Psychotherapy © 2013 American Psychological Association

2013, Vol. 50, No. 3, 360 –365 0033-3204/13/$12.00 DOI: 10.1037/a0031993

Mentalization-Based Psychotherapy Interventions With Mothers-to-Be

Rayna D. Markin
Villanova University

In recent years, the theory of mentalization has been applied to a number of clinically relevant areas
including psychotherapy for patients with borderline personality disorder, therapy with adolescents
and children, treatment of self-harm in young people, parent–infant early interventions, and even
community outreach (see Midgley & Vrouvam, 2012. Minding the child: Mentalizing interventions
with children, young people, and their families. London and New York: Routledge). Extending on
this body of work, the present article applies the theory of mentalization to psychotherapies that aim
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

to help first time expecting mothers psychologically adjust to and prepare for motherhood. Theory
This document is copyrighted by the American Psychological Association or one of its allied publishers.

and research suggest that pregnancy represents an intermediate space in which, under ideal
circumstances, the woman comes to represent herself as a mother, her unborn child as a separate and
intentional being, and her emotional bond or attachment to the fetus. However, the expecting
mother’s own conflictual experiences being mothered are likely to influence her ability to mentalize
her pregnancy, setting the stage for problems in the mother–infant dyad postpartum. This article
explores how mentalizing techniques may be used in psychotherapy to help mothers-to-be to
mentalize their emerging identity as a mother, their unborn child, and their developing relationship
to the fetus.

Keywords: mentalization, pregnancy, attachment

At times, Mother Nature seems to have the foresight of a psychotherapy. Psychotherapy with pregnant women may not only
fortuneteller. Perhaps this is most evident when considering the help the mother, but also her future child, through ameliorating
multifaceted functions of pregnancy. For the fetus, the typical 36 problems in the mother–infant attachment relationship before they
to 42 weeks in the womb allows for physical maturation, but also can occur.
for the wiring and organization of the brain that will one day lead
to social intelligence, rational thought, and the self-knowledge that Mentalization Theory: Mentalization and Attachment
one even has a brain, or a mind of one’s own. At the same time,
perhaps mother nature did not only have the fetus in mind when In this article, the author discusses how techniques derived from
deciding on a relatively long gestation period, but the expecting Mentalization-Based Therapy (MBT; Bateman & Fonagy, 2004)
mother as well, who must navigate the complex psychological can be used to help patients who are pregnant mentally prepare for
journey of preparing to become a mother to her newborn. As and adjust to motherhood. Mentalization theory emerged from
articulated by the psychoanalyst Raphael-Leff (1982), “we often Fonagy and colleagues’ experiences with the Adult Attachment
tend to forget that the purpose of pregnancy is not merely to create Interview (AAI; George, Kaplan, & Main, 1984), which measures
a baby but to produce a mother” (p. 3). In reality, expecting parents’ state of mind with respect to attachment (Hesse, 1999).
mothers invest a significant amount of emotional energy in prep- Fonagy, Gergely, Jurist, & Target (2002) observed a set of core
aration to mother. However, for some women, whether because of capacities present in individuals with a secure attachment state of
mental illness, significant life events, socioeconomic difficulties, mind but absent or distorted in individuals with an insecure at-
or a lack of early positive mothering experiences, professional help tachment state of mind. They refer to these capacities collectively
is needed to psychologically prepare for motherhood. Consistent as mentalization, or the capacity to envision mental states in one
with this, studies suggest that at least some stress is associated with self and in another, and to understand one’s own and another’s
pregnancy for most women (see Slade, Cohen, Sadler, & Miller, behavior in terms of underlying mental states and intentions (Fon-
2009, for a review), with up to one in seven women experiencing agy et al., 2002). Fonagy, Steele, & Steele (1991) operationalized
a mental health problem during their pregnancy (“Management of mentalization as the mother’s capacity for reflective functioning
Women with,” 2011). In essence, pregnancy is not just a medical and found that: (a) mothers with higher reflective functioning were
condition for women; it is a psychological process, which presents more likely to be securely attached, and (b) mothers’ antenatal
both great challenges and immense opportunities for the work of reflective functioning was more predictive of their infant’s security
at 1 year old than the mothers’ adult attachment classification (also
see Slade, 2005; Slade, Grienenberger, Bernbach, Levy, & Locker,
2005). From this, it is proposed that the expecting mother’s ability
Correspondence concerning this article should be addressed to Rayna D. to mentalize, and specifically her ability to mentalize aspects of her
Markin, Department of Education and Counseling, Villanova University, pregnancy, is the mechanism of change through which the psy-
302 SAC, 800 Lancaster Ave, Villanova, PA 19075. E-mail: Rayna chotherapy interventions below help patients to psychologically
.markin@villanova.edu. prepare for motherhood.

