Bateman, A., & Fonagy, P. (2016) | References

Core Concept: Understanding Mentalization-Based Treatment

Anthony Bateman and Peter Fonagy's Mentalization-Based Treatment for Personality Disorders: A Practical Guide represents the clinical culmination of decades of research into how the capacity to understand minds develops—and what happens when that development fails. Published in 2016 and now considered a standard reference for MBT practitioners worldwide, the book translates complex developmental and attachment theory into structured, deliverable treatment protocols. At its heart, MBT addresses a simple but profound question: how do we help people who cannot understand their own minds or the minds of others develop this fundamental human capacity?

The Mentalization Deficit as Core Pathology. Mentalization is the capacity to understand behaviour—your own and others'—in terms of underlying mental states: thoughts, feelings, desires, and intentions. A mentalizing person sees behaviour as meaningful, arising from internal psychological experience rather than occurring randomly or mechanically. When someone cuts you off in traffic, mentalizing allows you to think "Perhaps they're rushing to an emergency" rather than "They're evil and targeting me." When you feel suddenly anxious, mentalizing allows you to think "I must be worried about the presentation" rather than experiencing an incomprehensible bodily state. This capacity seems so basic that it's easy to assume everyone has it—but Bateman and Fonagy demonstrate that personality disorders involve profound mentalizing deficits that explain their most disabling features. The narcissist who cannot perceive others' perspectives, the borderline patient who cannot understand their own emotional reactions, the antisocial personality who cannot grasp others' suffering—all reflect different manifestations of impaired mentalization.

Developmental Origins of Mentalizing Capacity. Bateman and Fonagy trace mentalizing capacity to early attachment relationships. When a caregiver treats an infant as a psychological being with thoughts and feelings worth understanding—wondering what the baby might be feeling, responding to distress with curious attention rather than dismissal or overwhelm—the infant gradually develops the capacity to understand their own mind. The caregiver's "marked mirroring" of the infant's emotional states (reflecting the emotion in a modified, contained form) teaches the child that their internal experiences are real, meaningful, and can be understood. When this developmental process is disrupted through neglect, trauma, or the caregiver's own mentalizing deficits, the child fails to develop robust mentalizing capacity. They may grow into adults who cannot identify what they feel (alexithymia), cannot understand why they react as they do, cannot perceive others as having valid separate perspectives, and cannot regulate emotions that remain confusing physiological states rather than meaningful signals. This developmental framework explains why personality disorders are so difficult to treat: they involve fundamental capacities that typically develop in infancy and early childhood but were never adequately established.

The Structure and Process of MBT. MBT provides a structured treatment approach designed to develop mentalizing capacity in adults whose early development was disrupted. The treatment typically involves individual therapy combined with group therapy, extending over 12-18 months for Borderline Personality Disorder and potentially longer for Narcissistic Personality Disorder. The therapeutic stance is distinctive: rather than interpreting the patient's experience (which would model the therapist's mentalizing, not the patient's), the MBT therapist maintains a "not-knowing" position characterised by genuine curiosity about what the patient might be thinking and feeling. Questions like "I wonder what was going through your mind when that happened?" or "What do you imagine they were feeling?" stimulate the patient's own mentalizing rather than providing ready-made understandings. When mentalizing breaks down—as it inevitably does during emotional activation—the therapist slows the pace, returns to simpler interventions, and waits until the patient's arousal decreases enough for mentalizing to resume. This calibration requires moment-to-moment attention to the patient's mentalizing state.

MBT for Narcissistic Personality Disorder. While MBT was originally developed for Borderline Personality Disorder, Bateman and Fonagy have increasingly applied its principles to narcissism. Narcissistic pathology involves a distinctive mentalizing profile: profound deficit in mentalizing others' perspectives combined with avoidance of authentic mentalizing of the self. The narcissist cannot genuinely perceive that others have valid mental states separate from their own—others exist as functions (sources of narcissistic supply, mirrors, audiences) rather than as separate minds. Simultaneously, the narcissist avoids mentalizing their own vulnerable internal states, using grandiosity to bypass the shame, inadequacy, and fear that authentic self-reflection would reveal. MBT for narcissism therefore faces a double challenge: developing the capacity to perceive others' subjectivity while also accessing the narcissist's defended vulnerable self. The approach requires specific modifications—attention to the narcissist's difficulty being in the patient role, careful handling of envy and competition with the therapist, and explicit attention to how shame arises when mentalizing deficits are exposed. Treatment duration is typically longer than for BPD, and dropout rates remain challenging.

