Peter Fonagy, the Hungarian-born British psychoanalyst and clinical psychologist, looked tired as he entered the room set aside for our morning interview a few weeks ago at Tel Aviv’s Beit Hahayal (Soldier’s House). He’d flown in from London before dawn and would be leaving for Paris midday. During his few hours in Israel, Prof. Fonagy addressed 600 mental-health professionals on the subject of mentalization-based treatment at a conference organized by the Magid School of Psychotherapy at the Hebrew University of Jerusalem, the Israel Center for Mentalizing – established by Fonagy’s students in Israel – and the National Education Alliance for Borderline Personality Disorder, in the United States.
“Mentalization,” the key term in Fonagy’s therapy method, is the process by which we are able to understand ourselves and others, the way in which thoughts and feelings affect our behavior and theirs. Fonagy and his colleagues study both the development of mentalization, and the distortions and collapse of mentalization that occur with mental disorders, particularly in borderline personality disorder. Sufferers from BPD have difficulty regulating emotions and controlling impulses. They show a tendency to instability in relationships and self-image.
In mentalization terms, Fonagy spoke about people with BPD having a tendency to depend excessively on feelings at the expense of cognition. Thus, for example, if the therapist takes a quick glance at his watch, the BPD patient will interpret this to mean he is boring the therapist and will be flooded by thoughts of worthlessness and rejection. In such cases, the therapist’s emphasis will be on the rehabilitation of the cognitive-regulating elements of the patient’s mentalization process. Cognition will allow for a more logical analysis of the situation.
Fonagy is proud of the quantum leap in the number of references to mentalization in titles and abstracts of scientific publications – from 10 references prior to 1991, to 2,750 in the following 20 years. Mentalization-based treatment is receiving growing backing from evidence-based research with respect to treatment of additional psychiatric disorders, and also in connection with family and couples therapy.
The first international conference in mentalization-based treatment was held last November. In June 2013, Fonagy was named an Officer of the Order of the British Empire (OBE) for services to psychoanalysis and clinical psychology. He was the first in his profession in England – home in the second half of the 20th century to such luminaries of psychoanalysis as Anna Freud, Melanie Klein and Donald Winnicott – to be awarded with such recognition from the queen.
What sets Fonagy and his approach apart is his extensive experience in connecting psychoanalytical knowledge originating with Freud to contemporary, evidence-based scientific research. Fonagy tries to preserve what is best about psychoanalysis in a format that he believes is appropriate for the 21st century: direct, clear and based on evidence.
These are also the qualities one encounters in meeting Fonagy, who was born in 1952. He is cogent and sharp in his thinking, and surprisingly frank – for a psychoanalyst – about his personal life. He has no hesitation about being forthright and welcomes criticism, eager for a duel of minds.
How is it for you being in Israel?
I have an ethnic reason for liking being in Israel, and if I get invited and can make it, I come.
Do you still see Israel as a special place?
Yes, I do ... For anyone who is a Jew, you know, coming back to Israel is a bit different from going to New York or Paris or wherever.
You were born in Hungary, right?
I was, and I was brought up there for the first 15 years of my life.
And how did you get to London?
My father got a job in Paris as a professor and he moved the entire family there. But he thought I should have an English education, so he sent me on my own to England.
What brought you to psychoanalysis?
When I got to England, I was on my own. I couldn’t speak any English, was very isolated – all I could do was play soccer, which was useful but limited, and I got quite depressed. I was quite a depressed adolescent. I had lots of suicidal thoughts. Because of someone who lived on the same street as I was living on, I was referred to the Hampstead Clinic, which is now the Anna Freud Center. I had an analysis there with a woman by the name of Anne Hurry; she was the most wonderful human being. I was really very seriously depressed and she saved my life. I’m indebted to her and to the Hampstead Clinic for my life — and to psychoanalysis.
And now you give your life to it by working there...
Yes, I’m now the chief executive. It’s just an incredibly important time, adolescence. I think we now know from the point of view of brain development what an important time adolescence is, and it’s incredibly important to give help to adolescents, even though they don’t ask for it. I was lucky because I found my way to help, but most adolescents who find themselves in trouble do not. So I feel very passionate about trying to devise ways in which we can offer help to adolescents, even though they hate us for it, and they kick us in the shins – but we know better.
Did you undergo classical analysis?
