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The Psychoanalytic Study of the Child



VOLUME SIXTY



Founding Editors ANNA FREUD, LL.D., D.SC. HEINZ HARTMANN, M.D. ERNST KRIS, Ph.D. Managing Editor ROBERT A. KING, M.D. Editors PETER B. NEUBAUER, M.D. SAMUEL ABRAMS, M.D. A. SCOTT DOWLING, M.D. ROBERT A. KING, M.D. Editorial Board Samuel Abrams, M.D. Paul M. Brinich, Ph.D. A. Scott Dowling, M.D. Robert A. King, M.D. Anton O. Kris, M.D. Steven Marans, Ph.D. Linda C. Mayes, M.D.



Peter B. Neubauer, M.D. Wendy Olesker, Ph.D. Samuel Ritvo, M.D. Robert L. Tyson, M.D. Fred R. Volkmar, M.D. Judith A. Yanof, M.D.



Kindly submit seven copies of new manuscripts by post or as an email attachment in MS Word to Robert A. King, M.D. Yale Child Study Center 230 South Frontage Road P.O. Box 207900 New Haven, CT 06520-7900 Phone: (203) 785-5880 E-mail: [email protected]



The Psychoanalytic Study of the Child VOLUME SIXTY



Yale University Press New Haven and London 2005



Copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling. All rights reserved. This book may not be reproduced, in whole or in part, including illustrations, in any form (beyond that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except by reviewers for the public press), without written permission from the publishers. Designed by Sally Harris and set in Baskerville type. Printed in the United States of America. Library of Congress catalog card number: 45-11304 International standard book number: 0-300-10961-X A catalogue record for this book is available from the British Library. The paper in this book meets the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity of the Council on Library Resources. 10 9 8 7 6 5 4 3 2 1



Contents



INFANT-PARENT RESEARCH AND INTERVENTION A. Scott Dowling Introduction Beatrice Beebe Albert J. Solnit Award paper: Mother-Infant Research Informs Mother-Infant Treatment Tessa Baradon “What Is Genuine Maternal Love?”: Clinical Considerations and Technique in Psychoanalytic Parent-Infant Psychotherapy Arietta Slade, Lois Sadler, Cheryl de Dios-Kenn, Denise Webb, Janice Currier-Ezepchick, and Linda Mayes Minding the Baby: A Reflective Parenting Program Judith Arons “In a Black Hole”: The (Negative) Space Between Longing and Dread: Home-Based Psychotherapy with a Traumatized Mother and Her Infant Son Alexandra Murray Harrison Herding the Animals into the Barn: A Parent Consultation Model



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PSYCHOANALYTIC RESEARCH Nick Midgley and Mary Target Recollections of Being in Child Psychoanalysis: A Qualitative Study of a Long-Term Follow-Up Project Rona Knight The Process of Attachment and Autonomy in Latency: A Longitudinal Study of Ten Children



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Contents CLINICAL STUDIES



Karen Gilmore Play in the Psychoanalytic Setting: Ego Capacity, Ego State, and Vehicle for Intersubjective Exchange Lissa Weinstein and Laurence Saul Psychoanalysis As Cognitive Remediation: Dynamic and Vygotskian Perspectives in the Analysis of an Early Adolescent Dyslexic Girl Silvia M. Bell A Girl’s Experience of Congenital Trauma: The Healing Function of Psychoanalysis in the Adolescent Years



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PSYCHOANALYTIC PERSPECTIVES ON THE FUTURE AND THE PAST Harold P. Blum Psychoanalytic Reconstruction and Reintegration Cornelis Heijn On Foresight



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Index



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INFANT-PARENT RESEARCH AND INTERVENTION



Introduction



Who can tell the dancer from the dance? —William Butler Yeats



the following five papers are presented as a group to emphasize the unity of purpose of their authors in furthering parent— young child research and clinical practice and to highlight the variety of routes they have devised to provide creative and effective interventions. When Peter Wolff (1959) described infant states, the stage was set for the burgeoning field of infancy research. At about the same time, the important work of Chess and Thomas (1986) on temperament spelled out more explicitly the notions of Anna Freud and others that infants differed constitutionally in their regulatory and reactive styles—and that these differences had important, fateful consequences for the reactions they elicited in their caretakers. The findings of this research gradually made it possible to move beyond wellmeant but fundamentally authoritarian recommendations for infant care. This work thus set the stage for research that supports suggestions for care based on deepened developmental insight and on an appreciation of individual parent-infant differences. There seems to be no end to the fruitfulness of infant research as it provides descriptions of ever more complex competencies and innate capacities of infants and details the moment-to-moment interactions of infants with others with ever greater precision. There is universal agreement that such studies yield a goldmine of data; there is less agreement about the interpretation of the data and their significance for development and functioning in later childhood and adulthood. One area in which these data might be applied is that of parent-infant intervention. Many of the pioneers in advocating such intervention, including



The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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Introduction



Sally Provence, Albert Solnit, Peter Neubauer, and Selma Fraiberg, were grounded in psychoanalytic earth. One expression of their interest was the founding, with others from psychology and social work (and with the support of dedicated philanthropists), of Zero to Three, the foremost interdisciplinary advocacy organization for early childhood mental health (www.zerotothree.org/). It is a mark of the ferment and creativity of the papers published here that, alongside the commonality of their broad psychoanalytic orientation, emphasizing the central place of relationships in human development, the authors show wide variation in their techniques of studying infant-parent interaction, in their conceptualization of the clinical task of intervention, and in their specific techniques of intervention. It is our hope that these differing ideas, presented together, will stimulate a productive dialogue concerning both clinical and theoretical aspects of providing assistance to infants and their parents. The practitioners of parent-infant intervention are pragmatic integrationists as they strive to reach the goal of clinical effectiveness in promoting developmental competence. Building on the techniques of Selma Fraiberg—and in the grand tradition of providing social support to troubled children and adults—they investigate new roles for the therapist, often combining drive/defense and object relations theories in their techniques. The different kinds of dyadic disturbances targeted by the interventions described in this set of papers also suggest the first tentative steps toward an implicit typology or nosology of perturbed mother-infant interaction. From a practical point of view, some of the interventions, such as Slade et al., involve long-term work with quite troubled mothers who also struggle with poverty, adversity, and trauma; others, such as Beebe, present short, focused interventions with better functioning mothers who sensed that their relationship with their infant had become derailed in some important way. Two authors explicitly demonstrate the benefit of combining elements of modern attachment theory with psychoanalytic developmental theory. To varying degrees the papers also acknowledge or assume integration of psychoanalytic concepts with Piagetian psychology, recent findings in neuroscience, systems theory, and, above all, with the findings of infant developmental research. What the indications are for each of these forms of intervention (and what talents are required of the therapist) remain to be studied, as well as determining the longer-term impact of the different modalities.



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Issues of therapeutic efficacy aside, the five papers collectively raise provocative questions about the fashion in which the second-to-second interactions of parents and their young children, often on a non-verbal level outside of conscious awareness, shape each dyad’s enduring patterns of mutual influence and relating, and structure the child’s internal object representations, affective and cognitive self-regulation, and characteristic modes of coping with various forms of instinctual arousal. By opening to scrutiny the fine-grained structure and texture of ongoing parent-infant interaction that make up the quotidian stuff of early childhood life, these studies reveal the subtle, multifaceted nature of empathic attunement (and the potential derailments thereof ). This work continues the long-standing psychoanalytic agenda of understanding how the child’s mind becomes structured in the context of mother-infant interactions (Loewald, 1978; Ritvo & Solnit, 1958). How the consequences of these very early “procedural” (rather than “verbal”) modes of relating (and misrelating) come to be represented in later childhood or adulthood; how they interact with temperament to shape drive, defense, and character; and how they might be re-experienced and accessed in the transference or counter-transference are all important unanswered questions. The ongoing empirical study of these processes promises to deepen our understanding of the links between psychoanalysis and developmental psychopathology. For a number of years, researchers interested in infant development and in parent-infant interaction have made extensive use of video recordings, sometimes reviewed in frame-by-frame detail. Three papers describe the use of such video recordings in research but then go on to demonstrate how the same video microanalytic techniques can be used clinically with parents as an aid to insight and as a guide to more effective methods of care. The paper by Harrison extends these video analytic techniques, developed in infant research, to the study of parents in interaction with their young children. These five papers are the beginning of a continuing dialogue in these pages concerning interventions with parents and their young children. It is our personal conviction that these studies are valuable not only for the assistance they provide to practitioners in this field but also for their contribution to a more adequate empirical study and integration of physiological (“biological”), drive/defense (“structural”), and interpersonal (“object relations”) perspectives in our understanding of human psychology.



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Introduction BIBLIOGRAPHY



Chess, S. & Thomas, A. (1986) Temperament in Clinical Practice. New York: Guilford Press. Fraiberg, S., Adelson, E., & Shapiro, V. (1975) Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14:387– 421. Loewald, H. W. (1978). Psychoanalysis and the History of the Individual. New Haven: Yale University Press. Ritvo S. & Solnit A. J. (1958) Influences of early mother child interaction on identification processes. Psychoanalytic Study of the Child, 13:64 – 91. Wolff, P. (1959) Observation on newborn infants. Psychosomatic Med. 21: 110 –118.



