ArticleLiterature Review

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

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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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... But while mentalization-based interventions targeted at parents and infants or adolescents have increased, recent systematic reviews suggest that interventions with children aged 6-12 appear to be rather under-developed. For example, a review of the evidencebase for MBT identified 23 studies published between 1999 and 2018, of which five evaluated MBT with adolescents, and three evaluated interventions with children aged under five (Malda-Castillo et al., 2018). Only one study included in the review -a single-case report of MBT with a 7-year-old child -reported on the evaluation of a mentalization-based intervention related to middle childhood (Ramires et al., 2012). ...
... ((child* OR famil* OR parent* OR mother* OR father* OR carer* OR caregiver*) AND (mentaliz* OR mentalis* OR MBT* OR "reflective function*" OR mind-minded* OR "theory of mind") AND (therap* OR intervention* OR treatment*)) Five databases were searched: CINAHL, EMBASE, PsychInfo, Scopus and Web of Science. The range of databases was informed by previous reviews of MBT interventions (Malda-Castillo et al., 2018) and designed to include gray literature where possible to ensure breadth of findings. The specified terms were searched for in titles, abstracts and keywords of database items published between 1999 and 10 th December 2020. ...
... Most of the family-based models of MBT are transdiagnostic, but some authors describe how the approach can be used with specific categories of children, such as those with eating disorders (Kelton-Locke, 2016) or those referred to post-adoption support services (Downes et al., 2019;Midgley et al., 2018;Muller et al., 2012) The third format identified in the systematic review was mentalization-based parent trainings. In previous reviews (e.g., Malda-Castillo et al., 2018) such interventions have only been described in work with parents of under-fives, but this review identified a number of approaches to mentalization-based parent-training with children. As with interventions for children under five, these approaches largely build on the work of Slade (2005) on the concept of parental reflective functioning (PRF) and set out models of parent training which have an explicit focus on promoting this capacity. ...
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The ability to mentalize is an important developmental capacity that facilitates effective social and emotional functioning. Mentalization-Based Treatment (MBT), which aims to improve mentalizing capacity, is widely used in adults and in parent-infant therapy, but adaptations of MBT for middle childhood are less well documented. A systematic search of key databases was carried out using a PICO model. Papers were included if they explicitly described a mentalization-based approach to work with children aged between 6 and 12 and/or their caregivers. Where outcomes were reported, quality was assessed. A narrative synthesis of the literature was conducted. Sixty-two publications were included, reporting on 29 unique mentalization-informed interventions for middle childhood. Although the majority were formulated as direct therapeutic work with children and their families, several MBT interventions work with whole systems, such as schools or children’s social care. Only 22 papers reported outcomes and many were of poor quality, lacking in assessment of child mentalizing or child-reported outcomes. A broad range of mentalization-based interventions are available for middle childhood, demonstrating wide-reaching applicability. Better quality research is needed to examine the evidence base for these treatments.
... 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). ...
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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, APA 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. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
... χ 2 = 5.11 p = 0.024; r = 0.137). As previous reports showed differences between younger (18-24) and older (25)(26)(27)(28)(29)(30)(31)(32)(33)(34) young adults in the prevalence of substance misuse (e.g., [29]), age-related comparisons were performed, showing that younger young adults had increased illegal drugs use (p = 0.034) and decreased MZQ total score (p = 0.009) compared to older young adults (Supplementary Materials Table S1). ...
... Of relevance, mentalization-based treatments (MBTs), aiming at increasing mentalization capacity through psychotherapy approaches, have shown effectiveness across a wide range of clinical presentations, including personality, eating and depressive disorders [11,12,32]. According to our findings, it is possible that such forms of intervention, or interventions focused on psychological constructs closely related to mentalization (e.g., empathy, metacognition, theory of mind), may play a role in the treatment of young adults with PAU. ...
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Background: Alcohol is one of the most widely used drugs among adolescents and young people, and problematic alcohol use (PAU) is related to significant long-term biological, clinical, and psychosocial sequelae. Although preliminary reports have linked deficits in mentalization to increased vulnerability to addiction, no studies have specifically explored this phenomenon in relation to PAU. Methods: The association between mentalization impairment and PAU severity was investigated in a sample of 271 young adults (183 females, 65.9%; mean age: 23.20 ± 3.55 years; range: 18–34). Self-report measures investigating PAU and mentalization were administered to all participants. Results: Individuals with PAU reported a more frequent use of tobacco and illicit drugs in the last 12 months. PAU severity was negatively associated with mentalization capacity (rho = −0.21; p < 0.001), and also, when possible, confounding variables (i.e., gender, age, occupation, education, tobacco and illegal drugs use) were controlled for (rho = −0.17; p = 0.004). Conclusion: The present data showed that mentalization impairment is significantly associated with PAU among young adults, suggesting that it may have a role in the development and/or maintenance of alcohol use.
