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(p. 26) Work at the Anna Freud Centre 

(p. 26) Work at the Anna Freud Centre
Chapter:
(p. 26) Work at the Anna Freud Centre
Author(s):

Robbie Duschinsky

and Sarah Foster

DOI:
10.1093/med-psych/9780198871187.003.0003
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date: 06 December 2021

Introduction

Chapter 1 presented three biographical snapshots of some of Fonagy’s formative experiences: as a child in the Fónagy household, as an adolescent in therapy with Hurry, and as a young analyst in the 1980s. This chapter will continue chronologically into the 1990s, but with a greater focus on institutional rather than biographical context. It will explore Fonagy’s work as research director for the Anna Freud Centre in the 1990s, and the research conducted by Target and Fonagy examining the long-term outcomes of former patients at the Centre.

In considering the institutional context within which Fonagy and colleagues have developed their ideas, the focus on the Anna Freud Centre is in part an effect of the available textual record. Fonagy has stated in interview that, after the suicidal feelings and depression of his adolescence, ‘these two institutions saved me: both the Anna Freud Centre and University College London (UCL).’1 However, there is almost nothing in the public domain documenting Fonagy’s activity within UCL. This is despite the fact that he has spent his whole career at UCL: as undergraduate, graduate, lecturer, head of department for Clinical, Education, and Health Psychology since 2008, and as head of division for Psychology and Language Sciences since 2017.2 That said, Fonagy has expressed pride in the UCL tradition of ‘open-mindedness’, as the first English university to accept atheists and religious non-conformers, and then later the first to accept women.3 He has likewise signalled his sympathy for the utilitarian values of the founder of UCL, Jeremy Bentham, for whom the purpose of knowledge was its value in practical use.4

After describing Fonagy’s work at the Anna Freud Centre in the 1990s, this chapter will attempt to characterize some features of Fonagy’s leadership of the Centre since 2003. The Centre has seen an incredible transformation in this time. We will seek to situate this transformation in relation to the challenges and opportunities of the wider social context. The chapter will close with an attempt to briefly situate a number of the major collaborations from different eras of Fonagy’s work, introducing the dramatis personae for the rest of the book.

Research director at the Anna Freud Centre

After graduating as a psychoanalyst accredited to practise with adults in 1985, Fonagy pursued a private practice while also working as a lecturer in psychology at UCL. In 1989, he (p. 27) began training as a child and adolescent psychoanalyst at the Anna Freud Centre. His clinical supervisors were Rose Edgcumbe, Anne-Marie Sandler, and Marion Burgner. As we saw in Chapter 1, he had already come to identify limitations to interpretation as the primary form of clinical intervention, which characterized the ‘classical’ psychoanalytic technique. His critical appraisal of the inherited psychoanalytic tradition was not always encouraged:

You know, I nearly didn’t make it through my training. Halfway through I was pulled up by my progress advisor, who asked me if I was certain that analysis was the career for me. I asked why, and she said that it was because I had been critical in seminars. It’s not that my career is to criticize, I told her, I just wanted to test the ideas, and I tested them.5

Nonetheless, Fonagy was supported by his clinical supervisors to utilize the technique of ‘developmental help’ (see Chapter 1) in his work with child patients. Through the early 1990s, he reported cases in which it appeared to be this aspect of clinical technique that proved effective at reducing his child patients’ symptoms and helping them to understand themselves and others.6 For instance, Fonagy reported the case of William, a 7 year old who could not relate to or play with his peers. His mother wished that he had never been born and made him feel rejected. This was disguised by a barrage of talk to and about him, but which showed little recognition of his intentions, thoughts, or feelings. Neither she nor William’s father had played with him. Fonagy reported:

After three years of intensive ‘developmental help’, William was far more able to think about himself and others in terms of motives and feelings, and to explore the painful area of how different his thinking was from other people’s and how this had cut him off from them. Throughout the analysis, play, focused on uncovering the psychic reality behind the physical, and then on the different perspectives of different people, formed the backbone of all the therapeutic work.7

As well as pursuing training in child and adolescent analysis, from 1989, Fonagy was appointed research director at the Centre. One of his first projects was to put together a technique manual for child psychoanalysis at the Centre. This was undertaken in conjunction with Mary Target and Rose Edgcumbe, and as the doctoral project for Jill Miller. Initially, work on this manual was oriented by the principles of classical psychoanalytic technique for work with children and adolescents, with a focus on reticence and psychoanalytic interpretation of both patients’ symptoms and the dynamics in the patient–therapist relationship. However, there was a growing consensus that developmental help was of special importance for the therapy provided by the Anna Freud Centre. So Fonagy and colleagues started again, (p. 28) this time with developmental help as the focus. Again, however, this attempt failed: there was too much dissensus for a manual to be developed that met with enough approval to publicly represent the Centre.8 Part of the problem was that ‘the same words were being used in significantly different ways by different clinicians, who had always assumed that they were talking and writing about the same phenomena.9 Despite this, Fonagy was struck that amid the dissensus that blocked the publication of the manual ‘we found that we had use for very few terms. As for all the subtlety—you just don’t need it.’10

In the abandoned manual, Fonagy and colleagues attempted to characterize the core elements of developmental help. On the one hand, developmental help offers support to the child or young person’s ‘dare to change’, for instance—by drawing the patient’s attention to limitations of their current strategies and the possibilities held out by alternatives. In doing so, the therapist is encouraged to act with due acknowledgement that this may be quite challenging for patients whose symptoms reflect adaptations to an ‘environment perceived as dangerous or destructive in which improvement in his functioning would not be welcome’.11 On the other hand, the techniques of development offer direct assistance to the patient to support successful psychological functioning, and thereby ‘increase the child’s sense of being competent’. This may include ‘support in learning to control his feelings and behaviour, suggestions or demonstrations of how to manage difficulties he encounters, and so on’, and should be accompanied by a good deal of ‘encouragement and praise’.12 The therapist acts as an ‘auxiliary’ source of help for the patient’s capacities for affect regulation and behavioural control, encouraging the young person as they learn to achieve these capabilities independently.

The ideas circulating at the Anna Freud Centre during Fonagy’s training had particular importance for his later thinking in four regards. A first was the growing interest at the Centre in self-understanding and the experience of being understood to clinical work in general, but especially to work with children and adolescents and in patients presenting with borderline states. A second was the perspective that the most crucial aspect of ‘borderline’ phenomena was difficulties in relating to others, and that this may stem from trauma in the child–caregiver relationship. A third was the idea of developmental help, seeking to help young people find new forms of adaptation to their environment that would permit greater affect regulation and self-esteem. And a fourth important lesson, related to the work of Fonagy and colleagues on the manual, was that clinicians might have significant overlap in the core elements that contribute to successful therapy.

In these and other ways, the emerging stance of Fonagy and his immediate collaborators in the 1990s was indebted to the Anna Freudian tradition. However, Fonagy and colleagues appear to have experienced this tradition as ultimately no longer adequate for its contemporary tasks. Some aspects, alive and bright, were pulled out and preserved; others were (p. 29) patched with grafts from elsewhere. Anna Freud was centrally interested in the role of child–caregiver relationships and in education for providing scaffolding for an individual’s skills at self-regulation, and as the locus for preventative interventions.13 Both concerns were retained by Fonagy and colleagues. Anna Freud’s interest in both positive and negative factors in development, and a child’s adaptation to their circumstances, would be pivotal to the work of Fonagy and his collaborators. Anna Freud also tended to eschew psychiatric diagnoses as superficial, in favour of a quasi-interval scale of total mental health needs. This can be regarded as a relevant backdrop to Fonagy and colleagues’ critique of diagnosis-focused mental health practice, and their conceptualization of mental illness as a latent dimension.14

Yet the position of Fonagy and colleagues also represented an important and valuable advance, leading to a substantially more plausible theory. Several rather weak and speculative aspects of the Anna Freudian tradition were rejected, including Anna Freud’s use of drive theory and her appeal to the id, ego, and superego as if they were distinct agencies.15 Freud’s analysis of development in terms of oral, anal, and genital stages was also, appropriately, thrown out. Perhaps the most influential shift, however, was in the conceptualization of the psychological processes that generate positive and negative mental health. Anna Freud had emphatically argued for the therapeutic priority of psychological processes that serve as defence mechanisms against anxiety, unpleasant realities, and the conflict of incompatible drives. For Anna Freud, defences—for instance, fantasies of omnipotence, or workaholism as a sublimation—may contribute to pathology, or to positive adaptation, depending on the subtlety and sophistication of the defence, and its responsiveness to the demands of the environment.16 By contrast, Fonagy and colleagues advocated the therapeutic priority of psychological processes that obstruct the capacity to conceive of or reconsider thoughts and feelings. They have also conceptualized resilience as the capacity to learn from experience. So, for instance, the concept of repression, foundational for Freud, was abandoned by Fonagy and colleagues in favour of a revised account of distortions in cognitive and affective processing.17 Even when the accounts could in principle have been integrated—for instance, in considering what fantasies are helpful in facilitating the capacity to conceive of or reconsider (p. 30) thoughts and feelings, or in conceptualizing and working clinically with anxiety—such questions have been left essentially untouched, because the concepts for asking them have been set aside.18

Fonagy and colleagues stitched together work at the Anna Freud Centre with ideas from other traditions. This included the treachery of claiming commonalities and opportunities for mutual learning between the Anna Freudians and their traditional arch-enemies, the Kleinian school of psychoanalysis. For instance, Fonagy felt that the Kleinians had made major advances in studying the patient’s awareness of the clinician’s mind, and the patient’s experience of reality in patient–analyst interaction.19 He adopted a version of the Kleinian concept of ‘projective identification’ in the idea of the externalization of the alien self (see Chapter 6).

