Show Summary Details
Page of

(p. 1) Introduction 

(p. 1) Introduction
Chapter:
(p. 1) Introduction
Author(s):

Robbie Duschinsky

and Sarah Foster

DOI:
10.1093/med-psych/9780198871187.003.0001
Page of

PRINTED FROM OXFORD CLINICAL PSYCHOLOGY ONLINE (www.oxfordclinicalpsych.com). © Oxford University Press, 2021. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Clinical Psychology Online for personal use (for details see Privacy Policy and Legal Notice).

date: 06 December 2021

Peter Fonagy has been described as ‘one of the most acclaimed child psychologists of his generation’, and as leading a ‘revolution’ in the theory and delivery of therapeutic services.1 He has published over 500 scientific papers and 260 chapters, and has authored or co-authored 19 books. Since 2003, he has served as Chief Executive of the Anna Freud National Centre for Children and Families in London and, since 2008, as Head of the Division of Psychology and Language Sciences at University College London. He has also had a major role in UK health policy, including as Chair of the Outcomes Measurement Reference Group at the Department of Health, Chair of two National Institute for Health and Care Excellence (NICE) Guideline Development Groups, Chair of the Strategy Group for National Occupational Standards for Psychological Therapies, and co-chair of the Department of Health’s Expert Reference Group on Vulnerable Children. In 2015, he was the first UK recipient of the Wiley Prize of the British Academy for Outstanding Achievements in Psychology by an international scholar.

Fonagy’s research has been highly interdisciplinary, moving from psychoanalysis to attachment theory, and from attachment theory to a wider agenda in developmental psychopathology. He has attracted collaborators from among the most talented researchers and clinicians from various disciplines. These collaborations have combined with Fonagy’s remarkable receptivity and desire to learn to contribute to sustained theoretical change and elaboration over the decades. Yet, this continually evolving theory poses difficulties for readers in understanding and applying the approach. Fonagy has joked that readers of a psychological theory can ‘imprint’ on the work of one era, failing to see changes in a theorist’s stance or in the meaning given to terminology.2 On the one hand, there may be an undertow from early impressions, which lead later developments to be ignored or downplayed. Equally, someone familiar with the later work of Fonagy and colleagues may miss out on many insights from earlier periods that have not subsequently seen sustained attention. They may also miss the underpinning architecture of the ideas, which comes into focus most clearly when the diverse writings of Fonagy and colleagues are considered together and over time.

The volume and spread of these writings have also, to date, contributed to the lack of an integrative overview and evaluation.3 This will be our central goal here, continuing work in an earlier book—Cornerstones of Attachment Research—offering an integrative appraisal (p. 2) of the ideas of major psychological theorists who have engaged with ideas of attachment.4 Cornerstones of Attachment Research presents a comprehensive analysis of the ideas of Bowlby, Ainsworth, Main and Hesse, Sroufe and Egeland, and Shaver and Mikulincer. The present book can certainly be read independently, but—in Chapters 3 and 7 especially—is also a continuation of the ongoing story of attachment research, and its attendant strengths and weaknesses.

The need for an integrative overview and evaluation additionally stems from the segmentation of the audience of the works of Fonagy and colleagues. In a sense, each audience has had direct access to only a ‘part object’, obstructing both their evaluation and their use of the contributions of Fonagy and colleagues. Readers who know the work of Fonagy and colleagues on randomized trials may not know their work on the details of clinical technique, hindering their sense of how the clinical modality actually should work in practice. Readers who know the work of Fonagy and colleagues in attachment theory may have only a general sense of the model of modes of non-mentalizing, not only obscuring the fundamentals of the account of pathology but also of factors that undermine attachment security. Readers who have trained in delivering mentalization-based therapy may nonetheless not know the recent thinking of Fonagy and colleagues about the primary unconscious and, as a result, may push at closed doors with patients, or even deliver therapy in ways that make their patients’ symptoms worse.

We acknowledge that there are limitations to a review of written texts as a methodology for understanding a living psychological theory. Not least, the textual record offers an opaque window on the process by which, and the context within which, scientific and theoretical work was actually completed. Because this process and context shapes the very meaning of the work, this is a significant deficiency. One partial solution is to read the penumbra of wider texts in order to understand the interventions that were intended by a particular work; another partial solution is to supplement the published record with unpublished sources in the public domain, when these are available.5 A further strategy is to receive and integrate feedback from the psychological theorists themselves, in this case Fonagy and colleagues. All these solutions have been pursued, but they offer only an incomplete fix. In particular, it should be highlighted that we are not mentalization-based therapists: we have no doubt that this would be a different book, and have different strengths, if we had been trained and were practitioners in this modality.