... RF involves taking a reflective stance, being curious about the content of one's own and others' minds, and interpreting behavior in terms of underlying mental states (Fonagy et al., 2002). RF is the focus of mental health interventions such as Mentalization-Based Treatment (Bateman & Fonagy, 1999) and has been shown to be modifiable via intervention (see Malda-Castillo, Browne, & Perez-Algorta, 2018;Toth, Rogosch, & Cicchetti, 2008). In addition, RF has been associated with greater identity integration in adults . ...
... For example, the primary focus of Mentalization Based Treatments (MBT; Bateman & Fonagy, 1999) is improving mentalization or RF abilities. MBT approaches have now been used with a number of adolescent populations (see Malda-Castillo et al., 2018, for a review), and a recent study of MBT for adolescents (MBT-A; Rossouw & Fonagy, 2012) found that identity integration improved over the course of treatment (Laurenssen et al., 2014). Of note, MBT-A can be implemented with a parallel MBT-Parents group to help increase parents' RF abilities (Bo et al., 2016;Sharp & Rossouw, 2019). ...
Article
Introduction Identity integration, as opposed to identity diffusion, has been associated with greater self-esteem, meaning in life, and functioning. Trauma may have negative effects on identity; however, few studies have examined trauma and identity among adolescents, particularly those with psychiatric disorders. Moreover, factors that may promote healthy identity in adolescents who have experienced trauma have not been identified. This study aimed to test associations between childhood maltreatment and identity diffusion among adolescents with psychiatric disorders, and evaluated reflective function (RF) as a mediator of these associations. Methods 107 adolescents (Mage = 15.36, 75.7% female) who were inpatient at a psychiatric hospital in the United States completed self-report measures of childhood maltreatment (physical, sexual, and emotional abuse; physical and emotional neglect; total maltreatment), identity diffusion, and RF. Path analysis was used to test two models of the relations between childhood maltreatment, RF, and identity diffusion. Results Total maltreatment and all forms of maltreatment except physical abuse were significantly associated with identity diffusion at the bivariate level. In path analysis (Model 1), emotional and physical neglect were directly associated with identity diffusion, and RF mediated the association between emotional abuse and identity diffusion. In Model 2, RF partially mediated the association between overall level of maltreatment and identity diffusion. Conclusions Emotional abuse, emotional neglect, physical neglect, and total combined maltreatment exposure may be risk factors for adolescent identity diffusion. Targeting RF may help to build healthy identity among adolescents with symptoms of psychiatric disorders who have experienced maltreatment, particularly emotional abuse.
... Exploring the quality of studies investigating the effectiveness of MBT for BPD, a systematic review of 23 studies of various designs was conducted by Malda-Castillo, Browne, and Perez-Algorta (2018). Of the reviewed studies, 43% were rated as 'fair', 34% 'good', 17% 'poor' and 4% 'excellent'. ...
Article
Mentalization-Based Treatment (MBT) is a psychological intervention, delivered predominantly in a group-format, originally developed for individuals with a personality disorder. Evidence is growing for this approach as a successful model of treatment, with much of the research to date conducted within inpatient settings. This study explored service-users experiences of a community-based MBT programme in a probation setting for males, diagnosed with Anti-Social personality disorder (ASPD). Using thematic analysis, results from six semi-structured interviews revealed that individuals experienced MBT as largely positive and having had an impact on their lives. Five themes emerged; ‘Experience of the group’, ‘Attachment’, ‘Learning flexibility’, ‘Individual sessions’ and ‘Impact’ with associated categories and sub-categories. Participants appeared to reflect not only on their experiences but also the internal process that occurred during their time within MBT. This was understood as the transition from chronic epistemic vigilance to epistemic trust and implications for practice are discussed. Despite its limitations, this study contributes to the growing evidence-base for MBT and specifically its positive application within community contexts for offenders with ASPD – a traditionally ‘difficult to reach’ client group.
... This article has attempted to explore how GLM can help titrate the implementation of MBT that aim to address forensic mental health needs. MBT has been shown to be an effective treatment for a range of presenting difficulties (Byrne et al., 2020;Malda-Castillo et al., 2018), but evidence for its use in forensic settings and with clients presenting with ASPD is at a nascent level. Advocates of GLM informed mental health interventions have argued that it can provide an overarching and holistic framework that enables seamless integration of various components of offender rehabilitation, including risk management, assessment, process, and practitioner issues relevant to a forensic population (Barnao, Ward, & Robertson, 2016). ...
Article
Limited research to date has focused on strengths-based rehabilitative approaches, such as the Good Lives Model (GLM) and the additive benefits such approaches have in ameliorating mental health needs of those in contact with forensic services. Mentalization-based therapies (MBTs) may be an effective treatment in forensic settings. This article aims to provide an overview of how GLM theory can integrate MBT within forensic settings. The review provides a conceptual overview of the many commonalities between GLM and MBT principles and provides information about how MBT can be embedded within forensic communities adhering to GLM principles. The article closes by offering an overview of the evidence of MBT approaches for individuals with anti-social personality disorder (ASPD) and those in contact with forensic services.
