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(p. 238) The wider social system 

(p. 238) The wider social system
Chapter:
(p. 238) The wider social system
Author(s):

Robbie Duschinsky

and Sarah Foster

DOI:
10.1093/med-psych/9780198871187.003.0010
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date: 06 December 2021

Introduction

In the previous chapter, we described developments in mentalization-based therapy (MBT), as well as a few of its current attributes and salient outstanding questions. One set of questions that was left for this chapter was the relationship between individual mentalizing—and mentalizing-focused intervention—and the individual’s wider social and cultural ecology. This includes the matter of whether, in certain kinds of environment, improvement in mentalizing and/or epistemic trust may be harmful. On a wider scale, critics have alleged that, in attempting to adapt to the individual-centric environment of contemporary health provision, MBT itself has been complicit with the atomization of society.1 Yet, in recent years, Fonagy and his collaborators have become increasingly critical of individual-centric modes of explanation, placing greater emphasis on the wider social system and the role of human interdependence in facilitating or hindering mentalization and mental health. These themes have been especially at the forefront recently during the 2020 and 2021 COVID-19 lockdowns.2 Fonagy has advocated specifically that ‘we must use the health catastrophe to drive social change’.3

The chapter begins by examining the growing attention to the social environment shown by Fonagy and colleagues, and especially their exploration of the role of friends and friendships for mentalization and epistemic trust. We will then examine the reflections and research by Fonagy and collaborators on public mental health. The researchers’ hopes regarding school-based prevention will be given particular attention, and the chapter will also show how this work has shaped Fonagy’s efforts as a policy influencer. Finally, the chapter will appraise the considerations offered by Fonagy and colleagues of the role of culture, in particular the issue of whether attention to cultural processes should be regarded as mentalizing, non-mentalizing or as not mentalizing, and whether organizations and societies can themselves be said to institutionalize cultures of mentalizing or non-mentalizing.

Reflecting on his own autobiography, Fonagy has acknowledged that he would likely have committed suicide as an adolescent had it not been for the intervention of his neighbour, who helped him receive treatment from Anne Hurry (see Chapter 2). Conversations with his colleagues Peter Fuggle and Dickon Bevington at the Anna Freud Centre have also had a profound role in highlighting to Fonagy the importance of the wider social system around the individual. Fuggle and Bevington pioneered Adaptive Mentalization-Based Integrative Treatment (AMBIT), an approach to the delivery of supportive services concerned to (p. 239) nurture the capacity of these services to sustain mentalizing and epistemic trust.4 The emphasis of Fuggle and Bevington on the organizational context of mentalizing has helped Fonagy to see that ‘mental health is a community responsibility’.5 In the 2019 edition of the Handbook of Mentalising in Mental Health Practice, Bateman and Fonagy have expressed their wish to ‘improve long-term outcomes in interpersonal function, a domain known to have only moderately good outcomes following MBT for BPD [borderline personality disorder]’.6 Elsewhere in the Handbook of Mentalising in Mental Health Practice, Fonagy and colleagues urged colleagues to recognize ‘the value of thinking about ways in which a social climate can be encouraged to become more mentalising’.7 And they closed their introduction to the volume by stating that ‘it is this wider social context of mentalising, and our human collective responsibility to support it, that will be at the core of mentalising endeavours in the future’.8 Bevington and Fuggle have observed a coming transformation in the very conceptualization of mentalising, because ‘mentalising is increasingly understood less as an individual power or even as a dyadic transaction, and more as a social and contextually determined activity’.9 This transition in conceptualizing mentalizing may be supported by the Covid pandemic and lockdowns, which have highlighted the fundamental contribution of threats and supports in the social environment to mentalizing capacities.10

The social environment

In individual therapy, the patient may learn to drop epistemic vigilance and consider the personal relevance of interactions with the therapist. Fonagy and colleagues perceive that doing so is relatively unlikely to be harmful, because the therapist’s intentions are largely benign and dependable, for all that the psychoanalytic unconscious may convey countervailing harmonics. The MBT therapist ‘consistently recognises the patient’s agency, focuses on the patient as an actor, and negotiates from the perspective of the patient’s self’.11

(p. 240) In group therapy, this is more challenging as the wishes and plans of others may not be benign or dependable, and individuals may feel unsafe with the group. This has been reported as the most serious concern of patients undergoing MBT, especially those who attended groups with rolling membership.12 Bateman and Fonagy have presumed that, if well handled by the therapist, vulnerability and willingness to learn in the group context should not be harmful. In fact, they have argued that overcoming the challenges to mentalizing and epistemic trust in this potentially turbulent context will have additional benefit beyond that available from individual therapy: ‘the power of group therapy [lies in its potential] to stimulate the capacity of the patient to manage anxiety within highly charged circumstances while maintaining mentalising. It is in the group that patients can truly balance emotional states evoked in a complex situation and their ability to continue mentalising.’13 However, the difference in efficacy between individual and individual + group MBT has yet to be tested, and some patients report that they regard the group therapy as lacking benefit for them.14 Inderhaug and Karterud, and Folmo and colleagues, have also cautioned that Bateman and Fonagy may be over-optimistic about the capacity of the group therapist to achieve a safe and constructive group atmosphere.15 Karterud has reported findings that patients who began MBT with low reflective functioning scores on the Adult Attachment Interview responded especially well to individual therapy and especially poorly to group-based therapy.16

In contrast to both individual and (perhaps) group therapy, in which a certain safety can be ensured, Bateman and Fonagy acknowledged that the patient’s wider life outside therapy may well be characterized by danger and chaos—and is very likely to remain so at the end of MBT.17 This may include interactions with state services in which professionals appear far from benign or dependable.18 Allison has described how this may play out in the case of homelessness:

Many people who have chronic or repeat experiences of homelessness report traumatic childhood experiences such as abuse, neglect, bullying, witnessing alcoholism, or domestic violence. These difficult beginnings can leave them profoundly mistrustful of others. Not surprisingly, then, they are also often mistrustful of services and may refuse to engage or struggle to remain engaged, especially if the help on offer comes with rigid conditions (p. 241) attached. When they do try to get help and the attempt backfires, this further undermines their trust in the people around them.19

In fact, the interaction between current adversities and mentalizing difficulties may be sufficiently intense that this intrudes on psychotherapy. Therapists may be drawn in to the non-mentalizing dynamics of the wider social system, even as they try their best to help: ‘the practitioner becomes embedded within the client’s social survival mechanism and this survival mechanism tends to work to destroy balanced mentalizing’.20

Fonagy and colleagues fully accept that in an environment where others’ wishes and plans are not benign or dependable, epistemic vigilance is entirely appropriate.21 When therapy leads epistemic vigilance to be lowered without discrimination, a deterioration in the patient’s mental health can be expected.22 The idea that a patient’s capacity and willingness to learn from experience is responsive to the qualities and dependability of their social environment had been a long-standing tenant of the Anna Freudian tradition for child psychoanalysis (see Chapter 7). It was anticipated that psychoanalysts would work collaboratively with parents to make the child’s home environment feel secure and safe enough to facilitate the adoption by the child of new forms of adaptation.23 As a rule, children are generally more responsive to social environments than adults.24 Nonetheless, Fonagy and colleagues have increasingly perceived that for adults, too, the environment needs to be secure and safe enough for epistemic trust to be appropriate.

This was, in fact, already recognized by Fonagy back in 2003: ‘individual therapy, while prototypical of the process of rekindling mentalization, may not cut it on its own. It is in the shared communally constructed creation of mind, in the patient-therapist dyad, in the family, in the psychotherapy group, in the multidisciplinary team, or in the organization of the entire treatment.’25 However, in the early 2000s, Fonagy had no conceptual model available for thinking about the communally constructed creation of mind, so this point was not elaborated. In recent years, though, the concept of epistemic trust has been drawn upon for considering how an individual can benefit from their communities. Fonagy and colleagues (p. 242) have claimed that epistemic trust will have most benefit for patients if it is accompanied by the capacity to form and make use of stable relationships beyond therapy. And vice versa. Allison and Fonagy have concluded that, in successful MBT, it is the ‘evolutionary capacity for learning from a social situation that is rekindled’, and within this, ‘learning who one can be friends with is key’.26 Or, as Fonagy, Luyten, Allison, and Campbell have argued: ‘Enhanced mentalizing allows the patient to achieve improved social relationships and recognize who is a reliable and trustworthy source of information—that is, who one can “be friends with”.27 Signalling its importance, this phrase is repeated verbatim in the Handbook of Mentalising in Mental Health Practice.28

The concept of the ‘friend’ is a long-standing, if subtextual, concern in Fonagy’s writings. As we saw in Chapter 1, he has repeatedly recalled the importance of a lack of any friends among the conditions that contributed to his feelings of depression and suicidality as an adolescent, and that led him into therapy with Anne Hurry. The theme of the ‘friend’ in Fonagy’s academic writings first appeared in his 1992 tribute to George Moran, where he described how much of both personal and professional relevance he had gained from the friendship.29 The friendship was deeply felt: when Moran was dying, Fonagy took sabbatical leave from work to provide care and support.30 On assuming the position of director of the Anna Freud Centre, Fonagy emphasized the influence on his work of his ‘very special friendship’ with Moran.31 Fonagy’s descriptions of the intellectual aspects of the friendship resonate with the ideas of the anthropologist Ed Hutchins regarding ‘distributed cognition’ (see Chapter 7), in which certain thoughts or insights are possible thanks to the properties emergent within an interaction, rather than solely as the sum of the cognitive properties of the members of that interaction. For Fonagy, his weekly conversations with Moran about their clinical work, which they called the ‘Saturday club’, provided scaffolding for reflection.32 The conversations brought together the tradition of Anna Freudian psychoanalysis, the problem of insulin control of diabetic patients, the expectation of regular future conversation—among other factors—to form a semi-autonomous ecology for supporting thinking that could not have been achieved individually.

In Fonagy’s subsequent thinking, friendships were treated as something rather special. Even when other relationships lack the potential for playfulness, or are hindered by conflict or forms of non-mentalizing interaction, friendships carve out space for their own semi-autonomous functioning.33 Indeed, Fonagy has collaborated on innovative longitudinal (p. 243) work led by van Harmelen examining longitudinal predictors of the degree to which an individual functions better or worse than expected in adulthood, given their early childhood family experiences. Van Harmelen and colleagues found that, in the context of adverse experiences of early care, positive adolescent friendships predict resilience in adulthood better than do positive family relationships in adolescence.34 Fonagy has elsewhere also acknowledged that the capacity to trust in friendships in adolescence and afterwards is certainly shaped by family relationships.35 Nonetheless, for Fonagy, the true friend is someone who creates a social environment within which epistemic vigilance can be dropped, even if epistemic vigilance must be retained in other contexts. This can entail shared non-mentalizing, as in shared pretend mode with its attendant potential benefits and problems. However, the fall of epistemic vigilance can also make possible access to the minds of others as a source of personal learning and development, in acknowledgement of the limits of our current understanding of ourselves and the world.36

Fonagy’s awareness of the debt we can have to friends for learning and development, as well as for remaining mentally well, has perhaps shaped his unusual diligence in writing detailed, loving obituaries and tributes for late friends and colleagues over his career. It is difficult to think of any other major research psychologist who, across their career and not just in retirement, has written so many obituaries. Fonagy has also frequently described the benefit and pleasure he has gained from thinking and writing with academic friends in pursuing collaborative work.37 At a more general level, Fonagy and colleagues have repeatedly stated, based on their experiences, that a clinician’s capacity to mentalize is sustained or undermined by the support they receive to do so from supervision, colleagues, and from wider (p. 244) institution systems and their organizational cultures.38 The clinician needs support if he or she is to face down the ‘hours of sometimes immensely painful analytic listening, toleration of distress and uncertainty, and moments of almost indescribable emptiness’.39

Fonagy and colleagues have highlighted the contribution of friends to emotion regulation and mentalizing, for good or for ill. For instance, Fonagy and Luyten have drawn attention to a prospective study by Crick and colleagues that showed that ‘the best predictors of BPD features from fourth to sixth grade were indicators of social dysfunction such as friend exclusivity (overly close relationship with friend), relational aggression (impulsivity), and cognitive sensitivity (hostile, untrusting paranoid world view).’40 Fonagy and Luyten theorized that difficulties in social relationships can set off cascades of contributors to mental health difficulties, such as reciprocal relationships between non-mentalizing and difficulties with affect modulation.41 By contrast, more positively, Twemlow, Fonagy, and colleagues were interested that their mentalization-based intervention in schools (see below) had a very large effect on children’s reports of being able to form and make use of school-based friendships. The number of children who said that they found making friends easy doubled following the intervention, from 30% to 60% of pupils; the number willing and able to make friends with pupils of a different race increased from 30% to 50%.42 Such findings suggest important links between friendships and epistemic trust. Yet a concern with these two matters is not currently a priority in many therapeutic modalities. For instance, neither is a special priority within child psychoanalysis. In the Anna Freud Centre retrospective study follow-up, Fonagy and Target found that former patients at the Centre reported more difficulties forming and making use of friendships than their non-treated siblings.43 Fonagy and colleagues have also criticized the excessive focus on clinical indicators in evaluating the effectiveness of mental health interventions, to the neglect of day-to-day functioning and the capacity to form supportive friendships.44 This is contrary to research on what patients themselves report wanting from therapy.45

(p. 245) Fonagy has stated that he has often reflected on what constitutes the difference between a professional and a friend, reflections that appear to have influenced the injunction in the manual that the therapist should avoid posturing in ways that signal their expertise.46 Bateman and Fonagy have argued that an MBT therapist should ‘first engage in the process of “being ordinary” … If in doubt, say to the patient what you would say to a good friend if he/she was telling you the same story while sitting in a cafe and you wanted to transmit a sense that you were “getting” their emotional state.’47 The relationship with the therapist models the ordinary opportunities friendships provide for recognizing ostensive cues, and for gaining skills and confidence in deploying mentalizing and epistemic trust:

Meaningful change is thus possible only if the person can use their social environment in a positive way (and if the social environment is sufficiently supportive to allow this to happen). For this to happen, recognition of self-agency is key, and this recognition is best achieved through the ostensive cues that are provided by feeling appropriately mentalised by another person.48

However, the therapeutic context is not only a model for forming and making good use of friendships. It also provides a space in which the patient can reflect on and appraise their social interactions. It seeks to help the patient consider how to use mentalization and drop epistemic vigilance in discriminate ways, appropriate to the opportunities and threats of the environment.49 The most effective treatment, Fonagy has argued, is one that ‘enables the individual to access and support, find inspiration and consolation, from a whole range of other people’.50 However, both inspiration and consolation entail the discrimination of appropriate occasions for mentalization and epistemic trust.

In the 2016 MBT manual, Bateman and Fonagy encouraged therapists to act as an advocate for the patient with other services: ‘MBT recommends that early in therapy the patient’s social context is stabilized. Change will be impossible if housing, financial, employment, (p. 246) probation and other stresses are dominant. The MBT clinician is an active advocate for the patient’s link to the wider social system.’51 There seems a clear turn in the past few years in accounts of MBT towards depictions of an active role of the clinician in supporting the patient to end harmful relationships, build on and nurture friendships that appear more beneficial, stabilize their living conditions, and other strategies to improve the social environment outside of therapy.52 Fonagy and Allison have put forward the empirical prediction that ‘psychotherapy for BPD is much more likely to succeed if the individual’s social environment at the time of treatment is largely benign. Although we do not know of any systematic studies that have explored this moderator.’53 They have urged further work to address this question.54

Prevention and public mental health

One way in which the importance of social context has been registered in the work of Fonagy and colleagues over the years has been in their considerations of prevention and public mental health. The role of poverty, discrimination, and other social adversities and forms of oppression have long been registered as powerful contributors to mental illness.55 However, through the 1990s and early 2000s, the primary answer Fonagy and collaborators offered to these factors was to situate individual regulatory capacities as potential buffers for the effects of adversity. This reflected and responded to the growing focus on individual self-management, rather than collective solutions to social problems, in culture and policy more generally in these decades (Chapter 2). In their 2002 paper, ‘Early Intervention and the Development of Self-Regulation’, Fonagy and Target offered their view that there were no ‘effective models of intervention’ to address these society-wide factors. In the context of apparent fatalism about social change, they instead advocated a ‘move toward person variables that were of particular importance in making an individual vulnerable to risk’. A survey of such potential variables led them to conclude that ‘self-regulation is currently the most promising candidate’.56 Fonagy and Higgitt would later re-state the point, emphasizing the importance of childhood as a period in which self-regulation capacities are developed:

It does not necessarily follow that social causes have social solutions; aspirin will relieve a headache even if the cause is poverty. Thus, it is likely that an understanding of the (p. 247) pathways of health inequalities will offer the possibility of policies that might directly contribute to addressing social inequalities in health. Social engineering is unlikely to be a viable way to address the social gradient problem. The essence of prevention is to find a point along a causal path that allows the possibility of cost-effective psychosocial manipulation and intervention. This implies intervention in childhood and finding those who are ‘hard to reach’.57

In a pair of papers from 2004, Fonagy argued that public resources are limited, and so need to be targeted carefully. He argued in favour of directing resources towards prevention, especially towards support for families with young children—for instance, through intensive pre-natal mental health screening.58 When prevention fails, he proposed that services should prioritize those with biomarkers and family history suggestive of risk of mental health issues. This would include even the use of biomarkers rather than children’s behaviour in screening for child abuse, and the targeting of interventions for child maltreatment to those children with biomarkers indicative of greater responsiveness to intervention.59 Yet, over the past 15 years, it would appear that Fonagy’s stance has shifted. He has argued against his earlier stance that resources, and even child protection services, should be targeted on the basis of biomarkers and family history, perhaps due to reservations about the moral implications of such a position. Instead, he has proposed that differences in biomarkers and family history—much like differences in symptom profiles—may indicate groups who would benefit from different kinds of intervention when they show poor mental health and seek help.60

Fonagy has also qualified his earlier rather exclusive focus on individual self-regulation as the point that permits cost-effective psychosocial manipulation and intervention. He has stated in interview his view that ‘We should be looking at how we can work toward a more equal distribution of wealth, and in some ways try to prevent the extant inequalities from affecting future generations’61—but he has not advocated this position loudly or prominently. There is a sense in which Fonagy appears to remain pessimistic about the possibilities of social change, and of the evidence base for society-level interventions. This may be linked to the realist thread in his theorizing, which sees little value in optimism that change will be successful in the absence of supporting evidence and a practical delineation of intervention (p. 248) mechanisms (see Chapter 1). It may reflect Fonagy’s decades of work as a psychoanalyst. Fonagy has himself acknowledged that the consulting room context of individual analysis can contribute to making individual problems and individual solutions most salient.62 The consulting room is a sequestered space a): in which the therapist and client can be concerned with mental states, b) in which the practical fall-out of mistakes about mental states is constrained and not fatal for the interaction, and c) such mistakes can themselves be attended to. Originally psychoanalysis, and subsequently MBT, have been facilitated by the consulting room as this sequestered space.63 Indeed, it facilitates the claim that mentalization is the active ingredient in all good therapy, and as ‘common ground’ between modalities.64 However, the sequestration also has consequences for what thoughts or feelings seem salient.

Fonagy’s continued pessimism regarding social change may also, following Bollas, be regarded as influenced by the wider societal focus on individual responsibility for thoughts and feelings, which to a certain extent Fonagy’s work reflects and to which it responds (see Chapter 2). It should be emphasized, however, that there is no intrinsic link between the theory of mentalization and a focus on individual solutions to social problems or fatalism regarding social change. For instance, Dickon Bevington, medical director at the Anna Freud Centre, is politically outspoken on issues of social justice.65

By contrast, an increasing attention to the social context has led Fonagy to seek to examine how ‘socially excluded groups such as LGBT individuals, asylum seekers, and those from poorer backgrounds’ might be supported in their individual self-regulatory efforts.66

In response to the murder of George Floyd by a Minneapolis police officer, and subsequent civil protests, Fonagy recently publicly reflected on his stance. In the past, he has generally (p. 249) regarded social justice and mental health as distinct matters, making him hesitant to comment on issues of social justice as outside his expertise. However, he acknowledged that the #BlackLivesMatter campaign had brought him to re-evaluate this position: ‘seeing humanity denied changes the way we all think’.67 He subsequently issued a public statement: ‘To pretend that the problems of disadvantage, of racism and of difference belongs to others is to allow them to continue unchallenged. Discrimination is totally antithetical to the core values of the Anna Freud Centre and we pledge our solidarity with our BAME colleagues, clients and students. As an organisation committed to ensuring that all infants, children and young people achieve their potential, we must address inequality based on ethnicity and offer support.’68 It will be interesting to see what further ramifications may stem from Fonagy’s reevaluation of the relevance of social criticism over the coming years.69

To date, however, by far the primary intersection between the individual and society addressed by Fonagy and colleagues has been schools: ‘we have focused on the question of how we can influence the environments that children inhabit. And of course, the crucial environment that comes to mind is the school setting.’70 As we saw in Chapter 2, in Fonagy’s biography, experiences of being bullied in secondary school was an important contributor to his depression, after he had been sent away by his parents to live in London; by contrast, experiences of validation and self-actualization in higher education helped reduce feelings of depression and suicidality. Another tributary to an interest in schools in buffering adversity likely stemmed also from the Anna Freudian tradition. Allison and Campbell observe that the concern of Fonagy and colleagues for education and mental health is ‘in keeping with the tradition Anna Freud established of creating settings—such as the Matchbox School in Vienna in the 1920s and nursery schools or residential homes in the UK—whose ecology is conducive to growth and psychological development’.71 A further background influence has subsequently been identified by Fonagy, who has noted that his own attention to schools has occurred in the context of the growing sociological importance of schools in the late twentieth century, as children spend less and less time with their parents and more with their peers, so that ‘children have become socialising agents for other children’.72 This is a role (p. 250) that Fonagy feels has been increasingly recognized during the COVID-19 pandemic during periods when children have not been able to access schools except remotely.73

More proximally, for Fonagy the perception of schools as a critical site of preventative intervention appears to have stemmed from his collaboration with Stuart Twemlow in the early 2000s on the Peaceful Schools Project.74 Twemlow, Fonagy, and colleagues began by thinking about secure, avoidant, and anxious/ambivalent school social systems.75 These schools might look much the same when things are calm. But when an external or internal event presents a challenge to the school, this challenge is handled quite differently. In a secure school, the challenge is neither exaggerated nor minimized. There is collaboration in approaching the problem, making space for both individual feelings and evaluations of the situation on the way towards a well-coordinated collective response. In an avoidant school, the primary response to the challenge is denial and a sense of false bravado. The problem cannot be communicated about; instead, individuals in the school seem preoccupied with other tasks or difficulties they face. In an ambivalent/resistant school, challenges prompt a sense of ready panic, but without clear lines of communication for responding to the problem collectively or constructively. What hierarchy there is in the school tends not to be functional, and individuals may even undermine it further in their attempts to have their concerns heard. The school is also characterized by confusion between discipline and other domains such as relationships and safety, making it difficult to distinguish between more or less serious challenges, or how to judge a measured response to them. The result is a school in which there is a high level of expressed affect at the slightest provocation.

