Mentalization-based treatment of female patients with severe personality disorder and substance use disorder
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Personality disorder (PD) and substance use disorder (SUD) are frequently co-occurring conditions which severely affect individuals in different domains of their life. Around half of patients with SUD also suffer from a PD. Clinical research indicates that each of these conditions separately are difficult to treat and many obstacles to successful outcomes can be found. When these conditions occur together, consequences for treatment are even graver. Furthermore, these patients are often excluded from specialised psychiatric treatments for PD and are left to random treatment programmes in the SUD field where competence and knowledge on PD are often lacking.
This dissertation sought to explore, through different methodological approaches, the experiences and changes in mentalization-based treatment (MBT) of 18 female patients with comorbid PD/SUD. Do they achieve beneficial results from the treatment, and do they accept and endure this long-term combination treatment which is tailored to patients with borderline PD? The dissertation consists of three papers. The first paper was a single-case study which investigates the treatment process of a patient suffering from SUD and schizotypal PD, which is considered difficult to treat and that could enlighten the process of working with transference and handling countertransference. The methodology was a hermeneutical single case efficacy design (HSCED) and vignettes from the treatment process together with abundant data collection were used in the analysis. The research question for paper 1 was: What are the effects of disorganised attachment on personality functioning and substance abuse, and how is it transformed through MBT? What are the central mechanisms of change? In paper 2, thirteen patients were interviewed qualitatively on their experiences of MBT and their view on own pathology approximately 2 years after terminating MBT. A thematic analysis within a hermeneutical-phenomenological epistemology was the methodological approach chosen for the analyses of transcribed semi-structured qualitative interviews. The research questions of paper 2 was: How do female patients with clinical significant borderline traits and comorbid SUD experience their own central change processes after participating in a MBT programme? When these patients experience change in psychotherapy, what central change processes do they highlight? Do they experience changes in their ability to mentalize when looking back at the therapy process? In paper 3, longitudinal quantitative data were collected from 18 patients at baseline, every 6 months in treatment, at the end of treatment and at follow-up two years after treatment. The assessment protocol had measures on PD, SUD, interpersonal functioning, symptomatic distress, general functioning and self-esteem. Furthermore paper 3 aimed to evaluate the feasibility aspects of the pilot project. Linear mixed models were utilised for the analyses of the quantitative data. The research questions of paper 3 were: What is the feasibility of MBT with female patients with severe PD and SUD? Does MBT have any positive effect on PD/SUD patients’ substance use and personality structure (primary outcome)? Does MBT have any positive effect on symptom distress, interpersonal and social functioning (secondary outcome)? In paper 1 we found that: 1) that the patient had changed in a clinically significant way, 2) that MBT was the main causative process for her change, 3) that the main mechanisms of change were reparations of ruptures in the alliance, handling countertransference and working in the transference through constant efforts a mentalizing the relationship, and 4) that treatment gains made it possible for her to maintain her mentalizing abilities even in close relationships that formerly would activate profound mental confusion. In paper 2 we found that patients experienced meaningful psychological change after participating in MBT and that by gaining the ability to reflect on their own feelings and thinking processes, interpersonal encounters became more flexible and ultimately patients experienced an increased sense of an agentic self. The themes that described their change processes were “by feeling the feeling”, “by thinking things through”, “by walking in your shoes to see myself”, and “by stepping outside of own bad feeling in seeing you”. In paper 3, we found that preliminary data on changes in several outcome measures indicated that MBT treatment gave both clinically and statistically significant changes in primary and secondary outcome measures. Furthermore, in evaluation of the feasibility aspects of the study we concluded that embarking on a randomized controlled trial (RCT) with this study protocol and treatment programme is “feasible with close monitoring”. Treatment adherence and routines for frequent and coherent assessment are important to implement and monitor.
The findings in this dissertation indicate that MBT could be a potential beneficial treatment approach for female patients suffering from PD/SUD. Furthermore, different hypotheses on what are important mechanisms of change in MBT have been found. These include working in the transference, managing countertransference and mentalizing as a central change process. These suggestions for mechanisms of change should be further investigated in psychotherapy process studies. The lack of a control group and the limited number of participants suggest that conclusions must be made with caution. The feasibility aspects seem promising and larger studies on MBT with PD/SUD are recommended.