... The specific role of mentalizing in reducing borderline personality features in adolescents is somewhat clearer. The evidence to date provides preliminary support for the targeting of mentalizing deficits in reducing self-harm and other personality dysfunction (Rossouw & Fonagy, 2012) and is broadly in line with other systematic reviews of MBT approaches (Malda-Castillo et al., 2019) and MBT with adults presenting with borderline personality disorder (A. Bateman & Fonagy, 2008). ...
Article
Objectives Over the past decade, mentalization-based treatment (MBT) approaches have been developed specifically for children, adolescents and families. This study provides a systematic review of MBT applicable to both children and families. Method Five databases were searched to identify reports of MBT studies published up to February 2020. Studies were screened and reported according to PRISMA guidelines. Results A total of 34 studies were included in this review. Of these, 14 focused on parent–child dyads, two on child therapy, seven applied the approach to parenting, four evaluated the application of MBT to the school environment and seven focused on adolescent populations. Conclusion Despite methodological shortcomings and heterogeneity in design, the existing literature does provide tentative support for the use of MBT approaches for these populations, specifically in increasing mentalizing/reflective functioning. Further controlled and methodologically rigorous studies are required.
... Tailored interventions focusing on mentalizing skills, identified as basic abilities underlying various social skills, seem promising, as research has shown that mentalizing influences both the origin of and recovery from psychiatric diseases (Liotti & Gilbert, 2011;Luyten et al., 2020;Malda-Castillo et al., 2018). When dealing with psychiatric patients, therapists must provide security within the therapeutic relationship, because mentalizing abilities appear to be state-and trait-like and show considerable variability depending on the quality of the actual relationship (Liotti & Gilbert, 2011;Luyten et al., 2020). ...
Article
The psychological strain of many psychiatric disorders arises from difficulties encountered in social interactions. Social withdrawal is often the first symptom of neuropsychiatric disorders. The authors explore the various options for training social cognition skills. Social cognition was assessed using the Movie for the Assessment of Social Cognition (MASC). After completion of mentalization-based therapy (MBT) training, MASC scores improved significantly in health care providers (p = .006, r = .57). Mentalizing (operationalized with reflective functioning [RF]) was assessed in the MBT group (Group A) and compared with RF in a control group (Group B). RF was significantly higher in Group A (RF = 4.35, SD = 1.19) than in Group B (RF = 3.43, SD = 1.70) (p = .0385; Cohen's d = 0.65). MBT might be a promising intervention in social cognition training. Mentalizing skills might be associated with attitude.
... According to the theory underlying MBT, the core pathology underpinning BPD is a vulnerability to shift to nonmentalizing modes in states of emotional arousal, and MBT offers therapeutic interventions to help the patient regain adequate mentalizing and facilitate proper affect regulation (Bateman & Fonagy, 2004). Two recent reviews concluded that although more high-quality studies are needed, the current evidence indicates that MBT is a potentially effective treatment for BPD in adults (Malda-Castillo, Browne, & Perez-Algorta, 2018;Vogt & Norman, 2018). With respect to early intervention, mentalization-based approaches have been conducted for both adolescents with and without BPD features (Laurenssen et al., 2014;Rossouw & Fonagy, 2012). ...
Article
Background: Borderline personality disorder (BPD) typically onsets in adolescence and predicts later functional disability in adulthood. Highly structured evidence-based psychotherapeutic programs, including mentalization-based treatment (MBT), are first choice treatment. The efficacy of MBT for BPD has mainly been tested with adults, and no RCT has examined the effectiveness of MBT in groups (MBT-G) for adolescent BPD. Method: A total of 112 adolescents (111 females) with BPD (106) or BPD symptoms ≥4 DSM-5 criteria (5) referred to child and adolescent psychiatric outpatient clinics were randomized to a 1-year MBT-G, consisting of three introductory, psychoeducative sessions, 37 weekly group sessions, five individual case formulation sessions, and six group sessions for caregivers, or treatment as usual (TAU) with at least 12 monthly individual sessions. The primary outcome was the score on the borderline personality features scale for children (BPFS-C); secondary outcomes included self-harm, depression, externalizing and internalizing symptoms (all self-report), caregiver reports, social functioning, and borderline symptoms rated by blinded clinicians. Outcome assessments were made at baseline, after 10, 20, and 30 weeks, and at end of treatment (EOT). The ClinicalTrials.gov identifier is NCT02068326. Results: At EOT, the primary outcome was 71.3 (SD = 15.0) in the MBT-G group and 71.3 (SD = 15.2) in the TAU group (adjusted mean difference 0.4 BPFS-C units in favor of MBT-G, 95% confidence interval -6.3 to 7.1, p = .91). No significant group differences were found in the secondary outcomes. 29% in both groups remitted. 29% of the MBT group completed less than half of the sessions compared with 7% of the control group. Conclusions: There is no indication for superiority of either therapy method. The low remission rate points to the importance of continued research into early intervention. Specifically, retention problems need to be addressed.