The extrapolation of the Ainsworth attachment classifications to the social system of the school by Twemlow, Fonagy, and colleagues entailed identification of common elements. Like the infant of a secure dyad in the Strange Situation, in the secure school there is room for expressions of distress, which are not transformed by minimizing or maximizing strategies, and the expectation of collaboration to resolve the problem. Like the infant of an insecure dyad in the Strange Situation, in the insecure school there is a transformation of information about the problem, so that it either may not be acknowledged as a source of concern or becomes a preoccupation to the exclusion of other kinds of priorities.76 The innovative aspect of this picture was that a secure school was not conceptualized merely as the aggregate of secure or insecure individuals. Instead, the school was envisaged as having (p. 251) dynamic properties at the level of the social system characteristic of security or insecurity.77 Building on certain threads in the ideas of Main and Crittenden, security was elaborated as a state of non-distortion of information about threat and protection, whereas insecurity reflected certain transformations of this information (see Chapter 7). In general, Fonagy theorized that ‘in secure organizations social influence is exercised in a framework dominated by an awareness of the mental states, concerns, thoughts, and feelings of individuals within the system’.78 He also saw that in other organizations, too, the dynamics characteristic of insecurity could be seen. In fact, he remarked that ‘many of us work in organizations where bullying is as, if not more, pervasive than at the average elementary school’.79 An individual may have a secure or insecure attachment to individual caregivers, but Fonagy has argued that ‘being responded to sensitively most of the time by many people fosters trust in the availability of the entire network’, and that in such contexts, ‘secure attachment is to a system rather than an individual’.80 The idea of the externalization of the alien self was not invoked in conceptualizing these dynamics. This may reflect that the target audience for the work by Fonagy, Twemlow, and colleagues, likely educationalists and policy makers, may have been sceptical of this rather speculative and unobservable mechanism. However, it also perhaps reflects a decline in the frequency of appeal to the concept of the ‘alien self’ over the course of the 2000s.81

In 2009, Fonagy, Twemlow, and colleagues reported from a cluster randomized control trial of a mentalization-based intervention with school communities compared with pastoral–therapeutic interventions solely offered to disruptive students. The mentalization-based intervention had four major components. A first was use of reflective classroom discussions. For instance, 15 minutes were set aside at the end of each day for classes to reflect together on bully–victim–bystander relationships according to a structured format. Poster campaigns, stickers, and badges were used ‘to create a climate where feelings were labelled and distress was acknowledged as legitimate’.82 A second component was a classroom management plan, which supported teachers in understanding and correcting problems at the root in the social system of the classroom, rather than punishing individual children who misbehave. Consideration of role of bystanders in the facilitation or inhibiting of bullying was especially integral to the programme. A third component was teaching pupils (p. 252) nonaggressive physical and cognitive strategies for when they find themselves a bystander or a victim of bullying. Role play was used to help pupils see that these were structural roles, and could in principle be populated by anyone, but that the roles could be handled in various ways. A fourth component was the introduction of a peer mentoring system.

Both the mentalization-based intervention and the intervention focused on disruptive students were greeted enthusiastically by teachers. However, only the mentalization-based intervention proved effective. There were reductions in peer-reported aggression, peer-reported victimization, support by bystanders for aggressive behaviour, and an increase in concern about the experiences of victims of bullying. In the classroom, the schools that implemented the mentalization-based approach saw medium to large reductions in pupils off-task and disruptive behaviour by children as measured by researchers’ observations. Fonagy, Twemlow, and colleagues observed, from a review of the literature, that these behavioural changes were the largest seen to date in any randomized trial of a school-based intervention.83

The collaboration with Twemlow and related thinking about schools as social systems led Fonagy and colleagues to quite a distinctive position on the role of schools in society. This was reflected in the influential THRIVE model developed by Wolpert, Fonagy, and colleagues for the provision of child and adolescent mental health.84 THRIVE is the operating model used for 47% of the 0–18 population in England, and is recommended in the NHS Long Term Plan.85 Wolpert, Fonagy, and colleagues divided provision into distinct categories, with characteristic providers, goals, and discourses. Their goal was to structure services around the different strategies for providing help, rather than severity of need or diagnosis. This aimed to help facilitate shared decision making with young people about what strategies they think will be most relevant and useful. A first level of support was to help young people cope and to foster their resilience to challenges. It was argued that ‘wherever possible, this provision should be provided within education or community settings, with education often (though not always) the lead provider and educational language (a language of wellness) as the key language used’.86 A further level of support offered children help with mental health difficulties: ‘provision for this group should be provided with health as the lead provider and using a health language (a language of treatment and health outcomes)’. A distinctive aspect of the THRIVE approach to help was that ‘treatment would involve explicit agreement at the outset as to what a successful outcome would look like, how likely this was to occur by a specific date, and what would happen if this was not achieved in a reasonable timeframe’.87

Support for coping and help with mental health difficulties were contrasted by Wolpert, Fonagy, and colleagues with risk support. Here ‘social care may often be the lead agency and (p. 253) the language of social care (risk and support) is likely to be dominant’. The authors acknowledged that ‘perhaps the most contentious aspect of the THRIVE model’ is that services should acknowledge that not every child can be helped through mental health provision, and that only risk management rather than mental health treatment should be provided if there is reason to believe that mental health treatment would be ineffective. The goal of support for coping should be to improve young people’s resilience; the goal of help should be to reduce specific identified symptoms; and the goal of risk support should be to reduce young people’s risk of harm to themselves or others. In the THRIVE model, then, schools are given a critical role. When more complex needs emerge, specialist mental health services and/or social care might become involved. But schools are depicted by THRIVE as holding fundamental responsibility as the locus of primary support for young people by social systems beyond their families. Rather than prioritizing the expansion of specialist mental health provision, the THRIVE model suggests taking the school community as the fundamental target for intervention.

Fonagy and colleagues provide the example of the approach they would ideally like to see for ‘Billy’, an 11-year-old frequently found by his teacher ‘Ms. Jones’ to be disruptive in class, and to engage in power-struggles and bullying towards other students:

Would Billy benefit from individual therapy? Experience shows that boys like Billy respond poorly to such efforts, however skilled, if they do not take place in the context of concurrent family and social interventions. We feel that disrupting the vicious cycle that a child such as Billy finds himself in should be undertaken in school. Furthermore, it may be best, given Billy’s sensitivity to humiliation, if the intervention does not directly concern Billy at all but, rather, the whole class … The procedure in the context of our program would have been for Ms. Jones to stop the class immediately after Billy started creating a commotion, and mark some space for reflection on what was happening. In other words, she would recognise the assault on her own mentalising that she was experiencing … in the process seek to draw upon the collective mentalising capacity of her classroom to create an environment in which Billy’s arousal could reduce.88

There appears to have been a reciprocal support between Fonagy’s interest in schools and his growing attention to epistemic trust and learning. On the one hand, the idea of epistemic trust as an openness to learning from others is well encapsulated by the school context.89 On the other hand, the increased focus on epistemic trust has further solidified the conviction of Fonagy and colleagues that schools are a privileged locus for preventative work in public mental health, especially where teachers can mentalize and offer ostensive cues to pupils.90 (p. 254) Furthermore, the growing momentum at the Anna Freud Centre around using schools as a site for scalable public mental health intervention has led to major ongoing trials of various interventions, led by the UCL-Anna Freud Evidence-Based Practice Unit.91 This includes the ‘Education for Wellbeing’ trial, which will recruit 26,000 pupils across England to assess the relative effectiveness of five different school-based interventions.92 The Anna Freud Centre has also pursued research on strategies to support the mental health well-being of school staff, as part of facilitating mental health within schools.93

In recent years especially, Fonagy has been proactive in advocating to policy makers regarding individual self-regulation and schools as potential sites for public mental health preventative work.94 In relation to individual self-regulation, Fonagy has been critical of the effectiveness of specialist mental health services, both in terms of reach and in terms of aggregate clinical impact.95 So, instead of advocating for the resourcing of specialist mental health services, he has been a national policy leader in the expansion of primary care mental health services for children and adolescents, within the ‘Improving Access to Psychological Therapies’ framework. This included various provisions that could be delivered within a primary care setting, such as brief psychological therapies for anxiety and depression for children, and parenting classes when young children have conduct problems.

(p. 255) The exact nature of Fonagy’s policy work is difficult to document, because there is not much information in the public domain. In the context of major cuts to mental health services since 2011, as part of the government’s austerity agenda, Fonagy reports his sense that his policy engagement has contributed towards the direction of public resources towards child and adolescent mental health:

I think it’s the thing I’ve done that I’m most proud of. The service was not fit for purpose. In many parts it may still not be. In a situation where [mental health services for children and adolescents] suffered a financial penalty greater than at any time in its history, it has not collapsed … in the last budget of this government, £1.25 billion was set aside for children’s mental health—£250 million a year over the next five years. That’s getting back to the level it was at before the cuts began.96

Under the coalition government, Fonagy served as an academic adviser to Paul Burstow and Norman Lamb, Ministers of State for Care.97 In 2013, his work at the research–policy interface led to the award of an OBE by the Queen. And he was singled out by the Children’s Minister in 2014 for praise for his achievements in policy-relevant research.98

In 2017, Fonagy and colleagues were asked by the Department of Health to conduct a ‘systematic review of the evidence relating to the mental health of children and young people’. The systematic review and its conclusions have not been published, though future publication has been promised.99 However, the Department of Health Green Paper stated that Fonagy and colleagues had advocated for greater use of schools for preventing, identifying, and responding to mental health issues:

The school environment is well suited to a graduated approach to children’s mental health, where children at risk can be identified and interventions can be offered to address problems. As the school environment can present triggers for many difficulties (such as social anxiety), it is therefore also a good place to find support to manage them.100

The central innovation in the Green Paper was the creation of new Mental Health Support Teams attached to schools, with around 8,000 staff. This would be larger than the whole of the existing children and young people’s mental health services workforce in the NHS. It was (p. 256) also expected that schools would liaise more regularly with mental health services. The Anna Freud Centre would contribute to the training of this workforce through a new Diploma for Mental Health Practitioners in Schools. Fonagy has worked with the Secretary of State for Health, Jeremy Hunt, to argue publicly for the benefits of a school-focused approach to improving young people’s mental health.101 The Education and Health Select Committees have criticized the Green Paper, alleging that it passes responsibility for children’s mental health to schools, rather than offering either adequate resources to individual mental health provision or social change to address the factors at the root of young people’s suffering.102 The Committees also expressed concern that young people with potential additional mental health needs, such as those in care or on the edge of care, are given insufficient priority in the reforms. No doubt Fonagy would have wished that more resources were available. However, for decades he has consistently assumed public resources to be limited, and on this basis argued for a prioritization of primary prevention in schools, and a comparatively reduced prioritization of secondary mental health care. He has also been a consistent advocate for greater interagency working between sectors.103

Collective mentalizing capacity

In 2017, Di Stefano and colleagues alleged that it ‘seems that Fonagy and colleagues have paid little attention to the context in which the relational, mental, and affective experiences of the individuals originate and consolidate’. In doing so, Fonagy and colleagues fail to consider the ‘rules, meanings, and shared models of behavior that produce relationships and social exchanges capable of supporting or, on the contrary, hindering processes of exploration and meaning that individuals attribute to their own (and others) actions’.104 As we saw in Chapter 3, when Fonagy was initially elaborating the concept of mentalization in the early 1990s on the basis of existing work in social cognition, he included some elements of social cognition and not others. An important exclusion was that cognition about social norms was not taken up as part of the concept of mentalizing. In contrast to social cognition, then, mentalization was not concerned with norms about inequality, hierarchy, and intrinsic differences between groups that may play a significant role in oppression. Fonagy’s assumption (p. 257) in the early 1990s appears to have been that the key concerns of mentalisation—intentions, beliefs, affects—can only belong to individual subjects, and cannot belong to groups.

Later in the 1990s, when working on the reflective functioning scale with Howard and Miriam Steele and Anna Higgitt, Fonagy treated sociological discussions that place attachment figures in their cultural and historical context not simply as irrelevant to mentalizing, but specifically as bad mentalizing: ‘Passages rated as “1” may be sociological, excessively generalised, concrete or overwhelmingly egocentric.’105 They also advised coders to give low scores to accounts of mental states that seemed drawn from ‘shared culture’. It was assumed that ‘shared culture’ was opposed to the individual’s own sense of mental states as ‘personally significant and meaningful’.106 Across the reflective functioning scale manual, what references to social and cultural factors occur seem premised on the expectation of a trade-off between psychological-mindedness and sociological- or group-mindedness.107 This was a tendency supported by the poorly articulated distinction between ‘not mentalizing’ and ‘non-mentalizing’, sometimes leading one to be mistaken for the other. It may also have been supported by Fonagy’s distrust of the dynamics of large groups, which he regarded as tending away from acknowledgement of individual experiences.108 In the 2000s, Fonagy allowed that it would be possible to mentalize non-corporeal individuals, such as ‘explicating the mental states of story characters’ or the intentions of divine beings.109 However, groups were beyond the pale.110

(p. 258) Fonagy and Target have subsequently regretted their early rejection of sociological and group-focused thinking. In fact, Target has substantially redirected her approach over the past 15 years towards greater engagement with sociological theory and methods.111 Fonagy and Target have recognized that ‘every patient comes to an assessment with his own language and frame of reference for emotional distress, with his own theories consonant with cultural idioms for the expression of emotional distress’.112 In the landmark ‘What We have Changed our Minds About’ paper from 2017, Fonagy and colleagues stated that they had changed their minds ‘about the relationship between the individual and culture’, seeing the need for a ‘more systemic, less intrapsychic approach’.113

As we saw above, in the 2000s, Fonagy, Twemlow, and colleagues struggled to explicitly work out a basis for extrapolating mentalization from interpersonal processes to social systems, as they had with security and insecurity. Mostly, they seem to have assumed that a capacity to conceive of and reconsider thoughts and feelings could only be a property of individuals, and could only take as its target other individuals: ‘Culture is the product of individual minds. It’s an aggregate. It is whatever comes through from what lots of minds have in common.’114 In such statements, no autonomy was ascribed to social systems as more than the aggregate of individuals. However, as we saw social environment, there were other times when Fonagy, especially in work with Twemlow, moved towards an account in which the properties of a community itself could i) be considered to facilitate mentalization, or ii) be taken as the target of mentalization by individuals concerned with perspectives and affects circulating in a social system.115 Both were reflected in the first two components of their Peaceful Schools intervention. The class as a whole were asked to reflect together on bully–victim–bystander relationships, supported by the teacher’s understanding of and attention to these systemic dynamics. Teachers were encouraged to ‘draw upon the collective mentalising capacity of [the] classroom’.116

What could the collective mentalizing capacity of the classroom be? The nature of the Peaceful Schools intervention implicitly suggests some aspects. One is dedicated time. The collective expectation of time to reflect at the end of the day might be part of the collective mentalizing capacity, alongside the accumulation of previous successful discussions as a (p. 259) collective reference point.117 Another part of the scaffolding of collective mentalizing capacity may be space. That the daily discussions took place in a familiar classroom may suggest the physical space as a potential contributory to collective mentalizing capacity, as a secure base.118 The collective mentalizing capacity may encompass the circulation of images that make acknowledgement of feelings a taken-for-granted part of the institutional climate of the wider school. The school’s coordination and coherence of approach to discipline might also be part of its collective mentalizing capacity. No doubt the safety of the school environment would also be a relevant collective resource for facilitating mentalizing. None of these features seem readily reducible to merely the aggregate of the mentalizing capacities of the school’s members.

Nonetheless, the concept of a ‘collective mentalizing capacity’ remained underdeveloped, with three subterranean and partial exceptions. One partial exception has been thinking in the development and running of the Pears Family School within the Anna Freud Centre, founded in 2014. The school takes pupils excluded from or unable to cope with mainstream education. A requirement is that parents are willing to join a parent group and participate in the life of the school. The founding vision was for a community with ‘many of the features of a mainstream school alongside the non-institutionalized values of a family environment’.119 It is the ambition that each child returns to mainstream education after receiving sufficient benefit from the Family School, and to date this has been the case for the majority of children.120 Descriptions of the school do not make explicit mention of the collective mentalizing capacity institutionalized in the Pears Family School. However, at times, there seems implicit acknowledgement that mentalizing and epistemic trust in the school is more than the sum of these qualities in its members. One example is Fonagy’s response when the Pears Family School and Anna Freud Centre won the Grand Prix Design Award in 2019: ‘The space we have is one for bringing people together, and the environment encourages collaboration, creativity, and inclusivity.’121 This suggests acknowledgement of the role of physical space as a resource towards collective mentalizing capacity. Another example of implicit acknowledgement of collective mentalizing capacity is in a remark by Allison and Campbell about the ambitions of the school, that ‘the work of building a community at the school and ensuring that it functions as a mentalizing environment is a critical part of its therapeutic (p. 260) work … The community of Pears Family School seeks to operate as a mentalizing training ground for children and families.’122

Another partial exception to the underdevelopment of the concept of collective mentalizing capacity has been the work of Asen and Fonagy, considering the applicability of mentalization-based family therapy. In two papers from 2017 on family violence, they argued that ‘the family consulting room can be a unique environment where the collective mentalizing capacity of the family, with the support of the therapist’s own reflective capacities, can be mobilized to identify the thoughts and feelings that might have triggered a problematic interaction’.123 Implicit in their account is a distinction between individual mentalizing and collective mentalizing capacity. The former is defined as an ‘imaginative mental activity that entails perceiving and interpreting human behavior in terms of intentional mental states’.124 The latter is left undefined, but appears from the way the term is used to be a property of the family system that permits the identification and reflection on thoughts and feelings of and between its members. The individual mentalizing skills of family members support the collective mentalizing capacity. But even when these skills fail, the collective mentalizing capacity may have an independent contribution to offer.

By the same token, individual mentalizing skills may have reduced effect, or could even backfire, depending on the state of the family’s collective mentalizing capacity. Asen and Fonagy did not explicitly theorize collective non-mentalizing processes operating at the level of the family system, and distinct from the non-mentalizing of individuals in the family. However, they took steps towards such an account. They stated that ‘a system—be that a family or other social group—that is characterized by blindness to the mental states of self and others will tend to create systems of social influence where coercion and humiliation play a key role’.125 They discussed ‘escalating nonmentalizing interchanges’, in which the interactions of individuals in the family seem to become more than the sum of their parts in facilitating pretend mode, psychic equivalence, or teleological mode.126 They also describe the way that violence within the family system can be stabilized or destabilized by use of externalization of the alien self by a member or members of the family. Yet, at the level of clinical technique, their approach is quite firmly oriented by a focus on helping family members understand their own minds and those of others. There is little attention at the level of technique, beyond encouraging individual mentalizing, to facilitation of collective mentalizing capacity, or reduction of collective non-mentalizing processes. Despite clear apparent relevance, it remains unexamined—for instance, whether the group dynamics that would facilitate automatic mentalizing would help or hinder controlled mentalizing, and vice versa.

