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(p. 133) Conceptualizing the ‘self’ 

(p. 133) Conceptualizing the ‘self’
Chapter:
(p. 133) Conceptualizing the ‘self’
Author(s):

Robbie Duschinsky

and Sarah Foster

DOI:
10.1093/med-psych/9780198871187.003.0007
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date: 06 December 2021

Introduction

In Chapter 5, we described Fonagy and colleagues’ concept of ‘hypermentalization’ as a form of non-mentalizing in pretend mode. Hypermentalization is difficult to tell apart from mentalization. The elements that seem to be absent are grounding in present or past experience and the capacity for reconsideration of thoughts and feelings. Yet the construct of perceptual experience could use further consideration, above all in how it overlaps with or differs from the concept of ‘self’. The idea of ‘the self’ has been a critical one for Fonagy and colleagues for over 30 years. The theory of the self stemming from work on mentalization has been praised by allies as representing one of the main advances over prior work on ‘theory of mind’, such as Baron-Cohen (Chapter 3).1 Bateman and Fonagy have even described mentalizing as ‘first and foremost’ a ‘theory of the development of the self’.2

In part, this is because mentalization has developed as a clinical theory, in a context in which patients themselves have described their symptoms as relating to the ‘self’ and its problems.3 However, Fonagy and colleagues have also developed a surprising, and at times uncanny, account of the self, which has informed their theory of mentalization in diverse ways. This includes the distinction between mentalizing the self and mentalizing others, which Fonagy and Luyten gave as one of the four opposing poles of mentalization (before then qualifying that actually mentalizing self and mentalizing others is not actually an opposition). Yet, beyond this, consideration of the theory of the self is also essential for understanding how Fonagy and colleagues believe thoughts and feelings are constructed, the relationship between conscious and unconscious aspects of the self, and their account of what we glean and protect ourselves from within present or past experience.

The terms ‘mental states’ or ‘intentions’ serve as placeholders in the work of Fonagy and colleagues that help mentalization theory travel across disciplinary spaces to varied audiences, though at the price of simplification. At times, their writing can give the impression that thoughts and feelings about personal experience are lying around within minds, waiting to be recognized unless blocked by non-mentalizing.4 This may be an effect of Fonagy’s early indebtedness to the literature on theory of mind, in which mental states tend to be treated as singular and determinate.5 Fonagy and colleagues have paid little attention to differences (p. 134) between mentalizing unitary versus multiple or conflictual states of mind, which is surprising since their correlates could be expected to be quite different. As a point of contrast, in Bion’s work, thoughts and feelings could be inchoate, hybrid, characterized by inadequacy or overspill. He regarded this as important because whole domains of human experience are defined precisely by falling beneath or beyond determinate thoughts and feelings: this ranges from disavowed wishes, to experiences of the sublime, to taken-for-granted and sedimented habit. As Bion argued, even our most unitary and determinate thoughts and feelings are elaborated, and subjectively encountered as relevant, within a thick and heterogenous context of proto-thoughts and proto-feelings prompted by our past experiences and present environment.6

An interesting illustration is mood. Besides its use in the technical phrase ‘mood disorders’, the term appears remarkably rarely in the writings of Fonagy and colleagues, given that the theory of mentalizing is centrally concerned with mental states. This is despite the fact that they acknowledge that improvements in mood are one of the priorities they themselves have for treatment, perhaps even above symptomatic improvement.7 Fonagy and colleagues have, if somewhat unsteadily, generally treated mental states as if they were relatively determinate and linked with intentions. However, it has long been recognized by scholars of mood, at least since Edith Jacobson in the psychoanalytic literature, that mood does not necessarily have these qualities. Indeed, a mood does not need to be ‘about’ anything particular; it does not need to have a particular intended object.8 This is implicitly acknowledged by Fonagy and colleagues on the various occasions that the term ‘mood’ does appear in their writing. So, for instance, in their 1991 paper, Fonagy and colleagues state that reflective functioning developmentally incorporates skills at both ‘sensing and responding to the mood of another’ and ‘the understanding of others’ intentions’, distinguishing the two.9 In 2008, (p. 135) Baradon, Fonagy, and colleagues distinguish mental states, moods, self-esteem, and sense of social connectedness in analysing the narratives of incarcerated mothers with care for their infants.10 As we shall see in Chapter 7, factor analysis of mental health symptoms reveals mood as a distinct sub-factor with distinct correlates. Luyten and Fonagy have discussed a distinction between ‘feelings’, ‘affects’, and ‘emotions’, where affects (including mood) are characterized as a tone rather than an intentional mental state oriented towards an object. They state that all three ‘would come under this category of mentalising’.11 However, as we saw in Chapter 4, the definitions of mentalizing are uneven in whether inchoate and non-intentional forms of thought and feeling form part of the construct.12

What account Fonagy and colleagues offer of the dynamic properties and emergence of thoughts and feelings offered is often speculative, not fully fleshed out, and discussed primarily in venues for psychoanalytic audiences.13 It is also generally yet to generate commentary, whereas the more basic elements of mentalization theory have generated a large literature, albeit predominantly exposition (the primary exceptions are the few dedicated critiques of the concept of implicit mentalizing).14 A contributing factor is that ideas of proto-thoughts and feelings are bound up with work by Fonagy and colleagues reflecting on the idea of the ‘self’. This is a tricky concept, with a history of contradictory use of terminology regarding the self in psychoanalytic theory especially and psychological discourse more broadly.15

Fonagy and colleagues acknowledged the problems that the term ‘self’ could cause, and took psychoanalytic theory to task for loose use of the concept, though Fonagy and colleagues not infrequently fail to heed their own warnings. Critics have stated that, given the pivotal role of the concept of ‘self’ in work on mentalization, the lack of definition of the concept is a major problem for the theory as a whole.16 Fonagy and colleagues can be found (p. 136) at times leaning on the term’s imprecision for making evocative claims, in the manner they criticized in psychoanalytic discourse.17 For instance, as we saw in Chapter 3, Fonagy and colleagues have at times described disorganized attachment as caused by disorganization of the self; and at times they have described disorganization of the self as caused by disorganized attachment. Of course both may be true, but it raises the question of what is meant by ‘self’ in each instance. More generally, clarification of the concept of the self has important bearing for understanding the operation of both mentalizing and non-mentalizing. Additionally, recent statements have indicated that Fonagy and colleagues plan to further integrate their ideas about the self more firmly into approaches to clinical technique in the near future (see Chapter 8).

This chapter will begin by considering broader currents in social science and psychology that made the concept of ‘self’ salient at the point that mentalization theory was being developed, and the ways that Fonagy and colleagues have conceptualized the self. We discuss the concept of ‘alien self’, introduced by Fonagy and colleagues to describe the experience of desires and elements of personal experience that disturb self-representations. We will then explore the account they offer of sexuality and aggression, as two inevitable and especially potent components of the alien self.

What is a self?

Deployment of the concept of ‘self’ by Fonagy and colleagues can usefully be placed in the history of psychological theory. In Principles of Psychology in 1890, William James dedicated a chapter of ‘consciousness of self’, which he described as ‘justly regarded as the most puzzling puzzle with which psychology has to deal; and whatever view one may espouse, one has to hold his position against heavy odds’.18 From the turn of the century, the idea of the ‘self’ fell into decline as part of the emergence of psychology as an empirical discipline, which distrusted the concept as a mask and obfuscation of actual psychological mechanisms that could be identified, operationalized, and tested. The primary exception was Mary Whiton Calkins, who was forced to fight the current in order to maintain experiences of the ‘self’ as a legitimate object of psychological theory and scientific inquiry. Calkins felt that a concept of ‘self’ was needed in order to understand several features of psychological life, not least how individuals experience themselves as morally or socially obligated to others.19 The current reversed, however, in the early 1950s.20 Key second generation of psychoanalytic thinkers had fled Europe for New York in the 1930s and developed ego psychology, an approach that downgraded the centrality of drive theory and (p. 137) instead accentuated the individual’s adaptation to their environment.21 In 1950, one of the leading ego psychologists, Hartmann, introduced the term ‘self’ into psychoanalytic theory. He proposed that whereas ‘ego’ should be used for descriptions of intra-individual dynamics, the term ‘self’ should be used for examining the relationship of the individual with others.22 This was in part in response to an ambiguity in Freud’s writings, where the term ‘ego’ had encompassed both senses.23 In the same period as Hartmann’s introduction of the ‘self’ into psychoanalysis, concepts of ‘self-esteem’ and ‘self-actualization’ were put forward by American humanistic psychologists such as Abraham Maslow and Carl Rogers.24 Use of the term ‘self’ helped Rogers contrast his humanistic therapeutic approach with Hartmann and the position of the ego psychologists, for whom the ‘ego’ was to a large extent unconscious. Rogers’ deployed the idea of ‘self’ to highlight the active capacity of patients to know their own needs and to judge the goals and appropriate termination point for therapy.25

Examination of these discourses suggests that ‘self’ was less a determinate single object than a cluster of loosely related concerns, and their interrelation. Seven different referents of ‘self’ may be identified:

  1. 1. An individual as a discrete whole.

  2. 2. Her experience as an embodied subject.

  3. 3. Her passing or enduring knowledge of herself.

  4. 4. Enduring qualities of her personality, which she may or may not perceive.

  5. 5. Her agency.

  6. 6. Her social identity.

  7. 7. Her experience of personal authenticity.26

(p. 138) An important commentator at the time, Gordon Allport, called use of the term self ‘lazy’. He felt that the apparent obviousness and utility of the term lured psychologists into failing to draw distinctions between its varied meanings.27 It was easy for psychologists to talk right past one another, or their audiences, simply by assuming different meanings of the term. Allport felt that the concept appealed in part because of clear connections between these different phenomena, but simultaneously served to obscure their precise nature. Allport also astutely highlighted the social context of attention to the ‘self’, reflecting on the growing importance of individual self-management and personal lifestyle in the post-war economy and culture.28 Individual self-management and personal lifestyle would only grow as objects of concern and discussion over the subsequent decades (see Chapter 2). In the 1960s and 1970s, the ‘self’ would be re-absorbed by psychoanalysis in the work of Winnicott and Kohut. These psychoanalytic thinkers argued that failures of parental empathy and soothing responsiveness would lead developmentally to i) inauthentic and inaccurate self-knowledge on the part of individuals, ii) weaknesses and incoherencies in personality structure, iii) challenges in modulating emotions, and iv) difficulties with social relationships. The reason lay, Winnicott and Kohut argued, in the fact that all four are formed on the bedrock of early child–caregiver relationships.29

Commenting on these developments in their early book, Personality Theory and Clinical Practice, published in 1985, Fonagy and Higgitt criticized Rogers and humanistic psychologists for treating ‘the self as an entity and a causal agent able to consider and integrate perceptions’.30 This results in circular explanations, in which the role of thoughts and feelings get missed because motivation is simply assigned to ‘the self’ as the cause of action or beliefs. Fonagy was more sympathetic to the position of Winnicott and Kohut, whom he regarded as invoking the concept of ‘self’ in analysing the developmental outcomes of early care.31 In the 1990s, Fonagy and Target’s own emerging theory of mentalization aligned well, and to an extent was influenced by Winnicott and Kohut’s emphasis on the caregiver’s attention to the child’s thoughts, feelings, and/or intentions. Like these earlier thinkers, Fonagy and Target regarded qualities of the caregiver’s attention to the child as (p. 139) consequential for their later self-understanding, personality, capacities for affect regulation, and social relationships.32

Such an account also aligned with the conclusions of attachment theory in the late 1980s and early 1990s—for instance, in the work of Alan Sroufe33 (see Chapter 3). These different perspectives all converged on an account in which the child’s sense of self is ‘originally an extension of experience of the other’.34 This position became an abiding commitment for Fonagy from the 1990s, and one that he repeatedly identified with Hegel’s claim that ‘self consciousness exists in and for itself when, and by the fact that, it so exists for another; that is, it exists only in being acknowledged’.35 The passage from Hegel was interpreted by Fonagy and colleagues to mean that the child’s capacity to conceive of thoughts and feelings within itself stems from the reflective functioning of the caregiver, who provides emotional containment and acknowledgement of the child’s mental states and/or intentions.36 At times, Fonagy and colleagues extended this claim, to argue that the capacity to mentalize the self in adulthood or even the experience of having a self is an extension of interaction with and acknowledgement of others.37 However, this has been an unsteady claim. As we saw in Chapter 4, Bateman, Fonagy, and Campbell have recently claimed the opposite, that ‘to mentalise others requires the capacity to mentalise the self’.38 Examining the definitions of mentalizing in the final section of Chapter 4, it can be seen that sometimes Fonagy and colleagues imply that we understand the thoughts and feelings of (p. 140) ourselves through much the same means as we do the thoughts and feelings of others. And at other times they imply that, whereas the mental states of oneself require objectification and interpretation (‘seeing ourselves from the outside’), the mental states of others require inference and interpretation (‘seeing others from the inside’). When this contrast is drawn, the self’s mental states need to be ‘recognized’, whereas the mental states of others need to be ‘attributed’.39

From the 1990s to the present, the question of whether adults know the minds of others in the same way as we know our own minds has dogged Fonagy and colleagues as an unresolved issue.40 However, they have been entirely consistent on the developmental claim that a child’s self-representation is facilitated by parental reflective functioning. When this occurs, not only will the child’s capacities to form representations of thoughts and feelings be more elaborate and sophisticated, Fonagy and colleagues anticipated that representations of the child’s thoughts and feelings would also be comparatively more tolerably authentic and accurate. In the context of parental reflective functioning, Fonagy argued in 2000 that ‘the child’s emerging self-representation will map on to what could be called a primary or constitutional self (the child’s experience of an actual state of being, the self as it is)’, their perceptual experience.41 This growing focus on the importance of self-representation led Fonagy and Target to ambivalence about the way that Kohut especially, and Winnicott to an extent, invoked the idea of ‘self’ in explaining psychological symptoms. In 2003, Fonagy and Target argued that ‘the self is presented by Kohut in representational terms, yet he ascribes motivational properties to it. In this way, the self denotes most, if not all, of the personality and therefore becomes a superfluous term, much as the concept of ego was over-extended by ego psychologists.’ As a consequence, ‘by fitting all psychopathology into self-defects, Kohut has homogenised psychological disorder too much’.42

Fonagy agreed with previous commentators that psychoanalytic references to the ‘self’ had inherited from Freud’s ego the capacity to refer ‘alternately the individual, one part of a psychic structure, or the experiencing, subjective self’.43 In addition, however, he felt that the term had gained the capacity to refer to an individual’s self-concept, and to their motivations. To call all these ‘the self’, as did Kohut and sometimes Winnicott, was no doubt an evocative, metaphorical usage. But it was also a recipe for complacence, as a metaphorical description was substituted for work to identify precise explanation: ‘Confusion and ambiguity surround the status of the concept of self in psychoanalysis, particularly whether it is a theoretical (meta-psychological) construct of a system in the mind, part of our psychoanalytic theory of the mind, or an experiential one relating to the person’s cumulative affective experience.’44 Fonagy and Target’s (p. 141) criticism of Kohut and other psychoanalytic theorists would later be amplified by Luyten and Fonagy: ‘These metaphors are tremendously helpful from a phenomenological perspective but also have led to the reification of these self-experiences, as if we truly “have” a false or fragile self, or that we “have” an ideal and an actual self. Although helpful clinically, they provide a metaphorical description of the phenomenological experience of depression, rather than a true explanation.’45 The ‘self’ is a term for psychological theorists to conjure with, offering a luminous feeling of comprehension. The audience tend to nod along, given that there is usually some among the varied meanings of the term that both resonate and feel urgent for each person. Indeed, if psychic equivalence means to account for and explain thoughts and feelings and observable social behaviour in terms of immediate experience (see Chapter 5), then appeal to a hazy concept of ‘self’ by psychological theorists essentially erects a screen for diverse projections of immediate experience, and a lure towards this form of non-mentalizing.