Original Context: The Development of MBT

The Integration of Theory and Practice. Mentalization-Based Treatment emerged from Peter Fonagy's theoretical research on attachment and mentalizing, translated into clinical application through collaboration with Anthony Bateman. Fonagy's earlier work—particularly the 2002 book Affect Regulation, Mentalization, and the Development of the Self—established the theoretical foundation: mentalizing develops through early attachment relationships, and its absence underlies much psychopathology. Bateman brought clinical expertise in treating severe personality disorders and the practical sensibility to translate theory into deliverable treatment. Their collaboration began in the 1990s, producing the first randomised controlled trial of MBT for BPD in 1999. This trial demonstrated that patients receiving MBT showed significantly greater improvements in depressive symptoms, suicidal and self-mutilatory acts, hospitalisation rates, and social functioning than patients receiving treatment as usual. Subsequent trials replicated these findings, establishing MBT as an evidence-based treatment included in clinical guidelines.

The Partial Hospitalisation to Outpatient Evolution. MBT was initially developed and tested in a partial hospitalisation (day hospital) setting, where patients attended intensive treatment multiple days per week. The 2016 practical guide reflects MBT's evolution toward outpatient applicability, recognising that most clinicians and healthcare systems cannot provide partial hospitalisation intensity. The authors describe adaptations for once- or twice-weekly outpatient treatment while maintaining core MBT principles. This includes structured individual therapy, often combined with mentalizing group therapy, with clear attention to the therapeutic frame and crisis protocols. The shift to outpatient settings has increased MBT's accessibility while requiring modifications to maintain efficacy with reduced treatment intensity.

The Not-Knowing Stance as Technical Innovation. Central to MBT's distinctive technique is the "not-knowing" or "inquisitive" stance that distinguishes it from interpretive psychodynamic approaches. Traditional psychoanalytic technique involves the therapist formulating interpretations of the patient's unconscious processes and communicating these to the patient. MBT explicitly rejects this approach, arguing that therapist interpretations model the therapist's mentalizing capacity rather than developing the patient's own capacity. Instead, the MBT therapist expresses genuine curiosity, acknowledges uncertainty, and asks questions designed to stimulate the patient's mentalizing. "I'm not sure I understand—can you help me see what that was like for you?" models epistemic humility and invites the patient to reflect on their own experience. This stance requires therapists to tolerate not knowing, resist the urge to demonstrate expertise, and trust that the patient's own mentalizing capacity will develop through being repeatedly engaged.

Attention to Arousal and Mentalizing Collapse. A key MBT insight is that mentalizing is a vulnerable capacity that collapses under emotional arousal. When threat or attachment system activation increases beyond the patient's tolerance, mentalizing disappears and is replaced by either hypermentalizing (excessive, often paranoid attribution of mental states) or hypomentalizing (concrete, black-and-white thinking without access to mental states). The skilled MBT therapist monitors the patient's arousal level moment to moment, recognising signs that mentalizing is failing—increased physiological activation, concrete or paranoid statements, loss of reflective capacity. When mentalizing collapses, the therapist does not continue with the previous topic (which will only increase arousal further) but instead slows pace, acknowledges the current emotional state, and waits for arousal to decrease before reengaging reflective exploration. This attention to arousal regulation distinguishes MBT from approaches that might inadvertently push patients beyond their window of tolerance.

For Survivors: Understanding Mentalizing Deficits in Narcissistic Relationships

Why They Couldn't Understand You. If you've experienced a relationship with someone with narcissistic personality organisation—a parent, partner, or other significant figure—you know the bewildering experience of trying to communicate your perspective to someone who simply cannot receive it. You explained your hurt, clearly and repeatedly, only to see a blank stare or bizarre misinterpretation. You presented evidence of your experience only to have it dismissed, distorted, or turned back against you. Bateman and Fonagy's framework explains this as a genuine mentalizing deficit, not merely indifference or strategic cruelty. The narcissistic individual lacks the developed capacity to hold another person's mind in mind as separate from their own. When you expressed your subjective experience, they literally could not perceive it as valid and distinct—they processed your words through their own needs, interpretations, and defences. This deficit explains why your most careful attempts at communication failed: you were trying to engage a capacity that hadn't developed. This understanding doesn't excuse the harm caused, but it explains why changing the narcissist through communication was structurally futile.