360
 MENTALIZATION-BASED PSYCHOTHERAPY INTERVENTIONS 361

Mentalizing the Pregnancy: Suggested Interventions to baby. In essence, the expecting mother has the daunting task of
Facilitate Mental Processes internally representing her unborn child as possessing a mind of its
own without actually knowing the child, all while understanding
With the physical pregnancy there is also a mental pregnancy that the way in which she represents her unborn child’s mind in her
during which the pregnancy is actively mentalized and the mother mind might not even accurately reflect her actual child. On the
mentalizes herself as a mother.—Allen, Fonagy, & Bateman, 2008, other hand, mothers who define the real baby in terms of how they
p. 242 imagined the baby to be are operating in what Fonagy and Target
Although her body prepares the fetus for life as a newborn, the (1996) refer to as pretend mode, or psychic equivalence, where
mother’s mind prepares the self for the birth of a mother. When the mental representations are not distinguished from external reality.
mother’s ability to mentalize her pregnancy is thwarted, her psy- Some research suggests that a mother’s ability to mentalize the
chological preparation and adjustment to motherhood is also chal- fetus as a separate being predicts her ability to mentalize with the
lenged, including her ability to foster the mother–infant bond. This actual child, which ultimately predicts security of attachment (Ar-
article elaborates on three mentalizing tasks specific to pregnancy: nott & Meins, 2007, 2008; Meins, Fernyhough, Fradley, &
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

mentalizing the baby as possessing a separate mind, mentalizing Tuckey, 2001).

This document is copyrighted by the American Psychological Association or one of its allied publishers.

