This article reviews an approach to working with families that grounds in systemic thinking the framework of mentalization-based treatment. Employing a mentalizing stance, this approach aims to interrupt coercive, nonmentalizing cycles of interaction within the family system and replace them with mentalizing conversations in which epistemic trust and the shared social-emotional learning of the we-mode can be generated. The process thus promoted is a spiral of shared attention and co-mentalizing, constantly lost and then recovered, in which therapist and family members learn to hear, recognize, understand, and trust one another and repair the inevitable disruptions in mentalizing and trust that allow family members to experience a way of shared knowing— the we-mode—that they can apply to communicate and solve problems both within the family system and in the broader social systems in which the family is embedded.

Summary Metalization-Informed Systemic Therapy and its Evidence Base Concept and practice of «mentalizing» – the attitude and skills involved in understanding mental states, both one’s own as well as those of others – have been of increasing interest to many systemic therapists. The primary therapeutic focus of this approach is on the mental states (thoughts, feelings, wishes, needs, desires and beliefs) in order to enhance effective mentalizing among family members and thereby strengthening attachments and other aspects of family relationships. A range of different interventions which are compatible with a systemic framework are described in this paper and the emerging evidence base of mentalization-based family work is reviewed.

The therapeutic use of mentalizing – a person’s awareness of mental states in both self and others, with a focus on perceiving and interpreting feelings, thoughts and beliefs – can enrich traditional systemic work. Innovative techniques aimed at enhancing effective mentalizing among family members are described, with the aim of building ‘epistemic trust’ – the trust in the authenticity and personal relevance of interpersonally transmitted information. Feeling recognized in terms of one’s individual needs and thoughts – being mentalized – helps to establish trust, be that in a parent, partner or indeed a therapist. Mentalization-focused systemic work aims to enhance effective mentalizing and build better attachments all round. The emerging evidence base for the efficacy of this approach is summarized.

While participating in the study, both during the period of direct work with couples and subsequently when we were given access to the results, we found ourselves struck by a number of themes that seemed of particular significance in working with this client group under these particular circumstances. Some of these themes will, of course, be of general interest in all systemic work, or in all couples work; some are perhaps more relevant to the particular context of this work. We discuss in this chapter the themes that proved of relevance to both of us here; other themes are taken up in the individual clinical chapters (chapters three and four). Some of the themes are clinically significant, while others relate more to the experience, for clinicians, of being researched.

A requirement of the research project was that each treatment modality had to provide a protocol describing its approach. Eia Asen had already started this process during the pilot phase, and both authors then continued to struggle with several more versions. We found the writing of such a protocol difficult partly because of our distaste for pinning down our practice in what seemed a rigid and prescriptive format—psychotherapy is, after all, an art as well as a set of techniques—but also because the two of us orient ourselves at somewhat different ends of the systemic spectrum. Thus Elsa Jones could be described as being placed somewhere in the "post-Milan" group, strongly influenced by feminist and social constructionist ideas (Jones, 1993), whereas Eia Asen occupies a position that draws on a number of different approaches, from structural to strategic to post-Milan therapies (Asen, 1997). Thus the final working document stated that "each therapist is likely to use most of these techniques during the course of therapy with each couple" but some techniques were very unlikely to be used, at least in their pure form, by both therapists. Additionally, experienced therapists are unlikely to be 14working in a way that reflects a pure model, since, after a significant period as a practitioner, one's style becomes personal and influenced by a continuous learning process from colleagues, clients, and one's own life.

The London Depression Intervention Trial (LDIT: Leff et al., in press) was set up in 1991 to compare the effectiveness of antidepressant drugs, individual cognitive behaviour therapy (CBT), and systemic couple therapy. Patients diagnosed as "depressed" by psychiatrists were randomly assigned to one of these three treatment modalities. However, the CBT arm of the trial had to be stopped at an early stage because the drop-out rate was so high (8 out of the first 11 cases). The final comparison, therefore, was between drug therapy and systemic couple therapy and involved 88 subjects who met the research criteria and were taken into treatment.