Very classical analysis, with a couch and five times a week – but my analyst wasn’t very classical. One of the moments I remember from it is that, about a year into my analysis, I had my first car, which was an old “banger” – a Ford Anglia – and I went to lay down on the couch and said, “Such a wonderful car, it’s great.” She [Hurry] stopped, said “hold on a second,” went to the window and looked out, came back, sat down, and said: “Peter, it’s a wonderful car.” This I remember from my analysis.
She gave space to reality.
Exactly. She was a very, very human person, and what adolescents need – what I needed then – was really someone who was going to relate to me and see me where I was.
Can you tell us about classical analysis within mentalization-based treatment, the psychotherapy you helped develop?
In my view, nothing is lost from classical analysis in MBT. MBT is not a new school of psychotherapy; we already have 1,246 schools, we really don’t need another one. It’s a style of working ... [that aims to] actually make the process of therapy useful for someone who is absolutely filled with suspicion and doesn’t want to relate to the person who is offering help.
If a person comes to therapy with two fingers in their ears, determined not to listen, it doesn’t matter what you say. MBT is about helping them take the fingers out of their ears and communicate whatever wisdom we have to communicate to them, and establishing a sense of trust, creating in them a sense of being understood – which, I realize now, is actually important not so much because it gives insight to them, but also from the sense of being understood.
Change happens in psychoanalysis and in other forms of therapy perhaps not so much because of what happens in the consulting room, but because the consulting room changes the person’s attitude toward their social world. Psychoanalysis – because it has so much wisdom, and because it can tell you so much about what a person is like – is a really useful way of creating that kind of confidence in an individual, so they can trust the world once again.
You’re speaking about trust. I know you’ve been preoccupied these last few years with the idea of epistemic [from the Greek for “knowledge”] trust.
Basically the simple idea here is that as human beings, we have to be vigilant about what other people tell us. Because I’m incredibly vulnerable to what other people tell me – because that’s how we navigate the world, through communication – I have to be quite careful, because you might not have my interest in mind. That’s epistemic vigilance, which is healthy. It’s just testing whether you want to help me.
But if I had many adverse experiences, if I had been traumatized or have been poorly treated, or if I’m just a very anxious person, I gradually develop a chronic sense of vigilance that is mistrust – epistemic mistrust – and I don’t believe anything anyone tells me. I’m no longer subject to influence by those around me, and I develop a kind of hyper-vigilance or mistrust, which makes me very hard to reach.
Think of an adolescent. An average adolescent is in a state of often quite acute epistemic mistrust, no matter what you say to them. They don’t believe that what you’re saying is relevant to them, and they don’t open their mind to be altered by that communication. So this biologically created path for communication between two people where you say something and that makes me change my mind about the world, teaches me something about myself or about the world that modifies my behavior – that’s blocked.
The challenge of ADHD
In your book “Affect Regulation, Mentalization and the Development of the Self,” you focus on the idea of problems of thinking, such as attention deficit hyperactivity disorder and personality disorders.
I’m still focused on that.
What do you say to parents of a child with ADHD? Should they be worried?
They should be worried. It’s very hard not to be worried when you have a child with ADHD. To be honest, I was a child with ADHD. I was very active, I couldn’t sit still, I had lots of anxieties and lots of difficulties; I was never medicated and I grew out of it. I maybe still have a little bit of restlessness, but it’s not ADHD.
The problem with a child with attachment problems – and it’s a real vicious circle – is that if you’ve got a child who is more difficult to manage, then some of the biological processes that you need to establish in order to get them in the right place – and respond to them in a contingent way, so they find themselves in your mind and you can mirror their identity to them so that helps them organize themselves – that just doesn’t happen, because they’re all over the place. This can undermine some basic processes, which then makes things worse.
It’s a real, real challenge, and I think what helps a lot is supporting these parents. Not so much giving the child therapy, but supporting these parents being able to stay the course. [Letting them know] that even though the child is not responding as they’re hoping, they can create that space where they are available to the child.
For me, being positive is incredibly important, and teaching parents not to just use “time-out” and discipline and whatever and boundaries, but also to spend time with the child – build up credit in the bank, so the child comes to them for downregulating – regaining equilibrium in – their feelings.
Do you see what I mean? I’m not blaming the parents – if you have a child like that, all of us would behave like that. You need a bit of support with difficult kids so that you create the environment that the kid needs in order to develop properly.
So it’s not a [matter of] destiny?
Absolutely not. All that we know about modern genetics tells us it’s not a destiny.
Can we speak about treating borderline personality disorder? First of all, regarding the claims of psychoanalysts that BPD is the old hysteria?
