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Guide VIII-009

Mentalization-based art therapy

Dominik Havsteen-Franklin2013United Kingdom
A 35 · L 40 · M 2527 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Dominik Havsteen-Franklin's mentalization-based art psychotherapy (MBAP; CNWL NHS Foundation Trust and the International Centre for Arts Psychotherapies Training, ICAPT, UK; also called MBAT) as described in his openly available papers (Taylor Buck & Havsteen-Franklin 2013; Havsteen-Franklin et al. 2016; Havsteen-Franklin 2017) and in the CNWL 12-week image-making psychoeducation programme (Havsteen-Franklin, Patsou, Somaini & Camarena Altamirano 2020), supplemented by secondary accounts of his 2019 handbook chapter (Kuhn 2025; Parkinson et al. 2024). His 2016 book chapter (in Rubin, Approaches to Art Therapy) and the 2015 responsive art-making paper (Havsteen-Franklin & Camarena Altamirano, International Journal of Art Therapy) are not drawn on [uncertain]. Where the related Art MBT psychoeducation course for early-intervention psychosis (Parkinson, Cole & Trevelyan 2024) adds concrete procedures, it is labelled as that variant.

What it is: an art psychotherapy that uses the principles of Mentalization-Based Treatment (MBT; Bateman & Fonagy) inside the art therapy triangle of client, therapist and artwork. It was developed mainly for adults with borderline personality disorder (BPD) or "complex emotional needs" and for people with psychosis in UK secondary mental health care [source: CNWL course page; Havsteen-Franklin et al. 2020]. Havsteen-Franklin is one of several contributors to a wider mentalizing art therapy literature (e.g. Franks & Whitaker 2007; Springham and colleagues 2012 onward; Thorne 2016; Moore & Marder 2019), so it is a named approach within a field rather than a single trademarked protocol [source: Taylor Buck & Havsteen-Franklin 2013 references; BAAT InSight 2025; Springham 2020 review].

How change happens (as the sources describe it): image-making creates an external object that embodies inner and relational states; looking at and talking about it together, with a therapist who responds contingently and with curiosity, lets the client step back, see their mind "as an observer of themselves" and gradually regain epistemic trust (trust that other people's communication is reliable and relevant) [source: Taylor Buck & Havsteen-Franklin 2013; Havsteen-Franklin et al. 2020]. Improvised art-making is treated as implicit mentalizing and reflection on the artwork as explicit mentalizing [source: Havsteen-Franklin 2019 as summarised by Kuhn 2025 – secondary].

2. Framework

Professional frame. In the UK "art therapist" and "art psychotherapist" are legally protected titles; practitioners train to master's level and must be registered with the Health and Care Professions Council (HCPC); the professional body is the British Association of Art Therapists (BAAT) [source: Havsteen-Franklin 2017]. Havsteen-Franklin is an accredited MBT practitioner [source: Havsteen-Franklin 2017]; the MBT accreditation route itself is [uncertain]. Training specific to the approach: the CNWL/ICAPT 2-day mentalization-based arts psychotherapy training (gives an attendance certificate only, not accreditation) [source: CNWL course page] and a BAAT self-study introduction course [source: BAAT InSight 2025]. In practice: a psychotherapist who is not an HCPC-registered art therapist must not present this as art therapy or art psychotherapy; co-facilitate with, or refer to, a registered art psychotherapist, and get MBT training and supervision before using the mentalizing elements [synthesis]. Outside the UK use the national credential (e.g. AATA/ATCB credential in the US) [synthesis].

Phase 0: Assessment and formulation (up to 4 sessions). Covers attachment trauma, self-harm, identity disturbance, affect dysregulation, motivation, family, finances, social factors and risk. A formulation report is co-written with the patient, shared, and reviewed during the programme [source: Havsteen-Franklin et al. 2020]. Move on when: diagnosis confirmed (in the published programme all members had a confirmed BPD diagnosis), risk manageable in a group, and the person agrees to the group frame [source: Havsteen-Franklin et al. 2020; risk threshold is synthesis].

Phase 1: Image-making mentalization psychoeducation group (12 weekly sessions, 90 minutes). Closed group of people with BPD, two art psychotherapists facilitating, in a secondary-care adult mental health service. It works both as a standalone intervention and as preparation for longer treatment [source: Havsteen-Franklin et al. 2020].

  • Session sequence: attendance and refresher of the previous session → presentation and development of the week's theme → discussion → image-making → feedback → preparation for the next session [source: Havsteen-Franklin et al. 2020].
  • Weekly themes (adapted from Karterud & Bateman's MBT-I psychoeducation manual): (1) mentalizing and the mentalizing stance; (2) what it means to have problems with mentalizing; (3) why we have emotions and the core emotions; (4) registering and regulating emotions; (5) the significance of attachment relationships; (6) attachment and mentalizing; (7) what BPD is; (8–9) mentalization-based arts therapies, parts 1 and 2; (10) anxiety, attachment and mentalizing; (11) depression, attachment and mentalizing; (12) summary, conclusion and feedback [source: Havsteen-Franklin et al. 2020].
  • Materials: chalks, pens, paints, coloured pencils; artworks are kept until session 12 [source: Havsteen-Franklin et al. 2020].
  • Ground rules: confidentiality, respect, punctuality, no alcohol, drugs or violence, no contact between members outside the group [source: Havsteen-Franklin et al. 2020].
  • Ending: a collaborative decision about whether further treatment is needed [source: Havsteen-Franklin et al. 2020].

