MBT and Psychoanalysis

Peter Fonagy

[email protected]

As often happens in development, the new, in order to establish its identity and independence, can
find itself separated from its origins, and excited by novelty, scotomise its connections with its roots and its
past, and deprives itself of a continued source of inspiration.

As mentalization-based treatment entered its chronological and probably psychological adolescence,

just like its developmental analogue, it turned away from its family of origin and became increasingly
influenced by its new friends in the world of psychosocial treatment: developmental psychology, evidence-
based practice, third wave CBT, neuroscience, philosophy of mind, anthropology, social psychology and so on.
And yet the origin of MBT, historically and intellectually, is psychoanalysis and psychodynamic psychotherapy
(Fonagy, 1990). Over the last 15 years MBT has become an integrative model focused on social understanding
with its many components, from social referencing and social attention to empathy, imitation and the inferring
of desires and knowledge along with the development of self-awareness (Bateman & Fonagy, 2019). Yet, what
was unique about the MBT approach was provided by psychoanalytic thinking.

MBT came into the world on the crest of the wave of the Theory of Mind (well abbreviated to ToM).
ToM was the initial label used in the last Century, to refer to the capacity to explain people’s behaviour on the
basis of their mental states. The concept was embedded in a story about a doll, whose mistaken belief about
the location of a piece of chocolate, displaced when she was not looking, launched literally thousands of
experimental investigations (Devine & Hughes, 2018; Imuta, Henry, Slaughter, Selcuk, & Ruffman, 2016;
Wellman, Cross, & Watson, 2001). As the theory of mind industry took off, a wide range of experimental
designs and philosophical conceptualisations began to be squeezed into the shallow suitcase of ‘having a
theory of mind’ (e.g. Daniel C. Dennett, 1987 concept of 'taking an intentional stance'). Because the ToM term
confounded the concept with an experimental design, and using the noun risking reifying an activity or
process, the same alternative term, mentalizing, was independently proposed by two psychologists from
dramatically different traditions. Uta Frith (1989) introduced the term in presenting a cognitive account of
autism and George Moran, the then director of the Anna Freud Centre, and I (Fonagy, 1989) introduced the
term from a psychoanalytic perspective influenced by attachment theory and an important French tradition of
psychosomatics (Lebovici, 1967).

Coming from the tradition of attachment theory and having some (albeit thin) evidence base, we
argued that the attachment relationship of infant and carer was the paradigmatic foundation for the normal
development of mentalizing (Fonagy, Target, & Gergely, 2000). It was the psychoanalytic perspective that led
us (almost without hesitation) to claim that children’s theory-of-mind was formed out of what were
necessarily suppositions about the beliefs and emotions of their primary carers, their siblings and their own
experiences in relation to these. Although it was 30 years ago, I clearly remember first presenting the idea at
UCL, which was then an almost uniquely cognitivist department of psychology. Opposition came from those
who believed autism to be the paradigmatic example of a failure of mentalizing, and a belief that individuals
with that diagnosis were as likely to be securely attached as typically developing children. Mentalizing was
thought to be a capacity that developed independently of social experience and deficits reflected biological,
probably genetic, vulnerabilities. Since then, even the most ardent supporters of the cognitivist position have
relented somewhat on this issue (e.g. Brink, Lane, & Wellman, 2015). We tried to link to the psychoanalytic
context suggesting that, Oedipal anxieties arose in the fourth year of life around a child’s concerns about
parental retribution for incestuous sexual phantasies, because this was the maturational stage at which a
child’s theories about parental mental states emerged. But not unlike cognitivists, our psychoanalytic
colleagues showed little interest in mentalizing.

