Mentalization-based therapy (MBT)

Mentalization-based therapy is a form of psychological treatment that focuses on an individual's awareness of their own and others' way of reacting, thinking and feeling (mentalization). It was originally developed for people with emotionally unstable personality disorder (EIPS, borderline) but is now also used with other populations as well, for example for people with eating disorders and those with self-harming behavior.

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Question

What systematic reviews are there on the use of mentalization-based therapy?

Identified literature

Table 1. Systematic reviews with low/medium risk of bias
BPD = Borderline Personality Disorder; CBT = Cognitive Behavioural therapy; CI = Confidence Interval;DBT = Dialectical behaviour therapy; GAF = General Assessment of Functioning;MD = Mean difference MBT = Mentalisation based treatment; MBT-A= Mentalisation-based treatment for adolescents; N = number; OR = Odds Ratio; RCT = Randomised controlled trial; RR = Risk Ratio; SAS = Social adjustment scale; SD = Standard deviation; TAU = Treatment-as-usual; GAS = Global Assessment Scale; GAF = Global Assessment of Functioning Scale; SFQ = Social functioning Questionnaire
Included studies Population/Intervention Outcome and Results
Storebø et al, 2020 [1]
Borderline personality disorder
Study design:
Included only RCTs
Included a total of 75 RCTs, 7 RCTs on MBT

Included studies on MBT:

Bateman (1999); Jørgensen (2013); Laurenssen (2018); Philips (2018); Robinson (2016); Rossouw (2012); Bateman (2009)

See Table 1 for more information
Population:
Persons of all ages, in any setting, with a formal, categorical diagnosis of BPD

At least 70% of participants in each trial had to have a formal diagnosis of BPD


Intervention:

Any defined psychological intervention regardless of theoretical orientation (e.g., psychodynamic therapy, CBT, systemic therapy), in any kind of treatment setting

Compared to standard care, treatment-as-usual, wait list, no treatment or alternative treatment
BPD symptom severity:
End of treatment (5 trials, n=267)
SMD –0.13
(95% CI, –0.38 to 0.11)

Self‐harm (dichotomous):

End of treatment (3 trials, n=252):
RR 0.62
(95% CI, 0.49 to 0.80)

GRADE: Low Symbol for low certainty of evidence

Suicide-related outcomes:

End of treatment (3 trials, n=218):
RR 0.10
(95% CI, 0.04 to 0.30)

GRADE: Low Symbol for low certainty of evidence

Psychosocial functioning (GAS, GAF or SFQ):

End of treatment (3 trials, n=239):
SMD −0.54
(95% CI, −1.24 to 0.16)
Authors' conclusion:
“We found no unequivocal, high‐quality evidence to support one BPD‐specific therapy over another in the treatment of BPD; our subgroup analyses showed no differences in effect estimates between the different types of therapies. However, compared to TAU, we observed significant effects in favour of DBT for the primary outcomes of BPD severity, self‐harm and psychosocial functioning, and in favour of MBT for self‐harm, suicidality and depression. We rated the quality of the evidence for these outcomes as low, meaning that the true magnitude of these effects is uncertain.”
Witt et al, 2021 [2]
Self-harm, Children
Study design:
Included only RCTs
Included a total of 17 RCTs, 2 RCTs on MBT

Included studies about MBT:

Griffiths (2019); Rossouw (2012)

See Table 2 above for more information.
Population:
Participants of both sexes and all ethnicities, up to 18 years of age, with a recent (within six months of trial entry) presentation to hospital or clinical services for self-harm

Intervention:

Different types of psychosocial (incl. MBT-A) and pharmacological interventions, and natural supplements

Compared to TAU, no specific treatment or enhanced usual care
Self-harm:
Occurrence of repeated SH over a maximum follow-up period of 2 years (2 trials, n=85):
OR 0.70
(95% CI, 0.06 to 8.46)