How This Affected Your Own Mentalizing. Growing up with a caregiver who couldn't mentalise you has predictable effects on your own mentalizing capacity. If no one consistently wondered what you were thinking and feeling, treated your internal states as real and worth understanding, or accurately reflected your emotions back to you, you may struggle to know your own mind. This manifests as difficulty identifying what you feel (you may experience emotions as confusing physical states without clear meaning), confusion about what you want (having learned that your preferences didn't matter), and uncertainty about your own perceptions (having been systematically told that your experience was wrong). You may also struggle to understand others' mental states, tending either toward assuming you know what they think (hypermentalizing) or failing to consider their perspective at all (hypomentalizing). These difficulties are not character flaws—they are the predictable developmental consequences of inadequate mentalizing in your early environment. The hopeful news is that mentalizing capacity can develop in adulthood through relationships that provide what early attachment relationships failed to deliver.

Recognising Mentalizing Breakdown in Yourself. Understanding mentalizing helps you recognise when your own capacity is compromised. Under stress or attachment threat, everyone's mentalizing degrades—but those with early mentalizing deficits are particularly vulnerable to breakdown. Signs that your mentalizing has collapsed include: black-and-white thinking (someone is all good or all bad, situations have only extreme interpretations), certainty about others' motives (especially negative certainty—"I know exactly why they did that"), loss of reflective capacity (you can't step back and wonder about your experience), and physical signs of high arousal (rapid heartbeat, shallow breathing, muscle tension). Recognising these signs in yourself allows you to take steps to restore mentalizing: slow down, ground yourself physically, wait for arousal to decrease before making decisions or responding to conflicts. This self-monitoring capacity—mentalizing your own mentalizing—is itself a skill that develops over time and may require therapeutic support to establish.

The Path to Developing Mentalizing Capacity. Bateman and Fonagy's research demonstrates that mentalizing capacity can develop in adulthood through sustained therapeutic relationships. The mechanism is surprisingly similar to how mentalizing develops in infancy: through consistent interaction with someone who holds you in mind as a psychological being with thoughts and feelings worth understanding. A therapist who maintains genuine curiosity about your experience—who asks questions rather than provides answers, who acknowledges uncertainty, who is willing to be wrong—models the mentalizing stance while stimulating your own capacity. Over time, you internalise this capacity: the therapist's wondering about your experience becomes your own wondering, their curiosity about mental states becomes your curiosity. This process takes time and requires sustained therapeutic relationship, but it is real. Patients who complete MBT report improved capacity to understand themselves and others, better emotional regulation, more stable relationships, and reduced symptoms. The research evidence supports what many survivors intuitively sense: healing happens through relationship, through being truly seen by someone who can hold your mind in their mind.

For Clinicians: Implementing MBT Principles in Practice

Assessment of Mentalizing Capacity. Clinicians should assess mentalizing capacity across multiple dimensions: mentalizing self versus others, mentalizing automatic versus controlled processes, mentalizing cognitive content versus affective content, and mentalizing internal versus external features. Survivors of narcissistic abuse often present with specific patterns: difficulty mentalizing their own emotional states (having never had them adequately mirrored), hypermentalizing others' intentions (hypervigilance for threat), and oscillation between hypomentalizing under stress and hypermentalizing when anxious about relationships. The Reflective Functioning Scale applied to the Adult Attachment Interview provides formal assessment, though clinical observation of how patients discuss relationships and emotional experiences also reveals mentalizing capacity. Treatment planning should address identified deficits, recognising that developing mentalizing is a gradual process requiring sustained therapeutic relationship.

The MBT Therapeutic Stance. The MBT therapist's fundamental stance involves curiosity, not-knowing, and active attention to mental states. Rather than providing interpretations ("You're angry because..."), the therapist wonders aloud and invites exploration ("I notice something seems to have shifted—can you help me understand what you're experiencing right now?"). This stance requires genuinely not presuming to understand, acknowledging uncertainty, and trusting that the patient's own reflection will develop through being engaged. For survivors of narcissistic abuse—who often experienced caregivers who presumed rather than inquired, who told them what they felt rather than asking—this curious stance can be profoundly corrective. The therapist models that minds can be known without being controlled, that uncertainty is tolerable, and that another person can be genuinely interested in understanding rather than using their understanding for manipulation.

Mentalizing the Therapeutic Relationship. A distinctive feature of MBT is explicit attention to mentalizing the therapeutic relationship itself. When ruptures occur—and they will occur—the therapist and patient engage in collaborative exploration of what each was thinking and feeling. "I have the sense something went wrong between us just now. Can we try to understand what happened?" This meta-mentalizing develops the patient's capacity for reflection on relationships while demonstrating that relational difficulties can be understood and repaired rather than denied or catastrophised. For patients whose early relationships involved denial of ruptures or punishment for noticing them, this explicit attention can be transformative. The therapeutic relationship becomes both the vehicle for developing mentalizing and the object of mentalizing attention.

