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(p. 102) Forms of non-mentalizing 

(p. 102) Forms of non-mentalizing
Chapter:
(p. 102) Forms of non-mentalizing
Author(s):

Robbie Duschinsky

and Sarah Foster

DOI:
10.1093/med-psych/9780198871187.003.0006
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date: 06 December 2021

Introduction

According to the definitions discussed in Chapter 4, mentalization is absent when an individual interprets their own or others’ psychological experience and/or social behaviour without reference to mental states (thoughts and/or feelings). This could occur for any number of reasons. Fonagy and colleagues fail to draw an important distinction between non-mentalizing and ‘not mentalizing’. In the former, mentalizing is specifically blocked. In the latter, mentalizing is neither active nor blocked. Ordinary life is full of ‘not mentalizing’. Indeed, a great deal of our time is spent in interactions shaped by social conventions about the limits on appeal to mental states, where breach of these limits is treated as threatening, over-sincere, or an imposition.1 Such conventions can help procedural interactions run smoothly, without the threat of exposure or unwanted intimacy. However, individuals who have been trained by circumstances or have trained themselves to hold fast to mentalizing, rather than finding it a capacity to turn on or off as needed, may find such interactions hard to sustain. In considering ‘not mentalizing’, it is important to identify that even apparently mentalizing interactional frames can be conventionalized into ‘not mentalizing’: ‘How are you?’ ‘Good thanks, how are you?’.

In some cases, the opening question may function as a conventionalized opening for a mentalizing interaction that may or may not be taken up.2 In other cases, there is no true opening, only convention. Numerous cases of ‘not mentalizing’ may reflect domains of activity in which mental states are of secondary causal concern, but not blocked. Making music, for example, may not in the first instance represent a concern with mental states. Yet, attention to mental states is not blocked and may be specifically cultivated through taking an inquisitive stance to features such as sequence, tone, level of arousal, and the relation established with the audience.3 To take another example: an endocrinologist may interpret an adolescent’s psychological experience through reference to hormones rather than mental states. Or a scientist may interpret an adolescent participant’s experience through reference to neurological structures, or some other relatively material cause. This is not mentalizing rather than non-mentalizing. It could be contrasted to the same interpretation by a parent or a scientist who uses a material interpretation to duck consideration of the adolescent’s thoughts or feelings. Then we have non-mentalizing, through a focus on physical at the expense of psychological explanation, even if the physical cause is causally important in shaping behaviour.

(p. 103) Fonagy and colleagues have argued that all of us find ourselves in non-mentalizing states at points, which are simply part of the human condition. The researchers propose that non-mentalizing modes of processing operate according to very different assumptions compared to mentalized experience, and an individual in one of these states often disbelieves in mentalized accounts of reality. This can contribute to the intractability of these states, their contribution to extreme and unmeasured decision making, to conflicts in interaction with family and friends, and to the wider culture and political context of a society.4 Fonagy and colleagues have described three forms of non-mentalizing: pretend mode, psychic equivalence, and teleological mode. Sometimes they have implied that these are just three kinds of non-mentalizing that they have happened to stumble upon, and they have no particular importance beyond other forms of non-mentalizing, which could readily be identified.5 More frequently, however, pretend mode, psychic equivalence, and teleological mode are described definitively as ‘the’ forms of non-mentalizing.6 Pretend mode, psychic equivalence, and teleological mode have featured primarily in the writings of Fonagy and colleagues for clinical audiences. The characterization of the three modes of non-mentalizing is among the most potentially insightful contributions of their work. Nonetheless, no attempt has been made to operationalize the specific modes of non-mentalizing, with the exception of hypermentalizing, leaving their reflections speculative and obstructing further scientific development of the theory.7

This chapter will begin by describing pretend mode and specifying how it differs from mentalizing. A specific kind of pretend mode will then be described, termed ‘hypermentalizing’ by Fonagy and colleagues. Particular attention will be given to the pretend mode, in part because it has been discussed in most detail by Fonagy and colleagues; in part because it has two different forms; and also because it illustrates the way that the same capacity for pretend can be an asset or a disadvantage depending on its integration with other psychological processes and depending on the context. The chapter will then move on (p. 104) to address the two other kinds of mentalizing: psychic equivalence and teleological mode. It will be demonstrated how the forms of non-mentalizing are not simply the absence of mentalizing, but draw on specific aspects of the capacity to mentalize. This can be seen in Table 5.1, which offers a summary characterization of the key conclusions from this chapter about the forms of non-mentalizing and their respective relationships with mentalization.

Table 5.1 Descriptions of non-mentalizing forms

Form of non-mentalizing

Description

Aspect of mentalizing

Pretend mode

To conceive of thoughts and feelings implicated in motivations or intentions

Conceiving of the thoughts and feelings implicated in motivations and intentions of oneself and others.

Pretend mode: hypermentalizing

To conceive of thoughts and feelings implicated in motivations or intentions in order to account for and explain the observable social behaviour of others

Conceiving of the thoughts and feelings implicated in motivations and intentions in order to account for and explain the observable social behaviour and others.

Psychic equivalence

To account for and explain thoughts and feelings and observable social behaviour in terms of immediate experience

Accounting for and explaining the thoughts and feelings and the observable social behaviour [in terms of] present and past perceptual experience of oneself.

Teleological mode

Observable social behaviour is used to account for and explain the motivations and intentions of others and of oneself

Observable social behaviour [are used] to account for and explain the motivations and intentions of oneself and others.

Pretend mode

As described in Chapter 2, one of Fonagy’s first projects after appointment as research director at the Anna Freud Centre was collaboration with Target, Edgcumbe, and Miller in developing a manual for child analysis. In the course of this work, Fonagy and Target worked out ‘a heuristic map of the emergence of mentalisation’. They observed that children:

appear to be able to use the notion of mental states but paradoxically use it only when they can clearly separate it from physical reality (for example, in play). In this state of mind, which we have called pretend mode, thoughts and feelings can be envisioned and talked about but they correspond to nothing real.8

The concept of pretend mode—together with the idea of psychic equivalence—was introduced and elaborated in a series of major papers by Fonagy and Target published in the mid-1990s in the International Journal of Psychoanalysis under the title ‘Playing with Reality’. The (p. 105) concept was then further articulated by Bateman and Fonagy in their book on Mentalisation-Based Treatment for Personality Disorders.9

In the paper first introducing the concept of pretend mode, Fonagy gives the illustration of his work with a child patient. Rebecca was five years old when she was brought to the Anna Freud Centre for treatment by her mother. She lived sometimes with her grandparents and sometimes with her mother; her father had been a casual partner of her mother, and had no involvement in raising Rebecca. Rebecca’s symptoms included a combination of fears and conduct problems, which began following the death of her grandfather. Her play with Fonagy consisted essentially of a single game, in which Rebecca was an older girl, Hannah, and Fonagy was cast in the role of the father. Fonagy characterized this game as pretend mode on the basis that Rebecca could not tolerate any discussion that implied questioning whether the narrative corresponded to reality. The whole question was forbidden: ‘She refused to accept that her wish for grandfather or me to be her real father did not make it true. I could be either her analyst or her father, but never the analyst representing the father.’10 What made the game Rebecca was playing ‘pretend mode’ was that elements of imagination were being used to create accounts of her own mind and the mind of father figures specifically at the expense of her personal experience of the ‘hurt and shame of being fatherless’.11

In part, this use of pretend mode reflected Rebecca’s developmental stage, in which the distinction between representation and reality is not always fully secured. However, Rebecca’s intolerance of any questioning of her narratives of having a father also had roots in her home environment, in which her family could not discuss Rebecca’s worries about lacking a father. As a consequence, Fonagy proposed, the worries were cut off from the specifics of her own life as they entered into a fantasy narrative. And they were also cut off from modulation or doubt. Furthermore, Rebecca seemed stuck in this state, stating and re-stating the narrative about having a father such that it inhibited her capacity to engage in other forms of play. Had Rebecca been able to enter into pretend mode and then exit in a flexible way, then pretend mode would not have been at the expense of tolerating thoughts and feelings. In turn, these thoughts and feelings would then have been available for modulation, rather than expressed as fears and aggression.

Fonagy and colleagues described how components of mentalizing are ‘hijacked into the pretend mode of experience’.12 This claim becomes somewhat clearer by considering the ideas of Fonagy and colleagues as responding to those of Bion. For Bion, the identification, modulation, and coordinated expression of thoughts and feelings depend on a psychological apparatus that he terms the ‘alpha function’. The alpha function protects thoughts and feelings from invasion by proto-thoughts and feelings (e.g. unconscious wishes, passing ideas, aspects of embodied sensory experience) that would otherwise hinder their coherence. It also protects proto-thoughts and feelings from conscious processes that might otherwise stifle their creativity and richness, and in turn the capacity to convey this creativity and richness to determinate thoughts and feelings as the ability to consider different perspectives and develop these perspectives by learning from experience. However, the alpha function can (p. 106) be fragmented back into its constituent parts. When this happens, like a vehicle, the alpha function goes into reverse.13 The most potent obstacle to coherent thinking and feeling is the activity of these fragments. Not only does the unintegrated activity of these fragments systematically hinder their use as part of the alpha function for coherent thinking and feeling, but there is also the potential for invasion of thoughts and feelings by proto-thoughts and feelings, and vice versa. This leads to fragmented conscious thoughts and feelings, and over-concrete proto-thoughts and feelings. Both states hinder the potential for both perspective taking and for learning from new experiences.

Likewise, for Fonagy and colleagues, the forms of non-mentalizing are so potent precisely because they ‘hijack’ the constituent parts of mentalizing. Non-mentalizing is not then simply the obverse of mentalizing, but turns the equipment of mentalizing against itself. This point aligns with Bion’s earlier proposal that it may be productive for theorists to shuttle between attention to the elements that facilitate learning from experience, and attention to the elements that block learning from experience.14 In the previous chapter, we considered the elements of mentalization through attention to the various definitions that have been offered by Fonagy and colleagues. Mentalization was conceptualized as a capacity to conceive of and make available for reconsideration thoughts and feelings implicated in motivations and intentions in order to account for and explain the observable social behaviour and perceptual experience of oneself and others. In these terms, pretend mode can be regarded as conceiving of thoughts and feelings implicated in motivations or intentions. But it is the severed first part of mentalization. For mentalization requires also some attempt to account for and explain observable social behaviour and/or perceptual experience. Also highly conspicuous in its absence is the modulated and generative doubt about thoughts and feelings that underpins reconsideration. The resulting experience has something of an ‘as if’ quality, but it is not interrogated in terms of whether it agrees with reality.

Hypermentalizing

For Fonagy, the idea of ‘as if’ thinking seemed to very much characterize his experience as a clinician working with patients with borderline personality disorder (BPD) symptoms, where all kinds of things would be narrated, but without connection to the particulars of actual experience or behaviour, and without attention to the extent to which they corresponded with reality.15 As a result, therapeutic progress grinds to a halt.

Luyten, Fonagy, Lemma, and Target suggested five features of pretend mode that distinguish it from mentalizing:

(p. 107)

  1. 1. First, accounts organized by pretend mode tend to be ‘overly analytical, repetitive and lengthy’.16 Without the need to lock in pragmatically to the work of attempting to account for and explain the particulars of observable social behaviour, present perceptions or concrete past experiences, the activity of conceiving of thoughts and feelings can run without restraint.

  2. 2. Second, narratives tend to be out of touch with the speaker’s own affective experience as formed by the obstacles and tasks that prompt this experience. There is an ‘as if’ quality to the discourse: cogs are spinning, but the mechanism has not engaged with practical problems and their particularity.

  3. 3. In parallel, the accounts tend to be out of touch with the genuine bases on which the speaker could claim self-worth and perceived control over their life.

  4. 4. Fourth, speech in pretend mode rather than mentalizing is signalled by difficulties for the speaker in switching perspectives—for instance, from a focus on the motivations of the self to those of the other, or vice versa. Finally, Luyten, Fonagy, Lemma, and Target proposed that accounts in pretend mode tend to position the audience in such a way as to be subject to the speaker—for example, obligated to offer attention or compassion, or to place the audience under the speaker’s control. Pretend mode is not informed by concern with the present or past perceptual experience of others, and therefore tends to treat the needs of the speaker as of utmost importance.

  5. 5. This is not to imply that mentalization is always motivated by compassionate impulses.17 Nonetheless, Luyten, Fonagy, Lemma, and Target do seem to imply that effective mentalizing should, in general, contribute to motivations more accurately reflecting the needs of others and oneself, which in turn should contribute to beneficence. (We will return to this assumption in Chapter 8).

The form of pretend mode most easily confused with mentalization has been termed by Sharp, Fonagy, and colleagues ‘hypermentalization’.18 Bateman and Fonagy define hypermentalizing as ‘a tendency to elaborate models of internal states in the absence of relevant evidence’.19 In hypermentalization, pretend mode is applied to the sustained attention to the thoughts and feelings of other people through the interpretation of their observed (p. 108) behaviour. The researchers characterized three forms of hypermentalization. These illustrate both the diversity of hypermentalization, and its characteristic continuities:

Intrusive pseudomentalising: opaqueness of minds is not respected; extends knowledge of thoughts and feelings beyond a specific context; presents knowledge of thoughts and feelings in an unqualified way; presents thoughts and feelings with a richness and complexity that is unlikely to be based on evidence; when challenged, defaults to nonmentalising accounts.

Overactive form of pseudomentalising: idealisation of insight for its own sake; thoughts about other felt by them as confusing and obscure.

