The Efficacy of Mentalization-Based Interventions Among Autistic Individuals and Their Families: A Systematic Review.

Abstract

Autistic individuals often experience differences in social-cognitive processing, including mentalization, the capacity to understand one's own and others' mental states, which may influence social and emotional functioning. This systematic review synthesizes the current evidence base on interventions targeting mentalization and Theory of Mind (ToM), conceptualized here as related but distinct constructs, with ToM reflecting more specific cognitive perspective-taking skills within the broader mentalization framework. A comprehensive search across multiple databases, without restrictions on language or year of publication, identified 19 eligible studies involving autistic individuals and their caregivers. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT), providing an indication of methodological rigor across diverse designs, though not a formal assessment of risk of bias. Across studies, interventions were generally associated with improvements in reflective functioning and performance on structured ToM tasks (e.g., false-belief understanding). However, these gains were predominantly observed in proximal, task-based measures, with limited and inconsistent evidence for generalization to real-world social functioning. This pattern raises important questions regarding the ecological validity of commonly used ToM assessments and whether observed improvements reflect meaningful changes in everyday social interaction or task-specific learning. Substantial heterogeneity in study design, intervention characteristics, outcome measures, and participant profiles further limits comparability and precludes firm conclusions regarding effectiveness. Overall, while mentalization- and ToM-based interventions show promise, the current evidence base remains methodologically and conceptually constrained. Future research should prioritize ecologically valid outcome measures, clearer specification of intervention mechanisms, and more rigorous study designs, including long-term follow-up, to better determine whether these interventions support meaningful, real-world social and relational outcomes for autistic individuals and their families.