Efficacy of mentalization-based therapy in treating self-harm: A systematic review and meta-analysis.

INTRODUCTION: Mentalization-based therapy (MBT) and its adapted version for adolescents (MBT-A) are repeatedly highlighted as promising treatments for reducing self-harm, particularly in borderline personality disorder (BPD). Despite the availability of publications providing evidence of their efficacy in reducing self-harm, recent meta-analyses have yielded mixed results. To inform best-practice clinical decision-making, we conducted a systematic review and meta-analysis. We aimed to disentangle findings for both adolescents and adults on the efficacy of MBT(-A) in reducing self-harm (primary outcome) and symptoms of BPD and depression (secondary outcomes). METHODS: Web of Science, Scopus, Embase, PubMed/Medline, and Cochrane Review Database were searched for eligible studies published until September 2022. In total, 14 studies were identified, comprising 612 participants from nine MBT studies (six pre-post, three RCTs) and five MBT-A studies (two pre-post, three RCTs). Aggregated effect sizes were estimated using random-effects models. Meta-regressions were conducted to assess the effect of moderator variables (treatment duration, drop-out rates, and age) on effect sizes. RESULTS: Overall, both MBT and MBT-A demonstrated promising effects in reducing self-harm (g = -0.82, 95% CI -1.15 to -0.50), borderline personality disorder (g = -1.08, 95% CI -1.38 to -0.77), and depression (g = -1.1, 95% CI -1.52 to -0.68) symptoms. However, when compared to control interventions (TAU, SCM), MBT(-A) did not prove to be more efficacious, with the exception of MBT showing superior effects on BPD symptoms in adults (g = -0.56, 95% CI -0.88 to -0.24). CONCLUSION: Although the pre-post evaluations seem promising, this analysis, including RCTs, showed no superiority of MBT(-A) to control conditions, so that prioritizing the application of MBT (-A) for the treatment of self-harm is not supported. Possible explanations and further implications are discussed.

[Body-oriented mentalization based therapy in severe somatic symptom disorder]. / Lichaamsgerichte mentalisatiebevorderende therapie bij patiënten met een somatisch-symptoomstoornis.

BACKGROUND: Body-oriented mentalization based therapy (L-MBT) is used in specialist mental health care for the treatment of patients with somatic symptom disorder or functional neurological disorder. L-MBT focuses on increasing awareness of bodily sensations and integrating them with psychological functions such as thinking, feeling or remembering. The goal of L-MBT is that patients with somatic symptom disorders learn to mentalize their body signals and the associated inner experiences. There are favorable experiences in clinical practice, but to date the mechanism of change and the effectiveness of treatment with L-MBT has not yet been sufficiently scientifically demonstrated. AIM: To investigate whether patients with severe somatic symptom disorders improve their body awareness and mentalizing capacity during an intensive treatment program based on L-MBT. METHOD: Body awareness and mentalizing capacity were assessed in patients following intensive treatment at Altrecht Psychosomatics Eikenboom, a highly specialized treatment center for adults with a severe somatic symptom disorder or functional neurological disorder Patients’ body awareness was assessed with the Multidimensional Assessment of Interoceptive Awareness (MAIA-2), mentalizing capacity with the Mentalization Questionnaire (MZQ). Questionnaires were filled in at the start, halfway and at the end of treatment. RESULTS: Both body awareness and mentalizing ability improved significantly during the intensive L-MBT-based treatment with generally a large effect size. CONCLUSION: During an intensive treatment program based on L-MBT, there is an increase in body awareness and mentalizing capacity in patients diagnosed with a severe somatic symptom disorder.

Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT).

INTRODUCTION: Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT. OBJECTIVE: The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD. METHODS: Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037. RESULTS: Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056). CONCLUSION: Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

Emotion regulation in children (ERiC): A protocol for a randomised clinical trial to evaluate the clinical and cost effectiveness of Mentalization Based Treatment (MBT) vs Treatment as Usual for school-age children with mixed emotional and behavioural difficulties.

