Enhancing Mentalization in Children: The MBKT Approach

When a child struggles to understand their own feelings, misreads the emotions of others, or gets lost in fantasy without being able to connect it back to real experience, something important in their development may not be working as it should. Mentaliseren Bevorderende Kinder Therapy (MBKT) – known in English as Mentalization-Promoting Child Therapy, closely aligned with what is internationally referred to as Mentalization-Based Treatment for Children (MBT-C) – is a structured, intensive psychotherapy designed to address exactly this. Rooted in the theoretical work of Peter Fonagy, it helps children develop the ability to understand their own and others’ mental states, ultimately improving how they manage emotions and navigate relationships.

What mentalization actually means
The theoretical foundation: Fonagy’s model
Pre-mentalizing modes: the three states MBKT targets
Psychic equivalence
Pretend mode
Teleological mode
Integrating reality and fantasy: the developmental challenge
Structure of the therapy: intensive, relational, and play-based
Transference and countertransference as therapeutic tools
Transference in the playroom
Countertransference as clinical data
Outcomes: what MBKT aims to achieve

What mentalization actually means

Mentalization is defined as the process by which we make sense of each other and ourselves – implicitly and explicitly – in terms of subjective states and mental processes. A simpler way to put it: it is the ability to see others from the inside and ourselves from the outside. For children, this capacity is foundational. Research has consistently shown that the ability to mentalize contributes to a positive sense of self, healthy relationships, and better emotional regulation. When this capacity is underdeveloped or disrupted – due to trauma, insecure attachment, or developmental difficulties – children are left vulnerable to emotional overwhelm, behavioral problems, and interpersonal difficulties.

Mentalization is not a fixed trait. It is a dynamic, context-dependent ability that can be strengthened or weakened depending on stress, relationship quality, and developmental history. Temporary lapses in mentalization are normal, but the ability to recover from these lapses – especially under emotional pressure – is what distinguishes robust mentalizing from impaired functioning.

The theoretical foundation: Fonagy’s model

MBKT is grounded in the theoretical framework developed by Peter Fonagy and Anthony Bateman, who originally designed Mentalization-Based Treatment (MBT) for adults with borderline personality disorder. Over time, this model was adapted for children, adolescents, and families. A central idea in Fonagy’s framework is that mentalization develops through secure attachment. When a caregiver consistently and sensitively reflects a child’s inner states back to them – acknowledging feelings, interpreting intentions – the child gradually internalizes the capacity to do this for themselves.

This process also builds what Fonagy and colleagues call epistemic trust – a child’s sense that a trusted adult is a reliable source of knowledge about the internal and external world. Without epistemic trust, children struggle to learn from relationships, including therapeutic ones. Establishing this trust is therefore one of the earliest and most important tasks in MBKT.

Pre-mentalizing modes: the three states MBKT targets

A key clinical focus of MBKT is identifying and working through what are called pre-mentalizing modes – states of mind that reflect a breakdown in reflective functioning. Understanding these modes helps clarify what the therapy is actually treating.

Psychic equivalence

In this mode, a child equates their internal mental experience with external reality. What is felt in the mind is experienced as factually true in the world. A child who believes they are truly worthless because they feel worthless, or who is terrified of a thought as though the thought itself is a real threat, is operating in psychic equivalence. There is no gap between what is thought and what is real.

Pretend mode

The opposite of psychic equivalence, pretend mode involves a complete disconnection of mental states from external reality. A child in this state may engage in endless fantasy or storytelling that feels rich internally but has no connection to their lived emotional experience. It can look like creativity or imagination, but it functions as avoidance – a way of keeping painful reality at bay.

Teleological mode

Here, a child understands mental states only through observable, physical actions. Emotions are only “real” if they can be seen or proven. A child in this mode might feel unloved unless given a concrete demonstration of affection, and verbal reassurance alone carries no weight.

Integrating reality and fantasy: the developmental challenge

One of the most clinically important tasks in MBKT is helping children achieve what Fonagy and Target described as the integration of the psychic equivalence mode and the pretend mode into what they called a reflective or mentalizing mode. In healthy development, mentalization progresses from concrete, undifferentiated thinking through fantasy and creative pretend play, before integrating into mature affective mentalization. Normally, this integration is completed around the age of four or five, supported by a caregiver who plays with the child, reflects their emotions, and helps them see that a thought and a fact are different things.

