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MBIT is a manualised mentalization-based approach to working with hard to reach young people at risk of a wide range of life adversities including severe mental illness, substance misuse, family breakdown, school exclusion, offending and homelessness. The on-line manual (www.tiddlymanuals.com) describes how Adolescent Mentalization-Based Integrative Therapy (AMBIT) is a systemic intervention requiring attention to four different domains of intervention simultaneously; much emphasis is placed on the support systems for workers to maintain this balance in what are often chaotic working conditions. The purpose of this paper is to illustrate how these four main components of the AMBIT approach link together in actual clinical practice.

The authors illustrate the core techniques of the AMBIT approach, namely, “working with your client”, “working with your team”, “ working with your network” and “learning as a team” with a series of case vignettes, demonstrating the inter-relationship of these components rather than seeing them as separate strands.

A range of mentalization-based techniques such as “thinking together”, mentalized formulation, “disintegration grids” and web-based manualising are described and illustrated in relation to a series of case vignettes in order to address barriers to effective practice. The vignettes emphasise how these components must be linked together and held in balance, and how easily they become disconnected in working with young people’s ambivalent or even hostile relationships to help.

First, developing a shared, mentalized formulation of a young person’s difficulties is an important aspect of working with highly troubled young people. Second, mentalizing is a relational process and is easily disrupted, for both workers and young people, by raised anxiety and affect, a common feature of working with this client group. AMBIT provides specific methods, for example, “thinking together” for supporting the mentalizing of individual workers in their team in an explicit way. Third, workers from different agencies may often find it difficult to make sense of each other’s behaviour and decision making. AMBIT proposes the use of a mentalizing approach to this difficulty using a technique called a disintegration grid. Finally, AMBIT proposes a new practitioner focused approach to manualising as a method by which a team can become more explicit about its methods of working in order to support systematic practice and evaluate outcomes.

The innovative AMBIT approach proposes that clinicians need to attend to team and network relationships at least as much as their relationship with the client, in addition to adopting a stance of learning as a team from their casework. A high level of clinical skill is needed to support a team to achieve this balanced approach to casework. This work is of interest to all multi-disciplinary teams working with hard to reach young people.

Previous research indicates that mentalisation-based treatment (MBT) is an effective therapeutic programme for difficulties associated with borderline personality disorder (BPD). The purpose of this paper is to explore service user experiences of the therapy.

Seven adults (five female and two male), recruited via three NHS trusts, were interviewed. Participants were attending intensive out-patient MBT for BPD between 3 and 14 months. Data were analysed using interpretative phenomenological analysis.

Participants experienced the group component of MBT as challenging and unpredictable. They highlighted developing trust as key to benefitting from MBT. This was much more difficult to achieve in group sessions than in individual therapy, particularly for those attending MBT for less than five or six months. The structure of MBT generally worked well for participants but they identified individual therapy as the core component in achieving change. All participants learned to view the world more positively due to MBT.

Enhanced mentalisation capacity may help address specific challenges associated with BPD, namely, impulsivity and interpersonal difficulties. MBT therapists are confronted with the ongoing task of creating a balance between sufficient safety and adequate challenge during MBT. Potential benefits and drawbacks of differing structural arrangements of MBT programmes within the UK are considered.

Learning about service user perspectives has facilitated an enhanced understanding of experiences of change during MBT in addition to specific factors that may impact mentalisation capacity throughout the programme. These factors, in addition to implications for MBT and suggestions for future research, are discussed.

Effective treatment of patients with severe psychopathy is very difficult to achieve. This conclusion may be drawn from an extensive examination into the usage of the term ‘psychopathy’ in scientific research literature, in theoretical development from various psychological schools of thought, in the practice of therapy and in assessment. The central issue for the authors of this article is the inability of severely psychopathic patients to commit to the patient‐therapist relationship. Attachment theory and mentalisation‐based treatment are used here to define the cause and nature of this inability, which is incurred in very early childhood. These two models can aid in the development of more dynamic definitions of psychopathy, better suited to dynamic therapy formats.The ways in which psychopathy is defined partly account for a number of problems encountered in the practice of therapy. The authors assume that the treatment of psychopathy should be interactional and should match patients' individual levels of psychological development and mentalisation; highly psychopathic patients often perceive others as objects, ie. as part of the context, not as subjects, ie. autonomous personalities.The authors propose to conduct further research in order to verify the validity of their hypothesis. They also put forward a number of suggestions for therapy formats with a view to establishing effective working relationships with psychopathic patients.

The purpose of this paper is to examine a gap in knowledge about the interaction between mentalizing skills and social inclusion activity immediate after completing an intensive mentalization-based treatment (MBT) program.

Lived experience was explored through the use of timelines, repeated cycles of audio-recorded focus groups and inductive thematic analysis.