The reader should also note that the phrase ‘Fonagy and colleagues’, often used in this book, refers to a complex assemblage of people, discourses, institutional structures and priorities, research funding, scientific tools, clinical settings—and their interaction. It is both a collective endeavour of thought and effort, and a product of the achievements and trajectory of individual scholars within this group, with different areas of expertise.6 The theory is (p. 3) the result of what Hutchins calls ‘distributed cognition’, a network of processes that together create effects greater than the sum of their parts (see Chapter 7).7 This collective contribution has been frequently highlighted by Fonagy: ‘The work summarized in this paper is the result of a collaborative effort of a group of wonderfully talented individuals who have honoured the author with their friendship over the past years.’8 He joked in a paper from 2000: ‘This paper is a preliminary report of an ongoing collaboration with friends and colleagues Mary Target, George Gergely, and Efrain Bleiberg. Many of the ideas presented are theirs, but if they should be well received the author will have no hesitation in taking credit for them.’9 The differences between the multifaceted labour of clinical and research work and its frontstage, published description is just one of the many limitations of any historical review dependent on texts. However, one opportunity stemming from a comprehensive review of written texts over time is the chance for perspective taking.

Clarification of terms and concepts

Joseph Sandler, Fonagy’s friend and predecessor as Freud Professor at University College London, was very concerned to give theoretical terms due scrutiny and consideration. Sandler emphasized that, just as humans need to engage in reality testing in order to benefit from both fantasy and perception, so psychological theory itself needs to treated with due seriousness and be subject to ‘concept testing’. Because concepts help guide perception and thought, they will benefit from discussion, appraisal and, at times, ‘adaptive reorganization’ in order to remain in good working condition.10 He acknowledged that concepts need some elasticity in order to ‘take up the strain of theoretical change, absorbing it while more organized newer theories or part-theories can develop’; yet he also worried ‘concepts become stretched to encompass new insights and new ideas. Often such an expansion of the meaning of a conceptual term is not explicit’, and this can cause confusion and hinder scientific and clinical developments.11 Sandler observed that there can be resistance to efforts to appraise concepts that seem to work well enough for pragmatic purposes, even when it is known that their use nonetheless has resulted in significant disadvantages:

(p. 4)

The fact that they work well may in turn lead to an undue resistance to the progressive integration and modification of our concepts, so necessary for scientific development. This resistance can partly be overcome by the cultivation of a critical attitude towards our ideas, by discussion with colleagues, and by honest reading of the literature, but unless we are directly confronted with contradictions in our thinking, resistance to change due to secondary gains may prove too great.12

Sandler discussed various forms of ‘secondary gain’: use of imprecise or contradictory concepts can help avoid battles with authorities with stakes in the use of these concepts;13 it can help build apparent consensus; it allows a variety of people to project their own preconscious part-theories and fantasies on to the concept and feel satisfied with it. There may also be ways in which general concepts have their own acuity: after all, to see a blurred picture clearly is to see a blurred picture.14 Many of these forms of secondary gain, both positive and negative, can be seen in the case of Melanie Klein’s concept of ‘projective identification’ (see Chapter 6).15 However, Sandler felt that these forms of secondary gain should not distract from the harm unscrutinized concepts make to the effectiveness of causal claims, or the effectiveness of communication between groups.16

Fonagy has been a strong advocate of such attempts to confront contradictions and achieve integration in psychological theory: ‘while the clarification of terms and concepts is laborious, it is possible. It is also essential if we are to find out where theoretical differences are real, and to test these against each other, and where they may only be imagined.’17 Though these were certainly not rigid steps, in Fonagy’s view, the essence of Sandler’s approach was ‘to explore the history of a term or concept in psychoanalysis, then to elaborate on the multiple and frequently mutually incompatible meanings attached to the term. Having analysed the historical changes in terminology, he explains how misconceptions emerged or discussions at different levels of abstraction were conflated. Then, with a minimal number of assumptions, he proposes a highly economical model that encompasses the multiple uses of the varying meanings of the construct under scrutiny.’18 The function of such work is similar to a conceptual meta-analysis, as a concept’s aggregate relationships with other concepts are described and moderators identified that can account for variation between uses. Fonagy (p. 5) appreciated that Sandler’s methodology encompassed both attention to the wider context and developments over time, and an attempt to proactively and constructively synthesize these developments to draw relevant distinctions in how a concept has been used. In this way, it allowed theory to ‘stop and rewind’ to identify the points at which different perspectives in use of a concept came to diverge and contribute to misunderstanding. In their 2003 book Psychoanalytic Theories, clearly influenced by Sandler, Fonagy and Target presented a historical and conceptual review of psychoanalysis attentive to the role of varying meaning of psychoanalytic concepts, and attempting to clarify and integrate difficulties these had caused.19 This included, impressively, a frank appraisal of limitations with their own theory and terminology at the time, and especially with the term ‘mentalizing’ (see Chapter 4).

