Mentalization-based treatment

Mentalization-based treatment (MBT) is a form of psychodynamic psychotherapy, developed and manualised by Peter Fonagy and Anthony Bateman. MBT was designed for individuals with borderline personality disorder (BPD), who suffer from disorganised attachment and allegedly failed to develop a mentalization capacity within the context of an attachment relationship. Fonagy and Bateman claim mentalization is the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that BPD patients increase mentalization capacity which should improve affect regulation and interpersonal relationships.

The treatment should be distinguished from and has no connection with the more common Mindfulness-Based Stress Reduction (MBSR) therapy developed by Jon Kabat-Zinn.

More recently, a range of Mentalization-Based treatments, using the "mentalizing stance" defined in MBT but directed at children (MBT-C), families (MBT-F) and adolescents (MBT-A, and for chaotic multi-problem youth, AMBIT (Adolescent Mentalization-Based Integrative Treatment)) has been under development by groups mainly gravitating around the Anna Freud Centre.

Goals

The major goals of MBT are: (1) better behavioral control, (2) increased affect regulation, (3) more intimate and gratifying relationships and (4) the ability to pursue life goals. This is believed to be accomplished through increasing the patient’s capacity for mentalization in order to stabilize the client’s sense of self and to enhance stability in emotions and relationships.

Focus of treatment

A distinctive feature of MBT is placing the enhancement of mentalizing itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalization. The focus should be on the present state and how it remains influenced by events of the past. Other core aspects of treatment include bearing in mind patient’s deficits, using transference, retaining mental closeness, and working with current mental states. Transference under this model is distinct from the classical understanding of this term.

Treatment procedure

MBT is offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist activates the attachment system through a range of largely unconscious techniques. Activation occurs through the elaboration of current and past attachment relationships, the therapist’s encouragement and regulation of the patient’s attachment bond with the therapist and the therapist’s attempts to create attachment bonds between members of the therapy group.

Mechanisms of change

The safe attachment relationship with the therapist provides a relational context in which it is safe for the patient to explore the mind of the other. At the same time the individual is encouraged to mentalize, to experience and confront negative affect and to elaborate and review issues of morality. The simultaneous activation of the attachment system and development of psychological processes move the pattern of arousal within these systems closer to that characteristic of secure attachment and increase the mentalizing capacity.

Efficacy

Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder and the results have compared favorably with existing treatments. The lasting efficacy of MBT was demonstrated in an 8-year follow-up of MBT versus treatment as usual. Similar results were found in an 18-month follow-up study in which subjects were randomly assigned to an MBT treatment condition versus a Structured Clinical Management (SCM) treatment. (See below)

Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder. Am J Psychiatry 2009; 166:1355–1364.

8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual. Am J Psychiatry 2008; 165:631-638.

Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry. 2001 Nov;158(11):1932-3.

Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 2001 Nov;158(11):1932-3.

References

• Bateman, A.W., Fonagy, P. (2004). Mentalization-based treatment of BPD. Journal of personality disorders, 18, 36-51.
• Bateman, A.W., Fonagy, P. (2008). Comorbid antisocial and borderline personality disorders: mentalization-based treatment. Journal of clinical psychology, 64, 181-194
• Fonagy, P., Bateman, A.W. (2006). Mechanisms of change in metalization-based treatment of BPD. Journal of clinical psychology, 62, 411-430.
• Midgley N., Vrouva I. (Eds.) (2012). “Minding the Child: mentalization-based interventions with children, young people and their families.” Routledge, 2012

Further reading

• Allen, J.G., Fonagy, P. (2006). Handbook of mentalization-based treatment. Chichester, UK: John Wiley.
• Allen, J.G., Fonagy, P., Bateman, A.W. (2008) Mentalizing in clinical practice. Arlington, USA: American Psychiatric Publishing
• Mentalization Based Therapy (John M. Grohol, PsychCentral, March 17, 2008)