Fonagy and Target were impressed with the use of the term ‘self’ by Edith Jacobson and Joseph Sandler, who had both restricted the word to refer to an individual’s representations of their embodied experience and personality, and avoided using the term to refer to the totality of the person. For Jacobson, for example, the term referred to the individual’s representation of the bodily and mental qualities of the individual.46 Sandler took this further, generally avoiding the unqualified term ‘self’ except where meaning would be clear from context, and preferring the term ‘self-representation’.47 In his later work, Sandler amended his formulation to clarify that what is represented in the self-representation is always the self-in-interaction-with-others rather than any asocial essence to the individual.48 Fonagy appreciated the way that Jacobson and Sandler were careful in their uses of the concept, and he agreed that any notion of the self is in part a representation. However, he personally disagreed with quite such a radical curtailment of the term. In 2000, he offered ‘a definition of the self as a part of the mind that is capable equally of recognizing its mental activities as its own and of attributing mental states to others. It is more than a representation, because it has the capacity to shape and determine how representations (of itself, of others) will be formed.’49 For Fonagy, the self is a special kind of representation that is implicated in the conception of mental states.

(p. 142) The primary unconscious

The argument of Fonagy and colleagues about the relationship between mentalization and the self as a special kind of representation is intriguing and complex. Its basis lies in their account of perceptual experience, and its psychodynamic underpinnings. For Hegel and the phenomenological tradition, human experience emerges out of the prompting of the outside world, and an individual’s perceptual transaction with these prompts.50 It is out of this openness that self-perception, and the potential to doubt our perceptions, emerges. Fonagy and colleagues generally agreed with this premise, though they have framed it in their own ways. First, as we have seen (Chapter 3), Fonagy bracketed the cultural constitution of the subject, focusing very largely on the parent–child relationship as the pivotal ‘outside’ that prompts the emergence of the individual subject. He would return, however, to the question of wider cultural factors in recent years (Chapter 9). Second, for Fonagy and colleagues, perceptual experience is staged in a mental setting already shaped and populated by unconscious processes.

In a paper from 2016, Fonagy and Allison have distinguished three forms of unconscious process. First are mental processes that are simply not conscious, like the breathing reflex. These can become the object of consciousness and can be controlled, but are not in themselves potentially disruptive of the self-representation and its activity. From André Green’s reading of Hegel and Freud, Fonagy and Allison draw a second form of unconscious process: mental states of fragmentation, incoherence, and meaninglessness.51 These states are not with reference to, or ‘about’, anything particular (Brentano’s sense of ‘intention’); nor do they constitute motivations regarding wishes or plans for the present or past (Dennett’s sense of ‘intention’).52 Fonagy and Allison termed this the ‘primary unconscious’.53 The primary unconscious forms an irreducible backdrop to perceptual experience of the world.

For Green, states of fragmentation, incoherence, and meaninglessness are essential to the creation of meaning. They contour the edges of any meaning, and keep away other potential meanings from the one found to be relevant. Any questioning or vigilance regarding a meaning makes use of these states, where they can serve as erasers, scrubbing out or permitting alteration of existing beliefs, and allowing for detachment from existing commitments, values, and desires.54 They are part of the mind’s ‘unbinding’ function. We need to have a sense of what would be nonsense in order to distinguish what is relevant to us and viable as a meaning, and to revise this sense in light of circumstance of new information. Less (p. 143) positively, when individuals have had experiences that lead them to fear states of fragmentation, incoherence, and meaninglessness, then this can hold them in place, making change and learning from experience more difficult, and contributing to credulity. Fonagy and Allison, however, do not seem sure whether they would assign the primary unconscious the ‘unbinding’ role it is assigned by Green.55 And they do not return to the idea of the primary unconscious, or to Green’s work, in their subsequent discussions of epistemic vigilance and credulity. In their paper, the emphasis is rather on the way that the primary unconscious enters into determinate mental states as breakdowns, disruptions, or dislocations.56 In characterizing states of fragmentation, incoherence, and meaninglessness, Fonagy and Allison are explicit that these mental states are not marked by particular intentions. Indeed, when clinicians mischaracterize such disruptions experienced by patients in terms of motivations and intentions—i.e. mentalize them—this tends to exacerbate the states of fragmentation, incoherence, and meaninglessness. By contrast, Allison and Fonagy reported that supportive interventions that do not treat such states as representing intentions tend to be more clinically effective.

Distinct from the primary unconscious, what Fonagy and Allison have described as ‘the psychoanalytic unconscious’ is formed by disturbing or disruptive ‘intentions’ (in the sense of wishes and plans) with reference to the self, others, or the world. The idea is a kind of re-description of Freud’s description of the unconscious in terms of wishes as the origin of the conflicts and slips of everyday life, or Klein’s description of the unconscious in terms of phantasies invested in day-to-day perceptions and interactions.57 For Fonagy, ‘Freud’s major discovery, is that what the philosophers of mind call the intentional stance, which Richard Hopkins calls the sentential stance, applies to non-conscious as well as conscious mental functioning.’58 This account of Fonagy and Allison of wishes as intentional may be regarded as a revision of Freud’s original concept of libido as essentially object-seeking (i.e. pertaining to wishes or plans regarding the past or present), a model set out most influentially in The Unconscious in 1915.59 The idea that intentionality characterizes non-conscious as well as conscious mental states is a distinct, intriguing, and arguable claim about psychological life. Certainly there are other theorists, including Freud in his later work, who have discussed non-conscious mental states that lack intentionality, most importantly some (p. 144) forms of anxiety.60 The claim that intentionality is an inherent characteristic of the psychoanalytic unconscious would seem to suggest a relationship with teleological mode. However, these links are not drawn by Fonagy and colleagues, perhaps because the concepts have been developed for somewhat different audiences.

A valuable point of comparison for Fonagy and Allison’s overall account of the unconscious is Ronald Fairbairn.61 Fairbairn likewise divides the unconscious between states of fragmentation and aspects of the self-representation. However, there are critical differences. Fonagy and Allison offer no account of the origin or developmental function of the primary unconscious. Fairbairn presents an account in terms of a child’s feelings of not being loved, which affect all of us to varying degrees according to his argument. Fonagy and Allison do not discuss the interaction between the primary and psychoanalytic unconscious. By contrast, Fairbairn theorizes that the psychoanalytic unconscious is elaborated as a response to the feelings of fragmentation, incoherence, and meaninglessness that stem from feeling unloved. Finally, Fonagy and Allison appear to populate the psychoanalytic unconscious only with disturbing or disruptive intentions. By contrast, Fairbairn’s unconscious is a much more diverse and sociable place, including, additionally, internalized representations of loved ones with whom we sustain unconscious and preconscious inner dialogue.

Allison and Fonagy are in agreement with Fairbairn, however, in their argument that an important developmental foundation of the psychoanalytic unconscious lies in perceived failures or disruptions of acknowledgement and acceptance by caregivers.62 This includes many wishes and plans that are ‘nasty and horrid’; Fonagy and colleagues hold that the lack of social acknowledgement and acceptance has good reason!63 However, avoiding the determinism of Fonagy’s earlier discussions of the role of infancy, Allison and Fonagy argued that the psychoanalytic unconscious can be elaborated throughout life. Significant or sustained failures of interpersonal acknowledgement in the context of high arousal can feed the psychoanalytic unconscious. Traumatic experiences, in particular, add to the psychoanalytic unconscious by offering a part-mirror to states of fragmentation, incoherence, and meaninglessness from the primary unconscious.64 As a result, these become fastened to certain (p. 145) memory content and enter the psychoanalytic unconscious in the form of intrusive thoughts or feelings lacking an immediate object.65 Fonagy, Allison, and Campbell have also recently hinted that experiences that prompt pervasive distrust in the claims of others as dependable, generalizable, or relevant (see Chapter 7) can also contribute to states of ‘meaninglessness’, implicating a role for the primary unconscious.66

Fortunately, most of the time, unconscious intentions or negative states do not surface into the conscious meanings that organize thoughts and feelings. However, they certainly can and often do influence the wishes, fears, and inchoate senses that inflect and give colour and tone to our primary meanings (see Chapter 1). For Fonagy and colleagues, the idea of determinate thoughts and feelings belonging to the self, or thoughts and feelings belonging to another, is therefore a post-hoc description. Seen in context, this was not an unprecedented claim among psychoanalytic discussions of the ‘self’. Fonagy cited William Grossmann who had argued that:

The ‘self’ appears to be both supremely subjective yet also an objective organization, an organismic property, discernible by others. This apparent objectivity of ‘the self’ arises from the fact that a person and those around him may equate observable and characteristic behavioral organizations or traits with an internal entity, ‘the self’. In calling the self-concept a theory or a fantasy, I do not wish in any way to diminish its importance in regulating behavior. It seems to me that … it organizes and directs behavior.67

From 2000 onwards, Fonagy claimed an aligned position. For him, ‘the illusion of identity is adaptive because predicting behavior of others, as well as our own behavior, is significantly simplified by the attribution of mental-state motives. In order to be able to predict, we must assume consistency amongst these mental states. Thus, underlying the intentional stance is an idealization of the self, as well as of the self of the other.’68 It is an idealization that permits us to generate simplified and sanitized thoughts and feelings from past experience, and to use these to account for our embodied, perceptual experiences and behaviour. For instance, Bateman and Fonagy define ‘feelings’ as ‘the conscious experience of the body state during (p. 146) emotional activation’, acknowledging that this is a mediated and partial experience incorporating but irreducible to the body’s inchoate and heterogenous reactions and states.69 The exact similarities and differences between the formation of feelings and thoughts are not at all well spelt out by Fonagy and colleagues. Appeal to the omnibus term ‘mental states’ has rather masked this question. Nonetheless, Fonagy and colleagues give the impression that a similar process of construction, simplification, and sanitization occurs in the formation and use of thoughts and memories.70 In this way, the illusion of an intentional self offers a simplified and sanitized sense of personal continuity that is nonetheless flexible enough to absorb the more complex and less sanitized aspects of life as they become relevant.71

As we saw in the previous chapter, Fonagy described the incoherence that confronts us when we try to understand others through attention to their every behavioural cue. An individual’s concern with ‘fleeting but genuine expressions of momentary emotional states is ultimately a hinderance rather than a help in their attempt to navigate complex social relationships’, because other people are ‘a theatre for too many states of mind for a coherent understanding of a relationship to be reliably achieved by these means.’72 The simplification and sanitization of the other’s desires and experiences into ‘thoughts’ and ‘feelings’ implicated in motivations is therefore adaptive in allowing us to conceive of mental states in the other that can be used to account for their behaviour and infer their experience. To take an example: in loving, good-enough relationships, our attachment figures sometimes wish to kill us. This is normal. However, these wishes are usually fleeting, inchoate, and should receive acknowledgements and expression in no more than the tone or manner of safe and unthreatening responses.73 For instance, responsiveness may be coloured by exasperation.

When things are well, such momentary expressions are also contextualized by what happens next, as well as the wider context of the relationship. It is notable that, when coding disorganized attachment, the guidance from Mary Main is to discount brief displays of fearful, conflicted, or confused behaviour ‘if the baby goes to the parent as though for comfort after a bit of disorganisation’.74 A degree of simplification and sanitization is fine when past experience has led us to basically conclude that our needs will be acknowledged and, where possible, met. If the vile passing thoughts of our attachment figures do not hinder their reflective functioning, Fonagy and colleagues assume that they should not hinder our capacity to make use of attachment figures as a secure base and safe haven as needed as children and (p. 147) as adults. The ability to use social relationships as a secure base and safe haven for help in processing difficult or confusing thoughts and feelings was theorized by Fonagy and colleagues to facilitate our capacity to conceive of and think about our thoughts and feelings in a coherent and consistent way.75

The implication of the argument presented by Fonagy and colleagues is that mentalization of one’s own and others’ mental states genuinely, even if only to an extent, creates the coherence and consistency of thoughts, feelings, and/or intentions that it appears to merely represent. What partial personal coherence and consistency an individual has as an experiencing embodied subject, as a knower of themselves, as a personality, as an agent, as a social identity, or someone able to distinguish between personally authentic and inauthentic action—such attributions to the ‘self’ are theorized by Fonagy and colleagues as consequences, not primary causes, of mentalizing. As Bateman and Fonagy have argued: ‘our sense of personal continuity is dependent on envisioning the thoughts and feelings we had in the past and how these relate to our current experiences … mentalising, the representation of our mental states, is the spine of our sense of self and identity’.76 The image of mentalizing as a spine for the self seems a rather essentializing metaphor, and reflects a tendency in the work of Fonagy and colleagues to reify the concept. Nonetheless, the intention of Bateman and Fonagy appears to be to highlight that mentalization and non-mentalizing are very important for the kind of self-representation a person develops. As such, mentalization in turn is not treated as free-standing, but as contextually embedded. Fonagy and colleagues also acknowledge that the characteristics of our self-representations do in turn ‘shape the way people mentalize themselves’ by forming ‘a kind of heuristic for the individual making sense of his or her actions’.77

For instance, Fonagy has stated that it is a particular point of alignment between mentalization-based therapy and cognitive analytic therapy to see that ‘deficits in such reflective self representations are causal in stunting the development of a sense of oneself as an effective agent’.78 However, he disagreed with cognitive analytic therapy, which he regarded as holding that once a representation of self is assembled, it is then passive.79 Fonagy and colleagues have argued that the self-representation contributes actively to the process of imagining mental states in oneself and others, especially once the strengthened capacity for abstract representation of mental states becomes potentially available in the course of adolescence.80 For instance, an inchoate wish or experience may be surfaced and elaborated (p. 148) into a thought or feeling as a mental state due to its relevance to the concerns of the self-representation—perhaps its pertinence to personally relevant tasks, projects, or worries.

This perspective adds a deeply uncanny quality to Fonagy’s seemingly benign claim that caregiving that acknowledges the child as an agent supports the child’s representation of a ‘constitutional self’. This constitutional self is not, as it might appear at first sight, the ‘authentic’ and ‘true’ self of Rogers (or, sometimes, Winnicott).81 For Fonagy, an authentic and true focal awareness of our own chaotic and unnerving desires would be both authentically disturbing and truly obstructive. Instead, the appearance of a ‘constitutional self’ out of the complexity of experience is itself an illusion. Where formed through mentalization, it is an illusion that is resilient to breakdown because its coherence and consistency are based around the capacity to conceive of thoughts and feelings, and the capacity to reconsider them when more complexity needs to be considered. The main forms of non-mentalizing—pretend mode, psychic equivalence, and teleological mode—also offer the illusory coherence and consistency needed to inform action. This is part of what makes them adaptive under particular circumstances (see Chapter 7). However, the kind of coherence and consistency they offer blocks access to the reconsideration of thoughts or feelings. In fact, Fonagy and Target proposed, they can make the generative doubt that permits reconsideration feel as a kind of ‘mutilation’, because a sense of personal coherence and consistency is sustained only by excluding such doubt.82

(p. 149) In a chapter from 2012, Fonagy, Bateman, and Luyten interrogated the role of ‘self’ in forms of mental disorder, distinguishing between three kinds of disorders based on the failures of the illusion of personal consistency and coherence they represent.83 Disorders of the ‘integrity of self’, chief among them BPD, are caused by sustained use of non-mentalizing modes of processing, because these hinder the creation of durable, flexible, and adaptive illusions of individual intentionality as implicated in thoughts and feelings. Fonagy and colleagues described ‘disorders of self-recognition’, whereby an individual’s embodied experience has become decoupled from the appearance of personal relevance, a stance characteristic of pretend mode. Capgras’ syndrome (a condition in which familiar people are delusionally experienced as strangers) may be an extreme form, but Fonagy and colleagues proposed that self-harming behaviours also reflect a disorder of self-recognition. Third, ‘disorders of self-concept and self-image’ are prompted when non-mentalizing specifically distorts the simplification and sanification of embodied experience, with the result that incoherent or disturbing ideas or feelings, which would otherwise be fleeting or just colour perception, can become pinned as stable aspects of the individual’s perception of their own state and worth. Skårderud and Fonagy described the case of patients with eating disorders.84 The culture of Western societies symbolizes willpower and self-control in terms of control over weight. This predisposes teleological thinking in which the normal, passing feelings of distrust, bafflement, and frustration individuals experience may be noticed, ruminated on—and then mistaken as caused by the individual’s body fat. Mental states are read off perceptions of physical qualities rather than physical cues being used to inform mental states.

