Bateman, A., & Fonagy, P. (2013). Mentalization-Based Treatment. Psychoanalytic inquiry, 33(6), 595–613. https://doi.org/10.1080/07351690.2013.835170
For this month’s journal club, we are revisiting Anthony Bateman and Peter Fonagy’s 2013 article, Mentalization-Based Treatment, published in Psychoanalytic Inquiry. It explores a deceptively simple idea: understanding our own minds and remaining curious about the minds of others can make a profound difference to how we manage emotions and relationships.
Bateman is a psychiatrist and psychotherapist whose work has focused on personality disorders. Fonagy is a clinical psychologist and psychoanalyst associated with University College London. Together, they helped develop mentalisation-based treatment (MBT), initially for people with borderline personality disorder (BPD).
What I particularly appreciate about this paper is its integration of attachment theory, developmental understanding and practical psychotherapy. Its approach centres on helping people recover the ability to think and feel with greater flexibility, especially when relationships become emotionally overwhelming.
Mentalising is the process of making sense of our own behaviour and that of others in terms of feelings, thoughts, intentions, wishes and beliefs. It involves imagination, but also an awareness that our interpretations may be mistaken.
We do this throughout everyday life. We wonder why a friend seems distant, recognise that tiredness is making us irritable, or reconsider a conversation after discovering something we did not know at the time. Effective mentalising allows us to hold more than one explanation in mind.
For example, a delayed reply might initially feel like rejection. Mentalising creates room to consider other possibilities: perhaps the person is busy, overwhelmed or unsure what to say. The hurt remains real, while our explanation for it becomes less certain.
This capacity fluctuates in all of us. Under stress, particularly in emotionally significant relationships, curiosity can give way to certainty. We may become convinced that we know what another person intends, or struggle to distinguish our feelings from the facts of a situation.
BPD can involve substantial difficulties with emotional regulation, impulsivity, relationships and a stable sense of self. Bateman and Fonagy understand many of these difficulties through the interaction between attachment, emotional arousal and mentalising.
Their account does not mean that people with BPD are incapable of understanding themselves or others. Rather, this capacity can become particularly vulnerable when attachment concerns are activated—for example, by perceived rejection, separation or abandonment.
At these moments, a feeling may be experienced as an unquestionable reality: “I feel unwanted, so you must not care about me.” Alternatively, thoughts and emotions may become disconnected from lived experience, or only a concrete action may seem capable of proving that someone cares. These experiences can be intensely painful.
The treatment task is therefore to help restore the capacity to reflect when it becomes difficult to access.
One of the most compelling parts of the article is its discussion of attachment. Within the authors’ developmental model, secure attachment supports mentalising, while experiences of being understood can help strengthen a sense of security.
When we feel sufficiently safe, we can explore our inner world without being overwhelmed by it. We can acknowledge conflicting feelings, entertain different perspectives and remain interested in other people’s experiences. Imagination, playfulness and creativity have room to develop.
The authors describe different ways of managing attachment insecurity. Some people intensify their attempts to obtain closeness and reassurance when distressed. In therapy, this may involve rapid idealisation or powerful hopes that the therapist will provide safety. Disappointment can then bring an equally powerful shift towards mistrust, anger or withdrawal.
Others manage insecurity by distancing themselves from attachment needs. They may appear self-contained or emotionally detached, but outward composure does not necessarily tell us how secure they feel. When distancing no longer protects them, distress can become overwhelming.
These are patterns to understand within an individual formulation, rather than assumptions to make about everyone with BPD.
The clinical implication is that the pace and intensity of a therapeutic relationship matter. A dependable relationship can support mentalising; excessive emotional activation can undermine it. The paper’s discussion of attachment-stimulating environments should not be read as a blanket argument against hospital admission. It highlights the importance of a clear therapeutic purpose, structure and attention to the person’s response to care.
MBT aims to strengthen mentalising, support a more stable sense of self and help people remain able to reflect during emotionally charged interactions.
The outpatient model described involves assessment and preparation followed by approximately 18 months of treatment, including weekly individual and group therapy, crisis planning and coordinated psychiatric care. This describes a particular programme, rather than a fixed duration for every MBT service.
The surrounding structure matters. Treatment needs a shared focus, clear expectations, active support for engagement and coordination with other services. A reliable therapeutic relationship is central, with careful attention to how much emotional intensity the patient can manage.
The therapist takes an active role, continually adjusting interventions to the patient’s capacity to think about what is happening.
For me, one of MBT’s most valuable features is the humility it asks of the therapist.
The therapist remains curious about the patient’s experience, checks assumptions and acknowledges uncertainty. When a misunderstanding occurs, taking responsibility can help reduce tension and reopen a conversation that has become stuck.
An illustrative response might be: “I think I may have misunderstood you. Could we go back to what happened just before you felt I was dismissing you?”
This kind of intervention both explores the patient’s experience and demonstrates that another person can reconsider their own perspective. Over time, the patient may become more able to do the same.
The paper describes interventions including empathy and validation, exploration and clarification, identifying feelings, and examining what is happening within the therapeutic relationship. Their timing matters. When someone is overwhelmed, an elaborate explanation may be less useful than helping them feel understood and regain enough steadiness to reflect.
The therapist must also notice when their own mentalising is faltering. Feeling criticised, helpless or anxious can narrow a clinician’s perspective just as it can anyone else’s.
It is a misconception that MBT ignores transference. The relationship between patient and therapist provides an important opportunity to examine misunderstandings, expectations and emotional responses as they occur.
The emphasis is on collaboratively exploring how each person has understood an interaction. The immediate purpose is to restore curiosity and perspective, with interpretations paced to the patient’s ability to use them.
The approach draws on techniques familiar across several psychotherapies. Its distinctive feature is the consistent organisation of those techniques around maintaining or recovering mentalising.
The authors also emphasise its potential for use by ordinary clinical teams. Accessibility, however, should not be confused with an absence of training needs. Applying a seemingly straightforward intervention sensitively and consistently requires training, supervision and a coherent treatment framework.
The article reviews encouraging early research while acknowledging limitations, including small samples and the difficulty of identifying which components of a complex treatment programme produce change. It is best read as an account of the model and the evidence available in 2013, rather than a current comprehensive review.
What stays with me is the clinical stance running through the paper: a willingness to slow down, recognise uncertainty and remain interested in another person’s experience, particularly when that becomes difficult.
MBT offers a structured way of practising that stance. Its central ambition is deeply human—to help people stay connected to their own minds and to the minds of others during moments when emotion threatens to make that connection disappear.