... The authors of this study also noted that CBT with a family systems component are promising 274 . In addition, mentalization may also be effective in adolescents who self-harm 275 . Very few studies have focused on preventing suicidal ideation or behaviour in older adults 276 . ...
Article
Although recent years have seen large decreases in the overall global rate of suicide fatalities, this trend is not reflected everywhere. Suicide and suicidal behaviour continue to present key challenges for public policy and health services, with increasing suicide deaths in some countries such as the USA. The development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors. The involvement of multiple risk factors in conveying risk of suicide means that determining an individual’s risk of suicide is challenging. Improving risk assessment, for example, by using computer testing and genetic screening, is an area of ongoing research. Prevention is key to reduce the number of suicide deaths and prevention efforts include universal, selective and indicated interventions, although these interventions are often delivered in combination. These interventions, combined with psychological (such as cognitive behavioural therapy, caring contacts and safety planning) and pharmacological treatments (for example, clozapine and ketamine) along with coordinated social and public health initiatives, should continue to improve the management of individuals who are suicidal and decrease suicide-associated morbidity. Suicide and suicidal behaviour continue to present key challenges for public policy and health services. This Primer discusses the global burden of suicide and suicidal behaviours, and provides an overview of our current understanding of the mechanisms of suicide, including risk factors for suicidal ideation and the transition from ideation to suicide attempt.
... MBT is a manualized psychotherapeutic treatment which specifically focuses on improving patients' capacity to mentalize (Karterud, 2015;. It was originally developed for the treatment of borderline personality disorder Fonagy, 2004, 2008), but has since then been applied to a variety of mental disorders and clinical presentations (Malda-Castillo et al., 2019) such as depression (Jakobsen et al., 2014), eating disorders (Robinson et al., 2016), selfharm (Rossouw and Fonagy, 2012), and psychotic disorders (Weijers et al., 2016) in therapeutic individual and group settings (Schultz-Venrath and Felsberger, 2016). According to , well-functioning mentalizing can be described as a balance along four dimensions: Automatic vs. explicit mentalizing, mentalizing the self vs. others, cognitive vs. affective mentalizing, and mentalizing with regard to internal vs. external features. ...
Article
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In order to successfully interact with others in social encounters, we have to be attentive to their mental states. This means, we have to implicitly and explicitly interpret our own actions as well as the actions of others as meaningful on the basis of the ascription of intentional mental states. However, this ability, often referred to as mentalizing, seems to be impaired in autism spectrum disorder (ASD). Individuals with ADS show specific deficits relating to the representation of mental states of others. Especially, the spontaneous, intuitive attribution of and reaction to others' mental states seem to be impaired. Mentalization-Based Treatment (MBT) is a form of psychotherapy in individual and group settings that focuses on the education and enhancement of mentalizing. Although the scope of MBT is broad and MBT has been already proven to be useful in a variety of mental disorders, no attempt has been made to apply MBT in patients with ASD. In our study, we adapted MBT for adults with ASD in a therapeutic group setting to examine the feasibility as well as the effectiveness of the treatment in this patient group. During 15–20 weeks of weekly group therapy, we surveyed the patients' acceptability of the intervention. Additionally, changes in mentalizing difficulties were measured before and after treatment. Results show a high acceptance of the treatment and an improvement in the patients' mentalizing abilities, presenting MBT as a promising treatment option for ASD.
... According to the theory underlying MBT, the core pathology underpinning BPD is a vulnerability to shift to nonmentalizing modes in states of emotional arousal, and MBT offers therapeutic interventions to help the patient regain adequate mentalizing and facilitate proper affect regulation (Bateman & Fonagy, 2004). Two recent reviews concluded that although more high-quality studies are needed, the current evidence indicates that MBT is a potentially effective treatment for BPD in adults (Malda-Castillo, Browne, & Perez-Algorta, 2018;Vogt & Norman, 2018). With respect to early intervention, mentalization-based approaches have been conducted for both adolescents with and without BPD features (Laurenssen et al., 2014;Rossouw & Fonagy, 2012). ...
Presentation
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RCT study comparing MBT group treatment to TAU for adolescents with BPD
... 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. ...
Article
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La recherche permet de rendre visible ce que la vie quotidienne nous fait oublier. C’est dans le quotidien qu’on peut apercevoir ces petits détails qui peuvent du jour au lendemain nous faire plonger dans un contexte de vulnérabilité. Une situation familiale qui peut osciller dans ces zones de vulnérabilité est l’adoption, et en ce qui nous concerne plus précisément l’adoption internationale. L’adoption est souvent méconnue du grand public ou encore des intervenants. Pourtant, il y a de nombreux défis au quotidien, beaucoup de besoins, mais peu d’outils ou de ressources. Ce contexte amène les familles à composer avec ce qu’ils ont pour éviter de glisser vers la vulnérabilité. C’est pour cette raison que nous utilisons l’image du bricolage, puisque les familles tentent de se construire avec les matériaux qu’ils ont, ceux qu’ils cherchent, ceux qu’ils créent ainsi que ceux qu’ils leur manquent. C’est là l’extraordinaire dans l’ordinaire. C’est la complexité dans sa plus pure expression.