Destructively inaccurate pseudomentalising: denial of objective realities that undermine subjective experience; cast in terms of accusations; denying someone’s real feelings and replacing them with a false construction.20

If pretend mode entails conceiving of thoughts and feelings implicated in motivations or intentions, hypermentalization has further components of actual mentalizing. To hypermentalize is to conceive of thoughts and feelings implicated in motivations or intentions in order to account for and explain the observable social behaviour of others. So close to mentalization in many regards. All that is missing are the ability for reconsideration of mental states and attention to the specifics of present or past perceptual experience. But this is enough to unmoor the other component parts of mentalization, which start to float downriver. Conclusions are generated for which there is no basis in experience, and these are insulated from meta-cognitive reappraisal.21 In this sense, the distinction between psychological theory and hypermentalizing is somewhat porous, and will depend on the extent to which the theory is grounded in the concrete specifics of observation and measurement, and the extent to which the theory is open to reconsideration of its constituent elements. These are qualities that Fonagy described in the 1990s and 2000s as particularly under threat in psychoanalytic theory, but which are constitutive risks of any theory-building, which must stretch out from the heavy particularities of concrete experience, making use of both the buoyancy and the gravity of concepts. Localized access to pretend mode is vivifying for innovation, nonconformity to existing common sense and ethical vision, all components to varying degrees of any adequate psychological theory. However, the generation of theory needs to be pared with its pruning and evaluation (see Chapter 2).

Bo, Sharp, Fonagy, and Kongerslev have described hypermentalization as a breakdown of communication between affective and cognitive mentalizing. We would offer a different characterization: that hypermentalization lacks components 2 (reconsideration) and 8 (present or past perceptual experience) from the definition of mentalization presented in the previous chapter. The advantage of this conceptualization is that it aligns with Bateman and Fonagy’s observation that, in hypermentalization, it is controlled mentalization specifically that is offline, rather than cognition in general.22 Cognition in the form of component (p. 109) 6 (accounting for and explain) is still very firmly in play in hypermentalization. The other advantage of our characterization is that it is not clear what it means for a breakdown of communication to occur between affective and cognitive mentalizing. Our characterization specifies that the issue lies in the fact that reflection is not informed by perceptual experience and is not available for reconsideration, which is why it is a form of pretend mode thinking. This also explains why hypermentalization is a form of pretend mode thinking, a position which is asserted but not explained by Fonagy and colleagues.

Fonagy has speculated that the patients who helped Freud generate psychoanalysis as a talking cure were displaying symptoms of BPD, and that much of their thinking and speech reflected hypermentalizing. They could elaborate on their mental states at length. But they were also highly and quite enduringly suggestible, since their specific difficulty was in recognizing and reflecting on present or past experience as a source of thoughts and feelings. In this state, a shared pretend mode can readily be elaborated on the basis of clinician suggestion.23 For Fonagy, a significant proportion of psychoanalytic theorizing, based on work with hypermentalizing patients, is itself the speculative attribution of mental states cut rather free of attention to concrete particulars. There are also weak mechanisms available for disconfirming psychoanalytic hypotheses, both in the consulting room and in interaction between analyst peers (see Chapter 2). The characterization of some—though by no means all—psychoanalytic theorizing as hypermentalizing appears rather a devastatingly apt characterization, from Freud to the present day.24 Fonagy and colleagues have also proposed that the apparent success of patients with BPD on measures of theory of mind and interpretation of facial cues is actually because these measures fail to distinguish mentalization from hypermentalization. Individuals engaged in hypermentalizing may pay detailed attention to the external indicators of mental states assessed by these measures, but the initial ideas of participants are left unchecked by the potential for reconsideration.

To empirically examine this proposition, Sharp, Fonagy, and colleagues conducted a film-based assessment of social cognition with 111 adolescent inpatients between the ages of 12 and 17.25 The movie comprised a 15-minute film about four characters at a dinner party. At 45 points the movie was stopped, and participants were asked what the characters (p. 110) were thinking, feeling, or intending. The assessment was coded to distinguish between mentalizing and hypermentalizing. A clinical interview was also used to assess for BPD, and 23% of the sample met diagnostic criteria. Participants also completed a self-report measure of emotion regulation, the ‘Difficulties in Emotion Regulation Strategies Scale’. This measure treats as a single dimension a variety of somewhat different phenomena under the umbrella of ‘emotion regulation’: ‘awareness and understanding of emotions, acceptance of emotions, the ability to engage in goal-directed behavior and refrain from impulsive behavior when experiencing negative emotions, as well as the flexible use of situationally appropriate strategies to modulate emotional responses’.26

Sharp and colleagues found that the degree of mentalizing had no association with symptoms of BPD—in direct conflict with Fonagy’s early theory of the developmental pathway to BPD. However, in clear agreement with Fonagy and colleagues’ later account, the researchers found a very substantial (r = .41) relationship between hypermentalizing and symptoms of BPD, independent of age, gender, and other mental health symptoms. Sharp and colleagues also reported that 44% of the relationship between hypermentalizing and symptoms of BPD was mediated by difficulties with emotion regulation (see Figure 5.1). The findings demonstrate the importance of distinguishing between hypermentalizing and mentalizing, both for assessments of social cognition and theoretically. And the findings suggest the importance of emotion dysregulation for the stabilization of hypermentalization as a form of non-mentalizing into the symptoms associated with BPD. However, what aspects of emotion dysregulation are serving this role as yet remains unclear, due to the use of an umbrella measure of emotion regulation in this exploratory research.

Figure 5.1 Difficulties in emotion regulation (DERS) as a mediator of the relation between hypermentalizing (MASC) and borderline personality traits (BPFSC).

Figure 5.1 Difficulties in emotion regulation (DERS) as a mediator of the relation between hypermentalizing (MASC) and borderline personality traits (BPFSC).

Note: Values on each path are standardized β‎ values (path coefficient). Coefficient inside parentheses are standardized partial regression coefficient from equations that include both variables with direct effects on the criterion or dependent variable. *p < .05; **p < .01; ***p < .001.

Source: Reproduced from Carla Sharp et al., ‘Theory of Mind and Emotion Regulation Difficulties in Adolescents With Borderline Traits’, Journal of the American Academy of Child & Adolescent Psychiatry, 50(6): 563–573, Figure 1, DOI: https://doi.org/10.1016/j.jaac.2011.01.017 Copyright © 2011 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.

(p. 111) The capacity for pretend as an asset

The basis for pretend mode, hypermentalizing, and for mentalizing lies in the imaginative capacity to conceive of mental states. This capacity has been situated as resting developmentally on ‘playful exploration’, characterized by Bateman and Fonagy as a ‘basic emotion’, like anger, disgust, fear, sadness, and surprise.27 They argued that the capacity for playful exploration is inherent to humans. Though Bateman and Fonagy focus their attention on symbolic play, in principle, playful exploration is much wider than this. It entails the manipulation of something in the world—for instance, a toy—to consider its modalities—for instance, what it must, should, can, may, or might do. With the maturation of a child’s capacity for cognition, playful exploration is elaborated into the ability to take pleasure and interest from play with the modalities of representations, what they must, should, can, may, or might do. Fonagy and colleagues proposed that the ability to decouple the embodied experience of observed reality, and its felt immediacy, from representations of this reality is fed by playful exploration. This ability is of critical importance for mentalizing and reflective function: it is the capacity for imaginative, counter-factual representation that allows thoughts and feelings to be conceived of in others.28 Fonagy and colleagues also argued, perhaps more speculatively, that the identification and representation of thoughts and feelings in oneself likewise depend on the same process.29

The imaginative capacity to decouple experience and representation allows an individual to negotiate the implications of past or present perception, somewhat or wholly de-realizing them. In his essay, ‘Psychoses and child care’, Winnicott described one form of imaginary play that he regarded as quite problematic. It is characterized by ‘the lack of a beginning and end to the game, by the degree of magical control, by the lack of organization of play material according to any one pattern, and by the inexhaustibility of the child’.30 This seems to resonate with Fonagy’s account of Hannah’s narratives about her missing father, discussed above. By contrast, Winnicott describes a healthy form of de-realization, in which reality is incorporated in such a way as to make it available for perspective-taking. In agreement with Winnicott, Fonagy and colleagues proposed that the exercise of imagination can contribute to mentalization in the symbolic play of young children.

This was illustrated by a study by Tessier, Normandin, Ensink, and Fonagy.31 The researchers studied 39 children aged between 3 and 8 who had experienced sexual abuse, and (p. 112) 21 matched controls who had not experienced sexual abuse. The children were assessed with the Children’s Play Therapy Instrument to examine the coherence of beginning-middle-end sequences during a child’s fantasy play. The children also completed the adapted Adult Attachment Interview, coded using Ensink’s revision of the reflective functioning scale to be applicable to children and to distinguish mentalizing the self and mentalizing others (see Chapter 4). The researchers found that sexual abuse had a substantial association with reduced capacity to mentalize other people in the interview. But this relationship was wholly mediated by the coherence of sequences in the child’s fantasy play. There was, however, no mediation by the coherence of symbolic play on the effects of sexual abuse on the abused children’s reduced scores on the scale for mentalization of the self. The researchers argued that the capacity for effective symbolic play could serve to buffer the consequences of sexual abuse for making sense of other minds. But they were sorry to see that, at least on the evidence of this study, such buffering did not extend to the child’s capacity for identifying and interpreting their own mental states in interview.

The capacity for imagination is important not just for children but for adults too. Fonagy and Target described in detail the value of play and imagination for sensitive caregiving informed by reflective functioning. As we saw in Chapter 3, for Ainsworth, sensitivity requires more than the caregiver accurately identifying the child’s physical behaviour—for instance, an infant’s cry. Sensitivity requires the caregiver to ‘perceive and to interpret accurately the signals and communications implicit in her infant’s behaviour’.32 This entails conceiving of invisible mental states, in this case feelings implicated in motivations, which already in infancy may be as varied as hunger, discomfort, pain, loneliness, boredom, or confusion. To Ainsworth’s account of sensitivity, Fonagy and Target added that reflective function entails not just a capacity to acknowledge the child’s mental states, but also the capacity for perspective-taking, a kind of play with representations. Perspective-taking allows the caregiver to put their child’s demands into context and not be overwhelmed by them: a difficult task when confronted with an infant’s seemingly endless crying. Nonetheless, Fonagy and Target proposed that if the caregiver feels overwhelmed and totally subjected to the child’s displayed emotion, this in turn offers reduced containment for the child.33 By contrast, if a child’s emotion is met with acknowledgement but also with the caregiver’s capacity to hold this in perspective, to remain capable of imagination and perspective-taking, then this will contribute to the child’s ability to ‘ultimately use the parent’s representation of his internal reality as the seed for his own symbolic thought, his representation of his own representations’.34

Fonagy and colleagues have claimed that imagination and spontaneity can support innovation, nonconformity, and ethical vision. In fact, engaging in psychological theory itself entails use of this imaginative capacity. Problems with imagination and spontaneity arise, they have argued, when the ‘gating mechanism’ that would usually ‘bridle’ these responses fails. Imagination and spontaneity are then cut loose from i) the concrete particulars of (p. 113) experienced reality and/or ii) from the stabilizing effects of social referencing and norms.35 Their emphasis on this point can sometimes give the impression that Fonagy and colleagues value the stabilizing effects of social referencing and framing over nonconformity. This is probably an effect of the fact that their work emerges in part from a clinical context, in which stability and common reference points are important proximal assets and goals. However, Fonagy and colleagues have at times demonstrated a wider distrust in the judgement of individuals separated from social referencing and norms: ‘in general when people are left on their own to figure things out they tend to go astray in their thoughts and feelings’.36

Nonetheless, in their writings on play Fonagy and Target strongly underscored the benefits of a child’s developmental capacity for decoupling representation from past or present experience. They reviewed evidence that suggested that the subtlety of a child’s understanding of their own and others’ mental states as the basis for one perspective, rather than a simple expression of reality, is greater while in pretend play.37 The addition of playful exploration may make examination of mental states easier, in part perhaps because the heavy particularities of concrete experience can be dropped away. This could be why the use of projective doll play tasks in the assessment of children’s experience of relationships or thinking can be much more effective than straightforward versions of the same tasks.38

Fonagy and colleagues have argued that both the symbolic play of children and the creativity of adults are nourished by access to i) the concrete particulars of lived experience; and ii) to common reference points with others, including forms of social recognition and cultural knowledge.39 Yet Fonagy and colleagues also appear to accept that creativity is vivified by the capacity—in turn—to ‘gate’ knowledge of concrete particulars and common reference points in the perspectives of others, and access pretend mode for particular purposes. As we saw in Chapter 3, Fonagy praised the work of creators such as Baudelaire, Rimbaud, and Nerval, for whom the bridle did not sit comfortably.40 Given the reflections of Baudelaire, (p. 114) Rimbaud, and Nerval themselves on the nature and costs of creativity, it may be suspected that for these authors this ‘access’ was not always easy to modulate, and that this was intricately bound up with its power and effectiveness.

For instance, in Baudelaire’s poem ‘Crowds’, he argues that both access to the commons and the potential for independence from it are necessary for genuine creation: ‘multitude, solitude: equal and interchangeable terms for the active, fertile poet. The man who cannot people his solitude will not be able, either, to be alone in a busy crowd.’41 In The Painter of Modern Life he defied his reader to identify a truly beautiful work of cultural production that was not an effective composite of intersubjectivity and current cultural knowledge, together with something autonomous of them, out of keeping with anything timely.42 However, for Baudelaire, this composite was not in the first instance a methodological product of conscious intention, but of slow work on the self to become able to sustain and benefit from both rampages of individual imagination and immersion in the crowd. To take another example, Nerval’s final novel, left unfinished by his suicide, cuts off after the protagonist’s remarks of gratitude for the events that had ‘rendered me back to the renewed affection of my family and friends’, which had helped him to ‘a healthier view of the world of illusions in which I had for some time lived’. Simultaneously, he offered gratitude for his journeys beyond common social and cultural reference points, for all that these journeys could sometimes resemble hell.43

Besides the production of creative works, another context in which pretend mode has specific uses, one that especially interested Fonagy and Target, is the therapeutic setting. Here the relationship between pretend mode and shared perspective taking is squared in the collaboration between patient and therapist. In therapy there is a ‘dual reality’.44 This can take clients a bit of time to recognize, and early sessions are often spent helping the patient discover this. The patient must talk seriously about feelings and ideas which they also know are false, as if this was the most important thing in the world. And then leave the therapeutic setting and get on with responding to the practical challenges of a life that only partly intersect with the matters under discussion in their therapy. The transference relationship with the therapist is a kind of ‘illusion’. As Fonagy puts it wryly, ‘most of us who have had analytic experiences know what is meant by transference love, but few of us have serenaded our analyst on moon-lit summer nights’.45 However, this aspect of pretend within the therapeutic relationship is not a deficit, but part of how it works. Therapy loses its effectiveness if it is wholly subjected to the ugly, dismal, unsafe, or stultifying, because ‘the intrusion of unassimilable reality destroys the possibility of play, and this includes playing (p. 115) with ideas’.46 Part of the difficulty in supporting mentalization in self-critical, depressed patients is that ‘these patients may have little capacity for adaptive pretend functioning’, cutting off possibilities for playing with ideas.47 Yet, when there is also some pretend in play to offer safety, therapy is most beneficial when it intersects with the patient’s lived experience outside therapy and the ugly, dismal, unsafe, or stultifying things that it may contain. This was part of what impressed Fonagy about Hurry’s approach to his own analysis as an adolescent: his cheap, ugly car—seen by Hurry out of the window—could be valued for what it signified to an isolated young man (see Chapter 1).

