The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Mentalization Based Therapy (MBT) is a long-term psychological therapy used in the treatment of mental health disorders including borderline personality disorder (BPD), eating disorders such as Bulimia Nervosa and antisocial personality disorder. This manualised intervention targets deficits in mentalizing in the context of attachment relationships and facilitates improvements in mentalizing capacity. MBT therefore increases awareness about mental states, and the application of this awareness to the regulation of affects and the negotiation of interpersonal relationships.
MBT is a structured individual and group treatment – personalized through formulation (collaborative clinical agreement based on a framework of mentalizing).
MBT is typically delivered as follows:
- 12 week MBT-I Psychoeducation group
Followed by
- 12-18 months group therapy weekly (75-90 minutes), alongside
- Individual MBT therapy in 50 minute sessions (usually weekly or fortnightly)
MBT can be delivered to children, young people and adults, with specific adaptations, however the evidence in children is less well established.
Fidelity
Teams delivering MBT should follow the Quality Manual for MBT, which outlines minimum staff numbers and the training and supervision requirements to safely deliver an MBT treatment programme. At least some staff should be trained to MBT Practitioner level. Treatment adherence and practitioner competence is monitored using video or audio recording of treatment sessions and application of the MBT Adherence and Competence Scale (MBT-ACS) for adherence rating (1).
Modifiable Components
MBT can be used in the management of mental health disorders including BPD, eating disorders such as Bulimia Nervosa, and antisocial personality disorder. MBT can be delivered to children, young people and adults, and available treatment models also include MBT for families, and MBT for adolescents. MBT can be delivered in several settings, in individual and/or in group formats.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Implementation Support
Implementation support for MBT delivery is available through MBT Scotland, part of the Global Network of partner organisations to the Anna Freud Centre. MBT Scotland delivers accredited MBT Basic, MBT Practitioner and MBT Supervisor training courses and holds a register of accredited MBT practitioners and MBT supervisors. There is a quality manual to help service managers and clinicians to develop MBT treatment services. This document outlines standards for MBT services and training requirements for MBT practitioner, supervisor, and trainer status.
Start-up Costs
Training in MBT is regularly delivered by MBT Scotland through NES.
Costs of sourcing training through other national approved training organisations, e.g., Anna Freud Centre would be as follows:
3 day MBT Basic Course (£900-£1,000 per person)
2 day MBT Certificate Course for Practitioner Level (£650 per person)
Building Staff Competency
Qualifications Required
MBT is typically delivered by mental health professionals, including mental health nurses, psychiatrists, psychologists, and occupational therapists, who have completed an additional recognised training in MBT to practitioner level.
Training Requirements
Training is delivered in a stepped model, starting with the MBT Basic training, a one-month programme consisting of 3 days of live-instructor led online training and 21 hours self-guided content. To progress to Practitioner level, staff are expected to take on clinical work under supervision, which then allows access to the MBT certificate course (Practitioner level), a one-month programme consisting of 2 days of live, instructor-led online training, and 4 hours of self-guided content. As part of the MBT certificate course, clinical video or audio assessments are used to demonstrate practitioner use of basic MBT interventions. Achieving Practitioner status requires supervised clinical experience of treating 4 individual patients or 2 individuals plus one MBT Group, or 2 MBT Groups over 18 months with satisfactory supervisor report to confirm achievement of core competencies.
Supervision Requirements
MBT training and practice requires ongoing supervision of video or audio recorded sessions provided by an accredited MBT supervisor. It is also recommended that any MBT programme has monthly external supervision of the treatment programme by an accredited MBT supervisor.
Evidence - Rating: 4 - 5
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
Mentalizing theory is rooted in Bowlby’s attachment theory and its elaboration by contemporary developmental psychologists, whilst paying attention to constitutional vulnerabilities. MBT aims to enhance understanding of interpersonal behaviour in terms of mental states, as this is recognised as a key determinant of self-organisation and affect regulation. MBT delivery therefore addresses compromised mentalizing capacity, and enhances competences associated with understanding one’s own and other people’s minds. This is expected to translate to increased awareness about mental states, and the application of this awareness to the regulation of affects and the negotiation of interpersonal relationships.
Adults BPD - Rating: 5
Research Design & Number of Studies
Psychological therapies for Borderline Personality Disorder have been reviewed in a Cochrane Meta Analysis (2) and included 6 RCTs of MBT (3) (4) (5) (6) (7) (8). There has also been an 8 year follow up study of MBT vs Structured Clinical Management (9).
The RCT included people experiencing eating disorders as well as symptoms of BPD in a trial comparing MBT with Structured Supportive Clinical Management for Eating Disorders (7).
Adult Outcomes Achieved
Summary of outcomes for BPD from Cochrane Review Meta analysis (2):
- Psychological treatments, including MBT, are superior to waiting list control and may be more effective than treatment as usual in reducing BPD symptom severity, self harm, suicide related outcomes and depression, as well as improving social functioning (2)
- MBT was found to be more effective that usual treatment in reducing self harm, suicidality and depression (2)
- At 8 Year follow up the number of patients who continued to meet the primary recovery criteria in the trial was significantly higher in the MBT group (74% MBT vs. 51% structured clinical management) (9). Participants treated with MBT showed better functional outcomes in terms of being more likely to be engaged in purposeful activity and reporting less use of professional support services and social care interventions.
Summary of outcomes for BPD and co-occurring Bulimia Nervosa:
Results from a small RCT with very high rates of drop out indicated that MBT-ED may be associated with a greater reduction in shape and weight concern as well as a reduction in eating disorder and BPD symptoms compared to standard treatment or specialist supportive clinical management (SSCM-ED) (7). At 6, 12 and 18 months there was a decline in eating disorder and BPD symptoms in both groups. Only 15 of the 68 participants completed the 18-month follow up.
Adults Bulimia Nervosa - Rating: 4
Summary of outcomes for Antisocial Personality Disorder:
Results from one large multi-centre RCT of probation as usual vs probation plus 1 year MBT indicated significant reduction in aggressive behaviours (measured by OAS-M) in the MBT treatment group from baseline to 12 month follow up, with medium to large effect size. The model of MBT treatment was modified for use with this population, and consisted of weekly group therapy plus monthly individual therapy.
Need
Comparable Population
MBT has been shown to be effective in adults with eating disorders, with or without BPD.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
MBT is based on attachment theory, developmental psychology and contemporary psychoanalysis. The intervention targets deficits in self and other reflectiveness (i.e. mentalizing) within attachment relationships, and facilitates an improvement in the capacity to mentalize.
Priorities
MBT focuses on increasing awareness about mental states, and the application of this awareness to the regulation of affects and the negotiation of interpersonal relationships. MBT can be delivered to children, young people and adults for the treatment of a range of mental health conditions (including BPD, eating disorder, and antisocial personality disorder)
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
MBT is typically delivered by mental health practitioners, including mental health nurses, psychiatrist, psychologists, and occupational therapists, who have completed a recognised training in MBT (as described in section on building staff competency, above). The full out patient treatment programme includes weekly/ fortnightly individual therapy plus weekly MBT Group therapy in groups of 6-8 patients with 1-2 therapists over a period of 12-18 months. The MBT Quality Manual recommends a minimum of 4 MBT therapists to deliver a full programme, with appropriate supervision.
Technology Support
Access to technology is required for practitioner online training and for recording sessions for supervision.
Administrative Support
MBT is delivered in group and individual format. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Training costs apply if accessing training outside of NES training.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