... 16 Thus, one could understand mentalization as the ability to see oneself from the outside and others from the inside, which implies a capacity for curiosity and openness. 17 Mentalization has been described by four facets or dimensions. The first, implicit-explicit (sometimes also referred to as automatic-controlled), requires reflection, attention, and intentionality, and is predominantly verbal. ...
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Objective: Hopelessness is considered a risk factor for several mental and behavioral disorders. Research has shown that a stressful life event can be a significant predictor of hopelessness. The aim of the current research study was to explore the relationship between stressful life events and hopelessness, as well as to analyses the mediation effect of both mentalization and emotional dysregulation on this relationship. Methods: In a cross-sectional design, 607 participants recruited from the Spanish general population completed a series of measures. Results: Hopelessness was significantly related to stressful life events (r = 0.24, p o 0.001), emotion dysregulation variables (r = 0.18/0.38), and most measures of mentalization (r = 0.02/0.34). A good- fitting structural equation modeling-based mediation model (w2 /df = 2.04; root mean squared error of approximation = 0.042 [90%CI 0.033-0.050]; comparative fit index = 0.97; non-normed fit index = 0.97) showed that mentalization significantly mediated the relationship between stressful life events and hopelessness, while emotion dysregulation had no significant mediating effect. Conclusions: These results could have important clinical implications, such as the development of mentalization-based interventions for people living under a large number of stressors
... 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. ...
... 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. ...
Chapter
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Inspiré de l’expérience du Programme d’aide personnelle, familiale et communautaire (PAPFC2 : Lacharité, 2014) et de l’initiative AIDES (Chamberland et al., 2012) au Québec, le Laboratoire de recherche et d’intervention en éducation familiale (LabRIEF) de l’Université de Padoue met en œuvre, depuis 2011, le Programme d’Intervention Précoce pour Prévenir l’Institutionnalisation (P.I.P.P.I.), grâce au soutien du Ministère italien du travail et des affaires sociales. L’acronyme fait référence à la résilience de Pippi Longstocking1. L’objectif de ce chapitre est de présenter une évaluation des processus et des résultats de l’implantation du programme, axée spécifiquement sur les familles ayant des enfants âgés de 0 à 2 ans qui ont participé à celui-ci. Les questions suivantes seront abordées : quelles sont les conditions de vulnérabilité spécifiques de ces familles? Quels sont les dispositifs du programme planifiés et mis en œuvre avec ces familles? En quoi les processus d’intervention et les résultats obtenus diffèrent-ils selon l’âge des enfants? Y a-t-il des effets différentiels du programme au sein du groupe d’enfants les plus jeunes? L’analyse est descriptive et présente les variables du programme en comparant les données relatives au groupe des enfants âgés de 0 à 2 (groupe 02) ans avec celles relatives au groupe des enfants de 3 à 10 ans (groupe 3-10)2. Après la description du programme et des conditions de vulnérabilité qui caractérisent les situations initiales des enfants, une analyse des processus d’intervention et des résultats obtenus grâce à la méthode d’évaluation et aux dispositifs du programme est proposée. Une analyse des effets différentiels axée sur le groupe 0-2 suit. Les résultats sont discutés afin de mettre en évidence le potentiel et les difficultés de la mise en œuvre d’une action précoce et écosystémique, comme le P.I.P.P.I. vise à promouvoir, en petite enfance dans des familles vulnérables.
... 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. ...
... 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.
... The MBT-AA was designed as a 1-year MBT treatment program, primarily based on the group-part of the original MBT treatment program for BPD in adults Bateman, Kongerslev, & Bo, 2019;Karterud, 2015). The original MBT program has displayed good effect in the treatment of different PDs, including BPD (Bateman & Fonagy, 2008Vogt & Norman, 2018) and antisocial PD (Bateman, O'Connell, Lorenzini, Gardner, & Fonagy, 2016), and for adolescents with borderline features who self-harm (Malda-Castillo, Browne, & Perez-Algorta, 2018) and in adolescents with various other PDs (Hauber, Boon, & Vermeiren, 2017). The MBT approach focuses on enhancing and maintaining the capacity to reflect about one´s own and other´s feelings, thoughts and actions under stress and in emotionally intense interpersonal situations. ...
Avoidant personality disorder (AVPD) is amongst the most severe personality disorders (PDs) and associated with a marked reduction in social functioning. However, AVPD research is sparse and little is known about treatment efficacy. In adolescents with AVPD even less is known about the disorder, and no studies have investigated the effect of psychotherapeutic treatment for this group. In this study, we present a new group-oriented treatment approach, Mentalization-Based Treatment for Avoidant Adolescents (MBT-AA), based on Mentalization-Based Treatment (MBT) principles and with elements from positive psychotherapy. Furthermore, we report on findings from a small MBT-AA case example and show that the treatment program reduces avoidant personality pathology, internalizing pathology and increases mentalization. We discuss the results and the potential empowering aspects of this new approach.