“The hysteria of old” – I’m happy with that. From the descriptions, Freud’s patients sound very borderline. Of course, it’s not surprising that much of psychoanalysis was discovered with those patients, because they are incredibly accessible to elaborating their mental states. They hyper-mentalize quite a lot.
Also, unfortunately, they are very suggestible. If you tell them that this or that has happened, because they can’t turn inside and check out what’s going on in their own mind – they believe quite a bit of what you tell them. So it’s a dangerous game playing psychoanalysis in a classical form with these patients, because you can make them very dependent: Just explaining it to them, and their apparently understanding it, doesn’t actually help them recover.
Many people in the field are worried about the future of psychoanalysis. What do you see as the salvation of psychoanalysis, if you’re worried?
I’m not at all worried. Psychoanalysis doesn’t need saving. Psychoanalysis has more truth to it about the mind than any other psychology I know. My own experiences on the couch – and I spent about 18 years there – helped me immeasurably with understanding people. It’s the best psychology out there. It has discovered more about the mind than any other.
Now, am I worried about psychoanalytic institutions? Yes ... but it’s not the same as worrying about psychoanalysis. I’m not worried about spirituality – spirituality will survive, but whether the Catholic Church survives or not? Big difference.
The institutions of psychoanalysis often haven’t been very good stewards, and have become rival organizations more concerned with the differences between them than about advancing the discipline and advancing understanding.
Psychoanalysts are completely obsessed with their names being linked to particular knowledge ... that’s crazy. Truth survives independently of the person who discovers it. Knowledge doesn’t belong to the person who discovers it. Knowledge belongs to culture, and psychoanalysis as a piece of wisdom belongs to human culture. Psychoanalysis will survive forever.
‘Doing things differently’
A few months ago I interviewed a Lacanian analyst, and when I mentioned your name he became furious.
Marvelous! I have some Lacanian colleagues who respect what we do, particularly in Belgium, so it’s not every Lacanian who’s anti-empiricism. My feeling about the kind of empirical approach I take is [that it’s] just one of many scientific approaches. I never said – and wouldn’t ever want to say – that this is “the” approach. What I think psychoanalysis has missed out on – and the origin of mentalization-based treatment – actually comes from being honest about one’s feelings.
The way we discovered MBT was by being honest. I was working with George Moran and we had a club that we called the Saturday club. He was the director of the Hampstead Clinic, and we talked about cases where we were remarkably unsuccessful – we were doing the “right” thing and yet it didn’t work. These patients were adolescents with very poor control of their diabetes, and we gradually realized that all the interpretations we were giving didn’t make any difference to these young people. But once we started talking to them about their lives and what their thoughts and feelings were in very simple language – their minds changed and their diabetic control got better.
That convinced me of two things: one, the value of empirical measurement; and two, the value of failure. Actually, much more interesting than one’s successes are where one is not succeeding and trying to figure out what one did wrong and how one can do better. Measurement, and that attitude, allows one to be more exploratory and curious about technique, doing things differently.
What to me is a tragedy about psychoanalysis is sticking to the therapeutic techniques that Freud discovered by accident at the turn of the century before last. That is a joke. It’s ridiculous. How could he have discovered the only way of working with people that was reasonable? And yet, rather than find what’s essential in their understanding of the person, they stick to the couch and five times a week ... To me, it’s the ideas and the nature of the relationship you have with the individual that’s psychoanalysis. If you could define it by saying it’s all to do with free association or whatever, life would be so simple.
What do you feel regarding dreams? Are they relevant to MBT in any way?
Psychoanalysts disagree about it. I think dreams are the way people who cannot properly, internally, represent their mind [try to] represent their mind. So dreams give away a window on a person’s mind. Often, people tell me dreams and I see an honest depiction of mechanisms going on inside their minds that I otherwise would have missed.
I know you’re a committed socialist. Do you think that psychoanalysis and psychology are tools used for restraining the population? The new religion, in a way.
If you study human history, one of the most interesting changes that has occurred over the last 1,000 years is the dramatic decrease in violence – and the reason for that, I think, is because of increasing respect for the child and the infant. I think psychoanalysis has done a tremendous social service by generically focusing on childhood. So in terms of social influence, whatever it might do on the margins in terms of ensuring that the privileged can stay privileged – it has done a very massive amount.
Do you have children yourself?
Absolutely wrong. A rugby player and a girl who wants to be a policeman.