Innovations in Practice: Adolescent Mentalization-Based Integrative Therapy (AMBIT) - a new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs

Adapting Short-Term Mentalization-Based Therapy to ICD-11 Personality Disorder in Adolescents

Following the introduction of the 11th revision of the International Classification of Diseases (ICD-11), adolescents can now be diagnosed with a personality disorder based on severity ranging from mild to moderate to severe. This dimensional model has potential implications for treatment, as it allows clinicians and researchers to search for effective treatments targeting adolescents at different severity levels rather than offering all patients the same treatment. In this conceptual paper, we propose that the short-term mentalization-based therapy (MBT) program, originally developed to treat adults with borderline personality disorder (BPD), has potential clinical advantages for adolescents with ICD-11 personality disorder at the mild to moderate severity level. The short-term MBT program is a 5-month structured treatment approach including individual therapy, combined psychotherapy with the individual therapist also being one of the group therapists, and closed-group therapy to enhance cohesion and a feeling of security. The purpose of this paper is to make a case for the use of this format, as opposed to the traditional long-term MBT format, for adolescents with BPD. Future research should include large-scale randomized clinical trials powered to assess patient-important outcomes.

Working with Goals and Trauma in Youth Mental Health

There is good evidence of the value of working with goals in youth mental health services and settings. As such, goal-oriented practice is seen as a core component of good mental health interventions. Yet, there is debate among clinicians and academics about whether working with goals is a valid approach with clients who have experienced trauma. In this paper, I will explore the impacts of trauma and argue that working with goals, including the use of tools that facilitate these practices, such as the Goal-Based Outcome (GBO) tool, is as vital when working in trauma-informed interventions, as with any other mode of practice or client group.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Mentalization-based treatments with children and families: A systematic review of the literature

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.

Does your child need therapy? Maternal reflective functioning and perceived need for and use of child mental health treatment

Interventions to improve reflective functioning (RF) are being delivered to parents of children with mental health needs, yet whether this population differs in RF is unknown. We examine if mothers with varying levels of child mental health (CMH) treatment need and use differ in RF in a community sample of 212 mothers. Participants completed measures of general RF, parental RF, children's symptoms, perceived treatment need, treatment utilization, and perceptions of treatment efficacy at baseline and one year later. Low maternal RF was associated with elevated child symptoms, and a greater perceived need for treatment. Among mothers who believed their child needed services, those with low general RF were less likely to be utilizing services at baseline and in the next year. Mothers with lower parental RF also believed that CMH treatment was less effective. Findings support the use of RF-based interventions with parents identified because of their child's mental health.

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

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.

Gangs and Adolescent Mental Health: a Narrative Review

This study presents a narrative review of the literature on gang culture and its association with mental health, including an in-depth overview of the topic area and reference to key systematic reviews and meta-analyses. This review will define gang culture, discuss the multiple interacting reasons (biological, psychological and social) why some young people may be attracted to gangs; and the psychiatric morbidities associated with being part of a gang. Gang culture and some adolescent mental health problems are intricately linked. This paper highlights ways in which research, practice and policy could be extended to minimise the injurious effects of gang culture on adolescent mental health.

Efficacy of Mentalization-based group therapy for adolescents: the results of a pilot randomised controlled trial

BACKGROUND

Mentalization Based Therapy (MBT) has yielded promising outcomes for reducing self-harm, although to date only one study has reported MBT's effectiveness for adolescents (Rossouw and Fonagy, J Am Acad Child Adolesc Psychiatry 51:1304-1313, 2012) wherein the treatment protocol consisted of an intensive programme of individual and family therapy. We sought to investigate an adaptation of the adult MBT introductory manual in a group format for adolescents.

METHODS

The present study is a randomised controlled single blind feasibility trial that aims to (1) adapt the original explicit MBT introductory group manual for an adolescent population (MBT-Ai) and to (2) assess the feasibility of a trial of MBT-Ai through examination of consent rates, attendance, attrition and self-harm. Repeated measures ANOVAs were conducted to examine change over time in independent and dependent variables between groups, and multi level models (MLM) were conducted to examine key predictors in relation to change over time with self-report self-harm and emergency department presentation for harm as the primary outcome variables.

