential mentalization based treatment. Methods In a sample of 62 (out of 115) adolescents treated for personality disorders, assessment was done pre- and post-treatment using the Structured Clinical Interview for DSM personality disorders and the Symptom Check List 90. Results Significant reductions in personality disorder traits (t = 8.36, p = .000) and symptoms (t = 5.95, p = .000) were found. During pre-treatment, 91.8% (n = 56) of the patients had one or more personality disorders, compared to 35.4% (n = 22) at post-treatment. Symptom reduction was not related to pre-treatment personality disorder variables. Conclusion During intensive psychotherapy, personality disorders and symptoms may diminish. Future studies should evaluate whether the outcomes obtained are the result of the treatment given or other factors.
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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.
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The quality of implementation of evidence-based treatment programs for borderline personality disorder (BPD) in routine clinical care is a neglected issue. The first aim of this mixed-method naturalistic study was to explore the impact of organizational changes on treatment effectiveness of a day-hospital programme of mentalization-based treatment. Consecutively referred BPD patients were divided into a pre-reorganization cohort (PRE-REORG) and a cohort during reorganization (REORG). Psychiatric symptoms (Brief Symptom Inventory) and personality functioning (Severity Indices of Personality Problems-118) before treatment and at 18- and 36-month follow-up were compared using multilevel modelling. Effect sizes in the PRE-REORG cohort were approximately twice as large at 18 months (PRE-REORG: range 0.81-1.22; REORG: range 0.03-0.71) and three times as large at 36 months (PRE-REORG: range 0.81-1.80; REORG: range 0.27-0.81). The quantitative results of this study suggest that even when mentalization-based treatment is successfully implemented and the structure of the programme remains intact, major organizational changes may have a considerable impact on its effectiveness. Second, we aimed to explore the impact of the reorganization on adherence at organizational, team and therapist level. The qualitative results of this study indicate that the organizational changes were negatively related to adherence to the treatment model at organizational, team and therapist level, which in turn was associated with a decrease in treatment effectiveness. The implications of these findings for the implementation of effective treatments for BPD in routine clinical practice are discussed. Copyright © 2017 John Wiley & Sons, Ltd.
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This paper reports on three studies on the development and validation of the Parental Reflective Functioning Questionnaire (PRFQ), a brief, multidimensional self-report measure that assesses parental reflective functioning or mentalizing, that is, the capacity to treat the infant as a psychological agent. Study 1 investigated the factor structure, reliability, and relationships of the PRFQ with demographic features, symptomatic distress, attachment dimensions, and emotional availability in a socially diverse sample of 299 mothers of a child aged 0–3. In Study 2, the factorial invariance of the PRFQ in mothers and fathers was investigated in a sample of 153 first-time parents, and relationships with demographic features, symptomatic distress, attachment dimensions, and parenting stress were investigated. Study 3 investigated the relationship between the PRFQ and infant attachment classification as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. Exploratory and confirmatory factor analyses suggested three theoretically consistent factors assessing pre-mentalizing modes, certainty about the mental states of the infant, and interest and curiosity in the mental states of the infant. These factors were generally related in theoretically expected ways to parental attachment dimensions, emotional availability, parenting stress, and infant attachment status in the SSP. Yet, at the same time, more research on the PRFQ is needed to further establish its reliability and validity.
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Mothers with histories of alcohol and drug addiction have shown greater difficulty parenting young children than mothers with no history of substance misuse. This study was the second randomized clinical trial testing the efficacy of Mothering From the Inside Out (MIO), a 12-week mentalization-based individual therapy designed to address psychological deficits commonly associated with chronic substance use that also interfere with the capacity to parent young children. Eighty-seven mothers caring for a child between 11 and 60 months of age were randomly assigned to receive 12 sessions of MIO versus 12 sessions of parent education (PE), a psychoeducation active control comparison. Maternal reflective functioning, representations of caregiving, mother–child interaction quality, and child attachment were evaluated at baseline and posttreatment and 3-month follow-up. Mother–child interaction quality was assessed again at 12-month follow-up. In comparison with PE mothers, MIO mothers demonstrated a higher capacity for reflective functioning and representational coherence at posttreatment and 3-month follow-up. At 12-month follow-up, compared to PE cohorts, MIO mothers demonstrated greater sensitivity, their children showed greater involvement, and MIO dyads showed greater reciprocity. As addiction severity increased, MIO also appeared to serve as a protective factor for maternal reflective functioning, quality of mother–child interactions, and child attachment status. Results demonstrate the promise of mentalization-based interventions provided concomitant with addiction treatment for mothers and their young children.