Mother-Infant Research Informs Mother-Infant Treatment* BEATRICE BEEBE, Ph.D. *Winner of the Albert J. Solnit Award, 2005



A brief mother-infant treatment approach using “video feedback” is described. This approach is informed both by psychoanalysis and by research on mother-infant face-to-face interaction using video microanalysis. Two cases are presented. In the first, descriptions of the



Clinical Professor of Psychology in Psychiatry, Columbia University; Faculty, N.Y.U. Postdoctoral Program in Psychotherapy and Psychoanalysis; Faculty, Institute for the Psychoanalytic Study of Subjectivity, N.Y.C.; Faculty, Columbia University Psychoanalytic Center; Faculty, Columbia Psychoanalytic Center Parent-Infant Program. This work was partially supported by NIMH grant R01-MH41675, the Fund for Psychoanalytic Research of the American Psychoanalytic Association, the Kohler Stiftung, the Edward Aldwell Fund, and the Laura Benedek Infant Research Fund. I am grateful for the help of my research team: Caroline Flaster, Donna Demetri-Friedman, Nancy Freeman, Patricia Goodman, Michaela Hager-Budny, Sara Hahn-Burke, Elizabeth Helbraun, Allyson Hentel, Tammy Kaminer, Sandra Triggs Kano, Limor Kaufman-Balamuth, Marina Koulomzin, Sara Markese, Lisa Marquette, Irena Milentejevic, Danielle Phalen, Alan Phalen, Jill Putterman, Jane Roth, Shanee Stepakoff, Sandra Triggs Kano, Rhonda Davis, Helen Demetriades, Greg Kushnick, Paulette Landesman, Tina Lupi, Jillian Miller, Michael Ritter, Stephen Ruffins, Claudia Andrei, Emily Brodie, Lauren Cooper, Lauren Ellman, Nina Finkel, Matthew Kirkpatrick, Adrienne Lapidous, Michelle Lee, Sandy Seal, Nicholas Seivert, Hwee Sze Lim, and Marina Tasopoulos. I thank Frank Lachmann, Phyllis Ackman, Phyllis Cohen, George Downing, Juliet Hopkins, Barbara Kane, Lotte Kohler, Ilene Lefcourt, Mary Sue Moore, Wendy Olesker, Lin Reicher, and Johanna Tabin for their clinical consultations. I thank my statistical team, Howard Andrews, Karen Buck, Patricia Cohen, Henian Chen, Stanley Feldstein and Donald Ross. Joseph Jaffe has been an invaluable consultant and advisor. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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Beatrice Beebe videotaped interactions which informed the interventions are presented. In the second, knowledge of mother-infant microanalysis research informed the treatment, even though videotaping was not an option. The respective “stories” of the presenting complaints, the video interaction, and the parent’s own upbringing are linked. Specific representations of the baby that may interfere with the parent’s ability to observe and process her nonverbal interaction with her infant are identified. The mother has a powerful experience during the video feedback of watching herself and her baby interact. Our attempts together to translate the action-sequences into words facilitates the mother’s ability to “see” and to “remember,” fostering a rapid integration of implicit and explicit modes of processing. Introduction



more than two decades of research on maternal distress, mother-infant interaction, and infant and child developmental outcomes have shown that infants suffer when a parent is distressed. At times parental distress stems from longstanding character psycho-pathology. Research on depressed mothers and their infants shows that these infants are at risk for insecure attachments and compromised cognitive outcomes (Murray & Cooper, 1997). Maternal prenatal anxiety has been shown to predict behavior problems in the children at age 4 years (O’Connor, Heron, Golding, Beveridge, & Glover, 2002). Maternal unresolved mourning has been specifically linked to infant and childhood disorganized attachment, a form of insecure attachment that predicts childhood psychopathology (Lyons-Ruth, 1998). But even highly competent parents can become destabilized under the impact of illness, loss, or other traumas, such as the loss of the husbands of 100 pregnant women from the 9/11 World Trade Center tragedy (Beebe, Cohen, & Jaffe, 2002). In addition to maternal contributions, infants may also bring their own difficulties to the relationship, based on constitutional or developmental factors. In this paper I describe a brief mother-infant treatment approach using “video feedback.” This approach is informed both by psychoanalysis and by research on mother-infant face-to-face interaction using video microanalysis. Two cases are presented. In the first, Cecil, descriptions of the videotaped interactions which informed the interventions are included. In the second, Nicole, I show how knowledge of mother-infant microanalysis research can inform a treatment even when videotaping is not an option. Whereas the implicit, proce-



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dural mode of exchange addresses behavioral transactions which are usually out of awareness, the explicit, declarative mode refers to our symbolic, verbalized narrative. In the discussion, I suggest that the mother’s experience during the video feedback of watching herself and her baby interact, and our joint attempts to translate the action-sequences into words, facilitates the mother’s ability to “see” and to “remember,” stimulating a rapid integration of procedural and declarative modes of processing (see Beebe, 2003). Some mothers, however, require more extensive treatment (see Cohen & Beebe, 2002). Psychoanalytic pioneers such as Anna Freud, Melanie Klein, Margaret Mahler, Fred Pine, Anni Bergman, and Paulina Kernberg understood the importance of intervention in the first years of life. Parent-infant therapy specifically has been known for several decades, spearheaded by Adelson and Shapiro (1975); Call (1963); Ferholt and Provence (1976); Fraiberg (1971, 1980); Greenacre (1971); Greenspan (1981); Lebovici (1983); Spitz (1965), Lieberman & Pawl (1993); and Weil (1970), among others. Although therapeutic interventions are widely available for young children, mother-infant treatment remains less available. The last decade has shown great progress in conceptualizing methods of intervention with parents and infants. Both psychodynamic approaches aimed at the mother’s representations and interactional approaches attempting to intervene into specific behavioral transactions are effective (see for example Brazelton, 1994; Fraiberg, 1980; Field et al., 1996; Hofacker & Papousek, 1998; Hopkins, 1992; McDonough, 1993; Marvin, Cooper, Hoffman, & Powell, 2002; Malphurs et al., 1996; Murray & Cooper, 1997; Seligman, 1994; Stern, 1995; van den Boom, 1995). Many different kinds of mother-infant therapies have been shown to predict positive outcomes (Cramer et al., 1990). Nevertheless, even in current approaches to mother-infant treatment, the infant is in danger of being the “forgotten patient” (see Lojkasek, Cohen & Muir, 1994; Weinberg & Tronick, 1998). Weinberg and Tronick (1998) documented by video microanalysis that the infants of mothers with panic disorder, obsessive-compulsive disorder, and major depression were still in distress, even though the mothers reported improvement of their own symptoms with medication and individual psychotherapy. Our approach to mother-infant treatment integrates psychodynamic and interactional approaches within the context of feedback on videotaped interactions. We address the mother’s representations of and transferences to the infant as well as mother-infant interaction patterns visible on videotape.



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Microanalytic research describing face-to-face patterns has been extensively reviewed (see Beebe 2003, 2000; Beebe & Lachmann, 2002; Stern, 1985, 1995). Two treatment cases informed by mircroanalytic research have previously been presented in Beebe (2003) and Cohen and Beebe (2002); see also Freeman (2001). Face-to-Face Interaction Research The video feedback treatment method attends to specific patterns of mother and infant self- and interactive regulation which have been documented by three decades of video microanalysis research. This work focuses on face-to-face interaction rather than the regulation of feeding and sleep (but see as an exception Sander, 1977) and is most relevant for infants 3 to 12 months. The importance of mother-infant face-to-face interaction for social and cognitive development is extensively documented (see Belsky, Rovine, & Taylor, 1984; Cohn & Tronick, 1988; Cohn, Campbell, Matias, & Hopkins, 1990; Field, 1995; Lewis & Feiring, 1989; Leyendecker, Lamb, Fracasso, Scholmerich, & Larson, 1997; Martin, 1981; Malatesta et al., 1989; Lester, Hoffman, & Brazelton, 1985; Stern, 1985; Tronick, 1989). This research provides a rich resource for the parent-infant clinician, but has nevertheless remained strikingly under-utilized. A “dyadic systems view” of face-to-face communication informs our approach to this research (Beebe, Jaffe, & Lachmann, 1992; Beebe & Lachmann, 2002). Because each person must both monitor the partner and regulate inner state, in this view all interactions are a simultaneous product of self- and interactive regulation, and each form of regulation affects the other (Gianino & Tronick, 1988; Sander, 1977; Thomas & Malone, 1979). Both the individual and the dyad contribute to the organization of behavior and experience. Interactive regulation is defined as bi-directional contingencies in which each partner’s behavioral stream can be predicted from that of the other. It is a “co-constructed” process in which each partner makes moment-by-moment adjustments to the other’s shifts in behaviors, such as gaze, facial expression, orientation, touch, vocal quality, and body and vocal rhythms. Although the mother has the greater capacity and range of resources, the infant is a very active participant in this exchange, bringing remarkable capacities to seek and avoid engagement (Beebe & Lachmann, 2002; Beebe & Stern, 1977; Stern, 1971, 1985; Tronick, 1989). This emphasis on the contribution of both partners to the organization of the exchange avoids the temptation to locate the source of difficulty in only one partner or



