Tag: Mentalisation-Based Treatment

What is Adaptive Mentalisation-Based Integrative Treatment?

Published on by Andrew MarshallLeave a comment

Introduction

Adaptive mentalisation-based integrative treatment (AMBIT) is a novel adaptation (by Dickon Bevington, Peter Fuggle, Liz Cracknell, Peter Fonagy, Eia Asen, Mary Target, Neil Dawson and Rabia Malik) of the theory of mentalisation and practices of mentalisation-based treatment to address the needs of chaotic, complex and multiply comorbid youth, via team-based (predominantly outreach) multimodal practices.

Background

Previously called “Adolescent Mentalisation Based Integrative Treatment”, AMBIT changed its name to “Adaptive…” in recognition of the fact that it is now being used by a wide range of teams across the UK and internationally, that extend beyond the adolescent age range (adults with severe and enduring relational difficulties, families with children where there are safeguarding concerns, young adults, etc.) Adaptation is also at the heart of AMBIT, which encourages local teams to adapt, build upon, and share these adaptations to its core components; AMBIT aspires to be an Open-source model of therapy innovation. This name change was recognised a book published by Oxford University Press (Bevington, D., Fuggle, P., Cracknell, L., and Fonagy, P. “Adaptive Mentalization Based Integrative Treatment: a guide for teams to develop systems of care” OUP 2017).

These practices, shaped by an eightfold principled therapeutic stance and using mentalization as the integrating framework, balance the development of a strong therapeutic attachment to a key worker with strong peer-to-peer relationships between workers that are designed counteract the potential for destabilising effects from such intense work.

Mentalization is applied and fostered explicitly in four directions in AMBIT:

  • Towards the young person and their family/carers.
  • Towards colleagues and peers at the level of the team.
  • Towards the wider multi-agency network.

In addition, a range of manualized ‘barefoot’ adaptations of existing evidence-based treatment modalities are available to workers, but the approach also encourages the development of a culture of team-based reflection upon practice and outcomes, of learning, and of sharing. This has much in common with the notion of a “learning organisation” stance (see the work of Peter Senge) within local teams, but AMBIT includes the promotion of constrained and disciplined approaches to the local adaptation of each team’s own wiki-based practice manual. These wikis come to represent specific local implementations that offer a “fit” for local cultures and service ecologies. The collaborative disciplines around their adaptation is a practice referred to as “manualisation”; manualisation is seen as analogous to mentalisation at the level of the team (making sense of “why we practice in this way in that kind of situation”, and broadcasting this transparently, with a view to improving this current understanding through feedback.)

Treatment Manual

AMBIT deploys an open-source wiki-based approach to treatment manualisation based on TiddlyWiki; a server-side hosting platform allows multiple teams to develop their own locally adapted versions, each drawing on a shared common core of AMBIT material. Drawing on developments in programming, the authors have described the approach as an “open source approach to therapy”.

Implementations

As at March 2018, approximately 200 teams around the UK and internationally have been trained in AMBIT by the AMBIT programme based at the Anna Freud National Centre for Children and Families charity in London. Encouraging early outcomes evaluative evidence has been published, but as a novel approach there are as yet no completed randomised controlled trials.

Independent Reviews, Awards and Sponsors

AMBIT is described in a number of independent reviews, including a 2018 review on “Psychotherapeutic interventions and contemporary developments: common and specific factors” in the BJPsych Advances journal. It is described in Chapter 42 of the 3rd edition of Child Psychology and Psychiatry Frameworks for Clinical Training and Practice and in a review by the Youth Justice Working Group (2012), the Centre for Mental Health (2010) and in a literature review on integrative psychotherapy for children and adolescents by Krueger and Glass.

The AMBIT Collaboration was awarded the “Innovation Nation” award for Innovation in Collaboration from The Guardian newspaper and Virgin Business Media in 2012.

AMBIT has been supported by grants from Comic Relief, the City Bridge Trust and the James Wentworth Stanley Memorial Fund.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Adaptive_mentalization-based_integrative_treatment >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Mentalisation-Based Treatment?

Published on by Andrew MarshallLeave a comment

Introduction

Mentalisation-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioural, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganised attachment and failed to develop a robust mentalisation capacity. Fonagy and Bateman define mentalisation as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalisation capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.

More recently, a range of mentalisation-based treatments, using the “mentalising stance” defined in MBT but directed at children (MBT-C), families (MBT-F) and adolescents (MBT-A), and for chaotic multi-problem youth, AMBIT (adaptive mentalisation-based integrative treatment) has been under development by groups mainly gravitating around the Anna Freud National Centre for Children and Families.

The treatment should be distinguished from and has no connection with mindfulness-based stress reduction (MBSR) therapy developed by Jon Kabat-Zinn.

Goals

The major goals of MBT are:

  • Better behavioural control.
  • Increased affect regulation.
  • More intimate and gratifying relationships.
  • The ability to pursue life goals.

This is believed to be accomplished through increasing the patient’s capacity for mentalisation in order to stabilise the client’s sense of self and to enhance stability in emotions and relationships.

Focus of Treatment

A distinctive feature of MBT is placing the enhancement of mentalising itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalising. Therapy examines mainly the present moment, attending to events of the past only insofar as they affect the individual in the present. Other core aspects of treatment include a stance of curiosity, partnership with the patient rather than an ‘expert’ type role, monitoring and regulating emotional arousal, and identifying the affect focus. Transference in classical understanding of this term is not included in the MBT model. MBT does encourage consideration of the patient-therapist relationship, but without necessarily generalising to other relationships, past or present.

Treatment Procedure

MBT should be offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist works to stimulate or nurture mentalising. Particular techniques are employed to lower or raise emotional arousal as needed, to interrupt non-mentalising and to foster flexibility in perspective-taking. Activation occurs through the elaboration of current attachment relationships, the therapist’s encouragement and regulation of the patient’s attachment bond with the therapist and the therapist’s attempts to create attachment bonds between members of the therapy group.

Mechanisms of Change

The safe attachment relationship with the therapist provides a relational context in which it is safe for the patient to explore the mind of the other. Fonagy and Bateman have recently proposed that MBT (and other evidence-based therapies) works by providing ostensive cues that stimulate epistemic trust. The increase in epistemic trust, together with a persistent focus on mentalising in therapy, appear to facilitate change by leaving people more open to learning outside of therapy, in the social interactions of their day-to-day lives.

Efficacy

Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder. The first randomised, controlled trial was published in 1999, concerning MBT delivered in a partial hospital setting. The results showed real-world clinical effectiveness that compared favourably with existing treatments for BPD. A follow-up study published in 2003 demonstrated that MBT is cost-effective. Encouraging results were also found in an 18-month study, in which subjects were randomly assigned to an outpatient MBT treatment condition versus a structured clinical management (SCM) treatment. The lasting efficacy of MBT was demonstrated in an 8-year follow-up of patients from the original trial, comparing MBT versus treatment as usual. In that research, patients who had received MBT had less medication use, fewer hospitalisations and longer periods of employment compared to patients who received standard care. Replication studies have been published by other European investigators. Researchers have also demonstrated the effectiveness of MBT for adolescents as well as that of a group-only format of MBT.