Impact case study database

Impact on patients

The President of the International Society for the Study of Personality Disorders (ISSPD) which represents the global practitioner community, states that MBT has had “transformational impact” on practice in the treatment of personality disorder and brought “immense benefit to many of those suffering from this painful and debilitating set of mental conditions” in highly vulnerable groups [S1]. MBT was the first therapy to offer clear evidence from RCTs **[**e.g. R1] of lasting patient benefit (including five- and eight-year follow up). This evidence confirms that those receiving treatment enjoy a more fulfilling and gratifying quality of life in terms of less use of services and a greater likelihood of being involved in full-time education or employment. The benefits were confirmed by a Cochrane review [S2], making it one of only two therapies forBPD identified by Cochrane as having a substantial evidence base [S1]. It takes a non-stigmatising approach towards its client group, giving hope to patients by promoting kindness and understanding. This makes it relatively easy to implement with patient groups made suspicious by disappointment with the support they have previously received. These factors make MBT highly popular among members of the ISSPD and the mental health field in general [S1].

Underpinning new interventions

The team’s breakthrough linking attachment and mentalizing to social functioning [R1, R2, R5, R6], coupled with the core elements of MBT practice, is “precipitating a colossal wave of development in psychological treatments” [S3]. Unlike the majority of psychotherapy models it is theoretically grounded, with a clearly articulated mechanism of change that makes it easy to operationalise across the full translational spectrum [S1]. In addition, the same model can be used to treat children, adolescents, young people and adults. New therapies based on the research have been developed, trialled and rolled out in practice for the treatment of specific groups. These include Adolescent Self-Harm (MBT-A), trialled in 2012 and now used by practitioners in England, Scotland, N. Ireland and 15 other countries [S4], with a further group-based adaptation being trialled in 2019 with good evidence of improved patient outcomes. Therapies for adults with Antisocial Personality Disorder ; children and families (MBT-C, MBT-F); and Adaptive Mentalization-Based Integrative Treatment (AMBIT), also use the mentalization approach to optimise functioning of mental health and social care teams caring for children. A mentalization-based parenting intervention, the Reflective Fostering Programme, was developed in collaboration with the NSPCC and implemented in 2017 in interventions with 28 families, with foster carers reporting benefits of reduced stress, foster child behavioural and emotional wellbeing and meeting self-defined goals [S5]. In 2020, the NIHR funded a full-scale RCT (GBP91,736,095.21) involving over 700 foster carers recruited from local authorities across England and Wales.

In addition to their own interventions, the team’s research has underpinned novel interventions developed by others for a range of clinical groups and at-risk populations. In the early 2000s colleagues at Yale developed Minding the Baby Home Visiting [MTB-HV] to serve at-risk young families, most of whom have high economic and social needs, as well as histories of adverse childhood experiences and developmental trauma. MTB-HV is both inspired by and grounded in the UCL work [S6]. Benefits of the programme (as demonstrated in two RCTs) include: lower rates of obesity in toddlers, more on-time paediatric immunization, lower rates of rapid subsequent childbearing, a trend toward lower rates of child protection referrals, higher levels of reflective parenting, higher rates of secure attachment, lower rates of disorganized attachment, and less disrupted teen mother-child interactions. At 1 to 3-year follow--up there were significantly lower rates of maternally reported externalizing disorders. Longer--term analysis of data from families with 4 to 9 year-old children indicates that parents who had received the intervention are more supportive and reflective, and that their children have fewer internalizing, externalizing, and total problem behaviours [S6].

MTB-HV was designated as an Evidence-Based Home Visiting model by the U.S. Department of Health and Human Services in 2014 (one of only 19 models with this federal designation). It has since been implemented by other sites in Connecticut and Florida; in total, over 250 families have been served by MTB-HV in the US, with approximately 200 families served in the UK through a collaboration with the National Society for the Prevention of Cruelty to Children and the Anna Freud Centre. It is currently being implemented in nine municipalities in Denmark, where well over 100 families have been served to date . Over 300 individuals have received intensive introductory training in MTB-HV, with over 800 registrants in recent months to webinars on the programme’s foundations of reflection and the core approaches used [S6].