Phase 2: Longer-term mentalization art psychotherapy. The programme prepares people for an 18-month arts-based mentalization treatment; most interviewed members went on to a non-directive mentalization art psychotherapy group [source: Havsteen-Franklin et al. 2020]. Session length, frequency, whether individual sessions run alongside (as in standard MBT) and the ending procedure of this phase are not given in the sources [uncertain].

Within-image sequence (any phase). Havsteen-Franklin's 2019 chapter is summarised as moving from joint perception of the artwork's formal features, to exploring affect, to art-based narration [source: Kuhn 2025 summarising Havsteen-Franklin 2019 – secondary; Kuhn says four phases but names three, so the full sequence is uncertain]. His 2017 paper gives the same order in practice: describe texture and quality before form, agree on formal features, then explore the person depicted [source: Havsteen-Franklin 2017].

Across-treatment progression. Early on the arts ground the patient in emotional experience and stimulate reflexive capacity; later, once the patient can reflect, the work explores their relational context [source: Havsteen-Franklin 2017]. In the psychoeducation group, members moved from doodles and experimental marks toward figurative images with narratives about attachment and mentalizing [source: Havsteen-Franklin et al. 2020]. Criteria for moving on beyond these descriptions were not found; a usable rule is to move to more relational or activating work only when the person can stay with a feeling in the image and consider another view of it without arousal escalating, and to step back when they cannot [synthesis, consistent with Parkinson et al. 2024 scaffolding].

Variant: Art MBT psychoeducation for early-intervention psychosis. 10 weekly 2-hour sessions in a community art studio (chosen to reduce stigma), co-led by an art psychotherapist and a psychiatric registrar; based on the MBT Introductory Programme. Each session: last week's art displayed and used to recall the topic → new topic introduced with projected images → short teaching with handouts → art exercise → work put on the wall and looked at together while practising mentalizing questions. Topics: mentalizing, basic emotions, attachment, mentalizing culture (held in a museum or gallery), anxiety, trauma, depression, compassion, later "What is psychosis?". Afterwards participants could make Audio-Image Recordings [source: Parkinson et al. 2024]. A US 8-week group model for emerging adults (Moore & Marder 2019, Menninger Clinic) exists but was known only from a review [source: Springham 2020 review; uncertain].

3. Guiding principles

  • Mentalizing is the aim, not the art product or insight into content. Attend to how the person is thinking about minds (their own and others') more than to what the image "means" [source: Springham 2020 review of Moore & Marder; Havsteen-Franklin et al. 2016, element "explore self-other states of mind"].
  • Not-knowing, genuine curiosity, non-judgement. Ask rather than tell; treat your reading of an image as one hypothesis [source: Havsteen-Franklin 2017; Parkinson et al. 2024; Havsteen-Franklin et al. 2016].
  • Collaborative and explorative, not interpretation-led. Work out meaning with the client; do not offer transference interpretations or simply contain silently [source: Taylor Buck & Havsteen-Franklin 2013; BAAT InSight 2025].
  • Contingent, attuned, marked responding. Your response should match and resonate with the client's emotional state, including non-verbally, and be clearly about them (marked), so they can recognise themselves in it [source: Taylor Buck & Havsteen-Franklin 2013; Springham & Huet 2018 as cited in BAAT InSight 2025].
  • Transparency about difficulty and impact. Say openly when you are unsure, have lost the thread, or are affected, as a model of mentalizing yourself [source: Taylor Buck & Havsteen-Franklin 2013].
  • Epistemic trust is the route to change. Build reliability and relevance first (attunement, keeping people in mind) so that new perspectives can be taken in [source: Taylor Buck & Havsteen-Franklin 2013; Parkinson et al. 2024].
  • Regulate arousal before reflection. Mentalizing fails under high affect; image-making slows the pace; when arousal rises, return to empathic validation [source: Havsteen-Franklin 2017; Havsteen-Franklin et al. 2020; Parkinson et al. 2024].
  • The image is a shared third object. Look together at something outside both of you; this lowers interpersonal threat and gives a common reference point [source: Taylor Buck & Havsteen-Franklin 2013].
  • Structure communicates intent. Predictable session structure helps clients who struggle to read help as benign; facilitation should be careful, structured and sensitive because of retraumatisation risk [source: Springham 2020 review; Havsteen-Franklin et al. 2020].
  • Match directiveness to state. Be more directive and structured with disoriented or highly aroused clients; more open and improvised when they can reflect [source: Havsteen-Franklin et al. 2016].
  • Therapist as active participant. Making your own artwork alongside, or in response, shifts you from expert-observer to participant and opens non-verbal dialogue that can later be made explicit [source: Parkinson et al. 2024 citing Havsteen-Franklin & Camarena Altamirano 2015; Taylor Buck & Havsteen-Franklin 2013].
  • Implicit to explicit. Let improvised making carry implicit meaning, then bring it into words when the person can manage it [source: Kuhn 2025 summarising Havsteen-Franklin 2019; Havsteen-Franklin et al. 2016].
  • Validate first. Name and accept the feeling the image shows before exploring alternatives [source: Kuhn 2025; Parkinson et al. 2024].
  • No skill judgement. Clients often feel embarrassed and exposed about drawing; avoid praise or critique of quality [source: Havsteen-Franklin et al. 2020; Parkinson et al. 2024].
  • Watch your own mentalizing. Therapist rigidity, poor attunement, non-validation or over-close attachment can cause iatrogenic harm; use supervision [source: Havsteen-Franklin et al. 2016].

