MBT for children and adolescents with insecure attachment...

MBT for children and adolescents with insecure attachment and developing personality disorders in research and clinical practice

Nicole Muller & Kirsten Hauber & Martin Debanné

MBT for childrenand adolescents

1. MBT for Children: a time-limited approach

Nicole Muller

2. MBT forAdolescents: Intensive psychotherapy

Kirsten Hauber

3. MBT –A: new developments

Martin DebannéThe sick child, Gabriël Metsu 1664

CAMHS De Jutters

Total clients in all departments in treatment in 2017:

9644, age 0-23

1 MBTclinical unit for adolescents: De Albatros (age 14-23)

1 MBTdaycare unit for adolescents (age 14-23)

Outpatient unit with MBT-C (age 5-12),

MBT-A young (age 12-16) and MBT-A (age16-23)

MBT gendergroup

MBTF

MBTFamilygroup

MBT-Children time limited

Vincent van Gogh The first steps 1890

Acknowledgement: MBT for Children a time-limited approach

The co-authors of the MBT-C treatment guide:

- Nick Midgley, Anna Freud National Centre for Children and Families, UK

- Karin Ensink, Universite Laval, Montreal, Canada

- Karin Lindqvist, Erica Foundation, Sweden

- Norka Malberg, Yale Child Study Centre, USA

- Nicole Muller, De Jutters CAMHS, the Netherlands

-My team at the Jutters-The children and families i work with!

mentalization

Imaginative capacity to understand our own reactions and that of others as motivated by inner mental states such as feelings and intentions

Mentalization as an inner resource

• Know what I feel and why

• Know who I am (personality/ autobiographical narrative)

• Know weaknesses /difficulties/extreme temperament

• Challenge is mentalize/get a grip on extreme self states (related to disorganization, trauma, dissociation) and

to get back to controlled mentalizing

when in automatic disorganized/

traumatic modes

• Improve capacity to regulate emotions

• Enhance sense of self sometimes by creatingnarratives about life and/or traumatic events

• Enhance mentalizing about difficult aspects of the self, such as aggression, impulsivity, or over sensitivity or about difficulties, such as parental mental illness, divorce, or bullying

• Strengthening the ability to form and maintain relationships

Aims of MBT-C

• Time-limited, 12 weekly sessions after assessment phase

• Work with parents offered alongside the child's sessions

• Option of offering up to three 'blocks' of 12 sessions

• Review session after 8 sessions• Session length 45-60 minutes • The use of a calendar for the child• Focus formulation • Top-up or 'booster' sessions • Supervision group

MBT-C time limited framework

Marlene Dumas: girl feeling ashamed 1990

Who is MBT-C for?Children age 5-12 years

with “goodenough”parents/ safe haven

children often withinsecureattachmentstyle

who have difficultywith attention and emotioneregulation

and have mentalizingproblems

Marlene DumasYoung boy 1996

Anxiety disorderMood disorderBehavioral problems and ADHD+Reactive attachment disorder(Chronic) traumaComplicated grief or loss of anattachment figure

Combination of internalizingand externalizing problemsMild (and severe) mental process disorder (Fonagy)

Time-limited MBT-C : diagnoses

Building Blocks of Mentalizing

Mentalization

Affect Regulation

Attention Regulation

MBT-C assessment; working towards a motto

Jan Steen The forbidden party 1665

“John”, 9 years old

John lived the first two years of his live with hismother but was placed in fostercare becauseof serious mental problems of the mother. He had lived in two fosterfamilies before he cameto this family, where he could stay.

He has severe agressive outbursts and is isolated, has no friends and learningdifficulties.

"There was once a little chimpanzee. He lived for a while with his mother in a group but had to leave her when he was really little, because she couldn’t take care of him anymore. That was sad, because the chimpanzee hadn’t learned all the words and rituals that are used in a chimpanzee family. After travelling around, and staying in different places, the little chimpanzee came to a family of gorillas. This looked a bit like home, but sometimes he felt out of place and worried if the gorilla family would let him stay. He often lacked the words to describe what he thought or felt. He sometimes felt very alone because he missed his mother and because he had lived so long with others where he had felt like an outsider. When he felt sad he sometimes became angry, because that helped him feel a bit bigger. At the gorilla family, it often did feel like home, but sometimes it didn’t. He was a chimpanzee after all. So he decided he wanted to find his own words and rituals to become stronger and not so angry anymore and he decided he wanted to live with the gorillas and visit the chimpanzee family once in a while. The gorillas loved the little chimpanzee and they were willing to learn more about how it is to be chimpanzee ".

MBT- C is Play Centered

• Play regulates negative affects and diminishes stress

• Play helps to process major life events

• Play integrates new information affectively and cognitively

• Play offers a place to experiment with new behavior and new solutions

• Play stimulates fantasy and fosters creativity

Psychic Equivalence; how do you know?

