Mentalization-Based Therapy (MBT): How It Works & What to Expect

What Is Mentalization?

Mentalization refers to someone’s ability to infer and understand other people’s thoughts and feelings.¹ This ability develops when a child has a secure attachment with a caregiver.² Mentalizing is unique to humans since it requires a higher level of cognitive and emotional skills. It’s also imaginative, since you can never really know what’s in another person’s mind. However, when you see someone frowning, you might infer that they’re sad and reflect on why they could feel this way.

What Is MBT Therapy?

MBT therapy is an evidence-based treatment with roots in psychodynamic therapy.³ It’s based on the theory that people with borderline personality disorder often have difficulty mentalizing. This contributes to emotional instability, impulsivity, and relationship conflict. MBT helps them improve their mentalization and subsequently improve emotional regulation and interpersonal relationships.

Naturally, mentalizing is the key focus of MBT therapy.³ The therapist works to establish a healthy attachment with the client while encouraging their ability to mentalize. The client’s mind becomes the focus, and over the course of treatment they learn about their thoughts and feelings, how their thoughts and feelings impact their behavior, and how cognitive distortions lead to negative behaviors in relationships.

The goal of MBT is for the client to better mentalize themselves and others, to consider others’ thoughts and feelings, and to avoid misinterpreting others and responding in negative ways that hurt their relationships.

What Can Mentalization Based Therapy Help With?

MBT therapy can help adults and teens with BPD improve their capacity to mentalize. This helps them better regulate their emotions and maintain stable relationships.^2,3 Studies have shown that, because BPD often co-occurs with other mental health conditions such as eating disorders and substance use disorders, MBT can help with those problems as well.^4,5,6

Mentalization Based Treatment for Borderline Personality Disorder

People living with BPD struggle immensely with regulating intense emotions and reactions, which often prevents them from understanding their own mental processes when faced with certain situations.²

Mentalization based therapy can help with hyperactivation and deactivation, common symptoms of BPD:

• Hyperactivation: Since BPD sufferers are generally unaware of their own and others’ feelings, they tend to become hypersensitive towards anything that seems threatening to them, often overreacting in an explosive or angry manner.²
• Deactivation: People with BPD may appear serene and mentally self-aware when faced with distress, however, this is their effort to detach themselves emotionally to avoid experiencing painful feelings.²
• Mixed hyperactivation and deactivation: Those with BPD often present with a mix of hyperactivation and deactivation in relational dynamics. This creates a sudden mental shift that may and seem erratic and unstable to themselves and others.²

MBT Vs. DBT

Even though MBT and DBT possess similarities and are useful in treating BPD, they also differ in significant ways such as:

The Therapeutic Relationship & Length of Treatment

One major difference relates to how the therapeutic relationship is utilized. For instance, MBT centers on the relationship as a medium to study mentalizing and improve relationships. DBT on the other hand, employs the therapist-client alliance to alter dysfunctional behaviors and help develop effective coping skills. Additionally, the course of MBT can take up to 18 months, whereas DBT usually takes about a year.⁸

Theoretical Foundation

Another key distinction between MBT and DBT pertains to the theoretical foundation and their stance regarding BPD. MBT is mainly anchored on developmental psychopathology theory and considers that disturbed mentalizing capacities is often the result of underlying attachment issues. Conversely, DBT, which integrates elements of CBT and mindfulness, posits that emotional dysregulation is the core problem with BPD.⁸

Focus of Interventions

MBT seeks to enable people to understand and reflect on the thoughts and emotions that reinforce overt behaviors in themselves and others, while increasing the ability to self-regulate feelings and manage impulsiveness. However, the focus of DBT is on distress tolerance, emotion regulation, mindfulness, and effective interpersonal skills to alter unhealthy habits and foster the capacity to sustain painful or distressing feelings.⁸

Mentalization Based Therapy Techniques

Mentalization-based therapy is structured and active and treatment takes place over an 18-month period, during which a client participates in weekly individual and group therapy.² Before addressing their mentalization skills, the therapist works to develop a secure attachment with their client. In some cases, crisis intervention and medication management may be a part of the treatment plan.

Here are some of the techniques used in mentalization-based therapy:³

• Exploration of the client’s mental state
• Identifying and labeling emotions
• Validation and empathy
• Clarification of the connection between a client’s feelings and behaviors
• Challenging the client’s point of view while exploring their emotions
• Processing the client’s thoughts and feelings about the therapeutic relationship
• Encouraging the client to consider the therapist’s and other group member’s thoughts and feelings
• Reflecting on how the client’s perceptions of themselves differ from how others perceive them
• Addressing ruptures and impasses between client and therapist or the group as they arise

Is Mentalization Based Therapy Effective?

Mentalization-based therapy is considered an evidence-based treatment.³ Its effectiveness as a treatment for BPD is well-established, and more recent research has looked at using it with other populations beyond BPD.