BACKGROUND: The majority of children referred to Child and Adolescent Mental Health Services (CAMHS) in the UK will present with mixed emotional and behavioural difficulties, but most mental health treatments are developed for single disorders. There is a need for research on treatments that are helpful for these mixed difficulties, especially for school-age children. Emotion Regulation (ER) difficulties present across a wide range of mental health disorders and mentalizing may help with regulation. The ability to mentalize one's own experiences and those of others plays a key role in coping with stress, regulation of emotions, and the formation of stable relationships. Mentalization Based Therapy (MBT) is a well-evidenced therapy that aims to promote mentalization, which in turn increases ER capacities, leading to decreased emotional and behavioural difficulties. The aim of this study is to test the clinical- and cost-effectiveness of MBT compared to treatment as usual for school age children with emotional and behavioural difficulties. If effective, we hope this approach can become available to the growing number of children presenting to mental health services with a mix of emotional and behavioural difficulties. MATERIALS AND METHODS: Children referred to CAMHS aged 6-12 with mixed mental health problems (emotional and behavioural) as primary problem can take part with their parent/carers. Children will be randomly allocated to receive either MBT or treatment as usual (TAU) within the CAMHS clinic they have been referred to. MBT will be 6-8 sessions offered fortnightly and can flexibly include different family members. TAU is likely to include CBT, parenting groups, and/or children's social skills groups. Parent/carers and children will be asked to complete outcome assessments (questionnaires and tasks) online at the start of treatment, mid treatment (8 weeks), end of treatment (16 weeks) and at follow up (40 weeks). TRIAL REGISTRATION: Clinical trial registration: ISRCTN 11620914.

The effectiveness of a day hospital mentalization-based therapy programme for adolescents with borderline personality traits: Findings from Touchstone-Child and Adolescent Mental Health Service.

BACKGROUND: Individuals with borderline personality disorder (BPD) are at a substantial risk of harm to themselves and others, experience high levels of functional impairment and typically are high users of tertiary healthcare to address their mental health concerns. As indicators for BPD typically emerge in adolescence, a day therapy service in Bentley, Western Australia, Touchstone Child and Adolescent Mental Health Service (CAMHS), was developed as an intensive intervention for adolescents with indicators for BPD and its associated symptomology. Touchstone utilizes mentalization-based therapy (MBT) in a therapeutic community setting, where the current study sought to document the anecdotal outcomes using the data provided at Touchstone, to enable a greater understanding of this treatment approach for adolescents with indicators for BPD. METHOD: Forty-six participants attended the Touchstone programme between 2015 and 2020. The programme involved 6 months of MBT (group and individual), occupational therapy, education and creative therapies. Measures of self-injury, mood and emergency department presentations were collected pre- and post-programme. RESULTS: Results indicate that participants show a reduction in non-suicidal acts and thoughts, as well as a reduction in negative moods and feelings from pre-Touchstone to post-Touchstone. There is also a decrease in participant presentation to tertiary emergency departments for mental health concerns. CONCLUSIONS: The current study shows evidence for the efficacy of Touchstone as an MBT therapeutic community intervention to reduce symptoms of emerging BPD and effectively reduce presentations to emergency departments for mental health presentations, alleviating pressure on tertiary hospitals and reducing economic impact of adolescents within this demographic.

Holding a foster child's mind in mind: study protocol for a cluster-randomized controlled trial of mentalization-based therapy (MBT) for foster families.

