Mentalisation-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioural, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganised attachment and failed to develop a robust mentalisation capacity. Fonagy and Bateman define mentalisation as 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 patients with BPD increase their mentalisation capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.
More recently, a range of mentalisation-based treatments, using the “mentalising stance” defined in MBT but directed at children (MBT-C), families (MBT-F) and adolescents (MBT-A), and for chaotic multi-problem youth, AMBIT (adaptive mentalisation-based integrative treatment) has been under development by groups mainly gravitating around the Anna Freud National Centre for Children and Families.
The treatment should be distinguished from and has no connection with mindfulness-based stress reduction (MBSR) therapy developed by Jon Kabat-Zinn.
The major goals of MBT are:
- Better behavioural control.
- Increased affect regulation.
- More intimate and gratifying relationships.
- The ability to pursue life goals.
This is believed to be accomplished through increasing the patient’s capacity for mentalisation in order to stabilise 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 mentalising itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalising. Therapy examines mainly the present moment, attending to events of the past only insofar as they affect the individual in the present. Other core aspects of treatment include a stance of curiosity, partnership with the patient rather than an ‘expert’ type role, monitoring and regulating emotional arousal, and identifying the affect focus. Transference in classical understanding of this term is not included in the MBT model. MBT does encourage consideration of the patient-therapist relationship, but without necessarily generalising to other relationships, past or present.
MBT should be offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist works to stimulate or nurture mentalising. Particular techniques are employed to lower or raise emotional arousal as needed, to interrupt non-mentalising and to foster flexibility in perspective-taking. Activation occurs through the elaboration of current 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. Fonagy and Bateman have recently proposed that MBT (and other evidence-based therapies) works by providing ostensive cues that stimulate epistemic trust. The increase in epistemic trust, together with a persistent focus on mentalising in therapy, appear to facilitate change by leaving people more open to learning outside of therapy, in the social interactions of their day-to-day lives.
Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder. The first randomised, controlled trial was published in 1999, concerning MBT delivered in a partial hospital setting. The results showed real-world clinical effectiveness that compared favourably with existing treatments for BPD. A follow-up study published in 2003 demonstrated that MBT is cost-effective. Encouraging results were also found in an 18-month study, in which subjects were randomly assigned to an outpatient MBT treatment condition versus a structured clinical management (SCM) treatment. The lasting efficacy of MBT was demonstrated in an 8-year follow-up of patients from the original trial, comparing MBT versus treatment as usual. In that research, patients who had received MBT had less medication use, fewer hospitalisations and longer periods of employment compared to patients who received standard care. Replication studies have been published by other European investigators. Researchers have also demonstrated the effectiveness of MBT for adolescents as well as that of a group-only format of MBT.