What is mentalization?
What is mentalization-based treatment?
Research evidence for treatment focusing on mentalizing
Randomized controlled trial of MBT for BPD
Follow-up study of MBT for BPD
Cost-effectiveness study of MBT
Mentalization is the capacity to make sense of self and other in terms of subjective states and mental processes. Being able to understand other people’s behaviour in terms of their likely thoughts and feelings is a major developmental achievement that, we believe, is facilitated by secure attachment relationships. Our understanding of others critically depends on whether as infants our own mental states were adequately understood by our caregivers. Consequently the process is vulnerable to disruption.
Our premise is that unstable or reduced mentalizing capacity is a core feature of borderline personality disorder. Therefore, successful treatment must have mentalization as its focus or at least stimulate development of mentalizing as an epiphenomenon.
Mentalization-based treatment is a model of psychodynamic therapy rooted in attachment theory that aims to enhance the individual’s capacity to represent thoughts, feelings, wishes, beliefs and desires in themselves and in others in the context of attachment relationships. MBT is described in detail in several recent books; click here for more information.
Our programme of mentalization based treatment was developed and implemented by a team of generically-trained mental health professionals. The research took place within a normal clinical setting and in a locality and healthcare system in which patients were unlikely to be able to obtain treatment elsewhere. This allowed effective tracing of patients within the service and accurate collection of clinical and service utilisation data. Patients were treated at only two local hospitals for medical emergencies such as self-harm, enabling us to obtain highly accurate data of episodes of self-harm and suicide attempts requiring medical intervention. The programme was complex, but was designed so that it could be dismantled at a later date to determine the therapeutic components.
Our initial task in setting up the treatment programme was to review the literature, to consider the evidence for effective interventions, and to match those to the skills within the team. From the evidence discussed above we concluded that treatments shown to be effective with BPD had certain common features. They tended (a) to be well-structured, (b) to devote considerable effort to the enhancing of adherence, (c) to be clearly focussed, whether that focus was a problem behaviour such as self-harm or an aspect of interpersonal relationship patterns, (d) to be theoretically highly coherent to both therapist and patient, sometimes deliberately omitting information incompatible with the theory, (e) to be relatively long term, (f) to encourage a powerful attachment relationship between therapist and patient, enabling the therapist to adopt a relatively active rather than a passive stance, and (g) to be well integrated with other services available to the patient. While some of these features may be those of a successful research study rather than those of a successful therapy, we concluded that the manner in which treatment protocols were constructed and delivered was probably as important in the success of treatment as the theoretically-driven interventions.
With these general features in mind, we developed a programme of treatment and organised a research programme to test the effectiveness of the intervention. From the outset it was clear that this was to be ‘effectiveness research’ rather than ‘efficacy’ research – we would investigate the outcome of BPD treated by generically-trained non-specialist practitioners within a normal clinical setting. In this way, the treatment was more likely to be translatable to other services without extensive and expensive additional training of personnel.
Our evidence base remains small as far as treatment outcome is concerned; yet replication studies are underway and an increasing number of practitioners are using mentalization techniques in treatment, such that more information will become available soon. Our original RCT of treatment of BPD in a partial hospital programme offering individual and group psychoanalytic psychotherapy showed significant and enduring changes in mood states and interpersonal functioning associated with an 18-month programme. The benefits, relative to treatment as usual, were large (numbers needed to treat around 2) and were observed to increase during the follow-up period of 18 months, rather than staying level as with DBT. It should be remembered, however, that this partial hospital programme continued as non-intensive group therapy after eighteen months, whereas it is not clear what subsequent treatment patients in the DBT trials received.
Forty-four patients who participated in the original study were assessed at 3-monthly intervals after completion of the earlier trial. Outcome measures included frequency of suicide attempts and acts of self-harm, number and duration of in-patient admissions, service utilisation, and self-report measures of depression, anxiety, general symptom distress, interpersonal function and social adjustment. Data analysis used repeated measures analysis of covariance and non-parametric tests of trend. Patients who had received partial hospitalisation treatment not only maintained their substantial gains but also showed a statistically significant continued improvement on most measures in contrast to the control group of patients who showed only limited change during the same period. This suggests that ‘rehabilitative’ changes had developed enabling patients to negotiate the stresses and strains of everyday life without resorting to former ways of coping such as self-harming activity.
Healthcare utilisation of all patients who participated in the trial was assessed using information from case notes and service providers (Bateman & Fonagy, 2003). Costs of psychiatric, pharmacological, and Emergency Room treatment were compared 6-months prior to treatment, during 18-months treatment, and 18 months follow-up. There were no differences between the groups in the costs of service utilisation pre-treatment or during treatment. The additional cost of day hospital treatment was offset by less psychiatric in-patient care and reduced emergency room treatment. The trend for costs to decrease in the experimental group during 18 months follow-up was not apparent in the control group, suggesting that day hospital treatment for BPD is no more expensive than general psychiatric care and shows considerable cost-savings after treatment.
We have just completed the five-year follow-up of this sample and significant differences between the MBT and TAU groups remain. Click here to download a report of the five-year follow-up study (Bateman & Fonagy 2008).
The effective components of the programme remain unclear, but the common feature of all the different treatment elements was mentalization. Patients received a range of treatments along with group and individual therapy, including psychodrama and other expressive therapies along with some psychoeducation early in treatment. To determine whether the focus on mentalizing is a key component and to see if a more modest programme may be effective in a less severe group of borderline patients, we are currently undertaking a randomised controlled trial of individual and group psychotherapy alone offered in an out-patient programme. Results are not yet available. Nevertheless we have defined interventions that we believe are likely to enhance mentalizing, packaging them within a structured programme.
Bateman, A., & Fonagy, P. (1999). The effectiveness of partial hospitalization in the treatment of borderline personality disorder - a randomised controlled trial. American Journal of Psychiatry, 156, 1563-1569.
Bateman, A., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. American Journal of Psychiatry, 158(1), 36-42.
Bateman, A., & Fonagy, P. (2003). Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. American Journal of Psychiatry, 160(1), 169-171.
Bateman, A. W., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder - mentalization based treatment versus treatment as usual. American Journal of Psychiatry, 165, 631–638