BACKGROUND: Children in foster care are psychologically vulnerable and show more social, developmental, and behavioral problems than those living with their family of origin. Many foster parents struggle to care for these children, some of whom have experienced severe adversity. Research and theory suggest that developing a strong and supportive foster parent-child relationship is essential for foster children to become more well-adjusted and experience a decrease in behavioral problems and emotional maladjustment. Mentalization-based therapy (MBT) for foster families aims at increasing the reflective functioning of the foster parents, thus promoting the development of more secure and less disorganized child attachment representations, which is subsequently proposed as a factor that reduces behavioral problems and emotional maladjustment in children and promotes their overall well-being. METHODS: This is a prospective cluster-randomized controlled trial with two conditions: (1) the intervention group participating in MBT, and (2) the control group who receive usual care. Participants are 175 foster families with at least one foster child aged 4-17 years with emotional or behavioral problems. The intervention will be offered to foster families by 46 foster care consultants from 10 municipalities in Denmark. The foster care consultants will be randomized to MBT training (n = 23) or usual care (n = 23). The primary outcome is the psychosocial adjustment of the foster child measured by the Child Behavior Checklist (CBCL) as reported by foster parents. Secondary outcomes include child well-being, parental stress, parent mental health, parent reflective function and mind-mindedness, parent/child relations, child attachment representations, and placement breakdown. In order to explore implementation fidelity as well as practitioner experiences, we will administer questionnaires designed for this study and conduct qualitative research exploring the practice of the MBT therapists. DISCUSSION: This trial is the first experimental study of a family therapeutic intervention based on attachment theory for foster families within the Scandinavian context. This project will contribute with novel knowledge on attachment representations in foster children and the effects of an attachment-based intervention on essential outcomes for foster families and children. Trial registration ClinicalTrials.gov NCT05196724. Registered on January 19, 2022.

[Transference focused psychotherapy and mentalization based treatment. Εvidence based psychotherapies for borderline personality disorder].

Over the past decades mental health services around the world are faced with a high number of patients with borderline personality disorder (BPD) which has resulted in a particular emphasis on research for specialist treatments for this class of disorders. At least 5 psychotherapeutic models are based on evidence from clinical trials that support their effectiveness. In this review we present the latest research evidence as well as a summary of the basic characteristics of Transference-Focused Psychotherapy and Mentalization Based Treatment, which are not yet widely used in Greece. The two modalities originate from the psychoanalytic tradition and they have various points of convergence and divergence with regards to their structure (individual, group, combined) the role of the therapist and their use of basic theoretical concepts (eg. attachment, aggression). Their descriptive presentation in the form of a treatment manual and the standardisation of their training model, makes them accessible for training therapists and allows their introduction in psychiatric training programmes. We present a clinical case as an example of the application of the two approaches, along with the clinical and research paradigm originating from DeanCross Personality Disorder Service in London and the Centre for Understanding Personality Disorder, in order to compare the basic theoretical and technical characteristics of the two therapeutic modalities in view of their unique application within one outpatient service in the community. DeanCross provides a mixed MBT model (group, individual) with psychiatric input, which has been updated by the introduction of TFP in individual and group formats. Our review aligns with the international current that does not regard the two models in competition with each other; instead, we present a successful paradigm of their compatibility and mutual enrichment. The successful introduction of these therapies in the British public healthcare system, which is similar in its characteristics to the Greek national health system, is an encouraging prognostic factor when it comes to the applicability of these models in the Greek paradigm. It is a necessary prerequisite that clinical and theoretical knowledge of services that care for populations with a high prevalence of BPD is updated, and the current review makes a contribution in this direction.

Economic evaluation of day hospital versus intensive outpatient mentalization-based treatment alongside a randomized controlled trial with 36-month follow-up.