4. Intervention inventory

Scope note: the sources name these interventions but rarely give step-by-step procedures. Steps below follow what each source describes; anything added to make a step usable is marked [synthesis]. Example language is illustrative unless quoted and cited. Materials and safety (applies throughout): the published group used chalks, pens, paints and coloured pencils [source: Havsteen-Franklin et al. 2020]; other sources add charcoal, clay, ink and soft dough [source: Kuhn 2025; Havsteen-Franklin 2017; Parkinson et al. 2024]. Use non-toxic, labelled materials; avoid fixative and solvent sprays in unventilated rooms; keep clay damp and wet-clean surfaces (no dry sweeping) to limit silica dust; with people who self-harm, count scissors, craft knives, wire and glass in and out and avoid them in high-risk phases [synthesis].

4.1 Pre-group assessment and co-written formulation

  • Purpose: assess suitability and risk, build an early working alliance, and give the person a written account of their difficulties they can review as the group runs. Use before Phase 1 [source: Havsteen-Franklin et al. 2020].
  • Steps: (1) Offer up to four individual sessions. (2) Cover attachment trauma, self-harm, identity disturbance, affect dysregulation, motivation, family, finances, social circumstances and risk. (3) Write the formulation together, in the person's words where possible, and give them a copy. (4) Return to it at points in the programme (e.g. the attachment and BPD sessions) and at the end [source: Havsteen-Franklin et al. 2020; timing of reviews is synthesis]. (5) Agree a risk plan and crisis contacts before the first group [synthesis].
  • Example language (illustrative): "Let's write this together. Tell me if I've put anything in a way that doesn't fit you."
  • Watch for: agreement that feels compliant rather than owned (ask what they would change); risk that a group cannot hold; signs that being written about feels exposing. Working: the person corrects or adds to the formulation [synthesis].

4.2 Setting the group frame and ground rules

  • Purpose: make the therapists' intentions predictable and readable, which supports epistemic trust in people who struggle to see help as benign [source: Springham 2020 review; Havsteen-Franklin et al. 2020].
  • Steps: (1) In session 1 state the rules: confidentiality, respect, punctuality, no alcohol, drugs or violence, no contact between members outside the group [source: Havsteen-Franklin et al. 2020]. (2) Explain the fixed session sequence (refresher, theme, discussion, image-making, feedback, preparation) and keep to it every week [source: Havsteen-Franklin et al. 2020]. (3) Say what happens to artworks (kept by the service until session 12) [source: Havsteen-Franklin et al. 2020]. (4) Explain that no art skill is needed and that images will not be judged or interpreted for people [synthesis, consistent with Havsteen-Franklin et al. 2020 on embarrassment].
  • Example language (illustrative): "Each week will run the same way, so you'll know what's coming. Nobody here is being judged on drawing."
  • Watch for: rule-testing early on (lateness, outside contact); respond by restating the rule and exploring curiously what it meant, not by punishment [synthesis].

4.3 Theme-structured image-making (psychoeducation)

  • Purpose: make each week's mentalizing concept personally meaningful through an image; people who learn poorly from verbal teaching often engage better experientially [source: Havsteen-Franklin et al. 2020; Springham 2020 review].
  • Steps: (1) Refresh last week's theme, using last week's images if displayed [source: Havsteen-Franklin et al. 2020; Parkinson et al. 2024]. (2) Present the theme briefly (see the 12 themes in Section 2). (3) Discuss. (4) Invite image-making in response to the theme, used "in an improvised and explorative way" rather than as a fixed directive [source: Havsteen-Franklin et al. 2020]. (5) Share and give feedback. (6) Preview next week. Keep teaching short: participants struggle to concentrate in taught sections [source: Parkinson et al. 2024].
  • Example language (illustrative): "Today was about how emotions get registered and regulated. Take the next twenty minutes to make something about what that's like for you. It can be marks, colours, anything."
  • Watch for: images that are purely illustrative of the teaching (pretend-like, no felt connection); people who freeze on a blank page (offer 4.4). Working: images begin to carry personal relational content, such as members' published titles about feeling abandoned or about themselves in the group [source: Havsteen-Franklin et al. 2020].

4.4 Doodling and experimental mark-making as regulation

  • Purpose: give a low-threat way in when reflection or talking is too hard; making marks or doodles was offered when reflection felt too difficult, and some used drawing as a retreat when they could not get a word in [source: Havsteen-Franklin et al. 2020].
  • Steps: (1) Offer marks, doodles or colour without any requirement for a picture. (2) Allow the person to keep drawing during discussion if that helps them stay in the room. (3) Over weeks, invite movement from marks toward figurative images with a narrative [source: Havsteen-Franklin et al. 2020]. (4) Later, gently ask what the marks were like to make [synthesis].
  • Example language (illustrative): "If thinking feels too much right now, just make marks. You don't have to explain them."
  • Watch for: drawing used to avoid the group permanently (name it kindly later, see 5.2); calming of breathing and posture as signs it regulates [synthesis].

