martes, 3 de enero de 2017

Mentalizing: Artifice and Culture

Copyright © 2016
Avello Publishing Journal
ISSN: 2049 - 498X

Issue 1 Volume 6:
A Synthesis of ‘Analytic’ and ‘Continental’ Philosophy.

Carlos Rodríguez Sutil, University of Complutense, Madrid, Spain.

Relational psychoanalysis and other postmodern psychoanalytical orientations manifest their opposition to Descartes’ ontological dualism and its postulation of an internal more or less isolated mind. This ontology became long time ago the official language -the ‘official doctrine’ (Gilbert Ryle). Psychoanalysis understood as a technique assumes that an isolated mind, the analyst, is doing something to another isolated mind, the patient, or, at worst, the reverse.
Freud sometimes managed the conception of an unconscious subject relatively isolated from his environment, a solipsistic ego under the control of primary narcissism.  Fonagy doesn’t maintain, fortunately, such classical concepts as ‘primary narcissism’ or the drive/instinct theory, but gets trapped if not on the Cartesian thought at least in some form of the ‘official doctrine’ language, and his theorization conveyed and image excessively introspective of the action-reaction dynamic that is established between the infant and its social environment. The mind is not born with the individual but develops in the context of human interaction and the mind is not only internal but also external, mainly external, that is, the pragmatic context of interpersonal relationships. The internal space is something that is created (Vygotsky, Wittgenstein).

Before practice had demonstrates that the letters of the alphabet could bind winged words in row after row of script, no one would have conceived of a storage room or wax tablet within the mind.

Ivan Illich (1993, pp. 38-39)

Throw away the book. (Leon Hoffman cited by Paul Fonagy, 1999 b)

Chuang Tzu and Hui Tzu were strolling along the dam of the Hao River when Chuang Tzu said, "See how the minnows come out and dart around where they please! That's what fish really enjoy!"

Hui Tzu said, "You're not a fish - how do you know what fish enjoy?"

Chuang Tzu said, "You're not I, so how do you know I don't know what fish enjoy?"

Hui Tzu said, "I'm not you, so I certainly don't know what you know. On the other hand, you're certainly not a fish so that still proves you don't know what fish enjoy!"

Chuang Tzu said, "Let's go back to your original question, please. You asked me how I know what fish enjoy so you already knew I knew it when you asked the question. I know it by standing here beside the Hao."