the self as a mother, and mentalizing the mother’s emerging The ability of the expecting mother to appreciate the separate,
relationship with the fetus, and offers corresponding interventions unique, and opaque mind of her unborn baby is often hampered by
to facilitate mentalization in each of these three areas. the human tendency to perceive the unknown in terms of the
known. The fetus is, in psychoanalytic terms, the perfect “blank
Mentalization-Based Therapy Interventions slate,” in which the mother’s projections may land without ques-
tion or contradictory evidence (Raphael-Leff, 1990). In particular,
Allen et al. (2008) summarizes interventions designed to en- the mother’s past attachment experiences, if not mentalized, are
hance patient mentalization, which they call mentalizing interven- likely to shape how she perceives and relates to her unborn child.
tions. These interventions represent the style of interventions de- Consistent with this, Pollock and Percy (1999) found that pregnant
veloped initially for MBT; however, they may be applied in a women with a preoccupied adult attachment style were more likely
variety of therapies (Allen et al., 2008). The present article adds to to have a negative preoccupied attachment to the fetus. For these
the literature by applying these interventions to specifically help- women, ambivalence within adult attachment relationships ap-
ing patients to mentalize their pregnancy. MBT as a whole has peared to have translated to negative and ambivalent feelings
been found to be effective for patients with borderline personality toward the fetus. These mothers, who were also more likely to be
disorder (Bateman & Fonagy, 1999). Moreover, interventions to classified as possessing borderline personality traits, may have
enhance parental reflective functioning, as part of a parent–infant projected hostile affect onto the unborn child (Pollock & Percy,
intervention program called Minding the Baby (Slade et al., 2004), 1999), leading to descriptions of the fetus as “invading,” “control-
show encouraging results in an ongoing experimental two-group ling,” or “alien” (Condon, 1986). Pollock and Percy (1999) suggest
longitudinal study (Sadler, Slade, & Mayes, 2006). Each section that mothers’ attachment experiences and traumas are projected
below begins with a review of the theory and research supporting onto the fetus, perhaps setting the stage for mothers’ early attach-
the proposed area of intervention, followed by a case vignette that ment traumas to be projected onto and replayed within the mother–
applies mentalizing interventions (Allen et al., 2008) to helping infant relationship, a process referred to and empirically supported
expecting mothers to mentalize aspects of their pregnancy. as the intergenerational transmission of attachment (Grienen-
berger, Kelly, & Slade, 2005; Slade et al., 2005). In essence, the
Mentalizing the Fetus as Separate, Unknown, and as mother’s projections onto the fetus make less room in her mind for
the unique mentalistic qualities of her unborn child and cause the
Possessing Unique Mental States
mother to misattribute the mental states of her baby.
Mothers are believed to acquire an increasingly elaborate and
complex internalized representation of the fetus during pregnancy
Case Vignette: Techniques for Mentalizing the Fetus
(Rubin, 1984). However, the degree to which expecting mothers
represent their unborn child as possessing a separate mind varies Marcy is in her third trimester of pregnancy and has been
(Arnott & Meins, 2008). When the mother is unable to mentalize struggling with severe varicose veins. Marcy, who has a history of
or imagine the fetus as possessing a separate mind with particular trauma, feels as if the varicose veins, which resemble black and
needs and internal states, then boundaries may be blurred and blue marks, are physical “signs” of her baby’s (known to be a boy)
mental states misattributed. For example, Emily, who is 17 and abuse. Marcy is having difficulty mentalizing her baby’s mind as
pregnant, states that she goes to clubs because her baby likes to separate and unknown and instead projects mental states onto her
dance and have fun. At the same time, the profound difficulty unborn child that are based on her early traumatic attachment
involved in mentalizing one’s unborn child is that the child is experiences. These projections “glue” her to one rigid perception
largely unknown (see Slade, Patterson, & Miller, 2007). For this and representation of her baby’s mind that defines her experience
reason, the expecting mother’s subjective experience or internal- of not only her relationship to her fetus, but also her expectations
ized representation of the fetus has been referred to as the fantasy of her real baby (i.e., psychic equivalence).
or imagined baby (Bruschweiler-Stern, 2004). Bruschweiler-Stern Therapist: If I am understanding you correctly, in your mind,
(2004) theorized that, upon birth, the mother must negotiate the these veins are like a signal, like watch out, this baby is just like
ways in which her imagined baby resembles and does not resemble all the other men in your life, dangerous and abusive, and that is
her real baby in order to establish a new relationship with her new causing you a great deal of anxiety and pain right now. Is that
 362 MARKIN

right? (Therapist links two different mental states, the patient’s Mentalizing the Self as a Mother: Reflecting on
anxiety and pain and her belief that the fetus is dangerous and Maternal Identity
abusive, offering the patient a perspective on how her mind is
working in the room) In optimal circumstances, pregnancy is a time in which women
Marcy: (crying) Yes, exactly. begin to identify not only as a single woman but also as a mother.
Therapist: Can we slow down and try to understand these Mercer used the term maternal role attainment to refer to “the
feelings toward your baby? (Encourage patient to think about her process in which the mother achieves competence in the role and
integrates mothering behaviors into her established role set, so that
emotions in the presence of strong affect)
she is comfortable with her identity as a mother” (1985, p. 198).
Marcy: These veins are from the baby. Look at me! I look like
Essential to Mercer’s (1985) four phase model of maternal role
I was beaten!
attainment is the anticipatory phase, during the prenatal period, in
Therapist: I’m not sure why, but I don’t think we see the
which the woman uses role play and fantasy to prepare for moth-
situation the same way. I understand why you would think the veins
erhood during pregnancy. In subsequent stages of Mercer’s model,
resemble black and blue marks. But, it’s your certainty that these
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the mother is believed to move from following external role

veins mean that the baby has some malicious intention that, in my
This document is copyrighted by the American Psychological Association or one of its allied publishers.

