Adolescent Mentalization Based Therapy

Transcription

1 Adolescent Mentalization Based Therapy Dr Louise Duffy, Consultant Clinical Psychologist Dr Helen Griffiths, Consultant Clinical Psychologist NHS Lothian CAMHS / University of Edinburgh RCP in Scotland Child and Adolescent Faculty Conference. Nov 2016 With thanks to Anna Freud Centre and UCL for use of some of their material/slides

2 What mentalization is What we ll cover Markers of mentalizing Theory of development of mentalizing Mentalizing and the adolescent brain Application of mentalization As a therapy: MBT, MBT-A Evidence In Lothian CAMHS As a general approach: Mentalizing stance Video clips Exercise using a mentalizing approach to role-play a discussion with a young person you are finding particularly challenging.

3 Forewarning: There is nothing new in Mentalizing

4 What is mentalization? A form of imaginative mental activity about others or oneself Perceiving and interpreting behaviour our own and others in terms of intentional mental states (e.g. feelings, beliefs, desires, fears, hopes) When you think about what you are feeling or wonder what someone else might be thinking or feeling you are mentalizing. Allen 2005

5 What is mentalization? A bedrock neurodevelopmental capacity that is: Located primarily in the prefrontal cortex Fostered (or rekindled) in the experience of relationship with a trusted other, in which one has an iterative experience of being accurately mentalized (I find my mind in your mind.) Easily overwhelmed by powerful stress/arousal/attachment

6 What is mentalization? When you think about what you are feeling or wonder what someone else might be thinking or feeling you are mentalizing. Having mind in mind Seeing ourselves from the outside and others from the inside Understanding misunderstanding Those psychological skills that allow us to spontaneously and largely in an intuitive manner make sense of the actions of oneself and others by reference to mental states such as beliefs, desires and feelings. Peter Fonagy (2004)

7 What is mentalization? Mentalizing shapes our understanding of self and others. Good relationships are based on an ability to understand each other, and ourselves, fairly well. Problems with mentalizing can create difficulties in relationships as people will become unhappy if you re not aware of their needs and feelings or you misinterpret why they are behaving in certain ways.

8 The MBT Approach The MBT approach is based on a view that a core problem for many patients, especially those with BPD, is their vulnerability to a loss of mentalizing. This vulnerability becomes associated with interpersonal sensitivity which triggers dysregulated emotions and impulsivity Mentalization based treatment hopes to address this vulnerability and in this therapy the aim is on improving the young person (and families ) mentalizing ability The therapy is relational focussed and the therapist is seen as an active participant and a contributor to emotional impact on the patient.

9 Cognitive Behaviourism: The value of understanding the relationship between my thoughts and feelings and my behaviour. Systems Theory: The value of understanding the relationship between the thoughts and feelings of family members and their behaviours, and the impact of these on each other. BRAIN COMMON Mentalizing as an Integrative framework LANGUAGE MIND Psychodynamic: The value of understanding the nature of resistance to therapy, and the dynamics here-and-now in the therapeutic relationship. BIOLOGICAL, SOCIAL and ECOLOGICAL: The value of understanding the impact of context upon mental states: development, deprivation, opportunity, hunger, fear...

10 When emotion is high......mentalizing is in danger

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12 Curiosity How must it feel to be you right now, boss? I know that I don t KNOW what you must think, boss, but I can wonder what that is Why do I keep getting into trouble over my rabbit habit? Is there something about me and rabbits that stems from my childhood, I wonder?

13 Too vigorous, and Stuff ll get spilt Awareness of the impact on others:

14 The Opacity of other minds

15 Perspective-taking

16 Capacity to Trust

17 Narrative Continuity X X X START

18 Safe, playful interaction with the caregiver leads to the integration of primitive models of experiencing internal reality (Fonagy & Bateman) The development of mentalizing How does the capacity for mentalization develop? The caregiver s emotionally attuned responses to the infant s states becomes a source of information to the infant about his internal states Theory of Self Development Thinking arises in the context of the relationship with another. The caregiver thinks of the infant as agentive and through this the agentive sense of self is acquired

19 Learning About My Mind, Your Mind (My mother thinks) I think, therefore I am Mind in mind Contingent Marked Mirroring Sam-I-am

20 Mirroring sadness Unmarked mirroring Marked mirroring

21 But the mothers capacity to make sense of the baby s state is highly influenced by. How supported she is in her relationships How she feels about herself as a mother How her mother felt about her as an infant