— Zhuangzi, 17, tr. Watson 1968:188-9

This Taoist tale clearly shows the huge difficulties and contradictions we face when we tray to theorize about what really happens inside people’s minds. It is a field full of quicksand. Let’s take another perspective on this enigma. We are going to see a fragment of and old film directed by the great master Alfred Hitchcock “Dial M for Murder”. Now we read a brief description of the plot.
Tony Wendice is married to wealthy jetsetter Margot. She had an affair with an American crime-fiction writer Mark Halliday. Tony discovers the affair and decides to murder her, both for revenge and to ensure that her money will continue to finance his comfortable lifestyle. Tony meets an acquaintance from the University, Swann who has become a small-time criminal. Tony had stolen Margot’s handbag, which contained a love letter from Mark, and anonymously blackmailed her. After tricking Swann into leaving his fingerprints on the letter, Tony offers to pay him to kill Margot; if Swann refuses, Tony will turn him in to the police as Margot's blackmailer.
The plan is: the following evening Tony will take Mark to a party, leaving Margot at home and hiding her latchkey outside the front door of their flat. Swann is to sneak in when Margot is asleep and hide behind the curtains. At eleven o'clock, Tony will telephone the flat from the party and Swann must kill Margot when she answers the phone, open the garden doors, suggesting a burglary gone wrong, and exit through the front door, hiding the key again. When Margot comes to the phone, Swann tries to strangle her, but she manages to grab a pair of scissors and kill him. She picks up the telephone receiver and pleads for help. When Tony returns to the flat, he calls the police and, before the police arrive, Tony moves what he thinks is Margot's latchkey from Swann's pocket into her handbag, plants a Mark's letter on Swann. Chief Inspector Hubbard arrests Margot after concluding that she killed Swann for blackmailing her. Margot is found guilty and sentenced to death. On the day before Margot's scheduled execution, Hubbard asks Tony about large sums of cash he has been spending, tricks him into revealing that his latchkey is in his raincoat, and discreetly swaps his own raincoat with Tony's, and as soon as Tony leaves, he uses Tony's key to re-enter the flat, followed by Mark. Hubbard had already discovered that the key in Margot's handbag was Swann's latchkey, and deduced that Swann had put the key back in its hiding place after unlocking the door. Tony retrieves Margot’s handbag from the police station after discovering that he has no key. The key from Margot's bag does not work, so he finally uses the hidden key to open the door, proving his guilt. One of the last scenes shows how Tony ‘internally’ reasoning about the keys and Hubbard offering the audience the voice-off of what is happening into his head.
Since the time of Plato (Theaetetus) to think is to speak to oneself but it was not until Descartes that prevailed the conception of thought as an internal activity in a closed internal space, the mind (or the brain). One of the most dangerous ideas for a philosopher, said Wittgenstein (1945-48, § 605, § 606), is that we think in our heads, in a closed space, hidden. What we see in Hitchcock’s film is real, and in some way internal, although the signals are all exterior, and show the result of a long developmental process in a sophisticated intelligent adult, although morally deficient. That “internal” room is not something given from the scratch. 
Relationalists, intersubjetivists, and other neo-psychoanalysts, as well as Fonagy (2008), in short, all of us, we manifest our opposition to Descartes ontological dualism and its postulation of an internal more or less isolated mind. This ontology became long time ago the official language -the ‘official doctrine’ as Gilbert Ryle (1945) called it- and today has become a labor of Hercules to get rid of it. According to this doctrine all human beings, except little children and idiots, are living two parallel stories: that of the body and that of the mind. The soul, or mind, is the most immediately knowable existence for each person. The other's mind is not known directly, although it can be inferred: somehow is phosphorescent. The place of this inner life, the thought, is the head or, more specifically, the brain. One of the erroneous results of this framework is to consider that all behavior of the person has an internal cause, hidden, in principle unknown.  But the future also, as Ryle says, is unknown to us, and that does not mean it is hidden anywhere. The other mistake is to transpose the physical causality to mental events (Wittgenstein, 1945-49). Official doctrine, therefore, takes as something given, primitive, the existence of internal mechanisms.
I think that the arguments used by Fonagy sometimes fall, inadvertently, in current errors due to this Cartesian perspective. For instance, Fonagy states his anti-Cartesian position as follows:
 Our approach explicitly rejects the classical Cartesian assumption that mental states are apprehended by introspection; on the contrary, mental states are discovered through contingent mirroring interactions with the caregiver. (2008, p. 10; our emphasize)

Instead I would say, probably, that ‘mental states’ are not discovered but created by social interaction. The expression ‘mental state’ is a cultural-dependent term currently used in Western societies. There is a more basic principle in Cartesianism than that of the acquisition of contents by introspections, and it is the ontological separation of the two substances, mind en matter, spirit and extension, internal and external.
The position that we embrace regarding Cartesianism determines to a certain extent our position in the clinical setting. Psychoanalysis understood as a technique assumes that an isolated mind, the analyst, is doing something to another isolated mind, the patient, or, at worst, the reverse. The result can’t be a healthier human being; the human being is left aside, and the best outcome is a better polished object. Technical recommendations became fixed rules that persist today in our ‘collective psychoanalytic superego’ (Orange, Atwood, Stolorow, 1997). We experienced in our relationship with another - coherently with the technical position- that things happen sequentially, in the form of action and reaction, as in a one-way bridge, giving place to a linear causality. In brief, one is agent and the other patient, in some cases alternatively, in a kind of complementary relationship where the other's subjectivity is not recognized as such. This action-reaction myth is the one that dominates the classical psychoanalysis as well as most studies on current cognitive psychology, indebted to the ‘computer metaphor’. Such point of view was not shared by pioneers in developmental psychology, inspired by some form of constructivism, either ‘biological constructivism’ (Piaget and followers), or ‘social constructivism’ (Vygotsky, Bruner).
One of the main differences between relational and classical psychoanalysis lie in the increasing proximity or symmetry between therapist and patient, forming both a therapeutical couple. Therapy is no more something therapist do upon the patient, but rather a common task of mutuality and reciprocal experience, in a co-constructed field. Fonagy is well informed about relational psychoanalysis principles and theories (Cf. Fonagy, 1998). Let us quote Fonagy himself alluding to relational psychoanalysis:
It would be churlish to devote too much space to criticizing “work in progress.” These ideas are in the process of creation and an excessively critical stance can only serve to stifle such a critical process. I would prefer to point to some areas that I would like the authors to explore for the sake of completeness. (1998, p. 351)