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To explore the effectiveness of a mentalization-based therapeutic intervention specifically developed for parents in entrenched conflict over their children. To the best of our knowledge, this is the first randomized controlled intervention study in the United Kingdom to work with both parents postseparation, and the first to focus on mentalization in this situation. Using a mixed-methods study design, 30 parents were randomly allocated to either mentalization-based therapy for parental conflict—Parenting Together, or the Parents’ Group, a psycho-educational intervention for separated parents based on elements of the Separated Parents Information Program—part of the U.K. Family Justice System and approximating to treatment as usual. Given the challenges of recruiting parents in these difficult circumstances, the sample size was small and permitted only the detection of large differences between conditions. The data, involving repeated measures of related individuals, was explored statistically, using hierarchical linear modeling, and qualitatively. Significant findings were reported on the main predicted outcomes, with clinically important trends on other measures. Qualitative findings further contributed to the understanding of parents’ subjective experience, pre- and posttreatment. Findings indicate that a larger scale randomized controlled trial would be worthwhile. These encouraging findings shed light on the dynamics maintaining these high-conflict situations known to be damaging to children. We established that both forms of intervention were acceptable to most parents, and we were able to operate a random allocation design with extensive quantitative and qualitative assessments of the kind that would make a larger-scale trial feasible and productive.
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Background In this multi-centre randomized controlled trial (RCT) we compared modified mentalisation-based treatment (MBT-ED) to specialist supportive clinical management (SSCM-ED) in patients with eating disorders (EDs) and borderline personality disorder symptoms (BPD). This group of patients presents complex challenges to clinical services, and a treatment which addresses their multiple problems has the potential to improve outcome. MBT has been shown to be effective in improving outcome in patients with BPD, but its use has not been reported in ED. Methods Sixty-eight eligible participants were randomised to MBT-ED or SSCM-ED. The primary outcome measure was the global score on the Eating Disorder Examination. Secondary outcomes included measures of BPD symptoms (the Zanarini Rating Scale for Borderline Personality Disorder), general psychiatric state, quality of life and service utilisation. Participants were assessed at baseline and at 6, 12 and 18 months after randomisation. Analysis was performed using linear mixed models. ResultsOnly 15 participants (22 %) completed the 18 month follow-up. Early drop-out occurred significantly more in the SSCM-ED group. Drop-out did not vary with treatment model later in therapy and was sometimes attributed to participants moving away. There was higher drop--out amongst smokers and those with higher neuroticism scores. 47.1 % of participants in the MBT-ED arm and 37.1 % in the SSCM-ED arm attended at least 50 % of therapy sessions offered.Amongst those remaining in the trial, at 12 and 18 months MBT-ED was associated with a greater reduction in Shape Concern and Weight Concern in the Eating Disorder Examination compared to SSCM-ED. At 6, 12 and 18 months there was a decline of ED and BPD symptoms in both groups combined.Ten participants were reported as having had adverse events during the trial, mostly self-harm, and there was one death, attributed as ’unexplained’ by the coroner. Conclusions The high drop-out rate made interpretation of the results difficult. Greater involvement of research staff in clinical management might have improved compliance with both therapy and research assessment. MBT-ED may have had an impact on core body image psychopathology. Trial registrationCurrent Controlled Trials: ISRCTN51304415. Registered on 19 April 2011.
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Background Antisocial personality disorder (ASPD) is an under-researched mental disorder. Systematic reviews and policy documents identify ASPD as a priority area for further treatment research because of the scarcity of available evidence to guide clinicians and policymakers; no intervention has been established as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment which specifically targets the ability to recognise and understand the mental states of oneself and others, an ability shown to be compromised in people with ASPD. The aim of the study discussed in this paper is to investigate whether MBT can be an effective treatment for alleviating symptoms of ASPD. Methods This paper reports on a sub-sample of patients from a randomised controlled trial of individuals recruited for treatment of suicidality, self-harm, and borderline personality disorder. The study investigates whether outpatients with comorbid borderline personality disorder and ASPD receiving MBT were more likely to show improvements in symptoms related to aggression than those offered a structured protocol of similar intensity but excluding MBT components. ResultsThe study found benefits from MBT for ASPD-associated behaviours in patients with comorbid BPD and ASPD, including the reduction of anger, hostility, paranoia, and frequency of self-harm and suicide attempts, as well as the improvement of negative mood, general psychiatric symptoms, interpersonal problems, and social adjustment. ConclusionsMBT appears to be a potential treatment of consideration for ASPD in terms of relatively high level of acceptability and promising treatment effects. Trial registrationISRCTN ISRCTN27660668, Retrospectively registered 21 October 2008
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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.
