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Children’s mentalizing capacity may influence the therapeutic process in psychodynamic therapy. The literature points to the need to tailor the therapeutic intervention to the particular configuration of clinical and developmental problems presented by the children and recommends a shift in technique in the case of severely disturbed or traumatized patients with impaired mentalizing capacity. The aim of this study was to explore the therapeutic process in psychodynamic therapy with school-age children with different kinds of difficulties and mentalizing profiles. A longitudinal design based on the systematic case study method was adopted. Three children with different baseline mentalizing capacities and their psychotherapists participated. Two hundred seventy-three psychotherapy sessions were analyzed using the Child Psychotherapy Q-Set (CPQ) in order to identify the relationship patterns between patient and therapist. Different interaction structures were identified. When the child presented with a more developed mentalizing capacity at baseline, the treatment was more similar to a standard psychodynamic approach. When mentalization capacity was impaired, more directive, supportive and empathic interventions were observed. A child’s capacity for mentalization appears to impact the therapeutic process, with the adoption of certain therapeutic approaches and specific techniques depending on the child’s own baseline capacity to mentalize.