models in performing the mothering role to developing her own

mind, I have a hard time following. (Encourage mental flexibility
internal and more personal mothering model. The development of
in the presence of strong affect; model multiple perspectives [two
maternal identity is believed to take place simultaneously with role
minds can see the same situation differently], which helps to
internalization (Mercer, 1985).
encourage mental flexibility in the patient) From a mentalization perspective, the theory of maternal role
Marcy: Well, I know he [the Fetus] hasn’t actually beaten me. attainment may be understood as a process whereby the mother
Therapist: No, but that’s what it feels like to you and I’m trying comes to keep her mother self in mind. In other words, how does
to understand that feeling because it seems to be coming from a she understand the way in which her mind works in the context of
very deep place. (Encourage curiosity into the patient’s mind and her new mother role? Consistent with Mercer’s anticipatory phase,
understanding of emotional conflicts) Slade et al. (2007) argue that the woman begins to form a sense of
Marcy: Every man I’ve ever been close to has taken advantage self as a mother in the context of reverie, writing that reverie serves
of me and now it’s like, here we go again, but this time it’s almost “as a play space or intermediate area (Winnicott, 1971) in which
worse because . . . I forgot what I was saying. the pregnant woman begins to hold her baby and herself as a
Therapist: There is a lot of pain there around trusting men. mother in mind” and to “play with the idea of becoming a mother
You’ve had to protect yourself from your father, the baby’s father, in a variety of ways” (p. 6). Some of these reveries may cast
and now in your mind it’s hard to think about the baby in a oneself in a self-serving, overly positive light, in an effort to
different way. It doesn’t feel safe to trust, not even your own child, manage anxiety related to stepping into the mother role for the first
because it’s been your experience that every time you do you get time (Slade et al., 2007). On the other hand, perhaps because of
burned. (Support patient when in non mentalizing mode, empathi- socioeconomic difficulties, poor early attachment experiences, or
cally identify rigid projections/perspectives, help client understand untimely/unplanned pregnancies, some women may create overly
the meaning of her emotions in the context of past and present negative reveries, which come to define their experience of their
attachment relationships) pregnancy (Slade et al., 2007).
Marcy: So you don’t think my baby is like his father? Maybe this Slade et al. (2007) argue that reflective functioning helps the
is just a feeling I have? mother in these instances to recognize and reflect upon the func-
Therapist: I don’t know. None of us can possibly know what tion of such reveries. For instance, a mother may recognize that
your baby is really like yet. I think the important question is why she has a tendency to believe that she will always know what her
given the ambiguity of the situation do you hold so tightly to this baby wants when the baby cries because it makes her feel anxious
belief that he is just like his dad or his grandfather? (Challenge and helpless to think of not knowing. Similarly, a mother may
patient as she begins to mentalize more, point out non mentalizing recognize that she has a tendency to picture herself as feeling
“pretend” mode, explore rigidity of attachment reenactments). easily overwhelmed and anxious in response to her newborn’s
Marcy: (pause). The bruises, I mean the veins, they remind me needs because this was the way her own mother was with her. In
of when my dad would come after me with a belt (pause). My mom the latter example, this new mother is able to mentalize the effect
never stepped in to stop it. When I told her what was going on, she of the past on the present. Consistent with this, Raphael-Leff
blamed me, and I was convinced that it was my fault so I let it (1982, 1990) theorizes that a new mother’s emerging maternal
continue. identity is often unknowingly influenced by her own experiences
Therapist: That little girl was so unprotected. She was confused being mothered, and specifically, how her own mother figure took
and frightened and needed someone safe to turn to (client nods). on the maternal role. Mothers, with the ability to reflect on how
Now that you are the mom, what do you want to say to your baby their emerging maternal identity is influenced by their own mother,
about the “bruises” on your legs? (Therapist “speaks” for mother are theoretically in a better position to complete Mercer’s (1985)
and asks mother to “speak” for fetus in effort to separate past from final phase of role attainment, where the mother moves from
present; put emotions in context of past and present attachment basing her maternal identity on external figures to internalizing a
relationships)
Marcy: (crying). They aren’t her fault. She didn’t do anything 1
All case vignettes are fictionalized based on an amalgamation of
wrong. She don’t know any better.1 clinical experiences, and thus, no one person may be identified.
 MENTALIZATION-BASED PSYCHOTHERAPY INTERVENTIONS 363

