A systematic review of dialectical behaviour therapy, mentalisation-based treatment and internal family systems therapy for borderline personality disorder with comorbid depression and/or anxiety.

Making visible the clinical practice of mentalization-based therapy as illustrated by the therapy session material.

Abstract Research has established that borderline personality disorder (BPD) can be diagnosed before the age of 18. However, many clinicians are apprehensive about using the diagnosis and treating BPD in adolescence. Specialized treatments have been developed and evaluated for BPD in adolescence. Mentalization-based therapy (MBT) is one of these. However, long-term follow-up studies are lacking, and the potential effects of getting the BPD diagnosis and treatment in adolescence are not yet well understood. We set out to explore the experiences of MBT group treatment for BPD five years later. The aim was to understand how they experienced the treatment and how it may have influenced them since. Twelve women aged 19–23 were included in the study. The women had participated in a randomized controlled trial investigating group MBT five years earlier. Qualitative data was collected through semi-structured interviews. The data were analyzed using a narrative, phenomenological framework by an interdisciplinary research group. The results showed a common narrative consisting of four themes: (1) patients without influence, (2) the process of getting diagnosed in adolescence, (3) group therapy: dynamics & alliance, and (4) frustration & alternative coping strategies. The four themes were intertwined by two cross-cutting themes: (1) the system, (2) the life outside. The results showed that the BPD diagnosis had impacts on the participants’ identity and self-understanding. Feeling like a patient without influence made the participants unwilling to seek help from mental health services later in life. The MBT group treatment was generally experienced as unhelpful due to a range of treatment specific-, common- and systemic factors. The participants developed maladaptive coping strategies to deal with serious mental health problems to stay out of touch with the mental health services.

Brief individual psychological intervention for people with probable personality disorder: a multicentre, researcher-masked, randomised, controlled superiority trial in England.

Containing the crisis: mentalisation-based therapy reduces acute service use for emotionally unstable personality disorder in Northern Ireland.

Background. Non-suicidal self-injury (NSSI) occurs in 69-90% of women with borderline personality disorder (BPD) and represents a critical diagnostic criterion and therapeutic challenge. Despite its high prevalence and clinical significance, the dynamic psychological and neurobiological mechanisms underlying NSSI remain incompletely understood, and a substantial gap persists between acute symptom reduction and long-term psychosocial recovery. Aim. This study reviews NSSI in BPD, focusing on: identification of proximal psychological mechanisms and developmental factors influencing NSSI risk, and assessment of specialized therapeutic approaches' effectiveness in reducing NSSI and achieving sustained psychosocial functioning. Materials and Methods. A literature review was conducted using databases (PubMed, PsycINFO, and Google Scholar) for articles up to November 2025. Inclusion criteria focused on peer-reviewed studies examining NSSI in BPD populations using validated assessment tools. Results. Neuroimaging demonstrates that NSSI produces immediate amygdala deactivation, providing neurobiological reinforcement for this behavior. The Emotional Cascade Model identifies rumination instability and emotion differentiation deficits as key triggers for NSSI episodes. Childhood trauma dysregulates the HPA axis and correlates with functional deficits. Dialectical Behavior Therapy (DBT) shows a moderate effect size in reducing self-harm (Hedges' g = -0.622) and induces neuroplastic changes. Mentalization-Based Therapy (MBT) reduces suicide attempts, though social functioning often remains impaired even in long-term follow-up. Conclusions. Specialized psychotherapies effectively stabilize acute symptoms, but a clear gap persists between symptom control and functional recovery. Future research should adopt complex dynamic systems perspectives and prioritize outcomes reflecting social integration and quality of life.

The present study aimed to compare the effectiveness of short-term psychodynamic therapy and mentalization-based therapy on self-control in individuals with a borderline personality structure. The research employed a quasi-experimental design with a pretest–posttest control group and a 2-month follow-up. The statistical population included all individuals with borderline personality structure who referred to clinics in the western districts of Tehran during the second half of the year 2024 (October to March). From this population, 45 participants were selected using purposive sampling and randomly assigned into three groups (two experimental groups with 15 participants each and one control group with 15 participants). The assessment tools included the Personality Organization Questionnaire developed by Kernberg (2002) and the Self-Control Scale by Tangney et al. (2004). The first experimental group received mentalization-based therapy following the Bateman and Fonagy (2016) protocol, while the second experimental group received intensive short-term dynamic psychotherapy based on Davanloo’s (1995) protocol. Both interventions consisted of nine weekly 90-minute sessions. Data analysis was conducted using repeated measures analysis of variance (ANOVA). The results showed that both short-term psychodynamic therapy and mentalization-based therapy had a significant effect on self-control in individuals with borderline personality structure (p < .01). Moreover, no significant difference was found between the two therapeutic approaches in terms of effectiveness (p > .05). It can be concluded that both short-term psychodynamic therapy and mentalization-based therapy may be applied as effective therapeutic approaches to improve self-control in individuals with borderline personality structure.