That non-mentalizing can undermine the illusion of self-representation, and its coherent and consistent functioning, has significant implications for the goals of clinical work. A first point is that Fonagy has disagreed with those for whom ‘the main developmental achievement for any individual pertains to the achievement of a cohesive self’.85 This is a position he attributes especially to Anthony Ryle and cognitive analytic therapy, though he considers that it characterizes various forms of short-term counselling and psychotherapy. The problem with this approach, Fonagy argued, is that coherence and consistency are an illusion. To direct the client to seek a cohesive self risks failing to help them develop strategies for dealing with the inevitable, all-too-human aspects of the mind that exceed this coherence, and that at times disrupt or simply run contrary to our self-representation. Among these, for example, are experiences of desire and frustration, as we shall discuss shortly. Fonagy worried that a focus on achievement of a cohesive self ‘may re-enforce the splitting, rather than aid the individual to develop a capacity to tolerate ambivalence, intense affect and, in the long term, reduce impulsivity and the marked oscillation of self esteem’.86

(p. 150) Nonetheless, Bateman and Fonagy listed several ways that supporting a patient’s capacity to mentalize and to hold off from non-mentalizing processing should contribute to greater coherence and consistency of the self-representation.87 First, improved mentalizing and less use of non-mentalizing modes can be anticipated to heighten the viability, clarity, and acuity of conceptions of the thoughts and feelings of oneself and others, serving to inform and stabilize the self-representation.

Second, Bateman and Fonagy stated that this can help the ‘formation of a coherent sense of self’.88 Here they slip back into a cluttered use of the term ‘self’ that elsewhere they have criticized in others. From comparison of the Bateman and Fonagy paper with other work using similar language,89 the meaning would appear to be either i) that mentalization can be anticipated to contribute to the coherence and consistency of an individual’s experience as an embodied subject; or ii) that mentalization can be anticipated to contribute to a person’s sense of coherent personal agency. Or both meanings may have been intended. On the one hand, mentalization can be expected to help an individual sift their lived experience for making coherent thoughts and feelings, and also for making them available for pruning and revision, contributing further to coherence and consistency. On the other hand, even if the image of ourselves as agents is, in Fonagy’s view discussed above, an illusion, he has described it as a helpful illusion that is partly made real by its enactment. When a person acts with a sense of viable personal agency, this helps organize experience by helping to support and refine relevant thoughts and feelings.

Third in Bateman and Fonagy’s list, they proposed that mentalization and avoidance of non-mentalizing can also be expected to contribute to the ‘capacity to form secure relationships’.90 As we have seen, the ability to use social relationships as a secure base and safe haven for processing difficult or confusing thoughts and feelings was theorized by Fonagy and colleagues as helping to conceive thoughts and feelings and make them available for reflective function.

Finally, Bateman and Fonagy observed that emotional turmoil is likely to disrupt the self-representation and its contribution to the construction, identification, and use of relevant mental states. When a chronic and reciprocal disturbance occurs between emotional turmoil, mentalizing, and social relationships, the result is what has been called a personality disorder, or what Bateman and Fonagy described as a ‘destabilisation’ of ‘the self-structure’,91 though the exact meaning of the concept of ‘self-structure’, and its place within the metapsychology of mentalization theory, remains uncertain. The term originates in Rogers’ humanistic psychotherapy as a synonym for personality, but it is not clear whether or not Bateman and Fonagy intended it in this sense.92

(p. 151) Externalizing the alien self

As we have seen, Fonagy and colleagues characterize the coherence of self-representation as an illusion, but an adaptive one, because it contributes variously to the coherence and consistency of embodied experience, self-knowledge, self-structure, and personality, personal agency, social identity, and feelings about personal authenticity. However, for Fonagy and colleagues, this coherence and consistency are only ever partial, even under the best of circumstances. They remain vulnerable to disruption by the states of fragmentation and meaninglessness of the primary unconscious. And they remain vulnerable to the pull of the contrary and disturbing intentions of the psychoanalytic unconscious. Caregiver reflective function will support greater emotional containment and acknowledgement of a child’s intentionality and/or mental states, facilitating the coherence and consistency of the child’s emerging self-representation and their capacity to flexibly adapt this representation through mentalization. The result is ‘an authentic, organic self-image built around internalised representations of self-states’.93 However, total containment and acknowledgement are impossible; in fact, Fonagy has speculated that the fantasy of an omniscient mentalizing divine being may stem from this disappointment.94

All children develop a psychoanalytic unconscious, which for Fonagy and colleagues comprises intentions (in the sense of wishes and plans) with reference to the self, others, or the world that have been refused acknowledgement, and excluded from the self-representation.95 The result is the experience of an ‘alien self’, the experience of intentions that do not agree with the self-representation, and so do not feel like they belong to us.96 The idea of the ‘alien self’ was not original to Fonagy and colleagues, but stemmed from second-generation Kleinian refinements of the concept of projective identification. In the most general terms, projective identification means to imagine some part of oneself as able to be split off, and to expel it outside and away—for instance, into the environment or another person.97 The term ‘alien self’ was used by second-generation Kleinians to describe the individual’s experience of such disowned aspects of the self.98 For Kleinians, some of these (p. 152) aspects are wishes and plans disowned as too positive for the self-representation, forming an ‘ego ideal’; Fonagy and colleagues did not discuss these.99 Their account of the ‘alien self’ focused on those aspects that are disowned as unacceptable to the self-representation. They proposed a developmental account of the emergence of this alien self:

Even the most sensitive caregiver is insensitive to the child’s state of mind more than 50% of the time. Thus, we all have alien parts to our self-structure. The coherence of the self, as many have noted, is somewhat illusory. This illusion is normally maintained by the continuous narrative commentary on behaviour that mentalisation provides, which fills in the gaps and weaves our experiences together so that they make sense. In the absence of a robust mentalising capacity, with disorganised patterns of attachment, the fragmentation of self-structure is clearly revealed.100

For Fonagy and Target, then, mentalization is partly a confabulation: the production of a somewhat fictionalized story, woven into the experience of an individual ‘self’. In this, their position aligns with that of Winnicott, for whom the binding of the experience of self to an individual bounded body was dependent upon an ‘imaginative elaboration’. However, the reference by Fonagy and Target to ‘narrative commentary’ hints, further, that this is not just an elaboration based on ‘body functioning of all kinds and the accumulations of memories’, but also of available cultural narratives for integrating and reconciling gaps and experiences of being alive within a particular context.101 Though not explicit in Winnicott, this is well in line with his account of the importance of environmental factors and social communication in the formation of a sense of self.102 This role of cultural narratives in the imaginative elaboration of the self-representation and the alien self was not elaborated at the time by Fonagy and Target, conveying the impression that there would be little cross-cultural variation in the formation of the self as an individual. The acknowledgement of the self as a confabulation was not accompanied by recognition of contingency in the construction of personhood. This had the side-effect of contributing to a naturalization of individualism within mentalization theory (see Chapter 2) precisely at the point that the individual self was theorized as a narrative construction and, to an extent, confabulation.103 As we shall see in Chapter 9, Fonagy (p. 153) and colleagues have recently sought to amend and advance their position with greater attention beyond the individual and to questions of cultural variation.

For Fonagy and Target, the particular importance of the imaginative integration of the self-representation lay in its contribution to the experience of coherence and consistency through supporting mentalization and the capacity to form secure attachments. By contrast, a more accurate characterization of our experiences, intentions, self-knowledge, etc. is of ‘fragmentation’, a state ‘revealed’ when mentalization fails to generate confabulation and its ensuing coherence (see Chapter 3). The intentions of the psychoanalytic unconscious, let alone the meaninglessness of the primary unconscious, are disturbing and disruptive. As a consequence, any truly accurate and unmediated reflection of these in our behaviour would indeed be fearful, conflicted, and confused to an extent. The developmental importance of caregiver reflective functioning, in Fonagy and Target’s account, is that it supports the development of a mental apparatus for simplifying and sanitizing experience to permit the formation of coherent thoughts and feelings, capable of being subject to reconsideration. This apparatus can even offer protection in the context of later adversity and trauma: mentalization can fill in the gaps and weave our experiences together enough to make sense.

Yet ‘in the absence of a robust mentalizing capacity, in the wake of trauma, alien fragments in the self-structure are likely to be clearly revealed in all of us’.104 In the 2000s, Fonagy and Target situated poor caregiver reflective functioning as an important developmental basis for a strong alien self. The child is unable to find the basis of their coherent self-representation and intentionality in their caregiver’s responses. This leads to the ‘internalisation of representations of the parent’s state, rather than of a usable version of the child’s own experience’.105 These states may not be benign ones and may be further distorted by the child’s own unassuaged concerns if they are unable to use their caregiver as a secure base and safe haven for difficult thoughts and feelings. In this way, experiences of non-acknowledgement by attachment figures may form ‘the germ of a potentially persecutory object which is lodged in the self, but is alien and unassimilable’.106

In recent years, Fonagy and colleagues have argued for an important role for later experiences, after childhood, in the intensification of the experience of an alien self. In the absence of mentalization, traumatic experiences—for instance, political violence and torture—reduce an individual’s capacity to inhibit conflicting appraisals and to buffer the effects of emotional reactions on information processing.107 This hinders the individual’s capacity to sift coherent and consistent thoughts and feelings, and exclude intentions from the psychoanalytic unconscious incompatible with the self-representation.108 Fonagy and colleagues (p. 154) have also speculated that wider dehumanizing culture and institutionalized values may intensify the experience of the alien self (see Chapter 9).

The experience of an alien self ‘interferes with the relationship between thought and identity: ideas or feelings are experienced that do not seem to belong to the self. The alien self destroys the sense of coherence of self.’109 The feeling of coherence within perceptual experience, self-knowledge, and agency may be achieved through alternate means, in the use of pretend mode, psychic equivalence, or teleological mode. However, Fonagy and colleagues also consider another strategy that restores feelings of coherence, which stands as the closest candidate in their writings to a distinct, ‘fourth’ major form of non-mentalizing.110 This is termed ‘externalization of the alien self’. In fact, Luyten, Malcorps, Fonagy, and Ensink list externalization of the alien self alongside pretend mode, psychic equivalence, and teleological mode in their table of non-mentalizing in the latest edition of the Handbook of Mentalisation in Mental Health Practice.111 This could be regarded as a hint that its elevation to the official status of a mode of non-mentalizing may be under tacit consideration. However, declining reference to the concept in recent years would suggest otherwise, and instead point to the rather unstable and poorly integrated status of the concept for Fonagy and colleagues.

In the externalization of the alien self, ‘the other’s mind is being controlled or manipulated in order to restore a sense of self in the face of an assault that has inhibited the capacity to regard one’s own mind as coherent. This does not represent a complete absence of mentalizing; rather, it is a form of highly disrupted mentalizing in which the other’s mind is recognized and used to restore one’s sense of one’s own mind.’112 Externalization of the alien self is a revised account of the classic but overladen Kleinian concept of ‘projective identification’. This may have slowed its acknowledgement as a distinct form of non-mentalizing, because there was already an apparently encompassing term, and one with a very complicated and messy history.113 This would have made attempts to excavate and redefine the concept hazardous for Fonagy and colleagues in the 1990s and early 2000s, not only because the work would have been fiddly and technical, but also because it could have appeared as a capitulation to a (p. 155) Kleinian perspective at a point that Fonagy was being accused of being insufficiently Anna Freudian (see Chapter 1).114 The relatively insular London Kleinian group had taken up projective identification as their flagship concept in the 1990s, giving it a specific symbolic load in the immediate context in which Fonagy and colleagues were working.115

An outstanding problem with the concept of ‘externalization of the alien self’ is inherited from ‘projective identification’. As Fonagy and colleagues observed in the 1990s, the concept of projective identification risks confusing two things. On the one hand, phenomenology: what it feels like to the individual. On the other hand, explanation: the psychological mechanism entailed.116 This is precisely the distinction elided by psychic equivalence, where experience is taken as explanation; a good part of mentalization-based therapies is helping patients think about their experience, and consider possible explanations.117 Fonagy and Target acknowledged that the concept of projective identification appeals precisely because it feels like it captures the way patients can get under the therapist’s skin. But the reality of this feeling is distinct from a conceptualization of projective identification in terms of causal mechanisms.118 The same problem, however, has attended their uses of the concepts of ‘mentalization’ and ‘disorganized attachment’ (Chapter 3) as we have seen, and the concept of ‘epistemic trust’ as we will see in the next chapter (Chapter 7). It also attends their use of the terms ‘self’ and ‘alien self’.

Sometimes Fonagy and colleagues characterize the alien self as an aspect of an individual’s experience. Sometimes they treat it as a psychological structure. Sometimes it appears to be unconscious, outside of an individual’s experience. Sometimes it is treated as an aspect of all (p. 156) psychological processes to a greater or lesser degree. All of these are possibilities of course. A confusion between phenomenology and explanation has meant that Fonagy and colleagues have never really sorted these matters out or articulated their interrelation. Fonagy and colleagues tend to lack clarity on whether the feeling of externalizing the alien self is a fantasy and/or a kind of psychic equivalence, or whether something is actually externalized.119 If the former, the actual mechanisms that allow the other’s mind to be controlled or manipulated would need to be articulated, as would the exact overlap or causal relationship between externalization of the alien self and psychic equivalence.120 Kleinians such as Bion had identified this as a problem already for their concept of projective identification,121 and this issue appears to have been inherited by Fonagy and colleagues. Appeal to the alien self appears particularly in their more clinical publications. It rarely figures in their papers more concerned with underpinning mechanisms. Again, this may also have made it harder for externalization of the alien self to become identified as a fourth major mode of non-mentalizing, or for clarifying justification to be offered as to why it does not receive this status.

Like in pretend mode, psychic equivalence, and teleological mode, in externalization of the alien self—conceived of as a psychological mechanism—elements of mentalization are hijacked. Present and past perceptual experience, observable social behaviour, and motivations and intentions of the other are conceived, accounted for and controlled in order to avoid conceiving of thoughts and feelings in oneself. Bateman and Fonagy have described how ‘if the alien self is an experience of vulnerability, the person creates this experience in his communication partner by generating chronic uncertainty; if it is aggression, he simply has to irritate him; if it is depression or lack of interest and hopelessness, then he might force him to experience the potential of helping, only to dash his hopes again and again’.122 Fonagy gave the autobiographical example of his panicked phone calls home to his parents as an adolescent living alone in London, where he would ‘talk about his situation in catastrophic terms until his parents were palpably panicked, and then he would end the conversation feeling relieved’.123 (see Chapter 1).