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Objective: To test whether adherence to mentalization-based treatment (MBT) principles predict better patient in-session mentalizing. Methods: Two sessions for each of 15 patients with borderline personality disorder and comorbid substance abuse disorder were rated for MBT adherence and competence. Individual patient statements were rated for Reflective Functioning (RF), therapist statements were rated as demanding RF or not. Data were analysed using multilevel modelling. Results: MBT adherence and competence predicted higher session RF (β = .58-.75), even while controlling for pre-treatment RF. In addition, therapist interventions directed toward exploring mental states predicted higher RF of subsequent patient responses (β = .11-.12). Conclusions: MBT adherence and competence were significantly related to patient in-session mentalizing, supporting the validity of MBT principles. Results point to the importance of supervision for therapists to become adherent to MBT principles. The small number of patients and sessions limits generalizability of results.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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Assessing methodological quality of primary studies is an essential component of systematic reviews. Following a systematic review which used a domain based system [United States Preventative Services Task Force (USPSTF)] to assess methodological quality, a commonly used numerical rating scale (Downs and Black) was also used to evaluate the included studies and comparisons were made between quality ratings assigned using the two different methods. Both tools were used to assess the 20 randomized and quasi-randomized controlled trials examining an exercise intervention for chronic musculoskeletal pain which were included in the review. Inter-rater reliability and levels of agreement were determined using intraclass correlation coefficients (ICC). Influence of quality on pooled effect size was examined by calculating the between group standardized mean difference (SMD). Inter-rater reliability indicated at least substantial levels of agreement for the USPSTF system (ICC 0.85; 95% CI 0.66, 0.94) and Downs and Black scale (ICC 0.94; 95% CI 0.84, 0.97). Overall level of agreement between tools (ICC 0.80; 95% CI 0.57, 0.92) was also good. However, the USPSTF system identified a number of studies (n = 3/20) as “poor” due to potential risks of bias. Analysis revealed substantially greater pooled effect sizes in these studies (SMD −2.51; 95% CI −4.21, −0.82) compared to those rated as “fair” (SMD −0.45; 95% CI −0.65, −0.25) or “good” (SMD −0.38; 95% CI −0.69, −0.08). In this example, use of a numerical rating scale failed to identify studies at increased risk of bias, and could have potentially led to imprecise estimates of treatment effect. Although based on a small number of included studies within an existing systematic review, we found the domain based system provided a more structured framework by which qualitative decisions concerning overall quality could be made, and was useful for detecting potential sources of bias in the available evidence.
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Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component Summary and Mental Component Summary scales in the general US population (n = 2,333). The resulting 12-item short-form (SF-12) achieved multiple R squares of 0.911 and 0.918 in predictions of the SF-36 Physical Component Summary and SF-36 Mental Component Summary scores, respectively. Scoring algorithms from the general population used to score 12-item versions of the two components (Physical Component Summary and Mental Component Summary) achieved R squares of 0.905 with the SF-36 Physical Component Summary and 0.938 with the SF-36 Mental Component Summary when cross-validated in the Medical Outcomes Study. Test-retest (2-week) correlations of 0.89 and 0.76 were observed for the 12-item Physical Component Summary and the 12-item Mental Component Summary, respectively, in the general US population (n = 232). Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the 12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, self-reported 1-year changes in health, and recovery from depression. In 14 validity tests involving physical criteria, relative validity estimates for the 12-item Physical Component Summary ranged from 0.43 to 0.93 (median = 0.67) in comparison with the best 36-item short-form scale. Relative validity estimates for the 12-item Mental Component Summary in 6 tests involving mental criteria ranged from 0.60 to 1.07 (median = 0.97) in relation to the best 36-item short-form scale. Average scores for the 2 summary measures, and those for most scales in the 8-scale profile based on the 12-item short-form, closely mirrored those for the 36-item short-form, although standard errors were nearly always larger for the 12-item short-form.
