Commentary on “‘Trust Comes from a Sense of Feeling One's Self Understood by Another Mind’: An Interview with Peter Fonagy”

Issues that had been controversial a decade ago in psychoanalytic psychotherapy are mostly no longer so. There is, for example, little discussion now about the advantages or disadvantages of a relational approach: The overwhelming evidence favoring an interpersonal frame of reference for both development and adult functioning is generally accepted. Similarly, the large number of studies showing psychodynamic psychotherapy to be efficacious in a range of diagnostic conditions has multiplied, and the defenders of a narrowly defined view of evidence-based practice have been by and large exposed as ideologues. However, we are no clearer about why psychotherapy is effective, and speculations concerning “common factors” raise as many questions as they answer. Therapeutic alliance may indeed be predictive of the outcome of therapy, but is this to do with attachment, or some other aspect of social-cognitive function?

At University College London and the Anna Freud National Centre for Children and Families we have been preoccupied with the issue of treatment mechanisms for many years. Initially we provided a model proposing improvements in the capacity to mentalize as a central mechanism shared by a wide range of treatment approaches. Further reflection and empirical and clinical evidence have led us to doubt the sufficiency of this assumption. We have all seen many patients whose capacity to mentalize benefited from psychanalytic psychotherapy without corresponding improvement in their social-emotional functioning. It seems, then, that we should be more specific about where mentalizing becomes most relevant to intra- and interpersonal adjustment. At the same time, two other emerging lines of thinking have influenced our work. First, there is widespread acceptance of the futility of diagnostic groupings based on symptomatology alone (Caspi & Moffitt, 2018) and of the possibility of a common vulnerability for psychopathology, which has powerful resonances with the classical ps