GRADE: Very low Symbol for very low certainty of evidence

See review pp. 24–25 for complete list of secondary outcomes
Authors' conclusion:
“There is currently no clear evidence (“the evidence is very uncertain”) for the effectiveness of […] MBT-A […] in preventing repetition of SH.”
Witt et al, 2021 [3]
Self-harm, Adults
Study design:
Included only RCTs

Included a total of 76 RCTs, 1 RCT on MBT

Included studies about MBT:

Bateman (2009)

See Table 2 for more information
Population:
Participants of both sexes and all ethnicities, 18 years and older, with a recent (within six months of trial entry) presentation to hospital or clinical services for self-harm

Intervention:

Different types of psychosocial interventions (incl. MBT)

Compared to TAU, no specific treatment or enhanced usual care
Self-harm:
Occurrence of repeated SH over a maximum follow-up period of 2 years (1 trial, n=134):
OR 0.35
(95% CI, 0.17 to 0.73)

GRADE: High Symbol for strong scientific evidence

General functioning at post-intervention assessment, measured by GAF (1 trial, n=134):
MD 7.70
(95% CI, 3.03 to 12.37)

Social functioning at post-intervention assessment, measured by SAS (1 trial, n=134):
MD −0.41
(95% CI, −0.61 to −0.21)

See review pp. 45 for complete list of secondary outcomes
“There may be beneficial effects […] mentalisation-based therapy (MBT) […] at the post-intervention assessment. […] Given findings in single trials, […] MBT should be further developed and evaluated in adults.”
Midgley et al, 2021 [4]
Children and adolescents
Study design:
Included all study designs, both controlled and non-controlled studies.

The review included a total of 62 RCTs, where of 20 reported outcomes. 3 of these were RCTs and 5 had a quasi-experimental design.

Included studies about MBT

Fonagy 2009; Midgley 2017; Hertzmann 2016; Valle 2016;

See Table 3 for more information
Population:
The primary target of intervention had to be children aged between 6 and 12.

Intervention:

The interventions were those based on mentalisation-based treatment (MBT) or interventions based on other closely related theoretical constructs, such as promoting reflective-functioning or maternal mind-mindedness.
The review had an inadequate presentation of outcomes.

Significant results favouring the intervention were found for Child peer experiences

Child aggression and Carer expressed anger.
Authors' conclusion:
“Based on the small number of evaluation studies that have been conducted, the evidence for mentalization-based intervention effectiveness for children aged 6–12 suggests possible benefits in terms of parent/carer outcomes (PRF, self-efficacy, and stress) as well as children’s psychosocial functioning. However, the main finding from the review is that there is currently little evidence for these interventions and good quality-controlled studies that minimize bias are sorely needed.”

 

Table 2. Randomised controlled trials on MBT for borderline personality disorder, included in review by Storebø et al, 2020 [1].
Identified RCTs
Author
Year, Reference
Country
Population
Number of participants (n)
Intervention
Comparator
Laurenssen et al
2018 [5]
The Netherlands
Borderline
n=95
Day hospital mentalisation‐based treatment (MBT-DH)
Treatment as usual
Philips et al
2018 [6]
Sweden
Borderline
n=46
Mentalisation-based therapy (MBT)
Treatment as usual
Bateman et al
2009 [7]

Bateman et al
2016 [8]
United Kingdom
Borderline
n=168
Mentalisation-based therapy (MBT)
Structured clinical management
Robinson et al
2016 [9]
United Kingdoms
Borderline and an eating disorder
n=68
Mentalisation‐based treatment for eating disorders (MBT‐ED)
Specialist supportive clinical management for eating disorders
Jørgensen et al
2013 [10]
Denmark
Borderline
n=111
Mentalisation-based therapy (MBT)
Supportive group treatment
Rossouw et al
2012 [11]
United Kingdom
Adolescents (12 to 17) with borderline
n=80
Mentalisation-based therapy for Adolescents (MBT-A)
Treatment as usual
Bateman et al
1999 [12]

Bateman et al
2001 [13]

Bateman et al
2008 [14]
United Kingdom
Borderline
n=38
Mentalisation-based therapy (MBT)
Treatment as usual

