How to measure treatment fidelity
and
guidelines for mentalization-based
group therapy
Sigmund Karterud
University of Oslo
Oslo University Hospital
Dept. for personality psychiatry
Treatment integrity
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Do the therapist follow the treatment guidelines
or manual with respect to treatment targets and
mode of dealing with treatment targets?
In short: Do the therapist practice MBT («on
model») or is he/she doing other things?
Measures of treatment fidelity is neccessary for
claims of causality («the effects were due to the
specific ingredients of MBT») and for processoutcome research
Treatment guidelines and
treatment manuals
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Treatment guidelines are more loosely defined
Treatment manuals should be specified in a way
that make treatment fidelity measurable.
Work with treatment manuals favor theoretical
and clinical clarifications, i.e. construct
validation. E.g.: Exactly what qualifies as a
psychic equivalence phenomenon and how are
the appropriate interventions that aim at
modifying it?
Manuals for MBT
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In cooperation with a Nordic group for MBT, items
were identified, described and tested (based upon
theory, clinical experiences and extensive video studies)
and published:
Karterud & Bateman (2010): Manual for MBT and
MBT adherence and competence scale. Version
individual therapy
Karterud & Bateman (2011): Manual for mentalizationbased psychoeducational group therapy
Karterud (2012): Manual for MB group therapy and
MBT-G adherence and competence scale
The 17 items of MBT Adherence and Competence
scale
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Engagement, interest and warmth
Exploration, curiosity and notknowing stance
Challenging unwarranted beliefs
Adjustment to level of mentalizing
Regulating arousal
Stimulating mentalization through
the process
Acknowleding good mentalizing
Dealing with pretend mode
Dealing with psychic equivalence
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Focus on emotions
Focus on emotions and
interpersonal events
Stop and rewind
Validation of emotional reactions
Focus on transference and the
relation to the therapist
Use of countertransference
Monitoring own understanding and
correcting misunderstandings
Integrating experiences from
concurrent group therapy
A reliability study of the MBT-ACS (Karterud et al., in press)
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Design: 9 therapists delivered 2 sessions each,
i.e. 18 sessions that were rated by 7 raters
Analyzed by Generalizability theory and D-study
Overall reliability for 2 raters adherence = .60
Overall reliability for 2 raters competence = .68
Item
Adherence 2R
Competence 2R
Integrating group experiences
.88
.71
Relation to therapist
.74
.67
Exploration and not-knowing stance
.60
.63
Focus on interpersonal affects
.57
.61
Engagement and warmth
.54
Adjustment to level of mentalizing
.51
Challenging unwarranted beliefs
.52
.35
Focus on affects
.51
.61
Dealing with psychic equivalence
.43
.33
Stimulating mentalization
.42
.63
Acknowleding good mentalizing
.41
.26
Use of countertransference
.37
.22
Regulating arousal
.31
.31
Validating own understanding
.23
.43
Validatiing patient’s feelings
.23
.28
Stop and rewind
.10
.21
Dealing with pretend mode
.07
.25
Sources of variation
(percentage of total variation)
Item
Between
therapist
variation
Variation in
how much
raters
observe
Therapist
variation
across
sessions
Variation in
raters
ranking of
therapists
Residual
(including
error)
variance
Integrate
group
0
6
78
0
16
Relation to
therapist
45
6
15
0
35
Pretend
mode
3
6
0
24
67
Stop and
rewind
3
25
2
8
62
Mentalization-based group therapy
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Similar development as for individual MBT
Anthony Bateman & the Nordic group as a
think tank
Resulting in a (larger) manual and corresponding
MBT-G adherence and competence scale
The whole idea is providing guidelines PLUSS
means for testing if, and to what degree, these
guidelines are followed («on model»).
Aims of the guidelines
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To provide a theory, structure and techniques
for realizing the aim of «the group as a training
arena for mentalization»
Pitfalls with groups with many BPD patients:
Chaotic, regressive, overwhelming, pendulating
between psychic equivalence and pretend mode
functioning.
 How to provide structure and control of the group
while at the same time avoiding «individual therapy
in group», but create a collective reflective culture?
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Quality of object relations and
outcome of group psychotherapy
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Piper et al. (2007): The mean level of QOR in a
group predicts outcome for the inidividual
members.
Crucial for group composition. I.e. The best way
to improve outcome is to add better functioning
patients to psychodynamic groups.
