Using research on mentalising (theory of mind) to improve outcomes of suicidality, self-harm, violence and the functioning of social and mental health care teams
Submitting InstitutionUniversity College London
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
The pioneering work undertaken at UCL has had a major impact on clinical
practice for the treatment of self-harming, suicidal patients with a
diagnosis of borderline personality disorder and the techniques have been
drawn on in extensions to other common mental disorders including eating
disorder, substance misuse, and antisocial personality disorder. This
treatment, known as mentalisation based therapy or MBT, has since been
applied in a range of clinical settings including inpatient and outpatient
work in the UK and internationally. This case study presents two areas in
particular where our research has been applied: the treatment of
personality disorders, and in work with troubled adolescents.
Research on mentalising (theory of mind) led by Professor Peter Fonagy,
Professor Anthony Bateman and Dr Patrick Luyten has underpinned a
revolution in the treatment of people with borderline personality disorder
(BPD). Previously, there were no effective psychotherapies for BPD, which
is characterised by difficulties with emotion regulation and impulse
control, and unstable relationships and self-image. Only behaviour therapy
had an evidence base.
The research originated in the 1990s when Fonagy and colleagues
discovered that juvenile diabetics with poor insulin control struggled to
depict their social experiences accurately in mental state terms and that
this lack of `mentalising' capacity meant they often could not predict the
consequences of their own and others' actions. Listening to them talk
about their feelings and their understanding of feelings dramatically
improved their diabetic control (measured through glycosylated haemoglobin
levels). Clinical work both with these young people and BPD patients
suggested that failure of mentalising often followed a combination of
early neglect and childhood trauma.
This clinical discovery was informed by empirical research showing that
the development of theory of mind is mediated partly by social
relationships and not, as previously thought, only via genetic
transmission. When a person's ability to depict intention in mental state
terms is limited, they tend to act rather than communicate, and have
distorted expectations of others. We developed a manualised form of
psychodynamic psychotherapy known as Mentalisation Based Treatment (MBT)
specifically to address this deficit . MBT engages clients in
understanding their own and others' actions in realistic and accurate
mental state terms.
MBT has been subjected to rigorous empirical scrutiny that has
demonstrated its effectiveness and cost-effectiveness in a day hospital
setting. It has been shown to reduce hospitalisation, suicide and
self-harm by 55% compared to a control group, which showed limited change
or deterioration over the same period . An improvement in
depressive symptoms, a decrease in suicidal and self-mutilatory acts,
reduced in-patient days and better social and interpersonal function began
at six months and lasted until the end of treatment at 18 months. The
differences between MBT and comparison groups in suicidality, diagnostic
status, service use, use of medication, global functioning and vocational
status were maintained for 8 years following randomisation . An
analysis of health service utilisation costs for BPD showed that
mentalisation-based partial hospitalisation was no more expensive than
treatment as usual and resulted in considerable cost savings after
Although MBT was originally designed for BPD, we have also collaborated
with other researchers to adapt it for use with other clinical populations
including at-risk mothers of infants; eating disorders; depression;
trauma; drug addiction; and adolescent breakdown. In addition to being
used in a traditional two-person therapeutic context, MBT has also been
extended to a family context  and system-wide contexts (e.g.
schools ). RCTs have confirmed the effectiveness of adaptations
of MBT for BPD outpatients , aggression in school settings 
and self-harming adolescents . Currently MBT is the only
treatment that has been shown to have benefit in self-harming in
adolescence. Recently we have explored the neural mechanisms underpinning
the mentalisation deficit in BPD patients in an imaging study of trust and
social exchange where the participants were imaged simultaneously and
demonstrated deficits in interpersonal understanding . The
model is fully developed in .
References to the research
 Bateman A, Fonagy P. 8-year follow-up of patients treated for
borderline personality disorder: Mentalization-based treatment versus
treatment as usual. American Journal of Psychiatry. 2008 May;165(5):631-8.
 Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in
adolescents: A randomized controlled trial. Journal of the American
Academy of Child and Adolescent Psychiatry. 2012 Dec;51(12):1304-1313.e3.