Fonagy also asserted opportunities for mutual learning between psychoanalysis and non-psychoanalytic approaches to supportive and therapeutic work with children and adults. Fonagy went on record praising Cognitive Behavioural Therapy (CBT), a modality that was increasingly coming to dominate publicly funded mental health care, to an extent at the expense of psychoanalysis. Though he regarded CBT as offering less depth and richness than psychoanalysis, he felt that it had introduced new techniques and values that might be of general value to therapeutic work: ‘I think cognitive behavioural therapy is a fairly rigorous business and I have a lot of time for it. The therapists often know what they’re talking about and, if done well, CBT can be very good.’20 Fonagy knew he was courting controversy in making such assertions. In interview, he would describe his self-perception as follows:

I’m Peter Fonagy. I consider myself to be a Freudian. But in fact, it is the Freudians that I have somewhat greatest difficulty with. And many Freudians now consider me a Kleinian. And those who do not consider me a Kleinian consider me independent. And those who do not consider me independent consider me a renegade.21

My theoretical stance is really a distortion of Anna Freud’s thinking, although I know that, if she was alive, she wouldn’t think I was following her ideas. But I certainly feel that it’s really Anna Freud’s ideas that I’m trying to develop.22

(p. 31) One quality that set Fonagy apart from most other Anna Freudians, and contributed to their perception of him as a potential threat, was his concern with the scientific evaluation of psychoanalytic practice. This external standard was one in which most psychoanalytic practitioners had little skill or training. It also challenged established regimes of power and authority, especially the right to judge what counted as reality. Scientific evaluation was perceived by many of Fonagy’s colleagues as a profanation, with the result that ‘analytic therapists in particular have been defensive and suspicious in the face of the evidence culture as though the very idea of objective scrutiny represented a hostile intrusion into a quasi sacred private world.’23 Sigmund Freud had, at times, claimed that any element of psychoanalysis could be jettisoned if subsequent scientific developments suggested the need to update theory or practice.24 However, Freud had little interest in experimental studies as a means of evaluating and improving psychoanalytic practice.25

With a few exceptions such as John Bowlby,26 by the time Fonagy was training as an analyst, psychoanalysts had little appetite for either experimental research or the incorporation of new developments from other scientific disciplines. Instead, Fonagy saw around him that developments in psychoanalytic theory tended to stem from reflection on individual cases or a handful of cases, with ideas incorporated into the canon on the basis of the appeal to other clinicians, and without established systems to prune or disconfirm theory:

The abundance of clinicians claiming, on the basis of case reports, that their theory and technique are indispensable, is the gravest indictment of the logic of case-study methodology. It leaves open the possibility that an unspecifiable, but possibly very substantial, portion of coherent psychoanalytic generalizations, which meet the hermeneutic criteria of consistency and meaningfulness, are incorrect.27

Allied with Joseph Sandler’s concern regarding the conflation of description and explanation, and with work pursued by Ivan Fónagy on the nature of metaphor in science,28 Fonagy argued in the 1980s that ‘all the metaphoric language of psychoanalysis is a sign of inadequate information concerning underlying psychological processes. It indicates gaps in our knowledge which will only be filled by further experimental research.’29 No denigration of (p. 32) metaphor was intended; Fonagy himself clearly appreciated the value of a good metaphor in developing theory and in scientific exposition. Rather, his point was that metaphor should not be mistaken for causal-deductive claims about mental processes.

Fonagy’s distinction between evocative metaphor and causal-deductive psychology was over-sharp; lack of attention to what is evoked by the language of psychological theory would contribute to confusion regarding the meaning of his own theoretical terms like ‘disorganization’ and ‘self’ (see Chapters 3 and 6).30 However, in his discussion of metaphor, Fonagy is certainly persuasive in his critique of the language of psychoanalytic theory: this language may give a luminous feeling of comprehension, but Fonagy felt that its tendency towards encompassing metaphors masks imprecision, especially in conceptualizing and predicting causal processes. The audience nod along, and lose the sense that that the ideas are provisional estimates.31 This is because a shortcut has been enacted in the process of understanding, because individuals take away quite different meanings from the theory based on their existing presuppositions, while believing they hold a common notion. With psychoanalytic theory both superabundant and ultimately unreliable in the articulation of causal processes, Fonagy saw clinicians operating in practice on the basis of implicit assumptions and low-grade generalizations about what was felt to work with patients, assumptions that were not brought for public discussion or elaboration into testable hypotheses. The result was ‘a petrification of clinical practice’, a weak articulation of the underlying psychological processes acted upon in clinical interventions, and resistance to even thinking about the reform of how analysts are trained.32

Supported by a collaboration with George Moran, Director of the Anna Freud Centre until his early death in 1992, Fonagy sought to pursue and nurture research at the intersection of psychoanalysis and scientific practice.33 After completing his training as a child psychoanalyst in 1995, he co-convened yearly research training seminars in London, under the banner of the International Psychoanalytical Association, to support the development of empirical research projects by psychoanalysts and trainees, as a step towards a culture favourable to psychoanalytic research.34 As chairman of the International Psychoanalytic (p. 33) Association Standing Committee for Research from 1993 to 2005, Fonagy was also involved in the funding of psychoanalytic research.35

It should not be thought that Fonagy’s position was that of the dour empiricist: for example, he would act as an advocate for speculative psychoanalytic theory in academic contexts, arguing for recognition of its potential contribution.36 He valued the inherited tradition of hermeneutic thinking in psychoanalysis as having generated many unique and valuable proposals about the human mind and about the treatment of mental suffering. He was certainly not above offering untestable speculations at times. For instance, Fonagy and Target speculated, apparently seriously, that psychoanalysts’ aversion to new beliefs and knowledge from outside psychoanalysis was an ‘unconscious expression of infantile patterns’, which made them afraid to explore freely.37 As we will see in Chapter 5 on the modes of non-mentalizing, Fonagy and colleagues have not hesitated to give clinical guidance over decades without getting round to operationalizing relevant constructs for testing. Fonagy’s concern has not been with speculation per se, but with speculation intrinsically cut off from empirical testing. He felt, following Karl Popper and others, that a distinction should be drawn between the work of proposing hypotheses (the ‘context of discovery’) and the work of testing them enough to be able to be sure of the evidence and its replicability (the ‘context of justification’).38 Some analysts might wish to focus their energies on proposing hypotheses and some on testing them, but psychoanalysis as a discipline needed both activities for the sake of its internal health and development, as well as for its external standing.

In the second half of the 1990s and early 2000s, Fonagy wondered at times whether it was already too late for psychoanalysis to change fast enough to counteract its reputation as a scientific backwater, and to gain the credibility to receive research funding and opportunities (p. 34) for collaboration with significant figures in other disciplines.39 When he and Mark Solms attempted to establish a new MSc in neuropsychoanalysis at UCL, the application was met with rejection on the basis that psychoanalysis had insufficient collaborations with neuroscience to warrant a postgraduate degree at the intersection.40 Nonetheless, in general, Fonagy retained optimism and, in papers from 1997, urged major and immediate changes to psychoanalytic culture:

If we fail to meet the challenge confronting us, if child analysts offer their treatment for an overly extended range of disorders, while making little attempt to demonstrate its effects in a form accessible to others, the likely consequence is that child psychoanalysis will be discredited and disappear. This will be a great loss to psychoanalysts, but a still greater one to those children who specifically need this form of help but who will no longer have access to it.41

Fonagy, Bleiberg, and Target advised pursuit of cross-disciplinary collaborations and integrations of psychoanalysis with new developments in science. And, to achieve this, they called for six changes to psychoanalytic practice to generate the basis for scientific credibility.42

First, Fonagy argued that psychoanalysis needed better characterization of its interventions, to the point that these could be manualized. This would clarify the relationship between intervention, process, and outcome.43 A second was that better specification was needed regarding what interventions were appropriate for what symptoms (‘what works for whom?’). It should not be assumed that the same techniques, or even psychoanalytic approaches in general, would be equally effective for conditions as diverse as anxiety disorders, drug addiction, and postnatal depression. Third, clinical practices needed to develop independent and quantitative evidence of their efficacy.44 It might be a complex task to quantify the benefit a patient receives from psychoanalysis, given that this is generally assumed to be much more than the reduction in their presenting symptoms. Fonagy felt that this complexity was not an intrinsic obstacle to evaluation, though it required candid discussions about what benefits might be seen and how they might be authentically measured.

(p. 35) Fourth, Fonagy argued that developments in theory needed to be tied more closely to developments in clinical technique, which could be evaluated to demonstrate or disconfirm the practical value of the theory. If psychoanalysts approach anxiety disorders, drug addiction, and postnatal depression differently on the basis of ideas about their respective psychological mechanisms, then this should be specified, and the distinct components of the interventions articulated to facilitate their empirical evaluation and the optimization of treatment practice. Fifth, psychoanalytic treatments should be revised to be shorter, with better specified goals to facilitate transparency and evaluation. And sixth, clinical progress should receive ongoing evaluation using reliable procedures, which also feed in to clinical supervision.45 Of the six recommended changes to psychoanalytic practice, only this last would spare the Anna Freudian tradition, which had generally had a better history of evaluating clinical progress than other schools of psychoanalysis. On the five other grounds, Fonagy was directly calling for major alterations to the approach to psychoanalysis in which he had recently qualified.

The Anna Freud Centre retrospective study

In becoming research director for the Anna Freud Centre, Fonagy gained access to the Centre’s case files for research purposes. It was expected that therapists associated with the Centre would write detailed weekly reports on each patient, and further reports every two months. These would belong to the Centre, for the purposes of research. Many of the case files had been indexed as part of a large project in the 1960s. The indexing work raised valuable questions about what should be the appropriate ‘unit of psycho-analytic observation’. These questions led to penetrating studies of basic psychoanalytic concepts by Sandler and colleagues (see the Introduction), studies that were a formative influence for Fonagy.46

By the time Fonagy took the role of research director, there were 763 cases available for research and, unusually, well characterized. Anna Freud and Dorothy Burlingham’s sense of scientific values had led them to demand an unusual level of documentation. This included identification of symptoms such as conduct problems, anxiety, and depression. Cases at the Centre were also reporting against a quasi-interval system for coding mental ill health (see Chapter 7): category 1 (essentially normal), 2 (transient symptomatology or developmental strain), 3 (neurotic, with ‘permanent regressions, fixations, and symptom formation’), 4 (atypical, distorted personality development), and 5 (destructive processes disrupting mental growth).47 In the early 1990s, Mary Target began work on a PhD with Fonagy pursuing a retrospective study of patient records at the Anna Freud Centre to evaluate the effectiveness of the service. Target’s characterization of Fonagy as a doctoral supervisor was as ‘demanding’, ‘inspiring’, and ‘fun’, though ‘often infuriating’ because ‘much of the time I was left to get on with the work as best I could’.48

(p. 36) Fonagy and Target published their first reports from the study in 1994. At first sight, it appeared that psychoanalysis had very different outcomes for groups of child patients. Forty-six per cent of child patients, who initially presented with aggressive and disruptive behavioural problems, showed improvement in these symptoms by the end of analysis, compared with 73% of child patients presenting with symptoms of anxiety or depression. However, Fonagy and Target found that, if only analyses lasting at least three years were considered, the magnitude of change was identical. They interpreted these results as suggesting that ‘it appears that psychoanalysis can bring about substantial improvements in children with disruptive disorders, but the challenge is to keep these children in analysis long enough for them to benefit’.49 The researchers assessed factors such as whether there was a change in the therapist and whether there were regular meetings with the parents. These factors appeared to have no effect on the effectiveness of treatment of children showing aggressive and disruptive behaviour. Yet they predicted 20% of therapeutic outcome for children presenting with anxiety or depression.50 Examining patient-level factors that predicted improvement, Fonagy and Target found that the age of the child did not affect the likelihood of improvement in their symptoms, but that older children were less likely to lose their diagnosis.51 Later meta-analytic findings from trails data by Pilling, Fonagy and colleagues would report that, in general, younger children obtain greater benefit from psychotherapy than older children by follow-up.52 However, a meta-analysis focused specifically on mentalization-based parenting interventions found the opposite, that interventions targeting parents of 6–12 year olds had greater effectiveness than those targeting parents of younger children.53