Clinically counterintuitive to compose groups
with BPD patients only.
Solution: Change therapeutic strategy. Abolish
free associative group therapy. Alternatives?
9 group specific items in the manual
for MBT-G
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Monitoring the group boundaries
Regulating the group phases
Initiating and fullfilling «mentalizing turntaking»
Engaging the group members in mentalizing (external) events
Identifying and mentalizing events in the group
Care for the group and its members
Practicing authority
Assisting the group in discussions of group as a whole
relevant themes
Efficient and modelling cooperation with the cotherapist
And the following 10 items, adjusted from the
individual MBT manual
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Engagement, interest and
warmth
Exploration, curiosity and
not-knowing stance
Challenging unwarranted
beliefs
Regulating arousal
Acknowleding good
mentalizing
Dealing with pretend mode
Dealing with psychic
equivalence
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Focus on emotions
Stop and rewind
Focus on the relation
between patients and
therapists
Crucial design elements
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Psychoeducation on aim, task and role:
 Aim: Enhance mentalization in close relationships through group
participation
 Task: 1) Bring in relevant (interpersonal) events (of mentalizing failures or
successes) for exploration in the group and explore group interpersonal
events. 2) Attach to the group/members.
 Role: Explore external and internal events in a mentalizing mode
Compensating for the individual’s lack of self cohesion: Strengthening the
group cohesion by «minding the group» and opening each group session by
references to last session and the individual’s concern therein.
Authority with respect to structure and group values. E.g. stop and explore all
kinds of destructiveness in the here and now. Expect cooperation and defend
a communicational ethics (Habermas). The therapist is not-knowing with
respect to mental state, but knows and defends group values.
Within these boundaries: consistently adhering to a mentalizing mode
Crucial design elements
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A priviledged focus on interpersonal events neccessitates
allocation of space and time, e.g. a kind of (mentalizing)
turntaking.
MB group therapy is not free associative, but still dynamic, e.g.
working through the group process
The opening phase: 1) building bridges to last meeting, 2) who
has something to explore? (responsibility and reflection)
Mentalizing turntaking: 1) Enhancing narrative competencies
(clarifications: who, when, what?) 2) Identifying the mentalizing
problems, 3) Exploring these problems, 4) Closing the turn
(ideally stimulating reflection: did you/we learn anything?)
The crucial success element
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To stimulate and engage the group members in
mentalizing explorations (= creating a training arena for
mentalization)
The therapists should not do the mentalizing work on
behalf of the patients, but contain, assist and cooperate
(e.g. by model relation to cotherapist: Instead of making
an interpretation, ask the cotherapist!)
The 19 items contain detailed descriptions on how
these ideals can be realized and the traps avoided, and
clinical vignettes for each item on high versus low
achievement.
Similarities and differences with
psychodynamic group therapies
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Similarities: Developing and working through a safe, engaged and exploratory group
culture, pendulating between «there and then» and «here and now»
Differences:
 All patients in the borderline range
 MBT-G is timelimited (1,5-2 years)
 MBT-G is a conjoint therapy
 The aim, task and role is better defined in MBT-G
 MBT-G is not free associative
 MBT-G structures the group, e.g. turntaking
 MBT-G has interpersonal events as priviledged focus
 Therapists in MBT-G is more active in a specified way
 MBT-G is less tolerant of turbulence and chaos
 Therapists in MBT-G do less group-as-a-whole and individual interpretations
 Therapists in MBT-G are more transparent (e.g. relation to cotherapist)
Common pitfalls
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Therapists do not «mind the group», but starts with a round on
«how are» the various members.
Therapists create a dependency group (in Bion’s term) by taking
too much responsibility for the process and accepting (silently)
and acting on omnipotent projections, i.e. do not succeed in
engaging the patients in engaged explorations
Therapists adopt the guidelines in a mechanical way, not
practicing the mentalizing stance
Therapists are helpful by clarifying events, but do not identify
mentalizing failures and do not explore them
Therapists do not stand up for the norms of a secure base, but
allow destructive (verbal) behavior
Therapists do not intervene in pretend mode sequences
Concluding remarks
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It is possible to create engaged and vital and
non-destructive groups with a low dropout
frequency, with typical acting-out prone
borderline patients
It is facilitated by
a certain structure, and
 caring, authoritative, engaged therapists that exhibit
model behavior through a cosistent mentalizing
stance and a trustful and transparent cotherapist
relationship
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