With Sandler’s studies in mind, as well as approaches from the sociology of science,20 this book will explore 18 concepts that integrally organize the contributions of Fonagy and colleagues: adaptation, aggression, the alien self, culture, disorganized attachment, epistemic trust, hypermentalizing, reflective function, the p-factor, pretend mode, the primary unconscious, psychic equivalence, mentalizing, mentalization-based therapy, non-mentalizing, the self, sexuality, and teleological mode. As with Sandler’s work, the analysis of key concepts is appreciative as well as critical, and intended to facilitate the success of the overall enterprise. We are mindful that matters such as terminological precision and the articulation of categories are not the priority of individual pragmatic researchers or clinicians. Furthermore, the work of Fonagy and colleagues offers an unprecedented integration of ideas from across different disciplines; it is inevitable that there remain some loose threads. Nonetheless, problems with the articulation of concepts and loose threads, which may be only minor irritants on a particular occasion, may cause wide-ranging issues for a field, played out incrementally over decades, with costs mounting.21 For instance, while the underspecification of concepts may contribute at times to their appeal by offering a screen for diverse projections, this predicament can also contribute to miscommunication, self-doubt, and reduced acuity when the concepts need to be used for practical work.22

We have attempted to identify areas for theoretical refinement and loose threads, and, where possible, suggest a potential resolution or propose what future research needs to be done. For instance, in Chapter 4, we scope the diversity of ways the concept of ‘mentalization’ has been used—not as a criticism on the grounds of incoherence—but precisely as a means of attempting to synthesize a new definition. It is hoped that our overview and analysis will help those using the ideas of Fonagy and colleagues understand their underlying coherence and architecture, as well as a number of current limitations, and help researchers on mentalization and epistemic trust identify priorities for future research and theoretical development.

Our aim has been to offer reflections that are friendly and constructive, and actionable whenever possible. Exploration of tensions in the use of these concepts by Fonagy and colleagues is by no means a rejection of them, but rather an attempt to understand what problem (p. 6) or problems they aim to solve, how, and with what consequences for the theory as a whole. As Brecht observed in one of his dialogues, understanding a system of thought has analogies to understanding the dynamics of a family.23 Much like any family, concepts in such a system can sometimes be seen supporting one another, sometimes changing and improving themselves to offer better support in the future; sometimes they can be seen squabbling, sometimes sharpening their knives for the next squabble. Like members of a family, each has to compromise their own integrity at times for the sake of the group: they may be forced to be more pragmatic, more complicated, more confused, or isolated from others outside the family, or even compromise links with reality for the sake of the family. At the same time, each member may also be sustained, in a deeper sense, by the family’s collective capacities. The mode of life of concepts can be missed, however, if their self-presentation is taken at face value. It is not hard for concepts to sit down for dinner, or pose for a family photo, as if nothing had happened. But this may be far from the whole story.