Illustrating the externalization of the alien self, Fonagy and Target described the case of Callum, who displayed aggressive and controlling behaviour when his mother was present, and intense separation anxiety when she was absent. Fonagy and Target acknowledged that an aspect of these symptoms expressed attachment anxiety about the availability of the caregiver, based on past experiences. Yet they argued that ‘Callum’s need for closeness to his mother is not simply motivated by anxiety but also by the need for a vehicle to contain the (p. 157) alien part of himself’.124 In controlling his mother’s behaviour, he also achieved an indirect form of self-control, permitting greater feelings of coherence.

Fonagy and colleagues have described the alien self as formed by our intentions that are not given acknowledgement, initially by caregivers and then later in other social interactions. Sexuality and aggression are therefore powerful components of the alien self of most humans. Fonagy and colleagues have argued that these are the forms of intentionality that receive the least acknowledgement from caregivers, and that have the most circumscribed place in social interaction, ‘thus always remaining somewhat alien, and so prone to acting out’,125 though they acknowledge that there will be cultural variability in the degree and form of acknowledgement of these forms of intentionality. They suggest, for instance, that new social media may offer representations of sexuality and aggression that offer modes of part-acknowledgement and part-construction to sexual and aggressive intentionality (see Chapter 9). As a result, these aspects of the alien self may impinge more into the self-representation and its activities.126 Nonetheless, Fonagy and colleagues have assumed that some externalization of the sexual and aggressive selves is a basic facet of human experience.127 It is the externalization of the sexual and aggressive selves that gave earlier psychoanalytic theory, including Anna Freud, the impression that sexuality and aggression could be conceptualized as drives, characterized by intentions that in key regards exceed or transgress an individual’s image of themselves.128 The externalization of alien self in the cases of sexuality and aggression will be discussed in turn.

Sexuality and aggression

In Freud’s classical stance, a child’s sexual wishes are inherently unrealizable. The wishes are therefore excluded from consciousness but remain live in the unconscious. This creates a foundational conflict, implicated in various ways in mental health symptoms. For instance, in phobias, a forbidden sexual wish is regarded as linked to a particular object, which is then associated with fear and aversion. From the 1990s, Fonagy and Target expressed their agreement with Freud that sexual intentions are, at base, incongruent with self-representations. (p. 158) And they acknowledged that many patients with severe mental health problems also report unusual or distorted concern with their bodies, which may include problems related to sexuality. However, they argued that the basis of the symptoms lies in ‘the consequence of inadequate and incomplete self representation’.129

The concern with the body that may characterize these patients is actually a secondary effect of this inadequate and incomplete self-representation: under conditions of anxiety or worry, difficulties in integrating thoughts and feelings prompt ‘a movement back to a pre-reflective bodily self’.130 Some use of this strategy is wholly ordinary, and in fact beneficial: ‘the movement between physical and psychological experiences of the self is a dialectic. At times of psychological stress, we all find relief in exercise, in sexuality and other forms of regression to a pre-reflective state.’131 This movement is by no means the root of the patient’s problems. As such, Fonagy and Target argued that ‘classical technique, focusing upon the individual’s sexual conflicts without addressing the fragility of the self structure, will rarely lead to a satisfactory therapeutic solution’.132 What efficacy classical technique possessed was often based, they argued, in the capacity for discussion of sexual conflicts to serve as a concrete set of metaphors for other patterns in the life of the patient. But this metaphorical use and its benefits were only accessible to patients who were already capable of reconsidering their self-representation and its functioning.

A decade later, Fonagy and Target returned to these questions in characterizing the adult experience of sexuality. This was prompted by interest in the way that consideration of sexuality had increasingly dropped out of psychoanalysis. They identified several factors implicated in this shift. One was that the object of therapeutic concern, in the aftermath of humanistic psychology, had increasingly become the interplay between self coherence and interpersonal relationships. Fonagy and Target explicitly criticized psychoanalytic thinkers such as Laplanche who emphasized sexuality at, in their view, the expense of concern with interpersonal relationships. A second factor they felt was implicated in the turn away from sexuality was that psychoanalysts felt stigmatized by the accusation that they were obsessed with sex. A third factor, Fonagy and Target argued, was that interpretations focused on sexual conflicts tended to backfire with patients with personality disorders and severe mood disorders. For instance, forms of non-mentalization could make these interpretations (p. 159) appear as sexual suggestions by analysts, resulting in interpersonal drama and therapeutic complications.133

Fonagy and Target expressed concern that disinterest in sexuality in psychological theory put at risk attention to the alien self, present in all of us and with an especially active and disruptive role for patients with mental health problems. They speculated that caregivers are primed by evolutionary factors, often expressed in culturally specific ways, to ignore or reject signals of their child’s sexual excitement. Without secondary representation and acknowledgement, sexual intentions will, and absolutely should, form a part of the child’s alien self. Depending on the kind of non-acknowledgement a child’s sexual experiences have received, this will colour the way in which they feature within the alien self: ‘sexual feelings may feel too dangerous to share: they may for example be felt as too contagious and overwhelming to the relationship (unmarked mirroring), unacceptable (for example when there has been reflection of excitement and curiosity as aggression, or clear expression of disgust at the sexual body).’134 These are the kinds of concerns associated with what Fonagy and Allison have subsequently termed the psychoanalytic unconscious. Yet states of fragmentation, incoherence, and meaninglessness may also be implicated in some of sexuality’s less intentional mental states and actions: ‘There is a vacuum within a part of the self, where internal reality remains nameless, sometimes dreaded, perhaps vacuous or frightening—or exciting and mysterious, as is the case in normal sexuality.’135

There is no direct expression of sexual excitement. It is always mediated by developmental and cultural factors in how it is experienced and expressed, and by the qualities of the person or situation prompting desire. Despite this diversity, Fonagy and Target nonetheless argued that sexual excitement always entails some involvement of the alien self, even when this excitement finds expression in culturally permitted forms. Sexual pleasure comes in part from the externalization of the alien self in the excitement experienced in relation to an actual or fantasized partner.136 The implication is that there is a fundamental incompatibility between sexual excitement and mentalizing. Holding the two together is an essentially unstable achievement at best.137 As such, ‘normal sexuality, while not pathological, mimics a form of pathology … or is at least in the borderline spectrum’.138 Mentalizing may help generate ‘the interpersonal context for an erotically imaginative intercourse’, in which a spiral of reciprocally recognized cues supports intimacy and pleasure. Nonetheless, despite the debt that these pleasures may owe to mentalizing, their urgency will also be lessened by it. We may close our eyes in sexual pleasure, Fonagy suggested, in part because close attention to the other’s thoughts and feelings rather counteracts feelings of sexual excitement, since these (p. 160) are premised on localized non-mentalizing in the externalization of the alien self.139 Target has added that sexual pleasures may be helped along by other modes of non-mentalizing. We may experience pleasure as a demonstration of the strength or quality of the relationship (psychic equivalence). A partner’s pleasure may be experienced as concretely affirming their love (teleological mode). Or we may take pleasure from feelings of being merged with the other and safe from the world (pretend mode).140

The non-mentalizing of externalization of the alien self in sexuality may have an evolutionarily adaptive function. Not only does it direct sexuality away from the family during adolescence, helping to avoid incest. Fonagy and Target also offered their suspicion that the potential for localized heedlessness and recklessness in sexual life is adaptive for reproductive success, even if it may be very inconvenient in other ways.141 They proposed that, at an evolutionary level, sexual desire is in tension with the evolutionary benefits of stability and interpersonal understanding. Likewise, at the level of the individual, Fonagy and Target proposed that there is a trade-off between sexual excitement and the other benefits of relationships. The better integrated self-representation afforded by the relationship as a secure base and safe haven quietens the demands of the alien self, and with it the intensity of sexual excitement. The partner is partly internalized through preconscious identification, as a shared sense of ‘we’, which replaces the sense of mystery and excitement with familiarity and security.142 Though many relationships may be able to toggle backwards and forwards between the two, Fonagy and Target suggest that the relative incompatibility of sexuality and mentalizing is one of several reasons that desire tends to fade over time in long-term relationships. When this happens, sexual excitement may still be evoked by other people, they argued, to the extent that these individuals elicit aspects of the alien self that have not found purchase and integration within the present relationship.143

On the basis of this account, Fonagy and Target argued that sexuality should neither be the central focus of therapy nor should it be ignored or treated only as a metaphor. When sexual excitement appears in a therapeutic context, the therapist is advised to offer ‘recognition of the feelings, minor resonance without reciprocal excitement, without denial or distortion’.144 Sexuality is part of the alien self for a reason: its expression is often inappropriate and difficult to reconcile with mentalizing. Yet sexuality is relevant in therapeutic contexts, because it can provide important signals of the activity of the alien self. Sexuality may be used as ‘a vehicle for carrying repudiated aspects of the self such as aggression, envy, grandiosity, (p. 161) derogation, contempt, or plain selfishness’.145 Put another way, the most potent metaphors rub both ways, with true aspects as well as pretend aspects at once. Even if sexuality is in part a metaphor for other troubles, this is grounded in the powerful alien self aspects of sexuality:

Sexuality is not at root conflictual; rather, conflicts come to be expressed via the sexual metaphor. It is this psychic flypaper quality that makes psychosexuality such a key part of understanding our patients. Many truly painful conflicts are sexual, not because they are rooted there but because the otherness quality of sexuality frames the conflict as being external. As the psychosexual expresses, and does not disguise, the relational, frequently the only genuine route to understanding relational issues is through psychosexual experience.146

When therapists direct attention away from sexuality, this leaves the patient without support for making sense of and modulating feelings that may be sexual or that may be framed in terms of sexuality. Fonagy and colleagues hold that sexuality should be recognized by therapists, but so as to focus on supporting the patient’s capacity to mentalize related thoughts and feelings. Discussion of sexual matters may be inhibited in short-term therapeutic work by the patient’s shame or worries. And over time, the experience of the therapist as a secure base can be expected to inhibit sexual excitement. But at the point that the therapeutic relationship is evoking the alien self, and remains exciting and mysterious, sexuality is likely to be an especially important theme.

Having considered sexuality, we can now turn to a second, parallel contributor to the alien self in the work of Fonagy and colleagues. This is aggressive intentions. Whereas Fonagy and colleagues describe sexuality in terms that suggest that externalization of the alien self is generally involved, their stance appears to be less ambitious in relation to aggression, seeing externalization as an important cause but not implicated in aggression in all its forms.147 By contrast, the multiple causal factors that contribute to aggression are acknowledged especially in writing for developmental psychology audiences, in the context of a discipline in which unitary causal lines are not regarded as persuasive.148 For instance, Fonagy has recently highlighted the importance of economic deprivation for the prevalence of conduct problems, without implying that this relationship is fully mediated by externalization of the alien self.149 Nonetheless, the writings of Fonagy and colleagues suggest that externalization of the alien self may have a significant role to play in the initiation and maintenance of violence.

In classical psychoanalysis, a child’s aggressive wishes—like their sexual desires—cannot be fully realized and are prohibited by both caregivers and wider society. Again, for Freud, the conflict between unconscious aggressive intentions and conscious recognition of the inappropriateness of aggression was anticipated to be implicated in the symptoms of patients.150 Subsequent psychoanalytic theorists such as Kernberg built on this position to (p. 162) argue that excessive destructive and envious intentions, combined with a caregiving environment that was not able to offer containment of these responses, predispose BPD.151 They described by Fonagy, Moran, and Target, the authors set themselves against this account. They argued that aggression might better be seen as a defence against particular thoughts and feelings.

They described Moran’s treatment of a patient, David. On the basis of the concept of mentalizing theory, they argued that his ‘unprovoked, excessively aggressive acts could now be seen to be aimed at objects whom he experienced as viewing him in a negative way. It seemed as if, through attacking these individuals, he could temporarily rid himself of bad reflections of himself … It was preferable for David to strip his mind almost bare of mental content than to be exposed to the terrible power of the shaming gaze.’152 This account allowed the authors to pinpoint the conditions under which David would show aggression: ‘his aggression was activated on the numerous occasions when his sense of self required reinforcement and his identity was in need of bolstering’.153 Though the concept would only be offered some years later, we can see in this characterization the proposal that aggression represented a means for David to externalize an alien self associated with shame. This defence was interpreted as reflecting David’s difficulties in conceiving of and reflecting on his mental states and those of others. However, the defence was achieved precisely by reinforcing and solidifying this state of affairs.

Given that all humans have an alien self, rather than solely ask how violent behaviour develops, Fonagy and Target’s perspective suggested that another focus should be on how a failure to inhibit violent behaviour develops.154 Fonagy and Target proposed that violence did not reflect a single developmental trajectory: multiple developmental trajectories might converge on deficits in mentalizing combined with thoughts or feelings experienced as unbearable and as requiring externalization. Pervasively aggressive behaviour was therefore interpreted by Fonagy and Target as reflecting, and reinforcing, ‘a wish to attack thoughts, in oneself or in another’.155 For instance, they described self-harm as an externalization into the pre-reflexive body of intolerable thoughts or feelings that would otherwise occur in the patient’s own mind. The ritualized and structured form of an act of self-harm offers a way to access a certain kind of regularized feeling, and therefore provide a certain sense of clarity. (p. 163) And this is achieved in such a way as to direct attention to the body, and away from mental states. Likewise, Fonagy theorized that male violence against women represents an attack on thinking, this time through the body of the other. He was interested by the way that, in his experience, perpetrators reported that control over and intimidation of women offered them a feeling of personal coherence.156

In a paper from 2003, Fonagy characterized violence that functions to support the feeling of personal coherence as ‘representational violence’, because the object of the violence is used to ‘represent’ the aspects of the alien self that are refused mentalization.157 He contrasted this with a second basis for violence, ‘violence in the negative’. In this form, states of fragmentation, incoherence, and meaninglessness from the primary unconscious have become associated with specific other people or groups. These then have to be ‘destroyed to protect the mind from states which are experienced as out of control’.158 When some capacity for mentalization is available, the limited responsibility of the other for these states can usually be acknowledged. When mentalization is offline, and especially when teleological mode is active, physical force may be regarded as necessary in order to achieve control and change in the situation. Fonagy summarized: ‘representational violence’ is aimed at an object in its function as a signifier for mental states that are refused to be conceived or considered as thoughts or feelings; ‘violence in the negative’ is aimed at a signifier in order to prevent its expression of states of fragmentation, incoherence, and meaninglessness.

However, in another article of the same year, Fonagy argued that not all violence fits into this scheme, and that psychological theory ‘must take proper account of the existence of positive, survival-oriented aggression and also of aggression that is a genuine protest against hardship in life’.159 He argued that violence should not be denigrated: evolutionary pressures will have required humans to be capable of both nonviolent group life and of enacting violence under situations of threat, proposing that mentalization may have evolved as a capacity in part to help sustain nonviolence in social contexts where we feel recognized, while prompting non-mentalizing and violent responses in environments of nonrecognition.160 This perspective has significant implications for prevention (see Chapter 9). Similarly, the idea of social acknowledgement as a prompt, primed by evolution, for mentalizing rather than violence may help explain why ‘restorative justice’ approaches, in which an offender and victim of crime interact face to face and offer mutual acknowledgement, have been found to be especially powerful at reducing violent crime, compared with other less serious forms of crime.161 Restorative justice approaches differ markedly from the usual approach of criminal justice systems, which institutionalize teleological mode thinking in demanding concrete retribution for crime, even in the face of evidence that this appears to make future crime more, rather than less, likely.