 

Table 3. Randomised controlled trials on MBT for self-harm, included in reviews by Witt et al, 2021 [2,3].
Identified RCTs Author
Year, Reference
Country
Population
Number of participants (n)
Intervention Comparator
Griffiths et al
2019 [15]
United Kingdom
Adolescents with self-harm
n=53
Mentalisation-based therapy for Adolescents (MBT-A)
Treatment as usual
Rossouw et al
2012 [11]
United Kingdom
Adolescents with self-harm
n=89
Mentalisation-based therapy for Adolescents (MBT-A)
Treatment as usual
Bateman et al
2009 [7]
United Kingdom
Adults with self-harm
n=134
Mentalisation-based therapy (MBT)
Structured clinical management

 

Table 4. Randomised controlled trials on MBT for children and adolescents included in review by Midgley et al [4].
CAPSLE = Creating a Peaceful School Learning Environment
Identified RCTs
Author
Year, Reference
Country
Population
Numbers of participants (n)
Intervention
Comparator
Fonagy et al
2009 [16]
United States
Schools
n=9
CAPSLE, mentalisation focused whole school intervention
Manualised School Psychiatric Consultation (SPC)
Midgley et al
2017 [17]
United Kingdom
Foster parents
n=36
Mentalisation-based therapy, Hearts and mind
Usual clinical care
Hertzmann et al
2016 [18]
United Kingdom
High-conflict co-parents
n=30
Mentalisation-based therapy (MBT-PT/Parenting Together)
Parents’ group
Valle et al
2016 [19]
Italy
School children
n=46
Thoughts in mind project
Control activity

References

  1. Storebo OJ, Stoffers-Winterling JM, Vollm BA, Kongerslev MT, Mattivi JT, Jorgensen MS, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020;5:CD012955.
  2. Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, et al. Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 2021;3:CD013667.
  3. Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, et al. Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev 2021;4:CD013668.
  4. Midgley N, Sprecher EA, Sleed M. Mentalization-Based Interventions for Children Aged 6-12 and Their Carers: A Narrative Systematic Review. Journal of Infant, Child, and Adolescent Psychotherapy 2021;20:169-189.
  5. Laurenssen EMP, Luyten P, Kikkert MJ, Westra D, Peen J, Soons MBJ, et al. Day hospital mentalization-based treatment v. specialist treatment as usual in patients with borderline personality disorder: randomized controlled trial. Psychol Med 2018;48:2522-2529.
  6. Philips B, Wennberg P, Konradsson P, Franck J. Mentalization-Based Treatment for Concurrent Borderline Personality Disorder and Substance Use Disorder: A Randomized Controlled Feasibility Study. Eur Addict Res 2018;24:1-8.
  7. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009;166:1355-64.
  8. Bateman A, O'Connell J, Lorenzini N, Gardner T, Fonagy P. A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder. BMC Psychiatry 2016;16:304.
  9. Robinson P, Hellier J, Barrett B, Barzdaitiene D, Bateman A, Bogaardt A, et al. The NOURISHED randomised controlled trial comparing mentalisation-based treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder. Trials 2016;17:549.
  10. Jorgensen CR, Freund C, Boye R, Jordet H, Andersen D, Kjolbye M. Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial. Acta Psychiatr Scand 2013;127:305-17.
  11. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2012;51:1304-1313 e3.
  12. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 1999;156:1563-9.
  13. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001;158:36-42.
  14. Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry 2008;165:631-8.
  15. Griffiths H, Duffy F, Duffy L, Brown S, Hockaday H, Eliasson E, et al. Efficacy of Mentalization-based group therapy for adolescents: the results of a pilot randomised controlled trial. BMC Psychiatry 2019;19:167.
  16. Fonagy P, Twemlow SW, Vernberg EM, Nelson JM, Dill EJ, Little TD, et al. A cluster randomized controlled trial of child-focused psychiatric consultation and a school systems-focused intervention to reduce aggression. J Child Psychol Psychiatry 2009;50:607-16.
  17. Midgley N, Besser SJ, Dye H, Fearon P, Gale T, Jefferies-Sewell K, et al. The Herts and minds study: evaluating the effectiveness of mentalization-based treatment (MBT) as an intervention for children in foster care with emotional and/or behavioural problems: a phase II, feasibility, randomised controlled trial. Pilot Feasibility Stud 2017;3:12.
  18. Hertzmann L, Target M, Hewison D, Casey P, Fearon P, Lassri D. Mentalization-based therapy for parents in entrenched conflict: A random allocation feasibility study. Psychotherapy (Chic) 2016;53:388-401.
  19. Valle A, Massaro D, Castelli I, Sangiuliano Intra F, Lombardi E, Bracaglia E, et al. Promoting Mentalizing in Pupils by Acting on Teachers: Preliminary Italian Evidence of the "Thought in Mind" Project. Front Psychol 2016;7:1213.
Published: Report no: ut202130 Registration no: SBU 2021/601