The analysis of concepts entails careful thought about the language used to hold them. The language of psychological research and theory is a deceptively complex, multi-level system; this system has various entries and exits and opportunities for getting lost.24 The complexity is further compounded by the interdisciplinarity of the work of Fonagy and colleagues, as terms from various discourses are taken up, often adapted, and worked into new configurations, retaining some of their previous connotations even as they become invested with a degree of technical or context-specific meaning. Fonagy and colleagues have attempted to avoid unnecessary abstraction, and remain close to ordinary language whenever possible. Their concepts have been developed not solely for academics or as a ‘common language’ for clinicians.25 Another intended function has been for use in psychoeducation with patients. However, this then raises the ongoing challenge, in making sense of their work, of distinguishing between technical and ordinary uses of familiar words such as ‘self’, ‘mental’, ‘adaption’, and ‘disorganization’. Careful scrutiny is therefore needed of the use of concepts across texts and over time to understand their meanings. For the book, definitions and uses of terms were identified from a complete examination of published works co-authored or authored by Peter Fonagy, Liz Allison, Anthony Bateman, Chloe Campbell, Marco Chiesa, György Gergely, Patrick Luyten, Howard Steele, Miriam Steele, and Mary Target. This was supplemented by study of relevant grey literature by these researchers. The writings of other researchers in the wider collaborative network—dubbed wryly by Fonagy and others as the ‘mentalization mafia’26—were also extensively consulted. These included Jon Allen, Eia Asen, Dickon Bevington, Efrain Bleiberg, Jessie Borelli, Martin Debbané, Karin Ensink, Jeremy Holmes, Elliot Jurist, Sigmund Karterud, Alessandra Lemma, Linda Mayes, Nick Midgley, Tobias Nolte, Carla Sharp, Finn Skårderud, Arietta Slade, and Lane Strathearn.

(p. 7) Central collaborators

Fonagy has described opportunities for collaborative work as the greatest pleasure in his professional life.27 Over time, he has co-authored works with countless colleagues. However, five sets of central collaborators can be picked out as playing a special role in pooling ideas and efforts.

A first set characterizes Fonagy’s early work, during the 1980s. These are George Moran and Anna Higgitt.

George Moran served as Director of the Anna Freud Centre from October 1987 until his death at the age of 40 in January 1992. During these years, Fonagy was a trainee child analyst receiving supervision at the Centre. In turn, Moran was pursuing a PhD under Fonagy’s supervision, exploring the relationship between blood sugar regulation and regulation of emotional state in diabetic children. Moran’s doctoral research with Fonagy ‘became the playing-working field on which a deep and mutually affectionate friendship and working relationship was established and flourished. It was a relationship in which mutual respect was enhanced by hours of discussion, debate and disagreement to force into view the best approximation of truth that friends and collaborators could muster.’28

Anna Higgitt is a consultant psychiatrist and clinical leader in a community mental health team. From 1997, she has also held a role as senior policy adviser to the Department of Health.29 Higgitt and Fonagy married in 1990.

A second set characterizes Fonagy’s work in the early and mid-1990s. As well as Anna Higgitt, the two other key collaborators were Howard and Miriam Steele.

Howard and Miriam Steele arrived in London in 1986 to undertake doctoral research at University College London and clinical training at the Anna Freud Centre. Between 1987 and 1989, the Steeles conducted the Adult Attachment Interview with 100 expectant mothers and fathers in the third trimester. They also collected 96 infant–mother Strange Situation observations when the children were 12 months old, and 90 infant–father Strange Situation observations at 18 months. This was the basis for the University College London Parent–Child Project. Together with Fonagy, Howard and Miriam Steele, and Anna Higgitt developed the Reflecting Functioning Scale for the Adult Attachment Interview. Howard and Miriam Steele left London for the New School of Social Research in New York in 2001. They now hold Chairs in the Clinical Psychology Faculty and co-direct the Center for Attachment Research.

A third set are researchers with whom Fonagy elaborated the theory of mentalization in the 1990s and 2000s. Though diverse researchers were part of a wider community developing and thinking about these themes, Fonagy was especially influenced by his collaboration with Mary Target and György Gergely.

Mary Target pursued doctoral study with Fonagy, using a retrospective study of patient records at the Anna Freud Centre to evaluate the effectiveness of the service. Target had come from a background of a decade of work as a clinical psychologist in acute adult psychiatric services and child and adolescent mental health. She also trained as a psychoanalyst while completing her doctorate. Together with Fonagy, she published the influential series (p. 8) of papers on ‘Playing with Reality’ in the International Journal of Psychoanalysis, and a co-authored book, Psychoanalytic Theories: Perspectives from Developmental Psychopathology, in 2003. She is now Professor of Psychoanalysis at University College London, and a psychoanalyst in private practice. (In her clinical work, she practises under her maiden name, Mary Hepworth.)

György Gergely is a Hungarian clinical psychologist and experimental researcher associated with the Central European University in Budapest. Between 1996 and 1999, he was Visiting Senior Lecturer at University College London.30 During this time, his concept of ‘teleological mode’ as a form of non-mentalizing was integrated into Fonagy’s work. Together with Fonagy, Target, and Elliot Jurist, he was one of the authors of the 2002 book, Affect Regulation, Mentalization and the Development of the Self. He is also one of the originators of natural pedagogy theory, which helped prompt Fonagy’s turn to concern with epistemic trust.