(p. 164) In recent years, and in line with other perspectives in developmental psychopathology,162 Fonagy has increasingly drawn distinctions between mild aggressive problems and more intractable forms of antisocial personality disorder, while continuing to regard deficits in mentalizing as relevant to both. Various developmental pathways may converge in contributing to the inhibition of mentalizing, which can contribute to the externalization of the alien self, reduced feelings of personal agency, hostile attributions regarding others, and a low threshold for violent actions.163 In reflecting on these developmental pathways, Fonagy has acknowledged the likelihood that ‘some particularly intractable conduct problems have a genetic basis’.164 He has not held out expectation for an ‘aggressive genotype’. Rather, he has been more persuaded by the idea that there may be both genetic and environmental contributions to attentional control and affect regulation, which help sustain mentalizing. This conclusion is supported by findings that 90% of children with a diagnosed conduct disorder also have another mental health problem—for instance, with attentional problems 10 times higher than in the general population.165

What especially distinguishes antisocial personality disorder, for Bateman and Fonagy, are feelings of shame in the alien self, which are externalized through the domination of other people. This externalization is prompted by psychic equivalence, where shame threatens to dominate and define reality.166 The externalization of the alien self functions through the denigration and intimidation of other people, which holds at bay questions these others or the self might pose about the individual’s worth. Any potential or perceived slight is met with hostility, perhaps supported by teleological mode in which physical retribution seem the only real response.167 Like the other forms of non-mentalizing, the externalization of the alien self presents specific obstacles to the modulated doubt that helps sustain the inquisitive stance and consideration of alternate perspectives. Externalization of the alien self seeks to control the other’s behaviour, motivations, and experience, and in this way to avoid relevant feelings and thoughts that might otherwise disrupt a brittle self-coherence. The question of how to conceptualize whether such strategies are ‘adaptive’ will be pursued further in the next chapter. By the end of the 2000s, this account of adaptation had come to rather eclipse the idea of the alien self, which remained ‘on the books’ but without any scientific operationalization and poorly integrated with subsequent theoretical developments. This may be attributed to the essentially psychoanalytic underpinnings of the concept of externalization of the alien self, which has meant that the concept travels less easily, and is less (p. 165) intelligible to the scientific and policy audiences of the more recent work of Fonagy and colleagues.168 Nonetheless, Fonagy and colleagues’ recent interest in wider social systems and institutionalized non-mentalizing have drawn attention to experiences of social alienation (see Chapter 9). It may be that the alien self will receive renewed interest, through this link with alienating social systems.

Notes:

1 Ensink, K. and Mayes, L. C. (2010). ‘The Development of Mentalisation in Children from a Theory of Mind Perspective’. Psychoanalytic Inquiry, 30(4): 301–337.

2 Bateman, A. W. and Fonagy, P. (2003). ‘The Development of an Attachment-Based Treatment Program for Borderline Personality Disorder’. Bulletin of the Menninger Clinic, 67: 187–211, p. 192.

3 Adshead, G. and Fonagy, P. (2012). ‘How does Psychotherapy Work? The Self and its Disorders’. Advances in Psychiatric Treatment, 18(4): 242–249: ‘A key reason for people seeking psychological therapy is an experience of a disordered “self” ’ (p. 242).

4 Burman has discussed the apparent tension between the language of understanding mental states and the apparent psychoanalytic commitments of Fonagy and colleagues. Burman, E. (2016). Deconstructing Developmental Psychology (3rd edn), London: Routledge, p. 160.

5 Sedgwick, E. K. (2011). ‘Affect Theory and Theory of Mind’, in Jonathan Goldberg (ed.) The Weather in Proust, Durham, NC: Duke University Press.

6 Bion, W. R. ([1963] 1984). Elements of Psychoanalysis, London: Karnac Books; Matte-Blanco, I. ([1988] 2003). Thinking, Feeling, and Being, London: Routledge. Converging on a similar point from within the phenomenological tradition, see Merleau-Ponty, Maurice. ([1960] 1964). Signs, trans. Richard C. McCleary, Evanston, IL: Northwestern University Press; Merleau-Ponty, Maurice. ([1964] 1968). The Visible and the Invisible, trans. Alphonso Lingis, Evanston: Northwestern University Press. According to Sperber and Wilson, the penumbra of proto-thoughts and proto-feelings that array themselves around any potential determinate thought or feeling are part of what gives the question of relevance its particular urgency. For them, this is an essential reason for the need for epistemic vigilance, in order to filter this penumbra, and to identify those elements relevant to the self and/or conversational others. This element of Sperber and Wilson’s work does not appear to have been taken up by Fonagy and colleagues in their appropriation of the concept of epistemic vigilance. Sperber, D. and Wilson, D. (2004). ‘Relevance Theory’, in L. R. Horn and G. Ward (eds), The Handbook of Pragmatics, Oxford: Blackwell, pp. 607–632; de Saussure, L. and Wharton, T. (2019). ‘La notion de pertinence au défi des effets émotionnels’. Travaux Interdisciplinaires sur la Parole et le Langage (TIPA), 35: 1–23.

7 Fonagy, P. (2010). ‘The Changing Shape of Clinical Practice: Driven by Science or by Pragmatics?’, Psychoanalytic Psychotherapy, 24(1): 22–43: ‘From a professional’s standpoint, as from that of the ordinary member of the public, physical role limitation, physical function and pain have high priority, while those suffering disorders rate dignity and general wellbeing (mood, global assessment of life, having a partner, job, lots of social contact) as more important’ (p. 34).

8 Jacobson, E. (1957). ‘Normal and Pathological Moods: Their Nature and Functions’. The Psychoanalytic Study of the Child, 12(1): 73–113: ‘moods seem to represent, as it were, a cross-section through the entire state of the ego, lending a particular, uniform coloring to all its manifestations for a longer or shorter period of time. Since they do not relate to a specific content or object but find expression in specific qualities attached to all feelings, thoughts and actions, they may indeed be called a barometer of the ego state … Thus, anger at somebody or something may turn into an angry mood, love or hate into a kind or hostile mood, anxiety into an anxious mood, as soon as they have ceased to relate only to special, selected objects or notions’ (pp. 75–76). See also Mulhall, S. (1996). ‘Can there be an Epistemology of Moods?’. Royal Institute of Philosophy Supplements, 41: 191–210; Ratcliffe, M. (2010). ‘The Phenomenology of Mood and the Meaning of Life’, in P. Goldie (ed.), Oxford Handbook of Philosophy of Emotion, Oxford: Oxford University Press, pp. 349–371; Flatley, J. (2017). ‘Reading for Mood’. Representations, 140(1): 137–158.

9 Fonagy, P., Steele, M., Steele, H., Moran, G. S., and Higgitt, A. C. (1991). ‘The Capacity for Understanding Mental States: The Reflective Self in Parent and Child and its Significance for Security of Attachment’. Infant Mental Health Journal, 12(3): 201–218, p. 204.

10 Baradon, T., Fonagy, P., Bland, K., Lénárd, K., and Sleed, M. (2008). ‘New Beginnings—An Experience-Based Programme Addressing the Attachment Relationship between Mothers and their Babies in Prisons’. Journal of Child Psychotherapy, 34(2): 240–258, p. 249.

11 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. 412.

12 For instance, in their 2007 definition of mentalizing (Chapter 4), Fonagy and colleagues appear to unpack emotions into ‘needs, desires, feelings’, and thoughts into ‘beliefs, goals, and reasons’. The distinction here between ‘desires’ and ‘feelings’ links to long-standing psychoanalytic interest in desire as a form of intentionality (in the sense of wishes or plans regarding the past or present) that may well not be aligned with our self-representation, or readily conceived of or reconsidered. Green, A. (1999). The Fabric of Affect in the Psychoanalytic Discourse, New York: Routledge.

13 For instance, Fonagy and Allison’s theory of the nature of consciousness and of the unconscious has huge ramifications, but is put forward in a sustained way only in Fonagy, P. and Allison, E. (2016). ‘Psychic Reality and the Nature of Consciousness’. The International Journal of Psychoanalysis, 97(1): 5–24.

14 E.g.Kiverstein, J. (2011). ‘Social Understanding without Mentalizing’. Philosophical Topics, 39(1): 41–65; Davidsen, A. S. and Fosgerau, C. F. (2015). ‘Grasping the Process of Implicit Mentalization’. Theory & Psychology, 25(4): 434–454; Liljenfors, R. and Lundh, L. G. (2015). ‘Mentalization and Intersubjectivity towards a Theoretical Integration’. Psychoanalytic Psychology, 32(1): 36–60; Køster, A. (2017). ‘Mentalization, Embodiment, and Narrative: Critical Comments on the Social Ontology of Mentalization Theory’. Theory & Psychology, 27(4): 458–476. Another important critical commentary, addressing limitations in the acknowledgement of social context in the conceptualization of mentalizing, was Sperry, M. (2013). ‘Putting our Heads Together: Mentalizing Systems’. Psychoanalytic Dialogues, 23(6): 683–699. Wide swathes of the theory of Fonagy and colleagues have been left largely untouched by such commentaries, most notably the concepts of the self, primary unconscious, the different modes of non-mentalizing, and adaptation.

15 See e.g. Sandler, J. and Rosenblatt, B. (1962). ‘The Concept of the Representational World’. The Psychoanalytic Study of the Child, 17(1): 128–145.

16 E.g. Horne, M. (2003). ‘Affect Regulation, Mentalization, and the Development of the Self by Peter Fonagy, György Gergely, Eliot Jurist, Mary Target’. Fort Da, 9(2): 107–111; Ferraro, D. ([2011] 2014). ‘The Other, Clinical and Empirical: A Review of Fonagy et al. on Affect Regulation, Mentalization, and the Development of the Self’. Accessed at: https://melbournelacanian.wordpress.com/2014/11/24/the-other-clinical-and-empirical-a-review-of-fonagy-et-al-on-affect-regulation-mentalisation-and-the-development-of-the-self.

17 E.g. Fonagy, P., Luyten, P., Allison, E., and Campbell, C. (2017). ‘What We have Changed our Minds About: Part 1. Borderline Personality Disorder as a Limitation of Resilience’. Borderline Personality Disorder and Emotion Dysregulation, 4: 11: ‘It is not possible for these individuals to access mentalizing if the self is overwhelmed by negative interference.’ It can be inferred here that ‘self’ primarily means both working memory and phenomenological experience. But the reader is left speculating about the meaning of this claim, which appears to be explanatory. In fact, the underspecified use of the concept of ‘self’ makes the claim descriptive and metaphoric.

18 James, W. (1890). Principles of Psychology, New York: Holt, p. 330. See also Baumeister, R. F. (1987). ‘How the Self Became a Problem: A Psychological Review of Historical Research’. Psychological Review, 52(1): 163–176; Danziger, K. (1997). ‘The Historical Formation of Selves’, in R. Ashmore and L. Jussim (eds), Self and Identity: Fundamental Issues, New York: Oxford University Press, pp. 137–159.

19 Calkins, M. W. (1915). ‘The Self in Scientific Psychology’. American Journal of Psychology, 26: 495–524.

20 Hilgard, E. R. (1949). ‘Human Motives and the Concept of the Self’. American Psychologist, 4(9): 374–382; Sarbin, T. R. (1952). ‘A Preface to a Psychological Analysis of the Self’. Psychological Review, 59(1): 11–22.

21 Hartmann, H. (1939). Ego Psychology and the Problem of Adaptation, New York: International Universities Press; Jacobson, E. (1954). ‘The Self and the Object World: Vicissitudes of their Infantile Cathexes and their Influence on Ideational Affective Development’. The Psychoanalytic Study of the Child, 9: 75–127. Though not an ego psychologist, Karen Horney was also important in the development of ‘self’ discourse in psychoanalysis, again as a reaction to drive theory. Horney, K. (1950). Neurosis and Human Growth, New York: W. W. Norton.

22 Hartmann, H. ([1950] 1964). ‘Comments on the Psychoanalytic Theory of the Ego’, in Essay on Ego Psychology, New York: International Universities Press, pp. 113–141.

23 Fromm, E. (1970). ‘Freud’s Model of Man and its Social Determinants’, in E. Fromm (ed.), The Crisis of Psychoanalysis: Essays on Freud, Marx, and Social Psychology, New York: Holt, Rinehart, Winston, pp. 42–61; Bettelheim, B. (1984). Freud and Man’s Soul, New York: Vintage; Borch-Jacobsen, M. (1988). The Freudian Subject, Stanford: Stanford University Press.

24 Maslow, A. H. (1942). ‘Self-esteem (dominance-feeling) and sexuality in women’. The Journal of Social Psychology, 16(2): 259–294; Maslow, A. H. (1948). ‘“Higher” and “Lower” Needs’. The Journal of Psychology, 25(2): 433–436; Rogers, C. R. (1950). ‘The Significance of the Self-Regarding Attitudes and Perceptions’, in M. L. Reymert (ed.), Feelings and Emotions: The Mooseheart Symposium, New York: McGraw-Hill. Rogers, C. and Dymond, R. (1954). Psychotherapy and Personality Change, Chicago: University of Chicago Press. The term ‘self’ also came to be used by the ego psychologists.

25 Rogers, Carl. (1942). Counseling and Psychotherapy: Newer Concepts in Practice, Boston; New York: Houghton Mifflin Company; Rogers, C. R. (1951). Client-Centered Therapy: Its Current Practice, Implications, and Theory, Boston: Houghton Mifflin Company; Symonds, P. M. (1951). The Ego and the Self, New York: Appleton-Century-Crofts.

26 Our synthesis of seven referents in self discourse since the 1950s overlaps for the most part with Leary and Tangney’s distinctions between five meanings of the term ‘self’ in psychology: self as total person; self as personality; self as experiencing subject; self as beliefs about oneself; and self as executive agent. However, the importance of the use of ‘self’ to mean experience of personal authenticity was central to its use in the 1950s, and is also very relevant to Fonagy and colleagues—as was the use of ‘self’ to mean social identity in discussions about the receptivity of individuals to social and developmental influence. Leary, M. R. and Tangney, J. P. (2003). ‘The Self as an Organizing Construct in the Behavioral and Social Sciences’, in M. R. Leary and J. P. Tangney (eds), Handbook of Self and Identity, New York: Guildford, pp. 3–14.

27 Allport, G. W. (1955). Becoming; Basic Considerations for a Psychology of Personality, Volume 20, London: Yale University Press, p. 38.

28 See also Cushman, P. (1995). Constructing the Self, Constructing America: A Cultural History of Psychotherapy, Cambridge, MA: Perseus; Shaw, R. and Colimore, K. (1988). ‘Humanistic Psychology as Ideology: An Analysis of Maslow’s Contradictions’. Journal of Humanistic Psychology, 28: 51–74; Carrette, J. (2003). ‘Psychology, Spirituality and Capitalism: The Case of Abraham Maslow’. Critical Psychology, 8: 73–95; Malone, K. R. (2007). ‘The Subject as Drop-Out: Cultural Accountability and the Ethics of Psychoanalysis and Humanistic Psychology’. Theory & Psychology, 17: 449–471.

29 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; Kohut, H. (1971). The Analysis of the Self, New York: International Universities Press; Kohut, H. (1977). The Restoration of the Self, New York: International Universities Press. See also Harwood, I. (1987). ‘The Evolution of the Self: An Integration of Winnicott’s and Kohut’s Concepts’, in T. Honess and K. Yardley (eds), Self and Identity: Individual Change and Development, London: Routledge, pp. 55–77; Lunbeck, E. (2014). The Americanization of Narcissism, Cambridge, MA: Harvard University Press.

30 Fonagy, P. and Higgitt, A. C. (1985). Personality Theory and Clinical Practice, London: Methuen, p. 92.

31 Bach, S., Mayes, L., Alvarez, A. and Fonagy, F. (2000). ‘Panel 1: Definition of the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 5–24. Fonagy: ‘It was from instances of its apparent falsity or damage that psychoanalysis first sought to define what a coherent self might be. Consider, for example, Deutsch (1942) and the “as if” personality, Winnicott (1965) and the false self, or Kohut (1971) and the grandiose self … Paradoxically, when selfhood is authentic there is little need for the concept. The individual recognizes both impulse and prohibition; the compromise between them forms an attribute of the ego. It is when this process fails that the critical role of the self-structure asserts itself most urgently’ (pp. 20–1).