I appreciate deeply Fonagy’s theories as really useful instruments in the clinical work with personality disordered patients. Mentalization theory is useful as long as it agrees with the Western conception, shared by therapist and patient, of what is the mind and how goes on. However, for the very same reason, such a theory, or more precisely certain hard version of it that could be revealed by a careful reading of Fonagy’s texts, may deserve some criticism. My intention is, so long as I know, to point to some areas of his thought for the sake of, not completeness but of a better conceptual framework on Fonagy’s theoretical stance, and thus avoid some undesirable potential consequences for clinical work.  Well understood, those are consequences that can occur only in some cases, because fortunately most clinicians do not follow blindly the theoretical principles they learned, and are able to ‘throw away the book’ (Leon Hoffman cited by Paul Fonagy, 1999 a). Kohut (1984) said that empathy was not something he himself had invented but something already in use by other psychoanalysts of other orientations (Freudians, Kleinians, etc.).


One of the capabilities that define the human being is to take into account both his own mental states and that of the others in understanding and predicting the behavior. In developmental psychology this is what has been called ‘a theory of mind’ (Cf. Wellman and Liu, 2004). This concept serves to collect all intuitive ideas each one has about mental functioning and the nature of the experience, memory, beliefs, attributions, intentions, emotions and desires of their own and those belonging to other.
However, when abuses occur by parents, the son’s theory of mind weakens (Fonagy, 1991, 2001; Fonagy y Target, 1996). Fonagy explains convincingly that for the child is no longer a sure thing to think about desires, because this involves observing the parent wishes to hurt him. So high representation of mental events is inhibited, which provides certain benefits for the individual, allowing him, so to speak, to make a detour against an intolerable mental pain. The child seeks comfort in a merger down with the object, with a 'parent rescuer' in fantasy. Therefore it is logical to conclude that the analyst thinking and talking about thinking of the patient, can help to repair global or focal defects in the patient's mentalizing ability.
Fonagy suggest that mentalization is a theory that provides an integrative framework that could integrate brain and mind and can serve as a ‘common language’ for a range of therapeutic modalities (Fonagy and Allison, 2014, p.373). The mentalizing of patients may be a common factor across psychotherapies ‘not because patients need to learn about the contents of their minds or those of others, but because mentalizing may be a generic way on increasing epistemic trust, trust the reality of what the therapist says] and therefore achieving change in mental function’. (Fonagy and Allison, 2014, p.477)
Taking all this into account it seems appropriate to seek a precise definition of ‘mentalization’:
We define mentalization as a form of mostly preconscious imaginative mental activity, namely, interpreting human behavior in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons). Mentalizing is imaginative because we have to imagine what other people might be thinking or feeling; an important indicator of high quality of mentalization is the awareness that we do not and cannot know absolutely what is in someone else’s mind. We suggest that a similar kind of imaginative lap is required to understand one’s one mental experience, particularly in relation to emotionally charged issues. In order to conceive of others as having a mind, the individual needs a symbolic representational system for mental states and also must be able to selectively activate states of mind in line with particular intentions, which requires attentional control. (Fonagy, 2008, p. 4, emphasis added).

I beg Fonagy’s pardon if I compare his stance – complex and comprehensive - in some respects to that of Andrew Meltzoff. In the mid-70's, Meltzoff discovered that infants between 12 and 21 days of age can imitate both facial and manual gestures (Meltzoff and Moore, 1977). This behavior implies that human neonates can equate their own unseen behaviors with gestures they see others perform. More important for what concerns us here, Meltzoff (2007) proposed the ‘like me’ hypothesis about the infant development: ‘Here is something that is like me’. The infant experiences a regular association between his or her own acts and the underlying mental states. Subsequently, the infant projects internal experiences onto others performing similar acts, and begins to acquire an understanding of ‘other minds’: their mental states, emotions, desires, and so on. Imitating is an innate ability and the comprehension of the other’s mental states is a derivative. In the same vein Fonagy suggests:

… the ability to give meaning to psychological experiences evolves as a result of our discovery of the mind behind other’s actions, which develops optimally in a relatively safe and secure social context (2008, p. 29, emphasis added).