Destructive cycles between self-hatred and social-exclusion were first disrupted by MBT because people felt understood. Being understood reduced self-hatred which was an essential precursor for attempting new forms of mentalizing in social interactions. This process was challenging but continued as a virtuous cycle after treatment finished.

The sample was limited because at three, it was small. However, the study was co-produced between professional and service users at all stages. Lived experience was carefully explored in depth and triangulated between three people. The authors acknowledge too that they have reflected on experience within only one to three years after MBT finished. Future studies might usefully replicate the methodology to trace experience up to the eight year follow up point undertaken by Bateman and Fonagy (2008).

There is a great sense of loss for service users when therapy ends and that ending needs to be managed on both sides. Service users start to acquire powerful new skills and thought processes at the end of therapy. While this may not be overwhelming, they will not be used to them and so it helps when therapists help service users think about their plans and ideas for things they want to do or changes they might make in their lives.

While supporting quantitative data about the outcome of therapy, this study offers the type of qualitative detail about how the psychological and social interact post-therapy, which can inform the successful management of those processes by those involved.

This paper aims to explore the potential utility of Identity Structure Analysis (ISA) in single-case and group-level outcome and process evaluations.

A study was conducted to evaluate mentalization-based therapy by using ISA and its linked framework software, Ipseus. Ten patients with borderline personality disorder and substance use disorder were involved in the study. ISA/Ipseus was administered prior to and at the completion of the treatment. Five-year follow-up data, comprising behavioural indicators, were also collected and compared to ISA/Ipseus results.

Improvements occurred in the evaluation of stressful, demanding and emotionally burdening situations. Evaluations on concerned others also improved, together with progress in self-reflection. Changes in the evaluation of recovery-related themes were less salient. On a case level, changes in the self-states and role models were consistent with the results of the five-year-follow up data. An initial crisis state seems suggestive of progress, while initial defensive positions with high positive self-regard, of stagnation.

ISA/Ipseus, integrating the benefits of qualitative and quantitative approaches in evaluation, is a potential method to explore the complexity of identity changes during therapy.

The mentalisation based therapeutic community (MBTC) is a group experience which promotes the acquisition of the capacity to mentalise. Members of the community gain greater emotional stability and psychological robustness. The paper aims to discuss these issues.

MBTC works with three theoretical principles: the intrapsychic, interpersonal and social. It is a slow open group where each member completes a ten-week course. The approach is deliberately non-interpretive with an emphasis on personal responsibility and accountability in order to promote clarity of mind.

The authors’ experience is that the model engages group members with few drop outs.

The combination of mentalising and the use of therapeutic community principles within in MBTC has enhanced outcomes for group members.

This study aims to describe the effectiveness of two arms of a personality disorder service: a modified mentalization based therapy (MBT) day programme and an open access service‐user network (SUN) support. Both arms utilised therapeutic community principles in service delivery.

Personality disorder subtypes for all patients entering the modified MBT programme were diagnosed at a clinical assessment interview and corroborated through use of a standardized semi‐structured interview (SCID II). All patients were also allowed open access to a service user network community support group (SUN Project). Outcome measures were applied at baseline, mid‐therapy and end of therapy and included self‐report measures of depression, anxiety, general symptom distress, interpersonal function, social adjustment and patient satisfaction. Clinician‐rated measures of general health and functioning were also used. Data analysis used paired sample T‐tests and Wilcoxon Rank Sum tests, depending upon the assessment of parametric or nonparametric tests of trend. The open access nature of the SUN Project demanded a different data collection method. All members received a Standardized Assessment of Personality – abbreviated scale (SAPAS). Two validated empowerment questionnaires were sent to all SUN members that had achieved six months of membership: the first relating to the six‐month period before joining the SUN and the second to the six‐month period after joining the SUN Project. Paired sample T‐tests were used to compare sets of empowerment scores.

Patients who completed 18 months of MBT‐tc treatment showed a statistically significant improvement on the clinician‐administered measures relating to psychological, social and occupational functioning, compared to baseline. Patients also reported statistically significant improvement in using the brief symptom inventory. All SUN members perceived significant increases in empowerment across the five score subscales. No completed suicidal acts were recorded within the period of analysis within either arm of the service.

An integrated therapeutic community day service appears to afford improvements in perceived empowerment and symptom severity for patients. Further data collection with a larger sample is needed to clarify whether these outcomes support the development of a wider integration of the relatively low cost SUN Project model and MBT within therapeutic communities.

Following on from an earlier published study, the purpose of this paper is to further clarify with a larger sample and over a longer timescale of two years the effect of a therapeutic-community informed personality disorder service intervention upon psychiatric in-patient bed use. The service integrates two psychoanalytical models; a mentalization-based treatment (MBT) and a service user network (SUN) model.

