Mentalization-based treatment

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Mentalization-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioral, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganized attachment and failed to develop a robust mentalization capacity. Fonagy and Bateman define mentalization as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalization capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.

Contents

More recently, a range of mentalization-based treatments, using the "mentalizing stance" defined in MBT but directed at children (MBT-C), families (MBT-F) [1] and adolescents (MBT-A), and for chaotic multi-problem youth, AMBIT (adaptive mentalization-based integrative treatment) has been under development by groups mainly gravitating around the Anna Freud National Centre for Children and Families. [2] Moreover, the MBT model has been used in treating patients with eating disorders (MBT-ED) [3]

The treatment should be distinguished from and has no connection with mindfulness-based stress reduction (MBSR) therapy developed by Jon Kabat-Zinn.

Goals

The major goals of MBT are:

This is believed to be accomplished through increasing the patient's capacity for mentalization in order to stabilize the client's sense of self and to enhance stability in emotions and relationships. [4]

Focus of treatment

A distinctive feature of MBT is placing the enhancement of mentalizing itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalizing. Therapy examines mainly the present moment, attending to events of the past only insofar as they affect the individual in the present. Other core aspects of treatment include a stance of curiosity, partnership with the patient rather than an 'expert' type role, monitoring and regulating emotional arousal, and identifying the affect focus. Transference is not included in the MBT model. MBT does encourage consideration of the patient-therapist relationship, but without necessarily generalizing to other relationships, past or present.

Treatment procedure

MBT should be offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist works to stimulate or nurture mentalizing. Particular techniques are employed to lower or raise emotional arousal as needed, to interrupt non-mentalizing and to foster flexibility in perspective-taking. Activation occurs through the elaboration of current attachment relationships, the therapist's encouragement and regulation of the patient's attachment bond with the therapist and the therapist's attempts to create attachment bonds between members of the therapy group.

Mechanisms of change

The safe attachment relationship with the therapist provides a relational context in which it is safe for the patient to explore the mind of the other. Fonagy and Bateman have recently proposed that MBT (and other evidence-based therapies) works by providing ostensive cues that stimulate epistemic trust. The increase in epistemic trust, together with a persistent focus on mentalizing in therapy, appear to facilitate change by leaving people more open to learning outside of therapy, in the social interactions of their day-to-day lives.

Efficacy

Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder. The first randomized, controlled trial was published in 1999, concerning MBT delivered in a partial hospital setting. The results showed real-world clinical effectiveness that compared favorably with existing treatments for BPD. A follow-up study published in 2003 demonstrated that MBT is cost-effective. Encouraging results were also found in an 18-month study, in which subjects were randomly assigned to an outpatient MBT treatment condition versus a structured clinical management (SCM) treatment. [5] [6] [7] [8] The lasting efficacy of MBT was demonstrated in an 8-year follow-up of patients from the original trial, comparing MBT versus treatment as usual. In that research, patients who had received MBT had less medication use, fewer hospitalizations and longer periods of employment compared to patients who received standard care. Replication studies have been published by other European investigators. Researchers have also demonstrated the effectiveness of MBT for adolescents as well as that of a group-only format of MBT.

Related Research Articles

Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of intense and unstable interpersonal relationships, distorted sense of self, and strong emotional reactions. Those affected often engage in self-harm and other dangerous behaviors, often due to their difficulty with returning their emotional level to a healthy or normal baseline. They may also struggle with a feeling of emptiness, fear of abandonment, and dissociation.

<span class="mw-page-title-main">Histrionic personality disorder</span> Personality disorder involving excessive emotionality and attention-seeking

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early adulthood, including inappropriate seduction and an excessive desire for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, extroverted and flirtatious.

Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of:

<span class="mw-page-title-main">Schizoid personality disorder</span> Medical condition

Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, a degree of asexuality, and idiosyncratic moral or political beliefs.

Avoidant personality disorder (AvPD) or Anxious personality disorder is a Cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy, severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli as a maladaptive coping method. Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it. It appears to affect an approximately equal number of men and women.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Schizotypal personality disorder, also known as schizotypal disorder, is a cluster A personality disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM) classification describes the disorder specifically as a personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs. People with this disorder feel pronounced discomfort in forming and maintaining social connections with other people, primarily due to the belief that other people harbor negative thoughts and views about them. Peculiar speech mannerisms and socially unexpected modes of dress are also characteristic. Schizotypal people may react oddly in conversations, not respond, or talk to themselves. They frequently interpret situations as being strange or having unusual meanings for them; paranormal and superstitious beliefs are common. Schizotypal people usually disagree with the suggestion that their thoughts and behaviors are a 'disorder' and seek medical attention for depression or anxiety instead. Schizotypal personality disorder occurs in approximately 3% of the general population and is more commonly diagnosed in males.