In a child’s—or an adult’s—symbolic narratives, observations of social behaviour and aspects of perceptual experience are incorporated into the play, giving it vitality and resonance. This is the paradox and magic of play. But in pretend mode as a form of non-mentalizing, thoughts and feelings implicated in motivations or intentions are conceived specifically at the expense of awareness of observable social behaviour and/or perceptual experience. Fonagy and Target proposed that factors that undermine the development of mentalization—in the 1990s and 2000s they emphasized especially disorganized attachment relationships—may be anticipated to hinder the integration of imagination and understanding.48 On the one hand, the capacity for decoupling representation may risk representation uninformed by reality. This will result in chaotic or confusing narratives without effective sequencing. On the other hand, when mentalizing capacities are fragile, the decoupled representation may still feel like reality. Then children’s experiences of pretend may be quite anxiety-provoking.49 Recently, Fonagy and colleagues have come to characterize dissociation as an extreme form of pretend mode, in which observable social reality and/or perceptual experience are not simply ignored, but lost from awareness, through immersion in the pretend mode of non-mentalizing.50 Pretend mode does not simply predispose mental health problems, but in fact is proposed as the process through which certain symptoms such as dissociation occur.

Fonagy and Target have offered guidance on helping children and adults integrate imagination and understanding in the context of therapeutic work. Greater use of pretend mode is developmentally appropriate for children. Here the therapist may wish to facilitate pretend, while nourishing it with concrete particulars and intersubjective understanding, allowing the child to conceive of and reconsider their experiences. Target has reflected that, when working with older patients who lean heavily on pretend mode, in her experience, clinical ‘technique needed to be modified in the early stages to enable these patients, already too loosely connected to reality, to engage more authentically. Consistent gentle confrontation, and little development of a shared pretend mode, helped to create traction. After that, a more usual analytic technique became effective.’51 Skårderud and Fonagy have also stressed (p. 116) the importance of authenticity for work with adolescent and adult patients reliant on pretend mode processing. They urge that clinicians feel able to think aloud, referring to ideas, perspectives, meanings, feelings. But that these should always be tagged as belonging to the therapist. Otherwise there is a risk that the patient will pick up these elements as the basis for a shared pretend mode, without traction for the concretely lived experience of the patient and the personal and social challenges they face.52

Psychic equivalence

Besides pretend mode, a second kind of non-mentalizing described by Fonagy and colleagues was what they termed ‘psychic equivalence’. In this state, aspects of present experience are taken to represent facts that are inevitable and true.53 Within psychic equivalence, it is extremely difficult for the individual to entertain the idea that there could be any other perspective on how things are besides how it feels right now. As we saw in Chapter 4, mentalization may be conceptualized as a capacity to conceive of and make available for reconsideration thoughts and feelings implicated in motivations and intentions in order to account for and explain the observable social behaviour and perceptual experience of oneself and others. In these terms, psychic equivalence means to account for and explain thoughts and feelings and observable social behaviour in terms of an immediate experience. Missing here is the capacity to conceive of and reconsider perceptions of things. Present perceptions, even sensory perceptions, are profoundly mediated by wider psychological and social processes. But they may possess the quality of feeling immediate to the individual. Hegel termed this the feeling of ‘sense certainty’.54 In psychic equivalence, sense certainty is mistaken for reality. Present perceptions and their felt immediacy dominate the scene. For instance, feeling betrayed, an individual interprets the mental states and behaviour of themselves and others in terms of a betrayal. Feeling a sense of togetherness with another person, psychic equivalence leads an individual to the conclusion that this is because they are in reality together or a single unit, which can set up future disappointments.

Rather than perceptual experience being understood in terms of feelings and thoughts as implicated in motivations and intentions, within psychic equivalence mental states and behaviour are understood only in terms of an immediate experience. Indeed, even the capacity (p. 117) to compare and integrate information from different senses may be lost, as any immediate experience, even from one sense alone, gains the quality of sense certainty and comes to feel absolute and necessary. Possible differences between past experience and current perceptions are likewise lost or sidelined.

In clinical settings, psychic equivalence can contribute to a variety of symptoms. One of the central axes of trauma symptomatology is flashbacks, in which memories are experienced in the mode of psychic equivalence, feeling terrifyingly immediate, actual, and inevitable.55 Another of trauma’s central axes is avoidance of reminders of the event. Again, this can be interpreted as the operation of psychic equivalence, in which the experience of the reminder is felt to threaten the immediacy of the traumatic experience. The feeling of concreteness associated with psychic equivalence can also contribute to somatic symptoms following trauma, through the equation of psychological and physical pain and exhaustion.56 In contrast to experiences that feel over-real and inescapable, prompted by psychic equivalence, ‘the alternative to this mode of functioning, the heir of the pretend mode of psychic reality, is dissociation in the wake of trauma. The most characteristic feature of traumatization is the oscillation between these two modes of experiencing internal reality.’57

Psychic equivalence can also contribute to the symptoms of BPD in the domain of personal relationships. Under the terms of psychic equivalence, individuals cannot experience their fears, grievances, expectations, and other affectively laden attributions as unfounded, even when they seem improbable. And the present appears as the only reality: the sense of time, of existing with a past and future, is disturbed by the immediacy and unalterable quality of the individual’s experience. This hinders access to strategies such as patience, helpful distraction, taking a moment to regain composure, and other techniques deployed by the ‘gating mechanism’ that would otherwise prevent our current perceptions from stampeding into the form of set certainties.58 In a state of psychic equivalence, individuals can also be hyper-reactive to shame, because the badness of the self is experienced as total and without possible respite.59 Likewise, frustrations can blow up into dramatic outbursts and aggression, but without an accurate sense of the cause of the frustration: ‘In explaining a violent outburst, for instance, the patient might refer to the oppressive character of the room he was in.’60

Fonagy and colleagues proposed that the most important trigger for psychic equivalence is high arousal/emotionality. Strong emotion can also help sustain psychic equivalence by hindering access to controlled mentalizing.61 Fonagy and colleagues do not, so far as we (p. 118) can tell, ascribe a fundamental proximal trigger for pretend mode or teleological mode in this way, putting into relief the special link they see between high arousal/emotionality and psychic equivalence. In fact, given that they regard high arousal/emotionality as giving experience intensity, immediacy, and urgency, there is a sense in which the boundary between the constructs of high arousal/emotionality and psychic equivalence is permeable. Bateman, Fonagy, and Campbell propose that ‘emotions always feel real’.62 Nonetheless, not all high arousal/emotionality leads to psychic equivalence. When Fonagy and colleagues discuss the kind of high arousal/emotionality that leads to psychic equivalence, they tend to use the term ‘dysregulated emotion’,63 which might give one axis of specification to this notoriously hazy concept.64

As we saw earlier, Fonagy and colleagues do not wish to denigrate non-mentalizing, despite the fact that they feel that it can contribute to suffering, hinder measured decision making, and fuel interpersonal conflict. The capacity for pretend and ‘as if’ thinking can be an asset. Likewise, Fonagy and colleagues observe that the raw certainty and immediacy of psychic equivalence plays a part in many of the most dramatic, invigorating, and meaningful aspects of human life. Psychic equivalence can provide essential winter fuel for the hard times faced by individuals holding fast to ethical conviction or sense of vocation, allowing a personal perception of injustice or calling to outweigh other concerns. This can allow such values to take precedence over mental states such as disappointment or a wish for easier, pragmatic solutions. Likewise, psychic equivalence can contribute to the feeling of our personal relationships as consequential, and even to some of their satisfactions. Part of the pleasure of adult sexuality, Fonagy and Target claim, stems from entry into a state of psychic equivalence: the immediate experience of giving and receiving pleasure can (p. 119) be felt to characterize the relationship and the lovers themselves (see Chapter 6).65 The psychic equivalence underpinning romantic love, especially early in the relationship, is so taken for granted that expressions of this mode of thought are culturally mandatory and conventional. It is hard to find a Valentine’s Day card that is not framed from the position of psychic equivalence: characterizing the beloved as the best person in the world; collapsing past, present, and future in asserting eternal feelings; the relationship is described as magical, miraculous, without mundane cause or precedent.

Fonagy and Target also claimed that making use of psychic equivalence is part of how talking therapies offer relief from symptoms. Talking therapies provide ‘a unique opportunity for psychic change by offering a situation where an individual may re-experience the concreteness of the psychic equivalent mode of functioning with regard to his emotional life, together with the imaginative freedom and clear separation from external reality.’66 The patient can experience fantasies, thoughts, and feelings as real and concrete, without these threatening to become so outside the clinic, thanks to the aspects of therapy that helpfully invoke pretend mode.67 For instance, the therapist can offer reassurances that the patient’s expression of a wish to do something illegal or immoral will not be taken as, in itself, cause for concern or result in negative consequences for the patient or their relationship with the therapist. Once fantasies, thoughts, and feelings in their intensity and immediacy have emerged, the therapist can then work with the patient to make these adequately specified, represented, and made available for discussion and thought. This can only take place, however, once genuinely held fantasies, thoughts, and feelings are made available: ‘without the emotional immediacy and conviction, starting with the rawness of psychic equivalence, reflection would be sterile intellectualisation’.68 It is precisely out of an experience of immediately perceived reality as the truth that reality, perception, and truth can be articulated and distinguished.

Teleological mode

In research on theory of mind in the early 1990s, cognitive scientists drew a distinction between ‘teleological causality’ and ‘psychological causality’. In the former, an individual’s action is represented as causally related to a future goal state; in the latter, action is represented as ‘intentionally’ related to a future goal state.

Q: Why did the chicken cross the road?

Teleological causality: To get to the other side.

Psychological causality: It wanted to be on the other side.69

(p. 120) It was anticipated that teleological and psychological interpretations could be hierarchically organized. In one hierarchy, the cause of an action could be understood with reference to an ‘intention’: ‘he thanked me because he was grateful’. Or, in another hierarchy, an intention could be understood in terms of an action: ‘he thanked me so must have been grateful.’70

Drawing on these ideas, Gergely, Csibra, and colleagues examined the emergence of the capacities for representing a person’s action as causally related to a future goal state.71 In papers over the late 1990s, Gergely and Csibra characterized mentalizing explanations as those in which teleological causality occurs in the service of psychological causality. Conversely, teleological causality in the absence of concern with intentions represented a kind of non-mentalizing when applied to the explanation of social behaviour:

Developmentally, teleological interpretations are transformed into causal mentalistic ones by ‘mentalizing’ the explanatory constructs of the teleological stance: i.e. by turning representations of actual reality constraints into ‘beliefs’ (which mentally represent such constraints), and representations of future goal states of reality into ‘desires’ (which mentally represent goal-states).72

Gergely and Csibra argued that the two stances have very different implications for social interaction. When teleological causality alone is dominant, action can be modified only through direct and prompt action—for instance, through physical obstruction. Yet, when intentions are used to account for causal actions, ‘one becomes able to influence the other’s actions by changing the mental causes that generate it: i.e. by modifying the other’s inferred beliefs and desires through communicative interventions such as informing, promising, or pleading’.73

Fonagy and Target accepted the claim that teleological thinking in the absence of concern with intentions represented a kind of non-mentalizing.74 To pretend mode and psychic equivalence, they therefore added a third kind of non-mentalizing, which they termed ‘teleological mode’. This they defined as a form of mental processing in which behaviour is interpreted and evaluated only for its observable consequences without reconsideration of the mental states that may have motivated or prompted it. As with pretend mode and psychic equivalence, Fonagy and Target regarded teleological mode as having a precursor in the thinking characteristic of young children:

The compelling nature of physical reality is also obvious when children only impute intention from what is physically apparent. We noted that this teleological mode of thinking was present from a very early stage, but is compelling for all of us at moments when mentalizing (p. 121) has ceased, when physical reassurance is demanded and required if emotion regulation is to be reinstated.75

Likewise, in ‘states of reverie, dreaming, or intense emotional arousal, these old “vestigial” structures may become reactivated’, and the world’s meanings become oriented around the physical qualities of things rather than thoughts and feelings about them.76 For instance, unmentalized feelings of inner disintegration and mess evoking intense emotional arousal may prompt a bout of cleaning or list-making.77 The gesture of organizing is forced to carry a burden of achieving felt coherence, since this cannot be shouldered by acknowledged feelings. Risky sexual behaviour may likewise have a basis in many cases in teleological mode—for instance, in the assumption that interpersonal affection or self-worth can be real only if accompanied by physical behaviour taken to demonstrate this.78

This is not to say that thoughts and feelings are absent in teleological mode: mental states can be recognized, but only when they are felt to be observable.79 They do not serve as a basis for developing inferences about motivations. Instead, thoughts and feelings are equated with concrete behaviour and its observable causes. Luyten, Fonagy, Lemma, and Target provided as an example the way that an individual may only feel loved if he or she has access to tangible, ideally physical signifiers of others’ affection.80 Such thinking can make individuals operating in teleological mode unusually attentive and vigilant to others’ behavioural cues. This permits an indirect attention to and awareness of mental states, via ‘hypervigilance’ to their observable behaviour.81 However, mental states are not used to account for the motives behind behaviour. Nor are they available for reconsideration. As a consequence, one’s own and others’ (p. 122) physical cues and observable behaviour can give diverse and conflicting signals without the means to sift and interpret them. As we saw in Chapter 1, Fónagy and Fonagy had highlighted that secondary meanings are present across human speech in both childhood and adulthood, making almost every communication resonate with a variety of interpretable meanings. Only a fraction of this is concerted and conscious: ‘the face and the prosodic qualities of speech are a theatre for too many states of mind for a coherent understanding of a relationship to be reliably achieved by these means.’82 These external signs taken in isolation are unstable and labile, often showing contradictions between primary and secondary meanings. As a result, external behaviours can fail to reflect the underpinning, psychological organization.83

Like pretend mode and psychic equivalence, teleological mode has been regarded by Fonagy and colleagues as a hijacked component of mentalization. Specifically, it represents the severed component of accounting for and explaining observable social behaviour.84 In mentalizing a capacity to conceive of and make available for reconsideration thoughts and feelings implicated in motivations and intentions is deployed in order to achieve this accounting and explaining. In teleological mode, observable social behaviour is used to account for and explain the motivations and intentions of others and oneself. This is in contrast to mentalization where thoughts and feelings are used to account for and explain observable behaviour and perceptual experience. In the terms of Luyten and Fonagy’s four polarities, teleological mode is a kind of non-mentalizing in which ‘external mentalizing’ is used to infer internal states.

