Mentalization Based Treatment
Brief Historic Overview
Mentalization Based Treatment (MBT) was developed in the early 90s, by Professor Anthony Bateman and Professor Peter Fonagy, for the management of patients with Borderline Personality Disorder (BPD). It is a psychodynamically informed therapy, rooted in attachment theory and psychoanalytic concepts - mainly object relations theory. MBT was developed at St Ann’s Hospital in London, United Kingdom, and its main training centre is Anna Freud National Centre for Children and Families.
Initially developed for BPD, MBT is now being used for a wide range of disorders, such as Eating Disorders, Depression, Addictions and Antisocial Personality Disorder (ASPD).
The focus of MBT is to enhance patients mentalizing capacity. According to Bateman and Fonagy (2010), “Mentalization is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes.” In other words, it is the capacity to think about one’s own and others’ mental states (thoughts, emotions, needs) and their impact on interpersonal interaction. It is about awareness of the self and the other as an independent human being. This capacity is deeply dependent not only on individual genetic factors, but also on the quality of early object relationships and attachment. Bateman and Fonagy (2010) argued that BPD patients have a fragile mentalizing capacity – i.e. they have difficulty in thinking about their thoughts, feelings, desires and actions, inadequate emotional regulation as well as inconsistent and inaccurate perceptions of self and others. These make them vulnerable to experience very painfully the common difficulties in social and interpersonal interactions, resulting in unstable and chaotic relationships.
The central feature of MBT is to establish a safe attachment environment within which internal states can be represented, thought about and discussed and thereby the patient’s mentalizing capacity can be developed and strengthened, resulting in patients being better able to manage their intense emotional states and to respond to life’s challenges in more adaptive ways.
Mentalization and overlapping terms
The concept of mentalizing is complex, has particular boundaries and refers to phenomena that are fundamental to human interaction. It is therefore not surprising that it shares similarity with some other terms. We will give some terms here to help differentiating the concept of mentalizing:
Attending to mental states in self and others, and interpreting behaviour accordingly.
Theory of mind
Focusses on cognitive development and provides a conceptual framework for mentalizing.
Focuses primarily on cognition in the self.
Focuses on the present and is not limited to mental states.
Focuses on others and emphasizes emotional states.
Pertains to mentalizing of emotion in self and others.
Characterizes disposition to mentalize - very broadly defined.
Mental content that is the product of mentalizing process.
Theory of mind term that applies to others and focuses on cognition, thus leaving out self and emotions. The term also has connotations of telepathy delusions - ‘knowing’ the other’s thoughts directly.
Antithesis of mentalizing; the term originally was employed to characterise autism.
MBT draws on plenty of research in attachment, emotions and neurobiology, highlighting the importance of the emotional component in thinking, emotion processing and behaviour. It is a very persuasive and coherent treatment model, suggesting that mentalization is the central process of all effective psychotherapies. Moreover MBT aims to build on already acquired therapeutic skills rather than be just a treatment modality on its own. Psychodynamic, cognitive, systemic and other therapists can all learn and incorporate MBT in their practice. If one wants to implement MBT protocols - they are readily available. It is a well researched treatment modality - particularly in Borderline Personality Disorder, now showing also evidence of efficacy in treating other common psychiatric conditions.
The treatment is organised in one-team model and is a combination of group and individual therapy. The intensity varies between daily sessions to a two-session-a-week basis, for up to 18 months. Adults, children and young people can have access to MBT.
The MBT is a relatively new psychological treatment and as such more research is required to clarify its efficacy, although there is already evidence that it can be beneficial for clinicians who have a framework when working with patients with BPD (Daubney and Bateman, 2015). Randomised clinical trials have shown that MBT intervention can decrease psychiatric symptoms in patients with personality disorders, such as suicidality and hospitalisation (Bateman and Fonagy, 2009). Vogt and Norman (2018) published a systematic review of evidence of the efficacy of MBT in the treatment of BPD. They included 14 papers and the results showed superior or equal results in the management of mental health symptoms however the authors high-lightened the need for better quality papers as well as the limited knowledge in the MBT mechanisms.
Comment from an expert
“The failure to mentalize creates a kind of psychic version of an auto-immune deficiency state that leaves these individuals extremely vulnerable to later sometimes quite brutal social environments.” Psychotherapy for borderline personality disorder Mentalization-based treatment.
Anthony Bateman and Peter Fonagy
Comments from trainees
“The most useful theory we have been taught so far.”