A third partial exception to the neglect of collective mentalizing capacity is in work on group-based MBT, building on the long heritage of attention to group-level processes in group psychotherapy.127 Occasionally, Fonagy and colleagues describe the need to (p. 261) foster particular kinds of ‘group culture’ or ‘a secure atmosphere within the treatment milieu’.128 However, such claims are only ever made in passing. More generally, the collective mentalizing capacity of the MBT group has been treated as the sum of individual capabilities.129 It is revealing that in Sigmund Karterud’s manual for group-based MBT he specifically stated that the formation of group culture in contributing to or hindering mentalizing is beyond the scope of the manual.130 At points, Karterud referred to Foulke’s concept of ‘matrix’, the communication network of the group materialized by the history of their interaction.131 He emphasized the importance of such collective processes in shaping the potential for mentalizing. However, he also urged that a distinction between MBT and many other forms of group therapy is that in the former the therapist should generally avoid discussion of group-level processes, because what matters is the individual’s capacity to consider other individual minds and their own. Karterud also perceived a risk that discussion of group-level processes had special risks for entry into pretend mode. The MBT therapist may certainly think about group processes, but the primary way in which they engage with them is through ‘stimulating and assisting the group in discussion of group relevant themes’.132 There is barely mention even of group cohesiveness, which has otherwise been a concern in the literature on group therapy.133 Concern with the group matrix has also not spread beyond Karterud to other theorists of mentalization.134

The limited explicit concern with group culture, cohesion, and hierarchy by MBT therapists has been criticized by some patients, who feel that sometimes the ‘elephant in the room’ is not raised by therapists when this appears to relate to a group-level rather than individual-level phenomenon.135 Other patients report their impression that group MBT is asking them to mentalize the group, suggesting that this task is felt by some as expected or demanded by group MBT, even if this not a goal of the developers of MBT or the therapists delivering (p. 262) it.136 In fact, occasional remarks by Fonagy and colleagues have suggested ambivalence about what relationship they wish patients to have with the group. For instance, Fonagy and Adshead encourage therapists to ‘engender attachment bonds between members of the group, and with the group as a whole’.137 But this is not a recommendation that has recurred in subsequent papers.

Mentalizing cultures

In 2019, Asen, Campbell, and Fonagy published a chapter in the Handbook of Mentalising in Mental Health Practice specifically focused on social systems. As well as the culmination of previous partial attempts to address the topic, the choice to focus a chapter on social systems might be placed in the context of two other trends. First, Jurist has observed that mentalization theory must surely muster some response to the destruction of communal supports and dehumanizing government policies. These throw into relief the extent to which environments capable of sustaining mentalization and epistemic trust are dependent on societal infrastructures and collective processes, and we have seen how these can be broken or dismantled.138

Direct attention to social systems in the Handbook of Mentalising in Mental Health Practice might also be placed in the broader context of increased attention to this topic over the past decade from across various disciplines in the social sciences and humanities. For instance, work in neuroscience has documented that the activation of brain regions associated with mentalization, such as the medial prefrontal cortex, temporo-parietal junction, and precuneus, do not distinguish individual from group targets. The activation appears to be the same for participants reflecting on the potential ‘intentions’ of an individual or an organization.139 In fact, people can attribute mental states (thoughts and feelings) to a group even if they attribute those mental states to none of the group’s individual members, and vice versa.140 In 2011, Fonagy praised the growing development of attention to group-level processes in organizations and societies within psychoanalytic theory.141 The need for renewed attention to group-level processes has similarly been urged in recent years by Twemlow, who has explicitly reappraised his work with Fonagy in terms of an intervention to improve community-level processes in the schools.142 However, Twemlow drops the mentalizing (p. 263) framework in doing so, presumably following Fonagy’s classical assumption that only individuals can be the subject or target of mentalizing.

In their 2019 chapter, Asen and colleagues reflected that the long-standing focus on individual mentalizing since Fonagy’s work in the late 1980s was itself shaped by cultural values, which trained attention on individual responses to challenges. They acknowledged that, in their culture, an excessive causal role is attributed to individual agency compared with the contribution of contextual and collective factors.143 By contrast, ‘in other cultures, the central unit is not the body or “self” of the individual, but the community and especially the family’.144 For individuals to be judged not to be mentalizing because they are concerned with the dynamics or cultural memory of communal units rather than individuals would seem ethnocentric.145 Asen and colleagues accept that mentalisation-based interventions may risk exactly such ethnocentrism to the extent that they treat a patient’s attention to the beliefs and affects of collective units as either outright non-mentalizing, or as a distraction from the real work of attending to the beliefs and affects of individuals. And to the degree that a therapeutic modality is institutionally ethnocentric, it is likely to flounder, or at least face serious obstacles, in attempts to generate epistemic trust.146

The same would be true for other communal-level processes, such as social antagonisms, wealth inequalities, and structural discrimination. The ‘distributed cognition’ possible in friendships, considered earlier in the chapter, and in group problem solving would likewise be excluded as a legitimate target of mentalizing.147 As conventionally formulated, if patients were to raise such matters during MBT, technically this would be considered not (p. 264) mentalizing, and the therapist would be enjoined to redirect the patient’s attention towards the thoughts and feelings of individuals, specifically.148 MBT therapists may even see civic disobedience and political activism, perhaps correctly, as sustained by the sense of urgency from psychic equivalence. Individual therapists may adapt their practice, but technically the modality would suggest redirecting patients away from this kind of thinking. Critics such as Parker have criticized Fonagy and colleagues, alleging that MBT is inherently normalizing, with ‘patients effectively told how they could or should feel about key events in their lives or about their relationships with others.’149 This criticism is certainly too strong. Nonetheless, there is a more subtle normativity in MBT. The modality aims to get patients to engagement in mentalizing, but with mentalizing defined in politically and culturally circumscribed ways. Asen and colleagues appear to acknowledge this as a problem in recognizing that the modality was shaped by cultural values that directed focus to individual responses to challenges.

The Asen and colleagues chapter has three ramifications for the fundamental conceptualization of mentalization:

  1. 1. It implies recognition of the potential for shared wishes and plans, for ‘we’ or ‘they’—not merely ‘I’—to be the agent of action, to possess thoughts, and to sustain feelings. For ‘us’ to establish an institution, buy a flat, or perform an opera is not merely the aggregate of our efforts, purchases, or performances, but an irreducibly collective undertaking and commitment.150 The ‘irreducibly collective mode of cognition called the we-mode’ has been highlighted explicitly by Fonagy in recent workshops and conference presentations,151 and experimental support has been offered by Csibra and colleagues, who have shown that the results of judgements made on the basis of ‘we-intentions’ differ from those occurring on the basis of I-intentions’.152 Even in the (p. 265) archetypal scene of parental reflective function, ‘we-intentions’ may be relevant: for instance, when a parent displays marked mirroring and ostensive cues relating to same-sex gender roles or a collective family culture or project (‘yes, darling, that’s how we do it’). Conversely, if ‘we’ or ‘they’ can sustain ‘we-intentions’, then ‘we’ (or ‘they’) can also be subject to mentalizing. Asen and colleagues appear to be moving towards the treatment of social or cultural settings as legitimate targets of mentalizing—to the degree that these units have collectively held beliefs and feelings.

  2. 2. A second implication is that intentions, thoughts, and feelings can be shaped by the qualities and projects of collective units. This might include their distributions of social status or material resources, lines of coercion or solidarity, and collectively held values or affective atmospheres.153 Consideration of the role of these units in facilitating or hindering mentalizing may have earlier been regarded as either non-mentalizing or as a distraction from mentalizing. In 2012, Asen and Fonagy had explicitly drawn the comparison that ‘whereas systemic practitioners might seek explanations in the individual’s context, whether it is their family, social or cultural setting … an MBT-F therapist may, under certain circumstances, view this as a non-mentalizing stance to adopt’.154 The comments by Asen, Campbell, and Fonagy in 2019 suggest a wish to clarify the circumstances in which attention to social or cultural settings should not be regarded as non-mentalizing. This aligns with Fonagy’s growing conviction that ‘poor mental health is not simply in our individual minds. It is part of a social condition.’155

  3. 3. Third, Asen and colleagues appear now to suggest that different collective units, including societies and institutions, may differentially facilitate or hinder different forms of mentalizing (e.g. of the self or of others) and of non-mentalizing (e.g. pretend mode or psychic equivalence). This suggests directions for elaborating the developmental model of mentalization and epistemic trust in the future to take into account cultural moderators and mediators. For instance, Aival-Naveh and colleagues have argued that ‘the suspension of epistemic mistrust may be dependent not only on accurate mentalizing and ostensive cueing from an attachment figure, but also on norms and social roles, most notably—filial piety and respect’.156

Despite these advances, the 2019 chapter gives the impression of remaining suspended between two different models of social systems, without thorough integration. For instance, (p. 266) even on a single page (p. 233), the authors present two different definitions of the term ‘culture’:

Culture can be defined as a dynamic system of explicit and implicit rules established by groups in order to ensure their survival, involving attitudes, values, beliefs, traditions, customs, norms and behaviours … Culture could also be described as a system of knowledge shared by a relatively large group of people, passed on from one generation to the next.157

It would appear that the authors have two different objects in mind, though they give them both the same name, expressing—apparently without realizing—a wider divergence in social scientific practice between two uses of the term ‘culture’.158 A first sense is ‘anthropological culture’, taken to mean a collective form of life that shapes the perceptions and intentions of its members, with particular priority given to shared myths, presuppositions, and taken-for-granted practices. Anthropological culture also encompasses the role of social institutions and forms of self-perception in sustaining these myths, presuppositions, and practices. A second sense is ‘cognitive informational culture’, taken to mean the net information held by members of a group.159 In the former, the social system is conceived as having a degree of autonomy from its members, with group-level dynamics and attributes.160 In the latter, the social system is conceived as the sum of the information held by its members.161

To illustrate the difference: when a set of tools or concepts depend upon extensive specialist knowledge for their use, sustaining epistemic vigilance regarding their appropriate application hinders their spread into anthropological culture but not their ascension into cognitive informational culture. An example is the Strange Situation as a technical research (p. 267) tool, constrained in its use by expertise and resource demands. When a set of tools or concepts are circulated in a ‘light’ commodified version that requires little or no specialist knowledge, sustaining epistemic credulity regarding their appropriate application hinders their use within cognitive informational culture but precisely facilitates their spread within anthropological culture. An illustration is the idea of ‘attachment’, which has seen widespread take-up, but with poor alignment with how the concept was used in Bowlby’s technical writings.162 Another example might be the concept of ‘mentalization’ itself, which can have diverging roles in attempts to transfer technical information (cognitive informational culture) and in the communal processes that operate through shared myths and presuppositions operating within psychological research and practice (anthropological culture).

The two uses of the term ‘culture’ are reflected, and not reconciled, in uses of the concept of epistemic trust by Asen, Campbell, and Fonagy in thinking about social systems:

  1. 1. In some cases, the term ‘social system’ is used to refer to anthropological culture and explore collective characteristics that facilitate or hinder individuals and groups from learning from experience.163 This is clearest in the account by Asen and colleagues of the work of Bevington and Fuggle on creating organizational structures facilitative of mentalization-based integrative treatment. Indeed, there is friendly criticism of Fonagy’s writings in Bevington and Fuggle’s wish for ‘a shift away from the hope or expectation of creating individual mentalising’ in their chapter of the Handbook.164

  2. 2. In other cases, however, and perhaps predominantly, the term ‘social system’ is used by Asen, Campbell, and Fonagy in a way that makes it seem to represent the sum of individual qualities that help or hinder learning from experience. This learning might be at a group or institutional level or at an individual level, but, with culture interpreted as cognitive information held by members of a group, mentalizing remains solely the preserve of individuals. Collective mentalizing capacity falls into the background.

The two concepts of culture are not reconciled, and at times produce significant incoherence in the chapter. For instance, the authors seem unsure about whether the welfare state i) improves the aggregate epistemic trust and mentalizing of citizens and/or ii) reduces violence through shaping the collective norms, priorities, and concerns of institutions and the wider society.165

In contrast to the relatively poor coherence in their discussion of epistemic trust, in their 2019 chapter, Asen, Campbell, and Fonagy are more explicit than in earlier work about the existence of collective-level mentalizing processes. They even argue that it is possible to be ‘mentalised by relevant social systems’, not just individuals, and that individuals can ‘attempt (p. 268) to mentalise social systems’, not just one another.166 This is an important statement, readjusting the fundamental boundaries of mentalization theory. Teams, groups, organizations, societies are now to be treated as able to give and receive recognition; this makes them ‘partial persons’ in terms of their capacity to mentalize and be mentalized, on the basis of beliefs and affective atmosphere implicated in joint actions, preferences, and duties.167 One case is the work of Fonagy and colleagues themselves. Over decades, this research collective have themselves been distinctive in their remarkable capacity to incorporate learning from other specific collectives and research traditions within the contested space of academic knowledge.168

In recent presentations, Fonagy has proposed that this turn to attention to social systems and communities represents a ‘Copernican revolution’.169 The experience of being mentalized by social systems, more than mentalization by individual caregivers, may be the primary basis for the potential for epistemic trust, via secure attachment to and identification with the community. He has suggested that ‘the infant is responding to the sensitivity of a network towards their sense of agency, how much the network is paying attention to them, not a single individual. That is what fosters trust.’ As such, ‘we ignore too much the importance of the infant recognizing the specificity of the other as an instance of the general other. This particular other is part of the network of “my group of people, my community” to which I belong, and represents my identity.’170 A sense of belonging to the community facilitates epistemic trust in that community. Fonagy has therefore urged a shift in the study of child development to ‘assess the caregiver network’s sensitive responsiveness’, and test the contribution of this collective capacity to the development of epistemic trust, and conversely to the development of personality disorders.171 He expressed concern that accounts of mentalizing (p. 269) and epistemic trust have over-emphasized the importance of family interactions, and underestimated the importance of modern sociological processes that isolate families and hinder the functioning and integrity of communities, undermining their capacity to show sensitivity to individuals’ emergent sense of personal agency. Rather than treat ‘resilience’ as equivalent to epistemic trust (see Chapter 7), Fonagy has now proposed that we ‘conceptualize “resilience” less as a quality held by the child, and more as an outcome of the quality of the social network surrounding the child and the child’s capacity to access that network’.172 In the context of the COVID-19 lockdown, Fonagy has argued that this situation has especially highlighted just how limited the nuclear family is, and how important the wider social network, for meeting children’s needs.173

In their 2019 chapter, Asen and colleagues develop a framework for thinking about the harms of collective non-mentalizing. They give the example of organizations in which ‘psychic equivalence becomes institutional—it characterizes the function of a social system’.174 The paradigmatic example, for them, is George Orwell’s dystopian novel Nineteen Eighty-Four, in which thoughts and feelings are treated as real political threats, and therefore must be controlled, with a single viewpoint defended rigidly and even violently. However, Asen and colleagues observe that many more familiar social systems—schools, health services, political infrastructures—develop related characteristics as psychic equivalence becomes institutional.

Similarly, pretend mode and teleological mode can likewise become institutionalized in the culture and even the protocols of organizations.175 In pretend mode, especially in the form of hypermentalizing, within the institution there may be ‘endless “communication” and searching but it is destined to yield no change’. Meanwhile, there may be all kinds of awful behaviour contrary to the organization’s stated values, which are not registered due to the dominance of pretend mode.176 In institutionalized teleological mode, only concrete outcomes (p. 270) matter. For instance, New Public Management in the UK is a system oriented by teleological mode, in which the efforts of workers are not to be treated as real or meaningful unless they have demonstrable and successful consequences that can be audited and monitored by the system.177 This is certainly the institutionalized culture of many contemporary health and social care services.178 The institutionalization of teleological mode can also make organizations intensely concerned with perceived threats to their reputation, perceived as having catastrophic potential consequences.179

Since the 1990s, Fonagy has from time to time offered his personal impression of a ‘dehumanisation, the stripping of humanity, that is occurring at all levels of culture’ in social systems.180 This reflects major social and economic shifts, as well as the pervasive social exposure associated with new media, which in interaction have contributed to an increased recognition of mental illness and likely also a real rise in certain mental health issues among young people. Fonagy and colleagues have speculated that the increase in BPD may reflect a response to fragmented, dehumanizing social systems in the context of modernity. Fonagy has offered the examples of China and Russia as illustrating the societal conditions for the production of BPD, the prevalence of which has risen vertiginously in line with social fragmentation.181 However, he sees such particular cases as intensified forms of a sociological process characteristic of modernity more generally:

(p. 271)

The anomie of modern life—that is, a lack of social connectiveness leading to dysregulation—described by Durkheim, and connected by other authors with the conditions that might account for national variations in BPD, can be read as a description of a systemic collapse of epistemic trust.182

The comparison with Durkheim is revealing. What is shifting in modernity in general, and which is revealed most starkly in China and Russia, is not simply a breakdown of the experience of the claims and experience of others as dependable, generalizable, or relevant. It is a systematic collapse—i.e. a collapse at a systemic level, rather than only something occurring for individuals. For Durkheim, the shift away from solidarity based on strong social ties, in the context of modernity, does not alter the fact that individuals fundamentally remain shaped by their cultural and economic ecology, which channels relatively shared forms of moral and social perception and interpretation based on shared practices.183 This cultural and economic ecology will facilitate or undermine our experience of the claims and experience of others as dependable, generalizable, or relevant. For Durkheim, the most important aspect of this ecology was economic inequality, which hinders the achievement of solidarity between individuals.184 In the terms of Fonagy and colleagues, it hinders collective mentalizing capacity.185

In countries like the UK, Fonagy has speculated that the availability of mental health services and improvements may be mitigating the rise in BPD that would otherwise have been expected in the fragmented, dehumanizing social systems that have taken hold in so many sectors over recent decades.186 The epidemiology of BPD in part reflects its social construction by infrastructures of psychological classification. However, additionally, Fonagy has suggested that its epidemiology to an extent reflects the relative presence of anomie. Within societies, for example, Fonagy has proposed that the greater incidence of BPD among women may reflect their dehumanization and objectification, in which full subjectivity is tacitly ascribed more to men than to women in countless ways even while equality has ostensibly been achieved.187 As one case, Fonagy has drawn attention to the way that, (p. 272) despite discourses of gender equality, in practice ‘we have made mothers inappropriately and uniquely responsible’ for children and child care.188 In a recent newspaper article, he has highlighted that there is greater pressure on women students in higher education as they do exams and think about job market prospects, because expectations of success and equality are mismatched with an unequal economic and social reality.189

In 2015, Fonagy and Allison characterized mentalization theory as aligned with liberation politics, proposing that it ‘overlaps almost completely with queer theory’ in seeking and defending ‘the singular truth of the individual’s experience’ against ‘publicly accepted forms of knowledge’.190 To claim almost complete overlap with queer theory was unpersuasive, because at the time Fonagy and colleagues had no account of publicly accepted forms of knowledge,191 or of the formation of gender identities.192 With the 2019 chapter by Asen, Campbell, and Fonagy, earlier remarks about the potential harms caused by social systems are integrated with the theory of mentalizing in the conceptualization of non-mentalizing modes ‘becoming institutional’. This opens intruiging possibilities for thinking about forms of oppression like sexism and homophobia in terms of problems in collective mentalizing capacity, and the specific roles of pretend mode, psychic equivalence, and teleological mode. First, however, Fonagy and colleagues will need to develop a much more robust account of dominance, oppression, and social consecration to make sense of:

  • who is regarded as having the right to offer ostensive cues;

  • who is attributed real and socially pertinent mental states;

  • (p. 273) whose signals are subject to epistemic vigilance;

  • the costs or punishments associated with deviating from socially established conventions for ostension, for the recognition of mental states, and for the enactment of epistemic vigilance.193

Such an account has precisely been one of the major achievements of queer theory, and has been fundamentally absent in the work of Fonagy and colleagues. It is not false to regard queer theory as pitching the singular truth of the individual’s experience against publicly accepted forms of knowledge; this is one important element.194 More important to queer theory, however, is the role of publicly accepted forms of knowledge and practice in organizing and situating who is considered to have experience and the psychological and epistemic standing of that experience. To take an example, Ahmed has examined the gendered relations of power that can construct epistemic vigilance enacted by women as a distraction, enforcing epistemic trust and framing the women themselves as ‘spoilsports’ or ‘killjoys’.195

An important obstacle for Fonagy and colleagues over the years in conceptualizing dominance, oppression, and social consecration has been that the scene that has served as their lens on mentalization, and more recently on epistemic trust, has been the caregiver–infant relationship. Not that they have ignored that this relationship may be abusive; far from it. But the scene of recognition or misrecognition is of simple wishes and needs. Though an infant is dependent on the power of the caregiver, Fonagy and colleagues do not consider this scene as one in which there is any contest for dominance, any interest or manipulation on the part of the caregiver, and no necessity for the caregiver to justify his or her authority. At least by 12 months, these features are present, albeit perhaps not necessarily salient in child–caregiver interactions; it would have been quite different if Fonagy and colleagues had narrated the scene of parental reflective function with the child as a true preschooler. It was always a peculiar mismatch that in expositions of their theory in the 1990s and early 2000s by Fonagy and colleagues, the ages 2–3 were given priority for the development of mentalizing, but in accounts of parental reflective function the child seemed to have the characteristics of an infant, displaying simple intentions, but not battling to jump into the pond, wanting to wear their sibling’s clothes, or refusing to put down the attractively packaged product grabbed from the aisle in the supermarket.196 A scene of parental reflective function without conflict, deception, or cultural mediation has been retained over subsequent decades, even as the prioritization of preschool for the development of mentalizing has been abandoned by Fonagy and colleagues, and even as their focus has shifted from marked mirroring to ostensive cues and the development of epistemic trust.

