What works in mentalization-based treatment: systematic case studies in personality disorder and addiction

A review of the literature in personality disorders leaves no doubt that more research is needed for the understanding and management of this clinical condition. The frequent misuse of drugs and alcohol within this population adds an extra complication for the treatment of these individuals who are often neglected or mistreated by the health care system. The creation of specialist personality disorder teams following the National Institute of Mental Health (NIMH) report in 2003 gave new hope for both patients and professionals working in this area. Mentalization Based Treatment (MBT) is one of the promising psychological interventions for personality disorders, and there is evidence that it works for Borderline Personality Disorder. The aim of this study was to investigate if MBT is effective in patients with various concomitant personality disorder types and with co-morbid addiction problems. Since most research has focused on whether MBT works, it seemed important to also find out ‘what’ is it that works in MBT i.e. what are the helpful therapy processes or ‘ingredients’ of change. A research based MBT program was established in an outpatient setting, with six patients considered to be suitable; they engaged in twice weekly group psychotherapy, periodic clinical reviews with the consultant psychiatrist in psychotherapy and additional support from a psychosocial nurse, all within a mentalizing framework. Close links with the Community Mental Health Team and the Community Drug and Alcohol Service were maintained. An adjudicated form of the Hermeneutic Single Case Efficacy Design method (HSCED) was used, aiming to gain deep, contextual, knowledge into a small number of cases undergoing treatment. A rich case record was obtained for each case, including quantitative and qualitative data. Following the collection of data two researchers have engaged in a reflexive process, trying to gather affirmative and sceptic evidence regarding the efficacy and effectiveness of treatment. Nine ‘judges’ were then invited to give their expert opinion on each case resembling a legalistic trial. The judges rated their conclusions on a scale from 0% (no change) to 100% (changed completely), indicating that after one year of treatment the patients have made considerable (60%) positive changes and that these changes can be attributed to the therapy programme to a substantial (80%) degree. A number of treatment ‘ingredients’ have been discovered but these appear to be common factors in many psychotherapeutic approaches rather than specific to MBT. The HSCED method was considered to be an appropriate choice, showing that it can be of value in cases of severe disturbance within complex treatment programs. Nonetheless, some adaptations are recommended.