“I will definitely use MBT principles in my practice. They make sense”.
Anonymous feedback from trainees in General Practice (GP) rotating in Psychiatry, who received a pilot session of teaching on basic MBT principles.
Courses offered in Europe and Links to Societies
Online MBT Training at Anna Freud Centre. The link will open a one-page PDF with instructions.
The Center for Mentalization - www.centerformentalization.com
Institut for Mentalisering - www.institutformentalisering.dk
MBT-F (Mentalizing Based Treatment for Families). In collaboration with the Anna Freud National Centre for Children and Youth.
Basic Training and Practitioner Level Training at University of Heidelberg
Basic Training in Thessaloniki
International MBT centre in Dublin.
Gruppo Italiano MBT - www.gimbt.it
MBT Netherlands - http://www.mbtnederland.nl
Norwegian Institute For Mentalizing - www.inst-mbt.no
Basic training in Poznan
Mentalización - www.mentalizacion.org
Switzerland, France and Belgium
Basic training in Paris, Brussels and Geneva:
Réseau Francophone des Thérapies Basées sur la Mentalisation - mentalisation.org
University of Geneva: International MBT centre - mentalization.unige.ch
Anna Freud National Centre for Children and Families - www.annafreud.org
Other international centres can be found in Australia and the USA. Training is also offered in Mexico.
Research study into MBT as an intervention for children in foster care. https://www.ucl.ac.uk/pals/were-starting-first-research-study-mbt-intervention-children-foster-care
Mentalization for Offending Adult Males (MOAM). A randomised controlled trial, across 13 sites. Men diagnosed with ASPD receive treatment in weekly basis in the form of group MBT. This is a five-year project which started in 2016. https://tavistockandportman.nhs.uk/research-and-innovation/our-research/research-projects/mentalization-based-treatment-antisocial-personality-disorder/
Ongoing research projects on MBT in Norway. http://sigmundkarterud.no/index.php/hva-er-mbt/information-in-english and https://www.annafreud.org/media/4468/mbt-research-2016-karterud.pdf.
References and Recommended Resources
Espen Folmo. n.d. Mentalizing and MBT. Accessed 22 June 2019. https://www.youtube.com/watch?v=kxUHILbZNaY.
Bateman, A. W. Mentalization Based Treatment: Clinical Training Slides. http://www.ucl.ac.uk/psychoanalysis/people/bateman
Bateman, Anthony W., Dawn Bales, and Joost Hutsebaut. 2014. A Quality Manual for MBT. https://www.annafreud.org/media/7863/quality-manual-2018.pdf.
Bateman, Anthony, and Peter Fonagy. 2010. ‘Mentalization Based Treatment for Borderline Personality Disorder’. World Psychiatry 9 (1): 11.
Bateman, Anthony, and Peter Fonagy. 2016. Mentalization-Based Treatment for Personality Disorders: A Practical Guide. Oxford University Press.
Daubney, Michael, and Anthony Bateman. 2015. ‘Mentalization-Based Therapy (MBT): An Overview’. Australasian Psychiatry 23 (2): 132–135. doi:10.1177/1039856214566830.
Vogt, Katharina Sophie, and Paul Norman. 2018. ‘Is Mentalization-Based Therapy Effective in Treating the Symptoms of Borderline Personality Disorder? A Systematic Review’. Psychology and Psychotherapy: Theory, Research and Practice. doi:10.1111/papt.12194
Allen, Jon G., Peter Fonagy, and Anthony W. Bateman. 2008. Mentalizing in Clinical Practice. American Psychiatric Pub.
Bateman, Anthony, and Peter Fonagy. 2009. ‘Randomized Controlled Trial of Outpatient Mentalization-Based Treatment versus Structured Clinical Management for Borderline Personality Disorder’. American Journal of Psychiatry 166 (12): 1355–1364.
Dr Foteini Papouli is a Senior Teaching Fellow in Psychiatry, currently working for Northumberland Tyne and Wear NHS Foundation Trust (Newcastle-upon-Tyne, UK). Her background is in working with offenders suffering from Personality Disorder(s).
Dr Bárbara Almeida is a psychiatric trainee, from Hospital Magalhães Lemos, Porto, Portugal.
Dr Roberts Klotins was a psychiatric trainee in London during the writing of this chapter and has just finished the sub-specialty training in Medical Psychotherapy. He has started as a Consultant Psychiatrist in Psychotherapy at the Halliwick Unit, St Ann’s Hospital – where MBT was developed.