is there evidence that mbt is effective in the treatment of … · 2016. 11. 10. · reflective...

Is there evidence that MBT is effective in the treatment of antisocial personality disorder?

Prof Anthony W Bateman Slagelse November 2017

168 patients screened for eligibility

134 randomized

34 patients excluded: 10 did not attend interview 12 declined participation 5 did not meet inclusion criteria 4 met exclusion criteria 3 were uncontactable

71 patients allocated to MBT-OP

6 attended < 6 months

13 attended 6-12 months

52 completed treatment

71 included in analyses

63 patients allocated to SCM-OP

10 attended < 6 months

6 attended 6-12 months

47 completed treatment

63 included in analyses

Consort Diagram – IOP Study: Patient Recruitment Flow-Chart

Moderators of outcome?

Bateman, A., & Fonagy, P. (2013). Impact of clinical severity on

outcomes of mentalisation-based treatment for borderline personality disorder. British Journal of Psychiatry, 203, 221-227.

Predictive Recovery by Axis II Pathology

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.6.8

Line

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Rec

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Baseline 6 months 12 months 18 monthsAssessment Periods

SCM MBT

One Axis II Diagnosis

-.20

.2.4

.6.8

Line

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Rec

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y


SCM MBT

Two Axis II Diagnoses

-.20

.2.4

.6.8

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y


SCM MBT

Three Axis II Diagnoses

-.20

.2.4

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SCM MBT

Four Axis II Diagnoses

Predicted Self-Harm By Axis II Diagnoses

Two programmes of study:

MBT-ASPD – randomised controlled trial (MOAM)

SCM – training and implementation

Antisocial Personality Disorder

Bateman, A., & Fonagy, P. (2011). Antisocial Personality Disorder. In A. Bateman & P.

Fonagy (Eds.), Mentalizing in Mental Health Practice (pp. 357-378). Washington: APPI

Bateman, A., & Fonagy, P. (2016). Mentalization based treatment for personality disorders: a practical guide. Oxford: Oxford University Press

Bateman, A., O'Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). 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, 304, 304-311.

ASPD characteristics n  Failure to conform to social norms with respect to lawful

behaviours n  Deceitfulness n  Impulsivity or failure to plan ahead n  Irritability and aggressiveness n  Reckless disregard for safety of self or other n  Consistent irresponsibility n  Lack of remorse None of these features is endearing to others. The self-

serving attitude of people with ASPD and unpredictability makes people wary of them.

Why consider ASPD? ASPD Highly prevalent amongst UK offending population and is associated with increase likelihood of committing violent behaviours, future reconvictions and recidivism severity.

Societal costs Physical and emotional damage to victims, criminal justice system involvement, increase of health care, lost employment opportunities, relationship breakdown; family disruption and substance misuse.

Major public health implications Associations with psychiatric co-morbidity, substance abuse, suicide, family violence and early death.

Why Consider ASPD - Recommendations and Implementation of NICE Guidance Crawford et al (2009) Service provision for men with antisocial personality disorder who make contact with mental health services services. Personality and Mental Health 3: 165–171

n  ASPD who had had contact with mental health services Ø Nearly all participants met criteria for ‘probable

anxiety disorder’ Ø >50% were misusing alcohol and other drugs.

n  12 months following recruitment Ø 40% of the sample attended emergency medical

services Ø 20% had at least one period of inpatient treatment.

n  Only 21% participants received follow-up care during the 12 months following recruitment.

What is mentalizing?

Mentalizing is a form of imaginative mental activity about others or oneself, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).

Implicit- Automatic

Explicit- Controlled

Mental interior focused

Mental exterior focused

Cognitive agent:attitude propositions

Affective self:affect state propositions

Imitative frontoparietal mirror neurone system

Belief-desire MPFC/ACC inhibitory system

Impression driven

Appearance

Certainty of emotion

Treatment vectors in re-establishing mentalizing

Controlled

Inference

Doubt of cognition

Sensitivity to others Autonomy

Implicit- Automatic- Non -conscious- Immediate.

Explicit- Controlled Conscious Reflective

Mental interior cue focused

Mental exterior cue focused

Cognitive agent:attitude propositions

Affective self:affect state propositions

Imitative frontoparietal mirror neurone system

Belief-desire MPFC/ACC inhibitory system

Imbalance of mentalization generates problems Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.

Impulsive, quick assumptions about others thoughts and feelings not reflected on or tested, cruelty

Does not genuinely appreciate others’ perspective. Pseudo-mentalizing, Interpersonal conflict ‘cos hard to consider/reflect on impact of self on others

Unnatural certainty about ideas Anything that is thought is REAL Intolerance of alternative ways of seeing things.

Overwhelming dysregulated emotions, Not balanced by cognition come To dominate behavior. Lack of contextualizing of feelings leads to catastrophyzing

Rigid assertion of self, controlling others’ thoughts and feelings.