Understanding patients' experiences of psychotherapy is critical for enhancing treatments for mental health disorders. Despite increasing interest in patients' lived experience of long-term psychodynamic psychotherapy, this current literature has not been comprehensively synthesized. The purpose of this systematic review and meta-aggregation is to integrate and evaluate qualitative research on adults' experiences of long-term psychodynamic psychotherapy for complex mood disorders, with the aim of guiding clinical practice and future research. A systematic review and meta-aggregation of 10 qualitative studies was conducted. Participants were adults with complex mood disorders. Sixty-four findings were organized into five themes: (a) initial challenges in starting therapy, (b) nonlinear processes of change, (c) unique dynamics in group mentalization-based treatment, (d) the subjective value of gaining new perspectives, and (e) ambivalent emotions surrounding termination of therapy. Analyses drew on psychodynamic theory and process-outcome research, emphasizing mechanisms such as mentalizing, the therapeutic alliance, and insight-driven change. Patients described early engagement difficulties, gradual and unpredictable progress, pivotal group interactions in mentalization-based treatment, transformative self-insights, and mixed feelings at the end of therapy. More targeted qualitative and mixed methods research is needed to explore the subjective role of these mechanisms, as well as the potential role of intersession experiences and group processes in explaining treatment outcome in long-term psychodynamic psychotherapy. Limitations (e.g., limited studies, overrepresentation of mentalization-based treatment) point to the need for more diverse and comparative research. Overall, these findings underscore the value of mentalizing, alliance building, and fostering insight in treatment. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

ObjectivesAdolescent non-suicidal self-injury (NSSI) is a marker of severe emotional distress and a significant public health concern. This narrative review aimed to synthesize major theoretical models explaining the psychopathology of NSSI and critically evaluate the efficacy of evidence-based psychotherapies using the most recent high-level evidence.MethodsWe searched articles in major academic databases published from January 2000 up to June 2025. We prioritized studies on adolescents, including efficacy studies (randomized controlled trials and meta-analyses) addressing NSSI as a primary outcome, and key theoretical papers.ResultsNSSI was understood through integrated models, prominently featuring emotion dysregulation (biosocial theory), experiential avoidance (cognitive-behavioral models), impaired mentalization (attachment theory), and operant conditioning (functional model). The synthesis of high-level evidence, including a 2021 review from Cochrane, indicated that dialectical behavior therapy (DBT) had the strongest empirical support (high-certainty evidence) for reducing adolescent NSSI. However, while mentalization-based treatment, acceptance and commitment therapy, and attachment-based family therapy offered promising mechanism-specific approaches, evidence for their effectiveness for NSSI was preliminary or uncertain.ConclusionDBT is currently the first-line treatment for NSSIs in adolescents. However, the field must move toward personalized care. Future research should focus on validating alternative therapies through head-to-head randomized controlled trials, identifying the core change mechanisms across treatments, and implementing stepwise care models to improve accessibility.

IntroductionBorderline personality disorder is marked by emotional lability, unstable identity, and hypersensitivity to abandonment. Although mainstream treatments, such as dialectical behavior therapy, schema therapy, and mentalization-based therapy, reduce symptoms, they often bypass the subcortical affective systems shaped by early attachment trauma. This conceptual paper presents triangle therapy for borderline personality disorder, a neuroaffective intervention based on the premise that three ancestral affective conditions—silence, sound, and isolation—are hypothesized to shape autonomic dysregulation in borderline personality disorder.MethodTriangle therapy for borderline personality disorder proposes a 30-session protocol involving progressive exposure to each condition over ten sessions. Stimulus duration would increase from 5 to 50 min under continuous therapist attunement without verbal interpretation. The model emphasizes embodied co-regulation to support potential autonomic integration of historically overwhelming affective states.Hypothetical resultsPotential outcomes may include recalibration of vagal and sympathetic tone, extinction of catastrophic prediction errors, and emergence of symbolic-affective processing. The model integrates polyvagal theory, affective neuroscience, and psychodynamic frameworks on early neglect. Safety protocols and inclusion criteria are specified to support empirical evaluation.DiscussionTriangle therapy for borderline personality disorder is a theoretical model proposed to inform future research and clinical development. It is not a replacement for existing evidence-based treatments but is framed as a somatic pre-phase that may improve affective tolerance and therapy engagement. Empirical testing through pilot studies and multimodal physiological assessment is essential before clinical implementation. The protocol aims to provide new opportunities for treating severe affective instability in outpatient and inpatient settings.

