Mentalization-based therapy (MBT)

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 Suicide-related outcomes: End of treatment (3 trials, n=218): RR 0.10 (95% CI, 0.04 to 0.30) GRADE: Low 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 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 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.”

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.
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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.
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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.