An interesting finding by Gagliardini and Colli has been that mentalization-based therapists and psychoanalytic therapists may be more disposed to spot teleological mode than cognitive-behavioural therapists, given the greater focus of CBT on behaviours and manifestations of mental states, which may make teleological mode normalized to a certain extent by this modality.85 The precise contours of teleological mode can be seen by examining a strategy often used in CBT for patients with personality disorders: drawing up contracts with patients. A contract represents a physical embodiment of a determinate plan for future observable behaviour. Use of contracts became a popular clinical strategy from the 1980s in mandating patients with BPD to put aside specific self-destructive coping strategies.86 Luyten and Fonagy, writing in 2012, argued that use of contracts is inappropriate when patients are operating to a significant degree in teleological mode. In this mode, patients do not have adequate ‘capacity for volition’, so are not able to offer meaningful consent for a contract, which requires a minimal degree of knowledge of one’s own plans.87 By contrast, Skårderud and Fonagy, writing in the same year, argued that ‘because of the teleological stance that those with eating disorders often display, we consider written agreements to be very useful. (p. 123) They can assist in bringing about the mental attitude that “I believe it because I see it and I try to cooperate because I actually have signed”.’88

The apparent conflict is resolved, however, by Bateman and Fonagy in their 2016 book on Mentalization-Based Treatment for Personality Disorders. There the authors advocated against contracts that assume an individual’s capacity to know his or her own present or future intentions, and especially those that lead to discharge when the conditions are not fulfilled. However, contracts that target particular areas likely to cause problems in treatment specifically when the patient enters teleological mode can be a useful resource for engaging the patient in that mode.89 For example, a contract that states ‘Even if I demand it, please be careful about changing my medication in a crisis. I can consider this later when I am calmer’ can be helpful in response to the teleological demand to do something in response to felt crisis, even if this something is not a well-measured or ultimately beneficial response.90 The case of written contracts between therapist and patient illustrates that what is missing in teleological mode is above all the capacity to conceive of and reflect on the feelings and thoughts implicated in intentions, which can be accessed only indirectly insofar as they are equated with tangible signifiers such as a contract.

Why three forms of non-mentalizing?

Table 5.1 summarises the forms of non-mentalizing discussed so far. As mentioned at the start of this chapter, Fonagy and colleagues have tended to describe pretend mode, psychic equivalence, and teleological mode as ‘the’ three forms of non-mentalizing. Occasionally they have been referred to as three possible forms among others. And on one occasion hypermentalizing was added as a fourth.91 But in general the description of the three, with a definite article, is consistent. In Fonagy and Target’s initial introduction of pretend mode and psychic equivalence, the pair are presented as a natural fit as the opposite of mentalization. Mentalization was conceptualized as attention to and reflection on the reality of relationships, combined with the imaginative capacity to infer these invisible internal states. With the actual reality of relationships brought offline, Fonagy and Target assumed the result would be pretend mode. When the capacity to imagine invisible internal states went offline, Fonagy and Target assumed that the result would be psychic equivalence. In fact, before the co-authored papers with Target, Fonagy had initially termed psychic equivalence ‘actual (p. 124) mode’ to signify the over-definite sense that immediate experience is taken to represent facts that are inevitable and true. The phrase ‘actual mode’ signals the binary opposition he saw with pretend mode.92

This model was forced to shift in the 2000s with the addition of teleological mode. Perhaps it would have shifted anyway, as in the 2000s Fonagy and Target showed growing recognition that psychic equivalence needed better specification than the absence of imagination. Psychic equivalence seemed rather to account for observed behaviour and inferred mental states in terms of current perceptions. Fonagy and Target also showed growing recognition that pretend mode needed better specification about what aspect of reality had been sequestered. Yet through the 2000s there was no attempt to offer a model of the three forms of non-mentalizing, nor to operationalize the concepts. The reason for this is difficult to identify. It would have been quite possible, for instance, to develop a coding system of the Adult Attachment Interview for identifying pretend mode, psychic equivalence, and teleological mode. In the mid-2000s, Target supervised three doctoral projects creating and evaluating new scales for the Adult Attachment Interview based on the ideas about personality disorder she, Fonagy, and colleagues had been developing. However, no attempt was made to scale the modes of non-mentalizing. And the work from the doctoral projects was ultimately left unpublished.93

Ultimately, without operationalization and a clear model, the items contained in the container of ‘non-mentalizing’ were prone to tumble about. For instance, Fonagy and collaborators have at times reverted to their early account of a ‘prementalistic psychic reality, largely split into psychic equivalence and pretend modes’ as the polar opposites of one another, and in which teleological mode has no specified place.94 Similarly, the MBT Adherence and Competence Scale, developed by Karterud and an international team including Bateman and Fonagy, specifies that mentalization-based treatment requires that the therapist identify and seek to intervene with pretend mode and psychic equivalence, but there is no requirement for an MBT therapist to address teleological mode.95

One proposal put forward at times in the 1990s and early 2000s was that the logic of the three modes of non-mentalizing was that they reflected the thinking of pre-school children. During this time, Target was engrossed in reading the case files of child patients from the Anna Freud retrospective study, and Fonagy was practising as a child analyst. Fonagy may (p. 125) have had in mind Ivan Fónagy’s observations of phenomena similar to psychic equivalence, pretend mode, and teleological mode in his diary of Peter’s development (see Chapter 1). Yet, from the early 2000s, Fonagy and Target began to criticize the focus of psychoanalytic theory on early childhood developmental stages in conceptualizing the basis for adult mental illness. This entailed criticism of their own earlier work to the extent that it remained indebted to such an approach. They concluded that at best metaphorical or heuristic links could be drawn between the mental processes characteristic of children and the mental processes characteristic of unwell adults.96 Ultimately, ‘confidence in mapping particular forms of psychopathy to specific developmental epochs is unjustified … The metaphorical “baby” of psychanalytic theory which stands for “the past” will probably have to be abandoned.’97 Appeal to a basis in pre-school forms of thinking could not offer a sufficient justification for pretend mode, psychic equivalence, and teleological mode as the three forms of non-mentalizing. Today, forms of non-mentalizing are still described by some of Fonagy’s more psychoanalytically-oriented collaborators as “pre-mentalizing”, and this is even formalized in the name of one of the scales of the Parental Reflective Functioning Questionnaire.98 However this appears to be a holdover rather than a considered stance. The characterization of non-mentalizing as reflecting a childish form of thinking has generally been abandoned by Fonagy, even if to a lesser extent by some of his collaborators.

With Fonagy and Luyten’s 2009 conceptualization of mentalization as having four poles, this introduced an account that promised not only a justification for the modes of non-mentalizing, but also an account of the specific proximal contexts in which they would occur. Since the introduction of this account, it has subsequently been advocated by Fonagy and colleagues that ‘imbalances within the dimensions of mentalizing predictably generate the nonmentalizing modes’: ‘Psychic equivalence is inevitable if emotion (affect) dominates cognition. Teleological mode follows from an exclusive focus on external features of the neglect of the internal. Pretend mode thinking and hypermentalizing are unavoidable if reflective, explicit, controlled mentalizing is not well established’.99 This new framework appears to offer a logic as to why only three forms of mentalizing have been identified over two decades. Mentalizing has four poles: internal and external; affective and cognitive; self and other; implicit and explicit. External mentalizing at the expense of internalizing produces teleological mode. Affective mentalizing at the expense of cognitive mentalizing produces psychic equivalence. And automatic mentalizing at the expense of explicit mentalizing produces pretend mode.100

Yet this framework faces significant problems, partly inherited from trouble with Fonagy and Luyten’s original scheme of oppositions. First, the absence of cognitive mentalizing (p. 126) alone does not prompt pretend mode, though it plays a major role in sustaining it. Rather, as we have seen, pretend mode also requires that mental processing is not informed by current or past experience and its concrete constraints and tasks. This was the emphasis of Fonagy and Target’s early account but is missing as it has no place in Fonagy and Luyten’s model. Furthermore, explicit mentalizing at the expense of internal mentalizing would still be mentalizing. It would just be ponderous. To be able to engage in automatic mentalizing is adaptive. But Fonagy and colleagues’ recent definitions of mentalizing as a balance between the four poles (see Chapter 4) entail a conflation of mentalization with beneficial psychological functioning, at least in terms of the opposition between implicit and explicit mentalizing.

Second, problems also arise with the account of psychic equivalence as affective mentalizing at the expense of cognitive mentalizing. Affective mentalizing, according to Fonagy and Luyten, is the capacity to identify and interpret feelings in oneself or others. It is far from clear that psychic equivalence entails strengths in this capacity. Conversely, cognitive mentalizing was described as the capacity to identify and interpret thoughts in oneself or others. Again, as we saw earlier, psychic equivalence might better be characterized as accounting for and explaining thoughts and feelings and observable social behaviour in terms of immediate experience. Our embodied response to sensory cues means that present perceptions are the central site of affective experience.101 This gives the impression of affect-led non-mentalizing in psychic equivalence. But this does not therefore imply strengths in attending to or in interpreting the feelings of others, or of oneself. An individual may face systematic psychological obstacles to conceiving of or reconsidering either i) thoughts or ii) feelings in themselves or others as implicated in motivations. These predicaments should receive a name and further consideration by those interested in mentalization (not least as a basis for critical dialogue with recent developments in work on ‘theory of mind’). But the key point here is that neither situation would necessarily imply psychic equivalence.

Such concerns suggest the need for an alternative justification for and logic to the salience of pretend mode, psychic equivalence, and teleological mode. In the previous chapter, mentalization was defined as a capacity to:

  1. 1. conceive of

  2. 2. and make available for reconsideration

  3. 3. the thoughts and

  4. 4. feelings

  5. 5. implicated in motivations and intentions

  6. 6. in order to account for and explain

  7. 7. the observable social behaviour

  8. 8. and present or past perceptual experience

  9. 9. of oneself

  10. 10. and others.

(p. 127) Exercise of this capacity can be regarded as requiring two major syntheses, which then in turn need to be integrated.102 The first synthesis is of ‘experience’. This entails conceiving of and perceiving reality, both mental and physical. Addressing this synthesis, Winnicott distinguished between the ‘subjectively conceived’ and the ‘objectively perceived’ self and other as interacting components within human perception, and urges that only when these are brought together is mental life experienced as alive and creatively usable.103 He was especially worried by a situation he described as the ‘false self’, by which he meant a situation in which the experiences of others are used to account for and explain the motivations and intentions of others and oneself, to the exclusion of one’s own ‘subjectively conceived’ and the ‘objectively perceived’ experiences.104 In interpreting the idea of ‘objectively perceived’ experience, Winnicott emphasized that an objectively perceived object is still a perception, and therefore subjective in a sense, rather than the thing-in-itself. His emphasis is how we integrate perceptions granted or imposed by the object with perceptions stemming from what we want from the object and how we find ourselves imagining it. On similar lines, mentalization depends upon the achievement of a subjective conception of other and/or oneself, fed by specific information apprehended by perceptions of felt or reported experience and observable behaviour. Drawing on Winnicott, Fonagy and colleagues have regularly emphasized that we depend upon an element of imagination in understanding motivations and intentions, which always have a certain opacity to us.105

The second great synthesis is of what Fonagy and colleagues term ‘understanding’. This entails the activity of accounting for and explaining behaviour and/or experience with the (p. 128) discernment of motivations and intentions.106 When conception is poorly fed by specific information, the result is pretend mode: the conception of thoughts and feelings is understood to account for them. When this is combined with the second synthesis, and used for accounting for and explaining motivations and intentions, this produces hypermentalisation. When specific information from perceived reality is not treated as a personal perception, but felt simply as reality itself, the result is a sense of overwhelming immediacy. Combined with the second synthesis, and used for accounting for and explaining motivations and intentions, the result is psychic equivalence. Here personal experience is used to account for and explain the motivations and intentions of others and oneself. Mentalization also depends upon the achievement of an account or explanation of our own or others’ behaviour or experience. Teleological mode runs this process backwards, using observable social behaviour to account for and explain the motivations and intentions of others and oneself.