 I would say not that it “develops” but that it is “learned” through caregiver’s instructions.
Meltzoff’s (and Fonagy) hypothesis is indebted for the per analogiam argument raised by the English philosopher John Stuart Mill, in the nineteenth century, to solve the ‘other minds’ problem and the risks of solipsism and isolated mind stemming from Cartesianism. According to this the statement that other persons also have a consciousness is a conclusion we derive from their actions and visible manifestations, with the aim of making their behavior understandable. What is equivalent to say that to attribute consciousness to others is an inference and not an irrefutable experience.
I would suggest that the infant doesn’t compare an internal state to a visual stimulation, but merely that we are ‘programmed’ (is our nature) in a way that allows us to display spontaneously an emotional response, for instance, in front of a smile of the caregiver, and so we share his or her ‘mental state’. The ‘mental state’ is not originally an individual property but it is owned by at least two people (CF. Knoblauch, 2000, p. 158); the unconscious mind is also owned by two or more people (Lyons-Ruth, 1999, Gerson, 2004). When we think steadily that they are indeed private entities, it follows that they are expression of some inner feelings. Nevertheless, even acknowledging the fact that emotions require cognitive processing and physiological responses, something that I do not care to recognize, they are social phenomena that often occur by a perceptual contagion, without any cognitive mediation.
Fonagy postulates that symbolic representation of mental states may be seen as a prerequisite for a sense of identity (Fonagy and Target, 1996; Target and Fonagy, 1996; Fonagy and Allison, 2014). Thus, patients with severe personality disorders inhibit their reflective function, and have little access to an accurate picture of their own representational world. But I suspect that what these patients have is not a hidden or inhibited representational world, but rather they suffer from a lack, that is, they show deficits in their representational world. They have not acquired the necessary skills to represent and therefore don’t have a ‘complete’ representational world.
It is usual to construct our psychological (cognitive) theories on the basis of mental representations. However we don’t know yet how representation represents. I feel uncomfortable with the language of cognitive psychology that pervades relational psychoanalysis, and even not relational. Perhaps a mentalistic outlook should be suitable for all patients, regardless of their disorder. Also borderline disordered patients benefit from a mentalizing attitude on the part of the therapist. I guess these patients are in greater need of an empathic acceptance and recognition, and only secondarily to mentalization. Fonagy's answer probably is that mentalizing is not at all incompatible with acceptance and recognition, but maybe it should be better to think in terms of relational patterns – from a descriptive and external point of view - and rhythmicity (a scarcely mentalist concept) in the relationship therapist-patient.
In other part Fonagy (Fonagy, 1999 a; Fonagy, Steele, Steele, Leigh, Kennedy, Mattoon, and Target, 1995) confirms the idea that relationships – the perception of an analyst having empathy or healing intentions, and not only interpretations- lead to changes in representational structures. ‘Then, there is no qualitative difference between the means by which therapeutic change is achieved via interpretation and via a new relationship’ (Fonagy, 1999 a). To perceive the therapist as somebody who listens empathetically or has healing intentions bring changes through the same mechanism of change as interpretations.
But these two ‘technical’ stances are not equivalent, because if our praxis is mainly based on interpretation it means in a concealed way that we have the truth about the patient’s problems, and consequently adopt the classical position analyst-patient. Recently Margy Sperry (2013) based her criticism of Fonagy's ideas on a similar ground. When Fonagy sees the patient blocked in a prementalizing stage of development, Sperry says:

Such an assumption establishes the analyst as an authoritative and objective interpreter of the meanings and sources of the patient's mentalizing process, and minimizes the ways that analyst may contribute to the very phenomena that she is explaining. (id., p. 686).

But Fonagy surely will answer that:
However, interpretation is not enforced in some dictatorial way but offered as the start of trying to make sense of what otherwise may be an apparently meaningless event or feeling. It becomes a way in which a therapist can demonstrate that they are thinking in their own mind about the patient’s mind and inevitably it can be given with varying degrees of competence and sensitivity.  (Bateman and Fonagy, 2004, p. 131)