A fourth set of key collaborators are two researchers central to the development and validation of mentalization-based therapy (MBT), Anthony Bateman and Marco Chiesa. Increased funding was available in England for research on mental health services from 2006, thanks to the creation of the National Institute of Health Research. The growing reputation of the Anna Freud Centre also helped attract philanthropic donations to support research to develop and validate MBT, such as from the Borderline Personality Disorder Research Foundation and the Laurence Misener Charitable Trust.

Anthony Bateman is a consultant psychiatrist, Director of Psychotherapy Services and Research Lead at the St Ann’s Hospital, London. He is also a practising psychoanalyst. Bateman and Fonagy developed MBT as a manualized treatment modality. Bateman’s most recent publication is the second edition of the Handbook of Mentalizing in Mental Health Practice, co-edited with Fonagy.

Marco Chiesa was a consultant psychiatrist at the Cassel Hospital in Richmond from 1991 to 2015, where he served as Director of the outpatient Adult Personality Disorder Service. He also pursued a private practice as a psychoanalyst.31 Together with Fonagy, he was principal investigator of the Cassel Personality Disorder Study, a trial of a mentalization-based approach to therapeutic intervention with patients with personality disorders. These patients were also followed up over subsequent decades to examine the long-term implications of treatment. Subsequently, Chiesa led a study of patient characteristics and treatment pathways using data from 14 psychotherapy services. He has also collaborated with Fonagy in studying associations between personality disorder and reflective function.

A fifth set of significant collaborators have had an especially influential role in Fonagy’s most recent work, and are co-authors on the landmark 2017 papers entitled ‘What we have changed our minds about’.32

Patrick Luyten is a clinical psychologist and psychodynamic psychotherapist, with faculty positions at University College London and KU Leuven. After qualifying as a clinician, Luyten had conducted empirical work on depression and chronic fatigue syndrome (p. 9) at the University of Leuven and had previously collaborated with Sidney Blatt at Yale. It was through Blatt that Luyten was introduced to Fonagy. Luyten is now Director of the PhD in Psychoanalysis programme and Course Director of the PhD programme in Evidence-Based Child and Adolescent Mental Health at University College London. He also leads a treatment service for patients with depression and functional somatic disorders at KU Leuven.33 His recent research has included work on the effectiveness of clinical interventions, and the development of self-report measures of mentalization.

Elizabeth Allison is Director of the Psychoanalysis Unit at University College London, and a practising psychoanalyst. She has a doctorate in English literature from Oxford University.34 In writings with Fonagy, Allison has elaborated the idea of the primary unconscious, and the implications of epistemic trust for clinical practice.

Chloe Campbell is Deputy Director of the Psychoanalysis Unit at University College London. Her doctoral study addressed themes of race and empire in the history of Kenya.35 Together with Fonagy, she is one of the authors of the article ‘Bad Blood: 15 years on’, addressing the relationship between attachment theory and mentalization approaches.36 She has also contributed to current thinking about epistemic trust, especially drawing on interdisciplinary perspectives.

Overview of the book

After some biographical and contextual background in Chapters 1 and 2, Chapter 3 will detail Fonagy and Target’s development of the idea of ‘mentalizing’ in thinking about the meaning of borderline personality disorder (BPD). BPD is a psychiatric diagnosis identified on the basis of problems with ‘emotion dysregulation, impulsivity and social dysfunction’.37 Chapter 3 will also consider the role of Howard and Miriam Steele and of attachment theory in shaping Fonagy’s thinking about mentalizing and child development. Chapter 4 will close by outlining Fonagy’s current position on mentalizing and identify transitions that have occurred over time. Chapter 5 will address the three modes of ‘non-mentalizing’ identified by Fonagy and Target. These will each be explained in turn. The chapter will also inspect suggestions in the work of Fonagy and colleagues regarding reasons why, when mentalizing breaks down, it falls into these three forms.

Having situated the ideas of mentalizing and non-mentalizing, we will then consider what these mean for understanding human psychology. Chapter 6 will critically examine a key term in Fonagy’s vocabulary—’the self’—and consider the role of unconscious processes in the formation of thoughts and feelings. The chapter will also give attention to Fonagy’s discussions of the ‘alien self’, and the role this psychological agency plays in sexuality and (p. 10) in aggressive behaviour. Chapter 7 will explore the conceptualization of mental illness proposed by Fonagy and colleagues. The chapter will begin by considering the interest in adaptation among Fonagy and colleagues, as part of a broader trend within developmental psychology. The importance placed on learning from experiences with others in the origins of mental health and illness will be described. The chapter will also consider the critique of diagnostic categories offered by Fonagy and colleagues, and their account of the nature and structure of mental illness.