32 See the discussions of Winnicott and Kohut in 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.

33 Sroufe, L. A. (1989). ‘Relationships, Self, and Individual Adaptation’, in A. J. Sameroff and R. N. Emde (eds), Relationship Disturbances in Early Childhood: A Developmental Approach, New York: Basic Books, pp. 70–94: ‘Self should be conceived as an inner organisation of attitudes, feelings, expectations, and meanings, which arises from an organized caregiving matrix’ (p. 71).

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. 474.

35 Hegel, G. W. F. ([1807] 1977), Phenomenology of Spirit, trans. A. V. Miller, ed. J. N. Findlay, Oxford: Oxford University Press, p. 111. The first published citation of this passage by Fonagy was in Fonagy, P. and Target, M. (1994). ‘Understanding and the Compulsion to Repeat: A Clinical Exploration’. Bulletin of the Anna Freud Centre, 17: 33–55; and then next in Fónagy, I. and Fonagy, P. (1995). ‘Communication with Pretend Actions in Language, Literature and Psychoanalysis’. Psychoanalysis and Contemporary Thought, 18(3): 363–418. However, given how protracted the development of the latter paper was, there is reason to suspect that it is in fact the earlier work.

36 Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Matton, G., and Target, M. (1995). ‘Attachment, the Reflective Self and Borderline States: The Predictive Specificity of the Adult Attachment Interview and Pathological Emotional Development’, in S. Goldberg, R. Muir, and J. Kerr (eds), Attachment Theory: Social, Developmental, and Clinical Perspectives, New York: Analytic Press, pp. 233–278, p. 256. A sharp contrast with traditional psychoanalytic theory was drawn in 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: ‘For Freud, in infancy and early childhood, others in the external world were extensions of the self. While this may be an accurate description of the phenomenology, for us it is seems more accurate to see the self as originally an extension of experience of the other’ (p. 474).

37 E.g. 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: ‘The theoretical claim that self and other representations are shared and are the default mode of the motor system is reasonably well supported, as we have seen. People have a tendency to mirror actions automatically … the inhibition of imitative behaviour involves cortical areas that are also related to mentalizing … the capacity to inhibit imitative behaviour may be key to enabling us to generate a sense of “me”-ness through achieving a “not other”ness. In other words, each time we interpret the actions of another, there may be a sequence in which an initial imitative matching response with the other within a motor neuron self-other system interacts with the reflective mentalizing self-other system … This might explain why patients with BPD [borderline personality disorder] feel vulnerable to losing a sense of self’ (pp. 415–416).

38 Bateman, A., Fonagy, P. and Campbell, C. (2019). ‘Antisocial Personality Disorder in Community and Prison Settings’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 335–349, p. 347.

39 Bach, S., Mayes, L., Alvarez, A. and Fonagy, F. (2000). ‘Panel 1: Definition of the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 5–24, p. 19.

40 Køster, A. (2017). ‘Mentalization, Embodiment, and Narrative: Critical Comments on the Social Ontology of Mentalization Theory’. Theory & Psychology, 27(4): 458–476.

41 Fonagy, P. (2000). ‘Attachment and Borderline Personality Disorder’. Journal of the American Psychoanalytic Association, 48(4): 1129–1146, p. 1136. Earlier, immediate personal experience had been characterized as the ‘prereflective self’ by Fonagy and colleagues. Fonagy, P., Steele, M., Steele, H., Moran, G. S., and Higgitt, A. C. (1991). ‘The Capacity for Understanding Mental States: The Reflective Self in Parent and Child and its Significance for Security of Attachment’. Infant Mental Health Journal, 12(3): 201–218, p. 203.

42 Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 183.

43 Bach, S., Mayes, L., Alvarez, A., and Fonagy, F. (2000). ‘Panel 1: Definition of the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 5–24, p. 17.

44 Fonagy, P. (1995). ‘2: Peter Fonagy’. British Journal of Psychotherapy, 11(4): 575–584, p. 575.

45 Luyten, P. and Fonagy, P. (2016). ‘The Self in Depression’, in M. Kyrios, R. Moulding, M. Nedeljkovic, S. S. Bhar, G. Doron, and M. Mikulincer (eds), The Self in Understanding and Treating Psychological Disorders, Cambridge: Cambridge University Press, pp. 71–81, p. 72. Cf. Fonagy, P. (1999). ‘Relation of Theory and Practice in Psychodynamic Therapy’. Journal of Clinical Child Psychology, 28(4): 513–520: ‘Psychodynamic clinicians found a way around the empirical problems created by partially incompatible formulations that nevertheless needed to be employed concurrently. They loosened the definition of all the categories under consideration’ (p. 518).

46 Jacobson, E. (1954). ‘On Psychotic Identifications’. The International Journal of Psychoanalysis, 35: 102–108, p. 102. See also Jacobson, E. (1964). The Self and the Object World, New York: International Universities Press. Fonagy, P. (1995). ‘2: Peter Fonagy’. British Journal of Psychotherapy, 11(4): 575–584: ‘Jacobson (1964) and Schafer (1968) both made, to me, helpful distinctions between self as the totality of the person and self-representation’ (p. 575).

47 Sandler, J. and Rosenblatt, B. (1962). ‘The Concept of the Representational World’. The Psychoanalytic Study of the Child, 17(1): 128–145: ‘By the self-representation we mean that organization which represents the person as he has consciously and unconsciously perceived himself, and which forms an integral part of the representational world’ (p. 134). See also Fonagy, P. (2005). ‘An Overview of Joseph Sandler’s Key Contributions to Theoretical and Clinical Psychoanalysis’. Psychoanalytic Inquiry, 25(2): 120–147.

48 Sandler, J. (1993). ‘On Communication from Patient to Analyst: Not Everything is Projective Identification’. The International Journal of Psychoanalysis, 74: 1097–1107.

49 Bach, S., Mayes, L., Alvarez, A., and Fonagy, F. (2000). ‘Panel 1: Definition of the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 5–24, p. 19.

50 Ricoeur, P. (1994). Oneself as Another, Chicago, IL: University of Chicago Press.

51 The influence of Jim Grotstein’s work on Fonagy and Allison is difficult to pick apart. On the one hand, there are few elements in Fonagy and Allison’s account of the primary unconscious that are not already present in Grotstein’s earlier work. However, Grotstein’s account is awash with different ideas, which are not especially integrated. Fonagy and Allison cite Grotstein, but do not discuss his work. A reason may be that to do so would have required quite an extensive and subtle discussion; it may have been more economical to just include the citation. Nonetheless, there are points in Grotstein that could have perhaps benefited Fonagy and Allison’s model, such as the distinction between nothingness and meaninglessness. Grotstein, J. S. (1990). ‘Nothingness, Meaninglessness, Chaos, and the “Black Hole” I—The Importance of Nothingness, Meaninglessness, and Chaos in Psychoanalysis’. Contemporary Psychoanalysis, 26: 257–290.

52 Fonagy, P. and Allison, E. (2016). ‘Psychic Reality and the Nature of Consciousness’. The International Journal of Psychoanalysis, 97(1): 5–24: ‘As we move towards the primary unconscious, the mental world loses its ‘aboutness’, its intentional character, the quality rooted in the dyadic consciousness of marked contingent mirroring or even its failed derivatives through projective identification’ (p. 14).

54 Green, A. ([1993] 1999). The Work of the Negative, trans. A. Weller, London: Free Association Books; Green, A. (1998). ‘The Primordial Mind and the Work of the Negative’. The International Journal of Psychoanalysis, 79: 649–665.

55 Relevant here perhaps is Winnicott’s distinction between unintegration (relaxation of an integration) and disintegration (the breakdown of an integration), a distinction that Green tends to elide. Winnicott, D. ([1962] 1965). ‘Ego Integration in Child Development’, in The Maturational Processes and the Facilitating Environment, New York: International Universities Press, pp. 56–63; Winnicott, D. W. (1988) ‘Chaos’, in Human Nature, London: Free Association Books, pp. 135–138.

56 However, elsewhere Fonagy and colleagues have considered meaninglessness in ways that seem to correspond to Green’s characterization e.g. 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 R. Moguillansky (eds), Clinical and Theoretical Aspects of Perversion, London: Karnac Books, pp. 63–76: ‘The hallmark of the pretend mode is the experience of meaninglessness in the midst of the act of symbol creation’ (p. 69), though it may be that for Fonagy and colleagues there is more than one kind of experience of meaninglessness, and only sometimes is this inflected by the primary unconscious.

57 Fonagy, P. and Allison, E. (2016). ‘Psychic Reality and the Nature of Consciousness’. The International Journal of Psychoanalysis, 97(1): 5–24: ‘The implicit great threat posed by the primary unconscious is to the intentional quality or aboutness of experience—the feeling that it is being directed toward something. We take the view that the primary unconscious is not object related, and here we diverge from the Kleinian position that phantasies, that is, representations of instinctual aims towards objects, are the ‘primary content of unconscious mental processes’ (Isaacs, 1948, p. 81). The intrusions of the primary unconscious undermine the implicitly purposeful character of human experience, replacing intentionality with diffused meaninglessness’ (p. 15).

58 Low, J. (2003). ‘Psychoanalysis—It is a Signifier’. Journal of the Centre for Freudian Analysis and Research, 13, citing from an interview with Peter Fonagy.

59 Freud, S. ([1915] 2001). The Unconscious. Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 14, London: Vintage.

60 Freud, S. ([1926] 2001). Inhibitions, Symptoms and Anxiety. Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 22, London: Vintage, pp. 75–174; Arbiser, S. and Schneider, J. (eds) (2018). On Freud’s Inhibitions, Symptoms and Anxiety, London: Routledge. For discussions of the concepts of affect and intention in Freud, as well as their limitations, see Green, A. (1999). The Fabric of Affect in the Psychoanalytic Discourse, New York: Psychology Press; Johnston, A. (2010). ‘Affekt, Gefühl, Empfindung: Rereading Freud on the Question of Unconscious Affects’. Qui Parle, 18(2): 249–289. It is not clear whether all non-conscious mental states that, by degrees, lack intentionality would be assimilated by Fonagy and colleagues to the primary unconscious. Some, such as Kierkegaard, have argued that apparently non-intentional affects, such as anxiety, may seem to intend no specific object because they actually refer to our relationship with the world as a whole. See e.g. Kierkegaard, S. ([1844] 2013). Concept of Anxiety: A Simple Psychologically Orienting Deliberation on the Dogmatic Issue of Hereditary Sin. Kierkegaard’s Writings, Volume 8, Princeton, NJ: Princeton University Press. Other affects may have a similar structure, such as some forms of shame.

61 Fairbairn, W. R. D. (1943). ‘The Repression and the Return of Bad Objects (with Special Reference to the “War Neuroses”)’. British Journal of Medical Psychology, 19(3–4): 327–341; Fairbairn, W. R. D. (1944). ‘Endopsychic Structure Considered in Terms of Object-Relationships’. The International Journal of Psychoanalysis, 25: 70–92.

62 Fonagy, P. and Target, M. (1998). ‘Mentalization and the Changing Aims of Child Psychoanalysis’. Psychoanalytic Dialogues, 8(1): 87–114: ‘We suggest that developmental personality disturbances arise first from the child’s failure to find the image of his mind, his experience of himself as a thinker of thoughts, believer of ideas, feeler of emotions, in the mind of the caregiver (see Fairbairn, 1952)’ (p. 93).

63 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.

64 Fonagy, P. and Allison, E. (2016). ‘Psychic Reality and the Nature of Consciousness’. The International Journal of Psychoanalysis, 97(1): 5–24: ‘Neglect, physical abuse, emotional maltreatment, and all forms of adversity mirror and thereby, in our model, render potentially accessible to consciousness states of mind that would (‘within an average expectable environment’—Hartmann, 1950) remain far from conscious subjectivity in the primary unconscious. Neglectful, aggressive or sexually seductive parenting part-mirrors the states of destructiveness, isolation and despair that are perhaps ubiquitous, if occasional states of mind. When the child’s environment is contingent with (matches) such devastating mind states, the part-mirroring will bring these negative states of mind closer to subjectivity’ (p. 15).

65 Fonagy, P. and Allison, E. (2015). ‘A Scientific Theory of Homosexuality for Psychoanalysis’, in A. Lemma and P. E. Lynch (eds), Sexualities: Contemporary Psychoanalytic Perspectives, Hove, UK: Routledge, pp. 125–137, p. 133.

66 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. 73.

67 Grossman, W. I. (1982). ‘The Self as Fantasy: Fantasy as Theory’. Journal of the American Psychoanalytic Association, 30(4): 919–937, p. 926. Fonagy cites the conference presentation, on which the 1982 paper was based, in his remarks in Bach, S., Mayes, L., Alvarez, A., and Fonagy, F. (2000). ‘Panel 1: Definition of the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 5–24, p. 17, citing Ticho, E. A. and Richards, A. D. (1982). ‘Psychoanalytic Theories of the Self’. Journal of the American Psychoanalytic Association, 30(3): 717–733. He also cites a review of Grossman and Kohut’s concepts of the self: Havens, L. (1986). ‘A Theoretical Basis for the Concepts of Self and Authentic Self’. Journal of the American Psychoanalytic Association, 34(2): 363–378. Fonagy may have additionally been influenced by Laplanche’s interpretation of the ego in Freud as a fantasy. Laplanche, J. (1976). Life and Death in Psychoanalysis, Baltimore, MD: John Hopkins University Press. Fonagy would also have been doing research towards his book with Hepworth on psychoanalytic theories, which mentions in passing Lacan’s characterization of the ego. For Lacan, at least in his early work, the ego is as an imaginary function, one that operates within psychological life only as a representation. Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 17.

68 Bach, S., Mayes, L., Alvarez, A., and Fonagy, F. (2000). ‘Panel 1: Definition of the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 5–24, p. 22.

69 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘Emotions, which are the individual’s bodily reaction, as action programs, to specific stimuli. Feelings, which are the conscious experience of the body state during emotional activation’ (p. 307).

70 See 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; Fonagy, I. (1999). ‘The Process of Remembering: Recovery and Discovery’. The International Journal of Psychoanalysis, 80(5): 961–978; Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, Chapter 6.

71 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,: ‘The self, and particularly the sense of self‐coherence and self‐continuity over time, is an illusion (Bargh, 2011, 2014) that is the product of the capacity for reflective functioning or mentalizing’ (p. 91).

72 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 R. Moguillansky (eds), Clinical and Theoretical Aspects of Perversion, London: Karnac Books, pp. 63–76, p. 71.

73 Winnicott, D. W. (1949). ‘Hate in the counter-transference’. The International Journal of Psychoanalysis, 30: 69–74. See the discussion in Higgitt, A. and Fonagy, P. (1992). ‘Psychotherapy in Borderline and Narcissistic Personality Disorder’. The British Journal of Psychiatry, 161(1): 23–43, p. 30.

74 Main, M. (undated). Disorganised/Disoriented Classification Scheme: Major Considerations, unpublished manuscript. Received from Elizabeth Carlson, and cited with her permission.

75 However, major separations or the fear or threat of separations from attachment figures may, nonetheless, threaten to disrupt these benefits. Fonagy, P. and Moran, G. S. (1990). ‘Severe Developmental Psychopathology and Brittle Diabetes: The Motivation for Self-Injurious Behaviour’. Bulletin of the Anna Freud Centre, 13: 231–248: ‘internal danger … is invariably associated with the psychic distance of the object, felt by the patient to be either invading the self or abandoning it. In either case what is feared and anticipated is the destruction of the self. This is because it is the coherence and continued stability of the mental representation of the self that comes under threat either from unwelcome affect-laden transactions with a dangerous object or enforced or violent separation from a desired, protective one’ (p. 233).