However, it is very likely that in a relational analysis we use in a lesser extent the interpretation than it is usual in classic analysis, and even less in patients with a borderline functioning.
Fonagy (2008, pp. 4-9) says that the baby’s experience of himself as having a mind or self is not a genetic given, but evolves from infancy through childhood and depends upon the interaction with attuned caregivers. But at the same time he states that mentalization is the ‘evolutionary pinnacle’ of human intellectual achievement, after the selection processes of two million years of human evolution –a proposition that surely Hegel would had endorsed-. It implies a huge risk of misinterpretation to identify cultural change with Darwinian evolution. When we refer to the history of humanity prudence advises us to think merely on a strictly non-evaluative sense, rather than assume the existence of a positive development, avoiding any idea of improvement and the culturocentrism. It seems that inspired in social Darwinism, Fonagy suggests that our exceptional intelligence evolved not to deal with the hostile forces of nature but rather to deal with competition from other people. This fact is not grounded on genetics; the ‘social brain’ must reach higher and higher level of sophistication ‘to stay on top’. I suspect, however, that this competitiveness is only consistent with Western values.
Mentalizing entails making sense of the actions of oneself and other’s on the basis of intentional mental states (IIF) (Fonagy, 2008), that is, treating the object whose behavior you want to predict as a rational or intentional agent with beliefs and desires. This function provides developmental advantages. During the second year, children understand that they and others are intentional agents whose actions are caused by prior states of mind (desires, intentions) and that their actions can bring about changes in minds as well as bodies (id p. 26). In connection with that you can object that on many occasions desire and intention don’t precede action but accompany it or, maybe we should say, every act is an expression of desire or is an intentional action. Maybe Fonagy conveyed here and image excessively introspective of the action-reaction dynamic that is established between the infant and its social environment. Surely it is a much more complex phenomenon: Whose is the desire? When exactly appears the desire? I have a desire or the desire has caught me? Fonagy’s explanations sound excessively representational or cognitive. I prefer to talk not of representations but of patterns of action, mainly procedural.
Let us put another example. Fonagy added: 

In sum, the ability to give meaning to psychological experiences evolves as a result of our discovery of the mind behind other’s actions, which develops optimally in a relatively safe and secure social context. (2008, p. 29, emphasis added).

This fragment sound quit paradoxical. If I have to seek for a meaning ‘behind’ other’s actions it is because the social context is not safe and secure at all. What makes me distrust the good intentions of others is their behavior in the long run, nothing internal. There might be some signs in the here and now that make me distrust their ‘intention’. Also ‘intention’ is a generalized term I have learned to qualify long sequences of behavior. There are a lot of things we ignore but the truth should not be hidden behind. There is nothing behind, or ‘nothing is hidden’ (Malcolm, 1986). 
The acquisition of mentalization – Fonagy suggests (id., pp. 8-9) - enable the child to distinguish inner from outer reality and internal mental and emotional processes from interpersonal events. Regarding that we have to object that internal events are also interpersonal by definition: Thinking is to speak to oneself (Platon), and it is impossible for us to feel an emotion that is not located on the interpersonal level. It is a matter of fact what Fonagy argues: Self-awareness enables us to modify the way we present ourselves to others and to mislead them, ‘opens the door to more malicious teasing’ (id., p. 29). Children under four years usually belief that what they know, everybody knows. Experiments related to the false belief task seem to have probative value, although some researchers manifested disagreement (Cf. Bloom and German, 2000). Anyway, lying exists, but is an ability we have to learn (Wittgenstein: Lying is a language-game that needs to be learned like any other one, 1945-49, § 249). And it is only possible to doubt when there is certainty. We can assert that lying is only possible when there is truth. That does not mean that all our social relations are based on deception. For most of our actions you only have to bear in mind their ‘apparent’ meaning because main part of our social life is based on confidence. 
The French philosopher and historian of ideas Michel Foucault (1988) introduced the term ‘self-technologies’ which it is possibly applicable to the theory of mentalization. There are four major types of ‘technologies’:
(I) technologies of production;
(2) technologies of sign systems;
(3) technologies of power, which determine the conduct of individuals and submit them to certain ends or domination, an objectivizing of the subject; and
(4) technologies of the self.