4.5 Looking together (joint attention to the artwork)

  • Purpose: create a shared reference point outside both people that lowers interpersonal threat and makes states of mind visible and discussable [source: Taylor Buck & Havsteen-Franklin 2013 citing Isserow 2008].
  • Steps: (1) Place the image where client and therapist (or the group) can see it side by side, e.g. on a wall or table [source: Parkinson et al. 2024]. (2) Look before talking; let the maker set it down so it becomes shared rather than "theirs" [source: Kuhn 2025 citing Springham]. (3) Move into 4.6.
  • Example language (illustrative): "Shall we put it up and look at it together for a moment before we say anything?"
  • Watch for: the maker hiding or turning the image away (offer choice about showing). Working: shared gaze, more relaxed talk, the maker begins to comment on the image as something outside them [synthesis; Schaverien's identification to familiarisation shift, as cited in Taylor Buck & Havsteen-Franklin 2013].

4.6 Describing formal features first

  • Purpose: start from what both can see, which is safe and shared, before moving to feeling and story [source: Havsteen-Franklin 2017; Kuhn 2025 summarising Havsteen-Franklin 2019].
  • Steps: (1) Describe the texture and quality of marks and colour before the form or subject [source: Havsteen-Franklin 2017]. (2) Check and agree on the formal features together ("is that how you see it too?") [source: Havsteen-Franklin 2017]. (3) Then explore affect, then narrative (4.7) [source: Kuhn 2025 summarising Havsteen-Franklin 2019].
  • Example language (illustrative): "I notice the lines here are pressed hard and close together, and up here they're lighter. Do you see it that way?"
  • Watch for: disagreement about what is there (useful: shows different perspectives; explore rather than correct); rushing to meaning [synthesis].

4.7 Exploring the mind of the figure in the image

  • Purpose: practise mentalizing at one remove, about a figure, before applying it to self and others [source: Havsteen-Franklin 2017].
  • Steps: (1) Once formal features are agreed, ask about the depicted person or creature: questions such as "where is the person now?" and "How do you think they are feeling?" [source: Havsteen-Franklin 2017]. (2) Ask open feeling questions without interpreting [source: Kuhn 2025]. (3) Ask what others in the image might think or feel. (4) Only when the person can manage it, ask whether anything feels familiar in their own relationships [source: Havsteen-Franklin 2017 progression; wording synthesis].
  • Example language (illustrative): "What might be going on for her, standing at the edge like that? What might the others be thinking about her?"
  • Watch for: certainty ("she's just worthless"), which suggests psychic equivalence (see 4.19); intellectual over-elaboration without feeling (pretend mode). Working: the person offers more than one possible state for the figure [synthesis].

4.8 Tentative linking of the image to the here-and-now

  • Purpose: connect the image with something the person said or is feeling now, offered warmly and tentatively, so they feel recognised (mind-mindedness) [source: Taylor Buck & Havsteen-Franklin 2013, Abeba vignette].
  • Steps: (1) Notice a link between the image and a remark in the session (in the vignette, a figure rowing a boat and the patient's comment about being back in the group). (2) Offer the link as a question, with a "perhaps", in a warm tone. (3) Leave room for the person and group to reject or change it. (4) Notice the group's reaction, including anxiety about someone changing position [source: Taylor Buck & Havsteen-Franklin 2013].
  • Example language (illustrative): "I wonder if being back here feels a bit like that boat, something to hold you up? I might be wrong."
  • Watch for: group curiosity that turns condescending, noted in the vignette [source: Taylor Buck & Havsteen-Franklin 2013]; compliance with your link. Working: warming of the atmosphere, the person elaborates in their own words.

4.9 Side-by-side making and responsive art-making by the therapist

  • Purpose: the therapist makes art alongside or in response to the client, becoming an active participant; this opens a non-verbal dialogue that can later be made explicit, and the therapist's own making models reflection [source: Parkinson et al. 2024 citing Havsteen-Franklin & Camarena Altamirano 2015; Taylor Buck & Havsteen-Franklin 2013 citing Greenwood 2012]. Havsteen-Franklin & Camarena Altamirano (2015) present it as a method to facilitate mentalization, noted as especially relevant for avoidant attachment [source: Kuhn 2025, secondary]. The 2015 paper's own procedure is not drawn on [uncertain].
  • Steps (what sources show): (1) Make images in parallel or collaboratively; the published examples are a clay exercise that became shared, and an image used to show a shared sense of being stuck in the therapy [source: Taylor Buck & Havsteen-Franklin 2013]. (2) In groups, therapists may make their own work and put it on the wall with everyone else's [source: Parkinson et al. 2024]. Additional steps [synthesis]: (3) keep your image simple and about the shared situation or your sense of the client's state, not your own life; (4) offer it tentatively as "my picture of how it felt to me", inviting correction; (5) return attention to the client's image and response.
  • Example language (illustrative): "I made this while you were working. It's my sense of the room today, quite heavy. Does any of it fit for you, or not at all?"
  • Watch for: your image overshadowing the client's, being read as an interpretation or correction, or self-disclosure drifting into your own material; check in supervision [synthesis]. Working: the client responds to or adds to your image, or uses it to say something new.

4.10 Using an image to name stuckness in the relationship

  • Purpose: make an impasse in therapy discussable as a shared object rather than a fault in either person [source: Taylor Buck & Havsteen-Franklin 2013].
  • Steps: (1) When sessions feel stuck, notice it openly and transparently [source: Taylor Buck & Havsteen-Franklin 2013 on transparency]. (2) Invite either or both of you to make an image of how the therapy feels right now. (3) Look at it together (4.5–4.6) and ask what each of you sees [steps 2–3 synthesis around the published example].
  • Example language (illustrative): "It feels to me like we keep circling. I'm not sure what's happening, and I may be part of it. Could we each try to draw what the last few sessions have felt like?"
  • Watch for: the client hearing blame; make your own part explicit first [synthesis].