76 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 5.

77 Fonagy, P., Campbell, C., and Allison, E. (2019). ‘Therapeutic Models Mentalising’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 169–180, p. 171.

78 Fonagy, P. (1995). ‘2: Peter Fonagy’. British Journal of Psychotherapy, 11(4): 575–584, p. 576.

79 The position of Fonagy and colleagues here runs contrary to that of Meissner, who held that ‘if the self is merely and exclusively representational, it cannot serve as a source of action or agency … it fails the demands of the role of the self in subjectivity and personal agency’ Meissner, W. W. (1986). ‘Can Psychoanalysis Find its Self?’ Journal of the American Psychoanalytic Association, 34(2): 379–400, p. 382.

80 See Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications: ‘Perhaps Sandler’s most important contribution was his distinction between the experiential and the non-experiential realms. Whereas the former referred to Sandler and Joffe’s representational model, the latter entailed mechanisms, structures and apparatuses. The non-experiential is inherently non-conscious, although it is not repressed or dynamically inhibited. The distinction between a fantasy (conscious or unconscious) and the organized function underpinning it (fantasizing) remains an evocative example. The model makes clear that experience is not the agent of change; rather, change is brought about by structures in the non-experiential realm, which cause corresponding changes in the experiential. Thus self-representation cannot be an agent, but it is an entity that will determine how mechanisms of the mind behave … Sandler (1990) clarified his view of internal objects as “structures” within the non-experiential realm, albeit constructed out of subjective experience, conscious or unconscious. Once created, such non-experiential structures can modify subjective experience, including the child’s experience of actual objects (people)’ (p. 105). On adolescence as both a sensitive period and a challenging period for the solidification of a self-representation through the capacity to imagine mental states in oneself and others, see Sharp, C. and Rossouw, T. (2019). ‘Borderline Personality Pathology in Adolescence’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalisation in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 281–300. Similar ideas were presented already across Anna Freud’s work, and may have provided a background influence for Fonagy and colleagues on this point.

81 The case of Winnicott, always a little tricky to pin down as a theorist, is more complicated than Rogers. When he introduced the concept, Winnicott urged ‘The True Self appears as soon as there is any mental organization of the individual at all, and it means little more than the summation of sensori-motor aliveness’: 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, p. 149. This would not be illusion in Fonagy’s terms. However, in Winnicott’s later writings, the term is explicitly aligned with the idea of authenticity in Romanticism, and takes a more essentialist cast, which draws the concept back towards Rogers and the target of Fonagy’s critique. Winnicott, D. W. (1986). ‘The Concept of the False Self’, in Home is Where We Start From, New York: W. W. Norton, pp. 65–70. The potential for Winnicott’s concept of ‘true self’ to slide towards essentialism, and even moralizing essentialism, has been criticized by some commentators. However, Winnicott has also been defended by others on this count. See e.g. Papadima, M. (2006). ‘Dissociation, the True Self and the Notion of the Frozen Baby’. Psychodynamic Practice, 12(4): 385–402; Ruti, M. (2010). ‘Winnicott with Lacan: Living Creatively in a Postmodern World’. American Imago, 67(3): 353–374.

82 Fonagy, P. and Target, M. (1994). ‘Understanding and the Compulsion to Repeat: A Clinical Exploration’. Bulletin of the Anna Freud Centre, 17: 33–55: ‘The analytic goal must be to engender within the patient a true understanding. Understanding here implies detachment, i.e. the permanent loss of the omnipotent self (Gaddini, 1987). To admit to analytic understanding is equivalent to recognizing extreme fragility and vulnerability of a self which appears mutilated in comparison to the self that is proximal to the understanding object, however distorted that understanding may be’ (p. 53). The term ‘mutilation’, and in fact much of the wording of this statement, is drawn from Gaddini, E. ([1980] 1992). ‘Notes on the Body-Mind Question’, in Adam Limentani (ed.), A Psychoanalytic Theory of Infantile Experience: Conceptual and Clinical Reflections, London: Routledge, pp. 105–124, p. 115.

83 Fonagy, P., Bateman, A. W., and Luyten, P. (2012). ‘Introduction and Overview’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Publishing, pp. 3–42, p. 7.

84 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: ‘We will first describe the psychopathology of eating disorders by using the language of the mentalizing model. We understand these disorders as manifestations of an underlying self-disorder. This underlying disorder should be the central focus of psychotherapy’ (p. 348). See also Sacchetti, S., Robinson, P., Bogaardt, A., Clare, A., Ouellet-Courtois, C., Luyten, P., … and Fonagy, P. (2019). ‘Reduced Mentalizing in Patients with Bulimia Nervosa and Features of Borderline Personality Disorder: A Case-Control Study’. BMC Psychiatry, 19(1): 134.

85 Fonagy, P. (1995). ‘2: Peter Fonagy’. British Journal of Psychotherapy, 11(4): 575–584, p. 580.

86 Ibid. Ryle’s riposte to Fonagy was to claim that the sense of self is constituted by a person’s interpersonal and intrapersonal social experiences, not merely a representation of that experience. On this basis, Ryle and Kerr regarded the integration of a person’s interpersonal and intrapersonal social experiences as realistic and worthwhile, even if it is a task that is never complete. Ryle, A. and Kerr, I. B. (2003). Introducing Cognitive Analytic Therapy: Principles and Practice, New York: Wiley, p. 37.

87 Bateman, A. W. and Fonagy, P. (2003). ‘The Development of an Attachment-Based Treatment Program for Borderline Personality Disorder’. Bulletin of the Menninger Clinic, 67: 187–211, p. 195.

89 Fonagy, P. and Target, M. (1997). ‘Attachment and Reflective Function: Their Role in Self-Organization’. Development and Psychopathology, 9(4): 679–700.

90 Bateman, A. W. and Fonagy, P. (2003). ‘The Development of an Attachment-Based Treatment Program for Borderline Personality Disorder’, Bulletin of the Menninger Clinic, 67: 187–211, p. 195.

92 Rogers, C. R. (1959). Client-Centered Therapy: Its Current Practice, Implications, and Theory, Boston: Houghton Mifflin. The term’s first sustained use within psychoanalysis was in conceptualizing borderline and narcissistic personality disorders—for instance, in the work of Irene Fast, as well as Kernberg and then Kohut. The first explicit definition of the term appears to be in Frances, A., Sacks, M., and Aronoff, M. S. (1977). ‘Depersonalization: A Self-Relations Perspective’. The International Journal of Psychoanalysis, 58: 325–331: ‘We use the term “self-structure” to describe the coherent organization of those previously registered self representations which provide an individual with his experiential sense of psychological intactness, i.e. his sense of self’ (p. 325).

93 Fonagy, P. and Target, M. (2000). ‘Playing with Reality: III. The Persistence of Dual Psychic Reality in Borderline Patients’. The International Journal of Psychoanalysis, 81(5): 853–873, p. 864.

94 Fonagy, P. (2009). ‘Commentary on “Forgiveness”’, in S. Akhtar (ed.), Good Feelings: Psychoanalytic Reflections on Positive Emotions and Attitudes, London: Karnac Books/International Psychoanalytic Association, pp. 411–452: ‘In imagining understanding someone else fully, or being fully and accurately understood by them, we are forced into the world of imagination, the fantasy of an omniscient mentalising being’ (p. 423).

95 The elaboration of unacknowledged experiences into intentions in the psychoanalytic unconscious is described, though only briefly and speculatively, in Fonagy, P. and Allison, E. (2016). ‘Psychic Reality and the Nature of Consciousness’. The International Journal of Psychoanalysis, 97(1): 5–24: ‘Although it is “unmetabolized”, the psychoanalytic unconscious acquires a partial quality of intentionality or “aboutness” through the process of projective identification. When aspects of sexuality or destructiveness are communicated by the infant to the mother, she does not mirror but recognizes the experiences, transmitting them back infused with intentionality from her unconscious associations to the feelings’ (p. 13).

96 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. 439.

97 Goretti, G. R. (2007). ‘Projective Identification: A Theoretical Investigation of the Concept Starting from “Notes on some Schizoid Mechanisms”’. The International Journal of Psychoanalysis, 88: 387–406.

98 On their first usage, Fonagy and Target attribute the idea to Britton’s 1998 book on the imagination. However, Britton in turn was drawing on Grotstein. See Fonagy, P. and Target, M. (2000). ‘Playing with Reality: III. The Persistence of Dual Psychic Reality in Borderline Patients’. The International Journal of Psychoanalysis, 81(5): 853–873; Britton, R. (1998). Belief and Imagination, London: Routledge; Grotstein, J. S. (1977). ‘The Psychoanalytic Concept of Schizophrenia: II. Reconciliation’. The International Journal of Psychoanalysis, 58: 427–452; Grotstein, J. S. (1980). ‘A Proposed Revision of the Psychoanalytic Concept of Primitive Mental States: Part I. Introduction to a Newer Psychoanalytic Metapsychology’. Contemporary Psychoanalysis, 16(4): 479–546. The ‘alien self’ was predated in psychoanalytic theory by the idea of ‘ego-alien feelings’, which was a definite precursor, but lacked the implication of a sense of agency or intentionality that was within a person without belonging to them.

99 The reason for the neglect of positive introjects by Fonagy and colleagues is not clear. It could be that they assumed that positive introjects simply form part of the self-representation. Or it could be that they regarded positive introjects as of less clinical and developmental relevance. As a point of comparison, highlighting the importance of positive projective identification for caregiving, see Likierman, M. (1988). ‘Maternal Love and Positive Projective Identification’. Journal of Child Psychotherapy, 14(2): 29–46. It may also be that positive introjects can contribute, precisely by feeling somewhat other than the self, to the successful calibration of epistemic vigilance (see Chapter 7)—for instance, through establishing an effective ego ideal.

100 Fonagy, P. and Target, M. (2003). ‘Evolution of the Interpersonal Interpretive Function: Clues for Effective Preventive Intervention in Early Childhood’, in S. W. Coates, J. L. Rosenthal, and D. S. Schechter (eds), September 11: Trauma And Human Bonds, Hillsdale, NJ: Analytic Press, pp. 99–113, p. 106. See also 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.

101 Winnicott, D. W. (1990). Human Nature, London: Routledge, p. 23.

102 See e.g. Winnicott, D. W. (1968). ‘Communication between Infant and Mother, and Mother and Infant, Compared and Contrasted’, in Walter G. Joffe (ed.), What is Psychoanalysis?, London: The Institute of Psycho-Analysis/Ballière, Tindall & Cassell; Winnicott, D. W. (1971). Playing and Reality, London: Tavistock. Cf. Hutto, D. D. (2008). ‘The Narrative Practice Hypothesis: Clarifications and Implications’. Philosophical Explorations, 11(3): 175–192.

103 Cf. Ganeri, J. (2012). The Self: Naturalism, Consciousness, and the First-Person Stance, Oxford: Oxford University Press; Ganeri, J. (2017). Attention, Not Self, Oxford: Oxford University Press.

104 Fonagy, P. and Target, M. (2006). ‘The Mentalization-Focused Approach to Self Pathology’. Journal of Personality Disorders, 20: 544–576, p. 567.

105 Fonagy, P. and Target, M. (2000). ‘Playing with Reality: III. The Persistence of Dual Psychic Reality in Borderline Patients’. The International Journal of Psychoanalysis, 81(5): 853–873, p. 864. 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.

106 Fonagy, P. and Target, M. (1999). ‘Towards Understanding Violence: The Use of the Body and the Role of the Father’, in R. J. Perelberg (ed.), Psychoanalytic Understanding of Violence and Suicide, London: Routledge, pp. 53–72, p. 62.

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

108 Fonagy, P., Luyten, P., Allison, E., and Campbell, C. (2017). ‘What We have Changed our Minds About: Part 1. Borderline Personality Disorder as a Limitation of Resilience’. Borderline Personality Disorder and Emotion Dysregulation, 4: 11.

109 Fonagy, P. and Target, M. (2000). ‘Playing with Reality: III. The Persistence of Dual Psychic Reality in Borderline Patients’. The International Journal of Psychoanalysis, 81(5): 853–873, p. 864.

110 E.g. Bateman, A. and Fonagy, P. (2008). ‘Comorbid Antisocial and Borderline Personality Disorders: Mentalization‐Based Treatment’. Journal of Clinical Psychology, 64(2): 181–194: ‘Stability is maintained by interpreting the world according to teleological understanding much of the time, but in many instances, we suggest that stabilization of mental processes arises from the rigidity of the externalization of the alien self’ (p. 184).

111 Luyten, P., Malcorps, S., Fonagy, P., and Ensink, K. (2019). ‘Mentalising and Trauma Trust’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 79–102, p. 85, Table 5.1. Luyten and colleagues also hint at ‘re-enactment of trauma’ as a potential additional form of non-mentalizing, though it might be supposed that this could be accounted for in terms of the other three—or four—modes of non-mentalizing. The relationship between re-enactment of trauma and the forms of non-mentalizing is not addressed in depth by the authors.

112 Asen, E. and Fonagy, P. (2017). ‘Mentalizing Family Violence Part 1: Conceptual Framework’. Family Process, 56(1): 6–21, p. 13.

113 Sandler, J. (ed.) (1988). Projection, Identification, Projective Identification, Karnac Books. Bateman, A. W., and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘What psychodynamic clinicians would recognise as “projective identification”. This term has many meanings, and this has led us to talk about one aspect of this—the externalisation of the alien part of the self’ (p. 20). The idea of ‘externalization’ was developed by Anna Freud and Joseph Sandler in responding to Klein’s work, again attempting to distinguish specific meanings within the overburdened concept of projective identification. By ‘externalization’, Freud and Sandler intended the ascription of a troubling mental state of one’s own to someone or a group in the outside world, a defence mechanism they regarded as capable of becoming pathological if implemented too rigidly and intensely, but also as quite ordinary and sometimes functional in human life. Sandler, J., Kennedy, H., and Tyson, R. L. (1975). ‘Discussions on Transference: The Treatment Situation and Technique in Child Psychoanalysis’. The Psychoanalytic Study of the Child, 30(1): 409–441; Sandler, J. and Freud, A. (1981). ‘Discussions in the Hampstead Index on “The Ego and the Mechanisms of Defence”: IV. The Mechanisms of Defence, Part 1’. Bulletin of the Anna Freud Centre, 4(3): 151–199.

114 See e.g. Bach, S., Alvarez, A., Mayes, L., and Fonagy, P. (2000). ‘Panel 3: Fantasy Life and the Self’. Journal of Infant, Child & Adolescent Psychotherapy, 1(3): 51–62: ‘Peter Fonagy: I always had terrible trouble with the notion of projective identification. I was trained at the Anna Freud Centre and we just didn’t talk about things like that’ (pp. 60–61).

115 Hargreaves, E. (2004). In Pursuit of Psychic Change: The Betty Joseph Workshop, London: Routledge. See also Baert, P. (2012). ‘Positioning Theory and Intellectual Interventions’. Journal for the Theory of Social Behaviour, 42(3): 304–324. See also Brown, L. J. (2012). ‘The New Dictionary of Kleinian Thought. By Elizabeth Bott Spillius, Jane Milton, Penelope Garvey, Cyril Couve, and Deborah Steiner (Review)’. Psychoanalytic Quarterly, 81(3): 775–780: ‘Some years ago, I attended a symposium on the Controversial Discussions, hosted by the Massachusetts Institute for Psychoanalysis, at which the featured speakers were Ron Britton (representing the Kleinian view), Peter Fonagy (the contemporary Freudian view), and David Tuckett (the Independent view). At one point, Fonagy spoke about the tendency toward insularity among Kleinians, and also acknowledged a measure of envy about that group’s collective focus on systematically developing their concepts’ (p. 775).