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the other, for example, in maternal intrusiveness or in infant temperament difficulty. From birth and even in utero, infants perceive durations of events and temporal sequences (DeCasper & Carstens, 1980). By the time infants are 3 to 4 months, when most of this research is conducted, infants perceive the existence and magnitude of contingencies and can anticipate when events will occur (Haith, Hazan, & Goodman, 1988; Jaffe et al., 2001; Watson, 1985). These capacities enable the infant to anticipate how each partner changes predictably in relation to the other’s changes, organizing “expectancies” of “how I affect you,” and “how you affect me.” These infant capacities for the perception of sequence, contingency detection, and the anticipation of events underlie the generation of procedural, presymbolic representations of interactive sequences (Beebe & Stern, 1977; Beebe, Lachmann, & Jaffe, 1997; Gergeley & Watson, 1997; Stern, 1985; Tronick, 1989). Although the terms “mutual influence” or “mutual regulation” are often used to describe the co-construction of interactive regulation, we no longer use these terms because neither “mutuality” nor “influence” in their usual meanings is accurate. Mutuality usually connotes a positive interchange, but aversive interactions such as “chase and dodge” are also co-constructed, in the sense that each partner’s behavioral stream can be predicted from that of the other (Beebe & Stern, 1977). The term “influence” can also be misleading because no conscious intention to influence the behavior of the partner is implied in these contingency analyses (although obviously the parent has many conscious intentions to influence the infant). It is not a causal process but rather a probabilistic one. The interactions we study are extremely rapid, with individual behaviors lasting on the average 1/4 to 1/3 of a second; lag times between the onset of one individual’s behavior and the onset of the partner’s behavior are generally within 1/2 second (Beebe, 1982; Cohn & Beebe, 1990; Stern, 1971). Thus many aspects of these interactions occur out of awareness, often subliminally; they are “nonconscious,” rather than dynamically “unconscious” (see Lyons-Ruth, 1998), although again, the parent has many dynamically unconscious motivations as well. Thus we prefer the more neutral terms “bi-directional regulation” or “coordination” to describe these contingency analyses. Self-regulation is just as important as interactive regulation. While participating in the interactive exchange, each partner must simultaneously regulate his or her inner state. Both infant and parent bring constitutional proclivities such as temperamental dispositions and



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arousal regulation styles which affect self-regulation. Each partner’s self-regulation capacity and style affects the nature of the interactive regulation, and vice-versa. Whereas one meaning of “co-construction” is that each partner contributes to the interactive regulation, a second meaning is that inner and relational processes are co-constructed (see Beebe & Lachmann, 1998). Thus both partners come to expect particular interactive patterns, associated with particular self-regulation processes. Infant expectancies of different patterns of self- and interactive regulation provide one process by which parental distress can be transmitted to the infant and alter the trajectory of development. In applying this research to treatment, it is important to recognize that ranges of “normal” interactions are more ambiguous than extremes of difficulty, and there is no one optimal mode of interaction. Despite extensive research predicting developmental outcomes from face-to-face interaction patterns, there are no official “norms,” and this research is still in progress. All dyads use problematic patterns at some moments, as adaptive modes of coping and defense in the context of specific interactive dilemmas. The Infant’s Nonverbal Language The use of “video feedback” as part of parent-infant psychotherapy still constitutes a new approach to mother-infant treatment, despite the fact that Stern (1995; Cramer & Stern, 1988), McDonough (1993), Tutors (1991), and Downing (2004), among others, have been using variations of this technique for over a decade (for current work see for example Bakermans-Kranenberg, Juffer, & van Ijzendoorn, 1998; Hofacker & Papousek, 1998; Malphurs et al., 1996; Marvin, Cooper, Hoffman, & Powell, 2002; van den Boom, 1995). Video feedback is introduced to the parent as a way of learning about the infant’s “nonverbal language,” and of becoming aware of the ways the parent may respond. Video feedback is a remarkable clinical tool in the hands of an experienced “baby watcher” who is also a sensitive clinician. Videotape played in slowed time, or frameby-frame, acts like a “social microscope,” revealing subtleties and subliminal details of interactions which are too rapid and complex to grasp with the naked eye in ongoing time. It is difficult for anyone to be aware of his or her nonverbal behavior. If the video feedback is handled with great care to protect the parent’s self-esteem, it helps the parent to see how both infant and parent affect each other, mo-



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ment-by-moment. Video feedback provides an opportunity for the parent to process and reflect on the difficult moments in the interaction, as well as the successful ones (Fonagy, Gergely, Jurist, & Target, 2002). Microanalysis Teaches Us to Observe Video microanalysis can teach us to observe the subtle, fleeting details of the mother-infant action language. The infant’s repertoire during a face-to-face exchange is complex. There is a remarkable range of behaviors at the infant’s disposal to initiate, maintain, disrupt, or avoid a face-to-face encounter (Stern, 1971, 1985). The mother is instructed to play with the infant as she would at home. Until 9 to 12 months, we do not provide toys. The infant is placed in an infant seat opposite the mother, who is seated in the same plane. Two cameras, one on each partner’s face and upper torso, generate a split-screen view of the pair interacting. gaze We begin by observing gaze. Mothers tend to look at the infant’s face most of the time, and it is the infant who typically engages in a looklook away cycle, looking at mother’s face for a period of time, looking away, and then looking back (Stern, 1971, 1974). As the ethologists note, looking into the face of a partner can be very stimulating; most animals do not sustain long periods of such looking unless they are about to fight or make love (Chance & Larsen, 1996; EiblEibesfeldt, 1970). Field (1981) verified that infants organize their look-look away cycle to regulate degree of arousal. She monitored infant heart rate during face-to-face play and showed that the moment that the infant looks away is preceded by a burst of arousal in the previous 5 seconds; following the infant’s gaze aversion, heart rate decreases back down to baseline within the next 5 seconds, and then the infant returns to gazing at mother’s face. Thus infant gaze aversion is an important aspect of infant self-regulation. Brazelton, Kozlowski, and Main (1974) first showed that mothers typically pace the amount of stimulation according to this gaze cycle, stimulating more as the infant looks, and decreasing stimulation as the infant looks away. Although these are typical patterns, we have also noted a pattern of mutual “eye love” (Beebe, 1973; Beebe & Stern, 1977) in which mothers and infants can sustain prolonged mutual gaze for up



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to 100 seconds during periods of positive affect. These are the moments, of course, that every parent loves. Maternal difficulty in tolerating momentary infant gaze aversion is one of the most common pictures observed in mothers and infants who present for treatment. If the mother feels that her infant does not like her or is not interested in her, she may pursue the infant, increasing rather than decreasing the amount of stimulation. In her pursuit or “chase,” mother may call the infant’s name, pull the infant’s hand, or in rare instances actually attempt to force the infant’s head to get the infant to look. Maternal “chase” behavior is counterproductive; the infant then requires more time to regulate arousal down sufficiently to return to gazing at mother. Instead, if the mother can be helped to give the baby a “time-out” to re-regulate, “cooling it” when the infant looks away, trusting her infant to return to her, the infant will rapidly re-engage. head orientation We next observe infant head orientation to the mother: is the head oriented vis-à-vis, or displaced in the horizontal plane approximately 30, 60, or 90 degrees away? In the 90-degree aversion, first described by Stern (1971), the infant’s head is tucked into the chin, which takes considerable energy. Are head aversion movements in the horizontal plane complicated by oblique angles of the head down (or up) as well? These increasing degrees of head aversion are described by ethologists as degrees of severity of “cut-off” acts (Chance, 1962; McGrew, 1972). They are “read” by the partner as active initiations of disengagement. As the infant turns away up to about 60 degrees, he can still monitor the mother with his peripheral vision (tracking presence, direction, and intensity of movement); by 90 degrees away, or arching, however, he may lose peripheral visual monitoring of her movements. More usual gaze aversions retain head orientation within an approximately 30-degree angle from the vis-à-vis, retaining access to rapid visual re-engagement with minimal effort. In relation to the maternal “chase” behaviors above, the infant may “dodge” with increasing degrees of head aversion, as well as arching back, freezing (described by Fraiberg, 1982), or going limp and giving up tonus. Beebe and Stern (1977) described split-second sequences of “chase and dodge” in which maternal chase movements predicted infant dodges, as the infant monitored her every movement through peripheral vision; but infant dodges also predicted maternal chase behaviors, a reciprocal, bi-lateral interactive regula-



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tion. Through increasing head aversions, arching, or going limp, this infant had a remarkable “veto power” over the possibility of a sustained, mutual gaze encounter. face If mother and infant together manage the infant’s look-look away cycle so that the infant can comfortably regulate arousal, periods of sustained mutual gaze with infant vis-à-vis orientation can be enjoyed. During these periods, facial and vocal communication take center stage. By 3 to 4 months there is a flowering of the infant’s social capacity. Although the innervation of the facial musculature is myelinated before the infant is born, the full display of facial expression emerges only gradually from 2 to 4 months. The infant’s opening and closing of the mouth is a powerful and continuous form of communication. Even without any hint of widening or smiling, a fully opened mouth (“neutral gape”) is highly evocative (Beebe, 1973; Bennett, 1971). A fully widened smile by itself, with closed lips, is only moderately positive. As increasing degrees of mouth opening are added to a smile, positive affect increases up and up into the fully opened “gape smile,” hugely exciting for both partners. Mothers intuitively roughly match the infant’s increments, so that both build to a peak of positive facial excitement. Often both partners excitedly vocalize at such moments, further increasing the intensity (see Beebe, 1973; Beebe & Lachmann, 2002; Stern, 1985; Tronick, 1989). In general, mothers and infants tend to match the direction of the other’s positive-to-negative affective change, increasing and decreasing together (Beebe et al., 2004). Rarely is there an exact match of expression. Elaboration (Fogel, 1993), echo, or complementing (Trevarthen, 1977) are better metaphors than matching or imitation (Stern, 1985). Instead of the more romanticized notion that mothers and infants exactly match, or are in exact “synch,” Tronick and Cohn (1989) have shown that a more flexible process of match, mismatch, and re-match (disruption and repair) characterizes the exchange. Furthermore, a greater likelihood of rapid rematch (within 2 seconds) predicts secure attachment at one year. It is unusual for mothers to display no facial matching at all, particularly when infants are distressed. Malatesta et al. (1989) showed that unusual responses such as maternal joy or surprise to infant anger or sadness predict toddler preoccupation with attempts to dampen negative affect (compressed lips, frowning, sadness). We construe these patterns as “failures of facial empathy.”