Fonagy and Target acknowledged that there was considerable diversity of symptom profiles. So, for instance, within the ‘aggressive and disruptive’ group, there was actually much more improvement among children with oppositional defiant disorder (56%) than among those with a diagnosis of attention deficit hyperactivity disorder (36%) or conduct disorder (23%).54 There was also heterogeneity in the anxiety and depression group, with poorer outcomes for depression.55 Additionally, the distinction between ‘aggressive and disruptive’ behaviours and ‘anxiety and depression’ could be somewhat arbitrary. Many children displayed (p. 37) aspects of both profiles. An intriguing finding was that, among children presenting with aggressive and disruptive behavioural problems who remained in analysis for at least a year, 65% improved if there was an additional diagnosis of anxiety, whereas only 50% improved if there was no diagnosis of anxiety.56 This suggested that anxiety was generally a positive prognostic indicator, a finding that Fonagy and Target attributed to the role of anxiety as a signal of psychological conflict, at least in older children, which could then be resolved in the analysis through support in reconciling different perspectives on the problem: ‘the absence of anxiety may then be an indication of a pervasive distortion of representations, or more likely a substantial inhibition of mental processes, to a point where incompatibility is no longer experienced.’57 The finding that anxiety was a positive prognostic indicator has subsequently been supported by findings of a negative association between internalizing symptoms and impairment once general mental health (the p-factor, see Chapter 7) is taken into account.58 Another related finding reported by Fonagy and Target was that children with mixed emotional and conduct disorder seemed particularly likely to benefit from four- or five-times weekly treatment, compared with once-a-week treatment. This was also the case for children with depression and those without a clear diagnostic profile. By contrast, children with milder forms of anxiety or with separation anxiety problems were just as likely to show improvements from once-a-week treatment.59 A later meta-analytic study of child psychotherapy would indicate that moderate treatment intensity was more effective than high intensity across all disorders.60

In a number of cases, the records showed that children had reported to their analyst abuse or neglect by their parents. Most clinicians took this seriously and approached the parents or worked with other professionals to try to resolve the problems. Nonetheless, a sad finding from the retrospective study was that some clinicians interpreted the children’s reports as fantasy. In a later follow-up of a proportion of the child patients, Target and Fonagy found that ‘at the time of follow-up these individuals could be seen to be reliving and being (p. 38) preoccupied by the traumata, for example of intrusive memories or flashbacks that corresponded to actual experiences reported in the childhood file.61

The Anna Freud Centre retrospective study would be influential for the later thinking of Fonagy and colleagues in four regards in particular. First, Target and Fonagy identified pretend mode and psychic equivalence as forms of non-mentalizing through their work on the case files. This would form one of the most important bases for the development of their theory (see Chapter 5) and of Mentalization-Based Therapy by Fonagy and Bateman. Second, Anna Freud’s quasi-interval scale for assessing mental ill health as a latent variable beneath symptom clusters seems to have been relevant background to work by Fonagy and colleagues on the p-factor in the 2010s (see Chapter 7). Third, and most directly, the study showed that psychoanalytic therapy could contribute to robust improvement in patients’ symptoms over time, contrary to the claims of critics that suggested that psychoanalysis would either show no benefit or only had benefits that could not be documented. Fourth, children with anxiety problems improved just as well with once-a-week therapy as with four- or five-times-a-week therapy. This contributed to the interest of Fonagy and colleagues in lower-intensity therapies, and the delivery of mental health interventions for children and adolescents in primary care settings (see Chapter 8).

Transformations

The Anna Freud Centre retrospective study exemplified the willingness of Fonagy and colleagues to objectify and appraise the clinical efficacy of the Anna Freudian tradition of psychoanalytic intervention. Though Fonagy held the role of research director for the Centre, his stance was met by concern and scepticism by many of his fellow clinicians, who felt that his stance demonstrated insufficient appreciation for the richness of the Anna Freudian tradition in attempting to reduce its value to simplified outcome measures. Fonagy and his colleagues seemed to many at the Centre to be setting themselves up as independent of the community of Anna Freudians. He was also a controversial figure in the international psychoanalytic community, especially for his criticism of the concept of repression.62

The issue of Fonagy’s fidelity or infidelity to the Anna Freudian tradition would come to a head in 2002 with the retirement of Julia Fabricius as Director of the Centre. By this time, the Centre had a fourfold vision: conducting clinical training, analytic treatment, empirical research, and work on prevention. The Centre was comparatively rich, thanks to its estates in the heart of Hampstead. However, the institution was also financially overstretched in seeking to fulfil its different commitments.

Fonagy applied for the post of Director. In response, a petition was circulated to the board arguing against his appointment on the grounds that ‘Peter Fonagy clearly stated at the AGM (p. 39) that he does not think of himself as an Anna Freudian’, and that, while prioritizing research, he would pursue cost-cutting measures that would discontinue clinical training and scale back the provision of treatment by the Centre. As a result, it was argued that ‘we would go so far as to say that in his hands the identity and future of the Anna Freud Centre as an internationally renowned establishment dedicated to the Anna Freudian developmental perspective on child analysis would be destroyed.’63 Thirty therapists and former therapists associated with the Centre signed the petition.64 Fonagy withdrew his application. However, no other appropriate applicant could be found and Fonagy became Chief Executive the next year, with Mary Target and Linda Mayes as other members of the directorial team. Looking back on this moment of psychoanalytic history, Reeves has reflected that the petition:

now reads as a prescient though nostalgic letter, as the concerns raised in no way anticipated the sea-change the Centre would experience under Fonagy. It must also be said that no Anna Freudian child analyst or group of analysts came up with a clear vision to lead, protect, and fund the fourfold psychoanalytic clinic.65

Nearly 20 years later, the Anna Freud Centre certainly looks a different institution from the one inherited by Fonagy. It should be immediately acknowledged that it is difficult to discern how much of this change was the result of the decisions and priorities of Fonagy, how much the decisions of others, and how much circumstance. Nonetheless, the net effect has been that the Centre’s therapeutic, institutional, reputational, and financial resources have been almost wholly repurposed. While there are continuities in the strengths of all these elements, and some carry-overs such as parent–toddler groups,66 the mission and scale of the Anna Freud Centre have shifted.67 The Centre no longer offers long-term psychoanalytic therapy to children and adolescents. However, the Centre’s Early Years Parenting Unit offers 18 months of two-days-a-week mentalization-based treatment to parents with a personality disorder with a child under five referred by child protection services.68 Other clinical services are also (p. 40) provided. For instance, the Parent–Infant Project offers a range of psychotherapeutic interventions focused on the parent–child relationship. The service is free for parents of infants living near the Centre who are struggling in the caregiving role. The Parent–Infant Project draws on elements of traditional parent–child psychotherapy, but also of mentalization-based therapy.69 It delivers group-based outreach in primary care baby clinics, in collaboration with health visitors.70 The Centre also offers eight-week, manualized groups, both for parents and for foster-carers, focused on supporting caregiver mentalization.71 Many of the clinical services delivered by the Centre have been adapted to virtual delivery during the COVID-19 pandemic, entailing both use of new technologies and adaptations of clinical technique.72

Additionally, the Centre delivers innovative non-clinical services anticipated to have significant therapeutic benefit, and again these have been adapted for online delivery in the context of the pandemic.73 For instance, the ‘Contact and Residence Disputes’ service takes a mentalization-based approach to helping families locked in chronic legal disputes about custody and contact for their child or children.74 Such services signal the potential opening for a mentalization-based framework for professional practice across diverse contexts in which social understanding has difficulty forming or has broken down.

The training of child analysts has long gone. A clinical training in child psychotherapy remains, but the theoretical orientation of the course does not reflect an Anna Freudian perspective.75 Besides this, psychoanalysis is in the background rather than the foreground at the Centre, though there remain courses such as the MSc Psychoanalytic Developmental Psychology. The Hampstead estates have been sold as part of generating the funds for a £41 million new building near King’s Cross Station in London, supported in part through private philanthropy and the patronage of the British royal family. In 2019, the building won the Grand Prix Design Award and was described by the judges as ‘a homely, light-filled environment that supports children dealing with mental health problems and who are (p. 41) excluded from the school system’.76 In terms of the Centre’s focus, prevention has gained far greater prominence than in earlier incarnations, through the production of resources for schools, children and families, and helping professionals.77 For instance, the Anna Freud Centre’s Service for Schools delivers training in a multi-family group approach, in which six to eight families receive mentalization-based support by a teacher at the school together with a psychological professional.78 In the context of the COVID-19 pandemic, the Anna Freud Centre have issued a suite of prevention-focused resources and guidance for schools, children and families, and helping professionals.79 For instance, they have published guidance on ‘Helping babies and young children under 5 through the coronavirus crisis’, which focuses on strategies parents and early years workers can use to help young children understand the disruption to their lives, allow them to continue to feel well looked after, and to identify escalating problems with their mental health.80

On average, around 8,300 mental health professionals are trained a year at the Anna Freud Centre in mentalization-based approaches.81 As of 2018, over 5,000 mental health practitioners are affiliated with the Centre’s Learning Network, and over 6,500 teachers with the Centre’s Schools in Mind Network.82 In 2020, the Centre launched a new online training portfolio, which will have the advantage of making their courses much more readily available to practitioners outside of London, including internationally.83

The Anna Freud Centre is also a major player in influencing national mental health policy, with a close relationship with the Department for Education. In 2014, the Centre became host to a new specialist school for children aged between 9 and 14 who had been excluded from mainstream education.84 The scope of research at the Centre has also grown beyond recognition compared with 2003. The Centre receives over £2 million each year in grants for pursuing empirical research. It directly employs 63 researchers (out of 250 direct staff) and hosts 330 postgraduate students.85

The Centre has a network of Young Champions—young people who have experience of using mental health services and contribute to research, governance, training and outreach.86 On the Anna Freud Centre website is ‘On My Mind’, a section co-produced with (p. 42) Young Champions, with information, signposting, and resources for children and young people to make sense of mental health and mental health services.87 For instance, the Youth Wellbeing Directory provides a list of free mental health support organizations for young people, searchable by postcode or town. The website also has guidance for young people who are in a role that entails providing support for a friend or family member experiencing mental health difficulties.88 Among the ‘On My Mind’ resources are self-care tools for young people, including support for activities such as creative writing, dance, conversations with friends, self-talk, time away from technology, and distraction techniques for when difficulties cannot otherwise be resolved.89 These have been popular and well-used resources. Furthermore, the Centre has reported a 567% increase in use of these resources between March and April 2020, as the first COVID-19 lockdown commenced.90

Despite the multifaceted nature of the transformation of the Anna Freud Centre over time, a few societal changes may be identified as having played an especially significant role at a structural level. These changes were identified and responded to early by Fonagy and colleagues, shaping the direction of their research and institution-building. They were: 1) an epistemic shift: the rise of evidence-based medicine; 2) a sociological shift: the prioritization of individual self-management; 3) a policy shift: the deintensification of health and welfare interventions for individuals with mental health needs; and 4) an epidemiological shift: the increasing identification of depression, anxiety, and self-harm among young people.