RESULTS

Fifty-three young people consented to participate and were randomised to MBT-Ai + TAU or TAU alone. Five participants withdrew from the trial. Trial procedures seemed appropriate and safe, with acceptable group attendance. Self-reported self-harm and emergency department presentation for self-harm significantly decreased over time in both groups, though there were no between group differences. Social anxiety, emotion regulation, and borderline traits also significantly decreased over time in both groups. Mentalization emerged as a significant predictor of change over time in self reported self harm and hospital presentation for self-harm.

CONCLUSIONS

It was feasible to carry out an RCT of MBT-Ai for adolescents already attending NHS CAMHS who have recently self-harmed. Our data gave signals that suggested a relatively brief group-based MBT-Ai intervention may be a promising intervention with potential for service implementation. Future research should consider the appropriate format, dosage and intensity of MBT for the adolescent population.

TRIAL REGISTRATION

NCT02771691 ; Trial Registration Date: 25/04/2016.

Treatment outcomes and associations in an adolescent-specific early intervention for psychosis service

AIM

Compared with adult onset psychosis, adolescent psychosis has been associated with poorer outcomes in terms of social and cognitive functioning and negative symptoms. Young people experiencing first episode psychosis have developmental needs that frequently pre-date and are compounded by psychosis onset (a previous study). There is a lack of published studies of adolescent onset psychosis and further information is needed so that developmentally appropriate interventions can be developed. We report an observational naturalistic cohort study of an adolescent specific service, the Early Psychosis Support service (EPSS).

METHOD

We examined baseline demographic and clinical variables, treatments outcomes and predictors of outcome for this population.

RESULTS

The mean age of our sample was 16.3 years. Median duration of untreated illness (DUI) was 88 weeks, and median duration of untreated psychosis (DUP) was 16 weeks. We found significant improvements in positive symptoms, negative symptoms, disorganization, excitement, emotional distress and depression from 0 to 12 months. We found that baseline positive symptoms and DUI significantly predicted positive symptoms at 12 months and only negative symptoms at baseline predicted 12-month negative symptoms.

CONCLUSION

Our finding that specialist early intervention for adolescents experiencing psychosis is effective suggests that such treatment should be routinely offered in line with existing clinical guidelines. Our finding that DUI is predictive of poorer outcome at 12 months suggests that even earlier intervention from a specialist team may further improve treatment outcomes.

When do peers matter? The moderating role of peer support in the relationship between environmental adversity, complex trauma, and adolescent psychopathology in socially disadvantaged adolescents

INTRODUCTION

This study examined the longitudinal associations between environmental adversity (defined in terms of exposure to violence in the neighborhood, school, and media), complex trauma (operationalized as experiences of abuse and neglect), and adolescents' internalizing and externalizing symptoms.

METHODS

Using a cross-lagged panel research design, we investigated the moderating role of peer support in these relationships in a sample of 644 adolescents from a severely disadvantaged district of Lima, Peru, who were followed up in a 1-year prospective study.

RESULTS AND CONCLUSIONS

We found significant unidirectional dynamic relations, where both types of adversity were associated with higher levels of internalizing and externalizing symptoms. Peer support significantly moderated this effect, but only for complex trauma, in that higher levels of peer support were associated with a decreased impact of complex trauma on internalizing and externalizing symptoms. These findings highlight the importance of social relations and the quality of peer relations in particular as factors that may mitigate the risk of early exposure to trauma.

A Qualitative Study of an Employment Scheme for Mentors with Lived Experience of Offending Within a Multi-Agency Mental Health Project for Excluded Young People

The use of peer intervention schemes is increasingly popular within services for offending groups and there is growing evidence of their benefit for peers delivering the interventions. The current study explores staff and peer experiences of an employment scheme for peer mentors within a community project for young people involved in offending. Semi-structured interviews were conducted with full time staff (n=4) and peer mentors employed on the scheme (n=2). Thematic analysis revealed three themes of "Opportunity and Empowerment", "Supportive Processes" and "Role Definition and Structure". The results suggest that meaningful employment opportunities, with holistic support and processes for reflection and mentalisation of self and others, contribute to the personal and professional development of ex-offenders in peer mentoring roles.