Consideration of mentalization in terms of the syntheses of experience and understanding helps clarify why pretend mode, psychic equivalence, and teleological mode are not just incidental obstacles to mentalizing, but fundamentally incompatible. For full or specific mentalization to be present, an individual needs to be able to understand how misunderstanding of experience can take place. Otherwise there is no access to the generative doubt that underpins inquisitive stance. This is specifically what the three modes of non-mentalizing obstruct, even if they do so each in different ways. In turn, it may be anticipated that lack of access to generative doubt helps stabilize non-mentalizing. Allison and Fonagy have recently described ‘undue certainty about the veracity of an idea as psychic equivalence, while a total repudiation of this certainty we denoted as pretend mode; both are characteristic of a prementalizing phase in the development of psychic reality.’107 Here, again, we can see teleological mode dropping out when Fonagy and colleagues account for the logic of non-mentalizing. However, in the same terms, teleological mode can be considered as undue certainty that the meaning of social behaviour is signified by its outcome. In all three cases, generative doubt is not possible, and so neither is the inquisitive stance about mental states and pursuit of perspective-taking. As we saw in Chapter 4, Bateman and Fonagy have situated tentativeness and moderation as qualities of all good mentalizing.108

The importance of generative doubt is signalled by Fonagy’s characterization from the start of mentalization as making mental states available for reconsideration, albeit with confusion about whether this required explicit representation or could be an implicit process.109 The importance of generative doubt has been further headlined by recent theoretical work. Drawing on a model of resilience developed by Kalisch and colleagues,110 Fonagy and (p. 129) collaborators have characterized two forms of reconsideration that they regard as of special importance for how mentalization contributes to resilience.111 A first is the capacity to reconsider the valence of a present situation. Resilience is fostered by the capacity to reappraise the situation to identify those elements that may be used constructively.112 Undue certainty or uncertainty are hinderances for this appraisal, which depends on a generative doubt about our first impressions.113 A second form of reconsideration that contributes to resilience is reappraisal of past experience. Past experience may press in on us with certain impressions and sensations, as well as with thoughts or feelings about what has happened. Fonagy and colleagues regard resilience as fostered by the capacity to reappraise the past to achieve accuracy in identification of present-day threats. This includes the capacity to reappraise threat-associated impressions and sensations stemming from the past, that might contribute to inaccurate and overinclusive perceptions of threat in the present. Again, generative doubt is critical to this reappraisal: undue certainty or uncertainty both hinder the potential for reconsidering the past in inquisitive stance.

A methodological development has also underlined the centrality of generative doubt and inquisitive stance in the conceptualization of mentalizing. Recently, Fonagy and colleagues have worked to develop a self-report measure of mentalizing, with the promise of reduced labour and greater scalability compared with the Adult Attachment Interview. The construction of a self-report scale is, on the surface, paradoxical. How can an individual report on their capacity for conceiving and considering mental states, if this capacity is required in order to know the answer to the question? How can pretend mode, psychic equivalence, and teleological mode be identified by an individual using them, when their effect is to make their own premises appear certain? After some trial and error, Fonagy and colleagues sought to circumvent these problems by creating a Reflective Functioning Questionnaire (RFQ) (p. 130) with two scales.114 One scale represented over-certainty (RFQc) about the minds of oneself and others (e.g. ‘I always know what I feel’, ‘I usually know exactly what other people are thinking’, ‘My intuition about a person is hardly ever wrong’). The other scale represented indiscriminate uncertainty (RFQu) about the minds of oneself and others (e.g. ‘People’s thoughts are a mystery to me’, ‘I don’t always know why I do what I do’, ‘I believe there’s no point trying to guess what’s on someone else’s mind’).115

It should be acknowledged that an important limitation of the RFQ is that it does not seek to capture any positive qualities of mentalizing that may be distinct from the absence of non-mentalizing, such as curiosity about mental states, concern to integrate discrepant information about mental states, or effective use of support from others in conceiving or reconsidering mental states.116 The Parental Reflective Functioning Questionnaire, developed subsequent to the Reflective Functioning Questionnaire, does have three scales, one of which is ‘interest and curiosity’ in the child’s mental state, which seems an attempt to capture some of the positive content of mentalizing irreducible to the absence of non-mentalizing.117 Nonetheless, the use of well-modulated doubt as the criterion of mentalizing in the Reflective Functioning Questionnaire still supports the conclusion that pretend mode, psychic equivalence, and teleological mode are the main forms of non-mentalizing because (p. 131) the kind of mental processing they entail specifically undermines generative uncertainty and an ‘inquisitive stance’ towards mental states.118

A further advantage of the conceptualization of mentalization in terms of the syntheses of experience and understanding is that it clarifies the status of pretend mode, psychic equivalence, and teleological mode. Fonagy has stated his suspicion that they are not ‘a complete map of the nonmentalizing world’.119 We agree that there could be other forms of mental processing that would block generative uncertainty and access to the ‘inquisitive stance’. One example has been highlighted by Winnicott: when the experiences of others are used to account for and explain the motivations and intentions of others and oneself, to the exclusion of one’s own subjectively conceived and the objectively perceived experiences. And Fonagy and Target, discussing Winnicott, have indeed acknowledged this as an integral obstacle to mentalization.120

A further candidate for consideration as a form of non-mentalizing has been raised by Ensink, Fonagy, and colleagues. They have described states of withdrawal from others as fundamentally ‘incompatible’ with mentalization.121 Such states could occur for various reasons—for instance, anticipated pain or anxiety associated with contact with others, whether based on their actual past behaviour or on externalization of the alien self.122 For instance, technology addiction has been proposed as a case in which the capacity to understand the thoughts and feelings of others is blocked by a kind of withdrawal.123 Such claims are supported by empirical findings showing that extensive online game use is associated with unresolved loss and trauma on the Adult Attachment Interview, with the relationship mediated by symptoms of dissociation.124 If Fonagy and Luyten are right that understanding one’s own mind is secondary to understanding the minds of others, then sustained and intense withdrawal would prove an obstacle not just to understanding the mental states of others but also oneself.

It might be argued that withdrawal is not a distinct form of non-mentalizing, but rather a moment in the process of pretend mode, which depends upon an obstruction of sources of specific information about reality. However, if so, it is a distinct and separable moment, since not all withdrawal then prompts pretend mode. Withdrawal may even protect mentalizing, (p. 132) by sustaining a degree of reserve from collective non-mentalizing cultures (see Chapter 9).125 Nonetheless, over time, sustained withdrawal is likely to prompt pretend mode as a form of non-mentalizing. Where we withdraw ‘to’ is never a sphere in which others are psychologically absent. Our self-representation will nonetheless still contain narrative representations of the thoughts and feelings of others, and withdrawal will hinder the updating and modulation of these representational elements.126

Two further, perhaps more minor forms of non-mentalisation, mentioned above, might include systematic obstacles to mentalizing thoughts or feelings. However, the capacity to mentalize thoughts but not feelings does not represent the kind of systematic obstruction to generative doubt and inquisitive stance achieved by pretend mode, psychic equivalence, or teleological mode. Yet, as Bateman and Fonagy have observed, ‘with cognition there is always doubt’ and therefore the potential for ‘cognitive reappraisal’.127 Likewise, strong capacities for mentalizing feelings in the context of weak capacities for mentalizing thoughts is likely to hinder the coherence and consistency of accounts and explanations of experiences and observable behaviour. However, this configuration is again unlikely to represent a systematic obstacle to mentalizing.128

A further possibility might be difficulties mentalizing past experience, as opposed to present experience. There are innumerable ways in which present-day routines can be set up to hinder attention to thoughts and feelings from the past. Again, this would be troublesome for mentalizing, not least because comparison of past and present is a powerful aid to reconsideration. However, when consideration of thoughts and feelings in present experience is feasible, difficulties thinking about the past would rarely function as a block on mentalizing to the same extent as pretend mode, psychic equivalence, or teleological mode. These would all be minor forms of non-mentalizing, not on the same level as the pretend mode, psychic equivalence, and teleological mode for obstructing generative doubt and inquisitive stance. Yet, in the 2000s, as mentioned in Chapter 4, Fonagy, Gergely, and Target described the ability to ‘represent and differentiate between the mental models of the self and of the other about reality’ as one of the cognitive requisites for mentalization.129 As such, a potent potential form of non-mentalizing, and candidate for a ‘fourth’ major form, is what Fonagy and colleagues call ‘the externalization of the alien self’. This notion of ‘externalization of the alien self’, and the conceptualization of the self in general, will be the subject of the next chapter.

Notes:

1 See e.g. Benwell, B. and McCreaddie, M. (2016). ‘Keeping “Small Talk” Small in Health-Care Encounters: Negotiating the Boundaries between On-and Off-Task Talk’. Research on Language and Social Interaction, 49(3): 258–271.

2 Cameron, B. L. (2004). ‘Ethical Moments in Practice: The Nursing “How Are You?” Revisited’. Nursing Ethics, 11(1): 53–62.

3 Strehlow, G. and Hannibal, N. (2019). ‘Mentalizing in Improvisational Music Therapy’. Nordic Journal of Music Therapy, 28(4): 333–346.

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

5 E.g. Brent, B. K. and Fonagy, P. (2014). ‘A Mentalization-Based Treatment Approach to Disturbances of Social Understanding in Schizophrenia’, in P. Lysaker, G. Dimaggio, and M. Brüne (eds), Social Cognition and Metacognition in Schizophrenia: Psychopathology and Treatment Approaches, San Diego, CA: Elsevier, pp. 245–259: ‘One of the consequences of impaired mentalization from an MBT Standpoint is the likelihood that early, “pre-mentalistic” forms of thinking may emerge during stress; including: (1) psychic equivalence thinking, in which the ability to consider outside perspectives on one’s inner experience becomes lost and one’s own thoughts and/or feelings are taken as unequivocally real; (2) pretend mode thinking’ (p. 248, italics added).

6 Fonagy, P. and Target, M. (2004). ‘Playing with the Reality of Analytic Love: Commentary on Paper by Jody Messler Davies “Falling in Love with Love”’. Psychoanalytic Dialogues, 14(4): 503–515: ‘The modes of mental functioning that developmentally predate mentalization: the teleological stance, psychic equivalence, and pretend mode’ (p. 511); Fonagy, P., Campbell, C. and Bateman, A. (2017). ‘Mentalizing, Attachment, and Epistemic Trust in Group Therapy’. International Journal of Group Psychotherapy, 67(2): 176–201: ‘When mentalizing fails, individuals often fall back on non-mentalizing ways of behaving, which have some parallels to the ways young children behave before they have developed their full mentalizing capacities. The modes are: psychic equivalence, teleological, and pretend modes’ (p. 179).

7 The Reflective Functioning Questionnaire operationalizes ‘hypomentalising’, which is anticipated as the outcome of psychic equivalence and teleological mode. Fonagy, P., Luyten, P., Moulton-Perkins, A., Lee, Y. W., Warren, F., Howard, S., … and Lowyck, B. (2016). ‘Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire’. PLoS One, 11(7): e0158678. Some aspects of non-mentalizing were distinguished by Hausberg, M. C., Schulz, H., Piegler, T., Happach, C. G., Klöpper, M., Brütt, A. L., … and Andreas, S. (2012). ‘Is a Self-Rated Instrument Appropriate to Assess Mentalization in Patients with Mental Disorders? Development and First Validation of the Mentalization Questionnaire (MZQ)’. Psychotherapy Research, 22(6): 699–709. However, Fonagy and colleagues have never cited this measure; the reason for this is unknown. A new clinician-report measure of non-mentalizing distinguishes the three modes: Gagliardini, G. and Colli, A. (2019). ‘Assessing Mentalization: Development and Preliminary Validation of the Modes of Mentalization Scale’. Psychoanalytic Psychology, 36(3): 249–258.

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, p. 160–161.

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

10 Fonagy, P. (1995). ‘Playing with Reality: The Development of Psychic Reality and its Malfunction in Borderline Personalities’. The International Journal of Psychoanalysis, 76: 39–44,p. 41.

11 Ibid. 43.

12 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. 437.

13 Bion, W. R. (1963). Elements of Psycho-Analysis, London: Karnac Books.

14 Bion, W. R. (1962). Learning from Experience, London: Karnac Books: ‘Instead of sense impressions being changed into alpha-elements for use in dream thoughts and unconscious waking thinking, the development of the contact-barrier is replaced by its destruction. This is effected by the reversal of alpha-function so that the contact-barrier and the dream thoughts and unconscious waking thinking which are the texture of the contact-barrier are turned into alpha-elements, divested of all characteristics that separate them from beta-elements and are then projected thus forming the beta-screen … The reversal of alpha-function does violence to the structure associated with alpha-function’ (p. 25).

15 Fonagy, P. (1997). ‘Where Cure was Inconceivable. The Aims of Modern Psycho-Analysis with Borderline Patients’. Texte, 3(17): 11–25: ‘The patient’s pseudo-insights do not correspond to the primary level of their internal experience’ (p. 22). See also Fonagy, P. (2018). ‘Fonagy on “Playing with Reality: I. Theory of Mind and the Normal Development of Psychic Reality”’. PEP/UCL Top Authors Project, 1(1): 27.

16 Luyten, P., Fonagy, P., Lemma, A., and Target, M. (2012). ‘Depression’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, 385–418, p. 410.

17 Fonagy and colleagues offer few discussions of what motivations especially prompt mentalizing. This can give the impression that mentalizing others is free from uncivilized motivations and fantasies, such as the wish to control others, envy of their thoughts or feelings, or inability to be alone with our own thoughts and feelings. There is no reason that their position should imply this, and it would appear an implausible stance. Fonagy’s citations of Hegel are always of the Phenomenology of Spirit. However, a shift in Hegel’s position from the Phenomenology to later work such as The Science of Logic was towards the claim that reflection is not self-grounded, and that forms of accurate and well-judged understanding and reasoning about ourselves and others need to be examined for the forces and desires that organize and animate them, and which may not be fully understood or well reasoned. Hyppolite, J. ([1952] 1997). Logic and Existence, New York: SUNY University Press. Similar points have been made about reflection within psychoanalysis. See e.g. Bion, W. ([1977] 2019). Bion in New York and Sao Paulo, and Three Tavistock Seminars, London: Karnac Books.

18 Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., and Fonagy, P. (2011). ‘Theory of Mind and Emotion Regulation Difficulties in Adolescents with Borderline Traits’. Journal of the American Academy of Child & Adolescent Psychiatry, 50(6): 563–573; Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘The biggest challenge in recognising mentalising is being able to distinguish it from pseudomentalising’ (p. 127).

19 Bateman, A. and Fonagy, P. (2019). ‘Preface’, in Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, p. xx.

20 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 128.

21 Bo, S., Sharp, C., Fonagy, P., and Kongerslev, M. (2017). ‘Hypermentalizing, Attachment, and Epistemic Trust in Adolescent BPD: Clinical illustrations’. Personality Disorders, 8(2): 172–182.

22 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, pp. 12–13.