Yet it was the psychoanalytic roots of our thinking – I am referring to Anthony Bateman, Mary Target
and George Gergely, which made us depart from the cognitivist tradition and afforded MBT something more
than the Beckian social cognitivist approach current at the time. Where MBT tried to plough a fresh furrow
was to place the capacity for perceiving and interpreting human behaviour in terms of intentional mental
states into a dynamic context. MBT even its original formulation went beyond the then dominant definition of
mentalizing as a capacity that is simply selected and protected by evolution. MBT theory accepted the

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biological account that mentalizing enables optimal decision making, ensuring maximum personal and
community benefits, enabling learning from others whilst also supporting competing with them, evaluating
them and predicting their behaviour. But mentalizing as thought about in MBT, with its psychoanalytic flavour,
also brings into its remit the human imagination untethered in reality, impacted by myriads of contextual
factors, biased assumptions, distortions of understanding from irrelevant information, including inaccurate
beliefs, slanted values and frank prejudices motivated by the identity and group status of individuals
interacting (see also Park, Kim, & Young, 2021). In other words, ToM or mentalizing is effectively synonymous
with the theory of object relationships.

In a series of papers Mary Target and I attempted to grapple with some of this complexity (Fonagy &
Target, 1996, 2000, 2007a; Target & Fonagy, 1996). We linked mentalizing to Freud’s concept of psychic
reality and suggested a series of heuristics that helped to elaborate the psychoanalytic use of the concept
‘symbolisation’. At the core of these papers is the idea that we create mental reality through interpersonal
interaction. The capacity to understand action in terms of mental state terms depends on the quality of
relationships in childhood, and later. The potentially uncomfortable implication for psychoanalysis of this idea
is that the aim of therapy is not deepening specific understandings, but rather the capacity for understanding,
almost regardless of the specific unconscious conflicts which may bring a patient into treatment. In other
words, the ‘medium is the message’.

Of course, initially, and with some political expediency, we restricted our conceptualisation to severe
cases of mental disorder. We attempted to align our thinking with both Wilfred Bion (alpha function) and
Donald Winnicott (mirroring and containment). Not that we succeeded, but we made a conscious and
deliberate effort not to claim originality where there was none. We derive psychic equivalence and pretend
mode simultaneously from developmental science and the psychoanalytic thinking that preceded it (linking the
notion of the concrete to unmentalized thought and pretend to the defence of splitting). Notwithstanding our
efforts, the psychoanalytic community, at least in the UK, did not embrace the concept of mentalizing. Also,
notwithstanding a consistent effort to publish in psychoanalytic journals of record (e.g. Fonagy & Allison, 2016;
Fonagy & Target, 1995, 2007b), mentalizing is not a construct represented on the curriculum of the British
Psychoanalytic Society to the present day.

Yet mentalizing theory shares much with recent advances in psychoanalytic thinking. As we know, the
common clinical ground, idealized by Robert Wallerstein (1992) in his Presidential addresses to the IPA, was
shattered by the distinct metapsychology of intersubjectivity with a far more constructivist rather than
structuralist conceptual frame. A North American psychoanalytic movement began to gain traction in
mainstream psychoanalysis in the 1980s, through persuasive advocates like the brilliant Jessica Benjamin. In a
paper in Psychoanalytic Psychology on An Outline of Intersubjectivity (Benjamin, 1990), she points out, that
object relations theories, even those interested in intersubjectivity, have overlooked the core element of
intersubjectivity, which is mutual recognition. She showed that the capacity for mutual recognition can be
conceived as a separate trajectory from the internationalization of object relations. The subject gradually
becomes able to recognize the other person’s subjectivity, developing the capacity for attunement and
tolerance of difference.

Benjamin reinterprets Mahler’s rapprochement period describing the individual’s struggle to separate
from the object as a fight for recognition in which the outcome is the beginning of the ability to recognize
another person’s subjectivity. In so doing, she restates MBT’s central discovery. To be fair Jessica has always
cited our work. As we now suggest, the differentiation of self and other is a process that consists not merely of
separation, but the continual breakdown and repair of mutuality in the psyche’s stance toward the
interpersonal world beyond the self. The sense of the other comes and goes: the breakdown and
reconstruction of the interpersonal world is an endless experience of aggression and the creation of an
intrapsychic fantasy of mutuality. The psychoanalytic intersubjectivity approach shares much with our
developmental theory of mentalizing.