Psychotherapeutic interventions and contemporary developments: common and specific factors

In this article we start with the effectiveness paradox between different psychotherapeutic modalities, considering common factors, before moving on to give a brief overview of the three main psychotherapeutic approaches – psychoanalytic, cognitive–behavioural and humanistic – and their developments. We conclude that it is the therapeutic relationship – considered in the context of the above – that is core to all therapeutic engagement, medical or otherwise.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None

Innovations in Practice: Evaluating clinical outcome and service utilization in an AMBIT-trained Tier 4 child and adolescent mental health service

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.

20/20 Hindsight: A 25-year programme at the Anna Freud Centre of efficacy and effectiveness research on child psychoanalytic psychotherapy

OBJECTIVE

This paper describes the evolution of methods of enquiry-through 25 years of work, with Professor Peter Fonagy and many other colleagues-of research and theorizing about child and adolescent therapy outcomes.

METHOD

The work has focused on measuring psychoanalytic outcomes, but with an increasing interest in discovering therapeutic elements across treatment modalities.

RESULTS

Headline findings are described, with lessons from the ups and downs of developing (a) retrospective, follow-up, and prospective outcome studies, and (b) measures of child and family functioning. Issues of manualizing and measuring treatment process are discussed, together with the fruitfulness of mixed-method (quantitative and qualitative) process and outcome research with young people and families.

CONCLUSIONS

Using the dilemmas, experiences, and findings ‌‌of our group as examples, growing points and well as growing pains for the field are suggested.

Observation of Interactions in Adolescent Group Therapy: A Mixed Methods Study

Group psychotherapy is a useful clinical practice for adolescents with mental health issues. Groups typically consist of young people of similar ages but with different personalities, and this results in a complex communication network. The goal of group psychoanalytic psychotherapy is to improve participants' mentalization abilities, facilitating interactions between peers and their therapist in a safe, containing environment. The main aim of this study was to analyze conversation turn-taking between a lead therapist, a co-therapist, and six adolescents over the course of 24 treatment sessions divided into four blocks over 8 months. We employed a mixed-methods design based on systematic observation, which we consider to be a mixed method itself, as the qualitative data collected in the initial observation phase is transformed into quantitative data and subsequently interpreted qualitatively with the aid of clinical vignettes. The observational methodology design was nomothetic, follow-up, and multidimensional. The choice of methodology is justified as we used an ad-hoc observation instrument combining a field format and a category system. Interobserver agreement was analyzed quantitatively by Cohen's kappa using the free QSEQ5 software program. Once we had confirmed the reliability of the data, these were analyzed by polar coordinate analysis, which is a powerful data reduction technique that provides a vector representation of relationships between categories. The results show significant relationships between the therapist and (1) the activation of turn-taking by the participants and the co-therapist and silence and (2) conversation-facilitating interventions and interventions designed to improve mentalization abilities. Detailed analysis of questions demonstrating interest in others showed how the communication changed from radial interactions stemming from the therapist at the beginning of therapy to circular interactions half way through. Repetition was found to be a powerful conversation facilitator. The results also illustrate the role of the therapist, who (1) did not facilitate interventions by all participants equally, (2) encouraged turn-taking from more inhibited members of the group, (3) stimulated conversation from the early stages of therapy, and (4) favored mentalization toward the end. Despite its complexity, polar coordinate analysis produces easy-to-interpret results in the form of vector maps.