23 Ezrati, O. (2014). ‘Freud Off: Giving New Meaning to Psychoanalysis’, Haaretz, 5 April. Accessed at: https://www.haaretz.com/life/books/.premium-giving-new-meaning-to-psychoanalysis-1.5243899: ‘From the descriptions, Freud’s patients sound very borderline. Of course, it’s not surprising that much of psychoanalysis was discovered with those patients, because they are incredibly accessible to elaborating their mental states. They hyper-mentalize quite a lot. Also, unfortunately, they are very suggestible. If you tell them that this or that has happened, because they can’t turn inside and check out what’s going on in their own mind.’

24 One illustration is Freud’s appeal to symbolism to ‘overcome’ the opacity of the patient’s mind. Freud, S. ([1900] 2001). The Interpretation of Dreams. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 4, London: Vintage: ‘We are thus obliged, in dealing with those elements of the dream-content which must be recognized as symbolic, to adopt a combined technique, which on the one hand rests on the dreamer’s associations and on the other hand fills the gaps from the interpreter’s knowledge of symbols’ (p. 353). In itself, reference to cultural discourses in interpreting mental states seems readily justifiable (see Chapter 9). However, the very speculative account of mythic symbolism deployed by Freud can be seen to predispose hypermentalising in his clinical work. See e.g. Kris, A. O. (1994). ‘Freud’s Treatment of a Narcissistic Patient’. The International Journal of Psychoanalysis, 75: 649–664; Koellreuter, A. (ed.), (2016). What is this Professor Freud Like?: A Diary of an Analysis with Historical Comments, London: Karnac Books.

25 Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., and Fonagy, P. (2011). ‘Theory of Mind and Emotion Regulation Difficulties in Adolescents With Borderline Traits’. Journal of the American Academy of Child & Adolescent Psychiatry, 50(6): 563–573. See also Somma, A., Ferrara, M., Terrinoni, A., Frau, C., Ardizzone, I., Sharp, C., and Fossati, A. (2019). ‘Hypermentalizing as a Marker of Borderline Personality Disorder in Italian Adolescents: A Cross-Cultural Replication of Sharp and Colleagues’(2011) Findings’. Borderline Personality Disorder and Emotion Dysregulation, 6(1): 5.

26 Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., and Fonagy, P. (2011). ‘Theory of Mind and Emotion Regulation Difficulties in Adolescents With Borderline Traits’. Journal of the American Academy of Child & Adolescent Psychiatry, 50(6): 563–573, p. 566. Later research has found that the different phenomena included in the Difficulties in Emotion Regulation Strategies Scale have a bifactor structure, with one general emotion dysregulation factor and five uncorrelated specific factors. Both the general factor and the specific factors each demonstrated incremental validity. Hallion, L. S., Steinman, S. A., Tolin, D. F., and Diefenbach, G. J. (2018). ‘Psychometric Properties of the Difficulties in Emotion Regulation Scale (DERS) and its Short Forms in Adults with Emotional Disorders’. Frontiers in Psychology, 9: 539.

27 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 305. Though not cited, given the use of the term ‘exploration’, in the background here may be Bowlby and Hinde’s idea of the exploratory behavioural system as, like attachment, a form of behaviour predisposed in humans by our evolutionary history. See Bowlby, J. (1969/1982). Attachment, London: Penguin, p. 238 and Hinde, R. A. (1954). ‘Factors Governing the Changes in Strength Of a Partially Inborn Response. 1. The Nature of the Response, and an Examination of its Course’. Proceedings of the Royal Society, B, 142: 306–331.

28 Fonagy, P. (1991). ‘Thinking about Thinking: Some Clinical and Theoretical Considerations in the Treatment of a Borderline Patient’. The International Journal of Psychoanalysis, 72: 639–656: ‘Pretence and the understanding of another’s mental state have in common the need to be able to entertain a belief whilst at the same time knowing this to be false’; Luyten, P., Campbell, C., and Fonagy, P. (2020). ‘Borderline Personality Disorder, Complex Trauma, and Problems with Self and Identity: A Social‐Communicative Approach’. Journal of Personality, 88(1): 88-105 : ‘Mentalizing is the basic social cognitive tool that individuals use to constantly update and adaptively sketch out their imagined selves and the imagined minds of others.’

29 This proposal is elaborated in a recent doctoral project, supervised by Liz Allison: Hardy, A. (2018). The ‘Reality Oriented’ Imagination: A Philosophical Examination of the Imagination in ‘Mentalization’ and ‘Neuropsychoanalysis. Unpublished doctoral thesis, London: University College London.

30 Winnicott, D. W. (1953). ‘Psychoses and Child Care’. British Journal of Medical Psychology, 26(1): 68–74.

31 Tessier, V. P., Normandin, L., Ensink, K., and Fonagy, P. (2016). ‘Fact or Fiction? A Longitudinal Study of Play and the Development of Reflective Functioning’. Bulletin of the Menninger Clinic, 80(1): 60–79.

32 Ainsworth, M. (1969). ‘Sensitivity vs. Insensitivity to the Baby’s Signals Scale’. Accessed at: http://www.psychology.sunysb.edu/attachment/measures/content/ainsworth_scales.html.

33 Target, M. and Fonagy, P. (1996). ‘Playing with Reality II: The Development of Psychic Reality from a Theoretical Perspective’. The International Journal of Psychoanalysis, 77: 459–479. See also Byrne, G., Sleed, M., Midgley, N., Fearon, R. M. P., Mein, C., Bateman, A., and Fonagy, P. (2019). ‘Lighthouse Parenting Programme: Description and Pilot Evaluation of Mentalization-Based Treatment (MBT) to Address Child Maltreatment’. Clinical Child Psychology and Psychiatry, 24(4): 680–693 .

34 Target, M. and Fonagy, P. (1996). ‘Playing with Reality II: The Development of Psychic Reality from a Theoretical Perspective’. The International Journal of Psychoanalysis, 77: 459–479, p. 472.

35 Fonagy, P., Allison, E., and Campbell, C. (2019). ‘Mentalising, Resilience and Epistemic Trust’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 63–77, p. 70; Bateman, A. and Fonagy, P. (2019). ‘Preface’, in Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, p. xvii. For a comparison of mentalizing with the psychoanalytic notion of the superego, see Jurist, E. L. (2014). ‘Whatever Happened to the Superego?: Loewald and the Future of Psychoanalysis’. Psychoanalytic Psychology, 31(4): 489–501.

36 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 325.

37 E.g. Dias, M. G. and Harris, P. L. (1990). ‘The Influence of the Imagination on Reasoning by Young Children’. British Journal of Developmental Psychology, 8(4): 305–318; Gopnik, A. and Slaughter, V. (1991). ‘Young Children’s Understanding of Changes in their Mental States’. Child Development, 62(1): 98–110.

38 Woolgar, M., Steele, H., Steele, M., Yabsley, S., and Fonagy, P. (2001). ‘Children’s Play Narrative Responses to Hypothetical Dilemmas and their Awareness of Moral Emotions’. British Journal of Developmental Psychology, 19(1): 115–128; Steele, M., Steele, H., Woolgar, M., Yabsley, S., Fonagy, P., Johnson, D. (2003). ‘An Attachment Perspective on Children’s Emotion Narratives: Links cross Generations’, in R. N. Emde, D. P. Wolf, and D. Oppen-heim (eds), Revealing the Inner Worlds of Young Children: The Macarthur Story Stem Battery and Parent–Child Narratives, Oxford: Oxford University Press, pp. 163–181).

39 Fonagy, P. and Allison, E. (2018). ‘The Origin of Human Life: A Psychoanalytic Developmental Perspective’, European Psychoanalytical Federation, 31st Annual Conference, Warsaw, 24 March: ‘The potential space that Winnicott refers to is the imagined common ground between self-reflection (the experienced self) and the experience of the other’s reflection on the self. The larger this common ground, the closer the shape of self and the other’s perceived view of the self, the higher the level of epistemic trust experienced by the patient and the more open the patient’s mind is to imagining the analyst’s experience in relation to physical or mental phenomena to which the patient so far has no access. Patients unlock their imagination and accept a new reality when they feel that their reality has been adequately imagined and accepted.’

40 It is curious that Fonagy almost never mentions authors of fiction. The same is true for Bion. Nonetheless, both cite Baudelaire and Rimbaud as authors who illustrate the role of imagination and proto-thoughts and feelings in the effective and powerful depiction of mental states. Bion, W. R. (1976). ‘Emotional Turbulence’, in Clinical Seminars and Other Works, London: Karnac Books, pp. 295–305, p. 304. This seems less likely to be influence, and more likely theoretical convergence to the point of aesthetic overlaps.

41 Baudelaire, C.-P. (1995). Selected Poems, trans. Carol Clark, London: Penguin, p. 201.

42 Baudelaire, C.-P. (1972). ‘The Painter of Modern Life’, in Selected Writings on Art and Literature, trans. P. E. Charvet, London: Penguin, pp. 390–436.

43 Nerval, G. ([1855] 1999). ‘Aurélia’, in Richard Sieburth (ed.), Selected Writings, London: Penguin, pp. 265–316, p. 316.

44 Fonagy, P. (1991). ‘Thinking about Thinking: Some Clinical and Theoretical Considerations in the Treatment of a Borderline Patient’. The International Journal of Psychoanalysis, 72: 639–656, p. 652.

45 See also Fonagy, P. (1995). ‘2: Peter Fonagy’. British Journal of Psychotherapy, 11(4): 575–584: ‘Therapy, certainly psychoanalytic therapy, is in many respects a “pretend” experience. Therapist and patient discuss fantasies, feelings and ideas which they “know” at the same time to be false. John Klauber wrote beautifully about this in his paper on transference as an illusion (in Klauber and others, 1988). Most of us who have had analytic experiences know what is meant by transference love, but few of us have serenaded our analyst on moon-lit summer nights’ (p. 578), citing Klauber, John (1988). Illusion and Spontaneity in Psychoanalysis, London: Free Association Books.

46 Target, M. (1998). ‘The Recovered Memories Controversy’. International Journal of Psychoanalysis, 79: 1015–1028, p. 1026.

47 Luyten, P., Fonagy, P., Lemma, A., and Target, M. (2012). ‘Depression’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 385–418, p. 411.

48 Target, M. and Fonagy, P. (1996). ‘Playing with Reality II: The Development of Psychic Reality from a Theoretical Perspective’. The International Journal of Psychoanalysis, 77: 459–479.

49 Kaplan, N. R. (1989). Individual Differences in Six-Year-Olds’ Thoughts about Separation: Predicted from Attachment to Mother at One Year. Unpublished doctoral thesis, Berkeley: University of California. Luyten, P. and Fonagy, P. (2014). ‘Assessing Mentalizing in Attachment Contexts’, in S. Farnfield and P. Holmes (eds), The Routledge Handbook of Attachment: Assessment, London: Routledge, pp. 210–216.

50 Target, M. (2007). ‘The Interface between Attachment and Intersubjectivity: Another Contribution from Karlen Lyons-Ruth’. Psychoanalytic Inquiry, 26(4): 617–621, p. 620.

51 Target, M. (2008). ‘Some Thoughts on Lying and Pretending’. Plenary delivered to the British Psycho-Analytical Society Scientific Meeting, 18 June 2008, unpublished manuscript, Mary Target personal archive.

52 Skårderud, F. and Fonagy, P. (2012). ‘Eating disorders’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Publishing, pp. 347–384, p. 378.

53 Initially there was some ambiguity in Fonagy and Target’s account of psychic equivalence about what inner experience was considered ‘equivalent’ to. They later acknowledged that ‘In previous writings, we had conflated two features of psychic equivalence: (a) equation with other minds and (b) equation with the physical.’ Fonagy, P. and Target, M. (2007). ‘Playing with Reality: IV. A Theory of External Reality Rooted in Intersubjectivity.’ International Journal of Psychoanalysis, 88: 917–937, p. 927. This ambiguity is resolved by the 2010s, where—following the main line of argument present already in Fonagy and Hepworth’s writings from the 1990s—psychic equivalence was taken to be an equation of personal perception and reality. What matters for psychic equivalence is the lack of mediation that would occur when perceptions are recognized as perceptions, rather than reality.

54 Hegel, G. W. F. ([1807] 1977). The Phenomenology of Spirit, trans. A.V. Miller, Oxford: Oxford University Press. Heidegger offers a characterization of sense certainty that highlights the way that sense certainty undercuts perspective-taking since there is no perspective available to take: ‘sense certainty asserts itself to be the unchanging relation, admitting no distinction between I and object, wherein the poles of the relation as well as the relation itself are undifferentiated and not distinguished.’ This requires ongoing efforts to dodge or suppress information that might otherwise suggest this distinction: ‘What is shown again and again is the effort to keep from falling out of immediacy … and not posing questions.’ Heidegger, M. ([1930–1931] 1988). Hegel’s Phenomenology of Spirit, trans. Parvis Emad and Kenneth Maly, Indianapolis: Indiana University Press, pp. 70–2.

55 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. 442.

56 Luyten, P., Fonagy, P., Lemma, A. and Target, M. (2012). ‘Depression’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 385–418, p. 397.

57 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. 442.

58 Fonagy, P., Allison, E. and Campbell, C. (2019). ‘Mentalising, Resilience and Epistemic Trust’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 63–77, p. 70.

59 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 70.

60 Ibid. 130.

61 Ibid. 43.

62 Bateman, A., Fonagy, P. and Campbell, C. (2019). ‘Borderline Personality Disorder’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 323–334, p. 330. Given reflection, this claim seems somewhat unlikely. Jurist gives a whole chapter in his book on mentalizing emotion to discussing emotions that do not feel wholly real, and that prompt doubt in themselves. In a sense, this claim might instead be regarded as definitional, in clarifying what Fonagy and colleagues actually mean by emotion—i.e. an affective state which cannot prompt doubt in the reality of what is perceived. This gives further evidence for the porous boundary between the constructs of arousal/emotionality and psychic equivalence, discussed earlier in the chapter, if states of arousal/emotionality imply a lack of doubt in current perceptions. On emotions that do not feel wholly real, see Jurist, E. (2018). Minding Emotions: Cultivating Mentalisation in Psychotherapy, New York: Guilford Press, Chapter 1.