The results of a previous randomized trial showed that mentalization-based treatment for psychotic disorder (MBTp) was associated with greater improvement than treatment as usual (TAU) in social functioning up to 6months after treatment. The purpose of the present study is to examine the effect after 5 years. The researchers tried to find all patients who had participated in the trial (n=84) and to assess, blind to previous treatment status, their social functioning and mentalizing capacity. Social functioning was measured using the Social Functioning Scale, mentalizing using the Social Cognition and Object Relations Scale and the Hinting Task. Twenty-three MBTp patients and 23 TAU patients collaborated. There was no evidence of selective drop-out. A complete case, repeated measure analysis of variance on the basis of intention-to-treat showed that, 5 years post-treatment, MBTp patients still scored better on social functioning compared to baseline [ηp2=.25, p=.01], whereas TAU patients did not [ηp2=.01, p=.67], with a significant difference between the conditions [ηp2=.10, p=.03]. A sensitivity analysis with linear mixed models, however, showed weaker evidence for an additive effect of MBTp over TAU on social functioning 5 years post-treatment, F=3.731, p=.06. MBT patients also showed a greater improvement in one aspect of mentalizing, understanding of social causality [ηp2=0.17, p=.04], but not other aspects of mentalizing. The results suggest a durable effect of MBTp.

Numerous studies have demonstrated that the Alternative Model for Personality Disorders (AMPD) outperforms traditional categorical nosology (i.e., Section II) in predicting an array of salient clinical outcomes. However, despite the centrality of social-cognitive impairments in personality disorder, few studies have examined the superiority of the AMPD over Section II in predicting social-cognitive deficits. The current study addresses this gap by evaluating the incremental validity of AMPD-defined level of personality functioning (LPF) versus borderline personality features in predicting mentalizing - a social-cognitive construct proposed to underlie the development of personality disorder. Participants included 267 university students (Mage = 20.49, SD = 1.74) who completed self-report measures of LPF, borderline personality features, and two measures of mentalizing: the Reflective Functioning Questionnaire (RFQ) and the Mentalization Scale (MentS). Hierarchical regressions revealed that LPF explained additional variance in the RFQ beyond borderline features and internalizing psychopathology. Although borderline features also incremented LPF in predicting the RFQ, additional variance explained was less than half that contributed by the LPF over borderline features. LPF also incremented the variance explained in the MentS total score and subscales over and above borderline features and internalizing symptoms, whereas borderline features did not increment LPF in predicting any of the MentS variables. These results strengthen the evidence base for the superiority of the AMPD over Section II and suggest that mentalizing deficits are better captured by LPF than borderline personality disorder symptoms. Findings support the extension of mentalization-based treatment to AMPD-defined personality disorder, which should be explored in future research.

Background Adolescent depression affects approximately 13% of youth globally, often emerging before age 14 and leading to long-term impairments in social, academic, and emotional functioning. Evidence suggests that mentalization-based treatment (MBT), particularly its adolescent adaptation, may reduce depressive symptoms by strengthening reflective functioning. Methods This single-arm pilot study will evaluate the feasibility and acceptability of a short-term, family-inclusive MBT intervention for 15 adolescents aged 10–14 years with mild-to-moderate depression in Valparaíso, Chile. The intervention consists of 12 weekly sessions delivered in three phases: shared formulation, promotion of individual and family mentalization, and evaluation of therapeutic progress. Feasibility outcomes include recruitment, retention, and adherence rates. Secondary outcomes include changes in depressive and anxiety symptoms, family cohesion, and therapeutic processes. Qualitative interviews with adolescents, caregivers, and therapists will complement quantitative data. Results The study will generate parameters on feasibility, adherence, and acceptability, as well as preliminary estimates of clinical and process outcomes to inform the design of a future randomized controlled trial. Conclusions Findings will guide the cultural adaptation and potential scaling of adolescent and family MBT within the Chilean public health system. This protocol outlines the methodological framework and expected contributions of the study to clinical practice and research on adolescent depression.