<span class="mw-page-title-main">Psychodynamic psychotherapy</span> Form of psychoanalysis and/or depth psychology

Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

Complex post-traumatic stress disorder (CPTSD) is a stress-related mental disorder generally occurring in response to complex traumas, i.e. commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Child psychotherapy, or mental health interventions for children refers to the psychological treatment of various mental disorders diagnosed in children and adolescents. The therapeutic techniques developed for younger age ranges specialize in prioritizing the relationship between the child and the therapist. The goal of maintaining positive therapist-client relationships is typically achieved using therapeutic conversations and can take place with the client alone, or through engagement with family members.

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true. It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications. Along with cognitive behavioral therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice for depression.

In psychology, mentalization is the ability to understand the mental state – of oneself or others – that underlies overt behaviour. Mentalization can be seen as a form of imaginative mental activity that lets us perceive and interpret human behaviour in terms of intentional mental states. It is sometimes described as "understanding misunderstanding." Another term that David Wallin has used for mentalization is "Thinking about thinking". Mentalization can occur either automatically or consciously. Mentalization ability, or mentalizing, is weakened by intense emotion.

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

<span class="mw-page-title-main">Peter Fonagy</span>

Peter Fonagy, is a Hungarian-born British psychoanalyst and clinical psychologist. He studied clinical psychology at University College London. He is a Professor of Contemporary Psychoanalysis and Developmental Science Head of the Division of Psychology and Language Sciences at University College London, Chief Executive of the Anna Freud Centre, and a training and supervising analyst in the British Psycho-Analytical Society in child and adult analysis. His clinical interests center on issues of borderline psychopathology, violence, and early attachment relationships. His work attempts to integrate empirical research with psychoanalytic theory. He has published over 500 papers, and 270 chapters and has authored 19 and edited 17 books.

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

Supportive psychotherapy is a psychotherapeutic approach that integrates various therapeutic schools such as psychodynamic and cognitive-behavioral, as well as interpersonal conceptual models and techniques.

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.

<span class="mw-page-title-main">Andrew J. Gerber</span>

Andrew J. Gerber is an American psychoanalyst and the current president and medical director of Silver Hill Hospital in New Canaan, Connecticut. His principal interests and research lie in studying the neurobiological bases of social cognition, particularly in relation to autism spectrum disorders and change in response to psychotherapy. He is a member of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Psychoanalytic Association and the Psychoanalytic Psychodynamic Research Society.

Borderline personality disorder (BPD) is a psychological disorder characterized by chronic instability of relationships, self-image, moods, and affect, which is frequently misdiagnosed. This misdiagnosis can come in the form of providing a BPD diagnosis to a person who does not actually meet criteria or providing an incorrect alternative diagnosis in the place of a BPD diagnosis.

References

  1. Asen, E and Fonagy, P (2012) in: Handbook of Mentalizing in Mental Health Practice. Eds: Bateman, AW and Fonagy, P. American Psychiatric Publishing inc. Washington DC, 2012.
  2. Midgley and Vrouva, 2012.
  3. Skårderud, Sommerfeldt & Robinson, (2020) Sult Gyldendal Norsk Forlag AS.
  4. Bateman, A.W.; Fonagy, P. (2006). "Mechanism of change in mentalization based treatment of borderline personality disorder". Journal of Clinical Psychology. 62 (4): 411–430. doi:10.1002/jclp.20241. PMID   16470710.
  5. Bateman, A.W.; Fonagy, P. (2009). "Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder". Am J Psychiatry. 166 (12): 1355–1364. doi:10.1176/appi.ajp.2009.09040539. PMID   19833787.
  6. Bateman, A.W.; Fonagy, P. (2008). "8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual". Am J Psychiatry. 165 (5): 631–638. doi:10.1176/appi.ajp.2007.07040636. PMID   18347003.
  7. Bateman, A.W.; Fonagy, P. (2001). "Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up". Am J Psychiatry. 158 (11): 1932–3. doi:10.1176/appi.ajp.158.1.36. PMID   11136631.
  8. Bateman, A.W.; Fonagy, P. (2001). "Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial". Am J Psychiatry. 156 (10): 1563–9. doi:10.1176/ajp.156.10.1563. PMID   10518167.

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