A first shift was the growth of evidence-based health care within Britain and greater appeal to the authority of outcome data in health policy decision-making and administration.91 From the late 1980s, pressure had begun to grow within the National Health Service for mental health treatments to supply evidence of their efficacy. On the one hand, data from randomized trials was important ammunition to justify or compete for public funding. On the other hand, collection of routine data regarding outcomes was called for in order to demonstrate continued short- and long-term cost-effectiveness, as well as the improvement of services over time.92

Fonagy and Higgitt identified this trend in 1989, well ahead of the curve of their peers. They pleaded with the psychoanalytic community to respond to these oncoming pressures by the generation of evaluation research, and the development of robust and authentic quantitative measures for use in the collection of routine data.93 This was part of the context for the Anna Freud Centre retrospective study. The findings were timely for decisions in Britain and internationally regarding the continued funding of psychoanalytic treatments by the state and medical insurance companies.94 A further important development in the status (p. 43) of Fonagy and his group at the Anna Freud Centre as a credible and trusted source of scientific knowledge on mental health in general, not just on psychoanalysis, was the completion of major systematic reviews of the evidence base of mental health interventions.95 The first edition of What Works for Whom? was published in 1996 and reviewed over 2,000 studies.96 A companion volume, focused on interventions for children and adolescents, was published in 2002.97 In the wake of these publications, Fonagy and colleagues were commissioned in the early 2000s with large blocks of funding from the National Institute for Health and Clinical Excellence to develop clinical guidelines and outcome measures.98 Fonagy was also appointed in 2002 to the Department of Health’s Expert Group on Outcomes Measurement for mental health.

In Fonagy’s view, the demand for data-driven mental health treatments was quite valid, a perspective that has become increasingly mainstream in recent years among mental health practitioners.99 He felt that there would be benefits to patients of the movement towards evidence-based approaches to mental health treatment.100 Yet, additionally, Fonagy acknowledged that in some respects ‘the movement appears to be driven largely by financial considerations’, as well as ‘the motivation to impose social and political controls on the professional practitioner’.101 Rather than straightforwardly resist these pressures, Fonagy felt that the psychoanalytic community should respond to them through demonstrations of efficacy, cost-effectiveness, and manualization. This would then form the basis for arguments with policy-makers in terms that they would recognize. At a wider cultural level, he felt that in British society there was a growing expectation of demonstrable, short-term benefit from all activities and that psychoanalysis would have to adapt to this new reality.

A second societal shift, on which the work of Fonagy and colleagues has capitalized, has been sociological and cultural shifts towards a priority on individual self-management as the solution to social problems. Individuals are helped by their families, schools, workplaces, and other institutions to regulate and optimize their thoughts and feelings towards the end of coping with structural problems and economic precarity. This societal shift has sometimes (p. 44) been referred to by sociologists as ‘neoliberalism’, to characterize a culture focused on individual responsibility and self-regulation, stoked by feelings of anxiety and emptiness should this self-regulation fail.102 The individual is encouraged to relate to their own life in an entrepreneurial way. This includes attention to thoughts and feelings, indeed one’s whole ‘personality’, as needing development and optimization.103 Desires and attempts to image change are directed away from collective or policy solutions, treated as beyond reach, and instead turned inwards.

Christopher Bollas, from whom Fonagy originally took the ‘reflective’ in ‘reflective function’ (see Chapter 3), has recently observed that the thought of Fonagy and colleagues—like some of his own work—has reflected and responded to the increasing emphasis on individual self-management of thoughts and feelings.104 Extrapolating on Bollas, it may be observed that, in a complex consumption-focused society, knowledge of the motivations and intentions implicated in one’s own thoughts and feelings is important for distinguishing utility, sifting wants from needs, selecting among available goods, and judging what price is worth paying.105 Without this knowledge, we risk credulity, overextension, and flat-footedness. Furthermore, in a society in which the service sector accounts for the large majority of jobs, individuals have particular need of knowledge of the motivations and intentions implicated in the thoughts and feelings of others if they are to succeed in achieving sales, satisfying customers, receiving good ratings, and taking on debt in a strategic way. More generally, neoliberalism makes an individual’s ability to represent thoughts and feelings especially salient and important. Not only does this ability facilitate the optimal use of thoughts and feelings within an individual’s projects. It also facilitates a reduction in ways that thoughts and feelings may hinder these projects, or contribute more generally to social problems. Furthermore, the individual is held accountable for their thoughts and feelings, which reflects and responds to the wider perspective under neoliberalism in which individual responsibility or ‘ownership’ of their mental states and actions is emphasized, and in which the wider social, economic, and political context of mental states and actions is downplayed.106 (p. 45) Individual skill at understanding social understanding and misunderstanding becomes all the more pertinent when institutions that might otherwise facilitate social understanding have been hollowed out and replaced with infrastructures generating competition, distrust, and feelings of alienation. Such skill is also all the more relevant in a multicultural society, in which common culture cannot be presumed upon. Over the years, Fonagy and colleagues have become increasingly critical of individual-centric modes of explanation, and acknowledged that societal values may have influenced Fonagy’s own past thinking in this direction (see Chapter 9). They have also become increasingly concerned with alienation and culture, and the sociological conditions that undermine social understanding and trust.

A third trend over the past 30 years that has shaped the Anna Freud Centre has been the direction of public resources away from individualized and intensive health and welfare services. This can be regarded as the effect of two interrelated shifts in British health and welfare policy:

  • Increasing moral weight put on egalitarianism, scalability, and population health.107

  • Increasing focus on cost-effectiveness, and indeed cheapness even in the absence of cost-effectiveness, with public services constructed as a potentially unfair burden on the taxpayer.108

Again, Fonagy and colleagues caught this trend early, arguing in the Emanuel Miller lecture in 1992 for the need to ‘envisage a mental health service with the capacity to meet the demand for help (let alone the underlying need) at the same time as being equitable, accessible and acceptable to all those who need it’.109 Long-term psychoanalytic treatment of a few individuals seemed ‘dissonant’, he believed, both with crushing policy pressures to cut costs and with the democratic value of equitable access to mental health support for the huge numbers that could benefit from it.110 Fonagy argued that psychoanalysts should combat economic inequalities in access to mental health treatments: to do otherwise is to be morally complicit with the unequal distribution of wealth.111 Short-term psychoanalytically inspired (p. 46) therapies could also offer a ‘lifeboat’ for psychoanalytic clinicians in the context of the preference among policy-makers for scalability and cost-effective interventions.112

Despite reservations from within the psychoanalytic community about the efficacy of empirical evaluation, Fonagy, Target, and colleagues were committed to the question of whether the effectiveness of psychoanalytic approaches could be demonstrated empirically at scale. Through the 1990s and 2000s, they attempted to find funding for a randomized control trial of child psychoanalytic psychotherapy, comparing it with alternative treatments. However, the response from reviewers was that it was not worth funding the study because it could never be cost-effective.113 Ultimately, they were able to find funding for a trial of 28 weeks of psychoanalytic psychotherapy for adolescents with depression. The results were published in 2017. The researchers found that psychoanalytic psychotherapy was no more effective than two other, briefer, treatments—as measured by patient self-report and clinical interview after 36 weeks, 52 weeks, and 84 weeks.114 All three treatments resulted in an average of 50% reduction in depression symptoms. The cost of delivering a Cognitive Behavioural Therapy intervention was £904.57 per patient, compared with £1,396.72 for psychoanalytic psychotherapy. However, as we saw earlier in the section on the Anna Freud Centre retrospective study, psychoanalytic treatment is comparatively ineffective for depression in children. Psychoanalytic psychotherapy was therefore tested with a condition and client group where Fonagy and colleagues anticipated that it would be less effective than with other conditions and client groups—presumably because this was where funding for a trial happened to be available. There may also have been ‘sleeper effects’ of the psychoanalytic psychotherapy, or benefits not accessible to self-report, as argued by Target.115 Evidence from another trial by Fonagy and colleagues of long-term psychoanalytic psychotherapy (60 sessions), compared with treatment as usual for adults with treatment-resistant depression, did find large differences at follow-up at 42 months (30.0% versus 4.4% partial remission of symptoms), suggesting that psychodynamic therapies can show their effectiveness in the longer term, though whether the findings from this latter trial were because of the longer follow-up, the specification of treatment-resistant depression, or the adult rather than adolescent patient group is unclear.116 According to the trial protocol, an economic evaluation was conducted (p. 47) of the cost-effectiveness of long-term adult psychoanalytic psychotherapy compared with treatment as usual. However, findings from this evaluation were not published.

A fourth trend to which Fonagy and the Anna Freud Centre have been especially responsive has been the changing situation of young people. It is a complicated picture, because the past 30 years have brought many forms of freedom for young people, especially those from socially and economically less deprived families. However, rates of depression, anxiety, and self-harm among young people have, at a population level, generally risen over the period.117 On the one hand, as Fonagy has observed, this likely reflects that as a society ‘we have become better at expressing our thoughts, feelings, beliefs, wishes and desires and have passed this on to our children’.118 On the other hand, the epidemiology of adolescent mental illness likely partly reflects sociological changes.119 One contributing factor may have been increases in educational pressures in the context of frequent, high-stakes testing. Young people may have also experienced increasing worry about the consequences of failure in a social and economic context with fewer safety nets and the circulation of unrealizable images of what constitutes success.120 Furthermore, Fonagy has described the pervasiveness and image-focused qualities of new media as important aspects of contemporary life, contributing to their potential influence on individual self-representations (see Chapter 9).

Fonagy’s impression has been of a rise in despair among young people in the context of such changes, combined with a reduction in the availability and coherence of relevant community-based and third-sector supportive services:121

We see a growing mental health crisis across all groups. Trends highlight an increase in mental illness among some groups of children and young people, particularly emotional problems such as anxiety and depression… There can be little doubt that children and young people are experiencing new and multiple pressures in a demanding and fast-moving digitally enabled world.122

(p. 48) Payne and Fonagy have drawn attention to evidence that this mental health crisis is not evenly spread.123 Low socio-economic status is associated with twice the rates of anxiety and depression as the rest of the British population. Gay, lesbian, bisexual, and queer young people are over two and a half times as likely to experience mental ill health. And girls show rising rates of anxiety, depression, and body dysmorphia as they move through adolescence, suggesting particular challenges for young women.124

Fonagy as an individual, and the Anna Freud Centre as an institution, have been successful at presenting themselves as credible voices in the policy conversation about the future of children’s mental health. On the one hand, these voices have been used to campaign for greater investment in the mental health needs of children and young people.125 In evidence presented to the House of Commons Youth Select Committee in 2015, Fonagy strongly criticized a state of affairs in which children and young people received just over 6% of total national mental health expenditure. He regarded this as an injustice to the massive unmet need for mental health services for children and young people, and terrible foresight given the benefits of acting early in the life course to prevent or mitigate adverse developmental pathways.126

Fonagy and the Anna Freud Centre have also increasingly had a role in the development of policy. Fonagy has chaired two national clinical guideline development groups, as well as several expert reference groups for the Department of Health. For example, the 2017 Green Paper on Transforming Children and Young People’s Mental Health Provision, which put forward an increased role for schools in identifying and managing children’s mental health problems, was based on a review co-authored by Fonagy. The work of Fonagy and colleagues in policy engagement in public mental health and preventative work will be discussed further in Chapter 9.127

Notes:

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

2 Fonagy, P. (2017). ‘A Word from our New Head of Division Professor Peter Fonagy to all PALS Alumni’. Accessed at: https://www.ucl.ac.uk/pals/sites/pals/files/peter-fonagy-letter-to-alumni.pdf.