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Borderline Personality Disorder: An Evidence-Based Guide for Generalist Mental Health Professionals Anthony W. Bateman, & Roy Krawitz Oxford University Press, 2013, £24.99, pb, 240 pp. ISBN: 9780199644209 A 350-word review is not enough to do this book justice. Written by two psychiatrists, one
Book
Borderline personality disorder (BPD) is a severe personality dysfunction thought to affect some 2% of the population. This title presents a psychoanalytically oriented treatment for BPD known as mentalization treatment. With randomised controlled trials having shown this method to be effective, this book presents the first account of this treatment for BPD.
Book
This is a book for general mental health professionals who treat people with borderline personality disorder (BPD). It offers practical guidance on how to help people with BPD with advice based on research evidence. After a discussion of the symptoms of BPD, the authors review all the generalist treatment interventions that have resulted in good outcomes in randomised controlled trials, when compared with specialist treatments, and summarise the effective components of these interventions. The treatment strategies are organised into a structured approach called structured clinical management (SCM), which can be delivered by general mental health professionals without extensive additional training. The heart of the book outlines the principles underpinning SCM and offers a step-by-step guide to the clinical intervention. Practitioners can learn the interventions easily and develop more confidence in treating people with BPD. In addition, a chapter is devoted to how to help families - an issue commonly neglected when treating patients with BPD. Finally the authors discuss the top 10 strategies for delivering treatment and outline how the general mental health clinician can deliver these strategies competently.
Article
BACKGROUND: In this multi-centre RCT we compared modified Mentalization Based Therapy (MBT-ED) to Specialist Supportive Clinical Management (SSCM-ED) in patients with Eating disorders (ED) and Borderline Personality Disorder symptoms (BPD). This group of patients presents complex challenges to clinical services and a treatment which addresses their multiple problems has the potential to improve outcome. MBT has been shown to be effective in improving outcome in patients with BPD, but its use has not been reported in ED. METHODS: 68 eligible participants were randomised to MBT-ED or SSCM-ED. The primary outcome measure was the Global Score on the Eating Disorders Examination. Secondary outcomes included measures of BPD symptoms (the ZAN-BPD), general psychiatric state, quality of life and service utilization. Participants were assessed at baseline and 6, 12 and 18 months after randomization. Analysis was performed using linear mixed models. RESULTS: Only 15 participants (22%) completed the 18 month follow-up. Early drop-out occurred significantly more in the SSCM-ED group. Dropout did not vary with treatment model later in therapy and was sometimes attributed to participants moving away. There was higher drop-out amongst smokers and those with higher neuroticism scores. 47.1% of participants in the MBT-ED arm and 37.1% in the SSCM-ED arm attended at least 50% of therapy sessions offered. Amongst those remaining in the trial, at 12 and 18-months MBT-ED was associated with a greater reduction in Shape Concern and Weight Concern in the Eating Disorders Examination compared to SSCM-ED. At 6, 12 and 18 months there was a decline of ED and BPD symptoms in both groups combined. Ten participants were reported as having had adverse events during the trial, mostly self harm, and there was one death, attributed as “unexplained” by the coroner. CONCLUSIONS: The high drop-out rate made interpretation of the results difficult. Greater involvement of research staff in clinical management might have improved compliance with both therapy and research assessment. MBT-ED may have had an impact on core body image psychopathology.
Background To present clinical outcome data of the Adolescent Mentalization‐based Integrative Treatment (AMBIT)‐trained NHS Lothian Tier 4 child and adolescent mental health service in the context of service utilization and engagement. Method Data were obtained for a 2‐year period that included details of all face‐to‐face contacts between young people and clinicians along with routinely collected clinical outcomes data relating to anxiety, depression, symptoms of psychosis and quality of life. Results Improvements were observed in quality of life, symptoms and distress across the course of the intervention. Overall attendance rates were high (80%). Relative to those who were better engaged, the less well‐engaged group received the same number of appointments but spent longer in the service (χ²(1) = 5.26, p = .022), had more professionals involved in their care (χ²(1) = 4.91, p = .027) and showed a nonsignificant trend to more inpatient admissions. Later engagement was not associated with distress or symptoms at entry into the service with the exception of negative symptoms in the Early Psychosis Support Service cohort. Age and two quality of life factors were associated with later engagement (p < .05). Conclusions Our AMBIT‐trained Tier 4 CAMH service demonstrates change over the course of intervention consistent with the service model's theoretical expectations. Engagement with the service may be associated more with factors related to social circumstance and functioning than with key symptoms and distress. Less well‐engaged young people utilize increased service resource. AMBIT's mentalizing focus may improve service provision for young people who are poorly engaged with mental health services.