116 In the estimation of Fonagy and Hepworth, confusion of phenomenology and explanation characterized much of Klein’s terminology. Technically, this would mean that much of Kleinian therapy would be conducted close to psychic equivalence, a state in which phenomenology is taken for explanation. Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications: ‘Criticisms address the “fuzziness” of Klein’s descriptions. The emphasis on “phantasy” as the building block of mental structure means that mental structuralization has been moved into the experiential realm (see Sandler & Joffe 1969), rather than being seen as inaccessible to awareness. This carries the advantage of closeness to clinical experience, and rids theory of much reified pseudo-scientific terminology. However, it bypasses essential questions and findings about the mechanisms underpinning mental functions.’ (135, parentheses suppressed); ‘The attainment of the “depressive position” illustrates some of the ambiguities of Kleinian terms. This change (whether or not seen as a stable development stage) clearly implies a qualitative shift in the perception of the object from part to whole. It is not clear, however, if it also implies a) consciousness of conflicted feelings about the same person (e.g. love and hate); b) the unconscious integration of various images with no necessary conscious correlate; c) the ability to recognize that the same person can generate conflicting feelings, but that these do not necessarily “belong” to that person’ (p. 136).

117 E.g. Lemma, A., Target, M., and Fonagy, P. (2011). Brief Dynamic Interpersonal Therapy: A Clinician’s Guide, Oxford: Oxford University Press: ‘A DIT formulation has several components: 1) It describes the problem as seen by the patient. 2) It contextualizes the problem in a developmental framework … 3) It pulls together this information into an account that meaningfully links the patient’s difficulties with a psychological, dynamic process’ (pp. 111–112).

118 Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 135

119 Concerns about the lack of clarity in use of the concept of ‘externalization’ in this regard have been offered by Auerbach, J. S. (2005). Fonagy, P., Gergely, G., Jurist, E. L., and Targe, M. ‘Affect Regulation, Mentalization, and the Development of the Self (Book Review)’. Accessed at: https://www.apadivisions.org/division-39/publications/reviews/affect.

120 The possibility that the alien self is a kind of psychic equivalence is tantalizingly suggested in the first edition of Bateman and Fonagy’s Psychotherapy For Borderline Personality Disorder. Though the link is not discussed in the text, in Figure 3.6, Bateman and Fonagy suggest that externalization of the alien self has a special causal relationship with psychic equivalence not possessed by teleological mode and pretend mode. However, the nature of this link is not elaborated. And the diagram disappears from the subsequent edition of the book. If externalization of the alien self is indeed partly a species of psychic equivalence, then this would suggest another reason for its exclusion as a fourth form of non-mentalizing.

121 Bion, W. ([1977] 2019). Bion in New York and Sao Paulo, and Three Tavistock Seminars, London: Karnac Books.

122 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 21.

123 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 21.

124 Fonagy, P. and Target, M. (2003). ‘Evolution of the Interpersonal Interpretive Function: Clues for Effective Preventive Intervention in Early Childhood’, in S. W. Coates, J. L. Rosenthal, and D. S. Schechter (eds), September 11: Trauma And Human Bonds, Hillsdale, NJ: Analytic Press, pp. 99–113, p. 110.

125 Fonagy, P. and Campbell, C. (2015). ‘Bad Blood Revisited: Attachment and Psychoanalysis, 2015’. British Journal of Psychotherapy, 31(2): 229–250, p. 241.

126 Fonagy, P. and Allison, E. (2015). ‘A Scientific Theory of Homosexuality for Psychoanalysis’, in A. Lemma and P. E. Lynch (eds), Sexualities: Contemporary Psychoanalytic Perspectives, Hove, UK: Routledge, pp. 125–137: Primary unconscious becoming more important, as more mirroring of it: ‘The discomfort of desire as made real by its social experience is here to stay. We predict that, if anything, its potential for impingement will be enhanced by the increased contingent mirroring of psychic experience made available by the panoply of electronic media, the iPhone and Android apps’ (p. 135).

127 Slade has argued that some affects are inherently difficult to mentalize, among these ‘negative affects such as fear, sadness, and particularly anger.’ Slade, A. (2009). ‘Mentalizing the Unmentalizable: Parenting Children on the Spectrum’. Journal of Infant, Child, and Adolescent Psychotherapy, 8(1): 7–21, p. 8. While sexuality and aggression were given particular attention by Fonagy and Hepworth, it seems quite possible that experiences of fear will also contribute to the alien self. Fonagy and Hepworth’s focus on sexuality and aggression perhaps stemmed from their salience for psychoanalytic theory. Fear may also have been subsumed under the attachment response, even though Bowlby distinguished them and their activating and terminating conditions as behavioural systems. The neglect of fear may also perhaps arise from an expectation that caregivers are able to acknowledge their child’s fear more than their sexuality or aggression. If the latter assumption has been in play, it is—at least—debatable.

128 See e.g. Freud, A. (1949). ‘Aggression in Relation to Emotional Development; Normal and Pathological’. The Psychoanalytic Study of the Child, 3: 37–42.

129 Fonagy, P. and Target, M. (1994). ‘Understanding and the Compulsion to Repeat: A Clinical Exploration’. Bulletin of the Anna Freud Centre, 17: 33–55, p. 51.

130 Fonagy, P. and Target, M. (1994). ‘Understanding and the Compulsion to Repeat: A Clinical Exploration’. Bulletin of the Anna Freud Centre, 17: 33–55, p. 51. See also Fonagy, P. and Moran, G. S. (1990). ‘Severe Developmental Psychopathology and Brittle Diabetes: The Motivation for Self-Injurious Behaviour’. Bulletin of the Anna Freud Centre, 13: 231–248: ‘Emma’s sole route to her dead mother was via the creation of a state of constant near-death within her own body … The pain and discomfort she inflicted upon herself were probably only bearable because of the separation of her self representation from her representation of her physical state. As her bodily states were, to a certain extent, represented outside of her self structure, the body was available as a stage upon which the nature and functioning of the mental world could be enacted’ (p. 246).

131 Fonagy, P. and Target, M. (1994). ‘Understanding and the Compulsion to Repeat: A Clinical Exploration’. Bulletin of the Anna Freud Centre, 17: 33–55, p. 51. See also Luyten, P., Fonagy, P., Lemma, A., and Target, M. (2012). ‘Depression’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Publishing, pp. 385–418: ‘Exercise in particular may not only distract depressed patients, but also reinstil a sense of efficacy and control, lead to a libidinal reinvestment of the body, and probably have a stress-attenuating effect through its effects on the dopaminergic reward system’ (p. 399). Taking this claim yet further, Fonagy has stated on Twitter that ‘physical exercise is the closest we have to a panacea for mental health problems’. Accessed at: https://twitter.com/PeterFonagy/status/1160575072068866050?s=20.

132 Fonagy, P. and Target, M. (1994). ‘Understanding and the Compulsion to Repeat: A Clinical Exploration’. Bulletin of the Anna Freud Centre, 17: 33–55, p. 51.

133 Fonagy, P. (2006). ‘Psychosexuality and Psychoanalysis: An Overview’, in P. Fonagy, R. Krause, and M. Leuzinger-Bohleber (eds), Identity, Gender and Sexuality: 150 Years after Freud, London: International Psychoanalytic Association Press, pp. 1–19.

134 Target, M. (2015). ‘A Developmental Model of Sexual Excitement, Desire and Alienation’, in Alessandra Lemma and Paul E. Lynch (eds), Sexualities: Contemporary Psychoanalytic Perspectives, London: Karnac Books, pp. 43–62, p. 49.

135 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, p. 521.

136 Fonagy, P. (2008). ‘A Genuinely Developmental Theory of Sexual Enjoyment and its Implications for Psychoanalytic Technique’. Journal of the American Psychoanalytic Association, 56(1): 11–36: ‘One’s own pleasure can be experienced only when it has been placed into the other, in fantasy’ (p. 24). The model is not well adapted for examining fetishes where the other will not experience pleasure. Fonagy marked this as a problem for full exploration on another day (p. 27), though without subsequently returning to the question.

137 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, p. 524.

138 Fonagy, P. (2008). ‘A Genuinely Developmental Theory of Sexual Enjoyment and its Implications for Psychoanalytic Technique’. Journal of the American Psychoanalytic Association, 56(1): 11–36, p. 19.

139 Ibid. 26. However, there may be gender differences here: ‘I believe that while male sexual enjoyment culminates in the full externalization of the self into the object and its unconsciously fantasied control therein, female sexual arousal begins with an intersubjective identification with the partner and becomes increasingly “private” and inwardly turning as excitement mounts. In both cases, intersubjectivity is critical to fulfillment, but while male excitement moves toward seeing the split-off self as the other, the vector or focus of female excitement is an increasingly direct experience of a self uncontaminated by incongruity, assuming that a previous successful projection has taken place’ (p. 33).

140 Target, M. (2015). ‘A Developmental Model of Sexual Excitement, Desire and Alienation’, in Alessandra Lemma and Paul E. Lynch (eds), Sexualities: Contemporary Psychoanalytic Perspectives, London: Karnac Books, pp. 43–62, p. 46–47.

141 Fonagy, P. (2008). ‘A Genuinely Developmental Theory of Sexual Enjoyment and its Implications for Psychoanalytic Technique’. Journal of the American Psychoanalytic Association, 56(1): 11–36, p. 24.

142 Target, M. (2015). ‘A Developmental Model of Sexual Excitement, Desire and Alienation’, in Alessandra Lemma and Paul E. Lynch (eds), Sexualities: Contemporary Psychoanalytic Perspectives, London: Karnac Books, pp. 43–62, pp. 51–52.

143 Fonagy, P. (2008). ‘A Genuinely Developmental Theory of Sexual Enjoyment and its Implications for Psychoanalytic Technique’. Journal of the American Psychoanalytic Association, 56(1): 11–36, p. 25.

144 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, p. 527.

145 Fonagy, P. (2009). ‘Foreword’, in C. Clulow (ed.), Sex, Attachment and Couple Psychotherapy, London: Karnac Books, p. xx.

146 Fonagy, P. (2008). ‘A Genuinely Developmental Theory of Sexual Enjoyment and its Implications for Psychoanalytic Technique’. Journal of the American Psychoanalytic Association, 56(1): 11–36, p. 28.

147 Though admittedly what appears as a theoretical difference may be an artefact of genre. Fonagy and colleagues barely mention sexuality outside of their writings for psychoanalytic audiences.

148 Cicchetti, D. and Rogosch, F. A. (1996). ‘Equifinality and Multifinality in Developmental Psychopathology’. Development & Psychopathology, 8: 597–600.

149 Fonagy, P. (2019). ‘The Future Prospects of Mentalization Based Therapies’, 5th International Congress of Mentalisation Based Treatments, Haarlem, The Netherlands, 22 November.

150 See Freud, A. (1949). ‘Notes on Aggression’. Bulletin of the Menninger Clinic, 13(5): 143–151.

151 Fonagy’s impression of Bion and Kernberg’s positions is set out in Fonagy, P. and Higgitt, A. (1990). ‘A Developmental Perspective on Borderline Personality Disorder’. Revue Internationale de Psychopathologie, 1: 125–159, p. 142.

152 Fonagy, P., Moran, G. S., and Target, M. (1992). ‘Aggression and the Psychological Self’. Bulletin of the Anna Freud Centre, 15: 269–284, pp. 279–80.

153 Ibid. 281.

154 This was well aligned with the emergent perspective of developmental psychopathology e.g. Rutter, M. and Sroufe, L. A. (2000). ‘Developmental Psychopathology: Concepts and Challenges’. Development and Psychopathology, 12(3): 265–296: ‘The search needs to be for factors that fail to inhibit aggressive-disruptive behaviour, as well as for factors that foster it’ (p. 276). More recently, see Patalay, P., Fink, E., Fonagy, P., and Deighton, J. (2016). ‘Unpacking the Associations between Heterogeneous Externalising Symptom Development and Academic Attainment in Middle Childhood’. European Child & Adolescent Psychiatry, 25(5): 493–500.

155 Fonagy, P. and Target, M. (1995). ‘Understanding the Violent Patient: The Use of the Body and the Role of the Father’. The International Journal of Psychoanalysis, 76: 487–501, p. 489. The authors also offered some unpersuasive reflections on gender differences in violence. Ibid.: ‘Why do aggressive men more often direct their hostility towards others, while self-mutilation is more common in women? We believe that both forms of violence suggest an attempt to be rid of an intolerable phantasy of the thoughts in somebody’s mind, originally the thoughts of a parent. The gender imbalance may then reflect a wish to attack the thinking of the same-sex parent (with whom identification is potentially more painful and inescapable). For both girls and boys, the mother’s thoughts about the child have generally been intersubjectively experienced earlier, and are probably represented as within the child’s mind. The father’s thinking is, we suggest, represented in both sexes as external. The intolerable mental presence of the same-sex parent would then be felt to be inside the woman’s mind, but outside the man’ (p. 498).

156 Fonagy, P. (1999). ‘Male Perpetrators of Violence against Women: An Attachment Theory Perspective’. Journal of Applied Psychoanalytic Studies, 1(1): 7–27.

157 Fonagy, P. (2003). ‘The Violence in our Schools: What can a Psychoanalytically Informed Approach Contribute?’. Journal of Applied Psychoanalytic Studies, 5(2): 223–238. Representational violence: ‘The first kind of violence arises because of the overriding need for coherence in the experience of an agentive self … For its effectiveness, it depends on the experience of having created an intentional state in the victim that enhances the strength and coherence of the self by externalization.’ (pp. 232–233).

158 Ibid. 235.

159 Fonagy, P. (2003). ‘Towards a Developmental Understanding of Violence’, British Journal of Psychiatry, 183: 190–192, p. 190.

160 Ibid. 191.

161 Fonagy, P. (2012). ‘The Neuroscience of Prevention’. Journal of the Royal Society of Medicine, 105(3): 97–100, p. 99.

162 E.g. Mesman, J., Stoel, R., Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., Juffer, F., Koot, H. M., and Alink, L. R. (2009). ‘Predicting Growth Curves of Early Childhood Externalizing Problems: Differential Susceptibility of Children with Difficult Temperament’. Journal of Abnormal Child Psychology, 37(5): 625–636.

163 Taubner, S., Gablonski, T.-C., and Fonagy, P. (2019). ‘Conduct Disorder’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 301–321.

164 Fonagy, P. (2012). ‘The Neuroscience of Prevention’. Journal of the Royal Society of Medicine, 105(3): 97–100, p. 98.

165 Pilling, S. and Fonagy, P. (2012). ‘Developing Clinical Guidelines for Children and Adolescents: Experience from the National Institute for Health and Clinical Excellence’, in P. Sturmey and M. Hersen (eds.), Handbook of Evidence-Based Practice in Clinical Psychology, Volume 1, Child and Adolescent Disorders, New York: Wiley, pp. 73–102, p. 74.

166 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. 446.

167 Bateman, A. and Fonagy, P. (2012). ‘Antisocial Personality Disorder’, in A. W. Bateman and P. Fonagy (eds.), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Publishing, pp. 289–308; Bateman, A., O’Connell, J., Lorenzini, N., Gardner, T., and Fonagy, P. (2016). ‘A Randomised Controlled Trial of Mentalization-Based Treatment versus Structured Clinical Management for Patients With Comorbid Borderline Personality Disorder and Antisocial Personality Disorder’. BMC Psychiatry, 16(1): 304.

168 It may be that the reduced prominence of externalization of the alien self can also be attributed to the changing membership of Fonagy’s closest collaborators, with Target working increasingly less closely with Fonagy in recent years.