Academic journal article American Journal of Psychotherapy

Mentalization and Dialectical Behavior Therapy

Academic journal article American Journal of Psychotherapy

Mentalization and Dialectical Behavior Therapy

Article excerpt

Dialectical Behavior Therapy (DBT) and Mentalization-Based Treatment (MBT) are two approaches to the treatment of borderline personality disorder (BPD). While DBT has the most empirical support, MBT has a small but significant evidence base. Dialectical behavior therapy synthesizes behaviorism, mindfulness, and dialectics, while MBT is conceptually anchored in psychoanalysis, attachment theory, cognitive neuroscience, and developmental psychopathology. While coming from strikingly different orientations, DBT and MBT therapists share more interventions and stances than one might suppose. The central purported active ingredient of MBT is the capacity to mentalize, which is crucial for the formation of secure attachment, and this ability is thought to be weak and unstable in individuals with borderline personality disorder. This article explores the question of whether or not mentalizing is already present in DBT practice, whether it would be compatible with DBT conceptually and practically, and whether a focus on mentalizing would be of use to the DBT therapists and their patients.

KEYWORDS: Mentalization; mentalization-based therapy; MBT, dialectical behavior therapy; DBT, borderline personality disorder


Mentalization-based treatment (MBT) is a psychosocial treatment for borderline personality disorder (BPD) that has gathered significant support both in controlled research trials (Bateman & Fonagy, 1999, 2001, 2003, 2008, 2009) and in increasingly widespread application (Bateman & Fonagy, 2012). While MBT structures treatment around goals, agreements between therapist and patient, and crisis planning protocols, the defining feature and purported active ingredient in MBT is mentalization. Therapists adopt a curious, not-knowing stance, monitor attachment and mentalizing capacity, and use interventions aimed to restore or maintain the capacity of patients to mentalize. The MBT therapist shares a written case formulation with the patient that highlights the way in which problems with mentalizing were influenced by early attachments, have played a role in relationship patterns, and are likely to manifest in psychotherapy. Alongside the individual therapy, patients are provided psycho-education and structured exercises to bolster comprehension about mentalizing. Patients participate in group therapy during which they mentalize in order to to generalize their capacity.

Allen, Fonagy, & Bateman (2008) have claimed:

.. . we believe that therapists of all persuasions can benefit from a solid understanding of mentalizing and, furthermore, that patients also can benefit from this understanding-regardless of the type of treatment in which they are engaged. (p. 20; italics from the original)

Given that MBT is supported in controlled research trials, that it was originally designed for treating borderline personality disorder, and that the focus of MBT is the strengthening of capacities in the patient-all of which are features of dialectical behavior therapy (Linehan, 1993)- mentalizing may be of interest to DBT therapists.

Both MBT and DBT share some proximal aims: establish a secure attachment relationship in therapy, use empathy and validation in a reciprocal relationship, strengthen patient capacities to reduce emotional dysregulation and impulsive behaviors, and enhance self-awareness, attentional control, and flexible thinking in the contexts of emotions and relationships.

All of this is especially interesting given that MBT and DBT are derived from such different foundations. Mentalization-based treatment comes from psychoanalysis, attachment theory and research, and developmental psychopathology. Dialectical behavior therapy synthesizes acceptancebased approaches, behavioral science, and dialectical philosophy. Mentalization-based treatment has a more unitary focus than DBT, with MBT centering on an instability in mentalizing as the underlying problem in borderline personality. …

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