 Twemlow SW, Fonagy P, Sacco FC, Gies ML, Evans R, Ewbank R. Creating
a peaceful school learning environment: A controlled study of an
elementary school intervention to reduce violence. American Journal of
Psychiatry. 2001 May;158(5):808-10.
 Bateman A, Fonagy P. Randomized controlled trial of outpatient
mentalization-based treatment versus structured clinical management for
borderline personality disorder. American Journal of Psychiatry 2009. 2009
 King-Casas B, Sharp C, Lomax-Bream L, Lohrenz T, Fonagy P, Montague
PR. The rupture and repair of cooperation in borderline personality
disorder. Science. 2008 Aug 8;321(5890):806-10. http://dx.doi.org/10.1126/science.1156902
 Fonagy P, Luyten P. A developmental, mentalization-based approach to
the understanding and treatment of borderline personality disorder. Dev
Psychopathol. 2009 Fall;21(4):1355-81.
Details of the impact
Since we first developed the MBT model of intervention, we have actively
disseminated the research through publications, presentations and training
programmes. As a result, thousands of clinicians are delivering
mentalisation-based therapies around the world.
The original treatment method is described in two books, with
applications of the method in different settings and with different age
groups and clinical populations described in two recent books which have
sold more than 10,000 copies to date [a]. Since 1999, Fonagy and
Bateman have given a substantial number of high profile presentations to
clinical groups. In the period 2008-13 this amounted to 55 keynote
speeches in the UK and 154 internationally. They have also given a number
of online presentations, which have been uploaded onto YouTube and have
received more than 20,000 hits [b]. We originally established
training courses at the Anna Freud Centre (AFC) in London. Courses are
very popular and 50 places sell out within 40 minutes of going online. To
cope with the huge demand we have now set up courses and training centres
across the world including at UCLA in Los Angeles, McLean Hospital in
Massachusetts, the Menninger Clinic in Houston, at the University of Oslo,
at the de Viersprong Centre in the Netherlands and at the University of
Geneva in Switzerland [c]. Since 2008, 1,703 practitioners have
been trained in basic MBT, 384 in advanced MBT and 49 in MBT skills. 369
practitioners have been trained in MBT-F, an application of the model to
work with families, and 148 in MBT-A. 159 practitioners have attended
other AFC courses including a mentalisation component [d].
Treatment of Borderline Personality Disorder
Before our research, Borderline Personality Disorder (BPD) was often
regarded as untreatable and was either not treated at all or poorly
treated through Accident & Emergency, inappropriate admissions to
inpatient wards, or by community team staff who often lacked the skills to
work with these patients, at great cost to the NHS (Personality
Disorder: No Longer a Diagnosis of Exclusion, NIMHE 2003). In 2002,
a questionnaire issued to all Trusts in England providing general adult
mental health services found that only 17% of trusts provided a dedicated
personality disorder service, and there was no consensus that there was a
need to cater for this group.
Mentalisation failure is now globally acknowledged to be a key concept in
understanding therapeutic change in patients with BPD. It is recommended
in clinical guidelines for BPD in a range of countries: in the UK it is
recommended by the National Institute for Health and Clinical Excellence
(CG 78); in the US, by the American Psychiatric Association; in Australia
by the National Health and Medical Research Council, as well as in
guidelines in Spain, Italy and the Netherlands [e]. A large number
of trusts in the UK now offer specific MBT services for people with PD, as
do at least eight major centres internationally (Harvard, Mt Sinai, UCLA,
Texas Med Centre, University of Geneva, University of Oslo, De Viersprong
in the Netherlands, New Zealand, Mexico, Sweden, Hungary) [f]. We
asked managers of a sample of the UK teams where some staff had been
trained in MBT to complete a survey on the use of the intervention in
their teams. The response from 22 teams (72% response rate) confirmed that
the treatment was being offered on average to 59% of patients in trained
settings with the interquartile range percentage between 50% and 72%.