Studies on MBT have found:

• MBT was effective in improving functioning in a group of people with BPD who participated in individual and group therapy twice weekly for two years⁹
• A preliminary study compared MBT with short-term psychodynamic therapy for people diagnosed with eating disorders and found that both therapy approaches were effective⁴
• A group diagnosed with both BPD and antisocial personality disorder who participated in MBT showed decreased anger, paranoia, hostility, self-harm, suicidality, relationship problems, and psychiatric symptoms⁵
• A group of people diagnosed with BPD and substance use disorder who participated in MBT combined with substance use disorder treatment showed improvements, including fewer suicide attempts⁶
• A study looked at short-term psychodynamic psychotherapy with mentalization-based techniques among people with major depressive disorder and found that the combination of these two approaches were effective in improving depression⁷
• Mothering from the Inside Out (MIO) is a 12-week, mentalization-based course for substance using mothers; one study carried out in a community mental health center found that MIO helped improve mother-child interaction and reduced parenting stress¹⁰

Limitations & Criticisms of MBT

Although MBT for BPD has been found to be equally successful as (or better than) other well‐established modalities, most of the studies regarding efficacy have not shown to be of great quality. Similarly, there is limited data regarding the nature of the proposed methods used in MBT. Consequently, more compressive studies are necessary in order to support MBT’s effectiveness for treating BPD and other mental health conditions.¹¹

MBT Therapy Examples

The techniques and goals of MBT therapy are similar across diagnoses; however, people with different diagnoses may require crisis support, medication management, or coordination with other healthcare providers to fully address their mental health concerns.

Here are three examples of mentalization-based therapy for different diagnoses:

1. MBT for Borderline Personality Disorder (BPD)

MBT for BPD is a structured treatment involving weekly group and individual sessions with a trained therapist who takes an empathetic approach to develop a secure attachment. When the relationship is established, the client and therapist explore the client’s mentalizing abilities together. They may talk about events that occur in the therapeutic relationship and in outside relationships.

For example, if a client expresses anger toward a group member during their individual session, the therapist may explore their feelings and their perception of the group member’s intentions. The therapist could introduce alternative explanations for the group member’s behavior to help improve the client’s mentalization skills.

Individual and group therapists collaborate to improve the client’s mentalizing and emotional-regulation skills. Treatment typically takes place over 18 months.

2. MBT for Eating Disorders

MBT for eating disorders involves similar techniques and goals as traditional MBT for BPD. However, when adapted, the MBT therapist will collaborate with other treatment professionals, like psychiatrists, physicians, and nutritionists, to aid in the client’s care.
Addressing any medical issues related to the client’s eating disorder is important. Medications may be prescribed to treat psychiatric and eating-disorder symptoms, and weekly weigh-ins may be recommended to monitor the client’s progress.

3. MBT for Substance Use Disorder

When MBT is used to treat substance use disorders, clients participate in substance use disorder treatment in addition to individual and group MBT sessions. This may include additional therapy and self-help groups. The impact of substance use on a person’s mentalization abilities and relationships will also be explored.

For example, substance use may impair a person’s ability to consider other people’s thoughts and feelings. Using drugs and alcohol could also be a way of dealing with social anxiety or self-doubt. Clients will learn how to relate to others without using drugs and alcohol.

How to Find an MBT Therapist

To find a therapist who practices mentalization-based therapy for BPD, start by conducting a search using an online therapist directory. If a therapist practices MBT, they will often indicate it in their profile. You can also contact them directly to see if they offer MBT. Many therapists who offer MBT have received post-graduate training in this area. However, additional training is not required and many therapists use elements of MBT without considering themselves mentalization-based therapists.

How Much Does MBT Cost?

The cost of therapy depends on your location and an MBT therapist’s training and experience. Cost typically ranges between $100 – $200 per 50-minute session. Masters-level therapists, including social workers, counselors, and therapists, may charge around $100-$150 per session. Doctorate-level providers, like psychologists, may charge $150-$200 per session. MBT often costs more in urban areas, where the demand for services is higher.

You may be able to find MBT at a lower cost if you attend a community mental health clinic or meet with a pre-licensed provider. This includes graduate students or post-graduate students who are in the process of getting licensed. Though they have less experience, they are supervised by licensed clinicians.

Mental health insurance may cover all or a portion of your costs for therapy. Your deductible, co-pay, and coinsurance will depend on your specific plan. Contact your health-insurance company directly to find out whether therapy is covered and your total out-of-pocket costs.

What to Expect at Your First Appointment

The first therapy session of mentalization-based treatment involves a diagnostic assessment; a therapist will ask you several questions to gain an understanding of what led you to seek treatment.³ For example, they may ask about your early childhood attachments, current and past relationships, and any symptoms you’re experiencing.

The therapist will also talk to you about MBT and explain how it works, what to expect, the duration and frequency of treatment, and goals. They will also encourage you to ask any questions and talk to you about your diagnosis. After the first session, you should leave with a better understanding of how MBT can help you.

Alternatives to Mentalization-Based Therapy

Therapy is an important part of BPD treatment. Although BPD treatments vary in their specific approaches, they share common goals, including improving a person’s emotion regulation skills, interpersonal relationships, and self-image.

Alternatives to mentalization-based therapy are:¹²

• Dialectical behavioral therapy (DBT): DBT is an evidence-based treatment for BPD that teaches skills in four main areas (mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness). DBT involves weekly phone check-ins and group and individual therapy sessions.
• Cognitive behavioral therapy (CBT): CBT focuses on changing unhealthy thoughts and belief systems and replacing them with healthier alternatives. CBT also teaches coping and relaxation skills to manage negative emotions.
• Schema therapy: This type of therapy assumes that in early childhood, people develop schemas, which are deeply held beliefs about the self and others. When these schemas persist into adulthood, they can lead to unhealthy behaviors and patterns. Schema therapy helps people identify and change these negative schemas and develop healthier perceptions of themselves, others, and the world.
• Transference-focused psychotherapy (TFP): In TFP, clients are able to work through their reactions to the therapist in the here-and-now, which can help them develop healthier behaviors in relationships.

Final Thoughts on MBT Therapy

If you are dealing with BPD, mentalization-based therapy may be right for you. It can help you better understand yourself and others, which can improve your relationships and emotion regulation skills.