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Beatrice Beebe vocalization



A key feature of the vocal exchange is a turn-taking structure. Both partners contribute to turn-taking by matching the brief “switching pause” as turns are exchanged. Mothers contribute by slowing their speech rhythms, providing a great deal of repetition, and matching the intonation of the infant’s sounds. Vocal contours refer to the “shape” of the sound. Across cultures, a sinusoidal shape indicates approval and a rightward falling shape disapproval (Fernald, 1993). Mothers also optimally pause sufficiently to give the infant a turn. On the one hand, mothers who prattle continuously do not permit this; on the other hand, mothers who are silent partners can disturb the development of vocal turn-taking, an essential building block of language. When infants present for treatment with difficulty in sustaining mutual gaze and the face-to-face encounter, matching the infant’s vocal contours and rhythms can be an effective way to make contact with the infant. Because the infant does not have to orient or to look, approximately matching the infant’s rhythms (vocal or motoric) is a non-intrusive way of helping the infant feel sensed: someone is on his “wavelength.” vocal rhythm and the prediction of attachment: the midrange model Security of attachment as assessed at 12 to 18 months is a key milestone in the infant’s development. In the Ainsworth “Strange Situation” attachment test, mother and infant go through periods of free play, separations, and reunions (Ainsworth, Blehar, Waters, & Wall, 1978). Based on the infant’s reactions, individual infants can be classified as having a secure, insecure-avoidant, insecure-anxious-resistant, or disorganized attachment style. The secure infant can easily be comforted by mother and return to play, using mother as a secure base while being able to explore the environment. The insecure-avoidant infant shows little distress at separation, avoids mother at reunion, and continues to play on his own. The insecure-anxious-resistant infant is very distressed at separation, but cannot be comforted by mother’s return and does not easily return to play (Ainsworth et al., 1978). The insecure-disorganized infant simultaneously approaches and avoids the mother, such as opening the door for her but then sharply ignoring her. The mother herself acts frightened or frightening, and typically has a history of unresolved loss, mourning, or abuse (Lyons-Ruth et al., 1999;



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Main & Hesse, 1990). In contrast, secure attachment at 1 year is associated with better peer relations, school performance, and capacity to regulate emotions, as well as less psychopathology in childhood and adolescence (Sroufe, 1983). Disorganized attachment at 1 to 2 years is associated with oppositional, hostile-aggressive, fearful and disorganized behavior, low selfesteem, and cognitive difficulties in childhood (Lyons-Ruth, Bronfman & Parsons, 1999; Jacobson, Edelstein, & Hofmann, 1994). Over 50 studies have shown that the security of the child’s attachment to the parent is dependent on the emotional availability of the parent, using global assessments and clinical ratings (see van Ijzendorn, 1997 for a review). Nevertheless, we still lack a full understanding of the origins of attachment, its modes of transmission, and the role of the infant (and infant temperament) in this process. Fewer than a dozen studies have used microanalysis of videotape to predict attachment outcomes. Although infants typically vocalize only about 10% of the time at 4 months, vocalization is such a central means of communication that the way mothers and infants coordinate their vocal rhythms predicts infant attachment. Jaffe, Beebe, Feldstein, Crown, and Jasnow (2001; Beebe et al., 2000) predicted 12-month attachment outcomes from 4month vocal rhythm coordination, assessed with a technique that samples behavior every quarter of a second. As each individual shortens or elongates the durations of sounds and silences, how tightly or loosely does the partner coordinate with adjustments in his or her own sound and silence durations? Midrange degrees of mother-infant and stranger-infant coordination at 4 months predicted secure attachment; very high and very low degrees of coordination predicted insecure attachment classifications. This work led us to conceptualize interactive regulation on a continuum, with an optimal midrange, and two poles defined by very high (excessive) or very low (withdrawn) monitoring of the partner. High coordination increases the predictability of the interaction, construed as a coping strategy elicited by the uncertainty or threat experienced by both mother and infant. At the very low pole of coordination, both partners are behaving relatively independently of the other, interpreted as a withdrawal or inhibition of interpersonal monitoring. Although much research literature concentrates on the concept that lowered interactive coordination is a risk condition for infant development, a substantial body of work examining both high and low poles is now converging on an “optimum midrange model”



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as well (see Belsky et al., 1984; Cohn & Elmore, 1988; Lewis & Feiring, 1989; Malatesta et al., 1989; Sander, 1995; Roe, Roe, Drivas, & Bronstein, 1990; Leyendecker et al., 1997). In our vocal rhythm study, very high mother-infant bi-directional coordination predicted insecure-disorganized attachment, the most problematic of attachment classifications. We interpreted the high coordination on the part of both partners as vigilance, arousal, or hyper reactivity. Our research film of Clara at 4 months dramatically illustrates a very disturbing mother-infant pair with very high vocal rhythm coordination; subsequently, at one year, Clara was classified as showing disorganized attachment. In the research film, Clara is crying and flailing as the interaction begins. Mother excitedly repeats her name. Clara’s crying rhythm and mother’s rhythmic repetition of her name synchronize. Mother flashes big smiles at Clara as she synchronizes with the cry rhythm, as if attempting to “ride” high negative arousal into a more positive state. Both escalate, Clara screaming more loudly, mother now frantically vocalizing and moving Clara’s arms. Although most mothers would back off, this mother just keeps going, and each partner continues to “top” the other. By the end Clara has thrown up, sobbing and writhing. In addition to vigilant vocal rhythm coordination, this interaction illustrates “mutually escalating over-arousal,” a disturbance of the ability of the dyad to manage the infant’s distress. The optimum midrange model has direct clinical relevance. Vocal rhythm coordination is an important means of attachment formation and transmission. Whereas the midrange dyad retains more variability and flexibility, the tightly coordinated dyad is less flexible and variable. Too much predictability in the system may compromise flexibility and openness to change; too little may index a loss of coherence (Beebe et al., 2000). These concepts can be used in mother-infant treatments as a framework with which to evaluate interactive difficulties and the process of change, in any modality (not just vocal rhythm), as we do in the first case described below. The Key Role of the Face-to-Face Interaction An ongoing NIMH-funded study in our lab has examined maternal self-report depression and anxiety at 6 weeks and 4 months, motherinfant face-to-face interaction at 4 months, and infant attachment at 12 months, in a community sample of 132 families (Beebe, Jaffe, Chen, Cohen, Buck, Feldstein, et al., 2003). Maternal depression and anxiety at infant age 6 weeks or 4 months did robustly affect patterns



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of self- and interactive regulation at 4 months, but did not predict infant attachment outcomes at 1 year. Instead, it was the quality of the 4-month mother-infant face-to-face interaction itself that predicted infant attachment outcomes. The implication is that, in a community sample, distressed maternal states of mind at 6 weeks or 4 months do not necessarily lead to insecure infant attachment outcomes unless there is also difficulty in the face-to-face interaction. This study provides a further rationale for therapeutically supporting the quality of the mother-infant face-to-face interaction when mothers are distressed, which may then prevent later insecure infant attachment outcomes. Such an effort is currently underway with the 9/11 widowed mothers and their infants, using brief videotape-assisted clinical interventions (Beebe et al., 2002). self-regulation From birth onward, self-regulation refers to the management of arousal, the maintenance of alertness, the ability to dampen positive or negative arousal in the face of over-stimulation, and the capacity to inhibit behavior (Beebe & Lachmann, 2002). Neonates differ in their ability to regulate state (see for example Korner and Grobstein, 1977; Brazelton, 1994). Infant temperament patterns, including sleep, feeding, arousal difficulties, or special sensitivities to sound, smell, or touch, are an important area of inquiry in the treatment (see DeGangi, Di Pietro, Greenspan, & Porges, 1991; Greenspan, 1981; Korner & Grobstein, 1977; van den Boom, 1995). Disturbances of infant self-regulation can be noted in patterns of autonomic distress (hiccupping; vomiting) and disorganized visual scanning, as well as pulling the hair or ear, or a history of head-banging (Tronick, 1989). Although maternal touch is a primary means of soothing a distressed infant, and extra handling is associated with diminished irritability (Korner & Thoman, 1972), some infants with difficult temperaments do not tolerate a great deal of touch (see DiGangi et al., 1991). By the time infants are assessed in the face-to-face situation, typically at 3 to 6 months of age, state regulation has stabilized and fluctuations in the management of an alert state have receded with maturation of the nervous system. At this point it is difficult to distinguish between infant constitutional processing difficulties that may have existed at birth from problematic interactive patterns. Infant temperament and self-regulation are already intertwined with interactive regulation difficulties (see also Hofacker & Papousek, 1998). For this