Hypersensitive to others’ Moods, what others say. Fears ‘disappearing’

Hyper-vigilant, judging by appearance. Evidence for attitudes and other internal states hasto come from outside

Lack of conviction about own ideas Seeking external reassurance Overwhelming emptiness, Seeking intense experiences

Deficit of Reflective Function in Violent and Non-violent Prisoners with PD Levinson and Fonagy (2004)

0

2

4

6

8

10

Frequency

Deficit RF Non-deficit RF

Violent Non-violent

RF moderates the relationship between psychopathy and proactive aggressive behaviour Taubner, White, Zimmermann, Fonagy & Nolte, 2013, JACP)

0

5

10

15

300 350 400

Proa

ctive

aggr

essio

n (R

BQ)

Psychopathy (PPI-R)

low RFaverage RFhigh RF

Aggression

An evolutionary framework

n  Interpersonal aggression is an important evolutionary adaptation. Ø In certain human environments it is likely to

contribute materially to the survival of the individual's genes.

Ø In other contexts it is seriously maladaptive o it undermines the possibility of safe collaboration o It decreases optimization of human capacities for

meaning generation, communication and creativity.

The developmental framework

n Human infants are born with the potential to be aggressive and even violent

n  In the majority of cases this potential is not fulfilled

n Through development, given adequate environmental support, individuals gradually increasingly desist from physical and relational aggression

The mechanism for the development of violence: A failure of inhibition

n Family processes conceptualized as promoting aggression may interfere with the socialization of aggression Ø low income, low maternal education reflects

family environments in which children cannot learn to inhibit physical aggression, as well as difficulty learning alternative strategies to solve problems

Ø Characterised by disrespect for the child o Parenting qualities of disrespect for child o Similar qualities in the broader social environment

Antisocial personality disorder: a disorder of self and other

Self problems in ASPD in clinical practice n  Fixed perspective about self e.g. misunderstood,

ill-treated ‘v’ self-important, grandiose self n  Reduced interest in other and if present is self-

serving n  Rigid representation of others to support self

representation, especially of officials/establishment/systems

n  Schematic representations of self in world Ø Hierarchical relationships

n  Reduced sense of internal world and seek confirmation from other of their world view

Empathy

Empathy n  Empathy is not all or nothing – can be

concerned about someone’s distress with little understanding or have full understanding

n  Two way phenomenon – self-other and other-self

n  Constrains the individual and is associated with pro-social behaviours and necessary for altruism

n  Other-oriented empathy is negatively correlated with a range of antisocial behaviors, including aggression

Empathy in psychopathic and ASPD offenders Domes et al (2013) Journal of Personality Disorders 27: 67-84 Multi-faceted Empathy Test

Empathy

n  Offenders show empathy deficits in both the cognitive and the emotional domain when compared with the non-offender controls

n  Confounded by education levels to some extent with higher educational level associated with better cognitive empathy

n  Delinquency and violent offending may be more associated with reduced empathy than psychopathy itself

n  Clinical Note Ø How to increase emotional empathy without increasing, for

example, recognition of other vulnerability and opportunity to increase exploitation?

Ø How to increase perspective taking and not mimicry and dissimulation?

Ø How to increase other empathy and the two-way components of empathy?

Emotional recognition

Forest plots for facial cues for the six emotions. Dawel et al 2012

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Centrality of ‘moral’ emotions n  Shame and guilt are ‘‘negative” or uncomfortable

emotions Ø Shame involves a negative evaluation of the

entire self vis-à-vis social and moral standards. Ø Guilt focuses on specific behaviors (not the

self) that are inconsistent with such standards. n  Shame and guilt lead to different ‘‘action

tendencies” (Lindsay-Hartz, 1984) Ø Guilt is apt to motivate reparations. Ø Shame is apt to motivate efforts to hide or

disappear or attack

Shame

n  Different types of shame described Ø malignant aggressive (blame, attack, avoid) Ø benign life shame (motivating, behaving

morally/socially/interpersonally) n  Shame

Ø Low concern for others and High concern for self

Ø Threat of social exclusion Ø Triggers physical pain which suggests

immediate action if not moderated

Shame and aggression

n  Positive correlations: Ø  shame-proneness and physical aggression Ø  shame-proneness and verbal aggression for adults, college

students, adolescents, and children Ø  shame proneness and anger, hostility, and externalization of

blame n  Male college students’ anger fully mediated the relationship between

shame and psychological abuse of a partner n  Clinical Note

Ø Negative feelings of shame may lead to externalization of blame which may lead to higher levels of verbal and physical aggression

Ø Clinician needs to be sensitive to unmasking/exposing in group Ø Aggressive and antisocial individuals often use cognitive

distortions related to others to justify their activities

Therapeutic Challenge

The Therapeutic Challenge

Self Other

The stabilisation of mental processes on ASPD+BPD depends on rigid externalization of the alien self

