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Mentalization-based Treatment (MBT)

10 hours ago
12 min read

Mentalization, principles, session outline, research, training, practice suggestions

Three sections follow:

1.      Background Material that provides the context for the topic

2.      Suggestions for Practice

3.      A list of References

Feedback welcome!

Background Material



Mentalization

Mentalization allows individuals to perceive and interpret needs, desires, feelings, beliefs, goals, purposes, and reasons in themselves and others. It is the way a person’s mind tells that person what they, and others, are thinking and feeling, and why the person and others are behaving as they are (MHA, 2024; Perina, n.d.; Spectrum, n.d.).  Our own mental states are influenced by these beliefs and determine how we feel, act, and respond (Madeson, 2022).  For example, when shopping for a present for someone, people usually imagine a gift the recipient would like. The success of this prediction depends on the giver’s sense of what that person is like (Unruh, 2026). 


When mentalizing is working, people can hold a curious, flexible stance toward themselves and others. During an argument or misunderstanding, mentalization examples include:

  • Naming the feeling without jumping to conclusions (“I’m feeling hurt, but I’m not sure why yet.”)

  • Questioning your reactions (“I might be misinterpreting what they meant.”)

  • Acknowledging multiple possibilities at once (“There could be more than one explanation.”)

On the other hand, when mentalizing breaks down people will want to defend, justify, get angry back, or shut down.  Fast, rigid conclusions take over to protect people from perceived danger.  Common signs that mentalization is breaking down include:

  • Jumping to conclusions (“They didn’t reply. They must be mad at me.”)

  • All-or-nothing thinking (“This always happens. Nothing ever works out.”)

  • Assuming one knows what others are thinking (“They think I’m annoying.”)

  • Treating feelings as facts (“I feel worthless, so I must be worthless.”) (Ferraro, 2026)


In summary, mentalizing is a skill all people need to be able to do in a flexible manner when navigating everyday life. When people practise the skill of mentalizing flexibly, it helps:

  • develop a language for thoughts and feelings, and to understand why people do what they do,

  • develop a clear sense of self, and work towards personal goals and desires,

  • regulate emotions,

  • problem-solve,

  • reduce misunderstandings in relationships, and

  • reduce the need for other ways of coping such as self-injury, hospital admissions and substance use (Spectrum, n.d.).


Mentalisation Based Treatment (MBT)

MBT is rooted in attachment theory and psychoanalytic concepts. It posits that disruptions in early attachment relationships can lead to deficits in mentalization, contributing to mental health conditions (MHA, 2024) including borderline personality disorder (BPD), children and families, adolescents, addiction, narcissistic personality disorder, antisocial personality disorder, eating disorders, anxiety, depression, complex trauma, and OCD (obsessive-compulsive disorder) (Perera, n.d.; Ferraro, 2026).  Overall, if a person struggles with long-standing patterns of difficulty managing emotions or interpersonal interactions, MBT may help. 


MBT focuses on improving the ability of people to understand and interpret thoughts and feelings, both of themselves and others in a safe environment. This "mentalizing" process helps people build stronger, healthier relationships, manage emotions, and cope with stress in more adaptive ways (Perera, n.d.; Spectrum, n.d.; Unruh, 2026).  MBT tends to be a good fit for people who notice:

  • Intense or rapidly shifting emotions

  • Feeling easily misunderstood or rejected

  • Unstable or conflict-heavy relationships

  • Impulsive reactions they later regret

  • Getting stuck in rigid, self-blaming, or all-or-nothing thinking (Ferraro, 2026).


When mentalizing is working, people are able to pause, reflect, and hold more than one possible explanation for what’s happening inside them and between them and others.  When this ability is disrupted—often because of trauma, chronic stress, or early relational experiences—emotional regulation and relationships can start to feel exhausting and unstable and thinking tends to become more rigid, absolute, and self-blaming.  Rather than trying to eliminate difficult emotions or “fix” these rigid thoughts, MBT focuses on restoring people’s core capacity to make sense of minds. As mentalizing strengthens, many people find emotions feel more manageable, reactions slow down, and relationships become easier to navigate (Ferraro, 2026).


Core Principles

Bateman and Fonagy (2016) provide an overview of the approach to implement MBT with clients by describing general characteristics of therapy.  The general characteristics one finds in therapy should be:

  • keeping things short and straightforward;

  • remaining affect-focused;

  • focusing on the patient’s mind, not their behavior; and

  • relating discussions to the current event or activity.

The spectrum of interventions used in therapy includes:

  • empathic validation;

  • clarification, exploration, and challenge;

  • affect identification and affect focus; and

  • mentalizing the relationship.