When this development is disrupted, children may become stuck. Children who function primarily in psychic equivalence or pretend mode have great difficulty playing, reflecting, and interacting – there is usually little room for exploration or genuine thought. Things feel absolute, and responses are driven by unprocessed emotion rather than reflection. MBKT creates a safe therapeutic space where this integration can occur, often using play as the primary vehicle.

Structure of the therapy: intensive, relational, and play-based

MBKT is an intensive form of therapy. Sessions are often conducted multiple times per week, with the frequency determined by the severity of the child’s difficulties. The therapy typically combines talk and play – using the natural language of childhood (play) alongside direct verbal engagement – to access and work through a child’s inner world. Parent guidance and involvement are also a standard part of treatment, since children’s mentalizing capacity develops within the family context.

The therapeutic focus is more on process than on content. The goal is not primarily for a child to gain insight into where their difficulties came from; rather, it is to enhance their capacity to use mentalizing to manage emotions and relationships in real time. The therapist maintains an active, curious, and non-judgmental stance – modeling the very mentalizing attitude the child needs to internalize.

Transference and countertransference as therapeutic tools

MBKT draws on psychodynamic principles, and two of the most clinically significant are transference and countertransference. In the context of child therapy, these dynamics are particularly vivid and powerful.

Transference in the playroom

Transference occurs when a child unconsciously redirects feelings, expectations, and relational patterns from significant figures in their life – most often parents or caregivers – onto the therapist. A child who has experienced inconsistency or rejection at home might, in the playroom, test the therapist with defiance, seek excessive reassurance, or assign the therapist a role in play that mirrors the caregiver relationship. For young children, this transference is not experienced as fantasy – it is felt as subjectively real, as immediate as perception. The therapist becomes, in that moment, the object of genuine emotional experience.

In MBKT, the therapist does not simply interpret transference but uses it as a live window into the child’s inner world. By noticing how the child relates to them in the here and now, the therapist gains direct access to the relational patterns that are causing difficulty in the child’s wider life.

Countertransference as clinical data

Countertransference refers to the emotional reactions a therapist experiences toward a client – feelings that can range from protectiveness and warmth to frustration, boredom, or helplessness. In MBKT, countertransference is not treated as a problem to suppress but as clinically meaningful information. A therapist who notices an unusual urge to rescue a child, or who feels unexpectedly irritated, is likely picking up on the relational dynamics the child generates in all their significant relationships. Used thoughtfully – and processed through supervision – countertransference responses illuminate the child’s unspoken emotional world and the relational impact they have on others.

Together, transference and countertransference create a relational field within the therapy that reflects and contains the child’s inner experiences. The therapist’s job is to hold and mentalize these experiences – to think about what the child cannot yet think about themselves – and gradually help the child develop that same capacity.

Outcomes: what MBKT aims to achieve

The ultimate goals of MBKT are concrete and measurable. By improving mentalization, children develop better self-regulation – the ability to identify, tolerate, and manage their own emotional states without being overwhelmed. They also develop stronger interpersonal functioning – the capacity to read social situations accurately, respond empathically, and form and maintain relationships. A broad range of mentalization-based interventions for middle childhood have demonstrated wide-reaching applicability across diverse presenting problems, from conduct difficulties and anxiety to the effects of trauma and disrupted attachment.

Critically, these gains are not just about symptom reduction. When a child can mentalize, they become better equipped to make use of relationships for ongoing emotional learning – which means the benefits extend far beyond the therapy room and into every area of their life, including school, friendships, and family.

What do you think? Given that a child’s mentalizing capacity develops primarily through relationship, how much of a role do you think parents and caregivers should play in a child’s MBKT treatment – and what might change if they were more deeply involved? If a child is stuck in psychic equivalence – experiencing thoughts and feelings as absolute facts – what do you imagine it would feel like to live inside that mental state every day?

References

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Table of Contents

What mentalization actually means 🔗

The theoretical foundation: Fonagy’s model 🔗

Pre-mentalizing modes: the three states MBKT targets 🔗

Psychic equivalence 🔗

Pretend mode 🔗

Teleological mode 🔗

Integrating reality and fantasy: the developmental challenge 🔗

Structure of the therapy: intensive, relational, and play-based 🔗

Transference and countertransference as therapeutic tools 🔗

Transference in the playroom 🔗

Countertransference as clinical data 🔗

Outcomes: what MBKT aims to achieve 🔗