Objective: The aim of this study was to explore how patients with personality disorder (PD) and substance use disorder (SUD) experience mentalization-based treatment (MBT), in particular what they consider useful and less useful elements of the therapy. Method: Semi-structured qualitative interviews with 13 participants were conducted. Participants were interviewed on their experience of the different elements of MBT, their experience of working in the transference, and their view on MBT as a whole. Thematic analyses were performed within a hermeneutical-phenomenological epistemology, with an emphasis on researcher reflexivity. Results: The following themes were found in the material: “I am not alone,” “Taking blinders off,” “Just say it,” “The paradox of trust,” and “Follow me closely.” Three of these themes concerned therapist interventions; these involved addressing the relationship with the patients, addressing negative or unspoken feelings in the sessions, and validating and tolerating patients’ affect. Two themes concerned group therapy experiences; these were the experience of sameness with co-patients in group and the experience of discovering different perspectives in group. Conclusions: Patients’ experiences of useful elements in MBT resonate with theoretical tenets of (borderline) personality pathology, in particular attachment disturbances and emotional dysregulation. Patients highlight what we would label working in the therapeutic relationship, addressing transferential and counter-transferential processes explicitly, emotional validation, and enhancing mentalizing in its own right.

Scientific environment This dissertation is a result of collaboration between the Department of Clinical Psychology, University of Bergen and the Bergen Clinic Foundation. The funding for the pilot project came from the Norwegian health directorate and the Bergen Clinic Foundation had the executive economic responsibility. The Department of Clinical Psychology provided supervisors, office space and the main scientific environment. The Norwegian Network of personality-focused treatment programmes (DN) at the Oslo University Hospital (OUS) was also involved in the pilot project and provided assessment protocols and clinical and scientific advice.

The findings are in line with theoretical assumptions that increasing mentalizing capacity is a central change process for these patients. Furthermore, the findings demonstrate the complex interaction between different modes of mentalizing.

Personality disorders (PD) and substance use disorders (SUD) are highly comorbid conditions. However, their treatment services are often separated. The aims of this study was to investigate how extensive this separation was prior to a Norwegian health reform (2004) that promoted integration, and to discuss clinical challenges for an integrated treatment of PD and SUD. All patients with a diagnosis of PD (n=1783) admitted to 10 day hospital treatment programs (1993-2003) were examined. Diagnoses were assessed by Mini International Neuropsychiatric Interview and Structured Clinical Interview for DSM-IV interviews. Socio-demographic data, psychosocial functioning (Global Assessment of Functioning Scale), symptom distress (Symptom Check List-90-Revised), interpersonal problems (Circumplex of Interpersonal Problems) and treatment course were recorded. The majority of patients were females (72%) and the prevalence of SUD was low (14%). SUD occurred among all PD categories. Patients with borderline PD were over-represented and patients with cluster C disorders were under-represented in the SUD sample. The SUD sample contained more men and it was associated with more previous violence against self and others. The reported violence was partly explained by gender (males) and diagnoses (borderline and SUD). PD patients with SUD also displayed more aggression during treatment and dropped out more frequently. The findings demonstrate that the female dominated specialized psychiatric treatment services for PD to a large extent had excluded PD patients who also had SUD. The reasons are probably related to the surplus problems that characterized the SUD sample and gender issues. Implications for the development of the PD and SUD services with respect to an integrated treatment for these comorbid conditions are discussed.

Mentalization-based treatment for female patients with comorbid personality disorder and substance use 28/30 disorder: A pilot study Objectives: In this study, we investigated the feasibility of mentalization-based treatment (MBT) for patients with comorbid substance use disorder (SUD) and borderline personality disorder (BPD). No published study has ever specifically looked at MBT for these patients. Such individuals are known to have a very poor prognosis and harbor much pain and misery. Moreover, few randomized controlled trials exist on psychotherapy efficiency for patients with comorbid substance use disorder and borderline personality disorder. There is an urgent need for more knowledge on treatment for this patient group. Design: A pilot project within a naturalistic clinical setting with longitudinal data collection during treatment and at follow-up. Eighteen female patients attended a pilot project and participated in up to 36 months of treatment, according to the manuals. Patients were measured on primary (pre/post) and secondary (longitudinal) outcome measures before treatment, every six months during treatment, at the end of treatment, and at follow-up approximately two years after treatment. Methods: Statistical analyses of repeated outcome measures (GSI, CIP, GAF, WSAS, and RSES) and of pre/post measures (Axis I and II diagnosis) were performed with linear mixed models, and Cohens d was calculated. Results: Significant improvements on primary and secondary outcome measures were demonstrated, with effect sizes ranging from moderate to large. With respect to primary outcome, these SUD/PD patients were almost fully recovered from their SUD at follow-up (a predicted score of 0.2 Axis I SUD diagnosis at follow-up in comparison with a score of 1.8 at baseline). Conclusion: MBT as performed in this pilot project indicates promising results for patients with (mostly borderline) PDs and comorbid SUDs. Performing RCT studies is warranted.