... 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.
... 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. ...
... 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. ...
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Purpose of the Review This review aims to outline the most recent evidence on the efficacy and effectiveness of mentalization-based treatment (MBT) for personality disorders (PD) from 2015 to 2018 and to describe new treatment developments. Recent Findings Since 2015, 14 new—primarily effectiveness—MBT trials have been published. The main body of studies investigated adult populations (n = 11), patients with a borderline personality disorder (BPD) diagnosis (n = 8), and compared MBT with another psychotherapeutic treatment (n = 6). The majority of studies suggest that MBT has the potential to improve the clinical outcomes for adolescents and adults with a PD diagnosis, particularly BPD, and also with comorbid diagnoses and there are indications for changes in mentalizing being a specific mechanism of change promoted by MBT. Summary Despite promising findings, there is an urgent need for methodological sound and sufficiently powered studies to investigate both the efficacy and effectiveness of MBT, especially beyond BPD.
Article
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.
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Objective Childhood emotional abuse (CEA) is associated with various negative mental health outcomes. This study aimed to investigate the association between CEA and problematic social networking site (SNS) use in a sample of Italian adolescents. Design Using structural equation modeling, the study examined whether the relationship between CEA and problematic SNS use was sequentially mediated by self‐other differentiation and uncertain reflective functioning in 1308 Italian adolescents (628 males, age range 13–19 years). Results A history of CEA was positively associated with problematic SNS use. Furthermore, deficiencies in self‐other differentiation and uncertain reflective functioning partially mediated the relationship between CEA and problematic SNS use. Conclusions The present study provides additional insight into the psychological dynamics underpinning problematic SNS use among adolescents. The clinical implications of these findings are discussed.
Chapter
Addictive disorders and personality disorders (PD) have been connected since the early days of psychiatry to such an extent that initially substance use disorders (SUD) were conceptualized as personality pathology rather than distinct disorders in and of themselves. Admittedly, these two sets of disorders have many common features and indeed frequently co-occur in the same individual. Similarly, the presence of one disorder significantly impacts prognosis of the other disorder. Individuals with comorbid PD and SUD usually present with an earlier onset, an increased addiction severity, and greater impairment in functioning, and failure to accurately diagnose PDs could have an impact on their recovery and clinical prognosis. Severity of symptoms, resistance to treatment, and increased risk of relapse can potentially result in the presence of a comorbid personality disorder in individuals with addictive disorders. There is only a small amount of data available on treatment approaches for co-occurring addiction and PDs, but it seems that these patients are likely to respond to structured integrative psychosocial care and evidence-based relapse prevention pharmacotherapy for addiction. This chapter explores the interface between addictive disorders and personality disorders, 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, who tend to be stigmatized and marginalized.
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This evidence review aims to address these specific issues documenting what we know about the extent, nature and consequences of child sexual abuse and exploitation for children in different contexts and the evidence on effective interventions and strategies to prevent and respond to it.
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Purpose: Obesity affects both mental health and the quality of life, and it also causes diseases associated with increased mortality. The aetiology of obesity is thought to be multifactorial with biological, psychological and social elements. The psychological realm includes the capacity to be aware of one’s own and others’ mental states, that is mentalizing. We hypothesized that poor mentalizing might contribute to the development and/or persistence of obesity among adolescents. The present study aims to investigate the components of the mentalization model to better identify the psychological status of obese adolescents. Methods: This study was carried out on 100 adolescent girls aged 15 to 19 years who were either obese (N=50, Mean age=17.04, Mean BMI=30.24) or normal weight (N=50, Mean age=16.94, Mean BMI=20.95). All completed the reflective functioning questionnaire (RFQ), reading the mind in the eyes test (RMET), difficulties in emotional regulation scale (DERS), and Toronto alexithymia scale (TAS). Results: Multivariate analysis of variance, univariate analysis of variance, and independent t-test were used. Lower certainty and higher uncertainty on the RFQ were confirmed in the OB group indicating reduced mentalizing ability. Misperception and misinterpretation of emotional states conveyed in the eyes in the RMET were consistent the RFQ results. Alexithymia, including difficulty recognizing, expressing and reflecting on emotions, was also found and this also fits with poor mentalizing capacity. The OB group had difficulty in all components of DERS, apart from the “Strategies” subscale. Conclusion: Mentalization or reflective function is significantly poorer in obese, compared to normal weight adolescents. Poor mentalizing could be a cause of obesity, a factor leading to its persistence, or a consequence of obesity. Further research is required to differentiate these possibilities. Level of evidence Level III: case-control analytic study.