Mentalization-based treatment (MBT) has demonstrated robust effectiveness in the treatment of borderline personality disorder (BPD) in both day-hospital (MBT-DH) and intensive outpatient MBT (MBT-IOP) programs. Given the large differences in intensity and associated treatment costs, there is a need for studies comparing their cost-effectiveness. A health economic evaluation of MBT-DH versus MBT-IOP was performed alongside a multicenter randomized controlled trial with a 36-month follow-up. In three mental health-care institutions in the Netherlands, 114 patients were randomly allocated to MBT-DH (n = 70) or MBT-IOP (n = 44) and assessed every 6 months. Societal costs were compared with quality-adjusted life years (QALYs) gained and the number of months in remission over 36 months. The QALY gains over 36 months were 1.96 (SD = .58) for MBT-DH and 1.83 (SD = .56) for MBT-IOP; the respective number of months in remission were 16.0 (SD = 11.5) and 11.1 (SD = 10.7). Societal costs were €106,038 for MBT-DH and €91,368 for MBT-IOP. The incremental cost for one additional QALY with MBT-DH compared with MBT-IOP was €107,000. The incremental cost for 1 month in remission was almost €3000. Assuming a willingness-to-pay threshold of €50,000 for a QALY, there was a 33% likelihood that MBT-DH is more cost-effective than MBT-IOP in terms of costs per QALY. Although MBT-DH leads to slightly more QALYs and remission months, it is probably not cost-effective when compared with MBT-IOP for BPD patients, as the small additional health benefits in MBT-DH did not outweigh the substantially higher societal costs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): a feasibility study.

Conduct disorder (CD) is a common psychiatric disorder in youth characterized by persisting norm-violating or aggressive behavior. Considering high individual and societal burden, feasible and effective psychotherapeutic treatment is desirable. Yet, treatments and research in this patient group are scarce. This study investigates the feasibility of mentalization-based treatment for adolescents with CD (MBT-CD) in terms of acceptability of MBT-CD and scientific assessments by participants as well as necessary organizational resources to conduct a consecutive randomized controlled trial (RCT). Recruitment, adherence and treatment session numbers were descriptively analyzed. Treatment evaluation interviews were qualitatively analyzed. A subset of sessions of therapists without prior MBT experience was rated for MBT adherence. Quantitative data were used to plan a consecutive RCT. Pre to post treatment changes in diagnosis and self-reported aggression, mentalizing and personality functioning were preliminarily analyzed. N = 45 adolescents with CD were recruited. 43% dropped out. Acceptance of scientific assessments was somewhat lower than therapy adherence (questionnaires filled out by ~ 80% of adolescents in treatment), and low at follow-up (25% of treatment completers). Mean session number was 30.3. Most treatment completers were satisfied with MBT-CD. Referrals mainly came from child and youth services and psychiatry. Nine of 16 sessions rated for MBT adherence were adherent. A priori sample size estimation for a prospective RCT with a drop-out rate of 43% yielded a sample of N = 158 to detect an effect f = .15 with 80% power in a repeated measures ANOVA. Pre-post analyses revealed diagnostic improvement in 68%. Of self-reported data, empathy pathology improved. Findings provide a sound basis for a consecutive feasibility and pilot RCT. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02988453, November 30, 2016, https://clinicaltrials.gov/ct2/show/NCT02988453.

Benefícios da meditação para a saúde mental de universitários: uma revisão sistemática / Benefit of meditation for the mental health of university students: a systematic review