Threats to this externalisation cause arousal of the attachment system and experience of problematic emotions (shame)

Inability to control internal states leads to increase externalization

Mentalization failure Shame, Anger, Fear

Violent control of the perceived

source of threat

Paradox of treatment

n  Less is More – overactivation increases coercive behaviours and aggression

n Focus on imbalances in mentalizing Ø Identify absent mentalizing rather than

symptoms resulting from non-mentalizing e.g. aggression

Ø Bolster good interpersonal mentalizing and reduce focus on poor mentalizing

Ø Rebalance dimensions by increasing absent pole rather than decreasing overactive pole

Externalising and drop-out from treatment Henriette Löffler-Stastka; Victor Blueml; Christa Boes; Psychotherapy Research 2010, 20, 295-308.

Engagement in treatment n Explanation of model n  Involvement of experts by experience

Ø Completer sits in group and holds advice ‘surgery’

n Treatment in probation system rather than mental health

n  Identification of joint goals n Broader focus than aggression/violent

events – these are an end-product and not the problem

Core areas for treatment of ASPD n  Increase

Ø A) affective understanding o Recognition and acceptance of emotion in self –

shame and other emotions o Accurate understanding of emotion in other –

observe embodied mentalizing o Increase in empathy for others - ?increase eye

focus Constraint by others emotion Ø B) Relational pattern (self/other) identification

o  Processing of positive experience of self with others

o Recognition of fixed relational patterns outside and in group

Core areas for treatment of ASPD

n  Decrease Ø Concern for self in affect arousal and rapid switch

to control other Ø Externalising core aspects of self Ø Self-serving uses of others

Key mentalizing components in MBT-ASPD Group n  Identification of non-mentalizing interactions n  Focus on emotions

Ø Understanding emotional cues - external mentalizing and its link to internal states

Ø Recognition of emotions in others – other/affective mentalizing – cognitive and emotional empathising (look angry but feel hurt and desperate)

Ø Identification and naming of current feelings in self

Key mentalizing components in MBT-ASPD Group n  Focus on relational process

Ø Exploration of sensitivity to hierarchy and authority – self/cognitive

Ø Generation of an interpersonal process to understand subtleties of others’ experience in relation to ones’ own – self/other mentalizing – two-way mentalizing

Ø Identification of interpersonal patterns Ø Explication of threats to loss of mentalizing which

lead to teleological understanding of motivation – self/other mentalizing and self/affective mentalizing

Antisocial Personality Disorder

Bateman, A., O'Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). 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, 304, 304-311.

N=40 difference between groups at 18-months -0.45 (-0.80, -0.11), p<.011

N=40 difference between groups at 18-months

-0.61 (95% CI: -1.05, -0.17), p<.007

N=40 difference between groups at 18-months -0.64 (95% CI: -1.09, -0.18), p<.006

N=40 difference between groups at 18-months

-0.48 (95% CI: -0.78, -0.18), p<.002

difference between groups at 18-months -0.58 (95% CI: -0.89, -0.28), p<.000

N=40

MOAM

Mentalization for Offending Adult Males

ISRCTN32309003 DOI 10.1186/ISRCTN32309003

Evidence: Currently no treatment with a robust evidence base for alleviating ASPD

Research: Paucity of high quality studies is notable

Preliminary support for MBT: Pilot of MBT for ASPD at two UK centers suggests that treatment can be learned and reliably applied Next logical step: RCT comparing MBT to Usual Services to determine its clinical and cost-effectiveness

Outcomes Primary Outcome

Reduction in the frequency of aggressive acts

Secondary Outcomes:

Criminal: other (re)offending behaviour

Mental Health : anxiety and depression, drug and alcohol use, self-harm and suicidal behaviour, impulsivity, and beliefs

Health: quality of life, health and functioning

Service use: services including A & E and use of social services during the treatment and follow-up period.

Cost-benefit analysis to determine the actual cost of service delivery in both treatment conditions and whether MBT-ASPD leads to reduction in costs compared to PAU.

Research Design n  Multi-site randomized control trial in a real life NHS setting. n  Recruitment target 302 participants across 14 sites n  Participants randomly allocated to MBT or Probation as Usual (PAU) n  User Voice Peer Researchers collecting data alongside traditional Research

Assistants n  Participants are followed up every 3 months for 24 months post randomisation.

-Primary outcome measures and offending records obtained every 3 months post randomisation -Secondary outcomes collected every 6 months

MBT PAU Random allocation

•  Site •  Age (21-25; 26-39; 40+) •  Sentence (community or on licence after prison) •  Length (12 months or 12 months or more)

is there evidence that mbt is effective in the treatment of … · 2016. 11. 10. · reflective...

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