(p. 274) Queer theorists would ask: what has been the implication of the scenes in which Fonagy and colleagues predominantly imagine mentalizing taking place? These scenes are, above all, dyadic: the analytic clinic and parental reflective functioning. They would point to a certain epistemic bias in the image of what counts as mentalizing, because the way it has been imagined has tended to filter out the collective conditions, social antagonisms, and practical workaday phenomena beyond the dyad that might otherwise be recognized as facilitating or obstructing mentalization. One example, for instance, is the neglect of Fonagy and colleagues of the role of habit in facilitating or obstructing mentalizing.197 Another is their neglect of social oppression. It is notable that a quality of the four key ideas that Fonagy and colleagues drew from Gergely—marked mirroring, teleological mode, ostensive cues, epistemic trust is that each offers a way of considering the relationship between individual theory of mind and embeddedness in sociality. This is part of what makes them such powerful concepts and heuristics. However, each concept simultaneously limits the scope of acknowledgement of sociality. So, for instance, marked mirroring is irreducibly dyadic and social, but the dyad is removed from cultural context, adversities, and the pragmatic challenges of everyday life.198 Fonagy and colleagues know, of course, that these ideas are pragmatic simplifications. However, the problem has been that, in incorporating them, Fonagy and colleagues tended over the decades to lose track of what has been lost.199 For instance, in characterizing epistemic trust in terms of an individual open to learning from other individuals or from society, Fonagy and colleagues bracket the way that cognitive informational culture is invested by relations of power and exclusion, which influence what is supported to become knowledge. As black feminist epistemologists such as Hill Collins and Dotson have argued, the tools and skills that sustain cognitive informational culture are differentially accessible and, when accessed, differentially suited for use by dominant groups.200 The capacity to recognize oneself as a learner, or for others to recognize us as someone from whom they could learn, are likewise structured by intersecting forms of authority and prestige, invisibility, and denigration, which apply to both individuals and communities. As is the capacity to recognize mental states in others and in oneself. These processes are missed as, following (p. 275) Gergely, Fonagy and colleagues give ‘cognitive informational culture’ precedence over ‘anthropological culture’ in their thinking about learning.

With anthropological culture more in view, queer theory draws from Althusser and Foucault in imagining a different scene of recognition and misrecognition to that of Fonagy and colleagues. Here, the encounter is not between child and caregiver but between individual and institution, or representative of that institution.201 This fundamentally alters the stakes of questions about ostensive cues, the recognition of mental states, and the deployment of epistemic vigilance.202 Even the scene of marked mirroring and ostensive cues in early childhood appears in a different light, because the way in which the caregiver comes to offer acknowledgement of the child’s mental states, intention, and individuality is already contingent on forms of symbolic and material stratification, and a wider economic and cultural ecology. So, for instance, a caregiver’s recognition of the child’s playful exploration (see Chapter 5) will already be embedded within gendered systems of power, shaping what the child comes to recognize as their own curiosity and excitement, and the manner in which they feel they can dare to venture out into the world and learn from experience.203 As we saw in Chapter 6, for Fonagy and colleagues the self is partly imaginary, a confabulation weaving together diverse sources of information. This already offers an important qualification to any idea of ‘reflective’ function as simple, transparent knowledge. Yet, a further complexity left aside by Fonagy and colleagues, at least until recently, is the way that self-representation is always already saturated by a wider economic and cultural ecology (‘the symbolic’ in Lacanian terms), which not only prompts and informs the self-representation but also the integration of its elements, including the identification of intentions excluded from the self-representation to form part of the ‘alien self’.204 Seemingly moving in this direction, in (p. 276) conference presentations in 2019, Fonagy has argued that the ‘infant recognises the specific other as an instance of the generic other characteristic of the community’, acknowledging the cultural situatedness of recognition within the child–caregiver dyad.205

A published consideration of recognition and misrecognition, not by the parent but by collective units, has also been offered recently by Fonagy and colleagues in thinking about the role of distorted intentions and/or mental states for individuals seeking to cope with social institutions that discount their needs, identities, and experiences. In the Handbook of Mentalising in Mental Health Practice, Fonagy, Campbell, and Allison characterized ‘distorted social cognition’ as entirely ‘necessary for people to be able to live with the vivid human capacity for social imagination and function in an inherently socially imperfect world’.206 Non-mentalizing modes might be used more by individuals with significant histories of adversity and oppression, as part of their adaptation to this adversity (see Chapter 7). However, Fonagy and colleagues contend, we all engage in distorted social cognition to the degree that we must learn to cope with a society and institutions ‘in which the minds of individuals are either discounted altogether or systematically described as “culpable” or “undeserving”. To varying degrees, we have each experienced distortions and damage to the imaginative capacity that underpins both mentalization and ethical vision as part of becoming people able ‘to tolerate the social system well enough to navigate it’. The institutionalization of non-mentalizing modes hinders our ‘capacity for both critique and creativity’.207

This account of the role of institutionalized non-mentalizing in mediating structural oppression and personal indifference is distinctive, and represents a potential advance in thinking about dehumanizing institutional arrangements. An example can be seen in the attention Fonagy has given to the ways in which collective non-mentalizing capacity may be facilitated by the affordances of new media technologies. Fonagy has characterized new media as a double-edged sword: currently contributing to social and psychological pressures on young people, but with significant potential to facilitate mentalization, self-care, and the strengthening of relationships with others.208 He has argued against a technological determinist argument in which the pervasiveness and the image-focused aspects of new media are necessarily contrary to mentalization. Instead, he has proposed that social (p. 277) media is good for circulating ostensive cues without the substance of recognition, and for stimuli for rapid, implicit rather than careful, explicit mentalizing.209 To date, their predominant effect has been to reduce sustained consideration of thoughts and feelings. However, he regards this as an effect of their embeddedness within social practices not built to promote mentalizing, rather than an inevitable effect of the technology itself.210 He has given the example of his daughter, who was bullied at school, but who could use her phone to reach out to her parents rather than feeling left alone in the institutional context of the school.211

However, Fonagy and colleagues are yet to distinguish the social conditions that facilitate different forms of non-mentalizing—what would seem to be the greatest potential of a social systems interpretation of their theory.212 Furthermore, their hold on a social systems perspective remains precarious still. For instance, in the Handbook of Mentalising in Mental Health Practice chapter by Asen, Campbell, and Fonagy on social systems, the authors identify four characteristics of ‘a social system with a capacity for effective mentalising’.213 The foremost characteristic of social systems with a capacity for effective mentalizing is that the system needs to be capable of retaining different perspectives rather than being ‘stuck in one point of view’. Second, the system ‘must be able to permit modifications of convention, at least on a temporary basis’. Though justification is not given, it would seem that this is regarded as facilitating the other characteristics of a social system with capacity for effective mentalizing. Third, a social system needs to have means of identifying and responding to the experiences and goals of its members, rather than assuming sufficient knowledge of these in (p. 278) advance. Finally, ‘the social system needs to emphasize the importance of individual “ownership” of, and responsibility for, specific behaviours and actions, rather than explaining individual behaviours or actions as the result of some external force.’214

Yet there is a false opposition here. Why should awareness of causes of individual behaviour beyond the individual entail a denial or negation of individual responsibility? Would Asen and colleagues really treat the actions that the characters in Nineteen Eighty-Four are brought to as chosen, and as reflecting individual ownership and responsibility? As we read the book, especially the closing chapters, one of Orwell’s main concerns is with the way that feelings of personal responsibility can diverge terribly from the actual conditions for meaningful enactment of responsibility. As we saw in Chapter 6, Fonagy’s position has been increasingly qualified in recent years to balance two claims: where supports can make the illusion of personal agency somewhat meaningful and self-reinforcing, it can be a very helpful illusion because it becomes a kind of reality; where supports are unavailable to make the illusion of personal agency meaningful and self-reinforcing, the feeling of responsibility is persecutory and unhelpful. To take an illustration: if ‘we have made mothers inappropriately and uniquely responsible’ for children and child care,215 the inappropriateness stems in part from the fact that the apparent uniqueness of this responsibility is part of a wider system of sexism, and in the fact that the unique responsibility is an illusion that masks the necessary contribution of external supports or lack of supports for the activities of caregiving.216

The term ‘responsible’ needs to be considered carefully. Vincent, a philosopher, offers helpful distinctions, asking us to consider ‘the text of a notice that hangs in Café Doerak, my favourite bar in the Dutch city of Delft, “The management of this establishment is not responsible” ’. Vincent points out that:

This notice is terribly ambiguous, and one might imagine two people engaged in a frustrating argument about it, simply because each understands it differently, though neither realizes that this is so. But the text of this notice could be helpfully re-written …

CAPACITY: The management of this establishment are not (yet) psychologically mature.

VIRTUE: The management of this establishment are not dependable and might be reckless.

ROLE: The management of this establishment have no responsibilities towards its clients. (p. 279)

CAUSAL: The management didn’t causally contribute to losses suffered on these premises.

OUTCOME: The management can’t be blamed for whatever happens on these premises.

LIABILITY: The management won’t pay for any losses suffered on these premises.217

As has often occurred in Fonagy’s use of the term ‘responsibility’ since the 1990s, Asen and colleagues seem to have conflated some of these meanings. They appear to have assumed that attention to the causal role of system-level factors is incompatible with an individual’s sense of intentionality in their moral role, and thus with mentalizing.218 As a result, the authors slip back into a stance in which attention to the beliefs and atmosphere of collective units as causal for individual behaviour is treated not simply as ‘not mentalizing’ but as non-mentalizing, destructive of individual mentalizing capacity.

Naturally, there may be situations in which collective mentalizing capacity and individual mentalizing operate at the expense of one another. But attention to the beliefs and atmosphere of collective units as causal for individual behaviour should not in itself be regarded as opposed to an individual’s sense of intentionality. Jurist, among others, has identified this as, inadvertently, an ethnocentric, moralizing, and politically neoliberal stance.219 It does not sit comfortably with the trend towards greater acknowledgement—and critique—by Fonagy and colleagues of the properties of the social system in shaping human capacities, including the capacity for mentalization and the viability of feelings of responsibility (see Chapter 6). For instance, elsewhere in recent work, Fonagy and colleagues have highlighted evidence that ‘the prevalence of BPD can be relatively well predicted from the ratio of the average income of the richest 20% to that of the poorest 20% of the population. Hence, a general lack of social concern for equality may be directly related to the prevalence of BPD.’220 Such findings have led Allison and Campbell to argue that mental health difficulties in our society ‘are a collective responsibility and ought to be a collective concern’.221

Fonagy has recently argued against discourses of ‘responsibility’ in a society where young people are frequently made to feel powerless and encounter institutions and environments (p. 280) with inadequate support for enacting meaningful agency. Speaking to the Youth Select Committee:

I feel very strongly that, very differently from my own childhood, young people nowadays carry a far greater responsibility than I had to carry, in terms of my life course. My life course was far more set out and determined, and I didn’t feel personally responsible for it. I actually had far more authority over my life than young people do these days. That combination of having to take responsibility without authority makes young people very vulnerable.222

Nonetheless, where supports can make the illusion of personal agency into a kind of reality, it can still be regarded as very helpful. “Acknowledgement that ‘I am a person and I have agency’ ” is a perspective that supports the coherence and consistency of thoughts and feelings by supporting mentalizing and the capacity to make good use of social relationships.223

Behind the issue of responsibility in Asen, Campbell, and Fonagy’s account of mentalizing culture lies ongoing ambiguities in the conceptualization of intention. This concept has an underpinning role across the work of Fonagy and colleagues. In part, it is linked to the contributions of Gergely. Intention is critical in distinguishing mentalization from teleological mode; and as the other object, besides mental states, that can be taken as the target of marked mirroring and ostensive cues. Beyond this, though, Fonagy and Allison have reconceptualized the psychoanalytic unconscious in terms of intentions externalized from the self-representation. However, there is an ambiguity to the term, contributing here to conceptual and normative problems with how Fonagy and colleagues in turn conceptualize responsibility. It is logical that mentalizing social systems would help people consider how behaviour and experience can be accounted for in terms of thoughts and feelings implicated in motivations and intentions. That is part of what mentalizing means. However, it is not logical that acceptance of individual responsibility excludes acknowledgement of external causal factors.224 This seems to depend on an essentialized notion of intention as individual will, relatively impervious to circumstances. It also runs contrary to statements made by (p. 281) Fonagy and colleagues elsewhere, on occasions when intention is considered more carefully, that state that one needs ‘to feel responsible for and in control of one’s own mental life as well as behaviour in the world, but also to assess fairly accurately what is outside one’s control. Failures in the process of evaluation can lead at one extreme to a belief in one’s own omnipotent responsibility’.225

Given that the concept of ‘intention’ is a key component in accounts of mentalization and epistemic trust, it would appear that slippage in use of the concept will be a continued hindrance for work to conceptualize the role of culture. On the one hand, when intention is treated as equivalent to individual will, this is likely to hinder attempts to make sense of the kinds and forms of intention involved in we-intentions, and in the ascription of intentionality to collective units. On the other hand, it will hinder attempts to understand the role of culture and context in shaping how we come to thoughts and feelings. For instance, reification of the idea of intention will contribute to the continued neglect of proto-thoughts and feelings, which play such a key role in shared myths, prohibitions, presuppositions, and taken-for-granted practices and artefacts (‘anthropological culture’). Such issues may sustain the difficulties Fonagy and colleagues have had in integrating their concept of the primary unconscious with the rest of their thinking. Furthermore, given the turn in the most recent work of Fonagy and colleagues towards the pursuit of empirical trials of therapeutic interventions in the developing world,226 problems in their thinking about cultural differences may turn out to be particularly consequential.

Notes:

1 E.g. Rustin, M. (2015). ‘Psychotherapy in a Neoliberal World’. European Journal of Psychotherapy & Counselling, 17(3): 225–239.

2 See Allison, L. (2020). ‘On Learning from Loss: Rereading ‘Mourning and Melancholia’. Accessed at: https://www.ucl.ac.uk/psychoanalysis/learning-loss-rereading-mourning-and-melancholia; Fonagy, P. (2020). Tweet, 22 March. Accessed at: https://twitter.com/peterfonagy/status/1241676565387382786?s=11: ‘Current crisis shows just how dependent we are on each other.’

4 Bevington, D. and Fuggle, P. (2019). ‘AMBIT: Engaging the Client and Community of Minds’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 211–228.

5 Kirby, T. (2019). ‘Peter Fonagy—battling the enemy of loneliness’. The Lancet Psychiatry, 6(12): 987.

6 Bateman, A., Unruh, B. and Fonagy, P. (2019). ‘Individual Therapy Techniques’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 103–116, p. 108.

7 Fonagy, P., Campbell, C. and Allison, E. (2019). ‘Therapeutic Models’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 169–180, p. 178.

8 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, pp. 3–20, p. 18. See also Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre: ‘When we consider the extensive evidence of the impact of parents’ and carers’ mental health on the mental health and wellbeing of children and young people and the influence of community and neighbourhood on both children and families, the narrow focus of most treatment approaches on individual dysfunction is surprising.’

9 Bevington, D. and Fuggle, P. (2019). ‘AMBIT: Engaging the Client and Community of Minds’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 211–228, p. 221. See also Jurist, E. and Sosa, M. P. (2019). ‘Commentary on Mentalization and Culture’. Clinical Psychology: Science and Practice, 26(4): e12302 .

10 Lassri, D. and Desatnik, A. (2020). ‘Losing and regaining reflective functioning in the times of COVID-19: Clinical risks and opportunities from a mentalizing approach’. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1): S38.

11 Fonagy, P., Campbell, C. and Allison, E. (2019). ‘Therapeutic Models’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 169–180, p. 175.

12 Lonargáin, D. Ó., Hodge, S., and Line, R. (2017). ‘Service User Experiences of Mentalisation-Based Treatment for Borderline Personality Disorder’. Mental Health Review Journal, 22(1): 16–27.

13 E.g. Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 156.

14 Lonargáin, D. Ó., Hodge, S., and Line, R. (2017). ‘Service User Experiences of Mentalisation-Based Treatment for Borderline Personality Disorder’. Mental Health Review Journal, 22(1): 16–27: ‘Most participants described wanting individual sessions only and some did not see the purpose of group MBT’ (p. 19).

15 Inderhaug, T. S. and Karterud, S. (2015). ‘A Qualitative Study of a Mentalization-Based Group for Borderline Patients’. Group Analysis, 48(2): 150–163. See also Folmo, E. J., Karterud, S. W., Kongerslev, M. T., Kvarstein, E. H., and Stänicke, E. (2019). ‘Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance, and Epistemic Trust—A Qualitative Study of Mentalization-Based Therapy for Borderline Personality Disorder’. Journal of Contemporary Psychotherapy, 49(3): 141–151.

16 Karterud, S. (2011). ‘Constructing and Mentalizing the Matrix’. Group Analysis, 44(4): 357–373, p. 383.

17 Allison and Campbell warn against any assumption that socio-economic adversity will necessarily entail benefits to epistemic distrust. Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre: ‘it is important not to make simplistic assumptions about the quality of relationships implied by socio economic disadvantage. There is evidence that individuals who are less socio economically privileged tend to behave in more community and socially oriented ways in interpersonal trust experiments than more affluent individuals (Dubois, Rucker, & Galinsky, 2015)’, citing Dubois, D., Rucker, D. D., and Galinsky, A. D. (2015). ‘Social Class, Power, and Selfishness: When and Why Upper and Lower Class Individuals Behave Unethically’. Journal of Personality and Social Psychology, 108(3): 436–449.

18 Mason, C., Taggart, D., and Broadhurst, K. (2020). ‘Parental Non-Engagement within Child Protection Services—How Can Understandings of Complex Trauma and Epistemic Trust Help?’. Societies, 10(4): 93.

19 Allison, E. (2015). ‘Epistemic Trust: A New Perspective on the Barriers to Change in Chronic and Repeat Homelessness’, in What Works: Rethinking Hopelessness, Cobham, UK: Berkeley Foundation, p. 9. Accessed at: https://www.berkeleyfoundation.org.uk/media/pdf/r/r/Rethinking_Homelessness.pdf. Some analogues can be drawn, in some cases, with the experiences of state services among refugees. See the remarks by Fonagy in Novikova, M. (2019). ‘Can a Form of Therapy Focused on Understanding the Mental State of Others Help Refugees in the UK?’, Guardian, 21 June. Accessed at: https://www.theguardian.com/the-guardian-foundation/2019/jun/21/how-to-make-integration-mutual.

20 Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre.

21 See also Sperber, D., Clément, F., Heintz, C., Mascaro, O., Mercier, H., Origgi, G., and Wilson, D. (2010). ‘Epistemic Vigilance’. Mind & Language, 25(4): 359–393.

22 Allison, E. and Fonagy, P. (2016). ‘When is Truth Relevant?’. Psychoanalytic Quarterly, 85(2): 275–303: ‘If the truth that the lifting of epistemic hypervigilance uncovers is unremitting hostility and the absence of benign influence, the recovery of epistemic trust through therapy will generate no lasting improvement and may even lead to deterioration’ (p. 295).

23 Fonagy, P., Bleiberg, E., and Target, M. (1997). ‘Child Psychoanalysis: Critical Overview and a Proposed Reconsideration’. Child and Adolescent Psychiatric Clinics of North America, 6: 1–38.

24 Fonagy, P. and Sharp, C. (2008). ‘Treatment Outcome of Childhood Disorders: The Perspective of Social Cognition’, in C. Sharp, P. Fonagy, and I. Goodyer (eds), Social Cognition and Developmental Psychopathology, New York: Oxford University Press, pp. 411–470: ‘Interventions in young children draw their effectiveness from the parent’s influence on social cognition, while in middle childhood a combination of problem-solving and parent training might be most effective. By adolescence, social cognitive patterns are so well established that only a combination of a number of systems is likely to shift the young person’s social cognitive stance’ (p. 446).

25 Fonagy, P. (2003). ‘Clinical Implications of Attachment and Mentalization: Efforts to Preserve the Mind in Contemporary treatment. Epilogue’. Bulletin of the Menninger Clinic, 67: 271–280, p. 277.

26 Allison, E. and Fonagy, P. (2016). ‘When is Truth Relevant?’. Psychoanalytic Quarterly, 85(2): 275–303, pp. 295–296.

27 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. Bateman and Fonagy have also proposed that ‘perhaps the most important factor’ holding back temporary failures of mentalizing from doing harm are ‘the normally corrective response of the other person with whom one is interacting’. Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 125.

28 Fonagy, P., Campbell, C. and Allison, E. (2019). ‘Therapeutic Models’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 169–180, p. 176.

29 Fonagy, P., Moran, G. S., and Target, M. (1992). ‘Aggression and the Psychological Self’. Bulletin of the Anna Freud Centre, 15: 269–284, p. 269.

30 Personal communication, Peter Fonagy, December 2019.

31 Fonagy, P. (2003). ‘The Anna Freud Centre: About the Directors’. Originally at https://www.annafreudcentre.org/fonagy.htm. Accessed at: https://web.archive.org/web/20060925220711/.

32 Ezrati, O. (2014). ‘Freud Off: Giving New Meaning to Psychoanalysis’. Haaretz, 5 April. Accessed at: https://www.haaretz.com/life/books/.premium-giving-new-meaning-to-psychoanalysis-1.5243899.

33 A few years later, in 1997, Fonagy highlighted Dunn’s findings that ‘individual differences found in pretend play, management of conflict, and talking about mental states are not correlated between social situations (mother, siblings, close friend)’. Fonagy, P. and Target, M. (1997). ‘Attachment and Reflective Function: Their Role in Self-Organization’. Development and Psychopathology, 9(4): 679–700, p. 689. The implication is that the relational supports for mentalizing are relatively independent across these different relational forms. See also Chefetz, R. A. (2013). ‘A Fluctuating Capacity to Mentalize: Affect Scripts and Self-State Systems as (not so) “Strange Attractors”: A Discussion of Margy Sperry’s “Putting our Heads Together: Mentalizing Systems”’. Psychoanalytic Dialogues, 23(6): 708–714.