The number of psychiatric bed days used by patients attending each arm of the service model (SUN and MBT) was collated using the electronic patient records system. Bed use in the six-12-18-and 24-month period before each patient started treatment was compared with bed use in the same periods after starting treatment.

There appeared no significant increase after intervention in the group of patients using no psychiatric beds prior to intervention. Bed use in the second group (those using beds prior to intervention) appeared significantly reduced by six months and the reduction continued to prove significant at 12 and 18 months post-intervention. In relation to the component arms of the service, a significant reduction in bed use was seen in each of the MBT and SUN interventions at six, 12, 18 and 24 months after commencement. However, due to the small sample sizes, these results lacked sufficient power to afford a meaningful comment upon the effect of component arms.

Intervention by the TC informed two-model integrated personality disorder service had a statistically significant effect overall on reducing bed use, which was maintained at six and 12 months.

The paper supports the finding of the authors’ previous study; a therapeutic model of care that significantly reduces psychiatric bed use. That the reduction in psychiatric bed use continues to further appear highly significant at 18 months suggest that our service has an enduring effect upon inpatient psychiatric resources.

The paper describes a unique model of care currently successfully employed in the therapeutic management of people with personality disorder. The model is replicable and effective and offers some possibilities for the development of therapeutic-community informed practice.

The Service User Network (SUN) follows the ethos of the therapeutic community and draws upon coping theory and psychoanalytic understanding of personality disorder to provide a supportive group-based resource to adults struggling to cope. The paper aims to discuss this issue.

The original SUN Project has been successfully replicated, with the further addition and integration of psychoanalytically – derived approaches to the treatment of personality disorder within that replication. The most notable theoretical additions come from the mentalization-based therapy model and the Independent School of Psychoanalysis. In this paper, the author expands the original description of the model to include these theoretical additions, together with a fuller account of the original tenets of the treatment paradigm than previously described.

This provides an outline of a network-based therapy (NETBT) as a first stage in manualizing the model, as well as extending its use to support adolescents.

Network-based therapy is a new, evolving group treatment for adolescents and adults struggling to cope.

Borderline personality disorder (BPD) is a debilitating illness characterised by a pervasive pattern of emotional instability, interpersonal difficulties and impulsive behaviour in association with repeated self-injury and chronic suicidal ideation. People diagnosed with BPD also have high rates of co-occurring psychopathology, including disorders associated with disturbed impulse control, such as substance use disorder (SUD) and disordered eating behaviours. The co-occurrence of BPD and impulse control disorders contributes to the severity and complexity of clinical presentations and negatively impacts the course of treatment and recovery. This study qualitatively documents aspects of the lived experience and recovery journeys of people diagnosed with BPD and co-occurring SUD and/or disordered eating. This study aims to identify similarities with respect to themes reported at different stages of the recovery process, as well as highlight important factors that may hinder and/or foster recovery.

In-person, in-depth, semi-structured interviews were conducted with 12 specialist service consumers within a clinical setting. Ten women and two men (22–58 years; mean: 35.5 years) were recruited. Interview transcripts were analysed using thematic analysis principles.

As expected, participants with co-occurring disorders experienced severe forms of psychopathology. The lived experience descriptions aligned with the proposition that people with BPD engage in impulsive behaviours as a response to extreme emotional states. Key emergent themes and sub-themes relating to recovery comprised three domains: factors hindering adaptive change; factors assisting adaptive change and factors that constitute change. An inability to regulate negative affect appears to be an important underlying mechanism that links the three disorders.

This study highlights the potential shortcomings in the traditional approach of treating co-occurring disorders of BPD, SUD and eating disorders as separate diagnoses. The current findings strongly support the adoption of an integrative approach to treating complex mental health issues while concurrently emphasising social connection, support and general health and lifestyle changes.

The findings of this study contribute to the burgeoning BPD recovery literature. A feature of the current study was its use of in-depth face-to-face interviews, which provided rich, many layered, detailed and nuanced data, which is a major goal of qualitative research (Fusch and Ness, 2015). Furthermore, the interviews were conducted within a safe clinical setting with engagement facilitated by a clinically trained professional. There was also a genuine willingness among participants to share their stories in the belief that doing so would inform effective future clinical practice. Their willingness and engagement as participants may reflect their progress along the path to recovery in comparison to others with similar diagnoses. Finally, most of the interviewees were engaging in dialectical behavioural therapy (DBT)-style therapies; two were receiving mentalisation-based therapy treatment, and most had previously engaged in cognitive behavioural therapy or acceptance and commitment therapy-based approaches. The predominance of DBT-style therapy may have influenced the ways that themes were articulated. Future studies could supplement this area of research by interviewing participants receiving therapeutic interventions other than DBT for the treatment of BPD and heightened impulsivity.