Managing Mentalizing Breakdown in Session. Clinicians must monitor patients' arousal and mentalizing state moment to moment, recognising signs that mentalizing is failing. When the patient shifts from reflective to concrete, becomes certain about others' motives (especially persecutory certainty), or shows physical signs of high arousal, the therapist should not continue pursuing the current topic. Instead, slow down, acknowledge the emotional state, and use techniques to restore mentalizing: grounding, empathic validation, simpler questions, and waiting for arousal to decrease. Pushing through mentalizing breakdown reinforces the experience that reflection is dangerous and that one must act or collapse rather than think and feel. The skilled MBT therapist learns to calibrate intervention intensity to the patient's current mentalizing capacity, sometimes maintaining quite simple supportive presence during periods of breakdown.

Broader Implications: Mentalizing Beyond the Consulting Room

Mentalizing in Family Systems. Mentalizing deficits operate within family systems, not just individuals. A parent with poor mentalizing capacity raises children whose own mentalizing development is compromised. Siblings may develop different patterns depending on their position and the parent's differential treatment. Family therapy applications of MBT principles involve developing mentalizing capacity across the system—helping family members understand each other's mental states rather than assuming malicious intent. This is particularly relevant for families with a narcissistic member, where other family members may have developed either hypermentalizing (anxious monitoring of the narcissist's unpredictable states) or hypomentalizing (protective numbing to the emotional chaos) as adaptive responses. Family interventions can shift the system from non-mentalizing interaction patterns toward genuine curiosity about each member's experience.

Mentalizing in Parenting and Child Development. Bateman and Fonagy's work has direct implications for parenting interventions. Parental reflective functioning—the parent's capacity to mentalise the child—predicts child outcomes including attachment security, emotional regulation, and the child's own mentalizing capacity. Interventions that enhance parental reflective functioning may be among the highest-leverage approaches for preventing personality pathology in the next generation. Such interventions help parents move from "My child is doing this to annoy me" to "I wonder what my child is feeling right now—what might their behaviour be telling me about their internal state?" This shift in perspective transforms the parent-child relationship and supports the child's mentalizing development. For survivors of narcissistic parenting who are now parents themselves, developing parental reflective functioning can break the intergenerational transmission of mentalizing deficits.

Mentalizing in Organisations and Leadership. Leadership involves mentalizing—understanding the mental states of team members, stakeholders, and the systems within which one operates. Leaders with poor mentalizing capacity treat subordinates as functions rather than persons, fail to understand why their communications aren't received as intended, and create organisational cultures characterised by fear and compliance rather than engagement and creativity. Narcissistic leaders represent extreme mentalizing deficits in positions of power, with predictable organisational consequences. Applications of mentalizing concepts to leadership development help leaders recognise when they're failing to perceive others' perspectives, understand how their communications are experienced rather than just how they're intended, and create organisational contexts that support rather than undermine mentalizing capacity throughout the system.

Mentalizing and Social Trust. At a societal level, mentalizing relates to social trust and democratic functioning. Democracy requires citizens who can mentalise—who can perceive that others have different but valid perspectives, that opponents may have legitimate reasons for their views, and that disagreement doesn't necessarily indicate malicious intent. Cultures and media environments that promote non-mentalizing—seeing political opponents as evil rather than differently reasoned, assuming the worst about outgroups, treating certainty as strength and nuance as weakness—undermine the mentalizing capacity that democratic discourse requires. Fonagy has written about "epistemic trust"—the capacity to learn from others and update beliefs based on new information—as essential to both individual mental health and social functioning. This capacity, like mentalizing more broadly, develops through relationships characterised by genuine rather than manipulative communication.

Mentalizing in Educational Settings. Schools interact with children during the developmental period when mentalizing capacity is being established. Teachers who mentalise—who wonder about students' internal states rather than simply responding to behaviour, who express curiosity about what students are experiencing, who model reflective thinking about emotions—can provide corrective experiences for children from non-mentalizing homes. Conversely, educational approaches that respond only to behaviour without considering underlying mental states may reinforce the experience of not being seen as a psychological being. Training educators in mentalizing principles—not to make them therapists but to enhance their relational capacity—could support mentalizing development in children whose home environments cannot provide it.

Mentalizing and Digital Communication. Digital communication poses particular challenges for mentalizing. Text-based interaction strips away the nonverbal cues that support mentalizing in face-to-face communication: tone of voice, facial expression, body language, contextual information. This makes misunderstanding more likely and correction more difficult. Social media environments that reward certainty and outrage over reflection and nuance further undermine mentalizing. Understanding digital communication through a mentalizing lens helps explain phenomena like cyberbullying, online radicalisation, and the surprising cruelty that emerges in online environments—people who would never speak so harshly in person become vicious when the other is not perceived as a full mental being. Interventions that restore mentalizing to digital contexts—reminding users of the human behind the screen, slowing down reactions, creating space for reflection—might mitigate some of these effects.