34 Van Harmelen, A. L., Kievit, R. A., Ioannidis, K., Neufeld, S., Jones, P. B., Bullmore, E., … and NSPN Consortium. (2017). ‘Adolescent Friendships Predict Later Resilient Functioning across Psychosocial Domains in a Healthy Community Cohort’. Psychological Medicine, 47(13): 2312–2322.

35 E.g. Fonagy, P. (2019). ‘The Future Prospects of Mentalization Based Therapies’, 5th International Congress of Mentalisation Based Treatments, Haarlem, The Netherlands, 22 November: ‘Close family networks are maximally beneficial in childhood but only if they later transition to more diverse varied (large) or family and friend (mixed) networks. Supportive family relationships in childhood provide a secure base from which to later diversify social networks’, citing Manalel, J. A. and Antonucci, T. C. (2020). ‘Beyond the Nuclear Family: Children’s Social Networks and Depressive Symptomology’. Child Development, 91(4): 1302–1316. See also Fonagy, P. (1999). ‘The Transgenerational Transmission of Holocaust Trauma’. Attachment & Human Development, 1(1): 92–114: ‘Glen’s material contained many ideas from the Holocaust; he appeared to experience these as his own, notwithstanding the distance of two generations. We have noted the profound impact of the film Schindler’s List on his fantasies, as well as his paranoid anxieties of persecution. Perhaps even more relevant, his thinking was permeated by specific images which we can trace to his grandmother’s experiences, as probably imagined by his mother. In this category I would include: his cruel work regime, used to obliterate psychic reality; his terror of being mocked or humiliated by those he considered his friends’ (p. 105).

36 There are significant alignments between Fonagy’s discussion of the figure of the friend and the proposals of Gadamer. See Gadamer, H. G. ([1985] 1999). ‘Friendship and Self-Knowledge: Reflections on the Role of Friendship in Greek Ethics’, in Hermeneutics, Religion, and Ethics, trans. Joel Weinsheimer, New Haven, CT: Yale University Press.

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

38 E.g. Bevington, D., Fuggle, P., Cracknell, L. and Fonagy, P. (2017). Adaptive Mentalisation-Based Integrative Treatment: A Guide for Teams to Develop Systems of Care, Oxford: Oxford University Press: ‘Helping interventions (of whatever orientation or model) are situated within at least three interconnected systems: the family/care setting, the intervening team, and the wider welfare and educational network. For the worker, one key challenge is to continue working effectively when the interconnected systems create unintended contradictions or negative feedback patterns (what we describe as “dis-integration”)’ (p. 23).

39 Fonagy, P. (1996). ‘Commentaries’. Journal of the American Psychoanalytic Association, 44: 404–422, p. 408.

40 Fonagy, P. and Luyten, P. (2009). ‘A Developmental, Mentalization-Based Approach to the Understanding and Treatment of Borderline Personality Disorder’. Development and Psychopathology, 21(4): 1355–1381, p. 1356. Discussing Crick, N. R., Murray-Close, D., and Woods, K. (2005). ‘Borderline Personality Features in Childhood: A Short-Term Longitudinal Study’. Development and Psychopathology, 17(4): 1051–1070.

41 Luyten, P., Fonagy, P., Lemma, A., and Target, M. (2012). ‘Depression’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Publishing, pp. 385–418, p. 402.

42 Twemlow, S. W., Fonagy, P., Sacco, F. C., Vernberg, E., and Malcom, J. M. (2011). ‘Reducing Violence and Prejudice in a Jamaican All Age School Using Attachment and Mentalization Theory’. Psychoanalytic Psychology, 28: 497–511, p. 508.

43 Fonagy, P. and Target, M. (2002). ‘The History and Current Status of Outcome Research at the Anna Freud Centre’. The Psychoanalytic Study of The Child, 57(1): 27–60, p. 48.

44 E.g. Barlow, J., Barnes, J., Sylva, K., Fonagy, P., and Fearon, P. (2016). ‘Questioning the Outcome of the Building Blocks Trial’. Lancet, 387(10028): 1615–1616.

45 E.g. Katsakou, C., Marougka, S., Barnicot, K., Savill, M., White, H., Lockwood, K., and Priebe, S. (2012). ‘Recovery in Borderline Personality Disorder (BPD): A Qualitative Study of Service Users’ Perspectives’. PloS One, 7(5): e36517; Katsakou, C. and Pistrang, N. (2018). ‘Clients’ Experiences of Treatment and Recovery in Borderline Personality Disorder: A Meta-Synthesis of Qualitative Studies’. Psychotherapy Research, 28(6): 940–957. See also Fonagy, P. (2010). ‘The Changing Shape of Clinical Practice: Driven by Science or by Pragmatics?’. Psychoanalytic Psychotherapy, 24(1): 22–43: ‘From a professional’s standpoint, as from that of the ordinary member of the public, physical role limitation, physical function and pain have high priority, while those suffering disorders rate dignity and general wellbeing (mood, global assessment of life, having a partner, job, lots of social contact) as more important. Wellbeing should feature at least alongside, if not in place of, lists of symptoms in outcome studies (Pressman and Cohen, 2005)’ (p. 34).

46 Fonagy, P. (1998). ‘Prevention, the Appropriate Target of Infant Psychotherapy’. Infant Mental Health Journal, 19(2): 124–150: ‘On a personal note, I have to confess to having often felt uneasy about the mixture of roles and moralities involved in a psychotherapeutic relationship (friend and helper on the one hand, professional and expert on the other)’ (p. 131).

47 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 242. This prioritization of ordinariness follows very much along the same lines as Bion, who would tell patients at the start of therapy, ‘this is just an ordinary conversation about a very delimited range of experience—namely your emotional experience—and what happens to you if you cannot have emotional experience’. Culbert‐Koehn, J. (2011). ‘An Analysis with Bion: An Interview with James Gooch’. Journal of Analytical Psychology, 56(1): 76–91, p. 82. On the ‘ordinary’ as a rich and complex resource for interaction, see Cavell, S. (1994). In Quest of the Ordinary: Lines of Skepticism and Romanticism, Chicago: University of Chicago Press.

48 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 35.

49 Ibid.: ‘We suggest that successful treatments all involve three essential systems of communication relating to epistemic trust … Communication system 1: communication of therapeutic model-based content … Serves as an ostensive cue that increases the patient’s epistemic trust and thus acts as a catalyst for therapeutic success (“therapeutic alliance by any other name”). Communication system 2: mentalising as a common factor: the therapeutic setting serves to increase the patient’s mentalising. Communication system 3: social learning in the context of epistemic trust: The patient applies his/her restored mentalising in the wider (social) environment, which reinforces and builds upon what he/she has learned in therapy’ (p. 28).

50 Fonagy, P. (2016). ‘We have Hard Choices to Make on Children’s Mental Health’. Huffington Post, 10 October. Accessed at: http://www.huffingtonpost.co.uk/peter-fonagy/world-mental-health-day_b_12429138.html.

51 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 34.

52 E.g. Bateman, A., Fonagy, P. and Campbell, C. (2019). ‘Antisocial Personality Disorder in Community and Prison Settings’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 335–349.

53 Fonagy, P. and Allison, E. (2014). ‘The Role of Mentalizing and Epistemic Trust in the Therapeutic Relationship’. Psychotherapy, 51(3): 372–380, p. 379.

54 One step in this direction was undertaken by Bateman and Fonagy who developed a mentalisation-based intervention for families of people with BPD. Bateman, A. and Fonagy, P. (2019). ‘A Randomized Controlled Trial of a Mentalization-Based Intervention (MBT-FACTS) for Families of People with Borderline Personality Disorder’. Personality Disorders, 10(1): 70–79.

55 E.g. Fonagy, P., and Higgitt, A. (2000). ‘Early Influences on Development and Social Inequalities: An Attachment Theory Perspective’, in A. R. Tarlov and R. F. S. Peter (eds.), The Society and Population Health Reader, Volume 2: A state and community perspective, New York: New Press, pp. 104–130; Murphy, M. and Fonagy, P. (2013). ‘Mental Health Problems in Children and Young People’, in Department of Health, Our Children Deserve Better, Prevention Pays: Annual Report of the Chief Medical Officer (Chapter 10), London: Department of Health.

56 Fonagy, P. and Target, M. (2002). ‘Early Intervention and the Development of Self-Regulation’. Psychoanalytic Inquiry, 22(3): 307–335, pp. 312–313.

57 Fonagy, P. and Higgitt, A. (2007). ‘The Early Social and Emotional Determinants of Inequalities in Health’, in G. Baruch, P. Fonagy, and D. Robins (eds), Reaching the Hard to Reach: Evidence-Based Funding Priorities for Intervention and Research, Chichester, UK: John Wiley & Sons, pp. 3–34, p. 4.

58 Fonagy, P. and Higgitt, A. (2004). ‘Early Mental Health Intervention and Prevention: The Implications for Government and the Wider Community’, in B. Sklarew, S. W. Twemlow, and S. M. Wilkinson (eds), Analysts in the Trenches: Streets, Schools, War Zones, Mahwah, NJ: Analytic Press, pp. 257–309.: ‘Prenatal screening should include a prenatal assessment of mental health so that appropriate psychological or medical interventions can begin at this time’ (p. 267).

59 Fonagy, P. (2004). ‘Psychotherapy Meets Neuroscience: A More Focused Future for Psychotherapy Research’. The Psychiatrist, 28(10): 357–359: ‘Knowing that in individuals with the S/S genotype severe maltreatment doubles the probability of major depressive disorder (to over 60% from 30% for those with the genotype) helps us to focus interventions on childhood maltreatment for the first group to a greater extent than for the L/L group’ (p. 358). Fonagy, P. (2007). ‘My Brain Mapper’. Accessed at: https://www.ucl.ac.uk/news/2007/may/ucl-news-my-brain-mapper: ‘By using brain scans, rather than studying how children behave, we will be able to spot those who are in greatest need of intervention.’

60 Fonagy, P. (2010). ‘The Changing Shape of Clinical Practice: Driven by Science or by Pragmatics?’. Psychoanalytic Psychotherapy, 24(1): 22–43: ‘The moral here is not that psychotherapy should not be offered to people without this or that allele, but rather that the mechanism by which therapy achieves its effect may be quite different for these constitutionally distinguishable groups of individuals’ (pp. 37–38). See also Bakermans-Kranenburg, M. J., and van Ijzendoorn, M. H. (2011). ‘Differential Susceptibility to Rearing Environment Depending on Dopamine-Related Genes: New Evidence and a Meta-Analysis’. Development and Psychopathology, 23(1): 39–52.

61 Jurist, E. L. (2010). ‘Elliot Jurist Interviews Peter Fonagy’. Psychoanalytic Psychology, 27(1): 2–7: p. 5.

62 Interview with Peter Fonagy, cited in Maddox, L. (2018). Blueprint: How Our Childhood Makes Us Who We Are, London: Robinson, Chapter 7. See also Lee, N. N. (2014). ‘Sublimated or Castrated Psychoanalysis? Adorno’s Critique of the Revisionist Psychoanalysis: An Introduction to “The Revisionist Psychoanalysis”’. Philosophy & Social Criticism, 40(3): 309–338. There have been schools of therapy that give comparatively more weight to social and political context. However, the Anna Freudian tradition within which Fonagy trained was not one of them. Cf. Parker, I. (2011). Lacanian Psychoanalysis: Revolutions in Subjectivity, London: Routledge; Chancer, L. and Andrews, J. (2013). The Unhappy Divorce of Sociology and Psychoanalysis: Diverse Perspectives on the Psychosocial, London: Palgrave; Frosh, S. (2014). ‘Psychoanalysis as Political Psychology’, in P. Nesbitt-Larking, C. Kinnvall, and T. Capelos with H. Dekker (eds), The Palgrave Handbook of Political Psychology, Basingstoke: Palgrave, pp. 55–71; Cushman, P. (2015). ‘Relational Psychoanalysis as Political Resistance’. Contemporary Psychoanalysis, 51(3): 423–459.

63 Shapiro, S. A. (1996). ‘The Embodied Analyst in the Victorian Consulting Room’. Gender and Psychoanalysis, 1(3): 297–322; Callard, F. (2014). ‘Consulting Rooms: Notes towards a Historical Geography of the Psychoanalytic Setting’, in P. Kingsbury and S. Pile, (eds), Psychoanalytic Geographies, Farnham, Ashgate, pp. 73–88. A difference between psychoanalysis and MBT here is materially signified by the couch, which helps focus the setting on the mental states of the patient, rather than the potential for negotiated identification of mental states and mistakes in both parties, as in MBT. Cf. Skolnick, N. J. (2015). ‘Rethinking the Use of the Couch: A Relational Perspective’. Contemporary Psychoanalysis, 51(4): 624–648.

64 Munich, R. L. (2006). ‘Integrating Mentalization-Based Treatment and Traditional Psychotherapy to Cultivate Common Ground and Promote Agency’, in J. Allen and P. Fonagy (eds), Handbook of Mentalization-Based Therapy, London: Wiley, pp. 143–156.

65 It may also be noted that the ‘On My Mind’ resources on the Anna Freud Centre website include guidance for young people on activism as a form of individual self-care. Accessed at: https://www.annafreud.org/on-my-mind/self-care/activism: ‘Not only does activism give you distraction from your own life, but it also allows you to stop others being distracted from important issues. You get to give back to a cause that you are passionate about, whilst also gaining self-gratification in return. Taking part in group campaigns can also be a great way of meeting others who share your views.’

66 Fonagy, P., Hayes, D. and Stapley, E. (2019). ‘Understanding and Facilitating Self-Management in Child and Youth Mental Health for Socially Excluded Populations’. Accessed at: https://clahrc-norththames.nihr.ac.uk/nihr-clahrc_north-thames-academy/self-management-child-youth-mental-health/. A recent pioneering effort to consider mentalizing stigma also took the ‘intrapsychic filtering system’ of gender-nonconforming individuals as their focus: Scandurra, C., Dolce, P., Vitelli, R., Esposito, G., Testa, R. J., Balsam, K. F., and Bochicchio, V. (2020). ‘Mentalizing Stigma: Reflective Functioning as a Protective Factor against Depression and Anxiety in Transgender and Gender‐Nonconforming People’. Journal of Clinical Psychology, 76(9): 1613–1630 .

67 Fonagy, P. (2020). Tweet, 3 June. Accessed at: https://twitter.com/peterfonagy/status/1268186685965242368?s=11: ‘It should not “just be victims of injustice and dehumanization who bear responsibility of continuing to mentalize”.’

68 Fonagy, P. (2020). ‘Statement from Peter Fonagy on the Murder of George Floyd’. Accessed at: https://www.annafreud.org/insights/news/2020/06/statement-from-peter-fonagy-on-the-murder-of-george-floyd/.

69 Already a few weeks later, in a virtual talk, Fonagy offered reflections on the danger of collective hypervigilance resulting from ‘cultures of competition’—for instance, in the academic sphere in which individuals often receive rewards rather than teams, but also more widely in education and society. He explicitly advocated that such a shift in culture requires social and policy change, not solely adaptations in individual mentalizing. Fonagy, P. (2020). ‘Trust and Interdependence: Lessons from the Study of Human Attachments’, UCL Minds Event, virtual talk, 25 June.

70 Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre. See also Young-Bruehl, E. (2008). Anna Freud: A Biography, New Haven: Yale University Press. Emphasis on schools has been the most long-standing and significant area of focus beyond the individual for Fonagy and colleagues, with the exception of the family. However, in recent years, Fonagy has increasingly acknowledged the potential contribution of other institutions in prevention. Interview with Peter Fonagy cited in Maddox, L. (2018). Blueprint: How Our Childhood Makes Us Who We Are, London: Robinson, Chapter 7: ‘I think mental health is inappropriately and inaccurately seen as just a subjective process, and I think making schools more mentalising, making workplaces more mentalising, making families more mentalising, making pubs more mentalising. I think this is where it’s at.’

71 Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre.

72 Fonagy, P. (2018). ‘Peter Fonagy: Combating a Mental Health Crisis’. Accessed at: https://www.goldmansachs.com/insights/talks-at-gs/peter-fonagy.html: ‘Since the second world war, since secondary education became universal, children are being educated in very large classrooms, in very large schools. This has had all kinds of advantages. But one of the things that it led to is that the number of hours of contact between adults and children has actually dropped. So children have become socialising agents for other children, and that’s not how we were designed by evolution. We were designed by evolution to be looked after by people wiser than ourselves.’

73 Fonagy, P. and Smith, J. (2020). ‘Wellbeing: The Impact of the Pandemic and what Schools can do to Support Mental Health’. Trust, December 2020, https://trust-journal.org.uk/current-edition/wellbeing-the-impact-of-the-pandemic-and-what-schools-can-do-to-support-mental-health/

74 This work can be seen in the context of a more general policy and research trend towards concern with the role of schools in mental health promotion. Durlak, J., Weissberg, R. P., Dymnicki, A. B., Taylor, R. D., and Schellinger, K. B. (2011). ‘The Impact of Enhancing Students’ Social and Emotional Learning: A Meta-Analysis of School-Based Universal Interventions’. Child Development, 82: 405–432; Weare, K. and Nind, M. (2011). ‘Mental Health Promotion and Problem Prevention in Schools: What Does the Evidence Say?’. Health Promotion International, 26: 29–69.

75 Twemlow, S. W., Fonagy, P., and Sacco, F. C. (2002). ‘Feeling Safe in School’. Smith College Studies in Social Work, 72: 303–326.

76 Due to a common basis in an information-processing model, there are significant analogies here to Hinshelwood’s characterization of three kinds of group culture based on three kinds of relationship with the truth: the flexible, the rigid, and the fragmented. Hinshelwood, R. D. (1994). ‘Attacks on the Reflective Space’, in V. Shermer and M. Pines (eds), Ring of Fire: Containing Primitive Emotional States, London: Routledge, pp. 86–106. There is no indication that Twemlow and Fonagy knew of Hinshelwood’s prior work.

77 See also the discussion of social cohesion as a property of secure communities irreducible to the properties of the individuals that constitute it in Fonagy, P. and Higgitt, A. (2007). ‘The Early Social and Emotional Determinants of Inequalities in Health’, in G. Baruch, P. Fonagy, and D. Robins (eds), Reaching the Hard to Reach: Evidence-Based Funding Priorities for Intervention and Research, Chichester, UK: John Wiley & Sons, pp. 3–34, p. 23.

78 Fonagy, P. (2003). ‘The Violence in our Schools: What can a Psychoanalytically Informed Approach Contribute?’. Journal of Applied Psychoanalytic Studies, 5(2): 223–238, p.223.

79 Ibid. 225. Fonagy has been at University College London straight through from his undergraduate degree, so he may be referring to the way that this university operates at times. However, remarks elsewhere lead to the suspicion that he is referring more to the Institute of Psychoanalysis, e.g. 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.

80 Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast; Slides. Accessed at: https://www.borderlinepersonalitydisorder.org/wp-content/uploads/2019/02/Podcast-2.24.19-compressed.pdf.

81 The concept of projective identification is used by Twemlow when writing for a psychoanalytic audience at the start of the decade. Twemlow, S. W. (2000). ‘The Roots of Violence: Converging Psychoanalytic Explanatory Models for Power Struggles and Violence in Schools’. Psychoanalytic Quarterly, 69(4): 741–785.

82 Fonagy, P., Twemlow, S. W., Vernberg, E. M., Nelson, J. M., Dill, E. J., Little, T. D., and Sargent, J. A. (2009). ‘A Cluster Randomized Controlled Trial of Child‐Focused Psychiatric Consultation and a School Systems‐Focused Intervention to Reduce Aggression’. Journal of Child Psychology and Psychiatry, 50(5): 607–616, supplemental materials.

83 Ibid.: ‘Medium to strong effects for classroom observations (mean ES = .97, range: .84–1.1). Past research on school-wide multimodal interventions has only demonstrated modest effects on aggression against TAU [treatment as usual] (Wilson et al., 2003). Medium effect sizes are normally only associated with intense studies with small samples (Wilson et al., 2001; Smith et al., 2003). CAPSLE produced a number of modest and some large effect sizes, particularly with behavioral measures. The findings are also notable because the sample was not particularly high-risk and high-risk samples normally generate larger effects. (Mytton et al., 2002; Wilson et al., 2001, 2003)’ (p. 614).

84 Wolpert, M., Harris, R., Jones, M., … Fonagy, P. (2014). ‘THRIVE The AFC–Tavistock Model for CAMHS’. Accessed at: http://www.annafreud.org/media/2552/thrive-booklet_march-15.pdf.

85 National Health Service (2019). The NHS Long Term Plan. Accessed at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf.

86 Wolpert, M., Harris, R., Jones, M., … Fonagy, P. (2014). ‘THRIVE The AFC–Tavistock Model for CAMHS’. Accessed at: http://www.annafreud.org/media/2552/thrive-booklet_march-15.pdf.