The connection with modern (relational) psychoanalysis is also there at the level of technique. Owen
Renik (1993) spells out the implications of the relational perspective in his 1993 paper in the Psychoanalytic
Quarterly, Analytic Interaction: Conceptualizing Technique in Light of the Analyst’s Irreducible Subjectivity.
Renik confronts the reductionist ideology of the object relations tradition and makes the claim that all aspects
of an analyst’s clinical activity is determined in part by his or her personal psychology. There is a dramatic
change in the psychoanalytic approach to psychotherapy here. Renik mentions, only to discard, the traditional

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maxims designed to counteract suggestion by reducing the analyst’s subjective biases such as being without
memory or desire, remaining open to surprise, to see ourselves as students who learn from our patients, to
focus exclusively on the patient’s inner psychic reality. He adopts an oppositional stance. He says these
principles, if followed categorically, can be inhibiting rather than liberating. Such recommendations, Rennik
argued, were but imperfect placeholders for a systematic, comprehensive theoretical conception of analytic
technique which could embrace the unavoidable, pervasive subjectivity of the analyst.

MBT, like Renik eschews the classical psychoanalytic attitude, ubiquitous both at the time and still
popular in my view in many analytic training centers, according to which any theory of technique places the
analyst in a position of authority as the privileged interpreter of reality. MBT (like many relational
psychoanalysts) has no truck with the notion of objectivity in a therapeutic setting. MBT, again, like relational
psychoanalysis, exhorts the therapist to humility, especially those whose theory of technique denies the
inevitable subjectivity of technique. It should be unnecessary to attempt not to be passionately and irrationally
involved in our everyday clinical work. It is hopeless to ask ourselves to do so. To some degree, I feel, both
MBT and Renik are fighting the classical psychoanalytic strawman of analytic neutrality. That figure retired hurt
probably in the 70s. But there is more. Closer reading reveals that current relational analysts like adherent
MBT therapists feel uncomfortable with a therapeutic situation that reflects anything less than total equality
of status between patient and therapist.

This attitude is still struggling to get established certainly in London psychoanalysis. If we are honest,
notwithstanding our written advice, MBT is probably also struggling to reach this ideal. It took me more than a
decade to arrive at Renik’s therapeutic position. Aiming to counteract the power imbalance of the clinical
situation I now struggle with terms like client, patient, service user, expert by experience, etc. A few years ago I
landed fortuitously on a term I find satisfactory: conversational partner. But giving up power is hard and all too
often entails a process of self-delusion. It is however essential if we are to scale-up psychoanalytic (and MBT)
thinking so it is genuinely accessible to all.

Another point of contact between MBT and relational psychoanalysis is provided by Tom Ogden’s
paper, The Analytic Third: Working with Intersubjective Clinical Facts (1994). In that paper Ogden describes the
methods by which analysts attempt to recognise, understand and verbally symbolize for themselves and the
analysand the specific nature of the moment-to-moment interplay of the analyst’s subjective experience, the
subjective experience of the patient and the intersubjectively-generated experience of the analytic pair, which
Ogden names the experience of the analytic third. In this context the analyst’s subjective experiences
(ruminations, daydreaming, stray thoughts and fantasies) are indicators of the intersubjective experience
created by the analytic pair. The clinician’s somatic experiences can serve the same function.

When I read this paper, I strongly resonated with Ogden’s discovery. I too experienced an abdominal
sensation, (a gut feeling of reality) when I judged that the patient and I were intersubjectively connected. We
are talking to each other, we are real for each other, we are both present and listening respectfully to what the
other says – I would now call this experience being in the ‘we-mode’. MBT sees Ogden’s presumption of ‘the
third’ as a jointly held picture by patient and therapist which evolves as an alternative to those initially
presented by the patient and reactively conjectured by the therapist. But both presentation and reaction can
be incorporated into their joint discourse. This moment which we call the ‘we-mode’ refers to a feeling of we-
ness usually associated with social collaboration where both parties feel they are part of a set of thoughts and
feelings that are beyond each of their own minds and are shared, an irreducibly joint mode of cognition. The
we-mode is an experience which forms the basis for cooperation, commitment to shared goals, and catalyses
the development of epistemic trust and trustworthiness. The ‘we-mode’ generates an experience of feeling,
thinking and acting together. At this moment in the therapy, self-identification is subsumed into that of a
social unit enabling distinctive ways of functioning. The “I” of both patient and therapist now sees itself and
the interpersonal landscape as ‘we-structured’. There is no mysterious leap into a mystical interpersonal space
of “we-ness”, it is rather the transition, from feeling like individuals talking about a problem, to a team working
on it in an integrated way. The we-mode (or Ogden’s ‘third’) is the key to re-establishing trust. It is so because
it is a mutual creation. It naturally comes and goes, lost in non-cooperative interactions but restored
continually in the cultivation of trust, because it remains present and possible, even when it is lost. A critical
part of establishing the ‘we-mode’ for patient and therapist is the inquisitive stance of openness on the part of
the therapist about the way the patient’s thoughts and feelings impact on her or his subjective experience.
Illustrating how minds can affect minds is central to the process of enhancing mentalising.