3 Fonagy, P. (2014). ‘Why UCL?’. Accessed at: https://www.youtube.com/watch?v=XbvKbHO57ZI.

5 Fonagy, P. (2007). ‘Interview’, in L. E. Rubinstein (ed.), Talking about Supervision: 10 Questions, 10 Analysts = 100 Answers, London: International Psychoanalytic Association, pp. 39–49, pp. 45–46.

6 The ‘developmental help’ approach at the Anna Freud Centre found support also from Paulina Kernberg’s object relations approach, though it would not appear that Kernberg had significant direct influence on Fonagy. Kernberg, P. F. and Chazan, S. E. (1991). Children with Conduct Disorders: A Psychotherapy Manual, New York: Basic Books. Another, apparently independent voice from the period calling for a shift from interpretation to supportive counselling was Killingmo, B. (1989). ‘Conflict and Deficit: Implications for Technique’. International Journal of Psychoanalysis, 70: 65−79. The Sandlers recall that, at least in the UK context, a focus on relational support among Anna Freudians was influenced by work in the independent tradition (e.g. Winnicott). Sandler, J. and Sandler, A. M. (1994). ‘The Past Unconscious and the Present Unconscious: A Contribution to a Technical Frame of Reference’. The Psychoanalytic Study of the Child, 49(1): 278–292, p. 280.

7 Fonagy, P. (1995). ‘Playing with Reality: The Development of Psychic Reality and its Malfunction in Borderline Personalities’. The International Journal of Psychoanalysis, 76(1): 39–44, pp. 42–43.

8 Edgcumbe, R. (1995). ‘The History of Anna Freud’s Thinking on Developmental Disturbances’. Bulletin of the Anna Freud Centre, 18(1): 21–34: ‘As recently as five or six years ago, when Peter Fonagy, George Moran, Hansi Kennedy and I started trying to put together a Technique Manual, we began by trying to orientate it around classical technique with neurotic children. But we and the therapists whom we asked to comment on our formulations found this unsatisfactory and we were obliged start again, this time trying to formulate developmental help. But we failed to sort it out satisfactorily’ (p. 22).

9 Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 289.

10 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. 88.

11 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. 111, unpublished manuscript, Mary Target’s personal archive.

13 Freud, A. (1954). ‘Psychoanalysis and Education’. The Psychoanalytic Study of the Child, 9(1): 9–15; Freud, A. (1965). Normality and Pathology in Childhood, New York: International University Press.

14 Anna Freud also at times expressed scepticism of the role of single traumas in mental health symptoms, and argued—as Fonagy and colleagues would later—that accounts of trauma in therapeutic contexts may be important but in large part as narrative constructions through which a patient works to understand and recalibrate their experience of themselves. However, Freud was not consistent on this point. Freud, A. (1958). ‘Child Observation and Prediction of Development: A Memorial Lecture in Honor of Ernst Kris’. The Psychoanalytic Study of the Child, 13(1): 92–116. Another intellectual ancestor of Fonagy who may have provided a relevant backdrop was Winnicott, for whom mental ill health was arrayed quantitatively, with no sharp qualitative lines between diagnoses—‘even between health and full-blown schizophrenia’. Winnicott, D. (1971). Playing and Reality, London: Routledge, p. 66.

15 Midgley, N. (2012). Reading Anna Freud, London: Routledge.

16 The 10 defences privileged by Anna Freud were repression, regression, reaction-formation, isolation, undoing, projection, introjection, turning against the self, reversal into the opposite, and sublimation. Freud, A. (1946). The Ego and the Mechanisms of Defense, New York: International Universities Press. Some of these processes may be facilitated or actually achieved through forms of non-mentalizing (see Chapter 5). Regression, reaction-formation, and reversal into the opposite may be prompted by pretend mode. Undoing, projection, and introjection may be prompted by psychic equivalence, in which what is felt is experienced as real (e.g. that one can really undo an action through some symbolic reparation). Isolation may be achieved by teleological mode. However, the defence mechanisms and the forms of non-mentalizing operate on rather different levels of analysis, given that they are descriptions of the obstruction of mental processes that are conceived very differently. Exemplary in this regard is the causal centrality of anxiety for Freud, and its peripheral and epiphenomenal role for Fonagy and colleagues, in their conceptualization of the mind and of mental illness.

17 Fonagy, P. (2000). ‘Response’. The International Journal of Psychoanalysis, 81(2): 354–356. See also Pedersen, S. H. (2013). ‘Fonagy and Freud. Psychological versus Psychic Reality’. The Scandinavian Psychoanalytic Review, 36(1): 18–26.

18 Another point of potential integration could have been around Part II of Anna Freud’s Ego and the Mechanisms of Defence, which is centrally concerned with strategies to avoid social understanding by blocking occasions for learning from experience. So, for instance, a new defence mechanism is proposed by Anna Freud—‘restriction of the ego’— in which an individual structures their social environment to pre-emptively avoid unpleasure. However, Freud’s examples are largely of strategies to pre-emptively avoid certain thoughts and feelings about themselves or others. This suggests a role for the affordances of the environment in facilitating or hindering mentalizing that Fonagy and colleagues have themselves been concerned with, especially in recent years (see Chapter 9). However, the difference in metapsychology, and particularly Freud’s use of drive theory, has made her account of defences somewhat difficult for Fonagy and colleagues to play with and use, or to subsequently revisit. Freud, A. (1946) The Ego and the Mechanisms of Defence, New York: International Universities Press.

19 E.g. Joseph, B. (1985). ‘Transference: The Total Situation’. The International Journal of Psychoanalysis, 66: 447–454; Feldman, M. (1993). ‘Aspects of Reality, and the Focus of Interpretation’. Psychoanalytic Inquiry, 13: 274–295; Steiner, J. (1993). Psychic Retreats, London: Routledge. Fonagy and colleagues express enthusiasm for these works in 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. 448.

20 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. 93.

21 Palmer, S. (2015). ‘Controversial Discussions for the XXIst Century: An Interview with: Jan Abram, Dana Birkstead-Breen, Catalina Bronstein, Peter Fonagy, Bob Hinshelwood, Isabel Hernandez-Halton, Rosine Perelberg, Ken Robinson, Anne-Marie Sandler, Allan Schore, Mark Solms, Riccardo Steiner, and David Tuckett’. PEP Video Grants, 1(1): 2.

22 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. 96.

23 Goldbeck-Wood, S. and Fonagy, P. (2004). ‘The Future of Psychotherapy in the NHS’. British Medical Journal, 329: 245–246, p. 245. See also Chiesa, M. and Fonagy, P. (2010). ‘Scientific Research, the Therapeutic Community and Psychodynamic Psychotherapy’. Clinical Neuropsychiatry, 7(6): 173–181.

24 Freud, S. ([1940] 2001). An Outline of Psycho-Analysis (standard edn), Volume 23, London: Vintage, pp. 144–207, p. 159.

25 Shulman, D. G. (1990). ‘Psychoanalysis and the Quantitative Research Tradition’. Psychoanalytic Review, 77(2): 245–261.

26 Bowlby, J. (1981). ‘Psychoanalysis as a Natural Science’. The International Review of Psychoanalysis, 8: 243–256; Wallerstein, R. (1986). ‘Psychoanalysis as a Science: A Response to the New Challenges’. Psychoanalytic Quarterly, 55(3): 414–451.

27 Fonagy, P. and Tallandini-Shallice, M. (1993). ‘On Some Problems of Psychoanalytic Research in Practice’. Bulletin of the Anna Freud Centre, 16: 5–22, p. 6. See also Fonagy, P. (2000). ‘On the Relationship of Experimental Psychology and Psychoanalysis: Commentary by Peter Fonagy (London)’. Neuropsychoanalysis, 2(2): 222–232: ‘Clinical data clearly offer a fertile ground for theory building, but not for distinguishing good theories from bad or better ones’ (p. 228).

28 Fónagy, I. (1989). ‘The Metaphor: A Research Instrument’, in D. Meutsch and R. Viehoff (eds), Comprehension of Literary Discourse, Berlin and New York: W. De Gruyter, pp. 111–130.

29 Fonagy, P. (1982). ‘The Integration of Psychoanalysis and Experimental Science: A Review’. International Review of Psycho-Analysis, 9: 125–145; Sandler, J. (1983). ‘Reflections on Some Relations between Psychoanalytic Concepts and Psychoanalytic Practice’. The International Journal of Psychoanalysis, 64: 35–45. This point would later be repeated and elaborated in Luyten, P. (2015). ‘Unholy Questions about Five Central Tenets of Psychoanalysis that Need to be Empirically Verified’. Psychoanalytic Inquiry, 35(1): 5–23. For a sustained discussion of the value of metaphor, see Civitarese, G. and Ferro, A. (2013). ‘The Meaning and Use of Metaphor in Analytic Field Theory’. Psychoanalytic Inquiry, 33(3): 190–209; Havsteen-Franklin, D. (2019). ‘Creative Arts Therapies’, in Anthony Bateman and Peter Fonagy (eds). Handbook of Mentalising in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 181–195. See also Holmes, J. and Slade, A. (2017). Attachment in Therapeutic Practice, London: Sage: ‘Metaphor is inherently mentalising’ (p. 70).

30 For criticism of the contrast between metaphor and propositional discourse on the grounds that the latter, too, is subject to implicatures, see Sperber, D. and Wilson, D. (2008). ‘A Deflationary Account of Metaphor’, in Raymond W. Gibbs, Jr., (ed.), The Cambridge Handbook of Metaphor and Thought, New York: Cambridge University Press, pp. 84–105; Sperber, D. and Wilson, D. (2015). ‘Beyond Speaker’s Meaning’. Croatian Journal of Philosophy, 15(44): 117–149.

31 Bion had earlier raised an aligned concern, that psychoanalytic theory actually proves a systematic obstacle to learning from experience to the extent that the epistemic status of its language is misunderstood. However, whereas Fonagy contrasts metaphor and causal-deductive claims, Bion addresses a wider variety of ‘rows’ of kinds of claim, differentiating kinds of proto-thought and also kinds of abstract thought, again which he urges should not be mistaken for one another.

32 Fonagy, P. (2003). ‘Some Complexities in the Relationship of Psychoanalytic Theory to Technique’. Psychoanalytic Quarterly, 72(1): 13–47, p. 38. See also Fonagy, P. (2009). ‘When Analysts Need to Retire: The Taboo of Ageing in Psychoanalysis,’ in B. Willock, R. C. Curtis, and L. C. Bohm (eds), Taboo or not Taboo? London: Karnac Books, pp. 209–227, p. 220; Fonagy, P. (2012). ‘On Caution and Courage in Psychoanalytic Epistemology’. Philosophy, Psychiatry, & Psychology, 19(3): 213–215.

33 Moran, G. S. and Fonagy, P. (1987). ‘Psychoanalysis and Diabetic Control: A Single‐Case Study’. Psychology and Psychotherapy: Theory, Research and Practice, 60(4): 357–372.