88 This passage appears in Twemlow, S. W., Fonagy, P., and Sacco, F. C. (2005). ‘A Developmental Approach to Mentalizing Communities: I. The Peaceful Schools Experiment’. Bulletin of the Menninger Clinic, 69(4): 282–304, p. 289; and is repeated in Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, pp. 447–448. It might be argued that this strategy places Billy’s mentalizing and learning above the curricular learning of the class as a whole, whose lesson has to be paused to reflect on Billy’s feelings. It can be anticipated that Fonagy and colleagues would counter that Billy’s behaviour is already disrupting class learning, and that the opportunity for the class to use and develop collective mentalizing capacity will benefit their well-being, and—possibly—their future curricular learning. It is to be hoped that mentalization-based interventions in schools may be able to explore such questions.

89 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. See also Lane, J. D. and Harris, P. L. (2015). ‘The Roles of Intuition and Informants’ Expertise in Children’s Epistemic Trust’. Child Development, 86(3): 919–926.

90 Fonagy, P. (2019). ‘Attachment-Aware Teaching with Peter Fonagy’. Podogogy, 7(5): https://play.acast.com/s/tes-the-education-podcast/32054866-4898-47ce-b70d-3995276773a9; Fonagy, P. (2016). ‘Keynote Address’. Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkundei, 24 November, Berlin. Accessed at: https://twitter.com/TheLancetPsych/status/801813352515272705

91 E.g. Wolpert, M., Humphrey, N., Deighton, J., Patalay, P., Fugard, A. J., Fonagy, P., … and Panos, V. (2015). ‘An Evaluation of the Implementation and Impact of England’s Mandated School-Based Mental Health Initiative in Elementary Schools’. School Psychology Review, 44(1): 117–138.

92 The five school-based interventions are:

  1. 1. ‘A set of five lessons for Y9 that use role play designed to improve pupils’ understanding of mental health and reduce suicide rates. Developed in Sweden and America, Youth Aware Mental Health (YAM) encourages pupils to share their own ideas about how to maintain good mental health and how to help each other to find ways to resolve everyday dilemmas

  2. 2. A teacher training programme developed in Canada called The Guide. Adapted for England for the study, it develops teachers’ understanding of mental health, trains them on how to teach their pupils about it and addresses stigma

  3. 3. A series of eight lessons designed to increase young people’s skills around personal safety and managing their mental health, as well as helping them to identify their support networks

  4. 4. Training pupils in relaxation techniques embedded into the school day, every day for five minutes

  5. 5. Training pupils in mindfulness embedded into the school day, every day for five minutes.’

Accessed at: https://www.ucl.ac.uk/evidence-based-practice-unit/research/research-projects.

93 Garland, L., Linehan, T., Merrett, N., Smith, J. and Payne, C. (2018). Ten Steps Towards School Staff Wellbeing. London: Anna Freud Centre. Accessed at: https://www.annafreud.org/media/8506/school-staff-wellbeing-report-final-corrected-512.pdf.

94 Fonagy, P., and Higgitt, A. (2004). ‘Early Mental Health Intervention and Prevention: The Implications for Government and the Wider Community’, in B. Sklarew, S. W. Twemlow, and S. M. Wilkinson (eds), Analysts in the Trenches: Streets, Schools, War Zones, Mahwah, NJ: Analytic Press, pp. 257–309.: ‘Psychoanalysts have shrunk from involvement with public policy. The nature of a psychoanalyst’s commitment to an individual, the intensely personal nature of the interaction, which sustains the “no holds barred” study of subjectivity, is experienced by most analysts as incompatible with commitment to populations, institutions, organisations and other faceless systems. This attitude, of course, is illogical’ (p. 257). On schools as a locus for intervention, see Gee, B., Wilson, J., Clarke, T., Farthing, S., Carroll, B., Jackson, C., … and Notley, C. (2020). ‘Delivering Mental Health Support within Schools and Colleges—A Thematic Synthesis of Barriers and Facilitators to Implementation of Indicated Psychological Interventions for Adolescents’. Child and Adolescent Mental Health, 26(1): 34–46.

95 Fonagy, P. and Clark, D. M. (2015). ‘Update on the Improving Access to Psychological Therapies Programme in England: Commentary on … Children and Young People’s Improving Access to Psychological Therapies’. BJPsych Bulletin, 39(5): 248–251, citing Warren, J., Nelson, P., Mondragon, S., Baldwin, S., and Burlingame, G. (2010). ‘Youth Psychotherapy Change Trajectories and Outcomes in Usual Care’. Journal of Consulting and Clinical Psychology, 78(2): 144–155; Fonagy, P., Pugh, K., and O’Herlihy, A. (2017). ‘The Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) Programme in England’, in D. Skuse, H. Bruce, and L. Dowdney (eds), Child Psychology and Psychiatry: Frameworks for Clinical Training and Practice (3rd edn), Oxford: John Wiley & Sons, pp. 429–435.

96 Fonagy, P. (2015). ‘Peter Fonagy on Psychoanalysis and IAPT.’ The History of Emotions Blog, posted on 14 May by Jules Evans. Accessed at: https://emotionsblog.history.qmul.ac.uk/2015/05/peter-fonagy-on-psychoanalysis-and-iapt/. See also Pickersgill, M. (2019). ‘Access, Accountability, and the Proliferation of Psychological Therapy: On the Introduction of the IAPT Initiative and the Transformation of Mental Healthcare’. Social Studies of Science, 49(4): 627–650. More recently, Fonagy has also collaborated on an open letter to the government, advocating for greater allocation of funding for children’s well-being and mental health in the context of COVID-19. Bajawa, S., Thomas, E., Fonagy, P. et al. (2020). ‘Open Letter to Government on Young People’s Mental Health During Lockdown’. Accessed at: https://www.bps.org.uk/news-and-policy/open-letter-government-young-peoples-mental-health-during-lockdown.

97 University College London (2014) REF 2014, Psychology, Psychiatry, and Neuroscience: Environment Statement. Accessed at: https://results.ref.ac.uk/(S(jj2mvvb3fbee3zpqb1artx2d))/DownloadFile/EnvironmentTemplate/PDF?subId=1075.

99 Secretary of State for Health and Social Care and the Secretary of State for Education (2018). ‘Government Response to the First Joint Report of the Education and Health and Social Care Committees of Session 2017-19 on Transforming Children and Young People’s Mental Health Provision: A Green Paper’, p. 10. Accessed at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728902/HESC_Print__3_.pdf.

100 Department of Health (2017). Transforming Children and Young People’s Mental Health Provision: A Green Paper, London: HMSO, p. 10.

101 Department of Health and Social Care (2018). ‘Children and Young People’s Mental Health Green Paper’: webcast with Jeremy Hunt. Accessed at: https://www.youtube.com/watch?v=j4gAI402ndM. Fonagy is also co-signatory on a public letter advocating that assessment of schools should include appraisal of their provision for mental health. See Turner, C. (2018). ‘Ofsted is Considering New Assessment to Ensure Schools Look after Pupils’ Mental Health and Wellbeing’, 22 December. Accessed at: https://www.telegraph.co.uk/education/2018/12/22/ofsted-considering-new-assessment-ensure-schools-look-pupils/.

102 Education and Health Select Committees (2018). The Government’s Green Paper on Mental Health: Failing a Generation, London: HMSO.

103 The Anna Freud Centre has been funded to evaluate aspects of the new approach. This work is largely still ongoing, but in an early pilot of the new approach mental health leads from 255 schools took part in two-day workshops focused on interagency working. A study conducted by Cortina and colleagues at the Anna Freud Centre found that 55% of school mental health leads reported being in ‘monthly’ or ‘continuous’ contact with mental health services at follow-up, compared with a quarter at baseline. Limitations of the study should be noted: the data comes from self-report, and less than a third of participants completed the survey at both time points. Cortina, M. A., Shipman, J., Saunders, F., Day, L., Blades, R., Smith, J., and Wolpert, M. (2019). ‘Embedding Interagency Working between Schools and Mental Health Specialists: A Service Evaluation of the Mental Health Services and Schools and Colleges Link Programme Workshops’. Clinical Child Psychology and Psychiatry, 24(4): 906–920 .

104 Di Stefano, G., Piacentino, B., and Ruvolo, G. (2017). ‘Mentalizing in Organizations: A Psychodynamic Model for an Understanding of Well-Being and Suffering in the Work Contexts’. World Futures, 73(4–5): 216–223, p. 218–219. See also Sperry, M. (2013). ‘Putting our Heads Together: Mentalizing Systems’. Psychoanalytic Dialogues, 23(6): 683–699.

105 Fonagy, P., Target, M., Steele, H., and Steele, M. (1998). Reflective Functioning Manual, Version 5, London: UCL/Anna Freud Centre, p. 28.

106 Ibid.: ‘The passage may be “marked” in reflective-functioning because the view of mental states presented by the subject is unusual and surprising to the rater. Passages which cast an original perspective, which nevertheless is readily understandable to the rater, reflect mentalization on the part of the subject. Raters should however be aware of the possibility of “borrowed” reflective-functioning, where the subject is repeating ideas presented to him/her in other contexts. In such instances a rating of “3” would probably be more appropriate’ (p. 29); ‘the passage must contain sufficient “surprise” and coherence for the rater to feel it is unlikely to have come from contaminating sources. The passage should therefore have a personal character, i.e., experienced as personally significant and meaningful, and may seem to be developing further during the interview itself’ (p. 30); ‘In contrast to interviews rated “0”–“4”, interviews rated “5” give convincing indications to the rater that speakers have some kind of a model of the mind of attachment figures as well as a model of their own mind which is relatively coherent even if it is simple, and is unlikely to have been solely derived from shared culture rather than from personal experience’ (p. 34).

107 To take another example of this assumption: Luyten, P., Fonagy, P., Lowyck, B., and Vermote, R. (2012). ‘The Assessment of Mentalization’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Publishing, pp. 43–66: ‘What does bad mentalisation look like? … Focus on external factors (e.g. government, school, colleagues, neighbors)’ (p. 59).

108 E.g. Fonagy, P. (2003). ‘The Violence in our Schools: What can a Psychoanalytically Informed Approach Contribute?’. Journal of Applied Psychoanalytic Studies, 5(2): 223–238: ‘Coercion is the rule within most social systems.’ Ratner, R. H. (2014). ‘Interview with Peter Fonagy’, in Borderline. Master of Fine Arts, The University of Texas at Austin. Accessed at: https://repositories.lib.utexas.edu/bitstream/handle/2152/28667/RATNER-MASTERSREPORT-2014.pdf?sequence=1. From interview with Fonagy: ’Mentalization is one of best established of human capacities, can break in all of us. It is fairly predictable when it can break: large groups (hard to mentalize when we’re in a large crowd, as a consequence, large crowds are dangerous, you can forget what someone is feeling hence can perform atrocities‘ (p. 123).

109 E.g. Fonagy, P., Target, M., Gergely, G., Allen, J. G., and Bateman, A. W. (2003). ‘The Developmental Roots of Borderline Personality Disorder in Early Attachment Relationships: A Theory and Some Evidence’. Psychoanalytic Inquiry, 23(3): 412–459, p. 433; Fonagy, P. (2009). ‘Commentary on “Forgiveness”’, in S. Akhtar (ed.), Good Feelings: Psychoanalytic Reflections on Positive Emotions and Attitudes, London: Karnac/International Psychoanalytic Association, pp. 411–452, p. 423. Fonagy would later contribute to work in which the capacity to consider the mental states of fictional individuals was specifically used to operationalize mentalizing. See Fossati, A., Borroni, S., Dziobek, I., Fonagy, P., and Somma, A. (2018). ‘Thinking about Assessment: Further Evidence of the Validity of the Movie for the Assessment of Social Cognition as a Measure of Mentalistic Abilities’. Psychoanalytic Psychology, 35(1): 127–141.

110 This may have been reinforced by Gergely’s account of marked mirroring and ostensive cues as conveying acknowledgement of individual agency, a property that may have been assumed to only characterize individuals.

111 Target, M., and Fonagy, P. (2003). ‘Attachment Theory and Long-Term Psychoanalytic Outcome: Are Insecure Attachment Narratives Less Accurate?’, in M. Leuzinger-Bohleber, A. U. Dreher, and J. Canestri (eds), Pluralism and Unity? Methods of Research in Psychoanalysis, London: International Psychoanalytical Association, pp. 149–167: ‘We are gradually trying to feel our way towards an application of qualitative methodology from sociology’ (p. 165).

112 Lemma, A., Target, M., and Fonagy, P. (2011). Brief Dynamic Interpersonal Therapy: A Clinician’s Guide, Oxford: Oxford University Press, p. 57.

113 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.

114 See also Fonagy, P. (1999). ‘Interview with Peter Fonagy’, in S. M. Stein and J. Stein (eds), Psychotherapy in Practice: A Life in the Mind, Oxford: Butterworth Heinemann, pp. 77–98, p. 83.

115 Though not a discussion of the community as a target for mentalizing, a reflection on the community as a potential target for attachment (i.e. secure base/safe haven dynamics) was offered in Fonagy, P., Target, M., Steele, M., Steele, H., Leigh, T., Levinson, A., et al. (1997). ‘Morality, Disruptive Behavior, Borderline Personality Disorder, Crime, and their Relationships to Security of Attachment’, in L. Atkinson and K. J. Zucker (eds), Attachment and Psychopathology, New York: Guilford Press, pp. 223–274, p. 224: ‘Unstable attachment histories [are] more common in these [dangerous] neighbourhoods, thus reducing the overall likelihood of strong attachments to the community’ (p. 231).

116 This passage appears in Twemlow, S. W., Fonagy, P., and Sacco, F. C. (2005). ‘A Developmental Approach to Mentalizing Communities: II. The Peaceful Schools Experiment’. Bulletin of the Menninger Clinic, 69(4): 282–304, p. 289; and is repeated in Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, pp. 447–448.

117 On how the benefits of group-level processes for reconsideration of thoughts may be frequently underestimated, see Mercier, H., Trouche, E., Yama, H., Heintz, C., and Girotto, V. (2015). ‘Experts and Laymen Grossly Underestimate the Benefits of Argumentation for Reasoning’. Thinking & Reasoning, 21(3): 341–355. Mercier has also identified that the experience of a group majority is not reducible to the sum of the aggregates in contexts of social influence. Mercier, H. and Morin, O. (2019). ‘Majority Rules: How Good are We at Aggregating Convergent Opinions?’. Evolutionary Human Sciences, 1. Mercier was one of Sperber’s central collaborators in introducing the concept of epistemic vigilance (see Chapter 7).

118 The importance of the physical setting and a physical calendar as secure bases to facilitate young people’s mentalizing has been emphasized by Midgley, N., Ensink, K. and Lindqvist, K. (2017). Mentalization-based Treatment for Children: A Time-limited Approach, New York: American Psychological Association.

120 Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre: ‘64 per cent of pupils who have attended the school since it opened have been successfully reintegrated into mainstream school within the school’s own target of four terms. Of the pupils who have returned to mainstream schools since the school opened, 95 per cent have succeeded in retaining their school places.’

122 Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre.

123 Asen, E. and Fonagy, P. (2017). ‘Mentalizing Family Violence Part 2: Techniques and Interventions’. Family Process, 56(1):22–44, p. 29.

124 Ibid. 6–21, p. 8.

125 Ibid. 15.

126 Ibid. 13. We have not found any point in Fonagy’s writings where he discusses Freud’s Dora case study. However, this seems exemplary in showing pretend mode, psychic equivalence, and teleological mode helping to sustain one another within the family system. For a related interpretation of Dora, see Billig, M. (1999). Freudian Repression: Conversation Creating the Unconscious, Cambridge: Cambridge University Press.

127 Winship, G. (2003). ‘The Democratic Origins of the Term “Group Analysis”: Karl Mannheim’s Third Way for Psychoanalysis and Social Science’. Group Analysis, 36(1): 37–51; Roseneil, S. (2019). ‘Broader (than Psychoanalysis) and Deeper (than Sociology): The Psychosocial Promise of Group Analysis’. Psychoanalysis, Culture & Society, 24: 493–501.

128 Bateman, A. W. and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorders: Mentalization Based Treatment, Oxford: Oxford University Press, pp. 176, 263.

129 Potthoff and Moini-Afchari recommend a ‘binocular’ approach in which mentalization-based interventions are combined with attention to group-level processes. In this recommendation, it is assumed that mentalization-based group-therapy is concerned solely with individual minds, and offers little relevant to reflection or intervention with group-level processes. Potthoff, P. and Moini-Afchari, U. (2014). ‘Mentalization-Based Treatment in Groups—A Paradigm Shift or Old Wine in New Skin?’. Group Analysis, 47(1): 3–16.

130 Karterud, S. (2015). Mentalization-Based Group Therapy (MBT-G), Oxford: Oxford University Press, p. 70.

131 Foulkes, S. H. (1971). ‘The Group as Matrix of the Individual’s Mental Life’, in Selected Papers: Psychoanalysis and Group Analysis, London: Karnac Books, pp. 223–234. See also Karterud, S., Folmo, E., and Kongerslev, M. T. (2019). ‘Personality and the Group Matrix’. Group Analysis, 52(4): 503–519.

132 Karterud, S. (2015). Mentalization-Based Group Therapy (MBT-G), Oxford: Oxford University Press, p. 90.

133 Hornsey, M. J., Dwyer, L., and Oei, T. P. (2007). ‘Beyond Cohesiveness: Reconceptualizing the Link between Group Processes and Outcomes in Group Psychotherapy’. Small Group Research, 38(5): 567–592.

134 One exception: there is an extremely passing reference to the matrix concept in Fonagy, P., and Adshead, G. (2012). ‘How Mentalisation Changes the Mind’. Advances in Psychiatric Treatment, 18(5): 353–362.

135 Morken, K. T. E., Binder, P. E., Arefjord, N. M., and Karterud, S. W. (2019). ‘Mentalization-Based Treatment from the Patients’ Perspective–What Ingredients do they Emphasize?’. Frontiers in Psychology, 10. In a recent chapter, Bateman and colleagues have emphasized the importance of ‘active management of process of the group’. However, no more detail on what this entails is provided than i) managing the level of group arousal, and ii) ‘interventions that cultivate and maintain cohesion early in the group treatment’. Bateman, A., Kongerslev, M. and Bo, S. (2019). ‘Group Therapy for Adults and Adolescents’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp.117–133, pp. 130–131. However, elsewhere in the same book, Bateman and colleagues observe that ‘group work stimulates a hierarchical process within a peer group, which can be harnessed in vivo by the clinicians working with the group to explore participants’ sensitivity to hierarchy and authority and the mentalisation distortions that ensue.’ Bateman, A., Fonagy, P. and Campbell, C. (2019). ‘Antisocial Personality Disorder in Community and Prison Settings’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 335–349, p. 340.

136 See e.g. Arefjord, N., Morken, K., and Lossius, K. (2019). ‘Comorbid Substance Use Disorder and Personality Disorder’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 403–416: ‘It makes me dizzy sometimes, trying to mentalise myself, the group, and my family, it is too much for me … [with a smile]’ (p. 414).

137 Fonagy, P. and Adshead, G. (2012). ‘How mentalisation changes the mind’. Advances in Psychiatric Treatment, 18(5): 353–362, p. 355. See also Esposito, G., Karterud, S., and Freda, M. F. (2019). ‘Mentalizing Underachievement in Group Counseling: Analyzing the Relationship between Members’ Reflective Functioning and Counselors’ Interventions’. Psychological Services, Early View: ‘The crucial interventions were exploratory questions on mental states addressed to the individual or to the group and defense interpretations.’

138 Jurist, E. (2018). Minding Emotions: Cultivating Mentalisation in Psychotherapy, New York: Guilford Press.

139 Jenkins, A. C., Dodell-Feder, D., Saxe, R., and Knobe, J. (2014). ‘The Neural Bases of Directed and Spontaneous Mental State Attributions to Group Agents’. PLoS One, 9(8): e105341. For a parallel in phenomenology, see Salice, A. and Taipale, J. (2015). ‘Group-Directed Empathy: A Phenomenological Account’. Journal of Phenomenological Psychology, 46(2): 163–184.

140 Jenkins, A. C., Dodell-Feder, D., Saxe, R., and Knobe, J. (2014). ‘The Neural Bases of Directed and Spontaneous Mental State Attributions to Group Agents’. PLoS One, 9(8): e105341.

141 Fonagy, P. (2011). Back cover endorsement for E. Hopper and H. Weinberg (eds), The Social Unconscious in Persons, Groups and Societies, Volume 1: Mainly Theory, London: Karnac Books.

142 E.g. Koh, E. and Twemlow, S. W. (2017). ‘Towards a Psychoanalytic Concept of Community (III): A Proposal’. International Journal of Applied Psychoanalytic Studies, 14(4): 261–272, p. 264.

143 In a recent conference presentation, Fonagy has taken this further, reviewing research on the propensity to underestimate the importance of social factors. Fonagy, P. (2019). ‘The Future Prospects of Mentalization-Based Therapies’, 5th International Congress of Mentalisation Based Treatments, Haarlem, The Netherlands, 22 November: ‘Our view of the person overemphasizes individual agency.’ Fonagy discussed a paper by Haslam and colleagues, which showed that, while social integration and social support are among the most potent predictors of life expectancy, participants rated them the least potent from 11 options. Haslam, S. A., McMahon, C., Cruwys, T., Haslam, C., Jetten, J., and Steffens, N. K. (2018). ‘Social Cure, what Social Cure? The Propensity to Underestimate the Importance of Social Factors for Health’. Social Science & Medicine, 198: 14–21.

