Mentalization-Based Treatment From the Patients' Perspective - What Ingredients Do They Emphasize?

Art and mentalizing in early intervention psychosis: rationale and therapist insights on a new psychoeducational course

In this paper, we explore the rationale for a combined art therapy and mentalization-based treatment (MBT) group course for those experiencing a first episode of psychosis (FEP). We discuss the theoretical background for how art and MBT theory can help us better understand and work with groups of individuals experiencing FEP, particularly focusing on avoidance and insecure attachment styles. We outline the delivery of a ten-week psychoeducational Art MBT course within an Early Intervention in Psychosis (EIP) Service and discuss our experiential insights into this new modality as co-therapists. We conclude by proposing that art therapy and mentalizing practice together offer an accessible, useful and practical group structure for EIP services, which could improve individuals' mentalizing capacity and overall social functioning.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Mentalizing the patient-Patient experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study

Background

Mentalization-based therapy (MBT) is an evidence-supported psychotherapy approach for borderline personality disorder (BPD) that has been implemented in mental health services worldwide. Originally, MBT was developed as an 18-months program for BPD. However, a short-term (5 months) MBT program has been developed. Research into patient experiences with long-term MBT for BPD is scarce, and no studies have investigated patient experience with short-term MBT for BPD.

Objective

The objective of this study was to explore patient experience with short-term MBT for BPD in the Danish mental health services.

Methods

Semi-structured qualitative interviews were conducted with 12 outpatients diagnosed with BPD, who attended short-term MBT for 5 months. The interviews were verbatim transcribed and analyzed using thematic analysis with double coding.

Results

The analysis resulted in four subordinate themes: (1) Treatment duration - too short or appropriately short?, (2) The group as a "safe space," (3) Bad experiences impacted treatment negatively, and (4) My life has changed for the better.

Conclusion

The results suggest that most of the patients were overall satisfied with short-term MBT, which they experienced as having a positive impact on their lives. However, a subgroup of patients wanted more therapy. This study highlighted the strengths and limitations of short-term MBT for BPD as experienced by the patients, and points to barriers in developing service-user informed short-term treatment options for BPD.

The Norwegian network for personality disorders - development, contributions and challenges through 30 years

BACKGROUND

Established in 1992, the Norwegian Network for Personality Disorders (The Network) is a clinical research collaboration of specialist mental health and addiction services in Norway. Its primary focus is to facilitate systematic and relevant clinical assessment for patients with personality disorder and evaluate progress in psychotherapeutic treatment. However, large-scale data registers for personality disorder are still unique. This article presents the circumstances that led to the establishment of the Network, and its development and challenges in many areas, and through various phases.

METHODS

In the following, we will outline how this close interaction between researchers, clinicians, and well-adapted systems has facilitated cooperation and clinical research. We will highlight some key factors that have been decisive during the network's development, and not least for further adaptation and existence.

RESULTS

Through 30 years, the Network has succeeded in establishing a large and sustainable clinical research collaboration with a persistent focus on personality disorder and psychotherapeutic treatment. The collaboration has resulted in a broad range of scientific contributions to the understanding of personality disorder, assessment and measurement methods, treatment alliance, clinical outcomes, service utilization, and costs. In addition, The Network has also resulted in a number of synergy effects that have benefited clinicians, patients, and researchers.

CONCLUSIONS

The Norwegian Network for Personality Disorders has become an acknowledged institution in the field. Many aspects of its development, organization, maintenance, and solutions to challenges may be relevant to others who plan to establish, maintain, or further develop similar collaborations.

A trauma model of substance use: Elaboration and preliminary validation

The current study expands on and integrates previous theoretical models concerning the pathways that link child maltreatment to substance use disorder. The proposed model, based on the self-medication hypothesis, suggests that experiences of neglect and abuse during childhood can lead to substance use and abuse both directly and indirectly, via dissociation resulting from failed attempts to integrate experiences of maltreatment in childhood. The model was tested on ten substances (painkillers, stimulants, sedatives, marijuana, cocaine, ecstasy, hallucinogens, heroin, inhalants, and methamphetamine) via structural equation modeling (SEM) in a sample comprising 1040 community-dwelling adults (67 % women) aged between 18 and 78 (M = 29.55, SD = 11.37). Fit indexes of the SEM were good, thus supporting the hypothesized model. Specific forms of child maltreatment were related to increased use of specific substances; however, experience of childhood neglect (both physical and emotional) was found to have a central role in predicting use of most substances. Although no single pathway can fully explain the origins of substance abuse, the current study provides evidence of a critical developmental pathway to it, with implications for theory and clinical practice.

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.

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.

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.