4.11 Unpredictable materials

  • Purpose: offer materials that change unpredictably, such as ink dropped onto paper, to practise tolerating outcomes you cannot control [source: Havsteen-Franklin 2017].
  • Steps: (1) Offer wet paper and ink or diluted paint to drop and watch spread. (2) Before and after, ask what the person expected and what it is like when it does something else [step 2 synthesis]. (3) Link, if tolerable, to situations where others do not behave as expected [synthesis].
  • Example language (illustrative): "Let's see what the ink does. What did you think would happen? What's it like that it went that way instead?"
  • Watch for: distress or attempts to control or destroy the result; scale back to controllable media (pencils) if arousal climbs [synthesis].

4.12 Clay work

  • Purpose: clay is proposed to help re-establish a bodily sense of self [source: Havsteen-Franklin 2017, which labels this a hypothesis]; adding and removing material until a form "felt right" allowed playful testing of relationships with others [source: Kuhn 2025]; in Kuhn's case clay was more contained than agitated charcoal work [source: Kuhn 2025].
  • Steps: (1) Offer a fist-sized piece. (2) Invite handling without a goal, then shaping. (3) Allow adding and taking away freely. (4) Invite naming the piece; in Kuhn's case naming opened discussion of maternal themes [source: Kuhn 2025]. (5) Look at it together (4.5).
  • Example language (illustrative): "Just get a feel for it first. You can add or take away until it feels right."
  • Watch for: clay as regressive or overwhelming for some (smell, mess, body memories); offer tools or a board and a way to stop; damp-clean to limit dust [synthesis].

4.13 Validating the feeling in the image

  • Purpose: empathic validation is the safe base layer of the work and the place to return when arousal rises [source: Parkinson et al. 2024; Kuhn 2025; Havsteen-Franklin et al. 2016, "validating experience"].
  • Steps: (1) Name the feeling the image seems to hold. (2) Say that it makes sense given what the person has described. (3) Do not move to alternatives until the person feels understood. In Kuhn's case, validating the powerlessness and anger in a drawing was followed by visible affect change [source: Kuhn 2025].
  • Example language (illustrative): "There's a lot of anger in this, and something helpless too. That makes sense after what happened this week."
  • Watch for: validation that slides into agreeing with distorted beliefs (validate the feeling, not the conclusion) [synthesis].

4.14 Naming the feeling when talk becomes intellectual (pseudo-mentalizing)

  • Purpose: interrupt fluent but empty talk about the image (pretend mode) by bringing attention back to the feeling it shows [source: Kuhn 2025].
  • Steps: (1) Notice talk that is elaborate but affect-free. (2) Bring attention back to the image and name the feeling you see in it. (3) Validate. In Kuhn's case the patient later described their own talk as being like a press conference, and sadness emerged [source: Kuhn 2025]. Parkinson et al. describe a related move: helping someone stuck in overthinking to attend to the feeling in their work [source: Parkinson et al. 2024].
  • Example language (illustrative): "We've talked a lot about it. When I look at the picture itself, it looks lonely. What do you feel looking at it now?"
  • Watch for: shame at being "caught"; keep the tone warm and curious [synthesis].

4.15 Holding impulses to destroy the image

  • Purpose: keep an image available for later reflection when the person wants to tear or bin it in the moment [source: Kuhn 2025].
  • Steps: (1) Acknowledge the wish. (2) Ask whether the impulse could be held until the next session [source: Kuhn 2025]. (3) Offer to store the image safely, face down or in a folder (consistent with artworks being kept to session 12) [source: Havsteen-Franklin et al. 2020; folder detail synthesis]. (4) Explore next time what the urge was about.
  • Example language (illustrative): "You want to get rid of it. Could we put it away safely and decide next week?"
  • Watch for: respect the person's ownership; if they insist, let them, and explore afterwards rather than force [synthesis].

4.16 Matching materials to regulation

  • Purpose: choose media that help the person stay in a workable arousal range; therapists learned which materials felt safe for each person [source: Parkinson et al. 2024]; shifts from agitated charcoal to clay to colour tracked regulation in Kuhn's case [source: Kuhn 2025]; clearly structured, directed use of the medium helped disoriented patients in the Horizons data (a music therapy example) [source: Havsteen-Franklin et al. 2016].
  • Steps [synthesis built on these sources]: (1) For high arousal or disorientation, offer controllable, contained media (pencil, small paper, a clear simple task). (2) For flat or over-controlled states, offer more fluid media. (3) Note in records which media each person finds safe.
  • Example language (illustrative): "Paint felt a lot last week. Want to try pencils today, or something else?"
  • Watch for: rigid, heavily pressured lines with no variation as a sign of arousal or psychic equivalence [source: Kuhn 2025].

4.17 Pressing pause and taking distance

  • Purpose: teach self-regulation by stopping the action and stepping back, physically from the image or from the discussion [source: Parkinson et al. 2024].
  • Steps: (1) Introduce pause as a skill early. (2) When arousal rises, stop art-making or discussion and share and validate experiences without rushing to solutions [source: Parkinson et al. 2024]. (3) Optionally, step back from the image physically to see it from further away [synthesis]. (4) Resume when arousal settles.
  • Example language (illustrative): "Let's press pause. Put the brushes down a moment. What's happening for people right now?"
  • Watch for: pauses used to avoid all feeling; return to the image when calmer [synthesis].