22 What happens when it goes wrong? When the parent misperceives the baby s inner state, the mirroring would not accurately reflect the baby s feelings e.g. when the parent is frightened by a baby s distress, what the baby would see and experience is the fear in the parent, and hence the experience that they would take into themselves is the experience of: Inner distress which frightens the other and hence lead to an inner experience of I am frightening

23 Adolescent neurodevelopment Brain continues to develop throughout adolescence into early 20s Prefrontal cortex dramatic changes in adolescence Decline in volume of grey matter corresponding to synaptic pruning mentalizing located primarily in prefrontal cortex

24 Developmentally, Adolescents are particularly prone to stress-arousal, and low mentalizing

25 A Developmental trajectory, with high frequency fluctuations: Mentalization is fragile Programmed for overwhelm

26 Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J. (2015). Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis. Journal of the American Academy of Child & Adolescent Psychiatry., 54(2), e2.

27 MBT outcomes Bateman & Fonagy (1999, 2001, 2003): MBT superior than TAU including at follow-up MBT: 18-month period with weekly individual and group sessions, crisis planning and integrated psychiatric care Suicidality, diagnostic status, medication, global functioning, vocational status Roussow & Fonagy (2012): MBT superior than TAU for adolescents who self-harm MBT: 12 month period with weekly individual MBT-A sessions and monthly mentalization-based family therapy (MBT-F) Self harm behaviour, depression, borderline traits, attachment avoidance, mentalization

28 Clinical trials register (adolescents) Mentalization-Based Therapy to Prevent Suicidal Behavior in Adolescents With Bipolar Disorder (Miklowitz, LA) Individual and family therapy MBT in Groups for Adolescents With BPD or Subthreshold BPD Versus TAU - the M-GAB Randomized Controlled Trial (M-GAB) (Emma Beck, Denmark) Case formulation, MBT-I, MBT-G, MBT-P Group-based Mentalization Therapy for Adolescents (NHS Lothian) Up to 24 sessions group-based MBT

29 MBT in Lothian CAMHS Different training route pre MBT-A Focus on group therapy Tier IV AMBIT trained Early intervention Adapted manual, originally developed for adults with BPD, for adolescents presenting with self harm, experience of emotional distress and relational difficulties (i.e at risk of developing BPD)

30 MBT Skills Training Small grants to support supervision and further training: MBT-AI group manual: Duffy, Duffy, Griffiths, Happer

31 Initial clinical evaluation 3 groups: 29 female adolescents, mean age 15.6 years (SD= 1.5) Median no sessions attended = 7 Acceptable to young people Pre-post change on a number of variables showing small-to-medium effect sizes e.g. reflective function, crisis presentations, emotion regulation strategies RF accounted for variance in outcomes for selfharm, emotional distress, interpersonal problems, internal dysfunctional emotion reg strategies

32 Lothian MBT RCT Pilot RCT comparing MBT-A to TAU to determine: Effectiveness of recruitment strategies Compliance with protocol/procedures Trends towards reduced self harm Result will inform a future definitive RCT and give an indication for the potential for wider service implementation.

33 Mentalizing ourselves in our work We get stressed / upset / anxious / angry ourselves..and lose the capacity to mentalize and when that happens it significantly affects others capacity to mentalize This can happen when we are with patients

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35 Griffiths, H., Noble, A., Duffy, F., Schwannauer, M (2016): Outcome and service utilisation in an AMBIT- Trained Tier IV CAMH service Fuggle, P., Bevington D., Duffy, F., Cracknell, L (2016): The AMBIT approach: working with hard to reach youth

36 Mentalizing stance Inquisitive Terminating Non-mentalizing Highlighting mentalizing Holding the balance(s)

37 Video clip Dickon & girl exploring argument example of therapist stance Exercise: Spot elements of the stance in this clip Client's part played by actor. Watch the clip and try to spot the elements of the stance that you notice in this clip. Feel free to criticise the therapist, too

38 Video clip the therapist's mentalizing stance has been likened to flying as it is described by the character Buzz Lightyear in the film Toy Story: "it's just falling... with attitude". The critical elements of maintaining inquisitiveness, are to retain awareness of the extent of one's not-knowing, readiness to take responsibility for getting it wrong, and commitment not to get it wrong again in the same way.

39 mj7odo Dickon explaining posture 1.34

40 THANK YOU FOR LISTENING!

41 Video clip SnR2jk Anthony empathic validation 7.13