Ferraro (2026) suggests the following as principles:

  • Present-focused    Sessions centre on what is happening now

  • Curiosity over certainty      Therapists are curious rather than conclusive

  • Emotion regulation before insight  If emotions are overwhelming, the first step is stabilizing

  • Collaboration        Therapist and patient work together (Ferraro, 2026)


MHA (2024) suggests the following guidelines for therapists:

  • Focus on mentalization: bring attention to mental states and their impact on behaviour.

  • Emphasise relationships: understand and interpret interpersonal interactions.

  • Attachment security: provide a secure base from which to explore mental states safely.


How Mentalization Therapy Works

Clients who come for MBT treatment are often in a place of emotional dysregulation and mistrust.  In MBT, the therapist creates a “secure base” to promote healthy mentalization and emotional regulation.  Throughout treatment, therapists monitor levels of mentalizing, emotional arousal, and attachment as they fluctuate in session. The goal is to stimulate just enough emotional responsiveness to explore new perspectives and find meaning, but not so much that mentalizing collapses from overarousal.

The therapist explores the client’s ability to maintain and recover mentalizing when challenged by emotional interpersonal events, such as misunderstandings, disagreements, rejections, and intimacy. In treatment, developmental events and attachment figures are discussed to assess how well a person can mentalize within close relationships and when the ability to do so breaks down.

When poor mentalizing is seen (i.e., the client goes to extremes), the therapist intervenes with alternatives. This helps the client learn to find a balanced perspective. Eventually, the client can broaden overly rigid, reactive, unrealistic, and emotionally vacant perspectives and learn more appropriate interpersonal behaviors (Madison 2022).


Treatment Sessions

MBT practitioners work to create a safe environment in which patients can begin a deep exploration of their own feelings and those of others, ultimately developing their capacity for mentalization. The focus is on the client's present and not so much on the past (Perina, 2026).  People receiving MBT participate in both weekly individual therapy sessions and weekly group therapy sessions. Treatment duration is 18 months (Perina, 2026; Spectrum, 2026). 


In addition to leading individual and group therapy sessions, therapists attend a weekly reflection team meeting, in which they receive support from other therapists on their own mentalization regarding the treatment process (Unruh, 2026).


Sessions with individuals

Individual treatment sessions run for 50 minutes.  They provide an opportunity to discuss challenges the person may be experiencing/have experienced in their life.  For the most part the therapist tries to think and reflect with the person about problems to help the person gradually develop their own solutions. In doing so, the person will be practising the skill of mentalizing so they can use it more easily and flexibly outside of sessions (Spectrum, 2026).


The first step in MBT is to help patients stabilize their emotional expression and limit their impulsive behaviors (Unruh, 2026).  Sessions often begin with a recent situation that felt emotionally charged—an argument, a misunderstanding, a spiral, or something that happened in the therapy relationship itself.  From there, the person and therapist explore mentalization experiences, like:

  • What the person noticed internally

  • What the person thinks the other person might have been experiencing

  • Where the person may have jumped to conclusions

  • How the person’s emotions influenced his or her reaction (Ferraro, 2026)


As the therapist and patient work together to process the patient’s experiences, including interactions with the therapist, the patient’s mentalizing capacity usually stabilizes. The therapist does not take an authoritative or “correct” stance in such exchanges. Instead, the therapist takes a position of curiosity towards patients and sits “side by side” with the patient in a shared effort to work out what is going on.  The patient gradually begins to apply a more nuanced and flexible mindset to understanding self and others within the therapeutic relationship and relationships outside of therapy.  The goal isn’t to land on a single “right” answer, but to build flexibility in how the person understands thoughts, feelings, and intentions (Ferraro, 2026; Unruh, 2026).


MBT therapists ask questions of themselves, such as, “Why is the patient behaving like this?” “What might I have done that explains the patient’s state?” “Why am I feeling as I do now?” Such questions help the therapist maintain a “mentalizing stance.” The therapist may even share these questions with the patient to demonstrate ways to understand how another person may think and reach more accurate conclusions about another person’s behavior.  The point of these therapeutic interactions is for each person to reflect on the point of view of others alongside their own point of view. This increases the patient’s capacity to mentalize multiple perspectives that may differ (Unruh, 2026).


In MBT, the therapist emphasizes a stance of humility. As part of this process, therapists carefully monitor and acknowledge any misunderstandings they may have about the patient. They own up to and explore such misunderstandings when they do occur.  When the therapist changes their mind based on the experience and feedback of the patient, they demonstrate the openness and flexibility of mentalization. The patient witnesses and internalizes this process in therapy (Unruh, 2026).