Chapter 8 will draw out the implications of the previous five chapters for how Fonagy and colleagues have approached the task of therapeutic intervention. The chapter will describe “Mentalisation-based Therapy,” and the evidence so far regarding its effectiveness. Chapter 9 will also attempt to synthesize the diverse reflections of Fonagy and colleagues on mentalization and non-mentalization in social systems, which they have stated will be ‘at the core of mentalizing endeavours in the future’.38 The chapter will give attention to the work of Fonagy and colleagues on the school as an institution, and the potential for schools to contribute to the psychological well-being of their pupils. The chapter will also consider the researchers’ reflections on preventative interventions and public health infrastructures. Finally, the chapter will consider Fonagy’s reflections on the contribution of wider culture to the capacity of individuals and institutions to sustain mentalization and promote mental health and well-being. The Conclusion will draw together the claims from across the previous chapters. It will highlight the particular strengths of the work of Fonagy and colleagues, and identify a number of outstanding questions that face their paradigm.

Notes:

1 Doward, J. and Hall, S. (2019). ‘Therapy Saved a Refugee Child. Fifty Years on, He’s Leading a Mental Health Revolution’. Guardian, 27 April. Accessed at: https://www.theguardian.com/society/2019/apr/27/peter-fonagy-refugee-child-psychologist-anna-freud-centre.

2 Fonagy, P. (2015). ‘Mutual Regulation, Mentalization, and Therapeutic Action: A Reflection on the Contributions of Ed Tronick to Developmental and Psychotherapeutic Thinking’. Psychoanalytic Inquiry, 35(4): 355–369: ‘As with Freud, Bowlby’s critics were often apparently imprinted with the initial model; their attitude of hostility did not permit noting the change in Bowlby’s view’ (p. 357). Perhaps the most widespread case in the reception of the work of Fonagy and colleagues has been that the majority of readers seem to have imprinted on the idea of ‘pre-mentalizing’ states, as a kind of regression to childhood thinking, failing to notice that this has been replaced by the idea of ‘non-mentalizing states’ (see Chapter 5).

3 Liljenfors, R., and Lundh, L. G. (2015). ‘Mentalization and Intersubjectivity towards a Theoretical Integration’. Psychoanalytic Psychology, 32(1): 36–60. ‘This theoretical framework, which we will refer to as the theory of mentalization, is probably not yet to be seen as a full-fledged theory. Rather it is as a framework which is still developing’ (p. 37). In our view, there is no contradiction between the status of full-fledged theory and ongoing development.

4 Duschinsky, R. (2020). Cornerstones of Attachment Research, Oxford: Oxford University Press.

5 Skinner, Q. (2002). Visions of Politics: Regarding Method, Cambridge: Cambridge University Press.

6 Griffin, R. J. (2019). ‘The Profession of Authorship’, in Simon Eliot and Jonathan Rose (eds), A Companion to the History of the Book, New York: Wiley, pp. 773–785. In a sense, ‘Fonagy’, like the Crown in medieval legal and constitutional theory, has both individual and corporate identities.

‘Fonagy’ refers to an individual person, Peter Fonagy, who holds certain attitudes and has pursued certain actions. Yet, ‘Fonagy’ also refers to the embodiment of the assemblage of theoretical work occurring under his aegis. In this book, the phrase ‘Fonagy and colleagues’ is an attempt to signal the corporate identity, and ‘Peter Fonagy’ is invoked to refer to the individual person. However, there is inevitable instability: this division does not always hold. Maitland, F. W. (2003). State, Trust and Corporation, Cambridge: Cambridge University Press.

7 Hutchins, E. (1995). Cognition in the Wild, Cambridge, MA: MIT Press. On psychoanalytic theory as an ‘interactive’ product of individual thinkers and of the collective capacities of communities, see Winnicott, D. W. ([undated] 2016). ‘Outline for a Study in the Sociology of Knowledge’, in Lesley Caldwell and Helen Taylor Robinson (eds), The Collected Works of D.W. Winnicott, Volume 9, Oxford: Oxford University Press, pp. 391–394.