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 Finally, a word on technique. We parted company with most analytic colleagues when we moved
therapeutic action from insight to the generation of mental capacity. But there are signs that MBT and modern
psychoanalysis come together at the point of revision of the notion of therapeutic action. Howard Levine’s
2012 paper on action in analysis, entitled The Colourless Canvas: Representation, Therapeutic Action and the
Creation of Mind (Levine, 2012), recognizes the limitations of classical psychoanalytic work, addressing
representations with patients whose emotional states are overwhelming and peremptory or vague,
amorphous and poorly defined. With these patients, analysts may have to act -- by which he means to act to
help create words with which to form associations, imbue those words with consistent symbolic meaning and
link those associations to other narrative fragments. This sounds to me like MBT. But of course, this moves
psychoanalysis back to suggestion – Freud’s bête noire. Levin accepts that “In the analysis of unrepresented
and weakly represented mental states, the elements of mind must first be created by a work that begins in the
analyst's psyche and is then offered and inscribed in the psyche of the patient as part of an interactive,
intersubjective relationship and process”. So, free association for Levin gives way to expressive, catalytic
action in order to help precipitate or strengthen the patient's representational capacities. Levin, a classically
trained analyst asks: to whom does the representation belong? He avoids answering but in raising the question
we can see just how far psychoanalysis has come since the first papers on MBT appeared to create a schism

I could find many similar papers in the historical literature but the significance of this and other
similar recent papers that are tantamount to the legitimization of therapists doing things (not just interpreting
-- what used to be thought of prejudicially as enactment) and the recognition of the role of analysis as
constructing the mind rather than simply motivating insight. Ogden (2019) in his 2019 paper Ontological
Psychoanalysis or “What Do You Want to Be When You Grow Up? represented the move rather well in
contrasting the differences between what he calls the epistemological psychoanalysis of Freud and Melanie
Klein (having to do with knowing and understanding), and ontological psychoanalysis (having to do with being
and becoming). Consistent with our thinking in MBT, the shift is from the symbolic meaning of play and
dreams to the experience of playing and dreaming. While the epistemological psychoanalysis dominant thirty
years ago was geared to the understandings of unconscious meaning, ontological psychoanalysis is concerned
with experientially equipping patients with the mentalizing tools to discover meaning for themselves, and in
that way recovering (mental) life.

Recently, reading an excellent book soon to be published by Svenja Taubner, Josef Brockmann and
Peter Kirsch, I rather belatedly realized that the lack of interest of mainstream psychoanalysis in MBT ideas
was not an indication of narrowmindedness on the part of our psychoanalytic colleagues (not that they are not
guilty of that in other instances). Rather, it was the consequence of our lack of consideration of how key
psychoanalytic ideas could be restated and revitalized by being integrated into mentalizing discourse and
mentalizing language.

Where are the core psychoanalytic ideas in MBT? There are an overwhelming number of
psychoanalytic theories. Are they to count for nothing? Freud himself wrote very many more books on theory
(20 volumes of the SE) than he did on practice (scarcely two volumes) (Fonagy, 1999). Where is the
unconscious in MBT? Where are defences? Where are the structures of the so called second topography (ego,
the id and the superego)? Where are dreams and how can we understand them? Where are phantasies with a
‘ph’ and the fixations and vicissitudes of instinctual development? Where is internal conflict? Where are the
drivers of human misery, aggression, envy, perversion, narcissism and the mainstay of psychoanalytic thought,
sexuality?