4.18 Group mentalizing questions and reframing certainty

  • Purpose: members practise curious, not-knowing questions about each other's work; responding to others' art is a source of self-reflection [source: Parkinson et al. 2024; Springham 2020 review].
  • Steps: (1) After making, put work on the wall and look together [source: Parkinson et al. 2024]. (2) Invite questions about the experience of making, e.g. "What was it like to paint that bit?" [source: Parkinson et al. 2024]. (3) When someone makes a certain statement (including praise of skill), model rewording it into a curious question that names what draws you and invites the artist to say more [source: Parkinson et al. 2024].
  • Example language (illustrative, a reframe of praise): "Instead of 'that's brilliant', maybe: I keep looking at this corner and I'm not sure why. Can you tell us about it?"
  • Watch for: interpretation of each other's images, criticism, or comparisons of skill; redirect to questions [synthesis].

4.19 Recognising and responding to non-mentalizing modes in the art

  • Purpose: use the image and the making process to spot when mentalizing has gone offline and to respond in a way that restores it. The mode names come from MBT; their art-specific descriptions here come from secondary sources, not from a Havsteen-Franklin text opened [source: Kuhn 2025; Parkinson et al. 2024; uncertain for Havsteen-Franklin's own formulation].
  • Steps by mode:
    • Psychic equivalence (inner state taken as reality; "I am a monster"): heavy, rigid, high-pressure marks; certainty about what an image or other people mean; fears and delusions felt as simply true [source: Kuhn 2025; Parkinson et al. 2024]. Response: lower arousal, ask what the figure is feeling, validate the feeling held in the image; do not argue with the content [source: Kuhn 2025]. Distinguish feeling hopeless from being hopeless, because equivalence can feed suicidal narrowing [source: Kuhn 2025].
    • Pretend mode / pseudo-mentalizing: fluent, intellectual talk about the image with no felt link. Response: 4.14 [source: Kuhn 2025].
    • Teleological mode (only physical action counts): reliance on the physical making when thinking feels out of reach; on the therapist's side, a pull to do something concrete such as extending sessions or making calls [source: Parkinson et al. 2024; Kuhn 2025]. Response: let making regulate, then look at the work with others to move it into a relational process [source: Parkinson et al. 2024]; notice your own urge to act and think about it before acting [synthesis].
  • Example language (illustrative): "It feels completely real right now that everyone thinks you're a monster. Looking at the figure, what is she feeling?"
  • Watch for: your own loss of mentalizing (arguing, lecturing, over-reassuring) [source: Havsteen-Franklin et al. 2016 on therapist rigidity]. Working: the person can say "it felt like" rather than "it is" [synthesis]. Parkinson et al. report participants later recognised psychic equivalence as a loss of mentalizing [source: Parkinson et al. 2024].

4.20 Display and recall of previous artwork

  • Purpose: give continuity, link sessions, and let people see change over time [source: Havsteen-Franklin et al. 2020; Parkinson et al. 2024].
  • Steps: (1) Keep all work safely (to session 12 in the CNWL programme) [source: Havsteen-Franklin et al. 2020]. (2) At the start of each session display last week's work and use it to recall the topic [source: Parkinson et al. 2024]. (3) In the final session lay out the whole series for review (4.26) [synthesis].
  • Example language (illustrative): "Here's what we made last week. What do you remember about what we were thinking about?"
  • Watch for: distress at seeing earlier images; ask consent before displaying a person's work [synthesis].

4.21 Observational drawing of a familiar object (variant: Art MBT psychosis course)

  • Purpose: experience the not-knowing stance; separate assumptions from curious looking [source: Parkinson et al. 2024].
  • Steps: (1) Each person picks a familiar object from a pocket or bag. (2) They draw it as if seeing it for the first time [source: Parkinson et al. 2024]. (3) Discuss what they noticed that they had not known was there, and link to how we assume we know what others think [step 3 synthesis].
  • Example language (illustrative): "Draw it as if you've never seen one before. What do you notice?"
  • Watch for: perfectionism; reassure that accuracy is not the point.

4.22 Soft dough creature warm-up (variant)

  • Purpose: a playful, low-threat first-session task [source: Parkinson et al. 2024].
  • Steps: (1) Hand out soft dough. (2) Guide a simple sequence: form a body, add four legs and a tail. (3) Invite each person to turn it into a real or imagined creature [source: Parkinson et al. 2024]. (4) Share creatures briefly [synthesis].
  • Example language (illustrative): "Start with a body, then four legs, then a tail. Now make it into any creature you like."
  • Watch for: food-dough hygiene and allergies (e.g. wheat) if home-made dough is used [synthesis].

4.23 Looking together at portraits (variant)

  • Purpose: discover that people read the same face differently, as a direct lesson in opacity of minds [source: Parkinson et al. 2024].
  • Steps: (1) Show a portrait (projected or printed). (2) Each person says what emotion they see. (3) Reflect on differences without deciding who is right [source: Parkinson et al. 2024; step 3 detail synthesis].
  • Example language (illustrative): "Three of us see sadness and two see anger. What did each of us notice?"
  • Watch for: members who need there to be one correct answer; normalise uncertainty.