34 Emde, R. N. and Fonagy, P. (1997). ‘An Emerging Culture for Psychoanalytic Research?’ The International Journal of Psychoanalysis, 78(4): 643–651; Wallerstein, R. S. and Fonagy, P. (1999). ‘Psychoanalytic Research and the IPA: History, Present Status and Future Potential’. The International Journal of Psychoanalysis, 80: 91–109. See also Fonagy, P. (2018). ‘An Appreciation of Dr Wallerstein’s Contributions to Psychoanalytic Research’, in Wilma Bucci (ed.), From Impression to Inquiry, London: Routledge, pp. 18–21.

35 André Green would criticize Fonagy for using the financial resources of the International Psychoanalytical Association to incentivize trainee psychoanalysts to pursue research. In his view, Fonagy and colleagues were setting up a new ‘objectivist’ school of psychoanalysis. Green, A. (2000). ‘Science und Science-fiction in der Sauglingsforschung’. Zeitschrift fur psychoanalytische Theorie und Praxis, 15(4): 438–466. Fonagy and Hepworth would retort that scientific measurement is not a ‘school’, but precisely a means of constraining the organization of psychoanalytic theory to avoid a proliferation of incommensurable schools. Fonagy, P. and Target, M. (1996). ‘Should We Allow Psychotherapy Research to Determine Clinical Practice?’ Comments on Sol J. Garfield: ‘Some Problems Associated with “Validated” Forms of Psychotherapy.’ Clinical Psychology: Science and Practice, 3: 245–250, p. 248.

36 Polatinsky, S. (2005). Psychoanalysis and the Non-Conceptual. Unpublished doctoral thesis, University College London. Accessed at: http://discovery.ucl.ac.uk/1445792/1/U593116.pdf: ‘My sincere thanks to Peter Fonagy for his distinctive contribution of much needed humour and irreverence, and most importantly for his unstinting interest in this research project particularly in light of (in the face of) the implacable empiricists and logical positivists holding court (and fort!) at UCL.’

37 Fonagy, P. and Target, M. (2007). ‘The Rooting of the Mind in the Body: New Links between Attachment Theory and Psychoanalytic Thought’. Journal of the American Psychoanalytic Association, 55(2): 411–456, p. 446. This position was later updated with the more plausible proposal that the psychoanalytic community had adopted a stance of epistemic vigilance, making them quite capable of generating new ideas but within a context in which they were unable to learn from outside perspectives. Allison, E. and Fonagy, P. (2016). ‘When is Truth Relevant?’ Psychoanalytic Quarterly, 85(2): 275–303.

38 Emde, R. N. and Fonagy, P. (1997). ‘An Emerging Culture for Psychoanalytic Research?’ The International Journal of Psychoanalysis, 78(4): 643–651: ‘Exploratory methods, aimed at discovery, can be distinguished from hypothesis-testing methods, in the context of confirmation’ (p. 647). See also Fonagy, P. (2012). ‘On Caution and Courage in Psychoanalytic Epistemology’. Philosophy, Psychiatry, & Psychology, 19(3): 213–215: ‘Nietzsche talks of unpretentious truths that have been discovered by means of rigorous method, and opposes them to the metaphysics that blinds us and make us happy. He is essentially distinguishing boring Millian fact from evocative narrative. Holding on to these unpretentious truths demonstrates courage of a different sort from that shown by psychoanalytic investigations of the unconscious. It is a turning away from what is appealing toward what is true’ (p. 215).

39 E.g. 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. 56. Fonagy would later reflect on the predicament of art therapy, which he is confident is clinically effective, but which has not generated an adequate research base to now readily compete for a share of research funding. Fonagy, P. (2012). ‘Art Therapy and Personality Disorder’. International Journal of Art Therapy, 17(3): 90. Fonagy described this as an especially sad predicament for him since ‘I believe that with its many subspecialties, art therapy has the key, or perhaps a key, to our understanding of the mechanisms underpinning change in all kinds of psychological treatments … art therapy is closest to what we now understand to be the embodied roots of human consciousness and cognition’ (p. 90). See also Havsteen-Franklin, D. (2019). ‘Creative Arts Therapies’, in Anthony Bateman and Peter Fonagy (eds) Handbook of Mentalising in Mental Health Practice (pp.181–195), Washington, DC: American Psychiatric Association.

40 Fonagy, P. (2003). ‘Genetics, Developmental Psychopathology, and Psychoanalytic Theory: The Case for Ending our (not so) Splendid Isolation’. Psychoanalytic Inquiry, 23(2): 218–247, p. 242.

41 Fonagy, P. and Target, M. (1997). ‘The Problem of Outcome in Child Psychoanalysis: Contributions from the Anna Freud Centre’. Psychoanalytic Inquiry, 17(S1): 58–73.

42 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, p. 16.

43 In recent years, Fonagy’s advocacy of manualized therapies has not diminished. However, he has allowed greater acknowledgement that, where manualization is not coupled with the potential to tailor treatment to the patient, this probably reduces efficacy because therapists prototype patients rather than recognize and respond to their specificity (see Chapter 7).

44 Elsewhere Fonagy expressed worry that, if those sympathetic to psychoanalysis did not become engaged in trials, the modality would fail to have supporting evidence and lose reputation and access to public funding. And what trials were conducted would not be careful to pursue the complex work of identifying authentic indicators of success relevant to the modality. Fonagy, P. (2003). ‘Psychoanalysis Today’. World Psychiatry, 2: 73–80.

45 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, p. 16.

46 Sandler, J. (1962). ‘Research in Psycho-Analysis—The Hampstead Index as an Instrument of Psycho-Analytic Research’. The International Journal of Psychoanalysis, 43: 287–291; Fonagy, P. (2005). ‘An Overview of Joseph Sandler’s Key Contributions to Theoretical and Clinical Psychoanalysis’. Psychoanalytic Inquiry, 25(2): 120–147.

47 Freud, A. (1962). ‘Assessment of Childhood Disturbances’. The Psychoanalytic Study of the Child, 17: 149–158; Fonagy, P. and Target, M. (1994). ‘Who is Helped by Child Psychoanalysis? A Sample Study of Disruptive Children, from the Anna Freud Centre Retrospective Investigation’. Bulletin of the Anna Freud Centre, 17: 291–315, p. 294.

48 Target, M. (2003). ‘The Anna Freud Centre: About the Directors’. Originally at http://www.annafreudcentre.org/target.htm. Accessed at: http://web.archive.org/web/20060925220711/http://www.annafreudcentre.org/target.htm; Target, M. (2018). ‘20/20 Hindsight: A 25-Year Programme at the Anna Freud Centre of Efficacy and Effectiveness Research on Child Psychoanalytic Psychotherapy’. Psychotherapy Research, 28(1): 30–46.

49 Fonagy, P. and Target, M. (1994). ‘Who is Helped by Child Psychoanalysis? A Sample Study of Disruptive Children, from the Anna Freud Centre Retrospective Investigation’. Bulletin of the Anna Freud Centre, 17: 291–315, p. 302.

50 Ibid. Good psychological functioning of the mother, and poor psychosocial adaptation of the child patient, at commencement of therapy were also positive predictors of improvements for children with anxiety and depression, but less so for children with aggressive or disruptive behavioural problems. Fonagy, P. and Target, M. (1996). ‘Predictors of Outcome in Child Psychoanalysis: A Retrospective Study of 763 Cases at the Anna Freud Centre’. Journal of the American Psychoanalytic Association, 44: 27–77.

51 Target, M. and Fonagy, P. (1994). ‘Efficacy of Psychoanalysis for Children with Emotional Disorders’, Journal of the American Academy of Child and Adolescent Psychiatry, 33: 361–371, p. 367.

52 Pilling, S., Fonagy, P., Allison, E., Barnett, P., Campbell, C., Constantinou, M., … and Kendall, T. (2020). ‘Long-term outcomes of psychological interventions on children and young people’s mental health: A systematic review and meta-analysis’. PloS One, 15(11): e0236525.

53 Lo, C. K. and Wong, S. Y. (2020). ‘The effectiveness of parenting programs in regard to improving parental reflective functioning: a meta-analysis.’ Attachment & Human Development, Early View.

54 Fonagy, P. and Target, M. (1994). ‘The Efficacy of Psychoanalysis for Children with Disruptive Disorders’. Journal of the American Academy of Child and Adolescent Psychiatry, 33: 45–55, p. 45.

55 Fonagy, P. and Target, M. (1996). ‘Predictors of Outcome in Child Psychoanalysis: A Retrospective Study of 763 Cases at the Anna Freud Centre’. Journal of the American Psychoanalytic Association, 44: 27–77: ‘We would argue that childhood depression may in some instances reflect a dysfunction of mental processes associated with the creation of self representation, particularly those associated with self-monitoring and self-evaluation’ (pp. 54–55).

56 This proposal had already been suggested earlier by Conte, H. R., Plutchik, R., Picard, S. Karasu, T. B. and Vaccaro, E. (1988). ‘Self-Report Measures as Predictors of Psychotherapy Outcome’. Comprehensive Psychiatry, 29: 355–360.

57 This was a complicated picture, however, and moderated by age. Fonagy and Target, ‘Predictors of Outcome’: “Variables specific to each age group emerged; for example, for children under 6 a history of mental illness in the mother predicted worse outcome, while sleep disorder, phobias, or significant medical history were associated with good outcome. Among latency children, in contrast, a history of maternal mental disorder was associated with better outcome. For adolescents, several variables related to parental mental health were significant predictors; for instance, an antisocial father or mother who had attempted suicide predicted worse outcome, but anxiety in the father was associated with improvement. Difficulties in peer relationships or disruptive behavior at school predicted poor outcome.’ (pp. 40–41). For later reflections on the potentially adaptive contribution of anxiety, see St Clair, M. C., Neufeld, S., Jones, P. B., Fonagy, P., Bullmore, E. T., Dolan, R. J., … and Goodyer, I. M. (2017). ‘Characterising the Latent Structure and Organisation of Self-Reported Thoughts, Feelings and Behaviours in Adolescents and Young Adults’. PloS One, 12(4): e0175381, pp. 19–20.

58 Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H., Israel, S., … Moffitt, T. E. (2014). ‘The P Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders?’ Clinical Psychological Science, 2(2): 119–137; Lahey, B. B., Rathouz, P. J., Keenan, K., Stepp, S. D., Loeber, R., and Hipwell, A. E. (2015). ‘Criterion Validity of the General Factor of Psychopathology in a Prospective Study of Girls’. Journal of Child Psychology and Psychiatry and Allied Disciplines, 56(4): 415–422.

59 Target, M. and Fonagy, P. (1994). ‘Efficacy of Psychoanalysis for Children with Emotional Disorders’. Journal of the American Academy of Child and Adolescent Psychiatry, 33: 361–371, p. 368; Schachter, A. (2004). The Adult Outcome of Child Psychoanalysis: A Long-Term Follow-Up Study. Unpublished doctoral thesis, London: University College London.

60 Pilling, S., Fonagy, P., Allison, E., Barnett, P., Campbell, C., Constantinou, M., … and Kendall, T. (2020). ‘Long-term outcomes of psychological interventions on children and young people’s mental health: A systematic review and meta-analysis’. PloS One, 15(11): e0236525.

