Mentalization-Based Therapy in Practice

In this roundup of new research on mentalization-based therapy, discover how psychoanalytic interventions can mitigate the effects of trauma and help build secure attachment in childhood and adulthood.


Mothering From the Inside Out: Results of a second randomized clinical trial testing a mentalization-based intervention for mothers in addiction treatment (2017)

Suchman, N.E.; DeCoste, C. L.; McMahon, T. J.; Dalton, R.; Mayes, L. C.; & Borelli, J.


Mothers with histories of alcohol and drug use disorders often struggle to develop sensitive, responsive parenting styles and are at greater risk of losing custody of their children. Recent neuroscience research also indicates that chronic drug use has the potential to increase stress activation and vulnerability to relapse during caregiving activities. Despite the reality of heightened parenting deficits among individuals with addictive disorders, most addiction treatment programs and parenting interventions fail to address the specific needs of this vulnerable population.  

In this study, researchers assessed the efficacy of Mothering From the Inside Out, a 12-session individual therapy. The intervention focuses on improving maternal reflective functioning with the aim of mitigating the emotional distress experienced by mothers recovering from addiction. In the long-term, Mothering From the Inside Out seeks to achieve three goals:

  1. Improve mothers’ capacity for emotional regulation
  2. Enhance mothers’ capacity to engage in human attachment, rather than attachment to substances
  3. Support mothers’ capacity to develop engaging, empathetic, and supportive relationships with their children

In this study, researchers conducted a second randomized, controlled trial using a sample of 87 mothers receiving treatment for substance use disorders and caring for a child between 11 months and 5 years of age. Participants were randomly assigned to receive either 12 sessions of Mothering From the Inside Out or 12 sessions of a psychoeducation active control comparison.

Researchers found that at posttreatment and the 3-month follow-up, Mothering From the Inside Out participants demonstrated a higher capacity for reflective functioning. At the 12-month follow-up, Mothering From the Inside Out mothers demonstrated more sensitive caregiving behavior and their children showed greater involvement. Mothering From the Inside Out dyads also demonstrated greater reciprocity after 12 months. Mothers with greater addiction severity showed higher levels of reflective functioning than mothers with less severe substance use disorders after receiving the treatment, suggesting that Mothering From the Inside Out is best used with mothers who have the most severe substance use disorders.


The family cycle: Breaking the intergenerational transmission of trauma through mentalizing (2020)

Stob, V., Slade, A., Adnopoz, J., & Woolston, J.

For some parents, preventing child abuse and neglect starts with examining personal histories of trauma. Repressed trauma can make it difficult for adults to process their own emotions or respond with empathy to their children’s needs. This repression places parents at greater risk of reenacting patterns of abuse with their own children.

In this paper, researchers explored the utility of a clinical activity promoting mentalizing—or the ability to understand the thoughts and feelings of others—in shifting the intergenerational transmission of trauma. The Family Cycle activity is a mapping exercise that allows individuals to explore and reflect on how their adverse experiences affected them. This paper describes the use of the Family Cycle for parents with children participating in the Intensive In-Home and Adolescent Psychiatric Services (IICAPS), a program for kids at high-risk for psychiatric intervention.

After discovering significantly high rates of adverse childhood experiences among parents in IICAPS, researchers developed the Family Cycle activity to help parents and children uncover challenging emotional experiences and reflect on their impact. In this program, clinicians worked with parents through each phase of the Family Cycle activity, beginning with completing the adverse childhood experiences questionnaire (ACE-Q). Clinicians then walked parents through creating their own Family Cycle and attempting to predict their child’s Family Cycle, helping parents practice both mentalization and self-reflection. Parents also participated in a family session where their child presented their own Family Cycle. Finally, clinicians compared the child’s and the parent’s Family Cycles in a facilitated parent session. 

The Family Cycle activity created a crucial opportunity for parents to reflect on their childhood experiences and current parenting practices. By analyzing their own histories of trauma, parents could begin the process of mentalizing trauma and using self-reflection to consider how past trauma impacts their relationships and interactions with their children. Researchers concluded that this activity could be widely applicable to families at all risk levels in a range of outpatient settings.


Unresolved trauma and reorganization in mothers: Attachment and neuroscience perspectives 

Iyengar, U., Rajhans, P., Fonagy, P., Strathearn, L., & Kim, S.

Mothers with unresolved trauma often struggle to provide a strong caregiving response to their infants, which can negatively impact the baby’s development of secure attachment. In a process known as “attachment reorganization,” individuals with unresolved trauma work toward attachment security through critical reflection on their past and present experiences. 

Iyengar, et al. discovered in a previous study that among mothers with unresolved trauma, those who were reorganizing toward secure attachment were the only mothers with securely attached infants. In this literature review, researchers assessed the potential that attachment reorganization has to interrupt intergenerational transmission of insecure attachment. The review summarized relevant research on the transmission of maternal trauma, using both attachment theory and neuroscience perspectives to explore how unresolved trauma affects mothers’ attachment behaviors and their neurobiological responses to their infants’ cues. 

Researchers then expanded on the concept of attachment reorganization and clarified its differences from the concepts of mentalization, reflective functioning, and earned security. As a fluid and ongoing process, attachment reorganization helps individuals with unresolved trauma recognize their maladaptive patterns of thinking and take a self-reflective perspective on their history of trauma. Ultimately, attachment reorganization allows individuals to shift from a self-protective attachment strategy to a more adaptive and reflective stance.

The researchers’ prior study suggested that the process of attachment reorganization may in itself be enough to mitigate disrupted bonds between mothers with unresolved trauma and their infants. In this review, researchers presented an example of a mother with unresolved trauma who was reorganizing toward secure attachment. The mother demonstrated the ability to reflect on her past and understand the behavior of those who harmed her. While researchers noted that further empirical examination is needed, they concluded that the new patterns of thinking encouraged by attachment reorganization can help mothers build stronger, healthier relationships with their children.