4.24 Gallery or museum session on mentalizing culture (variant)

  • Purpose: practise mentalizing other cultures and makers in a non-clinical setting [source: Parkinson et al. 2024].
  • Steps: hold the "mentalizing culture" session in a museum or gallery; look together at works and wonder about makers' and viewers' minds [source: Parkinson et al. 2024; activity detail synthesis]. Plan access, travel and a quiet place to withdraw [synthesis].
  • Example language (illustrative): "What do you think the person who made this wanted us to feel?"

4.25 Audio-Image Recordings (variant, after the course)

  • Purpose: consolidate learning; participants make short films of two or three chosen artworks discussed in a set-template interview [source: Parkinson et al. 2024]. The template's content was not described [uncertain].
  • Steps: (1) Invite participants to choose two or three pieces. (2) Record a short interview about them using a consistent question set [source: Parkinson et al. 2024]. (3) Obtain written consent covering use and storage of the recording [synthesis].

4.26 Ending review and collaborative decision about further treatment

  • Purpose: close the programme, consolidate learning and decide together on next steps [source: Havsteen-Franklin et al. 2020].
  • Steps: (1) Session 12 summarises, concludes and gathers feedback [source: Havsteen-Franklin et al. 2020]. (2) Review the image series and the formulation together [synthesis]. (3) Decide jointly whether further treatment (e.g. the longer mentalization art psychotherapy group) is needed [source: Havsteen-Franklin et al. 2020].
  • Example language (illustrative): "Looking back at these twelve images, what do you notice has changed, and what still feels hard?"
  • Watch for: endings triggering abandonment feelings; anticipate this in sessions 10–11 [synthesis]. Members' own accounts included regained confidence and being able to step back and think, alongside a sense that stability could be lost at any time [source: Havsteen-Franklin et al. 2020].

4.27 Adaptations for children in schools (secondary)

  • Purpose: MBAT has been adapted for primary-school children with social, emotional and mental health needs (McDonald's research) [source: BAAT InSight 2025].
  • Steps reported: "detective work" in which child and therapist look for clues about thoughts and feelings in the artwork; child-friendly art therapy journals; naming bodily states (e.g. asking whether the child's heart is beating hard) and offering a way to understand what is happening [source: BAAT InSight 2025]. No session protocol was given [uncertain].
  • Example language (illustrative): "Let's be detectives. What clues are there about how this character is feeling?"
  • Watch for: safeguarding (see 5.9); never treat a child's artwork as evidence of abuse; act on what the child says or does, per local safeguarding procedure [synthesis]. Get parental consent and the child's own assent, and agree with school staff what is shared [synthesis].

5. Handling problems

The sources describe few problem-handling procedures; most of this section is marked [synthesis] and draws on general MBT and art therapy practice rather than on Havsteen-Franklin's texts.

5.1 "I can't draw" / embarrassment and exposure. Early embarrassment about drawing skill and feeling exposed was reported by group members [source: Havsteen-Franklin et al. 2020]; novices may say they do not know how to draw, and a mismatch between what they see and what they produce can reduce verbal reflection [source: Taylor Buck & Havsteen-Franklin 2013]. Response: offer marks and doodles (4.4); make your own simple marks alongside (4.9); never comment on skill; describe qualities, not quality (4.6); reframe praise (4.18) [synthesis].

5.2 Withdrawal into the image or out of the room. One member used drawing as a retreat when he could not get a word in [source: Havsteen-Franklin et al. 2020]. In Havsteen-Franklin's individual vignette, verbal reflection increased a young man's withdrawal; shifting focus from the interaction to the image slowed the pace and helped [source: Havsteen-Franklin 2017]. Response: allow drawing as regulation; later, name it warmly and ask what made talking hard; reduce verbal demand and talk about the image rather than the person [source: Havsteen-Franklin 2017; wording synthesis].

5.3 Overwhelm and retraumatising images. Images can re-traumatise (a member's image of a baby without a mother is the published example); facilitation must be careful, structured and sensitive [source: Havsteen-Franklin et al. 2020]. Mentalizing fails both when too hot and when numb [source: Kuhn 2025 citing Verfaille]. Response: press pause (4.17); return to validation (4.13) [source: Parkinson et al. 2024]; switch to contained media (4.16); step away from the image or turn it over; ground in the room; do not push for narrative while arousal is high; before the session ends, check the person's state and plan for after [steps beyond validation and pausing are synthesis]. Screen at assessment for current crisis or very recent trauma that the group cannot hold [synthesis].

5.4 Self-harm and suicidal imagery or statements. Patients in this population self-harm, and images may carry suicidal themes (a published title expressed thinking only of dying when abandoned) [source: Havsteen-Franklin et al. 2020]; image-making has been framed by some as an alternative to self-harm [source: Havsteen-Franklin 2017]. Response [synthesis]: treat suicidal content in an image as a communication to be explored and risk-assessed directly, not interpreted away; ask about current intent, plans and protective factors in plain language; follow the service's risk procedure, update the safety plan, and involve the care coordinator; lethal-means counselling covers safe storage and removal only. Distinguish feeling hopeless from being hopeless as a mentalizing intervention [source: Kuhn 2025], but never as a substitute for risk assessment [synthesis]. Remove sharp tools from the room when risk is raised [synthesis].

5.5 Non-attendance and dropout. Not addressed in the CNWL chapter [uncertain]. Parkinson et al. built trust with regular text reminders and a text-back option, including for late buses, as a way of showing people were kept in mind [source: Parkinson et al. 2024]. Response [synthesis]: contact after any missed session; ask curiously what got in the way; keep the person's images safe and tell them so; agree in assessment what happens after repeated absences.