8 For example, Fonagy, P. and Target, M. (2006). ‘The Mentalization-Focused Approach to Self Pathology’. Journal of Personality Disorders, 20: 544–576: George Moran, George Gergely, Miriam and Howard Steele, Helen Stein, John Allen, Efrain Bleiberg, Anthony Bateman, and Liz Allison are listed (p. 544).

9 Fonagy, P. (2000). ‘Attachment and Borderline Personality Disorder’. Journal of the American Psychoanalytic Association, 48(4): 1129–1146, p. 1129.

10 Sandler, J. (1962). ‘Research in Psycho-Analysis—The Hampstead Index as an Instrument of Psycho-Analytic Research’. The International Journal of Psychoanalysis, 43: 287–291, p. 289. For varying examples of this scrutiny of psychoanalytic concepts, see e.g. Sandler, J. (1960). ‘On the Concept of Superego’. The Psychoanalytic Study of the Child, 15(1): 128–162; Sandler, J. and Rosenblatt, B. (1962). ‘The Concept of the Representational World’. The Psychoanalytic Study of the Child, 17(1): 128–145; Sandler, J., Dreher, A. U., and Drews, S. (1991). ‘An Approach to Conceptual Research in Psychoanalysis Illustrated by a Consideration of Psychic Trauma’. International Review of Psycho-Analysis, 18(2): 133–141. Sandler’s critical examination of the concept of the ‘preconscious’ can be regarded, in retrospect, as important groundwork for Fonagy’s work. See Sandler, J. and Sandler, A. M. (1994). ‘The Past Unconscious and the Present Unconscious: A Contribution to a Technical Frame of Reference’. The Psychoanalytic Study of the Child, 49(1): 278–292, p. 280.

11 Sandler, J. (1983). ‘Reflections on Some Relations between Psychoanalytic Concepts and Psychoanalytic Practice’. The International Journal of Psychoanalysis, 64: 35–45, pp. 35–36.

12 Sandler, J. (1962). ‘Research in Psycho-Analysis—The Hampstead Index as an Instrument of Psycho-Analytic Research’. The International Journal of Psychoanalysis, 43: 287–291, p. 290.

13 For further reflections on gerontocracy and the ensuing problems for conceptual development, see Fonagy, P. (2009). ‘When Analysts Need to Retire: The Taboo of Ageing in Psychoanalysis’, in B. Willock, R. Curtis, and L. Bohm (eds), Taboo or not Taboo? Forbidden Thoughts, Forbidden Acts in Psychoanalysis and Psychotherapy, London: Karnac Books, pp. 209–227.

14 Sandler, J. (1960). ‘On the Concept of Superego’. The Psychoanalytic Study of the Child, 15(1): 128–162: ‘the Index has functioned rather like a microscope, and as in the examination of physical tissues, increasing magnification may cause grosser structures to disappear from sight—but this by no means implies that they cease to exist’ (pp. 144–145). See also Wittgenstein, L. (1953). Philosophical Investigations, Oxford: Blackwell.

15 Sandler, J. (1987). ‘The Concept of Projective Identification’. Bulletin of the Anna Freud Centre, 10(1): 33–49. See also Sandler, J. (1993). ‘On Communication from Patient to Analyst: Not Everything is Projective Identification’. The International Journal of Psychoanalysis, 74: 1097–1107.

16 Sandler, J. (1987). From Safety to Superego, London: Karnac Books.

17 Fonagy, P. (2000). ‘On the Relationship of Experimental Psychology and Psychoanalysis: Commentary by Peter Fonagy (London)’. Neuropsychoanalysis, 2(2): 222–232, p. 226.

18 Fonagy, P. (2005). ‘An overview of Joseph Sandler’s Key Contributions to Theoretical and Clinical Psychoanalysis’. Psychoanalytic Inquiry, 25(2): 120–147, p. 139. See also Bohleber, W., Fonagy, P., Jiménez, J. P., Scarfone, D., Varvin, S., and Zysman, S. (2013). ‘Towards a Better Use of Psychoanalytic Concepts: A Model Illustrated Using the Concept of Enactment’. The International Journal of Psychoanalysis, 94(3): 501–530. While the criteria proposed by Bohleber, Fonagy, and colleagues have not been followed strictly in examining the concepts of mentalization theory, they have been held in mind: relevance, falsifiability, operational definition, internal consistency, contextual consistency, parsimony, and (optional) extra-psychoanalytic convergence.