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reason, infant self-regulation is both a property of the individual and of the dyad. A study from our lab using second-by-second microanalysis of videotaped face-to-face interactions showed that 4-month infants who would be classified as insecure-avoidant at 12 months were already distinctly different from infants who would be classified secure (Koulomzin, Beebe, Anderson, & Jaffe, 2002). These future “avoidant” 4-month infants showed: (1) more self touch; (2) the necessity to self-touch while looking at mother in order to look for durations comparable to those of secure infants; (3) decreased range of facial expression, with constriction toward a predominance of neutral; (4) a disruption of the capacity to coordinate gaze and head orientation into a stable posture while smiling, so that infant gaze at mother occurred while head was “cocked for escape”; and (5) more “labile” behaviors (lasting one second), in contrast to “stable” (lasting 2 seconds or more). This study describes infant self-regulation patterns that are directly useful for identifying infants who are at risk for avoidant attachment. An examination of the mother’s contribution to the interactive process is planned. distress regulation Dyads show important differences in infant ability to manage moments of heightened distress, and maternal management of infant distress. Both partners bring capacities to soothe and dampen as opposed to escalate distress. Obviously the mother has greater range and resources in this process. The pattern of “mutually escalating over-arousal,” where each ups the ante, was illustrated above. In contrast, an effective form of distress regulation is a partial or loosely coordinated “joining” or matching of the infant’s fuss or cry rhythm, with “woe face” and associated vocal “woe” contours (vocal empathy). In this process, the rhythm (but not the volume or intensity) of the crying is matched, and then gradually slowed down (Beebe, 2000; Gergeley & Watson, 1997; Stern, 1985). the stranger as partner Identical to our research lab assessment, in our treatment cases mother and infant first play face-to-face, followed by infant and stranger. The stranger-infant interaction has been shown to be a sensitive predictor of infant attachment outcomes (Jaffe et al., 2001) and to discriminate treatment and control dyads (Weinberg & Tronick, 1998). Before the end of the first year, when some infants de-



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velop “stranger anxiety,” the stranger is both a novel challenge and at the same time an intensely interesting new partner. On the one hand, most 4-month infants are very sociable with the stranger, to the point where often the stranger has an initial advantage over the mother. On the other hand, some infants are wary with the stranger, for example the infants of the treatment dyads in Weinberg and Tronick’s (1998) study. We assess the infant’s capacity to engage the stranger and, if the interaction is stressful with the mother, the infant’s ability to “repair” with the stranger. The degree to which the stranger feels at ease with the infant vs. feels “wary” or needs to be “careful” not to over-arouse the infant is also noted. Psychoanalytically Informed Video Feedback “Mother-infant treatment occurs at a unique intersection of implicit ‘procedural’ (repetitive action-sequences) and explicit ‘declarative’ (symbolic) modes of processing, and it fosters a greater integration between the two modes” (Beebe, 2003, p. 34). Three orienting questions organize our approach: (1) In the procedural bi-directional “action-dialogue,” how does each individual’s patterns of behavior affect those of the partner? (2) In the declarative mode, can the parent verbally describe any of the ways in which he or she affects the infant, and the ways in which the infant affects the parent? (3) Are there ways in which the parent’s representation of the infant, and the parent’s own childhood history, may interfere with the ability to perceive the action-dialogue and to put it into words? In the initial contact I usually have a long telephone conversation with the parent. I explain my videotape approach and my preference that the first meeting be a lab visit, because I can “see” more with the aid of the videotaped interaction. However if the parent prefers, I start with an office visit. In the lab, infant with mother, father, stranger, and possibly nanny are videotaped in face-to-face interaction. The format of the lab visit for a treatment pair is identical to that for a research pair. The parent is instructed to play with the infant as she or he would at home. Each lab visit is followed within a few weeks by a two-hour feedback session in my psychotherapy office. This treatment format is extremely flexible. If a brief treatment is indicated, two to four lab visits and accompanying feedback sessions may be adequate, as in the first case presented below (see also Beebe, 2003). If a longer treatment is indicated, the same basic method is applicable. Or, in the case of a more serious situation, two therapists



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may easily collaborate, one proceeding with a standard individual treatment, and one functioning in the role of the consultant for the video feedback consultations (see Cohen & Beebe, 2002). An Ainsworth attachment test, coded by someone blind to the infant’s status, is usually included in each treatment, somewhere between 12 and 18 months. A long session, usually two hours, greatly facilitates the work of the feedback session. I have reviewed the videotape in detail prior to the session, informed by the patterns of regulation documented by research microanalyses, described above. In the session I follow the parent’s lead, attempting to construct with the parent the “stories” of the presenting complaints and the parent’s own history. This initial psychoanalytically informed conversation is a critical background to our ability to understand the “story” that unfolds in the videotape. Other important aspects of the parent’s history usually emerge during or after watching the videotape together. (It is extremely rare for a parent to refuse to view the videotape. In only two of approximately 50 cases that I have seen have a parent refused. In those cases I understood the refusal as an index of the level of trauma, and I simply used my own microanalysis to inform the interventions.) In viewing the videotape I attempt to translate specific details of interaction patterns revealed by microanalytic research into terms that the parent can use, based on a psychoanalytically informed view of the meaning of the parent’s complaints in relation to his or her own functioning and history, and based on my understanding of any temperament or arousal-regulation difficulties the infant may have. Viewing a small portion of videotape, often at the beginning of the interaction, usually is sufficient. Nonverbal interactions are highly repetitive, and similar patterns can be discerned over and over. I consider that one of my most important functions is to admire the parent-infant pair wherever possible. Bringing into awareness the ways in which this dyad already “finds” each other, enjoys each other, copes with disruptions, and negotiates repairs, is itself a powerful therapeutic intervention. My first goal is to point out a successful moment, using this example as an entry into learning to observe the small micro-moments of the interaction. Together we view the videotape slowly, trying to see exactly when and how and in what sequence each partner oriented, looked, cooed, smiled, or increased a smile by opening the mouth or reaching the head forward. I try to help the parent identify the exact moments where the parent responds to the infant and the infant responds to the parent. My goal is to give



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the parent “new eyes” to see the infant’s remarkable nonverbal language, and the infant’s ability to respond to minute, but nevertheless identifiable, behaviors. Together we try to describe what we see, finding a “new language” for their exchange as well. I encourage the parent to put into words what he or she is feeling, and what the infant may be feeling. Very likely I will play this positive portion several times, at least once in slow-motion. As we proceed I illustrate how evocative minute infant facial expressions can be, moments when the parent matches the infant’s vocal contours, how the parent paces and pauses, facilitating the infant “taking a turn.” I note infant self-regulation and self-soothing behaviors, and ways the pair manage moments of infant distress, as they occur in the interaction. Having studied the videotape in detail in advance, I will also have selected one or two central difficult interaction patterns that I would like the parent to be able to see. Together we try to observe the effects of each partner’s behaviors on the other in these difficult moments. I again inquire into what the parent felt, what the parent thinks the infant felt, and the meaning these moments have for the parent. It is here that the parent is likely to have a spontaneous insight into the problem. Being confronted with the implicit “action-dialogue” in the videotape often triggers the parent’s associations to aspects of his or her history that the parent always “knew” but could not productively use in the current context with the infant. Wherever possible I like to use research findings, illustrating with a drawing, to help parents understand the infant’s behavior, shifting attention away from “the right way to do it” to infants’ remarkable capacities. I emphasize what this particular infant needs to stay optimally engaged. My role is often to give permission to do less, to slow down, to wait. For example, with an infant who easily becomes overaroused and irritable, I suggest slower rhythms, more repetition, longer pauses, and more “waiting” when the infant looks away. I attempt to link the “stories” of the presenting complaint, the video drama, and the parent’s childhood history, in an effort to understand what may interfere with the parent’s ability to “see” the infant and the interaction. When specific representations of the infant (or “transferences”) seem to interfere with the parent’s ability to “see” the infant and how each partner affects the other, they are identified. At the end of the session the parent is encouraged to trust what has been learned, and to try not to be too self-conscious. Another videotaped assessment is scheduled in another month or two.



