What is the experience of engaging in mentalization-based treatment? A meta-ethnography of client perspectives of the therapeutic process and outcome
| Date | 20 August 2024 |
| Pages | 318-334 |
| DOI | https://doi.org/10.1108/MHRJ-11-2022-0069 |
| Published date | 20 August 2024 |
| Author | Niamh O’Leary,Christian Ryan,Philip Moore |
What is the experience of engaging in
mentalization-based treatment?
A meta-ethnography of client
perspectives of the therapeutic process
and outcome
Niamh O’Leary, Christian Ryan and Philip Moore
Abstract
Purpose –Mentalization-basedtreatment (MBT) is a psychotherapeutic approachthat aims to increase
mentalizing capacity.The purpose of this meta-ethnography was to synthesizethe available qualitative
literature on MBT to allowfor a more thorough understanding of the lived experienceof those who have
undergonethis therapy.
Design/methodology/approach –A systematic search of seven databases was carried out. The
CriticalAppraisal Skills Programme was used to appraise the paperssuitable for inclusion. The data were
synthesizedusing a meta-ethnographic approachin which the second-order constructsfrom each paper
were translatedand reinterpreted creatinga line of argument synthesis.
Findings –A total of 11 studieswere included in the meta-ethnography. Threeoverarching themes were
identifiedwithin the included papers which outlined thatparticipant experience of MBT consistedof three
different developmental stages. Navigating the therapeutic process describes the participant’s
experience of the therapeutic process of MBT. The processes of change in MBT outlined participant
reports of mechanisms of change experienced in MBT. Mentalizing self and others described the
experience of generalizing new knowledge and skills to the world outside of therapy and unveiled the
impactthat engaging in MBT had on participants.
Originality/value –This meta-ethnography offers new insights into how clients experience MBT as a
therapeutic process and offers suggestions for implementation in clinical practice as well as areas of
focus for researchof this therapeutic approach.
Keywords Qualitative, Meta-synthesis, Meta-ethnography, MBT, Mentalization,
Mentalization-based treatment
Paper type Literature review
Introduction
Mentalization-based treatment
Mentalization-based treatment (MBT) is an integrative approach to psychotherapy with a
theoretical basis in attachment theory which includes both cognitive and relational
components (Bateman and Fonagy, 2016). It was developed in the 1990s as a
therapeutic approach for Borderline Personality Disorder (BPD). MBT is a structured
therapeutic program with the central aim of increasing the resilience of an individual’s
mentalizing capacity. In this way, MBT seeks to support an individual to rekindle their
mentalizing capacity when it is lost, maintain mentalizing when it is present and increase
Niamh O’Leary, Christian
Ryan and Philip Moore are
all based at the School of
Applied Psychology,
University College Cork,
Cork, Ireland.
Received 3 November 2022
Revised 23 November 2023
Accepted 3 July 2024
PAGE 318 jMENTAL HEALTH REVIEW JOURNAL jVOL. 29 NO. 32024, pp. 318-334,©EmeraldPublishing Limited, ISSN 1361-9322DOI 10.1108/MHRJ-11-2022-0069
the resilience of the capacity to keep it going when otherwise it would be lost (Bateman
and Fonagy, 2016).
Structure of mentalization-based treatment
The initial phase of MBT involves completing an assessment of an individual’smentalizing
capacity and personality functioning. The therapist also focuses on engaging and
contracting the individual into treatment as well as building the therapeutic relationship and
identifying any potential treatment difficulties that may occur. During this phase, the
individual also attends sessions of psychoeducation, in the form of an introductory group
(MBT-I). The aim of this group is to introduce individuals to the concept of mentalizing and
personality disorders (PD) as well as prepare and motivate individuals for long-term
treatment.
The primary aim of the middle phase of MBT, comprised group and individual therapy, is to
facilitate the mentalizing process for participants. Group psychotherapy often elicits
interpersonal interactions that arehighly complex, and it is these interactions that are
harnessed to support participants to reflect on the mental states of themselves and others
within the group setting. In addition to the group, individual sessions are typically held on a
weekly basis. These sessionsnot only focus on mentalizing but also emphasize the repair of
any therapeutic ruptures that may occur and sustain the client’s motivation to attend. The
focus of the final phase of MBT is on the interpersonal and social functioning of the clientas
well as aiding them to process the end of therapy (Bateman and Fonagy, 2016). The
timeframe or number of sessions provided for either MBT-I oran MBT programme may vary
from service to service depending on capacity. However, it is noted by the authors that the
tasks of increasing understanding and motivation through knowledge and empowerment,
the development of the therapeutic relationship with clear goals and an increase in the
client’s capacity to mentalize as well as an increase in resilience of this capacity are more
important than the duration or absolutenumber of sessions provided.
The overall goals of MBT are to both increase an individual’s capacity to mentalize whilst
also increasing the resilience ofthis capacity. This is achieved through interpersonal
processes. As such, throughout each phase, the maintenance of a “mentalizing stance” by
the MBT therapist is crucial. The role of the therapist is to stimulate mentalizing processes
within the client and to make this an essential feature within all therapeutic interactions.
Throughout this process, the therapist maintains a “not-knowing” stance. This stance
models an acceptance that neither the therapist nor the client can be certain about what the
other is thinking. Over time, the aim is that this thought process will be internalized by the
client who with therefore gradually become more curious about both their own and others’
minds. As a result, the client is better able to reappraise themselves and their
understanding of others (Batemanand Fonagy, 2012).
Need for synthesis within the qualitative literature on mentalization-based treatment
The evidence base underlying the efficacy of MBT for treating BPD and other mental health
difficulties is still in its infancy. Until recently, the research literature for MBT had consisted
solely of studies using a quantitative methodology. Two systematic reviews have
summarized and reviewed the quantitative evidence base to date (Malda-Castillo et al.,
2018;Vogt and Norman, 2019) and have demonstrated the effectiveness of MBT in
achieving positive clinical outcomes for clients. However, few studies within the literature
have investigated the proposed mechanism of change of MBT, that of increased
mentalizing capacity. The measurementof mentalizing capacity through quantitative means
is problematic for several reasons and it is recognized that mentalizing as a construct is
both difficult to measure and difficult to compare across individuals (Fonagy et al.,2011).
The use of self-report measures to assess mentalizing capacity requires an individual to
VOL. 29 NO. 32024 jMENTAL HEALTH REVIEWJOURNAL jPAGE 319
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