Mentalization-based psychotherapy

Mentalization-based treatment (MBT) is an innovative form of psychodynamic psychotherapy, developed and manualised by Peter Fonagy and Anthony Bateman. MBT has been 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.

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.

Treatment procedure
MBT is offered to patients every 2 weeks 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 et al. have done extensive outcome research on MBT for borderline personality disorder and the results have compared favorably with existing treatments. The most recent study on this was an 8-year follow-up of MBT versus treatment as usual. Not all of these, however, were of a randomized, double-blind, placebo-controlled, crossover design.

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.