63 E.g. Bateman, A., Fonagy, P., and Campbell, C. (2019). ‘Borderline Personality Disorder’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 323–334: ‘We see dysregulated emotional thinking as triggering the concreteness of the psychic equivalence mode, which in turn makes it difficult for the individual to accept alternative perspectives that could help to contextualise and downregulate the intensity of the experience’ (p. 326).

64 Dysregulation connotes both intensity and out-of-context affect, but in fact only one or the other may be a problem. It suggests all affects that are poorly regulated, but it is not clear that joy or awe or political outrage, even if dysregulated, would be what Fonagy and colleagues wish to capture. It is also not clear whether the term ‘emotion dysregulation’ is intended to capture states such as flat affect. This would seem to depend on what is meant by ‘regulation’. Berlant, L. (2015). ‘Structures of Unfeeling: Mysterious Skin’. International Journal of Politics, Culture, and Society, 28(3): 191–213. One well-known definition of emotion regulation is that of Gross, in which it encompasses five processes: situation selection, situation modification, attentional deployment, cognitive change, and response modulation. It might be that for Fonagy and colleagues emotion dysregulation is the breakdown of one or more of these processes and/or other social processes. However, if so, then this would call for work to clarify the specific breakdowns on these five dimensions they anticipate would be associated with non-mentalizing modes. Appeal merely to the umbrella term ‘dysregulated emotion’ has negative consequences for the work of Fonagy and colleagues—for instance, in contributing to the difficulties keeping track of attentional deployment, which is sometimes distinguished from and sometimes included within emotion dysregulation; also in contributing to difficulties distinguishing emotion dysregulation from non-mentalizing. Gross, J. J. and Jazaieri, H. (2014). ‘Emotion, Emotion Regulation, and Psychopathology: An Affective Science Perspective’. Clinical Psychological Science, 2(4): 387–401.

65 Fonagy, P. and Target, M. (2004). ‘Playing with the Reality of Analytic Love: Commentary on Paper by Jody Messler Davies “Falling in Love with Love”’. Psychoanalytic Dialogues, 14(4): 503–515; Target, M. (2007). ‘Is our Sexuality our Own? A Developmental Model of Sexuality Based on Early Affect Mirroring’. British Journal of Psychotherapy 23(4): 517–530.

66 Target, M. and Fonagy, P. (1996). ‘Playing with Reality II: The Development of Psychic Reality from a Theoretical Perspective’. The International Journal of Psychoanalysis, 77: 459–479, p. 469.

67 Target, M. (2008). ‘Some Thoughts on Lying and Pretending’. Plenary delivered to the British Psycho-Analytical Society Scientific Meeting, 18 June. Accessed at: https://wcp.memberclicks.net/assets/documents/friday-eveplenary-target-lyingandpretending.pdf: ‘Islands of unbearable experience (as with Dr P), may be identified through the analyst’s sensitivity to the rawness of psychic equivalence, and his maintenance of the safe “pretend” frame.’

69 Csibra, G. and Gergely, G. (1998). ‘The Teleological Origins of Mentalistic Action Explanations: A Developmental Hypothesis’. Developmental Science, 1(2): 255–259, p. 255.

70 Leslie, A. M. (1993). ‘A Theory of Agency’, Technical Report TR-12, Rutgers University Center for Cognitive Science.

71 Gergely, G., Nadasdy, Z., Csibra, G. and Bıro, S. (1995). ‘Taking the Intentional Stance at 12 Months of Age’. Cognition, 56: 165–193.

72 Gergely, G. and Csibra, G. (1997). ‘Teleological Reasoning in Infancy: The Infant’s Naive Theory of Rational Action: A Reply to Premack and Premack’. Cognition, 63(2): 227–233, pp. 231–232.

73 Csibra, G. and Gergely, G. (1998). ‘The Teleological Origins of Mentalistic Action Explanations: A Developmental Hypothesis’. Developmental Science, 1(2): 255–259, p. 259.

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

75 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, p. 161.

76 Fonagy, P. (1994). ‘Mental Representations from an Intergenerational Cognitive Science Perspective’. Infant Mental Health Journal, 15(1): 57–68, p. 64.

77 This example is from Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 137. For careful disambiguation of the concept of enactment, which has links to teleological mode, see Bohleber, W., Fonagy, P., Jiménez, J. P., Scarfone, D., Varvin, S., and Zysman, S. (2013). ‘Towards a Better Use of Psychoanalytic Concepts: A Model Illustrated Using the Concept of Enactment’. The International Journal of Psychoanalysis, 94(3): 501–530.

78 Bateman, A., Fonagy, P. and Campbell, C. (2019). ‘Borderline Personality Disorder’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 323–334, p. 327.

79 Fonagy, P. (2016). ‘The Role of Attachment, Epistemic Trust and Resilience in Personality Disorder: A Trans-Theoretical Reformulation’, DMM News, 22, September. Accessed at: http://www.iasa-dmm.org/images/uploads/DMM%20%2322%20Sept%2016%20English.pdf: ‘The teleological mode refers to states of mind where mental attitudes are only recognised if they are accompanied by a tangible signifier and lead to a definite outcome. Hence, the individual can recognize the existence and potential importance of states of mind, but this recognition is limited to very concrete, observable situations’ (p. 3).

80 Luyten, P., Fonagy, P., Lemma, A., and Target, M. (2012). ‘Depression’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 385–418, p. 400.

81 Fonagy, P. (2000). ‘Attachment and Borderline Personality Disorder’. Journal of the American Psychoanalytic Association, 48(4): 1129–1146: ‘It is conceivable that, at a stage when such nonconscious mind-reading skills begin to evolve, the implications for the child of trying to infer the intentions behind their caregivers’ reactions are so negative that they are forced to fall back on the strategy of influencing the other by action rather than by words. However, they retain access at a nonconscious level to mental states, although they repudiate consciousness of it. It is not that borderline patients are “mind blind”; it is rather that they are not “mind conscious”. They pick up on cues that influence the behavioural system, but these do not surface in terms of conscious inferences’ (p. 1141). On the focus on observable behaviour under teleological mode as a form of hypervigilance, see Bateman, A., Fonagy, P., and Campbell, C. (2019). ‘Borderline Personality Disorder’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 323–334, p. 328.

82 Fonagy, P. (2011). ‘Discussion of Juan Pablo Jimenez’s Paper, “A Fundamental Dilemma of Psychoanalytic Technique. Reflections on the analysis of a Perverse Paranoid Patient”’, in J. P. Jimenez and Moguillansky, R. (eds), Clinical and Theoretical Aspects of Perversion, London: Karnac Books, pp. 63–76, p. 71.

83 The classic work here is Sroufe, L. A. and Waters, E. (1977). ‘Attachment as an Organizational Construct’. Child Development, 48(4): 1184–1199. See also Fonagy, P., Gergely, G., Jurist, E. L., and Target, M. (2002). Affect Regulation, Mentalization and the Development of the Self, London: Karnac Books.

84 In a presentation from October 2007, Fonagy characterized teleological mode as ‘misuse of (cognitive) mentalization’. Fonagy, P. (2007). ‘Infancy and Borderline Personality Disorder’. Accessed at: https://www.hebpsy.net/articles.asp?id=1510.

85 Gagliardini, G. and Colli, A. (2019). ‘Assessing Mentalization: Development and Preliminary Validation of the Modes of Mentalization Scale’. Psychoanalytic Psychology, 36(3): 249–258.

86 See Bloom, H. and Rosenbluth, M. (1989). ‘The Use of Contracts in the Inpatient Treatment of the Borderline Personality Disorder’. Psychiatric Quarterly, 60(4): 317–327; Miller, L. J. (1990). ‘The Formal Treatment Contract in the Inpatient Management of Borderline Personality Disorder’. Psychiatric Services, 41(9): 985–987.

87 Luyten, P. and Fonagy, P. (2012). ‘The Multidimensional Construct of Mentalization and its Relevance to Understanding Borderline Personality Disorder’, in A. Fotopoulou, D. Pfaff, and M. A. Conway (eds), From the Couch to the Lab: Trends in Psychodynamic Neuroscience, Oxford: Oxford University Press, pp. 405–427, p. 407.

88 Skårderud, F. and Fonagy, P. (2012). ‘Eating Disorders’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Publishing, pp. 347–384, p. 366. This aligns with Fonagy’s earliest discussion of contracts with patients with borderline personality disorder, in which he and Higgitt were broadly in favour. Higgitt, A. and Fonagy, P. (1992). ‘Psychotherapy in Borderline and Narcissistic Personality Disorder’. The British Journal of Psychiatry, 161(1): 23–43.

89 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘Because of the teleological stance that those with eating disorders often display, we consider written agreements to be very useful here (p. 99); ‘Contracts tend to be individualised and specific, often targeting particular areas likely to cause problems in treatment. We are not great proponents of draconian contracts likely to lead to discharge when their conditions are not fulfilled. Fluctuating mentalising capacity means that a patient who agrees to a contract at one point may not actually have the same competence in a different context’ (p. 166).

90 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, pp. 62–64.

91 Luyten, P., Fonagy, P., Lowyck, B., and Vermote, R. (2012). ‘The Assessment of Mentalization’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 43–66, Table 2.10.

92 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: ‘A stage of development when children experience an equivalence between the internal and external. I shall call this “actual mode”, alongside a representational mode of psychic functioning decoupled from external reality, a “pretend mode” ’ (p. 39).

93 Pearson, J. (2007). Evaluating an Alternative Coding Manual for the AAI for Use with People with Personality Disorders. Unpublished DClinPsy thesis, London: University College London; Lee, T. (2007). The Development of an Alternative Personality Disorder Coding Manual for Use with the Adult Attachment Interview (AAI): A Psychoanalytical Approach. Unpublished DClinPsy thesis, London: University College London; Buettner, A. (2009). Personality Pathology and Memories of Childhood: Development of a New, Psychoanalytically Informed Measure. Unpublished doctoral thesis, London: University College London.

94 E.g. Allen, J. G., Lemma, A., and Fonagy, P. (2012). ‘Trauma’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 419–444): ‘The inhibition of mentalising in a traumatising, hyperactivated attachment relationship leads to a prementalistic psychic reality, largely split into psychic equivalence and pretend modes’ (p. 432).

95 Karterud, S., Pedersen, G., Engen, M., Johansen, M. S., Johansson, P. N., Schlüter, C., … and Bateman, A. W. (2013). ‘The MBT Adherence and Competence Scale (MBT-ACS): Development, Structure and Reliability’. Psychotherapy Research, 23(6): 705–717. Though it should be noted that identifying and working with psychic equivalence appears to be both rare, and difficult to code reliably, using this scale. It may be that the scale will undergo revision or refinement in the coming years. Simonsen, S., Juul, S., Kongerslev, M., Bo, S., Folmo, E. and Karterud, S. (2019). ‘The Mentalization-Based Therapy Adherence and Quality Scale (MBT-AQS): Reliability in a Clinical Setting’. Nordic Psychology, 71(2): 104–115.

96 Fonagy, P. (2003). ‘Genetics, Developmental Psychopathology, and Psychoanalytic Theory: The Case for Ending our (Not So) Splendid Isolation’. Psychoanalytic Inquiry, 23(2): 218–247: “Through our growing knowledge of infants’ actual capacities we may limit speculation concerning the impact of infancy on adult function. The projective processes of infancy are unlikely to work in the adultomorphic way described by Bion (1957, 1962a, b) and Klein (1935, 1952, 1958), but this does not mean that these descriptions do not contain important truths about adult mental function, simply that “infancy” is used metaphorically in these theorizations about mental process.” (231).

97 Fonagy, P. (2010). ‘Development’, in R. M. Skelton (ed.), The Edinburgh International Encyclopaedia of Psychoanalysis, Edinburgh: Edinburgh University Press, pp. 118–121, p. 120.

98 Luyten, P., Mayes, L. C., Nijssens, L., and Fonagy, P. (2017). The parental reflective functioning questionnaire: development and preliminary validation. PLoS ONE, 12(5): e0176218.

99 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 19.

100 E.g. Bateman, A. and Fonagy, P. (2019). ‘Introduction’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalizing in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 14.

101 Skårderud, F. (2007). ‘Eating One’s Words, Part II: The Embodied Mind and Reflective Function in Anorexia Nervosa—Theory’. European Eating Disorders Review, 15(4): 243–252; Shai, D. and Fonagy, P. (2014). ‘Beyond Words: Parental Embodied Mentalizing and the Parent Infant Dance’, in M. Mikulincer and P. R. Shaver (eds), Mechanisms of Social Connections: From Brain to Group, Washington, DC: American Psychological Association, pp. 185–203. See also Merleau-Ponty, M. ([1945] 2012). Phenomenology of Perception, trans. Donald A. Landes, London: Routledge.

102 Drawing here from Hegel’s remarks on Kant’s synthesis of apperception and faculty of understanding. Hegel, G.W. F. ([1816] 2010). The Science of Logic, trans. and ed. G. Di Giovanni. Cambridge: Cambridge University Press. For Hegel, sense certainty (psychic equivalence) and mere appearance (pretend mode) were two moments in the dialectic that produces both lived experience, and the potential for consciousness of that experience (reflection).

103 Winnicott, D. W. (1960). ‘The Theory of the Parent–Infant Relationship’. The International Journal of Psychoanalysis, 41: 585–595; Winnicott, D. W. (1971). Playing and Reality, London: Routledge.

104 Dependence on the experiences and accounts of others for accounting for oneself is not in itself a false self in Winnicott’s terms. He terms this ‘compliance’, and sees it as an important developmental achievement. The false self arises when this dependence is exclusive, and one’s own experiences cannot be mined as a resource for this accounting activity. Winnicott, D. W. ([1960] 1965). Ego Distortion in Terms of True and False Self, the Maturational Process and the Facilitating Environment, New York: International Universities Press, pp. 140–152.