INTRODUÇÃO: Atualmente a ansiedade, o estresse e a depressão são os principais sintomas de problemas na saúde mental apresentados pelos universitários, estima-se que cerca de um terço desta população apresenta algum desses sintomas. OBJETIVO: Analisar as evidências clínicas sobre os benefícios da meditação na saúde mental de universitários através de uma revisão sistemática. METODOLOGIA: Foram identificados ensaios clínicos randomizados sobre os efeitos da meditação na saúde mental de estudantes universitários, redigidos em português, inglês e espanhol, e publicados entre 2018 e 2022. Foram excluídos ensaios quase randomizados, ensaios não randomizados, estudos observacionais, protocolos de ensaios clínicos, estudos preliminares, estudos que não tem a meditação como intervenção principal, reportagens e artigos sem acesso ao texto completo. As buscas foram realizadas em novembro de 2022, nas bases de dados: Embase; LILACS; MedLine/PubMed; SciELO e; The Cochrane Library. A ferramenta RoB 2 foi utilizada para avaliar o risco de viés e os artigos foram submetidos a uma análise de síntese qualitativa. RESULTADOS: Foram selecionados 19 artigos, sobre práticas de mindfulness, com 2054 participantes. A maioria dos estudos analisou os desfechos sobre o estresse, depressão, ansiedade e atenção plena, e os outros sobre qualidade de vida, satisfação com a vida e autocompaixão. Os estudos foram divididos em três categorias temáticas: intervenções assíncronas (8); intervenções online síncronas (4); intervenções presenciais (7). DISCUSSÃO: De forma geral, os resultados exprimem melhoras nos sintomas clínicos de estresse, ansiedade e depressão, além de promover atenção plena nos universitários. A meditação é uma prática de saúde que pode promovida por videochamadas, podcasts ou vídeos e podendo alcançar alunos da modalidade de ensino a distância, já que as iniciativas online parecem ter eficácia muito próxima das intervenções presenciais. CONSIDERAÇÕES FINAIS: Os resultados desta revisão contribuem para as evidências de que a meditação, principalmente o mindfulness, podem beneficiar a saúde mental de universitários, reduzindo os sintomas de estresse, ansiedade e depressão, além de melhorar a atenção plena. Estes resultados aparentam ser próximos tanto através encontros presenciais ou online, de forma síncrona ou assíncrona. Isso possibilita uma grande gama de possibilidades de aplicação na saúde de estudantes universitários. Mais estudos são necessários para avaliar os efeitos a médio e longo prazo, além de analisar e comparar as características, eficácia e aplicabilidade da meditação aplicada de forma presencial, online síncrona ou assíncrona.

INTRODUCTION: Anxiety, stress and depression are currently the main symptoms of mental health problems presented by university students, it is estimated that about one third of this population presents some of these symptoms. OBJECTIVE: To analyse the clinical evidence on the benefits of meditation on the mental health of university students through a systematic review. METHODOLOGY: We identified randomised controlled trials on the effects of meditation on mental health in university students, written in Portuguese, English and Spanish, and published between 2018 and 2022. We excluded quasi-randomised trials, non-randomised trials, observational studies, clinical trial protocols, preliminary studies, studies that do not have meditation as the main intervention, reports and articles without access to the full text. The searches were conducted in November 2022, in the databases: Embase; LILACS; MedLine/PubMed; SciELO and; The Cochrane Library. The RoB 2 tool was used to assess the risk of bias and the articles were subjected to a qualitative synthesis analysis. RESULTS: Nineteen articles were selected on mindfulness practices with 2054 participants. Most studies analysed outcomes on stress, depression, anxiety and mindfulness, and the others on quality of life, life satisfaction and self-compassion. The studies were divided into three thematic categories: asynchronous interventions (8); synchronous online interventions (4); face-to-face interventions (7). DISCUSSION: In general, the results express improvements in clinical symptoms of stress, anxiety and depression, as well as promoting mindfulness in university students. Meditation is a health practice that can be promoted by video calls, podcasts or videos and can reach distance learning students, since online initiatives seem to be very effective compared to face-to-face interventions. FINAL CONSIDERATIONS: The results of this review contribute to the evidence that meditation, especially mindfulness, can benefit the mental health of university students by reducing symptoms of stress, anxiety and depression, as well as improving mindfulness. These results appear to be forthcoming whether through face-to-face or online encounters, synchronously or asynchronously. This allows for a wide range of application possibilities in the health of university students. Further studies are needed to evaluate the medium- and long-term effects, as well as to analyse and compare the characteristics, effectiveness and applicability of meditation applied in person, online synchronously or asynchronously.

A clinical illustration of short-term mentalization-based therapy for borderline personality disorder.

OBJECTIVE: Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format. METHODS: Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety. RESULTS: The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning. CONCLUSIONS: Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.