more personal maternal role or identity. The vignette below illus- Therapist: How did that make you feel back then, as a child?
trates how the therapist uses mentalizing intervention to help the Casey: I didn’t understand why the other kids hugged their
patient mentalize her new maternal role. moms but I wasn’t allowed to. I would cry but I didn’t want to
show my mom because I wanted her to think I was strong.
Case Vignette: Techniques for Mentalizing the Self as Therapist: I noticed you started to rub your belly when you said
that. (Encourage multiple perspectives by highlighting behavior
a Mother
that contradicts patient’s perception of self as a mother)
Casey is a 30-year-old first time expecting mother. She sought Casey: (smiling) Hmmm . . . I didn’t notice. I guess I did.
therapy because she felt “numb” and “unexcited” about her preg- Therapist: How did that feel? (Label emotions)
nancy. Although this was something Casey wanted to change, she Casey: It felt nice. I don’t want my child to feel the way I did.
feared that she did not possess the ability to take on the mother I want her to feel like she is loved.
role. Although the pregnancy was unplanned, Casey and her hus- Therapist: It seems like in your mind you have this very fixed
band decided to keep the baby, stating that they felt pressure due idea that you are somehow destined to be just like how you
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

to their age. Casey’s therapist suggested that she join a support perceived your own mother to be, rejecting and not very affection-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