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Beatrice Beebe The Case of Cecil may: first contact



In my first contact with Mrs. C. over the phone she told me that she had an eight-year-old son and a 9-month-old baby boy, Cecil. The older son had always been easier and had seemed to match the mother’s temperament. This second baby had been different from the beginning. “He is a friendly baby, but he is not focused on me when I play with him. Cecil looks past me, unless I energetically try to engage him. He seems happier by himself. He seems more connected to the babysitter than to me.” Mrs. C. thought that perhaps Cecil needed a higher level of stimulation. Or perhaps she herself had disturbed the relationship initially, she wondered, by talking to her older son while nursing Cecil. Or maybe she had never given Cecil sufficient eye-contact and intimate engagement during nursing. The first consultation occurred in my office. Mrs. C. was warm, friendly, and seemed quite relaxed. Cecil made very good eye contact with me, with excited positive affect, and even had moments of a “gape smile.” The mother then took Cecil, tried to play with him face-to-face, and could not get Cecil to engage. Cecil never even looked at her. Mrs. C. said this was typical. Mrs. C. then tried a peek-aboo game, putting the blanket over Cecil’s head. As the blanket came off, there was a moment of brief eye contact, but Cecil emerged from the blanket momentarily dazed, with a sober look. He then smiled at his mother briefly, and looked away. My suggestion in this initial meeting was that although the peek-aboo game did have a moment of “built-in” eye contact, it did not seem to engage Cecil. Instead of trying to force more contact through high arousal games, I suspected she would have more success if she followed Cecil’s lead for eye-contact, letting him go when he looked away, and waiting until he initiated gaze before trying to engage him. I explained that looking away is the baby’s natural method of re-regulating his arousal when it has become a little too high. We agreed to do a split-screen lab videotaping, so that I could try to see more of the details of the interaction. From what I could observe in the office, I had difficulty understanding in more detail why the infant was so avoidant with his mother. june: first lab videotaping, cecil 10 months In the lab mother and infant were asked to sit face-to-face, with the infant in a high chair. The standard instructions to the mother are to



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play with the infant as she would at home. One camera is focused on the mother’s face, and one on the infant’s face, producing a splitscreen view, in which both partners can be simultaneously observed. In my microanalysis of the face-to-face play interaction, I observed that the mother continuously gave Cecil toy after toy. Microanalysis of First Two Minutes of Mother-Infant Interaction In the opening moments of the interaction, mother shook the toy toward Cecil, with abrupt, rapid movements, each accompanied by a strong sound, “gheh!” At each maternal movement, Cecil blinked, with mild startles. Mother then moved into, “What’s that!” showing the toy, making a series of “ooooh” sounds, and Cecil’s face showed a hint of a smile. As mother continued with, “Say hello, dolly, hello, Cecil, hi, baby,” Cecil’s face showed a hint of a slight mouth opening, and then receded into his more characteristic neutral expression, as if the stimulation was just a bit too much for him. After a brief interruption to get the seating and the camera angles right, Cecil briefly glanced at his mother with a neutral face, and then looked down. While he was still looking down, mother asked Cecil to look at the toy, but Cecil stayed with his head down. Then mother made an interesting noise, “gurooom!” and got Cecil’s attention. Cecil responded with his own “ghum!” There was then a repetition of the earlier series of mother’s rapid movements shaking the toy toward Cecil, each accompanied by a strong sound. At each Cecil blinked. Cecil then looked down and away, then shifted his body and hung over the side of the chair, limp. We have come to view such loss of postural tonus as a coping strategy in the face of overstimulation. While Cecil was still hanging over the side of the chair, not looking, mother found a new toy, and offered it with a “sinusoidal” shaped vocal contour (the contour of approval and flirtation): “Hello, Cecil; and do you know what else?” This vocal contour is usually reserved for greeting, once eye contact has already been made. It was successful in getting Cecil to look at mother, and to pay attention to the new toy, as mother continued, “Look what’s here, the dolly, look at her, look at her.” However, just at this moment, Cecil’s face took on a negative frown expression, and he looked down, moved his head down, then averted, moved his head farther down, and then uttered a fussy sound. Finally he gave up body tonus and collapsed his head into his stomach. Simultaneously with the collapsing tonus mother said, “Hello, Cecil” and gently tapped Cecil on the head with the toy. Cecil’s head collapsed further into his stomach.



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This is a detailed description of approximately the first two minutes of the interaction. At a more global level of description, in the rest of the ten-minute session there were nice moments of mutual gaze, and some interest on Cecil’s part in the toys mother offered. However, often without pausing in her movements, or sounds, mother offered Cecil another toy, and yet another. Periodically Cecil continued to collapse, into his stomach, or over the side of the chair, and mother gently tapped him on the head with the toy. When the play was more successful, there were nice long strings of vocal exchanges, and the mother beautifully matched the contours of Cecil’s sounds. Several times Cecil showed intense interest and vocal excitement in a toy, and mother joined the excited sounds. However, Cecil did not smile. When Cecil became fussy, started to cry and shake his body, mother offered more toys. Overall, Cecil was low-key, with his face mostly neutral. Occasionally there were some moments of eye contact, and some nice low positive moments. Mother showed excellent capacity for vocal rhythm matching, facial mirroring, and following the infant’s line of regard to an object of interest. But she did not give the baby a chance to respond, or to organize an interest in the toys on his own, and thus she disrupted the baby’s initiative. She also disrupted the baby’s arousal regulation, over-arousing the baby by never pausing, offering one toy after another, and then “chasing” the baby when he averted gaze. I understood Cecil’s difficulty with eye contact and the restriction of his facial expressiveness toward neutral as the baby’s attempt to reduce his arousal toward a more comfortable range, but at the expense of the social engagement. Toward the end of the ten-minute interaction, Cecil began to get fussy. Mother took a rattle and began to shake it, further increasing the intensity of the stimulation. Cecil got even fussier, orienting away, averting gaze. Mother then called to Cecil in the “sinusoidal” vocal contour usually reserved for greeting. Cecil did not respond. By the end Cecil was openly protesting the level of stimulation, very fussy, throwing to the floor all the toys that mother handed him, while mother never paused. stranger-infant interaction Following the interaction with mother, I played with Cecil for three minutes, while the mother watched the interaction over a TV monitor from another room. The infant’s ability to engage with a trained novel partner is a critical aspect of the assessment. Those babies who



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can “repair” the engagement with a novel partner are generally more resilient, whereas those who generalize the difficulty to a novel partner are in more difficulty (see Field et al., 1988). In evaluating this interaction, I noted that my tempo was noticeably slower than that of the mother. I waited for Cecil to look at me before I attempted to engage him. When he did look, he quickly smiled broadly. But then Cecil became fussy. When I handed Cecil a toy, he quickly threw it on the floor, and this was repeated over and over. In the process, Cecil was very physically active, turning around in his chair a lot. Eventually Cecil began to bang his own body gently against the seat, as if to both self-stimulate and self-soothe. There were then a few moments of eye contact with me, with midrange positive affect, but these were very brief. Each brief gaze encounter was followed by a sequence of immediate averting, mild negative facial expression, looking down on the floor at an object, and then hanging limp, sideways over the chair, body tonus collapsed. Each time I waited, and he came back into the engagement on his own. Once he looked, he became slightly excited, with a positive expression, and then immediately became negative and averted, looking down. My overall impression was that he easily over-aroused. On the other hand, he had the capacity to re-engage on his own when I waited. july: video-assisted intervention A two-and-a-half-hour period was set aside to meet with the mother to discuss how things were going and to review the videotape. The mother had already watched the tape and she felt bad. She realized that she was “trying too hard” and it was not working. She saw me as smoother, quieter. I suggested that as we watched the tape, we could try to make quite specific just what she was doing when she felt she was “trying too hard.” My own goal was to help the mother notice exactly what she did, and exactly what the infant did, as each responded to the other. In essence, I wanted to give her new “eyes,” a new ability to observe the details of interaction. In this process my goal was to help her confirm what she did quite beautifully, which elicited the response from the baby that she wanted, as well as to notice what did not work for her baby. I admired her facial empathy, her vocal responsiveness, and her well-modulated vocal contouring (see McDonough, 1993). She was quite surprised when I pointed out the infant’s blinks and startles at the beginning of the interaction, in response to her abrupt movements with the toys. She was also surprised to see me point out very subtle facial expres-



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sions of slight mouth openings, hints of shifts in cheek tonus, which can be expressions of interest and involvement, even when the infant is not smiling. We succeeded in defining the mother’s “trying too hard” as lack of pausing in movement or voice, trying to get the infant’s attention when he was turned away, and calling the infant in a “greeting” contour at moments when the infant was clearly not receptive. I told Mrs. C. my hypothesis that Cecil dampened his face, lowered his arousal, averted gaze, and turned away, as self-regulation strategies in the face of feeling over-stimulated. Mrs. C. then told me that her own mother was rigid, controlling, distant, and quite depressed, although she had managed to work. Her mother was never attuned, had never been able to sense Mrs. C.’s feeling state as a child, and never knew “where she was at.” Mrs. C.’s mother had “set the pace,” irrespective of where she was emotionally or what she needed. And now Mrs. C. could see that she was doing the same thing with Cecil—setting the pace, and setting it too fast for him. We then discussed my description of Cecil’s face as too neutral, and I showed her again a section of the videotape illustrating it. I reenacted for her the face I saw in the baby. Mrs. C. said that all of a sudden she saw Cecil’s face as like that of her own mother, who had always appeared impassive, hard to read, hard to reach. She saw that she now felt the same way about Cecil—that Cecil was hard to read, hard to reach, like her mother. And she saw that she would become anxious, and try harder with Cecil, as she had when her own mother had been so difficult to read. In this interaction, the mother’s ability to “see” Cecil’s “too-neutral” face seemed to be facilitated by watching the videotape as well as watching my own entry into the baby’s neutral face. Now “seeing” Cecil’s neutral face seemed to trigger her procedural “motor memory” of her own mother’s face. Together we saw how understandable it was that she could be treating Cecil the way her own mother had treated her by setting the pace, and that she could be seeing Cecil as like her own difficult and removed mother. We both empathized with how hard it must have been for Mrs. C., as Cecil seemed to become more and more un-readable. How natural it was to keep trying harder, as a way of reaching him. And how counterintuitive it was to lower the stimulation, to “try less hard,” to be slower and calmer, to wait, just when she was feeling more and more desperate to reach Cecil. We both felt sad over Mrs. C.’s own difficult childhood, and the aspects of it that entered into her interactions with Cecil. But as we