Limitations and Future Directions

The Evidence Base Beyond BPD. While MBT has robust evidence for Borderline Personality Disorder, research specifically on its efficacy for Narcissistic Personality Disorder remains more limited. Case series and uncontrolled studies suggest promise, but randomised controlled trials specifically for NPD are needed. The theoretical rationale for MBT's application to narcissism is strong—mentalizing deficits are central to narcissistic pathology—but empirical confirmation of clinical utility awaits further research. Clinicians should approach NPD treatment with appropriate humility about what the evidence currently supports, while recognising that MBT principles provide one of the more theoretically coherent approaches available.

Treatment Duration and Accessibility. MBT for personality disorders typically requires 18 months or more of treatment, posing practical challenges for healthcare systems and patients. Not all patients can access or sustain this level of treatment engagement. Research on briefer MBT formats—and on which patients might respond to shorter treatment—is ongoing but not yet definitive. Group-based MBT formats offer more cost-effective delivery while maintaining some mentalizing elements, though they cannot fully replicate the individual therapeutic relationship's intensive mentalizing work. The tension between treatment efficacy (which requires sustained, intensive intervention) and accessibility (which requires shorter, more available treatment) remains unresolved.

Training and Dissemination. Competent MBT delivery requires specific training in the approach—understanding mentalizing theory, learning the technical interventions, and developing the "not-knowing" stance that doesn't come naturally to clinicians trained in other approaches. MBT training programmes exist but are not universally available, and the approach's psychodynamic elements may limit acceptance in more cognitively-oriented treatment systems. Wider dissemination of MBT principles, even outside formal MBT treatment, could benefit clinical practice more broadly—any therapist can adopt a more mentalizing stance, even without delivering manualized MBT.

Integration with Trauma-Focused Approaches. Many patients with personality disorders also have trauma histories requiring specific trauma-focused intervention. How MBT integrates with approaches like EMDR or prolonged exposure remains an area for development. Some patients may need mentalizing capacity developed before they can effectively engage trauma processing; others may need trauma processing before they can sustain the therapeutic relationship required for mentalizing development. Clinical judgment currently guides these decisions, but more systematic research on integration and sequencing would be valuable.

Historical Context and Influence

Mentalization-Based Treatment for Personality Disorders: A Practical Guide appeared in 2016, representing the maturation of MBT from experimental intervention to established evidence-based treatment. The approach's development began in the 1990s when Anthony Bateman and Peter Fonagy sought to translate Fonagy's theoretical research into deliverable clinical practice. Their 1999 randomised controlled trial was a landmark demonstration that patients with Borderline Personality Disorder—a diagnosis widely considered untreatable—could show significant improvement with structured psychotherapy.

The theoretical foundation came from Fonagy's integration of attachment theory with psychoanalysis, particularly his work on reflective functioning and the development of mentalization through early relationships. Fonagy's 2002 book Affect Regulation, Mentalization, and the Development of the Self (with Gergely, Jurist, and Target) established the conceptual framework that MBT operationalises. The concept of mentalization itself drew on multiple traditions: psychoanalytic concepts of mind, developmental research on theory of mind, attachment theory's attention to early relationships, and neuroscience research on the brain systems underlying social cognition.

MBT gained inclusion in clinical guidelines including those from the UK's National Institute for Health and Care Excellence (NICE), establishing it alongside Dialectical Behaviour Therapy as a recommended treatment for Borderline Personality Disorder. This recognition reflected both the accumulating evidence base and growing recognition that personality disorders were treatable conditions rather than untreatable character defects. The 2016 practical guide consolidated decades of clinical experience into protocols accessible to practitioners beyond the original research centres.

The approach has influenced clinical practice beyond formal MBT delivery. The emphasis on mentalizing as a fundamental human capacity that can be developed through relationship has shaped how many clinicians understand personality pathology and therapeutic action. The "not-knowing" stance has been adopted across therapeutic orientations as a way of engaging patients' reflective capacity rather than providing ready-made understandings. The attention to how mentalizing collapses under arousal has informed crisis intervention and de-escalation approaches. Even clinicians who don't deliver manualized MBT increasingly think in mentalizing terms about their patients and their therapeutic relationships.

Mentalization-Based Treatment for Personality Disorders: A Practical Guide

APA Citation