Mentalizing as a mechanism of change in the treatment of patients with borderline personality disorder: A parallel process growth modeling approach.

Abstract

Although a number of effective psychotherapeutic treatments have been developed for borderline personality disorder (BPD), little is known about the mechanisms of change explaining the effects of these treatments. There is increasing evidence that impairments in mentalizing or reflective functioning-the capacity to reflect on the internal mental states of the self and others-are a central feature of BPD. To date, no study has directly investigated the core assumption of the mentalization-based approach to BPD, that changes in this capacity are associated with treatment outcome in BPD patients. This study is the first to directly investigate this assumption in a sample of 175 patients with BPD who received long-term hospitalizationbased psychodynamic treatment. Using a parallel process growth modeling approach, this study investigated whether (a) treatment was related to changes in mentalizing capacity as measured with the Reflective Functioning Questionnaire; (b) these changes could be explained by pretreatment levels of mentalizing and/or symptomatic distress; and (c) changes in mentalizing capacity over time were associated with symptomatic improvement. Mentalizing and symptomatic distress were assessed at admission, 12 and 24 weeks into treatment, and at discharge. Results showed that treatment was associated with significant decreases in mentalizing impairments (i.e., uncertainty about mental states) and symptomatic distress. Pretreatment levels of mentalizing and symptomatic distress did not predict these changes. However, improvements in mentalizing were strongly associated with the rate of decrease in symptomatic distress over time (r = .89). These findings suggest that increases in mentalizing may indeed in part explain therapeutic change in the treatment of BPD, but more research is needed to further substantiate these conclusions.

Metacognitive improvement and symptom change in a 3‐month treatment for borderline personality disorder

“…Of course, we cannot rule out the hypothesis that overall metacognition simply does not act as a mechanism of change, as our main finding nuances De Meulemeester et al . 's () study where a strong association was found between improvement in mentalizing and symptom change during treatment. Part of that difference could be explained by the nature of the method used, in addition to conceptual divergence of how the potential mechanism of change was defined.…”

“…Changes in reflective functioning were negatively linked with changes in personality organization. Recently, De Meulemeester, Vansteelandt, Luyten, and Lowyck () examined mentalization as a predictor and as a mechanism of change in a long‐term hospitalization‐based psychodynamic treatment for BPD patients. Levels of mentalization at onset did not predict symptom change but a strong correlation was observed between change in symptomatic distress and change in uncertainty about mental states.…”

Processes of Change in Psychotherapy for Narcissistic Personality Disorder

“…On the basis of the clinical issues outlined, it is essential not only to go beyond the mere demonstration of outcome in psychotherapy, but also to improve our understanding of the underlying processes at work in treatment (Clarkin, 2014;Kramer, 2019) by conducting psychotherapy studies similar to those that have addressed borderline personality disorder (De Meulemeester, Vansteelandt, Luyten, & Lowyck, 2018;Fonagy & Bateman, 2006;Gratz, Bardeen, Levy, Dixon-Gordon, & Tull, 2015;Levy et al, 2006). At the present time, the mechanisms of changes in NPD are insufficiently understood.…”

Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial

“…Levy and colleagues (2006) examined change in three forms of psychotherapy for BPD --TFP, DBT and supportive therapy -and found that only TFP was associated with an increase in mentalizing functions, along with development of more secure attachment patterns in some patients in this group [29]. Consistent results were presented by Fischer-Kern and colleagues [61] (see also de Meulemeester et al [62]; Maillard et al, [63]). Other research has underlined the moderating factor of mentalizing capacities for outcome for different categories of PD [64,65].…”