What we have changed our minds about: Part 2. Borderline personality disorder, epistemic trust and the developmental significance of social communication

In Part 1 of this paper, we discussed emerging evidence suggesting that a general psychopathology or 'p' factor underlying the various forms of psychopathology should be conceptualized in terms of the absence of resilience, that is, the absence of positive reappraisal mechanisms when faced with adversity. These impairments in the capacity for positive reappraisal seem to provide a comprehensive explanation for the association between the p factor and comorbidity, future caseness, and the 'hard-to-reach' character of many patients with severe personality pathology, most notably borderline personality disorder (BPD). In this, the second part of the paper, we trace the development of the absence of resilience to disruptions in the emergence of human social communication, based on recent evolutionary and developmental psychopathology accounts. We argue that BPD and related disorders may be reconceptualized as a form of social understanding in which epistemic hypervigilance, distrust or outright epistemic freezing is an adaptive consequence of the social learning environment. Negative appraisal mechanisms become overriding, particularly in situations of attachment stress. This constitutes a shift towards a more socially oriented perspective on personality psychopathology in which the absence of psychological resilience is seen as a learned response to the transmission of social knowledge. This shift in our views has also forced us to reconsider the role of attachment in BPD. The implications for prevention and intervention of this novel approach are discussed.

Innovations in Practice: A case control and follow-up study of 'hard to reach' young people who suffered from multiple complex mental disorders

BACKGROUND

Innovations Project (IP) was a new multidisciplinary team based within an inner city, walk-in health centre, North East England (throughout 2011). The aim was to describe the social and mental disorders of the hard to reach young people (HTRYP) from the IP and compare with a matched sample who attended a Community Mental Health Team (CMHT) and follow-up both samples 24 months after discharge.

METHODS

A retrospective review of clinical case notes of YP who attended the IP and CMHT. A 24-month (postdischarge) follow-up evaluation of the mental state and social function of the YP in both groups using Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA) and Children's Global Assessment Scale (CGAS).

RESULTS

Thirty-six referrals were accepted over a one-year period by the IP, 31 met criteria for the HTRYP, 15 were offered individually tailored therapy. The HTRYP who were more deprived compared to the CMHT matched sample (n = 115), experienced a higher median number of mental disorders (n = 3 compared to CMHT n = 1), higher severity scores and lower levels of social function (HTRYP HoNOSCA mean: 19.1 (95% CI 15.9-22.2) and CMHT mean: 11.2 (95% CI 2.0-23.0) p = <.001, and HTRYP CGAS mean: 51.0 (95% CI 46.0-56.2) and CMHT mean: 58.9 (95% CI 52.9-64.8), p = .05). The HTRYP made significantly greater improvement compared to CMHTYP; (HoNOSCA p = <.001 and CGAS p = <.002) at discharge. A total of 13 HTRYP and 9 CMHT YP attended the follow-up review at 24 months. There was substantial variability in terms of social function between the YP within each sample.

CONCLUSIONS

The term 'HTR' describes a state that may be often temporary, as opposed to lifelong. A bespoke service offering a developmental theoretical framework, regular reviews and an individualised care plan, was able to engage and had the potential to reduce morbidity suffered by HTRYP.

Service users as the key to service change? The development of an innovative intervention for excluded young people

BACKGROUND

Excluded young people, especially those affected by street gangs, often have complex unmet needs and high levels of health and social inequalities. This paper outlines the development of Music & Change, an innovative and comprehensive intervention accessible to young people, which aimed to holistically meet the mental health and other needs of its participants and ultimately to reduce offending rates. Its central principle was coproduction and partnership with its potential users.

METHOD

The setting was an inner-city housing estate; the core group of participants was 15 young people aged 16-22 years. The intervention used contemporary music skills (e.g. DJ-ing and lyric writing) and other coproduced project activities as a vehicle to build relationships with practitioners and address young people's multiple needs. Data were gathered using a focused ethnography, largely from field notes, and analysed using thematic analysis in order to ascertain users' perceptions of its delivery.

RESULTS

Young people identified six key principles of the intervention, such as the need for consistent relationships with trusted staff, mental health support to be wrapped round other youth-led activities and local service delivery within their safe territories.

CONCLUSIONS

Music & Change was valued by young people who do not easily engage with professionals and services. The findings led to the development of the 'Integrate' model, which is using these coproduced principles to underpin several new pilot projects that aim to address the health and social inequalities of excluded young people.