"If you don't have a word for something, you may doubt whether it's even real" - how individuals with borderline personality disorder experience change

Objective: This study explored how psychological change was experienced and what treatment-related factors or events were perceived as supporting or hindering their process by individuals with borderline personality disorder. Methods: Eight BPD sufferers attended a 40-session psychoeducational group intervention at a community mental health care center. At intervention end, personal experience of meaningful change was explored in an in-depth interview and data were content-analyzed. Change in BPD symptoms was assessed by the Borderline Personality Disorder Severity Index IV interview. Results: The qualitative content analysis on subjectively perceived meaningful change yielded three core categories: (1) improved ability to observe and understand mental events, (2) decreased disconnection from emotions, emergence of new or adaptive emotional reactions and decrease in maladaptive ones, and (3) a new, more adaptive experience of self and agency. Accordingly, (1) learning and (2) normalizing emerged as the main categories of helpful treatment factors. In turn, treatment-related factors perceived as obstacles were: (1) aggression in the group, and (2) inflexibility. With respect to symptom change, four participants were considered clinically as remitted, and two showed a reliable change. Conclusions: Long-term psychoeducational group therapy seems to enhance mentalization / metacognitive functioning and promote self (or personality) integration in BPD patients.

Moving forward: closing the gap between research and practice for young people with BPD

The study of personality disorders has come a long way, and this is characterized by the optimism prevalent within the community dedicated to its study. Outside this community - delays in intervention, ostracism, and ignorance remain common place. With a significant burden of disease and high costs at individual, social, and societal levels there is an urgent need to translate research into practice. Proposed solutions include educating the workforce to improve attitudes and developing more sustainable treatment alternatives. This paper brings forward a user perspective on the need to close the gap between what we know from research and what is done in policy and clinical practice.

"We Just Did Not Get on". Young Adults' Experiences of Unsuccessful Psychodynamic Psychotherapy - A Lack of Meta-Communication and Mentalization?

In order to avoid suboptimal psychotherapy, research needs to highlight and analyze obstacles in such treatments. This clinically oriented article brings together empirical material of unsuccessful psychotherapy with young adults; empirical material on the therapists’ views of the same therapies; and theoretical perspectives on mentalization, therapeutic alliance, and young adulthood. Through a secondary qualitative analysis, it presents a tentative process model of how suboptimal psychotherapy with young adults develops, how it could be handled clinically, and possibly prevented. In three studies, experiences of young adult patients (aged 18–25; n = 27), in psychoanalytic therapy at an outpatient clinic, who did not improve from therapy (defined as no reliable and clinically significant symptom reduction) and/or were dissatisfied, and their therapists, were analyzed. Patients described experiences of not being understood and not understanding therapy, whereas therapists described patient non-commitment. These results were compared from the developmental perspective of mentalization in young adulthood. The primary grounded theory analyses and secondary analysis resulted in a tentative process model of the development of suboptimal psychotherapy with young adults. Suboptimal therapy is described as a vicious circle of therapist underestimation of patient problems, therapeutic interventions on an inadequate level, and diverging agendas between therapist and patient in terms of therapeutic alliance, resulting in pseudo-mentalizing and no development towards agency. A benign circle of successful therapy is characterized by correct estimation of patient problems, meta-communication, and the repair of alliance ruptures. One clinical implication is that therapists of young adult patients need to establish verbal and nonverbal meta-communication on therapy progress and therapeutic alliance. The importance of the patients’ present mentalization capacity and adjusted interventions are demonstrated in an example. Research in the field should be process-oriented and investigate the effect of meta-communication and interventions targeted to foster therapeutic alliance based on this theoretical model, particularly for young adults.

Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT)

BACKGROUND

Mentalization-based treatment (MBT) is an evidence-based treatment for borderline personality disorder (BPD). Differences in treatment outcomes related to specific capacity of social cognition need further attention. This study aimed to investigate social cognition as a predictor of outcome.

METHOD

The study included 31 BPD patients who completed a test of social cognition (Movie for the Assessment of Social Cognition, MASC) before outpatient MBT. The MASC-scores indicated a person's theory of mind (ToM) and different error-types. During treatment repeated self-reports of alliance and clinical outcomes (symptoms, interpersonal problems, social functioning) were applied. Longitudinal analyses were based on Linear Mixed Models (n = 24).

RESULTS

The most frequent error-type was excessive ToM (hypermentalizing). Higher levels of excessive ToM were associated with greater improvement of alliance over time and good clinical outcomes. Insufficient ToM errors and low levels of accurate cognitive ToM responses were both associated with poorer improvement over time. The subgroup with frequent insufficient ToM errors had a larger total number of ToM errors. Insufficient ToM errors were associated with more childhood trauma, comorbid avoidant PD traits and/or PTSD, extensive prior treatment, and/or treatment irregularity.

CONCLUSION

This study demonstrates considerable variation of social cognitive capacity among BPD patients and good outcomes for patients with mainly ToM errors of hypermentalizing. It also indicates that poorly responding patients may represent a cohort with more complex problems of social cognition and insufficient mentalizing.