Literature search

PsycINFO via EBSCO 29 October 2021

Title: Mentalisation-based treatment
The final search result, usually found at the end of the documentation, forms the list of abstracts. AB = Abstract; AU = Author; DE = Term from the thesaurus; MH= Exact Subject Heading from CINAHL Subject Headings; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase; N = Near Operator (N) finds the words if they are a maximum of x words apart from one another, regardless of the order in which they appear.; W = Within Operator (W) finds the words if they are within x words of one another, in the order in which you entered them.
Search terms Items found
Intervention: Mentalisation-based treatment
1. (TI (mentalization OR mentalisation) N3 (treatment* OR therap* OR intervention)) OR (AB (mentalization OR mentalisation) N3 (treatment* OR therap* OR intervention)) 632
Study types: systematic review
2. PT Reviews OR (TI (Systematic* N3 review*) OR “Meta-analysis”) OR (AB (Systematic* N3 review*) OR “Meta-analysis”) 67 503
3. 1 AND 2 21

Embase via Elsevier 29 October 2021

Title: Mentalisation-based treatment
The final search result, usually found at the end of the documentation, forms the list of abstracts.

/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ' ' = Citation Marks; searches for an exact phrase; NEAR/n = Requests terms that are within 'n' words of each other in either direction; NEXT/n = Requests terms that are within 'n' words of each other in the order specified
Search terms Items found
Intervention: Mentalisation-based treatment
1. 'mentalization-based treatment'/exp OR ((mentalization OR mentalisation) NEAR/3 (treatment* OR therap* OR intervention)):ti,ab,kw 461
Study types: systematic review
2. ‘Systematic review’/exp OR ‘meta-analysis’/exp OR ((Systematic* NEAR/3 review*) OR ‘Meta-analysis’):ti,ab,kw 538 770
Final result
3. 1 AND 2 38

Medline via OvidSP 29 October 2021

Title: Mentalisation-based treatment
The final search result, usually found at the end of the documentation, forms the list of abstracts.

.ab. = Abstract; .ab,ti. = Abstract or title; .af. = All fields; Exp = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; .sh. = Term from the Medline controlled vocabulary; .ti. = Title; / = Term from the Medline controlled vocabulary, but does not include terms found below this term in the MeSH hierarchy; * = Focus (if found in front of a MeSH-term); * or $ = Truncation (if found at the end of a free text term); .mp = Text, heading word, subject area node, title; “ “ = Citation Marks; searches for an exact phrase; ADJn = Positional operator that lets you retrieve records that contain your terms (in any order) within a specified number (n) of words of each other.
Search terms Items found
Intervention: Mentalisation-based treatment
1. ((mentalization OR mentalisation) ADJ3 (treatment* OR therap* OR intervention)).ti,ab,kw 273
Study types: systematic review
2. Exp Systematic review/ OR exp meta-analysis/ OR ((Systematic* ADJ3 review*) OR “Meta-analysis”).ti,ab,kw 364 044
Final result
3. 1 AND 2 19
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