61 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, p. 163. See also Schachter, A. and Target, M. (2009). ‘The Adult Outcome of Child Psychoanalysis: The Anna Freud Centre Long Term Follow-Up Study’, in Midgley N, Anderson J, Grainger E, Nesic-Vuckovic T (eds), Child Psychotherapy and Research: New Approaches, Emerging Findings, London: Routledge, pp. 144–156.

62 See Fonagy, P. (2000). ‘Response’. The International Journal of Psychoanalysis, 81(2): 354–356. Leo Rangell, twice president of the International Psychoanalytical Association and the American Psychoanalytic Association, would describe Fonagy as having ‘helped bring about’ the ‘current fragmentation’ of psychoanalysis. Rangell, L. (2008). ‘Reconciliation: The Continuing Role of Theory’. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36(2): 217–233, p. 219. See also, Rangell, L. (2004). My Life in Theory, New York: Other Press.

63 Nagera, H. et al. (2002). ‘Open Letter to the Chair of the Trustees’. The Anna Freud Centre. Accessed at: http://www.thecjc.org/pdf/annafreud.PDF

64 White, K. and Schwartz, J. (2007). ‘Attachment Here and Now: An Interview with Peter Fonagy’. Attachment, 1(1): 57–61.

65 Reeves, J. K. (2017). ‘About Losing and Being Lost without Anna Freud’s ‘Revolutionary Overhaul’. Journal of the American Psychoanalytic Association, 65(6): 1077–1101, p. 1079. The changes to the Anna Freud Centre under Fonagy’s leadership can be regarded as foreshadowed by an earlier episode. In 1990, Fonagy joined the Executive Council of the International Psychoanalytic Association, serving as treasurer until 1995. Reports from this time reveal Fonagy’s careful cost-effectiveness analysis of the Association’s activities, and repeated confrontation of unpleasant truths about the viability of expenditure. This generated some controversy at times. However, by the end of Fonagy’s tenure as treasurer, the Association was no longer on precarious footing, and in fact had started to build up reserves. Fonagy, P. (1990). ‘Treasurer’s column’. International Psychoanalytical Association Newsletter. Accessed at: http://www.ipa.world/ipa/Images/PDFDocuments/IPA-News-Magazine/ipa-newsmag-1990-v22-i1.pdf: ‘We bear our own costs in mind … We aim to provide substance for the apocryphal remark “there is nothing quite as cost-effective as a good cost-effectiveness analysis.” ’ (p. 9). Andrade de Azevedo, A. M. (1995). ‘Secretary’s Column’. International Psychoanalytical Association Newsletter. Accessed at: http://www.ipa.world/ipa/Images/PDFDocuments/IPA-News-Magazine/ipa-newsmag-1995-v4-i2.pdf ‘It was considered remarkable that there had been hardly any over spending and indeed very little increase in costs for four years. Prof. Fonagy’s report was received with applause’ (p. 6).

66 Zaphiriou Woods, M. and Pretorius, I. M. (2016). ‘Observing, Playing and Supporting Development: Anna Freud’s Toddler Groups Past and Present’. Journal of Child Psychotherapy, 42(2): 135–151.

67 The most integrated and up-to-date account of the current work of the Anna Freud Centre is Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre.

68 McLean, D. and Daum, M. (2017). ‘The Use of Observation in Developing Parenting Capacity’, in Clare Parkinson, Lucille Allain, and Helen Hingley-Jones (eds), Observation in Health and Social Care: Applications for Learning, Research and Practice with Children and Adults, London: Jessica Kingsley Publishers, pp. 158–176. Accessed at: https://www.annafreud.org/what-we-do/our-help-for-children-and-families/our-clinical-work-and-projects/our-work-with-under-fives/early-years-parenting-unit-eypu/.

69 There are several differences in the Anna Freud Centre model of parent–infant psychotherapy from the approaches adopted elsewhere. See Baradon, T., Biseo, M., Broughton, C., James, J., and Joyce, A. (2016). The Practice of Psychoanalytic Parent-Infant Psychotherapy: Claiming the Baby (2nd edn), London: Routledge.

70 James, J. and Rosan, C. (2019). ‘Remodelling Baby Clinics: Opportunities to Support Parent–Baby Relationships’. Journal of Health Visiting, 7(8): 400–404.

71 Redfern, S., Wood, S., Lassri, D., Cirasola, A., West, G., Austerberry, C., … Midgley, N. (2018). ‘The Reflective Fostering Programme: Background and Development of a New Approach’. Adoption & Fostering, 42(3): 234–248. See also Dueger, S. K. (2015). An Attachment- and Mentalization-Focused Group: Experiences During One’s First Pregnancy. Unpublished doctoral thesis, Chicago: Chicago University.

72 Ventura Wurman, T., Lee, T., Bateman, A., Fonagy, P., and Nolte, T. (2020). ‘Clinical management of common presentations of patients diagnosed with BPD during the COVID-19 pandemic: the contribution of the MBT framework’. Counselling Psychology Quarterly, Early View.

74 Accessed at: https://www.annafreud.org/what-we-do/our-help-for-children-and-families/our-clinical-work-and-projects/our-work-with-families-involved-in-legal-proceedings/contact-and-residence-disputes/.There is, as yet, no research evidence evaluating a mentalization-based approach compared with ‘mediation as usual’.

75 Accessed at: https://www.ucl.ac.uk/pals/study/pals-phd-and-doctorate-programmes/doctorate-psychotherapy- child-and-adolescent-psychoanalytic. ‘The theoretical orientation of the training represents the thinking of the Independent School within the British Psychoanalytic movement. A Jungian pathway has been developed for those in Jungian analysis.’

77 E.g. the ‘You’re never too young to talk’ animation and teacher toolkit, aimed at years 5 and 6 pupils: https://www.annafreud.org/media/7228/tmh-parent-leaflet-final-all-approved-laid-out-for-web.pdf/.

78 Asen, E., Dawson, N., and McHugh, B. (2003). Multiple Family Therapy: The Marlborough Model and its Wider Application. London: Karnac Books.

80 Anna Freud National Centre for Children and Families (2020). Helping babies and young children under 5 through the coronavirus crisis, https://www.annafreud.org/media/11732/eyim_covidsupport_v1d2.pdf

81 The Anna Freud Centre (2018). The Big Move: Annual Report and Financial Statements for the Year Ended 31 August 2018. Accessed at: https://www.annafreud.org/media/9623/trustees-annual-report-ye310818.pdf.

84 Fonagy, P. (2016). ‘Why Do Families Matter?’, Huffington Post, 17 February. Accessed at: http://www.huffingtonpost.co.uk/peter-fonagy/childrens-mental-health-families_b_9227210.html. In 2017, the school was rated as ‘outstanding’ by inspectors in every category. Accessed at: http://www.thefamilyschoollondon.org/uploads/2014/03/The-Family-School-Ofsted-2017.pdf.

85 The Anna Freud Centre (2018). The Big Move: Annual Report and Financial Statements for the Year Ended 31 August 2018. Accessed at: https://www.annafreud.org/media/9623/trustees-annual-report-ye310818.pdf. The Anna Freud Centre (2019). ‘HRH The Duchess of Cambridge Launches Centre of Excellence to Drive Change for Child Mental Health’. Accessed at: https://www.annafreud.org/insights/news/2019/05/hrh-the-duchess-of-cambridge-launches-centre-of-excellence-to-drive-change-for-child-mental-health.

86 The Anna Freud Centre (2020). ‘Young Champions’. Accessed at: https://www.annafreud.org/on-my-mind/get-involved/young-champions.

91 McLaughlin, K., Osborne, S. P., and Ferlie, E. (eds), (2002). New Public Management: Current Trends and Future Prospects, London: Routledge; Smith, R. and Rennie, D. (2014). ‘Evidence-Based Medicine—An Oral History’. JAMA, 311(4): 365–367.

92 The question of how to capture young people’s own perception of outcomes has remained a particular concern of the Anna Freud Centre over the years. See e.g. Deighton, J., Croudace, T., Fonagy, P., Brown, J., Patalay, P., and Wolpert, M. (2014). ‘Measuring Mental Health and Wellbeing Outcomes for Children and Adolescents to Inform Practice and Policy: A Review of Child Self-Report Measures’. Child and Adolescent Psychiatry and Mental Health, 8(1): 14.

93 Fonagy, P. and Higgitt, A. (1989). ‘Evaluating the Performance of Departments of Psychotherapy’. Psychoanalytic Psychotherapy, 4(2): 121–153.

94 Fonagy, P. and Target, M. (1994). ‘Who is Helped by Child Psychoanalysis? A Sample Study of Disruptive Children, from the Anna Freud Centre Retrospective Investigation’. Bulletin of the Anna Freud Centre, 17: 291–315.

95 Target, M. (2018). ‘20/20 Hindsight: A 25-Year Programme at the Anna Freud Centre of Efficacy and Effectiveness Research on Child Psychoanalytic Psychotherapy’. Psychotherapy Research, 28(1): 30–46: ‘Probably the central plank of the bridge towards our getting support for a large-scale RCT [randomized control trial] including child psychotherapy was broader work on systematic reviewing of the evidence base of interventions for childhood mental health problems’ (p. 40). Fonagy states that ‘To be a trusted source of knowledge is our key aim’ at the Anna Freud Centre, in Kirby, T. (2019). ‘Peter Fonagy—Battling the Enemy of Loneliness’. The Lancet Psychiatry, 6(12): 987.

96 Roth, A. and Fonagy, P. (1996). What Works for Whom: A critical Review of Psychotherapy Research (1st edn). New York: Guilford Press.

97 Fonagy, P., Target, M., Cottrell, D., Phillips, J., and Kurtz, Z. (2002). What Works for Whom? A Critical Review of Treatments for Children and Adolescents, New York: Guilford Press.

98 Pilling, S. and Fonagy, P. (2012). ‘Developing Clinical Guidelines for Children and Adolescents: Experience from the National Institute for Health and Clinical Excellence’, in P. Sturmey and M. Hersen (eds), Handbook of Evidence-based Practice in Clinical Psychology (Vol. 1. Child and Adolescent Disorders), pp. 73–102. New York: Wiley.

99 Fonagy, P. (2015). ‘Peter Fonagy and the Undermining of Old Ideas on Personality Disorder’. Accessed at https://www.escap.eu/research/peter-fonagy-and-the-undermining-of-old-ideas-on-personality-disorder/: ‘Clinicians used to be very sceptical and hostile, saying: “Hold on there, you are trying to undermine our status quo.” Now a new, popular movement presents itself: a wide range of practitioners—from psychoanalytic to behavioural, to family and systemic oriented professionals—embrace the evidence-based way of working.’

100 Murphy, M. and Fonagy, P. (2013). ‘Mental Health Problems in Children and Young People’, in Our Children Deserve Better, Prevention Pays: Annual Report of the Chief Medical Officer (Chapter 10), London: Department of Health: ‘There is evidence that EBP [evidence-based practice] is statistically superior to usual care. Experimental work also demonstrates that the major benefit from EBP to child mental health services is in value, conceived of as the ratio of the outcome that matters to patients to the cost of delivering that outcome. Using EBP has been shown to reduce costs by up to 35% and duration of treatment by up to 43%’ (p. 6).