Pedagogical stance in mentalization-based treatment.

BACKGROUND: A common aspect of evidence-based treatments for people with borderline personality disorder (BPD) is pedagogical interventions and formats. In mentalization-based treatment (MBT) the introductory course has a clear pedagogical format, but a pedagogical stance is not otherwise defined. METHODS: Treatment integrity was quantitatively assessed in a sample of 346 individual MBT sessions. Nine group sessions and 24 individual MBT sessions were qualitatively subjected to interpretative phenomenological analysis (IPA). RESULTS: The dominating intervention type was MBT Item 16-therapist checking own understanding (31% of the interventions). IPA unveiled the following: (1) a pervasive, but hidden/implicit psychopedagogical agenda, (2) psychopedagogical content seemed precious for the patients, and (3) four tentative strategies for pedagogical interventions in MBT (a) independent reasoning; (b) epistemic trust; (c) mental flexibility; and (d) application of verified insights, knowledge, or strategies. CONCLUSION: Development and clarification of the pedagogical stance in MBT could further improve the quality of therapists' interventions.

Interpersonal Psychotherapy and Mentalizing-Synergies in Clinical Practice.

Interpersonal psychotherapy (IPT) is an evidence-supported, relationally focused treatment for people living with depression and other psychiatric disorders in the context of stressful life events. Mentalizing, also relationally focused, promotes the ability to perceive, understand, and interpret human behavior in terms of intentional mental states of others or oneself, in order to support social leaning. IPT and mentalization-based treatments (MBT) both seek to improve interpersonal effectiveness, albeit with different emphases in the therapeutic process, with IPT promoting interpersonal problem solving and MBT promoting understanding of the obstacles to this outcome. In this article, the authors propose that the central intentions of IPT and mentalizing are essentially linked and complementary; understanding others and oneself in relationships facilitates interpersonal problem resolution and symptomatic recovery and enhances resilience. The clinical synergies of IPT and mentalizing are elaborated and illustrated through a case example of treatment for a socially isolated woman with depression and interpersonal sensitivities.

Trauma and Outcomes of Mentalization-Based Therapy for Individuals With Borderline Personality Disorder.

OBJECTIVE: Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP). METHODS: All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment. RESULTS: Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP. CONCLUSIONS: Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.

Running a mentalization-based treatment (MBT) programme within a public community adult mental health service setting: a feasibility study.

OBJECTIVES: This article aimed to address the feasibility of mentalization-based treatment (MBT) for patients with personality disorder in a non-specialist setting. The development and implementation of an MBT Programme is described. METHODS: A multidisciplinary Consult Group met to plan the implementation of the programme. Participants attended a psychoeducation group (MBT Introductory Group), then weekly individual and group therapy. Fourteen participants started the full programme with eight completing at least 9 months, complete data are available for five participants who completed 27 months (first cohort) and 21 months (second cohort). Data include quantitative measures and qualitative questionnaires/interviews. All had a diagnosis of personality dysfunction with co-morbid disorder including anxiety/depressive disorder, post-traumatic stress disorder and eating disorder. RESULTS: Data on five participants revealed reductions in global level of distress, improvements in psychological well-being, less interpersonal difficulties and better work and social functioning. Qualitative data from feedback questionnaires (n = 18) and in-depth interview (n = 2) are discussed under the themes of mentalizing, treatment feedback/outcomes and group factors. Therapist reflections on the process identify the challenges involved in implementing a specialist psychotherapy programme within a general service and learning points from this are discussed. CONCLUSIONS: MBT is an acceptable treatment for patients with personality dysfunction. Prior to the implementation of a programme, factors at the therapist, team and organizational level, as well as the wider context, need to be examined. This is to ensure that conditions are in place for proper adherence to the model to achieve the positive outcomes demonstrated in the RCT studies.

Learning the subtle dance: The experience of therapists who deliver mentalisation-based therapy for borderline personality disorder.

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.

