Efficacy of Mentalization-Based Group Therapy for Adolescents: A Pilot Randomised Controlled Trial

Efficacy of Mentalization-Based Group Therapy for Adolescents: A Pilot Randomised Controlled Trial * Helen Griffiths1,2 , Fiona Duffy1,2, Louise Duffy2, Sarah Brown1,2, Harriet Hockaday1,2, Emma Eliasson1,2, Jessica Graham2, Alice Thompson1,2, Rachel Happer2, Maeve Butler1,2, Matthias Schwannauer1,2 1 Department of Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Medical School (Doorway 6), Teviot Place, EH8 9AG 2 NHS Lothian Child and Adolescent Mental Health Services, Royal Edinburgh Hospital, Tipperlinn Road, Edinburgh, EH10 5HF ABSTRACT   Background: Suicide is the leading cause of death in adolescents. Furthermore, up to one quarter of adolescents who self-harm will repeat self-harm within one year, highlighting the need for evidence-based prevention and treatment services. Mentalization Based Therapy (MBT) has yielded promising outcomes for individuals who self-harm, however to date only one study has examined MBT in adolescents, wherein the treatment protocol consisted of individual and family therapy. Currently, there has been no development or examination of MBT-A in a group format for adolescents. Methods/Design: The present study is a randomised controlled single blind feasibility trial that aims to (1) adapt the original explicit MBT introductory group manual for an adolescent population (MBT-Ai) and to (2) assess the feasibility of MBT-Ai through examination of consent rates, attendance, attrition and self-harm. Participants are adolescents presenting to Child and Adolescent Mental Health Services (CAMHS) with self-harming behaviors within the last 6 months. Young people will be randomised to a 12-week MBT-Ai group plus treatment as usual (TAU) or TAU alone. Participants will be assessed at baseline and at 12-, 24- and 36-weeks post-baseline. Discussion: This paper describes the development of a treatment manual and the protocol of a randomised controlled feasibility trial of MBT-Ai aimed at treating adolescents who selfharm. Further investigation of a full-scale trial will be necessary to instill benefits if pilot results suggest efficacy. Trial registration: NCT02771691 Keywords: adolescent, mentalization, MBT, group, self-harm * Correspondence to Dr. Helen Griffiths, Department of Clinical Psychology, School of Health in Social Science, The University of Edinburgh, Medical School (Doorway 6), Teviot Place, EH8 9AG. Email: Social Science Protocols, April 2018, 1-14. http://dx.doi.org/10.7565/ssp.2018.2647 1 1. Background Suicide is a leading cause of death in adolescence worldwide (Centers for Disease Control, 2014; WHO, 2017), resulting in over 67,000 deaths in adolescents aged 10-19 in 2015, or approximately 184 deaths a day (World Health Organization, 2017). Psychiatric history, suicide intent and self-harm are among the strongest risk factors for suicide, with evidence suggesting self-harm increases the risk of death by suicide approximately 10-fold (Hawton & Harriss, 2007, Chan et al., 2016). Although true prevalence of self-harm is difficult to depict based on varying definitions, the most well-known cross-sectional study to date documented a life-time prevalence of self-harm to be 27.6% in adolescents across 11 European countries, highlighting the scope of the problem (Brunner et al., 2014). Furthermore, repetition of selfharm is alarmingly common, and between 10-25% of adolescents will repeat self-harm within a year (Hawton & Harriss, 2008; Hawton & James, 2005) Self-harm often occurs within the context of a wider, complex mental health presentation, including the interaction of a variety of social, psychological and cultural factors (Hawton, Saunders & O’Connor, 2012). Personality traits apparent in adult borderline personality disorder (BPD), including emotion dysregulation and decreased social functioning, have been found to be predictive of and common within young people who self-harm (Mikolajczak, Petrides & Hurry, 2009; Crowell et al., 2012). Individuals with BPD show reduced capacities to mentalize - the imaginative mental activity that enables us to perceive and interpret human behaviour in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) (Allen, Fonagy & Bateman, 2008; Bateman & Fonagy, 2006). Mentalizing deficits are linked to problems with emotional regulation and impulsivity, especially within interpersonal interactions. This is frequently associated with significant emotional distress, self-harm and crisis presentations. There is an urgent need to reduce the high rates of repetition of self-harm seen within adolescents. Appropriate early intervention can often also prevent the escalation of parallel emotional distress and functional impairments. A recent meta-analysis by Ougrin and colleagues (2015) evidenced promising effects for three therapeutic interventions, namely cognitive behavioural therapy, dialectal behaviour therapy, and mentalization-based therapy – however, none of these effects had been independently replicated. This emphasizes the need for further examination. Furthermore, there remains a gap between clinical practice and research evidence, whereby best-practice within clinical settings is often based on interventions with little to no evidence (Burns et al., 2005). The need to further develop and replicate trials for self-harm in adolescence has been highlighted throughout the literature (Ougrin et al., 2015; Ougrin et al., 2012; De Silva et al., 2013; Hawton et al., 2015). Mentalization Based Therapy (MBT) was initially developed for the treatment of adults with a diagnosis of borderline personality disorder (BPD). It is proposed that a fragile mentalizing capacity vulnerable to social and interpersonal interaction is a core feature of the disorder (Bateman & Fonagy, 2010). Within this adult population, MBT reduced depression, anxiety, suicidal and self-mutilatory acts; and inpatient days, and improved social and interpersonal function in comparison to treatment as usual (Bateman & Fonagy, 1999) with continued improvements at eighteen months (Bateman & Fonagy, 2001). MBT has also been shown to be effective in an adult outpatient setting (Bateman & Fonagy, 2009). These findings require independent replication. There are very few randomised controlled trials (RCTs) to date which have evaluated MBT for adolescents (MBT-A). Rossouw & Fonagy (2012) found that MBT-A was more effective than treatment as usual for adolescents who self-harm, with a recovery rate of 44% in comparison to 17%. The treatment protocol involved weekly individual MBT-A sessions and monthly MBT family therapy (MBT-F). We are aware of one other mentalization-based Social Science Protocols, April 2018, 1-14. http://dx.doi.org/10.7565/ssp.2018.2647 2 therapy trial for adolescents in progress. Beck et al (2016) are investigating a group-based mentalization-based treatment programme for adolescents with BPD or subthreshold BPD. Given that the e (...truncated)