MBT benefits patients not only by reducing self-harming and
self-injurious behaviour, but also by reducing the risk of iatrogenic harm
from psychotherapy. There is also evidence to suggest that MBT achieves
changes in social functioning, increasing the chance of meaningful
employment, full time education and reducing reliance on health and social
services. Families also benefit from the improved outcomes of their
parents and siblings after MBT [g].
The AMBIT approach: working with troubled adolescents
In 2010 we developed a mentalisation-based integrative treatment
framework for acute, intensive, home and community-based interventions for
highly troubled and socially excluded young people (Adolescent
Mentalisation-Based Integrative Treatment, or AMBIT) in which to date 750
professionals from more than 50 NHS and voluntary sector teams from across
the UK have been trained [d]. Practitioners are now using the this
approach in Edinburgh, Derry, Belfast, Plymouth, Norfolk and services in
London and the south east of England.
Evidence from services who have implemented the approach training
clinicians to focus on mentalisation in their face-to-face,
inter-professional and interagency work showed that the improvements in
practitioner skills that come with the AMBIT method make a difference to
the mental health and wellbeing of young people and their families. For
example, the Adolescent Multi-Agency Support Service (AMASS) in Islington,
north London, followed up 120 families with adolescents on the edge of
care and found that the number of out of home placements dramatically
dropped and there were significant reductions in aggression, violence in
the home and in family relationships, as well as substantially reduced
mental health needs [h].
In the London Borough of Camden, a new `transformation team' is
developing a locality-wide approach to troubled families [i]. The
Cambridgeshire Adolescent Substance Use Service (CASUS) adopted the AMBIT
approach in 2009. A recent assessment showed that it resulted in
reductions in substance use, improvements in psychological well-being, and
positive progress in associated peer group and familial problems [j].
We have also recently been commissioned to train 12 teams in Belfast
covering the entire Social Services Team, including inpatient care,
outreach teams and youth offending teams. These serve the whole of Belfast
and some of the surrounding area. Voluntary organisation MAC-UK, which
runs an anti-gang violence street-therapy youth programme, has also based
its approach on the AMBIT model [k].
In 2012, the AMBIT approach was awarded a Guardian/Virgin Media
Innovation Nation Award for Innovation in Collaboration [l]. The
citation said: "AMBIT's innovative open source treatment approach
radically improves knowledge sharing across NHS and voluntary sector
Sources to corroborate the impact
[a] Sales figures can be corroborated by the Director of Marketing &
Sales, American Psychiatric Press. Contact details provided.
- Allen JG, Fonagy P, Bateman AW: Mentalizing in clinical practice.
Washington, DC, American Psychiatric Publishing, 2008.
- Bateman AW, Fonagy P, editors. Mentalizing in Mental Health Practice.
Washington: American Psychiatric Press, Inc; 2012.
[b] Links to YouTube presentations.
[c] Examples of clinics worldwide offering training in MBT:
[d] Numbers of participants can be corroborated by the Short Courses and
Conference Coordinator. Contact details provided. Information about our
courses is available here:
[e] Guidelines recommending MBT for BPD:
[f] Examples of clinics worldwide offering MBT as a treatment:
[g] Fonagy P, Bateman A. Progress in the treatment of borderline
personality disorder. Br J Psychiatry. 2006 Jan;188:1-3. http://dx.doi.org/10.1192/bjp.bp.105.012088
[h] The AMASS team have been trained and are using the AMBIT approach.
This can be corroborated by the Clinical Director, Islington CAMHS.
Contact details provided. Positive results for the service are outlined in
the Executive Summary of the AMASS evaluation 2007-2012. Copy available on
[i] The Transformation Team is part of London Borough of Camden. See the
following presentation (from the Camden Safeguarding Children Board's
website) which references the roll-out of the AMBIT approach: http://bit.ly/188eS6N.
The Transformation Team training manual can be seen here: http://ambit-camden.tiddlyspace.com/
[j] Positive outcomes can be verified by the CASUS service doctor.
Contact details provided. Information on the use of AMBIT by CASUS can be
seen here: http://bit.ly/1gfbqqU
[k] Can be corroborated by the CEO, Music and Change UK. Contact details
provided. See also their AMBIT page: http://ambit-mac.tiddlyspace.com/