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parted we both felt encouraged by understanding what the difficulty was. Mrs. C. felt very positive about the experience, and stated that she thought she could shift what she was doing with Cecil now. I suggested that she try to trust herself with what she had learned, without becoming overly self-conscious or self-critical. We agreed to do a follow-up split-screen videotaping and an Ainsworth “separation test” in a couple of months. august: second filming, 12 months There had been a long wait in the lab, and technical difficulty delayed the beginning of the filming. Even without such delays, sitting in a high chair for ten minutes is hard for any active 12-month toddler. Once we got started, there was no sound track for a couple of minutes. In evaluating the interaction, I observed that the mother was slower and softer, and she paused in between her movements and her vocalizations. Cecil made more eye contact, and it was more sustained. The mother did not push toys at Cecil; instead Cecil himself took a toy and explored it, and mother was able to wait. There was clearly more room for Cecil’s own initiative. Microanalysis of First Two Minutes of Mother-Infant Interaction As the videotape began, Cecil was tired. He had been there a long time, waiting for us to get going. Without the sound in this section, we see Cecil rocking his body back and forth in the chair. Mother then rocked her own body a bit too, matching the rhythm. Mother then showed Cecil a doll. Cecil concentrated on it, while mother held it quietly. After a few minutes, Cecil lost interest, and mother showed him another toy. Cecil took the toy, held it close to his body, explored it, again while mother waited quietly. Then there was an interruption at the door. Mother was told that the sound was now working, and was asked if she wanted to continue the filming. We agreed to continue. The interruption disturbed Cecil, and now he very much wanted to get out of the seat, holding his hand up in an appeal to be picked up. The mother was gentle, slow, and held him, but without taking him out of the chair. Mother made a “woe face,” joining the infant’s distress, and was very sorry that Cecil couldn’t get out yet. Cecil collapsed into his stomach, fussing, and mother matched the distress sounds. Mother then tried some puppet play, moving the puppet very slowly, and Cecil briefly engaged. Then Cecil was distracted by the sound of the camera moving, and mother joined his line of regard, explaining the noise. Cecil then made another bid to get out,



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and mother joined Cecil’s vocal distress with similar sounds, and held him close. Describing the rest of the session, at a more global level, after a few minutes mother did a peek-a-boo game, covering Cecil’s face with her hands and saying, “where is Cecil?” This time the quality was totally different: slower and very successful. Cecil emerged smiling, and sustained the positive affect. Then Cecil was briefly quiet, and mother waited. Cecil then heard the noise of the camera again, and mother joined his line of regard, and waited. Now Cecil wanted to get out again, and this time I stopped the filming after seven minutes. There was nothing the mother did in this second filming that seemed to interfere with the infant’s capacity to play and to respond. stranger-infant interaction We then attempted a stranger-infant filming, but Cecil would have none of it. He cried loudly, angrily, and threw any toys on the floor. Three different attempts by me to play with Cecil had to be aborted, since he was crying hard. Finally we organized a set-up in which Cecil sat in mother’s lap, and mother was instructed to “be the chair,” not to help or respond. For the first five minutes of the interaction, Cecil was disengaged. He was silent, made no eye contact, and every toy that I tried to engage him with was immediately thrown on the floor. However, at some point he finally made a vocalization, a “spit” sound. Immediately I matched this sound. And right away he looked at me and made another, similar one. All of a sudden the whole tenor of the interaction had changed, and we were engaged in a fascinating vocal dialogue. As we continued to match and elaborate on each other’s sounds, at some point Cecil began to move his tongue as he made the sounds, and it came out as “la-ler, la-ler.” He was intensely visually engaged. I tried making the “la-ler” sound, and we both burst into big smiles, and giggled. Variations on this rich vocal dialogue continued for the next four minutes. Cecil had been enormously responsive to my matching his vocalization. Since this form of engagement does not require the child to be visually engaged, it can potentially provide a less intrusive or demanding means of making contact. His own willingness to elaborate on the jointly formed patterns was critical to the success of the dialogue. Toward the end of the interaction Cecil began to be tired. Although he had been having a spirited, at times elated, turn taking di-



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alogue with me (as he sat in his mother’s lap), when he began to get tired, he arched away into his mother’s body, and avoided me. But then he was able to keep coming back to me, and to continue the rhythm of the vocal exchange. These movements away from me were his own self-regulatory efforts to manage his arousal within a comfortable range. The success of his self-regulation efforts could be seen in his continuing ability to re-engage me, in cycles of vocal dialogue, disruption, and then repair (see Tronick, 1989; Beebe & Lachmann, 1994). This aspect of the interaction with me was used as part of the therapy. It was a demonstration of a way to make contact without forcing, intruding, or chasing. It also vividly showed the power of vocal rhythm matching in making contact, since the child does not have to make eye contact. This laboratory filming ended with a brief discussion with the mother that her interaction with Cecil was going extremely well now. We made a decision not to pursue the attachment test since the visit had already been too long. Cecil was doing well, and all we needed to do was to watch to be sure he continued to be fine. follow-up contacts September A telephone conversation: “Things are just great. We were on vacation for three weeks and we had a lot of time to spend . . . I totally relaxed with Cecil. I got to know him better. I stopped my agendas, stopped comparing him to his brother. He is a delightful baby; we are just charmed by him, he is now so social. I had seen this side of him from time to time, but now it has really come out. He is more bonded with me too, he wants mommy only. He seems terrific. I’m enjoying how different he is from his brother. November A letter: “You have played an absolutely pivotal role in my life. . . . To begin with, Cecil; our connection is deep and easy and full of joy. He is an absolutely delicious, funny, charming, very loving little person. . . . you helped me relax and see him; I stopped focusing on who he was not and on how he and I were not. . . . So, having discovered Cecil, I fell in love with Cecil. No surprise. . . . In retrospect, my feeling of self-reproach was based on some accurately sensed stuff. I intuitively knew that I was not being with him or being emotionally re-



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sponsive to him anywhere near as much as I can be. Now I am, and let me tell you, the difference is not minor.” discussion of the c. case We return here to the theme that parent-infant treatment occurs at a unique intersection of implicit and explicit modes of processing and fosters a greater integration between the two. Our three orienting questions provide a framework for conceptualizing the treatment: (1) In the implicit mode of action-sequences, how does each partner affect the other? (2) In the explicit narrative mode, can the parent verbalize the nature of either partner’s effect on the other? (3) And does the parent’s representation of the infant interfere with the ability to perceive the nonverbal action dialogue? From the presenting complaints it is clear that parents are aware of some aspect of the infant’s behaviors, and particularly ways in which the infant affects the parent, such as, “my baby does not smile at me,” or “my baby does not look at me.” But it is harder to observe one’s own behaviors which affect the infant. Often various representations of the infant disturb this process further. Addressing the infant’s impact on the mother, Mrs. C. could observe as well as verbalize that her infant often did not look at her, or smile at her. When asked how she would respond to this, however, Mrs. C. was vague: “I try harder,” or “He needs more stimulation.” Addressing the mother’s impact on her infant, Mrs. C. had not been aware of the specific behaviors that we were able to describe together, for example, rapidly moving into the face, not pausing, continually offering toys. Identifying these specific behaviors enabled Mrs. C. to observe the moments in which they influenced the infant to disengage, for example, to startle, look away, collapse into the stomach, or inhibit initiation with toys. We were able to identify some of the “transferences” to the infant that seemed to disturb Mrs. C.’s ability to observe and verbalize both sides of the bilateral effects of each partner on the other. She acted like her own mother, who had “set the pace,” and her infant seemed to act like Mrs. C. had as a little girl, that is, to “withdraw.” Her own “setting the pace” behaviors (not pausing, continually offering toys) were out of her awareness. Mrs. C. was aware that her infant was withdrawing from her, but she was not aware of how similar her infant’s behavior was to that of her own in childhood. Thus she and her infant had “re-enacted” an aspect of her own history, the mother who sets the pace and the child who withdraws.



