What Does Evidence-Based Mentalization Therapy Look Like in Practice?
Published in Behavioural Sciences & Psychology
Mentalization has become one of the central concepts in contemporary psychotherapy, attachment research, and developmental psychology. The term refers to the capacity to form mental representations of intentional mental states — such as emotions, needs, desires, beliefs, and purposes — and thereby to understand these states in oneself and others. In recent decades, Mentalization-Based Therapy (MBT), developed by Peter Fonagy and Anthony Bateman, has emerged as an evidence-based treatment approach specifically aimed at strengthening this capacity.
Yet despite the growing popularity of the concept, one important question often remains surprisingly unclear: what does mentalization actually look like in clinical practice? Many clinicians may understand the concept theoretically while still lacking a vivid picture of how mentalizing is restored within actual therapeutic dialogue.
Our article, Making Visible the Clinical Practice of Mentalization-Based Therapy as Illustrated by Therapy Session Material, was written to clarify these questions in a concrete and educational manner. The background to the article was itself deeply dialogical. During the autumn of 2024, we began a series of conversations about mentalization and related concepts from two different professional perspectives. One of us approached the topic primarily as a doctoral researcher interested in conceptual clarity and theory development; the other as a practicing psychotherapist with years of direct clinical experience. Very quickly, we noticed that achieving a shared understanding of mentalization required far more than simply reviewing theoretical definitions.
This realization led us to examine an actual MBT session example in detail, and our dialogue gradually evolved into the idea of presenting our shared reflections in the form of an article.
The therapy example we analyze centers on a fictional patient, Susan, whose therapist unexpectedly had to cancel a session while she is already on her way to the appointment. What initially appears to be a relatively minor event gradually reveals itself to be emotionally overwhelming for the patient. Following the cancellation, Susan experiences intense distress and eventually induces vomiting. At first, however, she is unable to describe clearly what she felt. Her experience appears only as a vague “bad feeling” rather than as a differentiated emotional state connected to a meaningful relationship.
Our article describes how MBT helps transform such unmentalized emotional states into experiences that can gradually be recognized, reflected upon, and shared. The therapist does not impose interpretations from outside or claim to know the patient’s mind. Instead, the therapist adopts what MBT describes as a mentalizing stance: a curious, exploratory, and not-knowing attitude that repeatedly invites the patient to examine experience more closely.
When the therapist’s understanding feels sufficiently accurate and emotionally attuned, it strengthens the patient’s epistemic trust: the capacity to receive and internalize personally meaningful information from another person. In the session example, the gradual restoration of mentalizing ultimately leads to a shared relational state described as we-ness — a moment of mutual understanding in which both therapist and patient experience emotional connection and shared meaning.
We also aim to discuss how the mentalization-based approach relates to other forms of psychotherapy. MBT proposes that mentalizing is restored and strengthened primarily within the therapeutic relationship itself. What distinguishes the approach, however, is its particular focus on moments of rupture and repair, and on the careful working through of these moments in accordance with MBT principles. MBT focuses on helping the patient regain the capacity to reflect on feelings, intentions, and relationships while consistently working within the patient’s zone of proximal development.
In many ways, the process through which we wrote the article mirrored the very principles we were describing. The text itself emerged through dialogue, mutual questioning, clarification, and the gradual development of shared understanding. In this sense, the writing process itself reflected what mentalizing fundamentally is: a deeply human process through which people create meaning together.
By closely examining a single therapy interaction, we hope to offer psychotherapists, researchers, and students a clearer understanding of how mentalization can be supported, restored, and stabilized in therapeutic work. Making the mechanisms of action in MBT visible is important for all therapists interested in the role of mentalizing in psychotherapy. Psychotherapists interested in this approach may compare the mentalizing approach presented here with their own clinical way of working.
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