The Lighthouse MBT Parenting Programme (developed by the Head of Attachment and Perinatal Services in Oxford Health NHS Foundation Trust [S3]) is an innovative, intensive programme that aims to prevent child maltreatment by promoting sensitive caregiving in parents. It is a direct translation of the UCL team’s attachment and reflective parenting framework and was developed in close collaboration with Fearon and Fonagy. Its creator describes it as “a lifesaving and life enhancing revolution in mental health” that re-conceptualises the mechanisms through which children come to be harmed in order to prevent such harm. Since 2015 more than 100 parents have been supported by the MBT programme through clinical services in Oxford, Wiltshire, Bath & North East Somerset and Buckinghamshire. The programme is now run in Australia, Germany, Poland, Ireland and Spain, and a RCT on six UK sites is testing roll out of the programme into social care [S3].

Improving national and international practice

The Anna Freud National Centre for Children and Families [S4] (one of the UK’s leading children’s mental health charities) strongly supports MBT-based therapies and has partnered with the UCL team to devise professional training to enable practitioners around the globe to incorporate the research into their practice. So far, a total of over 14,900 practitioners from 36 different countries have received training in one or more of the MBT family of interventions, with demand for training places outstripping supply and sessions regularly selling out within 24 hours of being advertised [S4]. Training sessions have been held in all the nations of the UK as well as the United States, Austria, Finland, Japan, Italy, The Netherlands, Germany, Chile, Spain, Hong Kong, Sweden and Canada [S4]. MBT training centres have been established in seven European countries (Belgium, Denmark, Germany, Ireland, The Netherlands, Poland and Switzerland), three North American locations (Boston, Los Angeles, Canada), Australia and New Zealand [S4]. These figures include MBT training for 143 Mental Health Service practitioners to increase the skill base of community mental health services as part of the NHS Long Term Plan launched by Health Education England in 2019 [S4].

In a recent follow-up survey of practitioners who had received training in the family of MBT interventions 87% of the 290 respondents reported that MBT had been either very useful or extremely useful to their practice, and 89% reported that MBT had been very beneficial or extremely beneficial to their patients/clients. [S7]

Fonagy led the establishment of NHS England’s Child and Young People’s Increasing Access to Psychological Therapies Under 5s programme in 2015 and Fonagy and Fearon made a significant contribution to developing the national training curriculum, which had attachment-based interventions at their core [S8]. Since its inception, 89 CAMHS Under 5s practitioners have undergone the training so they can use attachment-based interventions in their practice.

Informing Care and Mental Health Policy and Guidelines

MBT has been highlighted as an evidence-based intervention for BPD in the reviews of clinical guidelines for BPD in Denmark, Sweden and Switzerland [S9] in the impact census period. In 2015, Fonagy and Fearon were key members (Fonagy as Chair) of the NICE Guideline Development Group on Children’s Attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care, which published guideline NG26 in 2015 reflecting the UCL team’s input [S9]. Since 2015 Fearon has been a member of the expert advisory group for Big Lottery’s Better Start programme to support attachment and children’s socio-emotional development across the city of Blackpool, and shared learning from the programme with practitioners in Nottingham [S10]. He is also a trustee of Foundation Years Information and Research, a charity supporting evidence--based policy for the early years within Parliament [S10]. Fearon gave evidence to the All -Party Parliamentary Inquiry on the First 1001 Critical Days in 2015 [S10] and in 2017 Fonagy chaired NHS England’s Perinatal Parent-Infant Pathway group, of which Fearon was also a member, and they continue to advise NHSE on the implementation of the Long-Term Plan’s Perinatal Programme.