This commentary, written for Journal of Clinical Psychology: In Session, synthesizes five case-based contributions on psychotherapy for adolescents with personality disorders (PDs). Although PDs often emerge in adolescence, age-adapted treatments remain scarce. Randomized clinical trials are still limited, making carefully constructed case studies important for identifying promising treatments. Three of the featured cases draw on mentalization-based therapy for adolescents, implemented in combined group-individual formats, adapted toward dimensional models of PD, or extended socioecologically to involve wider social networks, such as family, peers, and school systems. The remaining two derive from metacognitive approaches: one applying Metacognitive Interpersonal Group Therapy (MIT) for Adolescents in a case of dependent and borderline PD, and the other applying MIT for Eating Disorders with an adolescent with binge eating disorder and comorbid avoidant and obsessive-compulsive PD. Across studies, four shared priorities emerge. First, the capacity to think, reason, and regulate mental states, defined as mentalizing or metacognition, serves as a central mechanism of change. Second, impairments in self and interpersonal functioning are treated as the core pathology in PDs. Third, therapeutic progress depends on actively engaging the adolescent's broader social context rather than working solely within the therapist-patient dyad. Fourth, comorbidity, whether trauma-related disorders, substance use, eating disorders, or others, should be treated integratively to ensure targeted, personalized treatment. These cases demonstrate that innovation in adolescent PD treatment often begins with single cases. The task ahead is to translate these clinical examples into rigorously tested, developmentally sensitive, and ecologically grounded intervention models that can be applied in early intervention programs.

Eating disorders (EDs) frequently emerge during critical stages of childhood and adolescence, when identity development and emotional regulation are still maturing. Disturbances in self-concept clarity and identity integration may transform the body into a symbolic battlefield for autonomy, belonging, and self-worth. This review synthesizes developmental, psychosocial, neurocognitive, and therapeutic perspectives on the role of identity disturbance in EDs. A narrative review was conducted (2010-2025) using combinations of terms related to identity, self-concept clarity, self-discrepancy, objectification, interoception, and eating disorders (anorexia nervosa, bulimia nervosa, and binge-eating disorder). Findings indicate that identity vulnerability (expressed as low self-concept clarity, heightened self-discrepancies, and self-objectification) mediates the association between early adversity, sociocultural pressures, and ED symptoms. Neurocognitive studies reveal altered self-referential processing, default mode network connectivity, and interoceptive signaling. Clinically, comorbid borderline personality features further exacerbate identity disturbance and complicate recovery. Evidence-based treatments such as enhanced cognitive-behavioral therapy (CBT-E) effectively target core maintaining mechanisms, while adjunctive interventions (mentalization-based therapy, schema therapy, narrative approaches, and compassion- or acceptance-based methods) show promise in addressing identity-related processes and improving outcomes. Identity disturbance provides a unifying framework for understanding why ED symptoms become entrenched despite adverse consequences. Integrating identity-focused approaches with nutritional and medical care may enhance recovery and reduce chronicity in youth. Future research should adopt longitudinal and mechanistic designs to clarify pathways linking identity change to clinical improvement and test identity-specific augmentations to standard ED treatments.

Treating the suicidal patient is a risky, often emotionally exhausting process that strains the best therapist's capacity to maintain the primary focus of psychotherapy. When fear, desperation, and urgency to resolve the suicidal state become overwhelming, therapists and patients can get lost in protracted power struggles and crisis management (Plakun, 2001). Starting from the proposition that suicidal states are primarily driven by overwhelming affective experiences (Maltsberger, 2004), the authors expand upon an earlier clinical article (Fowler, 2013) to include new facets of interventions accompanied by clinical vignettes. Targeted research findings supporting these core interventions follow each vignette. Therapists are encouraged to flexibly shift among clinical interventions while carefully monitoring the emotional state and responsivity of the patient: (a) creating a sense of interpersonal safety in the therapy dyad; (b) coregulation of emotion utilizing mentalization-based therapy interventions (Bateman & Fonagy, 2016) and elements of therapeutic presence (Geller & Porges, 2014); (c) enhancing mentalizing by modeling curiosity about suicidal states of mind (Allen, 2011; Bateman & Fonagy, 2016); (d) identifying meaning(s) and pattern(s) that precipitate suicidal states; and (e) aiding the patient in fostering an enduring sense of trust. While informed by attachment theory, mentalization-based therapy, and polyvagal theory, these interventions are best conceptualized as common factors and can be utilized in conjunction with third-wave cognitive behavioral therapy, interpersonal, and integrative approaches. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Mentalization-based treatment (MBT) has promising transdiagnostic applications. The evidence base for its application in non-specialist settings, including general adult community mental health services requires further evaluation. This study explores the implementation of an MBT introductory (MBTi) group in an Irish secondary mental health service. Two online MBTi groups were delivered between 2020 and 2021. A concurrent mixed-methods design was engaged. Qualitative pre- and post-intervention measures include the Clinical Outcomes in Routine Evaluation (CORE) scale, the World Health Organization Quality-of-Life (WHOQoL-BREF) scale and the Reflective Functioning Questionnaire (RFQ). Paired sample t-test was employed to analyse change. Interviews were conducted with seven participants post-intervention and inductive thematic analysis was utilised to identify themes. Participants exhibited hypomentalizing tendencies, which improved following the delivery of the intervention (RFQu: MD = 0.54, p = 0.032, Cohen's d = 0.71). There were improvements across the wellbeing, problems and functioning subscales of the CORE. There was no change in the risk domain, which was low at baseline. Improvements were observed in the WHOQoL-BREF subscale of psychological health and social relationships. Five main themes emerged from post-intervention interviews: barriers and facilitators; attitudes to design and delivery; perceived intervention effectiveness; intervention coherence; COVID-19 specific issues. MBTi delivered in a non-specialist setting is associated with improvements in mentalizing capacity. The intervention is perceived as relevant and useful by participants, although the psychoeducation and online format conferred specific limitations. The findings support the role of MBTi as a feasible transdiagnostic intervention in general adult services, as part of a range of interventions.