We made modest efforts to connect with the last of these constructs (Fonagy, 2008), but by and large
MBT missed out on key conceptual drivers of object relations thinking, such as defensive organisations, the
paranoid schizoid position and, even more fundamentally, psychic conflict. Not wishing to make a grandiose
analogy, but it seems to me that John Bowlby found himself in a similar position trying to bring ideas from the
neighbouring discipline of ethology into psychoanalytic thinking (e.g. Bowlby, 1981, 1984). Bowlby found it
challenging to make the connections that were necessary for attachment theory to be of value to clinicians
whose ideas were shaped by the intricacies of the transference-countertransference matrix. On a far smaller
scale, mentalizing theory, also an orphan of disciplines abutting psychoanalysis, finds itself disowned both by
cognitive neuroscientists and by serious psychoanalytic thinkers. The former find the implementation of
neuroscience research and constructs in our theories both simplistic and potentially naïve as current advances
such as the default mode network are poorly reflected in our theorizing (Gilead & Ochsner, 2021). The latter

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find little that’s new in MBT and mourn the complexity and subtlety that disappears when subjectivity is
reduced to psychic equivalence, the pretend mode and teleological function (Hoffman, 2004, 2009).

Where MBT theory had failed to create the join-up was in failing to provide adequate clinical material.
We needed a bridge where clinical cases, therapies of real people, are seen simultaneously from the
traditional psychoanalytic and the novel theoretical perspective as Joseph Sandler achieved through the
Hampstead Index. We will not integrate mentalizing into psychodynamic thinking without creating an
understanding via focusing on a shared reality of the clinical encounters.

But hold on a moment! Is this not what mentalizing is all about? Isn’t mentalizing the creation of a
dual level structure where a common object is examined by two minds coordinating their perspective with
each other? Isn’t mentalizing about a shared focus which enables the acknowledgement of different
perspectives? Isn’t our theory all about coordinating our own perspective with that of another individual’s
mental state when focusing on an objective actual, physical, out there reality?

Looked at in this way our failure to develop a shared model with our colleagues from a
psychodynamic tradition clearly amounts to a failure of mentalizing. In terms of the polarities of mentalizing
heuristic which Patrick Luyten and I advanced (Fonagy & Luyten, 2009; Luyten, Fonagy, Lowyck, & Vermote,
2012) we have been guilty of imbalanced mentalizing. Not so much the overemphasis of cognition over affect,
which many see as a core weakness of the MBT approach. Much more in the failure to balance self with other.
In our effort to reduce the impact of the other on the self, to protect our perhaps fragile rudimentary model
from the far more sophisticated and advanced and complex set of psychodynamic ideas, we have repeatedly
and emphatically asserted our own position without seriously scrutinizing our psychodynamic colleagues’
perspectives on the same clinical world.

And as MBT teaches us the only thing to do when you notice a failure of mentalizing, inevitable given
the complexity of the psychological tasks our minds face, is to express humility and maybe offer an apology.
Incorporated in the apology is an acceptance of responsibility for an error of commission or, as is more the
case here, omission. It is my hope and my wish that the book by Taubner and colleagues I mentioned, and
other books written from a clinical practitioner perspective contribute to repairing what is to me certainly a
deeply regrettable gap. Some in the mentalizing family have tried in isolated instances to create a dual
structure. But the Taubner et al. book is the first which aims seriously and directly to tackle the issue.

MBT would not have been born without the psychoanalytic origin of its developers: George Moran,
Anthony Bateman, George Gergely, Mary Target, Patrick Luyten, Liz Allison, Nick Midgley and many others. I
believe it can continue to gain inspiration through integrating the thinking of modern psychoanalysis as the
most expansive theory of human mind currently available to us. Is it time for a re-wind and an attempt to
recapture what our automatic, self-focused, external cognitive polarised thought might have left
unscrutinised?

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