Introduction to the special issue: attachment-based treatments for adolescents

During the past decade, new attachment-based treatments (ABTs) for adolescents have been developed and tested in both field and randomized control trials. The papers in this special issue represent important contributions to defining a more general model of ABTs for adolescents. Our discussion of these papers is organized by a series of challenges to developing and evaluating these treatments. We first consider how disturbances in the caregiver-adolescent attachment bond are implicated in adolescent psychopathology and family distress. We then describe different potential targets for attachment-based interventions for adolescents and their caregivers. Finally we review the different interventions and change mechanisms that have been used to increase security in the caregiver-adolescent bond. A general model of ABTs for adolescents can be useful in guiding future efforts to measure change in attachment constructs, evaluate the dynamic process of change in attachment bonds, and test the effectiveness of specific treatment elements in reducing adolescents' symptoms and increasing attachment security.

Network based therapy: theoretical outline of a support model for adults and adolescents struggling to cope

Purpose

– The Service User Network (SUN) follows the ethos of the therapeutic community and draws upon coping theory and psychoanalytic understanding of personality disorder to provide a supportive group-based resource to adults struggling to cope. The paper aims to discuss this issue.

Design/methodology/approach

– The original SUN Project has been successfully replicated, with the further addition and integration of psychoanalytically – derived approaches to the treatment of personality disorder within that replication. The most notable theoretical additions come from the mentalization-based therapy model and the Independent School of Psychoanalysis. In this paper, the author expands the original description of the model to include these theoretical additions, together with a fuller account of the original tenets of the treatment paradigm than previously described.

Findings

– This provides an outline of a network-based therapy (NETBT) as a first stage in manualizing the model, as well as extending its use to support adolescents.

Originality/value

– Network-based therapy is a new, evolving group treatment for adolescents and adults struggling to cope.

The Adolescent Mentalization-based Integrative Treatment (AMBIT) approach to outcome evaluation and manualization: adopting a learning organization approach

AMBIT (Adolescent Mentalization-Based Integrative Treatment) is a developing team approach to working with hard-to-reach adolescents. The approach applies the principle of mentalization to relationships with clients, team relationships and working across agencies. It places a high priority on the need for locally developed evidence-based practice, and proposes that outcome evaluation needs to be explicitly linked with processes of team learning using a learning organization framework. A number of innovative methods of team learning are incorporated into the AMBIT approach, particularly a system of web-based wiki-formatted AMBIT manuals individualized for each participating team. The paper describes early development work of the model and illustrates ways of establishing explicit links between outcome evaluation, team learning and manualization by describing these methods as applied to two AMBIT-trained teams; one team working with young people on the edge of care (AMASS - the Adolescent Multi-Agency Support Service) and another working with substance use (CASUS - Child and Adolescent Substance Use Service in Cambridgeshire). Measurement of the primary outcomes for each team (which were generally very positive) facilitated team learning and adaptations of methods of practice that were consolidated through manualization.

Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service

This study sought to investigate frontline mental health professionals' perceptions of work stress and the rewards and demands associated with their work. Locally known as 'linkworkers', and from a variety of professional backgrounds, these staff worked mainly in general practice settings. Individual interviews were conducted with nine linkworkers, and the interview transcripts were analysed thematically. The main themes identified were the following: demands, coping, individual resilience, ownership and creativity, boundaries, secure base and service philosophy and ethos. Themes, categories and sub categories were presented and discussed with seven of the linkworkers in two focus groups. Focus group transcripts were analysed, and additional themes of recognizing limitations, disillusionment and the dilemma of setting boundaries were identified. These themes overlapped with those previously identified but were associated with service changes over time. The themes of ownership and creativity and service philosophy and ethos are significant, not only in relation to their impact on individual linkworkers but also in terms of their relevance for establishing and maintaining morale, engagement and a reflective culture within a service. The relevance of this work to accessible and newly developing mental health services is considered.

KEY PRACTITIONER MESSAGE

Supporting and listening to staff and allowing time for informal contact are valued by staff and enable the provision of empathic, compassionate services. Without space for reflection, staff groups may be vulnerable to the development and effects of unhelpful organizational defences, which reduce the effectiveness, quality and efficiency of caring services and increase perceived workplace stress. Services which foster staff engagement, ownership and creativity and employ "bottom up" approaches to service development are valued by staff and appear to increase staff morale and capacity to cope adaptively to change.