19 Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications.

20 For further reflections on method in our studies of psychological theory, see Duschinsky, R. (2019). ‘Attachment and the Archive: Barriers and Facilitators to the Use of Historical Sociology as Complementary Developmental Science’. Science in Context, 32(3): 309–326.

21 This is a major theme of Duschinsky, R. (2020). Cornerstones of Attachment Research, Oxford: Oxford University Press.

22 See e.g. Hutsebaut, J., Bales, D. L., Busschbach, J. J., and Verheul, R. (2012). ‘The Implementation of Mentalization-Based Treatment for Adolescents: A Case Study from an Organizational, Team and Therapist Perspective’. International Journal of Mental Health Systems, 6(1): 10.

23 Brecht, B. ([1961] 2019). Refugee Dialogues, trans. Tom Kuhn, London: Bloomsbury, p. 63.

24 Fonagy, P. (2007). ‘Interview’, in L. E. Rubinstein (ed.), Talking about Supervision: 10 Questions, 10 Analysts = 100 Answers, London: International Psychoanalytic Association, pp. 39–49: ‘Language carries its own intelligence. It’s important to bear in mind that people’s thinking is organized by their language. Knowing that helps you. Sometimes you make terrible mistakes: the language drives particular parts of content and you cannot drive it away from that’ (pp. 43–44). See also Cavell, S. (1994). In Quest of the Ordinary: Lines of Skepticism and Romanticism, Chicago: University of Chicago Press.

25 Fonagy, P. and Allison, E. (2014). ‘The Role of Mentalizing and Epistemic Trust in the Therapeutic Relationship’. Psychotherapy, 51(3): 372–380, p. 375.

26 E.g. Fonagy, P. (2013). ‘Mentalization Based Interventions and a Mechanism of Change in Psychological Therapy’. Improving Access to Psychological Therapies. Accessed at: http://www.uco.es/informacion/webs/fundacioncastilla/documentos/archivos/simposium/2013-simposio/presentaciones/fonagy-pres.pdf.

27 Fonagy, P. (2007). ‘E-interview with Dominic Fannon’. Psychiatric Bulletin, 31(9): 360: ‘What part of your work gives you the most satisfaction? Collaborating with colleagues in creating innovative treatment approaches, designing joint projects and writing as a team’ (p. 360).

28 Solnit, A. J. (1992). ‘George Stritch Moran: A Personal Appreciation’. Bulletin of the Anna Freud Centre, 15(4): 267–268, p. 268.

29 Baruch, G., Fonagy, P., and Robins, D. (eds) (2007). Reaching the Hard to Reach: Evidence-Based Funding Priorities for Intervention and Research, John Wiley & Sons, p. x.

32 Fonagy, P., Luyten, P., Allison, E., and Campbell, C. (2017). ‘What we have Changed our Minds about: Part 1. Borderline Personality Disorder as a Limitation of Resilience’. Borderline Personality Disorder and Emotion Dysregulation, 4(1): 11; Fonagy, P., Luyten, P., Allison, E., and Campbell, C. (2017). ‘What we have Changed our Minds about: Part 2. Borderline Personality Disorder, Epistemic Trust and the Developmental Significance of Social Communication’. Borderline Personality Disorder and Emotion Dysregulation, 4(1): 9.

35 Campbell, C. (2010). ‘Eugenics in Colonial Kenya’, in A. Bashford and P. Levine (eds), The Oxford Handbook of the History of Eugenics, Oxford: Oxford University Press, pp. 289–300.

36 Fonagy, P. and Campbell, C. (2015). ‘Bad Blood Revisited: Attachment and Psychoanalysis, 2015’. British Journal of Psychotherapy, 31(2): 229–250.

37 The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists nine criteria for BPD, of which five or more need to be met for a patient to receive a diagnosis. These are: unstable, intense relationships; inappropriate anger; frantic attempts to avoid abandonment; affective instability; impulsive and potentially self-damaging actions; recurrent self-injury or suicidality; chronic feelings of emptiness; paranoid thoughts or dissociative symptoms; and identity disturbances. See Bateman, A., Fonagy, P. and Campbell, C. (2019). ‘Borderline Personality Disorder’, in Anthony Bateman and Peter Fonagy (eds) Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 323–334, p. 324.

38 Bateman, A. and Fonagy, P. (2019). ‘Introduction’, in Anthony Bateman and Peter Fonagy (eds) Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, p. 18.