144 Asen, E., Campbell, C., and Fonagy, P. (2019). ‘Social Systems: Beyond the Microcosm of the Individual and Family’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 229–243, p. 233. Fonagy, P. and Campbell, C. (2019). ‘Supporting the Social Triad. A Commentary on Keeping Culture in Mind: A Systematic Review and Initial Conceptualization of Mentalizing from a Cross-Cultural Perspective’, Clinical Psychology: Science and Practice, 26(4): e12305 : ‘Coming from an attachment theory background, we have emphasized the individual’s experience of being inadequately mentalized as the root cause of an incapacity to trust. This may have been inappropriate and was probably the consequence of our own cultural bias.’ Jurist has explicitly argued that the boundaries of mentalizing should be large enough to include an individual’s attention to, and reflection on, cultural memory. Jurist, E. (2018). Minding Emotions: Cultivating Mentalisation in Psychotherapy, New York: Guilford Press, p. 141.

145 The argument that the mentalizing or and by collective units needs to be considered to avoid an ethnocentric theory has been developed in Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast/; Slides. Accessed at: https://www.borderlinepersonalitydisorder.org/wp-content/uploads/2019/02/Podcast-2.24.19-compressed.pdf. A parallel argument has recently been made by Pereira and Debbané. Drawing on Foucault, they have claimed that mentalization-based therapists should not just facilitate mentalization of i) self and ii) other, but also on iii) the cultural and institutional context of the therapeutic work itself. Without this sociological reflective functioning, they worry that therapists risk becoming insensitive to, or overburdened by, the power-relations that structure the therapeutic encounter, and as a result lose track of the basis and qualities of the patient’s mental states. Pereira, J. G. and Debbané, M. (2018). ‘An Integrative-Relational Approach in Schizophrenia: From Philosophical Principles to Mentalization-Based Practice’, in I. Hipólito, J. Gonçalves, and J. G. Pereira (eds), Schizophrenia and Common Sense, New York: Springer, pp. 193–207.

146 This latter point is implicit in the 2019 chapter, but was made explicitly by Fonagy in Fonagy, P. and Wampold, B. (2016). ‘Psychotherapy Debate with Peter Fonagy and Bruce Wampold at the Nordic Conference on Mental Health’. Accessed at: https://www.youtube.com/watch?v=U5fhhAZnduU.

147 See e.g. Laughlin, P. R. (2011). Group Problem Solving, Princeton: Princeton University Press.

148 Lyotard would call this a ‘differend’: the patterned and potentially wholly inadvertent subtraction of relevance from particular forms of social suffering, through a practice that promises acknowledgement—but does so on the basis of limited terms. Lyotard, J. (1988). The Differend: Phases in Dispute, trans. G. Van den Abbeele, Minneapolis, MN: University of Minneapolis Press. Our point here is regarding the general logic of MBT as set out in written texts, rather than how Fonagy or Bateman would individually practise as clinicians. In fact, there appears to be only one instance where Fonagy and colleagues mention patients discussing political views within MBT, and the nature of the case makes it difficult to extrapolate: Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘Many MBT-ASPD groups begin with dialogue seemingly in pseudo-philosophical-political mode about how awful the system is, how no one can be trusted, how the police are corrupt, and so on. In essence, this is pretend mode. Contrary to the usual exhortation about pretend mode (challenge it and do not allow it to become embedded), it is important to allow the participants to do this at the beginning of a group to give them a sense of unity’ (p. 383); ‘The aim of the group is to encourage participants to identify their current feeling in the group rather than to express bitterness about external organisations, and to increase their recognition of the way context influences their current feeling’ (p. 406). See also Aiello, G. and Pariante, C. M. (2013). ‘Citizen, Interrupted: The 2011 English Riots from a Psychosocial Perspective’. Epidemiology and Psychiatric Sciences, 22(1): 75–79. Here the London riots are interpreted as reflecting a lack of mentalizing on the part of the rioters. The authors acknowledge that ‘those arrested during the riots mainly came from deprived areas and had the poorest educational backgrounds’ (p. 75), but do not apparently regard this as having played a causal role.

149 Parker, I. (2019). Psychoanalysis, Clinic and Context, London: Routledge, p. 183.

150 Jankovic, M. and Ludwig, K. (eds), (2017). The Routledge Handbook of Collective Intentionality, London: Routledge; Salmela, M. and Nagatsu, M. (2017). ‘How Does it Really Feel to Act Together? Shared Emotions and the Phenomenology of We-Agency’. Phenomenology and the Cognitive Sciences, 16(3): 449–470.

151 ‘The Future Prospects of Mentalization Based Therapies’, 5th International Congress of Mentalisation Based Treatments, Haarlem, The Netherlands, 22 November, discussing Gallotti, M. and Frith, C. D. (2013). ‘Social Cognition in the We-Mode’. Trends in Cognitive Sciences, 17(4): 160–165. Also Fonagy, P. (2020). ‘Trust and Interdependence: Lessons from the Study of Human Attachments’. UCL Minds Event, virtual talk, 25 June.

152 Török, G., Pomiechowska, B., Csibra, G. and Sebanz, N. (2019). ‘Rationality in Joint Action: Maximizing Coefficiency in Coordination’. Psychological Science, 30(6): 930–941 .

153 See Seyfert, R. (2012). ‘Beyond Personal Feelings and Collective Emotions: Toward a Theory of Social Affect’. Theory, Culture & Society, 29(6): 27–46; Salmela, M. (2012). ‘Shared emotions’. Philosophical Explorations, 15(1): 33–46; Anderson, B. (2014). Encountering Affect: Capacities, Apparatuses, Conditions, London: Routledge; Mercer, J. (2014). ‘Feeling Like a State: Social Emotion and Identity’. International Theory, 6(3): 515–535; Krueger, J. and Szanto, T. (2016). ‘Extended Emotions’. Philosophy Compass, 11(12): 863–878; Smith, E. R. and Mackie, D. M. (2016). ‘Group-Level Emotions’. Current Opinion in Psychology, 11: 15–19; Collins, S. (2018). ‘ “The Government Should be Ashamed”: On the Possibility of Organisations’ Emotional Duties’. Political Studies, 66(4): 813–829.

154 Asen, E. and Fonagy, P. (2012). ‘Mentalization‐Based Therapeutic Interventions for Families’. Journal of Family Therapy, 34(4): 347–370, p. 351.

155 Fonagy, P. (2019). ‘Mental Health is a Care We must Share’. Guardian, 13 October. Accessed at: https://www.theguardian.com/society/2019/oct/13/isolation-not-social-media-cause-teenager-mental-ill-health.

156 Aival-Naveh, E., Rothschild‐Yakar, L., and Kurman, J. (2019). ‘Keeping Culture in Mind: A Systematic Review and Initial Conceptualization of Mentalizing from a Cross‐Cultural Perspective’. Clinical Psychology: Science and Practice, 26(4): 25: ‘different aspects of mentalizing may be more important depending upon culture. Consequently, it can be expected that different cultures will exhibit different mentalizing profiles … we cannot simply assume that people across cultures have a similar ability, or need, to perceive internal mental states.’ See also Fonagy, P. and Campbell, C. (2019). ‘Supporting the Social Triad. A Commentary on Keeping Culture in Mind: A Systematic Review and Initial Conceptualization of Mentalizing from a Cross-Cultural Perspective’. Clinical Psychology: Science and Practice, 26(4): e12305 .

157 Asen, E., Campbell, C. and Fonagy, P. (2019). ‘Social Systems: Beyond the Microcosm of the Individual and Family’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 229–243, p. 233.

158 Duncan, J. S. and Duncan, N. G. (2004). ‘Culture Unbound’. Environment and Planning A, 36(3): 391–403; Fornäs, J. (2017). Defending Culture: Conceptual Foundations and Contemporary Debate, London: Palgrave. Though not immediately relevant to this discussion, it may be helpful to note that a third sense of ‘culture’ also operates within social scientific discourse, distinct from anthropological culture and cognitive informational culture. This is culture as ‘refinement’.

159 In psychoanalytic terms, anthropological culture can be described as prioritizing rows C (myths) and D (preconceptions) on Bion’s grid—elements that do not form discrete and determinate thoughts, and may reside as much in the community as within the minds of individuals. Cognitive informational culture can be described as prioritizing rows E (conception) and F (concept)—elements that form relatively more refined, individual thoughts. Bion, W. R. (1963). Elements of Psychoanalysis, London: Karnac Books. To draw a distinction between anthropological culture and cognitive informational culture is not to imply that they are not compatible. For instance, Vygotsky held that anthropological culture organizes the kinds of tasks a child faces and the kinds of cognitive informational tools provided or withheld for responding to those tasks. Luria, A. R. (1979). The Making of Mind: A Personal Account of Soviet Psychology, trans. Michael Cole and Sheila Cole, Cambridge, MA: Harvard University Press, p. 44.

160 This model of culture seems to be presumed when Allison and Campbell write about ‘cultural barriers to considering the perspectives of children and young people’. Examples given by the authors include ‘the stigma around mental health problems, which challenge the limits of our capacity for understanding and can evoke fearful responses, and the systemic tendency for the political process to neglect children because they do not have the vote’. Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre, p. 11. Cf. Bonanno, G. A., Romero, S. A., and Klein, S. I. (2015). ‘The Temporal Elements of Psychological Resilience: An Integrative Framework for the Study of Individuals, Families, and Communities’. Psychological Inquiry, 26(2): 139–169.

161 The orientation of Fonagy and colleagues towards this latter definition of culture is certainly influenced by Gergely. However, an earlier and background influence may be Winnicott who, after acknowledging that the term has multiple meanings, stated that ‘in using the word culture I am thinking of the inherited tradition. I am thinking of something that is in the common pool of humanity, into which individuals and groups of people may contribute, and from which we may all draw if we have somewhere to put what we find.’ Winnicott, D. W. (1967). ‘The Location of Cultural Experience’. The International Journal of Psychonalysis, 48: 368–372, p. 370.

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

163 See also 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: Compromise of the processes of social learning ‘is a systemic failure of communication that may characterize a family, the members of a social group such as a gang, a social subculture, or indeed an entire culture’.

164 Bevington, D. and Fuggle, P. (2019). ‘AMBIT: Engaging the Client and Community of Minds’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 211–228, p. 221.

165 The same ambiguity is present in Lorenzini, N., Campbell, C. and Fonagy, P. (2019). ‘Mentalisation and its Role in Processing Trauma’, in Bernd Huppertz (ed.), Approaches to Psychic Trauma: Theory and Practice, Lanham, MD: Rowman & Littlefield, pp. 403–422.

166 Asen, E., Campbell, C. and Fonagy, P. (2019). ‘Social Systems: Beyond the Microcosm of the Individual and Family’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 229–243, p. 235.

167 However, it is unclear whether Asen and colleagues regard the capacity for individuals to be ‘mentalised by relevant social systems’ as implying some concept of group mind or ‘group experience’; it would depend on what was meant, and the kind of social system in question. Cf. Fonagy, P. (2017). ‘The Big Kahuna: Countries with the Highest Incidence of BPD’. Accessed at: https://www.youtube.com/watch?v=lcVSMuxApaY: ‘To me, mentalising is not something that exists within an individual. Not even something that exists between a mother and a child. Not even something that exists between a family. It is something that a community of human beings owns.’

168 Cf. Wilholt, T. (2016). ‘Collaborative Research, Scientific Communities, and the Social Diffusion of Trustworthiness’, in M. S. Brady and M. Fricker (eds), The Epistemic Life of Groups: Essays in the Epistemology of Collectives, Oxford: Oxford University Press, pp. 218–233.

169 Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast; Slides. Accessed at: https://www.borderlinepersonalitydisorder.org/wp-content/uploads/2019/02/Podcast-2.24.19-compressed.pdf. Fonagy, P. (2019). ‘The Future Prospects of Mentalization Based Therapies’, 5th International Congress of Mentalisation Based Treatments, Haarlem, The Netherlands, 22 November.

170 Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast; Slides. Accessed at: https://www.borderlinepersonalitydisorder.org/wp-content/uploads/2019/02/Podcast-2.24.19-compressed.pdf.

Fonagy cites Weisner: ‘The question that is important for many, if not most, parents and communities is not, “Is [this individual] child ‘securely attached?” ’, but rather, ‘How can I ensure that my child knows whom to trust and how to share appropriate social connections to others?’ Weisner, T. S. (2015). ‘The Socialization of Trust: Plural Caregiving and Diverse Pathways in Human Development across Cultures’, in H. Otto and H. Keller (eds), Different Faces of Attachment, Cambridge: Cambridge University Press, pp. 263–277, p. 263.

171 Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast; Slides. Accessed at: https://www.borderlinepersonalitydisorder.org/wp-content/uploads/2019/02/Podcast-2.24.19-compressed.pdf. See also Dagan, O. and Sagi‐Schwartz, A. (2018). ‘Early Attachment Network with Mother and Father: An Unsettled Issue’. Child Development Perspectives, 12(2): 115–121. The contribution of in-group/out-group dynamics to mentalizing and epistemic trust had earlier been discussed briefly in Luyten, P. and Fonagy, P. (2015). ‘The Neurobiology of Mentalizing’. Personality Disorders, 6: 366–379.

172 Fonagy, P. (2018). ‘Meeting the Mental Health Needs of Looked-After Children and Care Leavers’, in Marc Bush (ed.) Addressing Adversity: Prioritising Adversity and Trauma-Informed Care for Children and Young People in England, London: Young Minds, pp. 170–179, p. 176. Accessed at: http://www.instituteofhealthequity.org/resources-reports/addressing-adversity-prioritising-adversity-and-trauma-informed-care-for-children-and-young-people-in-england.

173 Fonagy, P. (2020). ‘Trust and Interdependence: Lessons from the Study of Human Attachments’. UCL Minds Event, virtual talk, 25 June. See also Lassri, D. and Desatnik, A. (2020). ‘Losing and regaining reflective functioning in the times of COVID-19: Clinical risks and opportunities from a mentalizing approach’. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1): S38.

174 Asen, E., Campbell, C. and Fonagy, P. (2019). ‘Social Systems: Beyond the Microcosm of the Individual and Family’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 229–243, p. 231.

175 An example is given in passing by Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘Intriguingly, the justice system has, by and large, adopted the same teleological stance. The logic of “justice being seen to be done” is acceptable to prisoners and guards in equal measure’ (p. 64). The potential for externalization of the alien self to become institutionalized has been a familiar concern in psychodynamic organizational theory, under the rubric of projective identification. See e.g. Hinshelwood, R. D. and Chiesa, M. (eds), (2002). Organisations, Anxieties and Defences: Towards a Psychoanalytic Social Psychology. New York: Wiley-Blackwell. The series editors were Fonagy and Hepworth.

176 The characteristics of institutionalized pretend mode are not detailed in the 2019 chapter, but appear in an earlier conference presentation with substantial overlap in content: Fonagy, P. (2012). ‘Mentalization and Attachment: The Implication for Community Based Therapies’. Paper presented at the Community of Communities 10th Annual Forum, March, London. Accessed at: https://www.slideshare.net/raffaelebarone/mentalization-and-attachment-the-implication-for-community-based-therapies: ‘Social systems that create fear and hyperactivate attachment can destroy thinking capacity and force the system back to pre-mentalistic modes of social thinking. Such social systems can be self-reinforcing and therefore highly stable in their instability. They undermine the very social mechanism that could alter their character: human collaboration (negotiation and creativity).’ Institutionalized pretend mode is also described in Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘People experience their thoughts and feelings as having no consequence for others, leading ultimately to the experience of an empty and meaningless social existence: this is a social system that is operating in the pretend mode. Selfishness and extreme egocentricism then emerge out of the unreality of anything other than one’s own thoughts and feelings’ (p. 451).

177 New Public Management is comprised of seven doctrines: 1) Hands-on and active management; 2) Explicit standards and measures of performance; 3) Emphasis on measuring the quality of outputs; 4) Breaking up state services so that they can be placed in competition; 5) Promoting competition between services; 6) Importing techniques for controlling workers from the private sector; 7) Disciplining costs and promotion of cost-effectiveness. McLaughlin, K., Osborne, S. P., and Ferlie, E. (eds), (2002). New Public Management: Current Trends and Future Prospects, London: Routledge. An early use of mentalization theory to think about the implications of these doctrines for an institution’s capacity to acknowledge staff thoughts and feelings was attempted by Siltala, J. (2013). ‘New Public Management: The Evidence-Based Worst Practice?’. Administration & Society, 45(4): 468–493.

178 Bevington, D., Fuggle, P., Cracknell, L. and Fonagy, P. (2017). Adaptive Mentalisation-Based Integrative Treatment: A Guide for Teams to Develop Systems of Care, Oxford: Oxford University Press.

179 It should be qualified that the institutionalization of non-mentalizing is not, in itself, a problem. Consider the court system: there is extensive pretend mode in all the court ritual, both symbolizing and masking that the institution is backed in the final instance by the violence of the state; this helps set the frame for psychic equivalence within which the court is felt as holding authority; the result is the capacity to treat behaviour and evidence in teleological mode—for instance, with the payment of damages treated as assuaging personal insult or injury. Each of these has its place for the rule of law, but also produces serious and structural obstacles to mentalizing in this environment.

180 E.g. Fonagy, P. (1999). ‘Interview with Peter Fonagy’, in S. M. Stein and J. Stein (eds), Psychotherapy in Practice: A Life in the Mind, Oxford: Butterworth Heinemann, pp. 77–98: ‘An interest in the human mind is becoming less important as part of the professional work of a number of key groups, including doctors … This is a major danger, a danger in how we handle ourselves as people and how society works. I don’t think it is the doctors’ fault, nor is it due to the advancement of science—it is a cultural thing. It is the dehumanization, the stripping of humanity, that is occurring at all levels of culture. If you look at television, for example, you will see people being portrayed as behaving like machines. The “cops and robbers” kind of stories where people are shot or shoot without intention, without desire and without belief. They also die without intention … I think this is mirrored in medical education, which is allowing itself to focus on technical advantages while de-emphasizing the more human aspects of patients … I’ve been teaching medical students for seventeen years and I’ve noticed a change … I don’t know what’s causing it, nor what the main driving force behind it is, but I think it is culture-wide’ (p. 84). See also Fonagy, P. (1999). ‘Male Perpetrators of Violence against Women: An Attachment Theory Perspective’. Journal of Applied Psychoanalytic Studies, 1(1): 7–27: ‘Society has relinquished its caretaking function, demolished its institutions for supporting emotional development’ (p. 23).

181 Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast. At the same time, the increased use of non-mentalizing prompted by fragmented, dehumanizing social systems in turn can reinforce them: ‘Social systems that create fear and hyperactivate attachment can destroy thinking capacity and force the system back to pre-mentalistic modes of social thinking. Such social systems can be self-reinforcing and therefore highly stable in their instability. They undermine the very social mechanism that could alter their character: human collaboration (negotiation and creativity)’ Fonagy, P. (2012). ‘Mentalization and Attachment: The Implication for Community Based Therapies’. Paper presented at the Community of Communities 10th Annual Forum, March, London. Accessed at: https://www.slideshare.net/raffaelebarone/mentalization-and-attachment-the-implication-for-community-based-therapies.

182 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. For instance, in the case of parents: ‘the relative social isolation in which modern parents engage in caregiving makes it much harder to access another trusted person/mind to help think about stressful situations in order to regulate affect and regain balanced mentalizing’, Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre.

183 Rawls, A. W. (2012). ‘Durkheim’s Theory of Modernity: Self-Regulating Practices as Constitutive Orders of Social and Moral Facts’. Journal of Classical Sociology, 12(3–4): 479–512.

184 Durkheim, E. (1984 [1893]). The Division of Labour in Society, trans. W. D. Halls, Book 3. London: Macmillan.

185 For an interpretation of solidarity in terms of mentalizing, see Luyten, P., Nijssens, L., Fonagy, P., and Mayes, L. C. (2017). ‘Parental Reflective Functioning: Theory, Research, and Clinical Applications’. The Psychoanalytic Study of The Child, 70(1): 174–199, p. 179.

186 Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast.

187 Fonagy, P. (1999). ‘Epistemological and Methodological Background’, in Fonagy, P. (ed.), An Open Door Review of Outcome and Process Studies in Psychoanalysis, London: International Psychoanalytic Association, pp. 8–85, p. 50. See also Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre: ‘racial discrimination is a powerful predictor of general psychopathology (Clark, Anderson, Clark, & Williams, 1999), with the most powerful associations observed for depression and anxiety (Banks, Kohn-Wood, & Spencer, 2006; English, Lambert, Evans, & Zonderman, 2014) and conduct problems … Being at the receiving end of essentialist homogenizing beliefs creates generic vulnerability through disrupting effective communication and the potential of adaptation and adjustment through learning. Within this framework, prejudices of all kinds, but particularly prejudice based on ethnic divisions, can generate psychological problems by disrupting the natural flow of information within social networks.’

188 Fonagy, P. (2018). ‘Peter Fonagy: Combating a Mental Health Crisis’. Accessed at: https://www.goldmansachs.com/insights/talks-at-gs/peter-fonagy.html.

189 Fonagy, P. cited in Thomson, A. and Sylvester, R. (2020). ‘Panic and Anxiety after Education is Plunged into Limbo’. The Times, 31 March.

190 Fonagy, P. and Allison, E. (2015). ‘A Scientific Theory of Homosexuality for Psychoanalysis’, in A. Lemma and P. E. Lynch (eds), Sexualities: Contemporary Psychoanalytic Perspectives, Hove, UK: Routledge, pp. 125–137, p. 130–131.