• Quickly changing emotions• Under-regulation of the self• Black and white thinking• No clear distinction between self and other• No clear distinction between real – not real• No clear distinction between inside and outside• Afraid to fantasize or experiment with fantasy play;

afraid to pretend• Play is aggressive, hostile and can

be destructive

Children who struggle to establish pretend mode

• Children stuck in psychic equivalence may not dare to think in pretend terms –

so play is often very wild, chaotic and destructive;

in games, losing is not acceptable. (Zevalkink et al., 2012).

• Sometimes the therapeutic challenge is to help a child establish pretend mode – a capacity to play…

Helping establish pretend mode with children

• attuning and making contact; playing with boundaries; giving reality value and promoting self-agency

• for attention regulation - via ostensive cues, marked affect-mirroring

• therapist as an active commentator, trying to invite child to expand the play.

• this approach can help child learn about existence of mental states and engage in ‘pretend mode’

Girl in white kimono, George Breitner1894

MBT-A

22

MBT-adolescents study:intensive MBT group psychotherapy

• Intensive MBT-A

Part 1: Aim was to examine if MBT alters personality disorders, attachment representations and symptomology

Part 2: Aim was to investigate whether the same therapeutic factors of Yalom were found and which ones were related to changes, in unstructured reports of therapy outcome after intensive MBT

The cheerful family, Jan Steen 1668

Setting

Overview of study population on gender, DSM-IV Axis I classification and Axis II personality disorders according to the

SCID-II (N = 60)n %

Gender

Female50 83.3

Male 10 17.7

Axis I disorders

Mood disorders 41 61.0

Anxiety disorders 25 37.0

Identity disorder 11 16.0

Eating disorders 8 12.0

Substance

dependence

5 7.0

Dissociative

disorders

2 3.0

Obsessive

compulsive

disorder

1 2.0

Attention deficit

hyperactivity

disorder

5 8.0

Girl with pearl earring, Johannes Vermeer 1665

At t1, 91.8% (n = 56) of the patients had one or more personality disorders, compared to 35.4% at t2 (n =

22).74.1% (n = 46) showed a decrease in the number of SCID-II personality disorders at t2

t-1: M = 1.42, SD = 1.21, range 0-4; t-2: M = 0.48, SD = 0.78, range 0-4; z = 5.76, p = .000 , d = 0.92, 95% CI

[0.77-1.26]27

SCID-II t1 SCID-II t2

N % N %

No PD 6 9.7 40 64.5

Paranoid PD 13 20.9 5 8.1

Schizoid PD 2 3.2 0 0.0

Antisocial PD 1 1.6 0 0.0

Borderline PD 23 37.1 7 11.3

Avoidant PD 34 54.8 11 17.7

Dependant PD 3 4.8 1 1.6

Obsessive Compulsive PD

8 12.9 3 4.8

Depressive PD 29 46.8 9 14.5

Passive Aggressive PD 2 3.2 0 0.0

PD NOS 2 3.2 1 1.6

SCID-II at t-1 and t-2 (N = 62)

Pre post SCIDII personality disorders and pre SCL-90 symptoms of distress (N=62)

150

170

190

210

230

250

270

290

SCL 90 (t1) SCL 90 (t2)

0 SCID-II

1 SCID-II

2 SCID-II

>2 SCID-II

Attachment representations

Insecure-dismissing

(Ds)Secure-Autonomous (F) Insecure-

Preoccupied (E)

Attachment representations

(Bowlby, Ainsworth, Main)

Unresolved/Disorganized (U)

Cannot Classify (CC)

Overview of AAI attachment representations in relation to other norm groups in N and %

Total sample

N=60

Non-clinical

Mothers1

N=700/748

Non-clinical

Adolescents1

N=503/617

Non-clinical

adolescents2

N=76/64

Hospitalized

Adolescents2

N=66/40

N % N % N % N % N %

F 10 16.7 399 56.0 222 44.0 34 44.7 5 7.6

Ds 10 16.7 112 16.0 171 34.0 12 15.8 12 18.2

E 1 1.7 63 9.0 55 11.0 13 17.1 13 19.7

U/CC 39 65.0 126 18.0 55 11.0

U 8 13.3 12 15.8 19 28.8

CC 31 51.7 5 6.6 17 25.8

Forced attachment classifications

N % N % N % N % N %

F* 15 25.0 434 58.0 321 52.0 40 56.3 7 16.3

Ds*

E*

15

30

25.0

50.0

172

142

23.0

19.0

216

80

35.0

13.0

15

9

22.5

21.1

17

16

44.2

39.5

* Three way attachment classifications (i.e. regardless U/CC)1 Bakermans-Kranenburg, 2009 2 Allen, Hauser and Spurrell, 1996: In this study transcripts with U in

combination with CC were excluded from forced classifications data.