group for other expecting first-time mothers. ate. Yet, in my mind, you actually have a lot of love to give but
Casey: I went to the pregnant person group you sent me to don’t always feel comfortable showing it. (Identifying rigidity of
yesterday. I didn’t like it. The other women all talked about how patient’s conclusions, encourage mental flexibility or multiple
they spoke to their babies and read to them. It’s just stupid. It’s not perspectives)
like your baby can hear you in there. Casey: I’d like to think you are right. I think it’s scary for me.
Therapist: So you see yourself as different from the other moms If I’m not like my mother, then I really have no idea what kind of
in the group. How do you feel about those differences? (Support mother I will be, it’s like a black hole.
patient when not mentalizing; encourage patient to label emotions) Therapist: I’d like to talk more about that fear with you. I think
Casey: I’m just not the mothering type! I’m just not that kind of we have to figure out together what goes on in your mind that stops
mother who is all baby all the time. you from having more moments of connection, like the one you just
Therapist: How do you see yourself as a mother? (Encourage had, with your baby. (Explore rigid attachment reenactments with
patient curiosity into how her mind is working essentially how she fetus)
holds herself as a mother “in mind”)
Casey: I never thought I was cut out for this job. If there was a Mentalizing the Mother–Fetus Relationship: Maternal
job interview for being a mother I would never be hired. I picture
Attachment to the Fetus
this baby coming out and saying, “Can I trade her in?”
Therapist: Wow, I’m struck by how much you put yourself down. Research suggests that as pregnancy progresses the emotional
You seem to have a very fixed idea of what you will be like as a bond, or attachment, between mother and unborn child develops
mother before you even get the chance to prove yourself right or (see Canella, 2005 for a review). Cranley (1981) defined maternal–
wrong. Where did this perception of yourself come from? (Identify fetal attachment as “the extent to which women engage in behav-
nonmentalizing “pretend” mode and rigidity of patient’s conclu- iors that represent an affiliation and interaction with their unborn
sions) child” (p. 181). More recent research has revealed two distinct
Casey: I look at other pregnant women and they seem to be so dimensions of antenatal emotional attachment, the quality and
“lovey” with their babies. I’m not that way with anyone. My quantity of attachment patterns in the mother–fetus relationship
husband is always like, why don’t you hug me more, or, say nice (Condon, 1993). Quality of affective experience toward the fetus
things to me, and that’s just not my style. I mean sometimes I want consists of experiences of closeness/distance, tenderness/irritation,
to but I feel weird . . . positive/negative feelings, having a clear/vague mental picture of
Therapist: What do you think your husband needs in those the child, concept of the fetus as a person/thing, and acknowledg-
moments? ment that the fetus is dependent on the mother for his or her
Casey: I think he just wants attention honestly. well-being. Quantity or intensity of attachment refers to the moth-
Therapist: Maybe, but is there another way of understanding er’s time spent thinking about the fetus and her interest in him or
what’s going on inside of him? Because I’m thinking that with both her. High quality and quantity attachment relates to the mother’s
your husband and with the women in the new mothers group you desire to know about, avoid separation or loss from, protect,
have a hard time imagining what’s in their heads when they act identify, and gratify needs of the fetus, and represents the ideal
affectionate? (Help patient identify mental states in the mind of pattern of involvement (Leifer, 1977). Research suggests that a
another while recognizing that one can never know what is in woman’s adult attachment style mirrors her attachment style to the
another’s mind) fetus (see Canella, 2005 for a review, Pollock & Percy, 1999) and,
Casey: I guess because it’s different than me. I’m not affection- moreover, maternal–fetal attachment predicts the quality of attach-
ate. ment in the mother–infant dyad postnatal, at least in the first 8
Therapist: So what do you do when you need to feel close to months, and the mother’s adjustment postnatal (see Canella, 2005
someone? for a review; Leifer, 1977).
Casey: I haven’t needed that since I was little. Research and theory suggest that it is crucial for the mother to
Therapist: O.K., well what did you do when you were little? mentalize within the mother–infant attachment relationship (Meins
Casey: I remember asking my mom for hugs and she would push et al., 2001; Arnott & Meins, 2007; Slade, 2005). Grienenberger
me away. (2012) suggests that a parent’s attachment state of mind predicts
 364 MARKIN

the specific area in which he or she has difficulty mentalizing with Therapist: How do you imagine I’m similar to you? (Explore
the child, with more preoccupied parents failing to mentalize the attachment reenactment with the therapist; explore patient’s men-
child’s need for autonomy and mastery and the more dismissive tal states related to sameness in therapy relationship)
parent failing to mentalize the child’s need for intimacy and affect. Client: Little things, like the other day I went shopping and I
Similarly, the expecting mother’s attachment state of mind may bought matching outfits for me and the baby and I thought this is
predict the specific area in which she has difficulty mentalizing the something you would do and it made me smile.
maternal–fetal attachment relationship. Expecting mothers with a Therapist: I don’t know how this will sound to you but in some
dismissive state of mind may be more likely to have difficulty with respects, in my mind, we do seem similar. We are both mothers
the sameness of pregnancy, whereas mothers with a preoccupied who love our children and I really value your big heart. But, in
state of mind are more likely to have difficulty with the differen- other ways, I think we are different people with unique minds.
tiation between self and fetus, leading to distorted, denial of, or Actually, I don’t think I would buy matching outfits. In my mind
bizarre reflective functioning. For instance, women with a dismis- though, our differences don’t make us any less close. I’m wonder-
sive state of mind may distort or deny the stage of pregnancy that ing how it makes you feel that we see this differently. (Encourage
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Raphael-Leff (1982) calls fusion, where the embryo is integrated multiple perspectives; clarify projections or what is going on in the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

