Introduction

The theory of mentalising and epistemic trust introduced by Peter Fonagy and colleagues at the Anna Freud Centre has been an important perspective on mental health and illness. This book is the first comprehensive account and evaluation of this perspective. The Introduction situates the aims of the book. It highlights the priority given by Fonagy and colleagues to open discussion and clarification of key terms and concepts, and discusses which terms and concepts will be given particular focus over the subsequent chapters. The chapter also introduces Fonagy and his collaborators, and presents a summary of each chapter of the book.

Work at the Anna Freud Centre

This chapter will place Fonagy’s work in institutional context, exploring his work as research director for the Anna Freud Centre in the 1990s, and attempting to characterize some features of his leadership of the Anna Freud Centre since 2003. The Centre has seen an incredible transformation in this time. We will seek to situate this transformation in relation to the challenges and opportunities of the wider social context. The chapter will close with an attempt to introduce some of the major collaborations from different eras of Fonagy’s work, introducing the dramatis personae for the rest of the book.

The wider social system

Critics have alleged that in attempting to adapt to the individual-centric environment of contemporary health provision, mentalization-based therapy itself has been complicit with the atomization of society. Conversations with his colleague Peter Fuggle and Dickon Bevington at the Anna Freud Centre have also had a profound role in highlighting to Fonagy the importance of the wider social system around the individual. Pursuing these questions, this chapter begins by examining the growing attention to the social environment shown by Fonagy and colleagues, and especially their exploration of the role of friends and friendships for mentalization and epistemic trust. It will then examine the reflections and research by Fonagy and collaborators on public mental health. The researchers’ hopes regarding school-based prevention will be given particular attention, and the chapter will also show how this work has shaped Fonagy’s efforts as a policy influencer. Finally, the chapter will appraise the considerations offered by Fonagy and colleagues of the role of culture, in particular the issue of whether attention to cultural processes should be regarded as mentalizing, non-mentalizing or as not mentalizing, and whether organizations and societies can themselves be said to institutionalize cultures of mentalizing or non-mentalizing.

Mentalization in transition

Increasingly over the 2000s, Fonagy and colleagues became increasingly dissatisfied with their initial model, identifying that the concept of ‘mentalization’ was too absorptive and that they had placed too much weight on early childhood experiences and the role of disorganized attachment. Attempts to correct these problems led to a revised and more mature account of forms of mentalizing. In this chapter, we will trace these developments of the 2000s, paying particular attention to Fonagy and Luyten’s 2009 account of four dimensions of mentalizing. The chapter will close by attempting to discern the underpinning logic of the concept of mentalization across its diverse uses and definitions. A single synthesized definition will also be proposed.

Conclusions

The Conclusion draws together the threads of the book. It emphasises the goal of the book as constructive appraisal. Some outstanding questions for work on mentalisation and epistemic trust are raised, and future directions considered. The book ends by highlighting some of the most enduring contributions of work by Fonagy and colleagues.

Adaptation and mental health

In the 1990s, Jeremy Holmes and Otto Kernberg alleged that, despite significant strengths, the theory of mentalization has risked becoming a disempowering, deficit-focused model of mental ill health. One resource available to Fonagy and colleagues in responding to this concern was attachment research, which had developed a model of attachment strategies as evolutionarily-primed responses to adverse conditions. We will survey the reflections of Fonagy and colleagues regarding three attachment theorists: Mary Main, Pat Crittenden, and Jay Belsky. The synthesis proposed by Fonagy and colleagues will then be described, as well as their related reflections on vigilance, trust, learning, and the structure of mental health symptoms.

Mentalization-based therapies

Clinical work as a psychoanalyst working with adults and children directly informed Fonagy’s concern with mentalizing, which grew out of technical innovations in ‘developmental help’ offered at the Anna Freud Centre. In turn, the theory developed by Fonagy and colleagues fed into the emergence of mentalization-based therapy (MBT) as a treatment modality. Initially, in the 1990s, the target of this intervention was patients with borderline personality disorder (BPD). However, MBT has subsequently been used with patients facing a variety of mental health symptoms, including common symptoms like anxiety and depression. This chapter will describe the development of MBT over time, including variants such as dynamic interpersonal therapy (DIT). We will also consider some remaining questions about MBT, including the potential for MBT to harm some groups of patients.

Conceptualizing the ‘self’

The idea of ‘the self’ has been a critical one for Fonagy and colleagues for over 30 years. Consideration of the theory of the self is 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. 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.

Forms of non-mentalizing

Fonagy and colleagues have described three forms of non-mentalizing: pretend mode, psychic equivalence, and teleological mode. Sometimes they have implied that these are just three kinds of non-mentalizing that they have happened to stumble upon, and that they have no particular importance beyond other forms of non-mentalizing, which could readily be identified. More frequently, however, pretend mode, psychic equivalence, and teleological mode are described definitively as ‘the’ forms of non-mentalizing. The characterization of the three modes of non-mentalizing by Fonagy and colleagues is among the most potentially insightful contributions of their work. Nonetheless, Fonagy and colleagues have not attempted to operationalize the specific modes of non-mentalizing, with the exception of hypermentalizing, leaving their reflections speculative and obstructing further development of the theory. This chapter will characterize the three modes of non-mentalizing. Finally, we will examine why it might be that no further forms have been identified in the past 20 years.

Mentalizing in development

In their 2003 book, Psychoanalytic Theories, Fonagy and Target observed critically that it is quite characteristic of psychological theories to have a primary concept or two with a host of meanings. This concept then serves in part as a symbol of collective endeavour. Over the past decade, they have acknowledged that this has been the case with the concept of ‘mentalizing’. To seek to understand the meanings of the concept, this chapter traces the emergence of the theory of mentalizing, the problems it was introduced to address, the theoretical perspective it encapsulated, and the clinical implications that stemmed from this perspective. It will then examine the development of the reflective functioning scale. The chapter will close with an analysis of some related ambiguities in the use of the concept of disorganized attachment by Fonagy and colleagues.