Mentalization-based therapy (MBT) formulates eating disorders as disorders of the self. This article examines the meaning of self-hatred and self-directed negativity as manifestations of self-alienation and vulnerable mentalizing. Relevant concepts are examined to substantiate MBT as a clinical approach to negative self-representations and epistemic mistrust. In this context, MBT states that a clinician's not-knowing stance is crucial to help elucidate underlying states of mind. Additionally, representing the patient as possessing an agentic-self is seen as crucial to the generation of curiosity about rigidified definitions of the self. Clinical vignettes are provided, and guidelines relevant to clinical practice are proposed.

The clinical management of the borderline personality disorder (BPD), and of emotional dysregulation disorders in general, raises problems both during the diagnostic and the treatment processes. Despite these challenges, clinical experience and the data from the literature make evident that the remission of the symptoms and the recovery from such disorders is now possible, under the condition of being treated with continuity. Various effective therapeutic approaches are available, such as the Dialectical Behavioral Therapy (DBT), the Mentalization-based Therapy (MBT), the Transference Focused Therapy (TFP). Of late, although the current body of research remains limited, preliminary evidence suggests that the multilevel experiential approach, Group Experience Therapy (GET) has shown promise in managing emotional dysregulation, reducing suicidal and self-harming behaviors, and enhancing patients' quality of life. This paper serves as a brief introduction to the model's rationale.

BackgroundThe evidence for the optimal duration of psychotherapy for borderline personality disorder (BPD) is scarce. Two previous trials have compared different durations of psychotherapy. The first compared 6 months versus 12 months of dialectical behaviour therapy for BPD (the FASTER trial). The second compared 5 months versus 14 months of mentalisation-based therapy for BPD (the MBT-RCT trial). The primary objective of the present study will be to provide an individual patient data pooled analysis of two randomised clinical trials by combining the two short-term groups and the two long-term groups from the FASTER and MBT-RCT trials, thereby providing greater statistical power than the individual trials. Accordingly, we will evaluate the overall evidence on the effects of short-term versus long-term psychotherapy for BPD and investigate whether certain subgroups might benefit from short-term versus long-term psychotherapy.MethodsAn individual patient data pooled analysis of the FASTER trial and the MBT-RCT trial will be conducted. The primary outcome will be a composite of the proportion of participants with a suicide, a suicide attempt or a psychiatric hospitalisation. The secondary outcome will be the proportion of participants with self-harm. Exploratory outcomes will be BPD symptoms, symptom distress, level of functioning and quality of life. We will primarily assess outcomes at 15 months after randomisation for the FASTER trial and at 16 months after randomisation for the MBT-RCT trial. Predefined subgroups based on the design variables in the original trials will be tested for interaction with the intervention as follows: trial, sex (male compared with female), age (below or at 30 years compared with above 30 years) and baseline level of functioning (Global Assessment of Functioning baseline score at 0–49 compared with 50–100).Ethics and disseminationThe statistical analyses will be performed on anonymised trial data that have already been approved by the respective ethical committees that originally assessed the included trials. The final analysis will be published in a peer-reviewed scientific journal and the results will be presented at national seminars and international conferences.PROSPERO registration numberCRD42024612840.