As therapy progresses, the patient continues to build on their ability to mentalize. The individual becomes more curious about their own and others’ internal experiences. They become better at understanding and assessing their own and others’ states of mind (Unruh, 2026).


Sessions in groups

Group therapy sessions last for 90 minutes.  The group therapy program typically starts with a 6-week introductory program where participants learn what they can expect from the MBT treatment program. Following this, participants commence the ongoing weekly group.  Groups typically have two facilitators and up to eight group members.  Together with co-participants or therapist support, each person explores what was going on in their own mind and what might have been going on in other peoples’ minds, particularly in situations that have caused a strong emotional response or problematic reaction.  This involves participants being curious about their own and others’ experiences, asking each other questions, and sharing perspectives. This serves as a live skills practice group where everyone practices the skill of mentalizing (Spectrum, 2026; Unruh, 2026).


Five Mentalization-Based Techniques

Specific techniques apply to MBT (Madison, 2022).

  1. Support & empathy          Empathetic statements strengthen rapport and the therapeutic relationship, which is an essential foundation of MBT.  The therapist must be able to provide support, give the client autonomy, and judiciously praise them in order to elicit change. Empathy and support create new, healthy bonds between client and therapist, which is essential to the attachment theory that MBT is grounded in.

  2. Clarification        In MBT, the therapist needs to clarify and elaborate to get a detailed picture of behavioral sequences and associated feelings. This clarification helps the client make connections between actions and feelings.  Clarification includes repeating statements back to the client and asking questions the client can answer clearly.

  3. Exploration         With exploration, the client can develop a curiosity of thoughts, feelings, and motivations.  This helps the client share the therapist’s perspective and consider alternative experiences of the same event. Exploration provides an opportunity for the client to work on interpersonal relationship skills.

  4. Challenging         Challenging the client is a technique of exploring their underlying emotional state by confronting their perspective. This technique is a balance of pushing the client into conflict and finding acceptance with alternate beliefs.

  5. Transference      Transference is often used in MBT to direct the patient’s emotions toward the therapist in order to analyze them.  While transference has often been seen as a negative in therapy, it can have numerous benefits when used intentionally. It helps patients think before they react to their own feelings and the perceived feelings of others.


MBT Activities

The following three activities (Madison, 2022) provide a snapshot of the type of activities a therapist may use in MBT sessions:

  1. The Dream Journey activity provided by the Center for Mentalization helps clients find a safe place. By taking time to relax each part of the body, the client can let go of physical and emotional tension and distress. Once the client is in a relaxed state, they are asked to imagine a pleasant place to be. This becomes their “safe space,” which can be an anchor for exploring negative, irrational, and problematic thoughts and feelings.

  2. The Mentalization Model activity helps clients with interpersonal relationships. In the activity, the client is asked to think about an important relationship in their life.

    1. The first step is to ask the client to identify their personal feelings about the relationship, needs from the relationship, goals of the relationship, reasons to keep the relationship, and specific thoughts about the relationship.

    2. The next step is to have the client do the same thing from the other person’s perspective, imagining the answers the other person would provide.

    3. Finally, the client is asked to reflect on the differences between the perspectives (self and other) and what it was like to imagine the other person’s emotions, needs, goals, reasons, and thoughts.

  3. The Triune Brain activity helps clients understand the three states of the brain: executive, emotional, and survival. After some psychoeducation on the three aspects of the brain, clients can identify specific examples of when each part of the brain is used and expressed in life.  By simply identifying thoughts, emotions, and behaviors for which each area of the brain is responsible, clients can become more self-aware and learn the ability to mentalize.


Research

Overall, studies suggest MBT can help reduce intense emotional swings and relationship chaos, while improving people’s ability to understand their own thoughts and feelings and make sense of others. Research also suggests that the benefits of MBT tend to last beyond the end of treatment. In other words, it aims to build skills for the future, not just offer temporary symptom relief. Most research has studied programs that last 12–18 months or longer, which reflects MBT’s focus on steady, long-term change rather than quick fixes (Ferraro, 2026).


While randomized controlled trials (RCTs) of MBT are limited, a few have demonstrated promising results. One of these included 53 individuals struggling with self-harm and borderline personality traits.  After 12-weeks of MBT intervention, social anxiety and self-harm behaviors decreased and emotional regulation improved. In another RCT, 44 patients were randomly assigned to either a control or mentalization (MBT) group. Improvements in impulsivity, suicidal ideation, self-harm, and depression were significantly better in the MBT group after 18 months.  Additionally, an eight-year follow-up demonstrated that the benefits are long lasting. The MBT group also had higher levels of social functioning and employment history, suggesting better interpersonal skills (Madeson, 2022).