191 The claim to almost complete overlap with queer theory was also unpersuasive given the lack of sustained social criticism by Fonagy and colleagues. One step towards making this claim more real has been that the Anna Freud Centre joined London Pride in 2019. Fonagy gave a statement that: ‘It is profoundly wrong that people we know and love fear rejection from their friends and families, from their colleagues and workplaces, feel vulnerable to abuse and fear violence simply because of their sexual identity. Being accepted is a human need. It is not a privilege to have that need met, but a basic right, one from which all other opportunities flow. When we can all assert our individuality and flourish, and when we have the respect we need to feel proud of who we are, we will have a fairer society. It’s in recognition of this aspiration that the Anna Freud Centre is marching in celebration and solidarity with Pride.’ Accessed at: https://www.annafreud.org/insights/news/2019/07/anna-freud-centre-staff-students-and-champions-march-to-mark-london-pride/. The Centre issued guidance from one of their Young Champions on how mental health services can better serve as safe spaces for people who identify as LGBTQ+: accessed at: https://www.annafreud.org/insights/blogs/2019/07/how-mental-health-services-can-present-themselves-as-safe-spaces-for-people-who-identify-within-the-lgbtqplus-community/. Recently, the Centre have also responded critically to the judicial review of the Gender Identity Development Service, advocating greater acknowledgement of the capacity of trans and gender-questioning young people to self-determination. https://www.annafreud.org/insights/news/2020/10/statement-from-the-anna-freud-centre-on-the-gender-clinic-judicial-review//.

192 Straker, G. and Winship, J. (2011). ‘The Dangers of the Universal: A Critique of Fonagy and Target’s Theory of Sexual Enjoyment’. Studies in Gender and Sexuality, 12(4): 288–302.

193 Sedgwick, E. K. (2008). Epistemology of the Closet, Berkeley, California: University of California Press; Butler, J. (2005). Giving an Account of Oneself, New York: Fordham University Press; Berlant, L. (ed.) (2019). Reading Sedgwick, Durham, NC: Duke University Press.

194 Huffer, L. (2012). ‘Foucault and Sedgwick: The Repressive Hypothesis Revisited’. Foucault Studies, 14: 20–40.

195 Ahmed, S. (2010). The Promise of Happiness, Durham, NC: Duke University Press; Ahmed, S. (2017). Living a Feminist Life, Durham, NC: Duke University Press.

196 The problem is actually acknowledged by Bateman and colleagues in a paper from 2007, though not subsequently rectified. The scene of thinking about parental reflective function remained infancy: Bateman, A. W., Ryle, A., Fonagy, P., and Kerr, I. B. (2007). ‘Psychotherapy for Borderline Personality Disorder: Mentalization Based Therapy and Cognitive Analytic Therapy Compared’. International Review of Psychiatry, 19(1): 51–62: ‘the problem with the concept of contingent and marked mirroring is that it appears to offer a one-sided and reductive account of the maternal–infant interaction … The mentalizing perspective is a dynamic developmental view where the respective capacities of child and parent, and therefore the nature of their contribution to interactions, change as the child matures. While the mentalizing approach considers that contingent mirroring may be the key contribution of the parent in the first year of life, this gives way to more complex interaction’ (p. 55).

197 The role of habit in facilitating or hindering awareness of thoughts and feelings has been a classic concern of phenomenology since Husserl, and has continued in the work of queer theorists developing the phenomenological tradition e.g. Ahmed, S. (2006). Queer Phenomenology: Orientations, Objects, Others, Durham, NC: Duke University Press.

198 An aligned criticism has been offered by Køster, A. (2017). ‘Mentalization, Embodiment, and Narrative: Critical Comments on the Social Ontology of Mentalization Theory’. Theory & Psychology, 27(4): 458–476: ‘in spite of a strong interactive focus, it remains fundamentally rooted in a Cartesian ontology, overlooking embodied, expressive, enactive and sociocultural dimensions of social cognition’ (p. 460); ‘Bernhard Waldenfels (2015) distinction between “frontal” vs. “lateral” variants of sociality. Whereas frontal sociality refers the type of “face-to-face interaction” which completely dominates the framework of MT, lateral sociality designates the equally prominent dimension that we find ourselves “side-by-side” in a shared relation to a cultural world of practices, norms and objects etc. which are saturated with social reference and meaning. Whereas the early attachment context might supply the child with a basic understanding of the rhythm and structure of this lateral dimension, it hardly seems persuasive to claim that these forms of social understanding exclusively or even primarily owe their ontogenesis to the early infant/caretaker interaction. Rather, these norms are learned from actual engagement in these social practices in their proper contexts’ (p. 467).

199 Similar concerns have been raised by Shaw, C., Lo, C., Lanceley, A., Hales, S., and Rodin, G. (2019). ‘The Assessment of Mentalization: Measures for the Patient, the Therapist and the Interaction’. Journal of Contemporary Psychotherapy, 50(4). It may be noted that the concepts were also incorporated by Fonagy and colleagues into the developmental model quite early, on the basis of one or two empirical studies generally conducted by Gergely—that is to say, before much is known about factors that might clarify the roles of context and culture. That said, marked mirroring and teleological mode were introduced 20 years ago now, but moderators have still barely been considered.

200 Dotson, K. (2014). ‘Conceptualizing Epistemic Oppression’. Social Epistemology, 28(2): 115–138; Dotson, K. (2017). ‘Theorizing Jane Crow, Theorizing Unknowability’. Social Epistemology, 31(5): 417–430; Hill Collins, P. (2019). Intersectionality as Critical Social Theory, Durham, NC: Duke University Press, Chapter 4.

201 Althusser, L. (1971). ‘Ideology and Ideological State Apparatuses’, in Lenin and Philosophy, trans. Ben Brewster, New York: Monthly Review Press; Foucault, M. (1982). ‘The Subject and Power’. Critical Inquiry, 8(4): 777–795. Curiously, Winnicott has moments when he makes links between the parent–child scene and the wider scene of cultural subjectivation. However, in these cases, society is always mediated by the mother. His accounts are also almost always positive, with these two elements acting in potential concert: ‘The mother’s confidence in her husband or in the support that she will get, if she calls out, from local society, perhaps from the policeman, makes it possible for the child to explore crudely destructive activities which relate to movement in general, and also more specifically destruction that has to do with the fantasy that accumulated round the hate. In this way (because of environmental security, mother supported by father, etc.) the child becomes able to do a very complex thing, that is to say, integrate all his destructive impulses in with the loving ones’: Winnicott, D. W. ([1967] 1986). ‘Delinquency as a Sign of Hope’, in Clare Winnicott, Ray Shepherd, and Madeleine Davis (eds), Home is Where We Start From: Essays by a Psychoanalyst, New York: Norton, pp. 90–100, p. 94.

202 What is ‘shown’ to the infant in ostension—for instance, the caregiver’s desire for the child to pay attention to particular information—is already embedded in forms of symbolic and material stratification, and a wider economic and cultural ecology. Marcia Cavell has criticized Fonagy directly on these grounds. Cavell, M. (2006). Becoming a Subject: Reflections in Philosophy and Psychoanalysis, Oxford: Oxford University Press, p. 69. Likewise, see Straker, G. and Winship, J. (2011). ‘The Dangers of the Universal: A Critique of Fonagy and Target’s Theory of Sexual Enjoyment’. Studies in Gender and Sexuality, 12(4): 288–302. For relevant work in queer and feminist theory, see e.g. Butler, J. (2004). Undoing Gender. London: Routledge; Benjamin, J. (2005). ‘What Mothers and Babies Need: The Maternal Third and its Presence in Clinical Work’, in S. Brown (ed.), What do Mothers Want? New York: Analytic Press, pp. 37–54. Object relations theory has been an important influence on the attention of queer theorists to infancy. However, attention to this site has also helped contest the classical liberal characterization, at least since Locke, of child–caregiver relationships as somehow outside of the forms of oppression that structure wider society.

203 Young, I. M. (2005). On Female Body Experience: ‘Throwing Like a Girl’ and Other Essays, Oxford: Oxford University Press.

204 Lacan, J. (1977). Écrits: A Selection, London: Tavistock; Gasché, R. (1986). The Tain of the Mirror: Derrida and the Philosophy of Reflection, Cambridge, MA: Harvard University Press. That these were complexities knowingly left aside is shown by the fact that, in their 2003 book, Fonagy and Hepworth offer a summary precisely of Lacan’s critique of psychoanalysts who over-focus on the imaginary aspects of the mirror stage at the expense of the symbolic. Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 17.

205 Fonagy, P. (2019). ‘The Future Prospects of Mentalization Based Therapies’, 5th International Congress of Mentalisation Based Treatments, Haarlem, The Netherlands, 22 November; Fonagy, P. (2019). ‘Why is it So Hard to Learn to Do Things Differently? On Not Being Able to Learn from Experience’. GAP Call-In Series Podcast. Accessed at: https://www.borderlinepersonalitydisorder.org/gap-call-in-series-podcast.

206 Fonagy, P., Campbell, C. and Allison, E. (2019). ‘Therapeutic Models’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 169–180, p. 178. It is interesting that the term ‘social cognition’ is used here. As noted in Chapter 3, mentalization was introduced to characterize three of the four elements that Dunn had ascribed to social cognition. These were understanding of the i) origin, ii) location, and iii) functioning of mental states. Dunn had also considered children’s iv) understanding of social and cultural conventions. In referring to ‘social cognition’ here, there is tacit acknowledgement that distorted understanding of social and cultural conventions is also operational. In the Introduction to the Handbook (p. 4), Fonagy and Bateman indeed reiterate that mentalization is not coextensive with social cognition, but rather ‘is the aspect of social cognition that enables individuals to make sense of the behaviour of themselves and others’, without reference to social and cultural conventions.

208 Wallwark, E. (2016). ‘Thousands of Children Start School ‘Not Ready for the Classroom’, Parents’ Smartphone Habits to Blame’. Huffington Post, 09/05/2016. Accessed at: http://www.huffingtonpost.co.uk/entry/children-not-school-ready_uk_57308969e4b0ade291a2342e: ‘Professor Peter Fonagy, chief executive of the Anna Freud Centre agreed that smart phones don’t necessarily have to be a barrier to communication. “To the extent that smart phones stand in the way of that natural process they are indeed a problem,” he said. “However, what is stopping parents from using smart phones to have a conversation with children about how school went, what they have learnt, and for children [to] write about their reactions to new experiences? It may be perfectly possible to use smart phones to promote social relationships even though the tendency is for it to replace rather than enhance parent child interactions.”

209 Duschinsky, R., Collver, J., and Carel, H. (2019). ‘“Trust Comes from a Sense of Feeling One’s Self Understood by Another Mind”: An Interview with Peter Fonagy’. Psychoanalytic Psychology, 36(3): 224–227.

210 E.g. Fonagy, P (2018). ‘Peter Fonagy: Combating a Mental Health Crisis’. Accessed at: https://www.goldmansachs.com/insights/talks-at-gs/peter-fonagy.html: ‘With social media, and as kids have drawn back into their bedrooms and are using smartphones and are using a range of digital devices, what we have found is that they become less happy. Social media is not a replacement for social contact with real human beings. It is particularly when kids compare themselves ‘upwardly’, with models that are better. So for example body image, particularly among young women, is negatively related to screen time with Facebook and Instagram where there are photographs. Whereas looking just at text, your body image is unaffected.’

211 Interview with Peter Fonagy, cited in Rampton, M. (2019). ‘So your Kid Wants a Phone—Now What?’, Huffington Post, 18 October, https://www.huffingtonpost.co.uk/entry/what-age-give-child-a-phone_uk_5da6e5d0e4b062bdcb1b3f29: ‘ “It’s the function of a phone that really matters, far more than the physical reality of having one,” he says. “It’s what a kid uses it for.” We can’t ignore the advantages of children having them. It’s great to be able to keep in touch with family and friends, says Fonagy, who stresses that phones aren’t inherently a bad thing. “After age nine or ten your main social network is other children, and using a phone to maintain that network seems, to me, good,” he says.’ He gives the example of when his daughter was bullied at school and was able, while sitting on her own and deeply upset, to reach out to her parents to share her distress.

212 In both editions of the Handbook of Mentalising in Mental Health Practice, Fonagy and colleagues highlight the potential relevance of their theory to conceptualizing war. However, in doing so, they do not advance much beyond Bion, who argued that one of the central objectives in warfare or other forms of sustained violence is to stop the other side thinking, and that lack of thinking helps perpetuate futile violence. Bion, W. R. (1940). ‘The War of Nerves’, in Miller, E. (ed.), The Neuroses in War, London: Macmillan, pp. 180–200. Differentiating the modes of non-mentalizing, this claim could be further specified to identify the role of pretend mode, psychic equivalence, and teleological mode (and externalization of the alien self) in offering false certainties or uncertainties, and blocking inquisitive stance about the minds of the enemy, allies, or one’s own forces. This line of thought may also help pursue a distinction, neglected in the work of Fonagy and colleagues, between mindless violence and mentalized violence—for instance, some forms of civil insurrection.

213 These characteristics were already presented by Fonagy in conference presentations from 2012, and in Bateman and Fonagy 2016; they appear to reflect an older position less well integrated with recent thinking. Fonagy, P. (2012). ‘Mentalization and Attachment: The Implication for Community Based Therapies’. Paper presented at the Community of Communities 10th Annual Forum, March, London. Accessed at: https://www.slideshare.net/raffaelebarone/mentalization-and-attachment-the-implication-for-community-based-therapies; Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, pp. 449–450.

214 Asen, E., Campbell, C. and Fonagy, P. (2019). ‘Social Systems: Beyond the Microcosm of the Individual and Family’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 229–243, pp. 234–235. By way of comparison, only the first and third of these characteristics are identified in the account of mentalizing organizations offered by Di Stefano, G., Piacentino, B., and Ruvolo, G. (2017). ‘Mentalizing in Organizations: A Psychodynamic Model for an Understanding of Well-Being and Suffering in the Work Contexts’. World Futures, 73(4–5): 216–223. Di Stefano and colleagues identify some elements missing from the account of Asen, Campbell, and Fonagy. These include the role of the organization in regulating arousal, in treating thoughts and feelings as intelligible and of communal interest, and in offering an environment in which uncertainty and ambiguity can be tolerated. See also Koh, E. and Twemlow, S. W. (2018). ‘Towards a Psychoanalytic Concept of Community (IV): The Well‐Functioning Community’. International Journal of Applied Psychoanalytic Studies, 15(1): 5–15.

215 Fonagy, P. (2018). ‘Peter Fonagy: Combating a Mental Health Crisis’. Accessed at: https://www.goldmansachs.com/insights/talks-at-gs/peter-fonagy.html.

216 Fonagy, P. and Target, M. (2002). ‘Fathers in Modern Psychoanalysis and in Society: The Role of Father and Child Development’, in J. Trowell and A. Etchegoyen (eds), The Importance of Fathers: A Psychoanalytic Re-Evaluation, New York: Brunner-Routledge, Taylor & Francis, pp. 45–66; Fonagy, P. and Higgitt, A. (2007). ‘The Early Social and Emotional Determinants of Inequalities in Health’, in G. Baruch, P. Fonagy, and D. Robins (eds), Reaching the Hard to Reach: Evidence-Based Funding Priorities for Intervention and Research, Chichester, UK: John Wiley & Sons, pp. 3–34. See also Duschinsky, R., Greco, M., and Solomon, J. (2015). ‘The Politics of Attachment: Lines of Flight with Bowlby, Deleuze and Guattari’. Theory, Culture & Society, 32(7–8): 173–195.

217 Vincent, S. (2011). ‘ “A Structured Taxonomy of Responsibility Concepts” ’, in N. Vincent, I. van de Poel, and J. van den Hoven (eds), Moral Responsibility: Beyond Free Will and Determinism, New York: Springer, pp. 15–35, p. 26.

218 E.g. Fonagy, P., Target, M., Steele, M., Steele, H., Leigh, T., Levinson, A., et al. (1997). ‘Morality, Disruptive Behavior, Borderline Personality Disorder, Crime, and their Relationships to Security of Attachment’, in L. Atkinson and K. J. Zucker (eds), Attachment and Psychopathology, New York: Guilford Press, pp. 223–274, pp. 256–257. Examining uses of the term ‘responsibility’ in Fonagy’s work, it would seem that the problem was initiated by his use of the term in the 1990s to encompass the Kleinian problematic of guilt and reparation, in which accepting responsibility initiates the depressive position, acceptance of truth, and the basis for moral life with others. However, in Klein, this is responsibility for imagined attacks on the mother, rather than actions in reality. On this basis, taking inappropriate responsibility for faults that lie, in part, in environmental causes was regarded by Winnicott as no less pathological than the abdication of responsibility and the derogation of the environment. Winnicott, D. W. (1986). ‘Berlin Walls’, in C. Winnicott, R. Shepherd, and M. Davis (eds.), Home is Where We Start From, New York: W. W. Norton, pp. 221–227, p. 223.

219 Jurist, E. (2018). Minding Emotions: Cultivating Mentalisation in Psychotherapy, New York: Guilford Press. Jurist encourages mentalization theory to become more ‘cautious about using the term “emotion regulation”. Emotion regulation has not emerged in a vacuum; it has come to the fore in a specific place and time, which valorises individual responsibility and is sceptical of communitarianism. Personally, I am wary of the moralising discourses that preach self-discipline, which can be associated with neoliberalism, and which obscure how dependent we are on others’ (p. 48).

220 Luyten, P., Campbell, C., and Fonagy, P. (2019). ‘Borderline Personality Disorder, Complex Trauma, and Problems with Self and Identity: A Social‐Communicative Approach’. Journal of Personality, 88(1): 88–105.

221 Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre. See also Fonagy, P. (2017). ‘The Big Kahuna: Countries with the Highest Incidence of BPD’. Accessed at: https://www.youtube.com/watch?v=lcVSMuxApaY.

222 Youth Select Committee (2017). ‘Oral Evidence Taken before the Youth Select Committee on Friday 7 July. Accessed at: http://www.byc.org.uk/wp-content/uploads/2017/10/Youth-Select-Comittee-07.07.17-morning.pdf. See also Chivers, T. (2016). ‘12 Things you Probably Didn’t Know about Happiness’. Accessed at: https://www.buzzfeed.com/tomchivers/12-scientific-facts-about-happiness, citing an interview with Fonagy: ‘the combination of responsibility and the absence of agency is a particularly toxic phenomenon’.

223 Asen, E. and Fonagy, P. (2017). ‘Mentalizing Family Violence Part 1: Conceptual Framework’. Family Process, 56(1): 6–21: ‘It would seem that the need for each individual to be recognized as a person in their own right is so powerful because, among other things, being recognized in this way is a precondition for the opening up of epistemic trust. To make knowledge resonate—to imbue it with epistemic trust—we need to feel that it is relevant to us, and this is linked to an acknowledgement that “I am a person and I have agency” ’ (p. 16).

224 Even Dennett, whose reification of intentionality was taken up by Fonagy and colleagues, acknowledges that it is a logical error: ‘The intentional stance towards human beings, which is a precondition of any ascriptions of responsibility, may coexist with mechanistic explanations.’ Dennett, D. (1981). Brainstorms: Philosophical Essays on Mind and Psychology, Cambridge, MA: MIT Press, p. 253. In a recent interview, Fonagy argues that mentalization allows one to act with ‘agency’ rather than to be a ‘victim’, at the mercy of what is evoked in us by our environment. BBC Radio 4 (2020). ‘Peter Fonagy on a Revolution in Mental Health Care’. The Life Scientific Podcast, 28 January. Accessed at: https://www.bbc.co.uk/programmes/m000dpj2. It is wholly persuasive that difficulties in conceiving of and reconsidering the thoughts and feelings of others increase the likelihood that a person will feel that the actions of others are intended at their expense, contributing to a sense of being a victim. Yet, the opposition between mentalizing/agency and victimhood also seems to assume some of its appeal on the basis of wider cultural narratives that situate rationality, agency, and responsibility as opposed to weakness, victimhood, and influence by the environment. See e.g. Stringer, R. (2014). Knowing Victims: Feminism, Agency and Victim Politics in Neoliberal Times, London: Routledge; Johnstone, M. A. (2020). ‘Plato on the Enslavement of Reason’. Canadian Journal of Philosophy, 50(3): 382–394.

225 Fonagy, P., Edgcumbe, R., Target, M. and Miller, J. (1999). Contemporary Psychodynamic Child Therapy: Theory and Technique. London: The Anna Freud Centre and University College London, p. 54. See also Fonagy, P. (1998). ‘Prevention, the Appropriate Target of Infant Psychotherapy’. Infant Mental Health Journal, 19(2): 124–150, p. 137.

226 For instance, a randomized-control trial of the use of play therapy for children in Ethiopia to accompany an emergency food intervention. Accessed at: https://www.annafreud.org/what-we-do/research-policy/research-themes/testing-what-treatment-works-best/emotional-stimulation-in-the-context-of-emergency-food-intervention-in-the-treatment-of-malnourished-children-a-randomised-controlled-trial/. Palmer, R. (2016). Emotional Stimulation as an Addition to Therapeutic Food Intervention for Treatment of Young Children with Severe Acute Malnutrition in a Low-Income Country. Unpublished doctoral thesis, London, University College London. Fonagy and colleagues are also pursuing a trial of group-based psychotherapy in Kenya and Lebanon. Accessed at: https://www.nihr.ac.uk/news/research-funding-boost-for-mental-health-in-low-and-middle-income-countries/24900.