Mentalization-Based Treatment in a Naturalistic Setting in Ireland: A Cohort Study.

OBJECTIVE: This study evaluated the real-world effectiveness of mentalization-based treatment by assessing the clinical status of patients before and after completing the treatment program, which was nested within a general adult community mental health service, and by comparing these patients with a treatment-as-usual group. METHODS: In this retrospective longitudinal naturalistic study, patients with a primary diagnosis of borderline personality disorder received either mentalization-based treatment (N=34) or treatment as usual (N=51). Data were collected from clinical charts and hospital databases. Presentations to the emergency department (ED), psychiatric and medical hospitalizations, and rates of loss to follow-up were analyzed for both groups. RESULTS: In the 2 years after a course of mentalization-based treatment, significant reductions were noted in psychiatric hospitalizations (p=0.018). Compared with the treatment-as-usual group, the intervention group had significant reductions in ED presentations (p=0.004) and medical admissions (p=0.040), when the analysis controlled for age and gender. At study endpoint, the proportion of patients lost to follow-up in the treatment-as-usual group was larger (χ2=7.59, df=1, p=0.006), with three deaths in the treatment-as-usual group and none in the mentalization-based treatment group. CONCLUSIONS: Mentalization-based treatment embedded within a community mental health team may have a positive effect, with significant improvements in unscheduled service use and notable reductions in ED presentations, hospitalizations, loss to follow-up, and mortality. There may be value in building on this study with more prospective, systematic research and patient-reported outcomes to assess the practical significance of this intervention in general psychiatric settings.

Patient experiences of therapy for borderline personality disorder: Commonalities and differences between dialectical behaviour therapy and mentalization-based therapy and relation to outcomes.

OBJECTIVES: Dialectical behaviour therapy (DBT) and mentalization-based therapy (MBT) are widely used evidence-based psychological treatments for borderline personality disorder (BPD). The study aimed to establish evidence on common and unique, and helpful and unhelpful, treatment processes. DESIGN: Mixed-methods. METHODS: In-depth qualitative interview data on patient experiences during treatment were combined with quantitative outcome measures in 73 patients diagnosed with a personality disorder and receiving DBT or MBT. RESULTS: Across both DBT and MBT, accounts of learning not to react impulsively, learning to question one's thoughts and assumptions, learning to communicate more effectively, and exposure to painful emotions that may previously have been avoided were each associated with less baseline-adjusted self-harm at the end of treatment. Difficulties in interacting with other group members were more likely to be described by patients receiving MBT than DBT, whilst difficulties in the therapeutic relationship were equally common. Both of these types of difficult experience were associated with higher baseline-adjusted levels of BPD traits and emotional dysregulation, at the end of the 12-month study period. CONCLUSIONS: The findings identify novel evidence of common therapeutic processes across DBT and MBT that may help to reduce self-harm. The findings also highlight the potential iatrogenic effect of difficulties in the alliance with therapists or with other group members. This underscores the importance of listening to patients' voices about what they are finding difficult during therapy and working to address these relational challenges, so that the patient is able to progress and make best use of the treatment. PRACTITIONER POINTS: Regardless of whether dialectical behaviour therapy or mentalization based therapy is used, helping service-users to learn not to react impulsively, to question their thoughts and assumptions, and to communicate more effectively, may be beneficial for reducing self-harm. Across both types of therapy, exposure to painful emotions is a difficult experience for service-users, but may also be beneficial for reducing self-harm, if carefully managed. Whilst service-users' experiences across both types of therapy have much in common, accounts of mentalization based therapy stand out in more often describing both helpful and unhelpful experiences of interactions with therapy group members. Service-users across both types of therapy report the benefits of learning intrapersonal mentalization skills, whilst recipients of mentalization based therapy uniquely extend this to learning interpersonal mentalization. Ruptures in the therapeutic alliance, and distressing interactions with group members, may be iatrogenic and must be carefully managed.