A 2019 systematic review of 14 studies found that MBT led to significant reductions in self-reported symptoms of distress, suicide attempts, and self-harm.  This review found that MBT reduced levels of anxiety and depression and helped increase the quality of life among BPD patients. The positive effects were seen in hospital settings, inpatient and outpatient clinics, and through a variety of qualitative and quantitative research designs (Madeson, 2022).


Research-backed benefits of MBT include:


MBT is one of several treatments proven effective in treating patients with borderline personality disorder (BPD).

  • In a 1999 randomized controlled trial, patients in an outpatient hospital, who received MBT (as opposed to standard treatment), showed decreased suicidality, reduced hospitalization, and improved social skills 18 months, 36 months, and 8 years after treatment.

  • A 2009 randomized controlled trial of outpatient MBT recruited and trained therapists in either MBT or structured clinical management (SCM). Then 134 BPD patients were assigned to work with therapists from one of the two groups. When assessed at six months, 12 months, and 18 months, the percentage of patients who attempted suicide, engaged in self-harm, or required hospitalization was significantly lower in the MBT group.  A follow-up study published in 2020 demonstrated that the gains made in treatment persisted for six subsequent years after treatment ended, and that patients treated with MBT had better functional outcomes (Unruh, 2026).


Therapist Training

MBT was developed to be quickly learned and easily implemented by a variety of mental health professionals, including psychiatrists, psychologists, social workers, nurses, and mental health counselors. Licensed mental health professionals can learn MBT in a three-day training course followed by expert clinical supervision (Unruh, 2026).


The course offered by the Anna Freud Center includes three components of training: basic training, supervision, and a certificate for practitioners. It comprises a mix of 18 live hours and 21 hours of self-directed study (Madeson, 2022): https://www.annafreud.org/training/courses/mentalization-based-treatment-basic-training/ 


An internet search for ‘Mentalization training in one’s country of origin may provide local training opportunities, including the Anna Freud Centre course mentioned above.  For example,


Australia:


United States:


Great Britain:


Suggestions for Practice


The core principes of MBT (present-focused, curiosity over certainty, emotion regulation before insight and collaboration) fit well with social work values.  Likewise, the specific techniques outlined above also fit well with social work, i.e. offering support and empathy, obtaining clarification, exploring as appropriate, challenging when necessary and managing transference.


Social workers have the required foundation to implement a mentalization approach and can upskill to use mentalization techniques as part of practice with a three-day training course. 


Understanding the concept of mentalization is a valuable tool to be aware of when supporting clients.


Pointing out the advantages of healthy mentalizing may be relevant to some clients.  When people practise the skill of mentalizing flexibly, it helps:

  • understand why people do what they do,

  • regulate emotions,

  • problem-solve,

  • reduce misunderstandings in relationships, and

  • ·       reduce the need for other ways of coping such as self-injury, hospital admissions and substance use.


Being aware of the variety of disorders, other than borderline personality disorder, that MBT can be used to address may give social workers another avenue to explore and discuss with patients when dealing with, for example, children and family problems, adolescents, addiction, anxiety, depression, and trauma.


References


Bateman, A., & Fonagy, P. (2013). Mentalization-based treatment.  Psychoanalytic Inquiry, 33, 595-613.  doi: 10.1080/07351690.2013.835170


Bateman A., & Fonagy, P. (2016).  Principles for the mentalizing clinician.  In A. Bateman & P. Fonagy (Eds.), Mentalization-based treatment for personality disorders: A practical guide (pp. 206-233)..  Oxford University Press. https://doi.org/10.1093/med:psych/9780199680375.001.0001 


Ferraro, K. (2026). What is mentalization-based therapy? Radial.  https://www.meetradial.com/blog/mentalization-based-therapy


Madeson, M. (2022). Mentalization-based therapy guide: Best worksheets and techniques.  Positive Psychology https://positivepsychology.com/mentalization-based-therapy/


MHA: Mental Health Academy. (2024). What is mentalization based treatment?  https://www.mentalhealthacademy.com.au/blog/what-is-mentalization-based-treatment 


Perina, K. (n.d.). Mentalization-based therapy.  Psychology Today.  https://www.psychologytoday.com/us/therapy-types/mentalization-based-therapy


Spectrum. (n.d.).  Mentalization-based treatment (MBT).  https://www.spectrumbpd.com.au/treatments/mentalization-based-treatment-mbt


Unruh, B. (2026). Mentalization-based treatment: Understanding yourself and others.  Deconstructing Stigma.  https://deconstructingstigma.org/guides/mbt

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