Each implies certain modes of training and modification of individuals, depend on the historical moment, and not only involve the acquisition of certain skills but also the acquisition of certain attitudes. Technologies of the self permit individuals to effect a certain number of operations on their own bodies and souls, thoughts, conduct, and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immortality.
The modern consciousness is devoted to two essential problems which were not present in the mind of old cultures: Obeying the law and self-knowledge (Foucault, 2001, p. 305). The two mandates of Greek antiquity were ‘Take care of yourself’ and ‘Know thyself’ and the second covered and obscured the first. Says Bruno Snell (2007, pp. 289-90) that the bad conscience is a state of mind first reported by Euripides, as well as shame, embarrassment to others. The Homeric heroes had no bad conscience, not to say guilt. Instead, they had the Furies or Eumenides, goddesses of vengeance pursuing those who had committed crimes of blood, especially parricide. In any case, it was an external factor to the individual's mind. I would not dare to say that the culture of ancient Greece was inferior to ours.
On the one hand, borderline patients sometimes are very sensitive to the other mental states, well understood in order to control and manipulate (Cf. Fonagy, 1999 b).  Mentalizing is an ego or self-technology developmentally acquired that admits positive and negative purposes. Fonagy warns us to identify more mentalizing with the best disposition to serve prosocial ends (2008, p. 29). I would put it in Piagetian terms: overcoming the stage of concrete operations to reach the stage of formal operations does not mean it has been reached an autonomous morality. It looks necessary to complete mentalization theory with a theory of moral development. I recommend the tripartite scheme of the stages of moral development established by Lawrence Kohlberg (1964; Kohlberg, Levine, and Hewer, 1984): pre-conventional, conventional and post-conventional morality. Post-conventional morality is rather an achievement reached by some individuals, regardless of their dominant personality, although it is barred for ‘hard skin’ narcissist and antisocial subjects. In the individual decision-making process three different expressions arise that represent three groups or types of subjects: ‘I want it’, ‘the group approves it’, and ‘it is the correct’. The second one, corresponding to the conventional morality, is characteristic of borderline personalities, where the ‘internal’ incorporation of the rules has not yet been achieved; while pre-conventional morality (I want it) is typical of psychopaths and ‘hard skin’ narcissists. Conventional morality involves the fear of losing the appreciation of the significant other.


Freud sometimes managed the conception of an unconscious subject relatively isolated from his environment, a solipsistic ego under the control of primary narcissism.  Fonagy doesn’t maintain, fortunately, such classical concepts as ‘primary narcissism’ or the drive/instinct theory, but gets trapped if not on the Cartesian thought at least in some form of the "official doctrine" language. For instance when we read: ‘[Small] Children  do not know fully that they are separate, that their internal world is something private and individual, of which they will eventually take ownership or at least claim privileged access.’ (Fonagy, 2008, id. p. 31)
The mind is not born with the individual but develops in the context of human interaction and the mind is not only internal but also external, mainly external, that is, the pragmatic context of interpersonal relationships. The internal space is something that is created, as we can see, for example, in the description supplied by Vygotsky (1977) of how the egocentric speech is built, as an intermediate phase or ‘transition’ between the external language (social) and inner speech, when the child is talking to himself, for example, explaining the actions of his game, for anyone but himself, but aloud.
Morris Eagle (2011, p. 170), not long ago, said that in the current psychoanalytic literature representations are unconscious not only because they are defensive processes but because they have been acquired nonverbally in the early stages of life. He is referring to the procedural unconscious (Cf. Lyons-Ruth, 1999). However, when he added, correctly, that these representations are similar to the habits and motoric skills incorporated into the body, why continue to maintain that they are ‘representations’? Human beings, like any organism, behaves usually following a sequence of acts, that sequence can be represented by a scheme or script, the script is a reconstruction we make ourselves and don’t have to be ‘represented’ in any way within the body or the brain.
As Knoblauch (2000, p. 158) states, affects are not in the person but are continually built as an emotional field that slides between people who are influencing each other. What the person performs in practice are operational schemes, learned in context, and not internal images.
What goes on within also has meaning only in the stream of life. (Auch was im Innern vorghet hat nur im Fluss des Lebens Bedeutung) (Wittgenstein, 1951, II, p.30).

Errors arise from our tendency to give a value per se to these internal images, when in fact the internal image has stability only if contrasted with the use (Wittgenstein 1945-48, § 258, § 293, II, p.196/451). Whoever becomes blind, after some time, loses the ability to represent the world in visual images. For Wittgenstein the essential postulate are not representational systems, but interpersonal communication.        
There is no difficulty for me to recognize that the theory of mentalization provides an integrative framework that could constitute the ‘common language’ Fonagy and Allison (2014, p. 375) suggest. They propose mentalization; other experts highlight other concepts: attachment, empathy, recognition, etc. Anyway Fonagy and Allison are right when state that a key factor is:
… the patient’s experience of another person having the patients mind in mind, and that therapy (…) works by reviving the patient’s capacity to interpret behaviour as motivated by mental states, both in themselves and in others. (emphasis added)

Whenever we understand that ‘having the patients mind in mind’ is equivalent to empathy and recognition, and that the patient’s capacity to ‘interpret behavior as motivated by mental states’ could be substituted by ‘agency’. Then my conclusion is that our differences could be in a great proportion merely question of language, a confusion of tongues. But nonetheless I fear that some of the expressions found in Fonagy’s texts may encourage in some novice therapist to assume an authoritarian or dogmatic attitude.
Someday we will have to spend no small time to resolve the issue of the representation, and its central role in contemporary psychology, not only in its cognitive versions.


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