Article
Reflective functioning or mentalizing is the capacity to interpret both the self and others in terms of internal mental states such as feelings, wishes, goals, desires, and attitudes. This paper is part of a series of papers outlining the development and psychometric features of a new self-report measure, the Reflective Functioning Questionnaire (RFQ), designed to provide an easy to administer self-report measure of mentalizing. We describe the development and initial validation of the RFQ in three studies. Study 1 focuses on the development of the RFQ, its factor structure and construct validity in a sample of patients with Borderline Personality Disorder (BPD) and Eating Disorder (ED) (n = 108) and normal controls (n = 295). Study 2 aims to replicate these findings in a fresh sample of 129 patients with personality disorder and 281 normal controls. Study 3 addresses the relationship between the RFQ, parental reflective functioning and infant attachment status as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. In both Study 1 and 2, confirmatory factor analyses yielded two factors assessing Certainty (RFQ_C) and Uncertainty (RFQ_U) about the mental states of self and others. These two factors were relatively distinct, invariant across clinical and non-clinical samples, had satisfactory internal consistency and test-retest stability, and were largely unrelated to demographic features. The scales discriminated between patients and controls, and were significantly and in theoretically predicted ways correlated with measures of empathy, mindfulness and perspective-taking, and with both self-reported and clinician-reported measures of borderline personality features and other indices of maladaptive personality functioning. Furthermore, the RFQ scales were associated with levels of parental reflective functioning, which in turn predicted infant attachment status in the SSP. Overall, this study lends preliminary support for the RFQ as a screening measure of reflective functioning. Further research is needed, however, to investigate in more detail the psychometric qualities of the RFQ.
Article
Patients with borderline personality disorder (BPD) have deficits in neurocognitive function that could affect their ability to engage in psychotherapy and may be ameliorated by improvements in symptom severity. In the current study, 18 patients with BPD completed neurocognitive tests prior to beginning mentalization-based therapy and again after 6 months of treatment. Twenty-eight nonpsychiatric controls were tested over the same period of time but received no intervention. Before starting treatment, patients performed lower than controls on tests assessing sustained attention and visuospatial working memory. After 6 months of treatment, patients showed significantly greater increases in sustained attention and perceptual reasoning than controls, with initial deficits in sustained attention among patients resolving after treatment. Improved emotion regulation over the follow-up period was associated with increased auditory-verbal working memory capacity, whereas interpersonal functioning improved in parallel with perceptual reasoning. These findings suggest that changes in neurocognitive functioning may track improvements in clinical symptoms in mentalization-based treatment for BPD.
Article
Background: Many respiratory tract infections are treated with macrolide antibiotics. Regulatory agencies warn that these antibiotics increase the risk of ventricular arrhythmia. We examined the 30-day risk of ventricular arrhythmia and all-cause mortality associated with macrolide antibiotics relative to nonmacrolide antibiotics. Methods: We conducted a population-based retrospective cohort study involving older adults (age > 65 yr) with a new prescription for an oral macrolide antibiotic (azithromycin, clarithromycin or erythromycin) in Ontario from 2002 to 2013. Our primary outcome was a hospital encounter with ventricular arrhythmia within 30 days after a new prescription. Our secondary outcome was 30-day all-cause mortality. We matched patients 1:1 using propensity scores to patients prescribed nonmacrolide antibiotics (amoxicillin, cefuroxime or levofloxacin). We used conditional logistic regression to measure the association between macrolide exposure and outcomes, and repeated the analysis in 4 subgroups defined by the presence or absence of chronic kidney disease, congestive heart failure, coronary artery disease and concurrent use of a drug known to prolong the QT interval. Results: Compared with nonmacrolide antibiotics, macrolide antibiotics were not associated with a higher risk of ventricular arrhythmia (0.03% v. 0.03%; relative risk [RR] 1.06, 95% confidence interval [CI] 0.83-1.36) and were associated with a lower risk of all-cause mortality (0.62% v. 0.76%; RR 0.82, 95% CI 0.78-0.86). These associations were similar in all subgroups. Interpretation: Among older adults, macrolide antibiotics were not associated with a higher 30-day risk of ventricular arrhythmia than nonmacrolide antibiotics. These findings suggest that current warnings from the US Food and Drug Administration may be overstated.