into the mother’s sense of self rather than experienced as a “for- mind of the therapist; Help patient to identify mental states in the
eign body” (p. 6). On the other hand, women with a preoccupied mind of another as separate.)
(Therapist then helps patient process her anxiety around differ-
state of mind may reject or distort what Raphael-Leff (1982) calls
ences and her fear of rejection within the therapeutic relationship
the differentiation stage, where the woman begins to experience
and how this theme also plays out in her relationship with her
the fetus as “familiar yet separate and autonomous” (p. 6).
unborn child.)
What are the implications of theory and research on maternal–
fetal attachment and mentalization on therapist technique? What-
ever aspect (sameness or differentiation) of attachment that the Concluding Remarks
expecting mother has difficulty mentalizing within the maternal–
fetal relationship will likely replicate itself within the therapeutic The psychological experience of pregnancy is akin to a spider
relationship. Here, the therapist’s goal is to provide a secure base web, everything sticks. Conflicts from the mother’s past that were
experience that facilitates the mother’s exploration of mental states previously acknowledged as merely flying around the periphery
now stick like glue, as they are embedded into her web of expe-
(hers, yours, and the babies) (Allen et al., 2008). In particular, the
rience. Creating a new life reopens the door to early attachment
therapist helps more dismissive mothers to explore mental states
experiences in one’s own life. This reawakening of unresolved
related to sameness or closeness, whereas the therapist helps more
conflicts often leads to much psychic pain and disequilibrium for
preoccupied mom’s to explore mental states related to differenti-
the mother, which if left unresolved, can color the way in which
ation or autonomy, within the therapeutic relationship. Then, the
she thinks about and relates to herself as a mother and to her
therapist can then help the patient to link attachment patters and
unborn child. However, this challenge also represents the unique
related mental states within the therapeutic relationship to her
opportunity that psychotherapy offers mothers-to-be. Psychother-
relationship with the fetus. Consistent with this, attachment theo- apy may help the expecting mother to reflect on, or mentalize, her
rists argue that if patients establish a more secure attachment to the early attachment experiences, enhancing the well-being of the
therapist then this will lead to change in the patient’s attachment mother and eventually the mother–infant dyad. In this article, three
style in close relationships (e.g., Bernier & Dozier, 2002). Accord- areas of intervention—mentalizing the fetus, the self as a mother,
ingly, preliminary research suggests that change in attachment to and the mother–fetus relationship—were suggested to help the
the therapist predicts change in attachment in close relationships expecting mother mentally adjust to and prepare for parenthood.
(e.g., Janzen, Fitzpatrick, & Drapeau, 2008). Although specific techniques were offered to facilitate these three
mental processes, these techniques are suggested to be effective
within a secure, mentalizing, therapeutic relationship. Newborns
Case Vignette: Mentalizing the Mother–Fetus
are not the only ones that need to be “held.” Beyond any specific
Relationship intervention, it is the goal of the therapist to hold the mother’s
The following patient–therapist exchange illustrates how the mind in his or her mind so that the mother may hold the child’s
therapist may help an expecting mother with a preoccupied state of mind in hers.
mind mentalize the differentiation between self and fetus, using
mentalizing interventions, by first focusing on the therapist–patient
References
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sentations, postnatal mind-mindedness, and infant attachment security:
similar, I sense it’s very comforting to you? What about that is
A preliminary study of mothers and fathers. Bulletin of the Menninger
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be close, like with you and me. I know you don’t come out and say pregnancy to the first year of life. Infant Behavior and Development, 31,
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 MENTALIZATION-BASED PSYCHOTHERAPY INTERVENTIONS 365

Bateman, A. W., & Fonagy, P. (1999). Effectiveness of partial hospital- Leifer, M. (1977). Psychological changes accompanying pregnancy and
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client-nominated relationship building incidents: Client attachment, at- Received January 7, 2013
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