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
Objectives This study aimed to understand therapists' lived experiences of delivering mentalisation-based therapy (MBT), including their experiences of service user change. Method One-to-one semi-structured interviews or focus groups were conducted with 14 MBT therapists and analysed using interpretative phenomenological analysis (IPA). Results Four superordinate themes were identified: (1) experiencing the challenges and complexities of being with service users during MBT; (2) being on a journey of discovery and change; (3) being an MBT therapist: a new way of working and developing a new therapeutic identity; and (4) being a therapist in the group: seeing it all come together. Conclusion Our findings highlight the complexity, challenges and individualised experience of working therapeutically with service users with a diagnosis of BPD. The study provides a perspective of service use change that is enriched by idiosyncrasies within the therapeutic encounter. We conclude with a consideration of implications for MBT research and clinical practice.
Article
This cross-sectional mixed method community action study exploring the virtue of humility was conducted as part of a collaborative practical theology project at a pluralistic, ecumenical Mainline Protestant seminary. Students ( N = 65) in a spiritual formation graduate class completed quantitative measures of humility, spiritual well-being, differentiation of self (DoS), mentalization, and mindfulness, while open-ended qualitative data captured their perspectives about the role of humility in formation. Qualitative results revealed important nuances about emerging religious leaders’ views on humility, including experiencing this virtue as (a) facilitative to their vocational growth (e.g., promoting learning, self-understanding, relational connections, and deeper spirituality), (b) challenging (e.g., self-deprecating, unnecessary, and contrary to ministry), or (c) some combination of both. Quantitative results documented positive associations between relational capacities (e.g., DoS, mentalization) and humility, and these links were mediated by mindful awareness. Implications for measuring and promoting holistic spiritual development among emerging religious leaders are discussed.
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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 randomized controlled feasibility trial (RCT), 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 (CBT) 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 Behavioral Analysis System of Psychotherapy (CBASP), Mentalization-Based Psychotherapy (MBT) and/or Mindfulness (MBCT) 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 six 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. Ethics and dissemination: This study obtained approval from independent Ethics Committees. All findings will be disseminated broadly via peer-reviewed articles in scientific journals and contributions to national and international conferences. Trial registration: German Clinical Trials Register (www.drks.de): DRKS00022093.
Article
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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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.
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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To build the evidence for a randomized controlled trial, a pilot study was conducted to investigate the feasibility, acceptability and effectiveness of a group-psychotherapy based on Metacognitive Interpersonal Therapy (MIT-G) for patients with personality disorders (PDs). Ten outpatients with PD diagnoses were offered 16 sessions of MIT-G delivered in group format. Effect sizes were calculated for changes from baseline to treatment end for clinical symptoms, interpersonal difficulties, and metacognition. Nine patients finished the full treatment protocol with nonsignificant large effect sizes obtained for change in depression, metacognition, impulsiveness and interpersonal problems measures. This is the first study suggesting that MIT-G is acceptable to outpatients across the spectrum of PDs and is associated with improvements in clinical symptoms, social functioning and metacognition. Despite the limitations of a pilot study, evidence of MIT-G effectiveness was sufficient to warrant further investigation.
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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. © 2017 Luyten et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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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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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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Objective: To compare the benefits and harms of third-wave cognitive therapy versus mentalisation-based therapy in a small sample of depressed participants. Setting: The trial was conducted at an outpatient psychiatric clinic for non-psychotic patients in Roskilde, Denmark. Participants: 44 consecutive adult participants diagnosed with major depressive disorder. Interventions: 18 weeks of third-wave cognitive therapy (n=22) versus 18 weeks of mentalisation-based treatment (n=22). Outcomes: The primary outcome was the Hamilton Rating Scale for Depression (HDRS) at end of treatment (18 weeks). Secondary outcomes were: remission (HDRS <8), Beck's Depression Inventory, Symptom Checklist 90 Revised and The WHO-Five Well-being Index 1999. Results: The trial inclusion lasted for about 2 years as planned but only 44 out of the planned 84 participants were randomised. Two mentalisation-based participants were lost to follow-up. The unadjusted analysis showed that third-wave participants compared with mentalisation-based participants did not differ significantly regarding the 18 weeks HDRS score (12.9 vs 17.0; mean difference -4.14; 95% CI -8.30 to 0.03; p=0.051). In the analysis adjusted for baseline HDRS score, the difference was favouring third-wave cognitive therapy (p=0.039). At 18 weeks, five of the third-wave participants (22.7%) were in remission versus none of the mentalisation-based participants (p=0.049). We recorded no suicide attempts or suicides during the intervention period in any of the 44 participants. No significant differences were found between the two intervention groups on the remaining secondary outcomes. Conclusions: Third-wave cognitive therapy may be more effective than mentalisation-based therapy for depressive symptoms measured on the HDRS. However, more randomised clinical trials are needed to assess the effects of third-wave cognitive therapy and mentalisation-based treatment for depression. Trial registration number: Registered with Clinical Trials government identifier: NCT01070134.
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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.
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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.