Distribution in number and percentages of AAI

attachment classifications by five- (a) and three- way*

(b) at the beginning and the end of the treatment

(N = 33)

a) Attachment

classifications

b) Forced attachment

classifications*

Pre Post Pre Post

N % N % N % n %

F 6 18.1 13 39.4 8 24.2 16 48.5

Ds 5 15.2 6 18.2 7 21.2 7 21.2

E 0 0.0 0 0.0 18 54.5 10 30.3

U 3 9.1 5 15.2

CC 19 57.6 9 27.2

Pre post SCL-90 versus AAI groups (N=33)

Pre

SCL-90

Pre

SCL-90

Post

SCL-90

Post

SCL-90

mean Sd mean Sd p

AAI Improved 233.50 58.71 162.79 49.45 .002

AAI unchanged 245.08 66.67 192.00 57.25 .005

AAI

deteriorated

245.67 15.95 258.00 96.63 .824

Potret of a mother with 4 children, Jürgen Ovens, 1650 - 1678

Attachment outcomes1. The CC-category was overrepresented 2. At t2 the number of securely attached adolescents increased with 21.2%. 3. Significant reductions in insecureattachment (z = -2.95, p = .001) in wholesample

Conclusions effect study

Significant reductions in:• insecure attachment (z = -

2.95, p = .001), • personality disorder traits

(t = 8.36, p = .000) and • symptoms (t = 5.95, p =

.000)MBT seems to alter adolescents insecure attachment positively, next to personality pathology and symptoms

Treatment of sick people, Jan Luyken 1684 34

Farewell letters studyThe aim of this study was to investigate whether the same therapeutic factors of Yalom were found and which ones were related to changes, in unstructured reports of therapy outcome after intensive group psychotherapeutic treatment by high risk adolescents with clinically diagnosed personality disorders. Girl Reading a Letter at an Open

Window, Johannes Vermeer 1657-1659

Yalom’s 12 therapeutic factors of success and 4 new factors (N=70)

1. Altruism 37.1%

2. Cohesion 97.1%

3. Universality 1.4%

4. Interpersonal learning input 51.4%

5. Interpersonal learning output 94.3%

6. Guidance 88.6%

7. Catharsis 55.7%

8. Identification 94.3%

9. Family re-enactment 2.9%

10. Self-understanding 18.6%

11. Instillation of hope 1.4%

12. Existential factors 30.0%

13. Self-esteem 27.1%

14. Turning point 10.0%

15. Resilience 15.7%

16. Epistemic trust 12.9%

Self portret, Vincent van Gogh 1887 36

Three factors were associated with therapeutic recovery

• Interpersonal learning input: having learned how to come across to others

’My reactions to others were often unpredictable and caused a lot of insecurity in the group. An example was my suicide attempt in the beginning of my treatment. I have scared many groupmates and still regret it to this day.’

’I was shocked, but accepted the tips. Eventually I started working on it, because yes, I really needed that kick in the pants.’

’It was difficult but due to the confrontations and support I received, I was able to take steps.’

’Thank you for helping me to get to know myself. Thank you for having taught me that I am allowed to be vulnerable. Thank you for your commitment and patience.’

Three factors were associated with therapeutic recovery

• Self-esteem: the sense of value to the group en being self-confident

’But not anymore; I am full of self-confidence, and I am myself.’

’But above all that I am capable of much more than I think myself.’

Three factors were associated with therapeutic recovery

• Turning point:a crucial moment of change in the treatment.

’From the moment I went to day treatment, there was a turning point in my treatment for me.’

’And when the subject was raised by Willy and Pieter, I found out that I was completely lost in caring for others. I therefore did not do anything about my own problems and felt incredibly depressed. That conversation with Willy and Pieter, was and turning point for me in my treatment.’

’I did a psychodrama about my acting out and how it got in the way of the contact with the group and that really was the turning point for me.’

Three factors were associated with therapeutic recovery

• Turning point:a crucial moment of change in the treatment.

’I actually only had contact with them (subgroup) and I was missed by the group, I felt unseen and I damaged myself so that I was seen. That is why I got a treatment policy conversation, I personally see this as one of the turning points in my treatment.’

’The realization came when I thought that no one liked me anymore, nobody shared secrets with me any more, I had to talk about real things. It was the end of the world for me, I even wanted to quit treatment. Then I fell, something broke. People were not there for me to hurt or bully me but to see me as a person. I have jumped, the contact I have with people now is real and the real contact is 10 times better than that secrets hassle.’

Conclusions therapeutic factors of success study

• All therapeutic factors of success of Yalom and four new factors were identified as valid, although in very different percentages

• Three of all 16 factors were found to be correlated significantly with therapeutic success: interpersonal learning input (p = .004), self-esteem (p = .044) and turning point (p = .006)

The leter writer, Frans van Mieris 1680 41

General conclusions

• Attachment insecurity and personality pathology in a high risk sample of adolescents is malleable

• MBT seems to change insecure attachment positively

• The farewell letters highlighted the importance of 16 therapeutic factors of success in group psychotherapy

• Generalizability to other adolescent personality disorder intensive psychotherapy services is to be determined

Thank you for yourattention!Nicole Muller

n.muller@dejutters.com

Kirsten Hauber

k.hauber@dejutters.com

The milkmaid, Johannes Vermeer 1660