101 Fonagy, P. (1999). ‘Process and Outcome in Mental Health Care Delivery: A Model Approach to Treatment Evaluation’. Bulletin of the Menninger Clinic, 63(3): 288–304.

102 Binkley, S. (2011). ‘Psychological Life as Enterprise: Social Practice and the Government of Neo-Liberal Interiority’. History of the Human Sciences, 24(3): 83–102; Adams, G., Estrada‐Villalta, S., Sullivan, D., and Markus, H. R. (2019). ‘The Psychology of Neoliberalism and the Neoliberalism of Psychology’. Journal of Social Issues, 75(1): 189–216.

103 Scharff, C. (2016). ‘The Psychic Life of Neoliberalism: Mapping the Contours of Entrepreneurial Subjectivity’. Theory, Culture & Society, 33(6): 107–122; Teo, T. (2018). ‘Homo Neoliberalus: From Personality to Forms of Subjectivity’. Theory & Psychology, 28(5): 581–599; Gill, R. and Orgad, S. (2018). ‘The amazing Bounce-Backable Woman: Resilience and the Psychological Turn in Neoliberalism’. Sociological Research Online, 23(2): 477–495.

104 Bollas, C. (2015). ‘Psychoanalysis in the Age of Bewilderment: On the Return of the Oppressed’. International Journal of Psychoanalysis, 96(3): 535–551. Bollas’s breakthrough paper was centrally concerned with individual self-management, and one of the detailed clinical cases is specifically focused on self-management in the workplace environment. Bollas, C. (1982). ‘On the Relation to the Self as an Object’. The International Journal of Psychoanalysis, 63: 347–359: ‘We are constantly engaged in acts of self management, from our choice of vocation to our choice of clothing, from our perception and facilitation of our needs to our management of our own personal realities to partially gratify those needs, from our recognition of, and planning for, holidays to our differing abilities to cognize and confront economic and familial realities.’ (p. 349).

105 Cf. Polezzi, D., Daum, I., Rubaltelli, E., Lotto, L., Civai, C., Sartori, G., and Rumiati, R. (2008). ‘Mentalizing in Economic Decision-Making’. Behavioural Brain Research, 190(2): 218–223; Weiland, S., Hewig, J., Hecht, H., Mussel, P., and Miltner, W. H. (2012). ‘Neural Correlates of Fair Behavior in Interpersonal Bargaining’. Social Neuroscience, 7(5): 537–551.

106 Sociologists have termed this societal shift ‘governmentality’, because the individual is asked to manage (govern) their own thoughts and feelings (mentality) in responding to social problems, rather than having recourse to collective or welfare responses to these problems. Schechter has adapted the term sociological ‘governmentality’ to refer to ‘governmentalization’, in characterizing the cultural alignment between a therapeutic focus on individual thoughts and feelings, on the one hand, and a policy focus on individual responsibility for coping with social problems, on the other. Schechter, K. (2014). Illusions of a Future: Psychoanalysis and the Biopolitics of Desire, Durham, NC, Duke University Press.

107 Mold, A., Clark, P., Millward, G., and Payling, D. (2019). Placing the Public in Public Health in Post-War Britain, 1948–2012, London: Palgrave. In Fonagy’s view, this was a shift across many countries, but was especially intense in Europe. Fonagy, P. (2000). ‘On the Relationship of Experimental Psychology and Psychoanalysis: Commentary by Peter Fonagy (London)’. Neuropsychoanalysis, 2(2): 222–232, p. 227.

108 Rao, A. S., Lemma, A., Fonagy, P., Sosnowska, M., Constantinou, M. P., Fijak-Koch, M., and Gelberg, G. (2019). ‘Development of Dynamic Interpersonal Therapy in Complex Care (DITCC): A Pilot Study’. Psychoanalytic Psychotherapy, 33(2): 77–98: ‘The Tavistock Adult Depression Study (TADS) (Taylor et al., 2012) has demonstrated the effectiveness of a psychoanalytic approach and the importance of follow-up data to consider the sustainability of change. However, the demand and capacity imbalance are increasingly putting pressures on services to cut down the length of the individual treatment’ (p. 78).

109 Fonagy, P., Steele, M., Steele, H., Higgitt, A., and Target, M. (1994). ‘The Emanuel Miller Memorial Lecture 1992: The Theory and Practice of Resilience’. Journal of Child Psychology and Psychiatry, 35(2): 231–257, p. 231.

110 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, p. 8; Fonagy, P. and Bateman, A. (2009). ‘A Brief History of Mentalisation-based Treatment and its Roots in Psychoanalytic Theory and Practice’, in Brownescombe Heller, M., and Pollet, S. (eds), The Work of Psychoanalysts in the Public Health Sector, London: Routledge, pp. 156–176: ‘Preserving the key subtleties and respect for complexity of mind that psychoanalysis offers in its unparalleled richness, while at the same time enabling more than the few to have the benefit of its long-term value. This is the goal which we set ourselves on this journey that began 20 years ago’ (p. 174). See also Kazdin, A. E. (2019). ‘Annual Research Review: Expanding Mental Health Services through Novel Models of Intervention Delivery’. Journal of Child Psychology and Psychiatry, 60(4): 455–472.

111 Jurist, E. L. (2010). ‘Elliot Jurist Interviews Peter Fonagy’. Psychoanalytic Psychology, 27(1): 2–7: ‘I think the social inequalities in health should concern us majorly as psychoanalysts. It’s an embarrassment, because most psychoanalysts are in independent practice, and they are advantaged by the unequal distribution of wealth … 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’ (p. 5).

112 Target, M. (2018). ‘20/20 Hindsight: A 25-Year Programme at the Anna Freud Centre of Efficacy and Effectiveness Research on Child Psychoanalytic Psychotherapy’. Psychotherapy Research, 28(1): 30–46, p. 39. For a contrary position, arguing that the lifeboat offered by mentalization is too compromised to be worth reaching for, see House, R. (2012). ‘General Practice Counselling amidst the ‘Audit Culture’: History, Dynamics and Subversion of/in the Hypermodern National Health Service’. Psychodynamic Practice, 18(1): 51–70.

113 Target, M. (2018). ‘20/20 Hindsight: A 25-Year Programme at the Anna Freud Centre of Efficacy and Effectiveness Research on Child Psychoanalytic Psychotherapy’. Psychotherapy Research, 28(1): 30–46.

114 Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., … and Senior, R. (2017). ‘Cognitive Behavioural Therapy and Short-Term Psychoanalytical Psychotherapy Versus a Brief Psychosocial Intervention in Adolescents with Unipolar Major Depressive Disorder (IMPACT): A Multicentre, Pragmatic, Observer-Blind, Randomised Controlled Superiority Trial’. The Lancet Psychiatry, 4(2): 109–119; Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J., … and Senior, R. (2017). ‘Cognitive-Behavioural Therapy and Short-Term Psychoanalytic Psychotherapy versus Brief Psychosocial Intervention in Adolescents with Unipolar Major Depression (IMPACT): A Multicentre, Pragmatic, Observer-Blind, Randomised Controlled Trial’. Health Technology Assessment, 21(12): 1.

115 Target, M. (2018). ‘20/20 Hindsight: A 25-Year Programme at the Anna Freud Centre of Efficacy and Effectiveness Research on Child Psychoanalytic Psychotherapy’. Psychotherapy Research, 28(1): 30–46.

116 Fonagy, P., Rost, F., Carlyle, J. A., McPherson, S., Thomas, R., Pasco Fearon, R. M., … and Taylor, D. (2015). ‘Pragmatic Randomized Controlled Trial of Long‐Term Psychoanalytic Psychotherapy for Treatment‐Resistant Depression: The Tavistock Adult Depression Study (TADS)’. World Psychiatry, 14(3): 312–321. Treatment-as-usual consisted of various interventions, as directed by the referring practitioner, and could include referral to other specialist provisions. On age as a moderator of the effectiveness of interventions for depression, see Cuijpers, P., Karyotaki, E. Eckshtain, D. et al. (2020). ‘Psychotherapy for Depression across Different Age Groups: A Systematic Review and Meta-Analysis’. JAMA Psychiatry, 77(7): 694–702 .

117 Twenge, J. M., Joiner, T. E., Rogers, M. L., and Martin, G. N. (2018). ‘Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates among US Adolescents after 2010 and Links to Increased New Media Screen Time’. Clinical Psychological Science, 6(1): 3–17; Patalay, P. and Gage, S. H. (2019). ‘Changes in Millennial Adolescent Mental Health and Health-Related Behaviours over 10 Years: A Population Cohort Comparison Study’. International Journal of Epidemiology, 48(5): 1650–1664.

118 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

119 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. See also, Fonagy, P. cited in Thomson, A. and Sylvester, R. (2020) ‘Panic and Anxiety after Education is Plunged into Limbo’. The Times, 31 March: ‘Between 20–27 per cent of female students now have common mental health disorders including depression, anxiety and phobias … There is greater pressure to achieve high grades and compete for jobs, from social media, financially and in what they think is expected of them as a woman, their goals and aspirations.’

120 Cf. Blackman, S. and Rogers, R. (eds). (2017). Youth Marginality in Britain: Contemporary Studies of Austerity, Policy Press.

121 Fonagy, P. (2004). ‘What Evidence for Evidence-based Prevention?’ Journal of Infant, Child, and Adolescent Psychotherapy, 3(4): 419–443, p. 434; Fonagy, P. (2014). ‘Evidence Submitted to the House of Commons Health Committee Children’s and Adolescents’ Mental Health and CAHMS’. Accessed at: http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-committee/childrens-and-adolescent-mental-health-and-camhs/written/8009.html%23_edn1; Fonagy, P. and Allison, E. (2016). ‘Commentary on Kernberg and Michels’. Journal of the American Psychoanalytic Association, 64(3): 495–500, p. 496.

122 Fonagy, P., Lenehan, C., and O’Sullivan, A. (2017). ‘Foreword’, in Improving Mental Health Support for our Children and Young People, London: Social Care Institute for Excellence, p. 2.

123 Payne, C. and Fonagy, P. (2018). ‘A Response to the Figures on the Mental Health of Children and Young People in England Released Today by NHS Digital’. Accessed at: https://www.annafreud.org/insights/news/2018/11/a-response-to-the-figures-on-the-mental-health-of-children-and-young-people-in-england-released-today-by-nhs-digital.

124 Sadler K., Vizard T., Ford T., et al. (2018). Mental Health of Children and Young People in England, 2017. London: NHS Digital. Accessed at: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017.

125 Fonagy, P. and Pugh, K. (2017). ‘Editorial: CAMHS Goes Mainstream’. Child and Adolescent Mental Health, 22(1): 1–3.

126 Youth Select Committee (2015). Oral evidence taken before the Youth Select Committee on 3 July. Accessed at: http://old.byc.org.uk/media/272544/youth_select_committee_03.07.15_pm.pdf

127 Department of Health/Department of Education (2017). Transforming Children and Young People’s Mental Health Provision: A Green Paper, London: HMSO.