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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.
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Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. Given the generality of this definition, most mental disorders will inevitably involve some difficulties with mentalization, but it is the application of the concept to the treatment of borderline personality disorder (BPD), a common psychiatric condition with important implications for public health, that has received the most attention. Patients with BPD show reduced capacities to mentalize, which leads to problems with emotional regulation and difficulties in managing impulsivity, especially in the context of interpersonal interactions. Mentalization based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalizing. it has been tested in research trials and found to be an effective treatment for BPD when delivered by mental health professionals given limited additional training and with moderate levels of supervision. This supports the general utility of MBT in the treatment of BPD within generic mental health services.
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Background Contradictions and initial overestimates are not unusual among highly cited studies. However, this issue has not been researched in psychiatry.AimsTo assess how highly cited studies in psychiatry are replicated by subsequent studies.Method We selected highly cited studies claiming effective psychiatric treatments in the years 2000 through 2002. For each of these studies we searched for subsequent studies with a better-controlled design, or with a similar design but a larger sample.ResultsAmong 83 articles recommending effective interventions, 40 had not been subject to any attempt at replication, 16 were contradicted, 11 were found to have substantially smaller effects and only 16 were replicated. The standardised mean differences of the initial studies were overestimated by 132%. Studies with a total sample size of 100 or more tended to produce replicable results.Conclusions Caution is needed when a study with a small sample size reports a large effect. © The Royal College of Psychiatrists 2015.
Article
This study presents 18 months naturalistic follow-up data from a randomized outcome study comparing 2 years of combined (individual and group) mentalization-based treatment (MBT) and supportive group psychotherapy (SP) for patients with borderline personality disorder. Development during follow-up was assessed using a battery of self-report questionnaires, Structured Clinical Interview for DSM-IV axis II personality disorders, (SCID-II), present state examination (PSE) interviews, and therapist-rated Global Assessment of Functioning (GAF). A total of 58 of 63 patients who had completed 2 years of treatment participated. Treatment effects attained at termination were sustained at 18 months follow-up, and there were no significant differences between the groups. Half of the patients in the MBT group met criteria for functional remission at follow-up, compared with less than one fifth in the SP group. Three quarters of the participants in both groups had achieved diagnostic remission, and almost half of the patients had attained symptomatic remission on most outcome measures 18 months after treatment termination. It is concluded that significant outcome of 2-year MBT and SP conducted by experienced therapists in a well-organized clinic was sustained 18 months after treatment termination.
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Patients with limited focal frontal and nonfrontal lesions were tested for visual perspective taking and detecting deception. Frontal lobe lesions impaired the ability to infer mental states in others, with dissociation of performance within the frontal lobes. Lesions throughout the frontal lobe, with some suggestion of a more important role for the right frontal lobe, were associated with impaired visual perspective taking. Medial frontal lesions, particularly right ventral, impaired detection of deception. The former may require cognitive processes of the lateral and superior medial frontal regions, the latter affective connections of the ventral medial frontal with amygdala and other limbic regions.
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Antisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. Informed by this developmental perspective, we provide a framework for the management and treatment of adults with antisocial personality disorder, highlighting the importance of creating a safe setting and recommending adaptations of therapeutic technique to facilitate the engagement of this ‘treatment-rejecting’ patient population. We conclude with an outline of the current government policy on the treatment of high-risk offenders with personality disorder.
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The present study extends the body of evidence regarding the effectiveness of day hospital Mentalization-Based Treatment (MBT) by documenting the treatment outcome of a highly inclusive group of severe borderline personality disorder (BPD) patients, benchmarked by a carefully matched group who received other specialized psychotherapeutic treatments (OPT). Structured diagnostic interviews were conducted to assess diagnostic status at baseline. Baseline, 18-month treatment outcome and 36-month treatment outcome (after the maintenance phase) on psychiatric symptoms (Brief Symptom Inventory) and personality functioning (118-item Severity Indices of Personality Problems) were available for 29 BPD patients assigned to MBT, and an initial set of 175 BPD patients assigned to OPT. Propensity scores were used to determine the best matches for the MBT patients within the larger OPT group, yielding 29 MBT and 29 OPT patients for direct comparison. Treatment outcome was analysed using multilevel modelling. Pre to post effect sizes were consistently (very) large for MBT, with a Cohen's d of −1.06 and −1.42 for 18 and 36 months, respectively, for the reduction in psychiatric symptoms, and ds ranging from 0.81 to 2.08 for improvement in domains of personality functioning. OPT also yielded improvement across domains but generally of moderate magnitude. In conclusion, the present matched control study, executed by an independent research institute outside the UK, demonstrated the effectiveness of day hospital MBT in a highly inclusive and severe group of BPD patients, beyond the benchmark provided by a mix of specialized psychotherapy programmes. Interpretation of the (large) between condition effects warrants cautionary caveats given the non-randomized design, as well as variation in treatment dosages. Copyright © 2014 John Wiley & Sons, Ltd.