The Expanding Scope of Mentalization-Based Treatments

Mentalization, or the capacity to make sense of ourselves and others in psychological terms, is what makes us uniquely human. In our earliest social encounters, mentalization is kindled by the daily interchanges we have with our caregivers, whose imagination of the needs, wants, and feelings behind our signals of distress supports our survival. Through these early bonds, we develop an ability to handle ourselves independently and to adequately comprehend what happens in the minds of those around us. As we navigate that social environment, we learn important lessons that help us grow and adapt as human beings to an ever-changing world.

Mentalization defines our human potential and vulnerability. Without adequate mentalizing, we are unable to contain our reactions to stress. Poor mentalizing is socially destructive. It impairs our ability to cope, communicate, and collaborate with others. As much as mentalizing can promote mental health and rewarding interactions, its instability can equally result in vulnerability for mental illness and social isolation. Herein lies the potential for psychotherapy to heal and revive psychological development. Psychotherapy can foster mentalization as a common mechanism of change and growth, across approaches and diagnoses.

Three decades ago, Peter Fonagy and Anthony Bateman catalyzed a movement to develop psychological treatments based in mentalization. Skeptics described mentalization as “old wine in new bottles.” However, Fonagy and Bateman broke new ground by repackaging traditional ideas from psychoanalysis with novel empirical findings of developmental psychology and neuroscience in a manualized psychotherapy found effective for the treatment of borderline personality disorder. Mentalization-based treatment (MBT) became the first psychodynamically oriented evidence-based treatment for the self-destructive symptoms and psychosocial impairments related to borderline personality disorder, proving that old ideas, revised to incorporate emerging scientific findings, remain relevant to and can enhance the development of effective interventions for serious mental illness.

Since its development, MBT has continued to evolve with innovations in psychiatric research. Fonagy and Bateman have extensively updated MBT’s attachment-based foundation to incorporate the role of trust. This paradigm shift reformulated the understanding of personality development in terms of epistemic trust, that is, one’s openness to receiving and applying socially transmitted knowledge (1). People with personality disorders remain stuck in epistemic mistrust, where their rigid dysfunctional beliefs about themselves and others cannot be updated when new information is given. Patients with severe personality disorders lack the preconditions for experiencing relationships with others as reliably rewarding, generating an epistemic blockade to social learning and development (1). As psychiatry moves toward a transdiagnostic model of psychiatric illness, impairments in mentalization and epistemic trust have been considered a general psychopathology factor or, put differently, a risk factor for severe chronic psychiatric illness and disability in general (2, 3).

While the scientific basis of mentalization is rich and sophisticated, its translation into a treatment approach is fundamentally basic, flexible, and broadly relevant. Jon Allen has identified the restoration of mentalizing in attachment relationships as the basis of “plain old therapy” (4). The ultimate goal of MBT is to promote stable attachment in which strong emotions are coregulated and reflected upon, so that elaborated, realistic, and flexible perspectives on oneself and others develop in order to enrich epistemic trust and the capacity to adaptively grow throughout a lifespan. Being understood by the therapist, who takes seriously each patient’s point of view and offers their own perspective in a genuine but fallible sort of way, enables patients to work with the therapist to build a shared understanding of life’s challenges in a “we-mode” where perspectives can be enriched, modified, and updated (3). Therapy can rekindle epistemic trust through this creation of a joint mode of consideration—this we-mode—to reduce isolation, clarify experience, and enhance social learning. By applying these experiences to life outside of treatment, patients become able to join others in more rewarding social collaboration that provides strategic advantages as well as a satisfying sense of self and belonging.

This special issue of the American Journal of Psychotherapy on the expanding scope of MBT marks three decades of progress in the conceptual definition, scientific elaboration, and translation of mentalizing into clinical practice. It includes seven articles that illustrate MBT’s potential applications. The issue opens with an article that illustrates the flexible integration of MBT across age groups and in productive integration with other psychotherapeutic approaches. Volkert and colleagues (5) have contributed an engaging and clinically cogent article on the use of mentalization-based approaches for parents, children, youths, and families. This wonderful article provides straightforward descriptions of how mentalization can be used to understand transactions within the family that can be modified to reduce psychological risk and promote a more rewarding environment for both parents and children. Two empirically driven articles broaden MBT’s relevance to clinical features that may co-occur with borderline personality disorder as well as with other diagnoses. In the first, Smits and colleagues (6) report on the effect of trauma on outcomes for patients in a randomized controlled trial of borderline personality disorder. With a rich discussion of the impact of trauma on attachment, mentalization, and epistemic trust, this article provides evidence that a history of trauma does not influence the effectiveness of MBT in reducing borderline personality disorder symptoms or improving interpersonal functioning but that the rate of improvement is enhanced by a higher level of care for patients with more substantial trauma. McLaren and colleagues (7) then review whether hypermentalizing, that is, the tendency to ascribe complex mental states to others without ostensible evidence, is a specific marker of borderline personality disorder. Their meta-analytic review of 36 studies with over 4,000 participants points to the likelihood that hypermentalizing is a marker of general psychopathology rather than borderline personality disorder specifically, and therefore may be relevant to the treatment of patients transdiagnostically.

In addition, three Psychotherapy Tools articles are presented. The first two present adaptations of MBT to two personality disorders, antisocial and narcissistic personality disorder, that do not seem to respond reliably to psychiatric intervention. Anthony Bateman describes MBT’s group therapy–driven approach to antisocial personality disorder, which establishes a sense of group collaboration (“we-ness”) in mentalizing attachment patterns and emotional vulnerabilities that motivate violent or aggressive behavior (8). Additionally, Sebastian Simonsen, Sebastian Euler, and I present an adaptation of MBT’s basic components to understand attachment styles, imbalanced mentalizing profiles, and epistemic trust of patients with narcissistic personality disorder, who may be distinguished by challenges to engaging in a collaborative we-mode (9). In the third Psychotherapy Tools, Law and colleagues (10) illustrate the incorporation of MBT in an interpersonal psychotherapy treatment for individuals with depression facing stressful life events.

The issue closes with a Clinical Case Discussion by Drozek and Unruh (11), which illustrates how MBT works in the treatment of a patient with borderline personality disorder.

True to its origins, MBT has fostered a vibrant community of researchers, treatment developers, and practitioners around the world who join efforts to explore new directions for empirical discoveries and clinical applications. Those who have contributed articles to this special issue are leaders in that community who have advanced MBT’s robust growth across the globe. In addition, the reviewers and editors of the American Journal of Psychotherapy have generously provided their time and insights to enhance and sharpen our collective work. It has been an honor and pleasure to enter a we-mode in joint collaboration during this otherwise isolating atmosphere of the pandemic. I would especially like to recognize Holly Swartz, editor-in-chief, for her supportive and wise guidance, as well as the steady organization and deft oversight of Heidi Koch-Bubel and Demarie Jackson, who continuously ushered this stream of activity moving toward its completion. The task of bringing together members of the MBT and American Psychiatric Association Publishing families has been a meaningful experience of attachment, collaboration, and learning.