105 E.g. Fonagy, P. and Target, M. (2006). ‘The Mentalization-Focused Approach To Self Pathology’. Journal of Personality Disorders, 20(6): 544–576: ‘Mentalizing is imaginative because we have to imagine what other people might be thinking or feeling; an important indicator of high quality of mentalization is the awareness that we cannot know absolutely what is in someone else’s mind. We suggest that a similar kind of imaginative leap is required to understand one’s own mental experience, particularly in relation to emotionally charged issues’ (p. 544). There are significant parallels here between the position of Fonagy and colleagues and that of Kant in conceptualizing ‘productive imagination’ and conceptual understanding within human cognition, and the necessity of both. Of particular relevance is §24 ‘On the application of the categories to objects of the senses in general’ in the doctrine of the elements in Critique of Pure Reason. In Kant’s Lectures on Logic, he suggested that ‘imagination and understanding are two friends who cannot do without one another but cannot stand one another either, for one always harms the other. The more universal the understanding is in its rules, the more perfect it is, but if it wants to consider things in concreto then it absolutely cannot do without the imagination.’ Kant, I. (2012). Lectures on Logic, trans. J. Michael Young, Cambridge: Cambridge University Press, p. 447: Fonagy and colleagues even tend, like Kant, to align productive imagination with automatic processing and conceptual understanding with controlled mentalizing, though Fonagy and colleagues are less strict (but also less clear) in this assumption of alignment than Kant. For Kant’s position, see Leech, J. (2014). ‘Making Modal Distinctions: Kant on the Possible, the Actual, and the Intuitive Understanding’. Kantian Review, 19(3): 339–365: ‘We need the concepts of possibility and actuality to cope with our divided cognitive architecture. There is something about the way we are able to cognize objects, come into epistemic contact with them, and think about them, that leaves a gap between our thoughts of things and the existence of those things. If we are to assure ourselves of genuine representation of real objects, and the possibility of knowledge of them, then we need a way to distinguish the actual cases from the merely possible. We at least need to be able to conceptualize this difference to make sense of sceptical worries, and to formulate strategies for avoiding error (e.g. seek out some direct experience of a purported possible thing—a consistent concept is not sufficient for existence)’ (p. 358–359).

106 The term ‘understanding’ has varied meanings of course, and is not wholly stable across the writings of Fonagy and colleagues. Nonetheless, when the term appears, it tends to entail the development of an accurate account of something through appeal to intentional mental states. This has also been Fonagy’s account of the concept of understanding in a recent interview:BBC Radio 4 (2020). ‘Peter Fonagy on a Revolution in Mental Health Care’. The Life Scientific Podcast, 28 January. Accessed at: https://www.bbc.co.uk/programmes/m000dpj2. Though certainly there are differences, a predecessor for this account of ‘understanding’ is Jasper’s definition, as a process through which ‘we sink ourselves into the psychic situation and understand genetically by empathy how one psychic event emerges from another’, Jaspers, K. ([1946] 1963). General Psychopathology, trans. J. Hoenig and M. W. Hamilton, Baltimore, MD: Johns Hopkins University Press, p. 301. Perhaps the greatest difference here is that, whereas Jaspers appeals to empathy, mentalization is conceptualized as focused on the discernment of motivations and intentions.

107 Allison, E. and Fonagy, P. (2016). ‘When is truth relevant?’ Psychoanalytic Quarterly, 85(2): 275–303, p. 279.

108 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 118.

109 Fonagy, P. (1989). ‘On Tolerating Mental States: Theory of Mind in Borderline Patients’. Bulletin of the Anna Freud Centre, 12: 91–115, p. 96.

110 Kalisch, R., Müller, M. B., and Tüscher, O. (2015). ‘A Conceptual Framework for the Neurobiological Study of Resilience’. Behavioral and Brain Sciences, 38: e.92. See also Kalisch, R., Cramer, A. O. J., Binder, H., Fritz, J., Leertouwer, I., Lunansky, G., Meyer, B., et al. (2019). ‘Deconstructing and Reconstructing Resilience: A Dynamic Network Approach’. Perspectives on Psychological Science, 14(5): 765–777.

111 The term ‘resilience’ is a widely used buzzword. As Fonagy notes, ‘resilience has been conceptualised variously as a tool, characteristic, potential, attitude, act, asset, value, process, trait, skill, resource, strength … capacity, disposition, performance, competency’, and many others. The definition preferred by Fonagy is that of Rudrauf: ‘The ability of a system to resist dynamically a perturbation or adverse condition that challenges the integrity of its normal operation and to preserve function as a result in reference to some initial design or normative functional standards.’ Rudrauf, D. (2014). ‘Structure-Function Relationships behind the Phenomenon of Cognitive Resilience in Neurology: Insights for Neuroscience and Medicine’. Advances in Neuroscience: 1–28, p. 4. Fonagy, P. (2015). ‘Psychotherapy for Emerging Borderline Personality Disorder’. Keynote address to the European Society of Child & Adolescent Psychiatry, Madrid, 21 June. Accessed at: https://www.escap.eu/uploads/Events/Madrid%202015/peter-fonagy-escap-presentation.pdf.

112 Freund and Staudinger have criticized Kalisch for assuming that only positive appraisals contribute to resilience. They regard the capacity for negative appraisals as also important. Freund, A. M. and Staudinger, U. M. (2015). ‘The Value of “Negative” Appraisals for Resilience. Is Positive (Re) Appraisal Always Good and Negative Always Bad?’ Behavioral and Brain Sciences, 38: e101. If Fonagy and colleagues are read as simply endorsing Kalisch’s model, they would be vulnerable to the same criticism. However, it would appear—though it is not spelt out—that they apply the model especially to reconsideration rather than the conception of experience. The criticism by Freund and Staudinger therefore does not apply. In fact, the capacity to reappraise present-day thoughts and feelings more soberly is raised in Fonagy, P., Allison, E., and Campbell, C. (2019). ‘Mentalising, Resilience and Epistemic Trust’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, 63–77, p. 68. Likewise implied is the contribution to resilience of a capacity to reappraise positive past thoughts and feelings, not just past threat-related sensations. These latter points are dealt with explicitly in Bo, S., Bateman, A., and Kongerslev, M. T. (2019). ‘Mentalization-Based Group Therapy for Adolescents with Avoidant Personality Disorder: Adaptations and Findings from a Practice-Based Pilot Evaluation’. Journal of Infant, Child, and Adolescent Psychotherapy, 18(3): 249-262.

113 Badoud and colleagues have referred to experiences of self and others unhindered by undue certainty or undue uncertainty about mental states as “calibrated mentalisation”. Badoud, D., Prada, P., Nicastro, R., Germond, C., Luyten, P., Perroud, N., and Debbané, M. (2018). ‘Attachment and Reflective Functioning in Women with Borderline Personality Disorder’. Journal of Personality Disorders, 32(1): 17–30, p. 22.

114 Fonagy, P., Luyten, P., Moulton-Perkins, A., Lee, Y. W., Warren, F., Howard, S., … and Lowyck, B. (2016). ‘Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire’. PLoS One, 11(7): e0158678. For critical appraisal of the psychometric properties of the two scales of the RFQ see Spitzer, C., Zimmermann, J., Brähler, E., Euler, S., Wendt, L. P., and Müller, S. (2020). ‘Die deutsche Version des Reflective Functioning Questionnaire (RFQ): Eine teststatistische Überprüfung in der Allgemeinbevölkerung’. Psychotherapie- Psychosomatik - Medizinische Psychologie, Early View. Müller, S., Wendt, L. P., Spitzer, C., Masuhr, O., Back, S. N., and Zimmermann, J. (2020). ‘A Critical Evaluation of the Reflective Functioning Questionnaire’. https://psyarxiv.com/5rhme/. An earlier scale was developed by Hausberg, M. C., Schulz, H., Piegler, T., Happach, C. G., Klöpper, M., Brütt, A. L., … and Andreas, S. (2012). ‘Is a self-Rated Instrument Appropriate to Assess Mentalization in Patients with Mental Disorders? Development and First Validation of the Mentalization Questionnaire (MZQ)’. Psychotherapy Research, 22(6): 699–709. This scale had four factors: avoidance of thinking about mental states; difficulties perceiving inner states; psychic equivalence; and difficulties modulating affect. However, Fonagy and colleagues appear to have not known about or ignored the existence of this scale. It is not mentioned anywhere in their work, not even in the 2016 paper developing their own scale.

115 There is something of a contrast that can be drawn here between Fonagy and Bion in that the former emphasizes the threat of indiscriminate uncertainty. For the latter, the threat of excessive certainties is so pervasive that indiscriminate uncertainty—while likely to be avoided—is not explicitly characterized as a problem. For instance, Bion speculated that all else is ultimately disposable, but that a psychoanalytic situation is operative if neither therapist nor patient feel ‘compelled to search “irritably” for certainty as a method of stifling doubts, uncertainties, mysteries, half-truths and neither is compelled to assert anything as a means by which doubt and uncertainties are evaded’. Such claims suggest that an essential strand of the psychoanalytic tradition is a commitment to generative doubt, making it seem unlikely that it would be an especially clean marker of Dynamic Interpersonal Therapy compared with other low-intensity psychodynamic therapies. Bion, W. R. ([1969] 2014). ‘Further Cogitations’, in Chris Mawson (ed.), The Complete Works of W. R. Bion, Volume 15. London: Karnac Books.. See also Ricoeur, P. (1970). Freud and Philosophy: An Essay on Interpretation, New Haven: Yale University Press.

116 It might be argued that the relationship between mentalizing and non-mentalizing would mirror adult attachment styles, which are conventionally measured on two dimensions of insecurity. However, recent psychometric work on adult attachment styles has indicated that this approach neglects a third factor, of security, distinct from the absence of insecurity. Gillath, O., Hart, J., Noftle, E. E., and Stockdale, G. D. (2009). ‘Development and Validation of a State Adult Attachment Measure (SAAM)’. Journal of Research in Personality, 43(3): 362–373; Frıas, M. T., Shaver, P. R., and Mikulincer, M. (2014). ‘Measures of Adult Attachment and Related Constructs’, in G. J. Boyle and D. H. Saklofske (eds), Measures of Personality and Social Psychological Constructs, Philadelphia, PA: Elsevier, pp. 417–447. Evidence in support of this conclusion comes from a factor analysis of aspects of a clinician-report measure of mentalizing, in which mentalizing was identified as a distinct factor, not merely the inverse of the non-mentalizing factors. Gagliardini, G. and Colli, A. (2019). ‘Assessing Mentalization: Development and Preliminary Validation of the Modes of Mentalization Scale’. Psychoanalytic Psychology, 36(3): 249–258. It is also notable that these researchers found that MBT therapists rated ‘good mentalizing’ higher than CBT therapists, suggesting that they had been trained to recognize this as a distinct quality of clinical interactions.

117 Luyten, P., Mayes, L. C., Nijssens, L., and Fonagy, P. (2017). ‘The parental reflective functioning questionnaire: development and preliminary validation’. PLoS ONE, 12(5): e0176218.

118 By way of comparison, Luyten and colleagues drew upon a theoretical review of the concept to identify three essential elements of parental reflective function (PRF) in developing a self-report measure: ‘(a) interest and curiosity in mental states, (b) the ability to recognize the opacity of mental states, and (c) nonmentalizing modes characteristic of parents with (severe) impairments in PRF (e.g. malevolent attributions, inability to enter into the subjective world of the child)’. Again, the first and second factors can be regarded as reflecting a discriminated capacity for doubt and reconsideration. Luyten, P., Mayes, L. C., Nijssens, L., and Fonagy, P. (2017). ‘The Parental Reflective Functioning Questionnaire: Development and Preliminary Validation’. PLoS One, 12(5): e0176218.

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

120 Target, M. and Fonagy, P. (1996). ‘Playing with reality: II. The Development of Psychic Reality from a Theoretical Perspective’. The International Journal of Psychoanalysis, 77: 459–479, p. 467. See also Fonagy, P., Moran, G. S., and Target, M. (1993). ‘Aggression and the Psychological Self’. The International Journal of Psychoanalysis, 74: 471–485: ‘Winnicott (1965) describes how a “false self”, dedicated to pleasing the object, but eschewing genuine reflection, may develop’ (p. 475).

121 Ensink, K., Leroux, A., Normandin, L., Biberdzic, M., and Fonagy, P. (2017). ‘Assessing Reflective Parenting in Interaction with School-Aged Children’. Journal of Personality Assessment, 99(6): 585–595, p. 588.

122 See Steiner, J. (2003). Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients, London: Routledge.

123 Schimmenti, A. and Caretti, V. (2010). ‘Psychic Retreats or Psychic Pits?: Unbearable States of Mind and Technological Addiction’. Psychoanalytic Psychology, 27(2): 115.

124 Schimmenti, A., Guglielmucci, F., Barbasio, C., and Granieri, A. (2012). ‘Attachment Disorganization and Dissociation in Virtual Worlds: A Study on Problematic Internet Use among Players of Online Role Playing Games’. Clinical Neuropsychiatry, 9(5): 195–203.

125 Duschinsky, R., Reisel, D., and Nissen, M. (2018). ‘Compromised, Valuable Freedom: Flat Affect and Reserve as Psychosocial Strategies’. Journal of Psychosocial Studies, 11(1): 68–92. See also Winnicott, D. W. (1988). ‘Withdrawal and Regression’, in Human Nature, London: Free Association Books, pp. 141–142.

126 Winnicott, D. W. (1945). ‘Primitive Emotional Development’. The International Journal of Psychoanalysis, 26: 137–143.

127 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 52.

128 Tuber, S. (2015). ‘Psychological Mindedness in the Face of a Learning Disability: The Utility of Play’. Journal of Infant, Child, and Adolescent Psychotherapy, 14(3): 288–293; Derks, S., van Wijngaarden, S., Wouda, M., Schuengel, C., and Sterkenburg, P. S. (2019). ‘Effectiveness of the Serious Game “You & I” in Changing Mentalizing Abilities of Adults with Mild to Borderline Intellectual Disabilities: A Parallel Superiority Randomized Controlled Trial’. Trials, 20(1): 1–10.

129 Fonagy, P., Gergely, G., and Target, M. (2007). ‘The Parent–Infant Dyad and the Construction of the Subjective Self’. Journal of Child Psychology and Psychiatry, 48(3–4): 288–328, p. 290.