5.6 Ruptures with the therapist. The published vignette describes a client feeling judged and rejected by the therapist; no formal repair protocol is given [source: Havsteen-Franklin 2017]. Sources stress transparency and acknowledging your impact [source: Taylor Buck & Havsteen-Franklin 2013] and repair when the image-artist-therapist triangle becomes misattuned [source: Taylor Buck & Havsteen-Franklin 2013]. Response [synthesis, consistent with these sources]: notice the shift; stop and name it; own your part first; ask what it felt like; use the image to look at what happened (4.10); check whether the repair landed.

  • Example language (illustrative): "I think what I said a moment ago felt like a judgement. I'm sorry; that wasn't my intent, but I can see it landed that way. What was it like?"

5.7 Group conflict and avoidance. Conflict triggered avoidance in one member, who stayed outside the conflicts [source: Havsteen-Franklin et al. 2020]; group curiosity can become condescending [source: Taylor Buck & Havsteen-Franklin 2013]. When a member left early at another's request during attachment activation, supervision judged that this isolated both and blocked mentalizing [source: Kuhn 2025]. Response [synthesis]: slow the group down; ask each person what they think the other is feeling; use the images as the focus rather than the people; do not let members exclude each other; return to the ground rules.

5.8 Demands for interpretation ("What does my picture mean?"). Interpretation is discouraged in this approach [source: Kuhn 2025; Taylor Buck & Havsteen-Franklin 2013]. Response: say honestly that you don't know, then wonder together (4.6–4.7) [synthesis].

5.9 Children and young people. For school or CAMHS adaptations (4.27): obtain parental consent and the child's assent; agree confidentiality limits in age-appropriate language at the start; follow statutory safeguarding and mandatory-reporting duties; a drawing alone is not evidence of abuse, and no artwork-based diagnostic inference should be made; act on disclosures and observed indicators via the designated safeguarding lead; involve parents and carers unless that would increase risk [synthesis]. Store artworks as part of the confidential record [synthesis].

5.10 People with psychosis. Participants could be certain fears and delusions were real (psychic equivalence) [source: Parkinson et al. 2024]; more directive, clearly structured use of the medium helped disoriented patients [source: Havsteen-Franklin et al. 2016]. Response: keep tasks simple and concrete, co-lead with a medical colleague where possible as in the Parkinson model, do not argue with delusional content, and keep close links with the care team; this is an adjunct within psychiatric care, not a replacement for it [source: Parkinson et al. 2024 for co-leadership; rest synthesis].

5.11 The therapist's pull to act (teleological countertransference). Urges to extend sessions or make calls are described as a teleological pull [source: Kuhn 2025]; the therapist's own attachment patterns can be activated [source: Kuhn 2025 citing Verfaille]. Response: notice, pause, discuss in supervision; video-based supervision has been used [source: Kuhn 2025]; keep the frame unless risk requires action [synthesis].

5.12 Rigid, repetitive or compliant images. Rigid, pre-planned images with blank faces mirrored a client's view of others as distant [source: Havsteen-Franklin 2017]. Response: describe the formal features with curiosity (4.6), introduce unpredictable materials (4.11), or make a responsive image (4.9) [source: Havsteen-Franklin 2017 for 4.11; combination synthesis].

5.13 Breaches of the outside-contact rule. The CNWL group bans contact between members outside the group [source: Havsteen-Franklin et al. 2020]. Response [synthesis]: raise it in the group without shaming; explore what the contact meant and how it affects others; restate the rule and its reason.

5.14 Using the method without art therapy training. Without HCPC registration (UK) the person must not call the work art therapy, and the art-making techniques here should be used only within co-facilitation or supervision by a registered art psychotherapist; the CNWL 2-day course gives an attendance certificate, not accreditation [source: Havsteen-Franklin 2017; CNWL course page; recommendation synthesis].

Sources

Sources:

Further reading (not drawn on) [uncertain]:

  • Havsteen-Franklin, D. (2016). Mentalization-based art psychotherapy. In J. A. Rubin (Ed.), Approaches to Art Therapy: Theory and Technique (3rd ed., pp. 144–163). Routledge.
  • Havsteen-Franklin, D. (2019). Creative arts therapies. In A. Bateman & P. Fonagy (Eds.), Handbook of Mentalizing in Mental Health Practice (2nd ed., pp. 181–196). American Psychiatric Association Publishing (known only via Kuhn 2025 and Parkinson et al. 2024).
  • Havsteen-Franklin, D., & Camarena Altamirano, J. (2015). Containing the uncontainable: Responsive art making in art therapy as a method to facilitate mentalization. International Journal of Art Therapy, 20(2), 54–65.
  • Havsteen-Franklin, D. (2014). Consensus for using an arts-based response in art therapy. International Journal of Art Therapy, 19(3), 107–113.
  • Karterud, S., & Bateman, A. (2011). Manual for Mentalization Based Psychoeducational Group Therapy (MBT-I). Gyldendal Akademisk.
  • Moore, K., & Marder, K. (2019). Mentalizing in Group Art Therapy: Interventions for Emerging Adults. Jessica Kingsley.
  • Springham, N., & Huet, V. (2018). Art as relational encounter: an ostensive communication theory of art therapy. Art Therapy (cited via BAAT InSight 2025).
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