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Similarly, the infant seemed to act like Mrs. C.’s own mother, since the infant had an “impassive” face, neutral, impossible to read, which reminded Mrs. C. vividly of her own mother’s face. Mrs. C.’s response to her own infant’s impassive face was very similar to her response to her mother’s face when she had been a little girl, that is, to become anxious and to try harder. Presumably the similarity of this interaction with ones in her childhood interfered with Mrs. C.’s ability to see that her “trying harder” was just pushing her infant farther away from her. These transferences were identified in the process of watching the videotape. Being presented with the procedural level of action sequences which are out of the mother’s awareness, presumably because they are connected to painful childhood experiences, facilitates the mother’s ability to see, and to remember. The mother is being asked to make a unique integration of procedural and declarative information, in an arena that has been out of awareness due to some kind of unresolved pain. This work allows the mother to shift her representation, for example, from the baby rejecting her, to the baby as over-stimulated and attempting to dampen his arousal. The optimum midrange model of regulation described above is useful as a framework for evaluating the progress of the treatment. At the outset of the treatment, Cecil could be described as preoccupied with self-regulation (looking away, showing lowered level of arousal, constricting the range of the face), with lowered levels of contingent coordination with mother’s behaviors through facial, visual, and vocal behaviors, and with his initiative shut down, body collapsed. Mother could be described as a “high coordinator,” very contingently responsive to the infant’s every move, with excellent facial-mirroring and vocal rhythm matching, but interacting with levels of stimulation that were too high, with patterns that were spatially intrusive, that disturbed the infant’s initiative. Following the videotape intervention, the mother was able to move from high- to more “midrange” coordination, less vigilantly responsive to every infant move. She was able to pause more, do less, wait, tolerate the infant’s disengagement without “chasing,” tolerate the infant’s distress, and give the infant space to initiate play. Moments of matching were interspersed with “waiting” for the infant’s own moves (of self-regulation, or initiative), so that they did not seem “excessive,” or imposed. The infant for his part shifted from a “low-coordinator” and became more “midrange” in his level of contingent tracking of the mother, more midrange in facial responsivity with both positive and negative expressions rather than a predominance of



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neutral, more visually engaged, and much more active in initiating play with objects. The Case of Nicole The case of Nicole is a useful counterpoint to the Cecil case, which illustrates mild maternal intrusion coupled with some temperament and arousal regulation difficulty in the infant. Nicole, on the other hand, illustrates a maternal “absence of provision.” Because this family was from a distant city, and I happened to be traveling nearby, the mother-infant pair was not evaluated in my lab, but rather in an office, and they were only seen in person for one extended three-hour evaluation, together with a number of follow-up telephone consultations. Since the problem turned out to be an absence of intimate engagement, rather than a complex misregulation of engagement between infant and mother, it was a case in which a detailed videotape evaluation was luckily not essential. In the Cecil case, I was not able to detect the problem without the videotape microanalysis. In the case of Nicole, knowledge of the microanalysis research was nevertheless essential to the treatment. Mrs. N. was referred by her therapist, who described her as an anxious new mother, strongly involved in her hard-driving career. Mrs. N. had become worried that her five-month-old baby was not as responsive to her as she was to the Nanny, and she had requested a consultation with an infant “expert.” The therapist suggested that Mrs. N. probably had difficulty giving focused attention to her daughter because she had never gotten much herself. The first contact was a telephone session. Mrs. N. felt “disconnected” from her daughter. She described feeling crushed when she arrived home to see her daughter laughing and giggling with the Nanny, but Nicole would not even look at her. “I’ve been going 100 miles per hour all day, and Nicole has been with someone laid back with nothing to do but to be with her. I take Fridays off, and it takes her quite a while to warm up. My husband does not think it is anything to worry about. But what will it do to her in the long-term? I feel like she does not love me, that I’m not good as a mother, I’m not as natural as the Nanny. How much I need her love. I envisioned a different reaction to me. She smiles more to my husband and the Nanny than to me.” “I have never seen myself as a mother. I was little ‘Miss Career.’ My mother was domestic, but she resented it. We were toys and dolls to her. Now I want to pick back up the domestic side, but it does not



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come naturally.” I commented that evidently she did not have a model of what it would be like to really enjoy one’s child: her mother resented children and domesticity. It was very understandable that it would be hard for her to learn. “I don’t measure up to the Nanny; she knows exactly what to do. I don’t mind if she loves the Nanny, but I want her to love me more. It’s my nature to be doing three things at once. Instead of being able to relax, and take the time to be with her, I’m on the phone. I tell myself, this is her time, don’t pick up the phone.” As she told me this, I sensed the rapid clip of her speech. I commented on how aware she was that she needed to try to relax and slow down to be with Nicole. “I don’t like myself when I am with her. I feel like my mother when she’s running around like crazy and can’t get organized.” I said that evidently she had learned to be like her mother in this, and perhaps it had been a way of being close to her own mother. But now she’s not so happy about it, and she’s trying to help herself change it. We then discussed exactly what happens when she comes home from work. She nurses Nicole when she comes in, but the infant will not look at her. “Maybe it’s because I always had the phone in my ear when she was nursing. Have I hurt her now? Can it be fixed? Would I have had a better relationship with her if I had been different? She did not deserve a mother like me.” And then she cried. I empathized with her agony over feeling that she had disturbed her relationship with Nicole. I told her how important it was that she had taken the step of calling me, and that she was struggling to find a way to slow down to be with Nicole. She lamented that she did not do it right, and that she had been stupid. I said that we needed to find a way of re-righting this without blaming. She responded that I had a beautiful voice, and that she felt smart for trying to get help. The second contact was a three-hour consultation with the mother and baby. Although the father came as well, he declined to be involved. This was the only contact in which I actually saw them in person because of the extremely long distance involved. Nicole at 5 1/2 months was a big girl, and heavy. Mrs. N. propped her up at one end of the couch with a toy. As she was settling Nicole in, the infant’s body arched away from her. Mrs. N. then sat at the other end of the couch. I pulled up a footstool and sat halfway between the two of them. The baby played with the toy, putting each different part of it in her mouth, quite placid and self-sufficient. She never looked at her mother or at me, nor did she look around the room, while her mother talked to me about her work schedule and her dilemma of work vs. home life.



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Nicole then needed her diaper changed. She had a large bowel movement. Mrs. N. was gentle, solicitous, and managed it well. Now Mother and Nicole were together on the couch, and Mrs. N. showed me a “pull-to-sit” game that she plays with Nicole, a game that her friend had taught her. The baby clearly knew the game, anticipating the moves with her body, but she did not look at her mother, her face showed no animation, and at the last moment before attaining the sitting position, her head oriented up and 30 degrees away from the vis-à-vis. Mrs. N. then held Nicole lying across her lap on the infant’s back. This was the nicest connection they made, slow, both bodies relaxed, both looking at the other, but without smiling. Mrs. N. then began to talk about how terrible she felt: “Have I hurt her, what will be the effect, will she know her own mother, should I stop working?” She cried during most of this discussion. After about an hour, I suggested that we start to see how we could help her engage Nicole more. I said that I did not think the issue was the amount of time that she worked, as much as finding a way to make a connection with Nicole. I explained that first I needed to play with her to try to see her range of responsiveness. Nicole chortled, with high positive affect, sustaining long gazes with me. She was marvelously socially engaged. From this interaction it was clear that the difficulty was not an incapacity on the part of the infant. Evidently, the social engagements with her Nanny and her father were going well. I then set about trying to teach Mrs. N. how to engage Nicole. The first thing I taught her was vocal rhythm “matching,” making sounds contingent on the baby’s sounds, both matching and elaborating on the intonation, pitch, and rhythm. I chose this first because the child does not have to make eye contact in this mode of relating. Mrs. N.’s sounds were thin and squeaky. She did not give the sounds a robust prosody, she could not elaborate on them, and she did not put any words to the sounds. She did not seem to know how to play. I coached the sounds from the sidelines. Eventually the sounds she made were adequate to make some contact with the baby. Nicole oriented to her a bit more, and returned some of Mrs. N.’s sounds with her own, beginning a rudimentary vocal dialogue. But Nicole did not look at her mother. Noting how flat her face was as she interacted with Nicole, I then tried to teach Mrs. N. facial mirroring, by having her roughly match some of my faces (gape smile, mock surprise). I tried to get her to move her face in ways similar to the ways I moved mine (small increments of open mouth, open a little more, then a little more; moving



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the upper lip in and out of a purse etc.). She was unable to play with her face; her face was tight, flat, and unvarying. I then had the idea of showing her how to unlock her jaw, and how to massage her face. I asked her if she would be interested in trying this. She agreed. In this process she had an association to her mother’s angry, tight face, and she became a little teary. I suggested that her reaction to her mother’s angry face was expressed in her own facial tightness and constriction. She was receptive and felt sobered by this idea. The attention to the behavioral details of the procedural level, particularly the constriction, seemed to trigger her representation, which we could then address and elaborate at the symbolic level. We then moved to an attempt at face-to-face interaction between mother and baby. At first Nicole was very gaze avoidant and her whole body arched away from her mother. The infant made absolutely no eye contact. Gradually I taught Mrs. N. to slow down and to make some slow rhythmic sounds, and to do vocal rhythm matching if Nicole made any sound. When the infant would give her a darting glance, I taught her to give an exaggerated mock surprise greeting. The instant the infant looked away, I taught her to “cool it.” Nicole began looking a bit more. We spent quite a while at this. By the end of the three-hour session Nicole showed some brief partial smiles to her mother. The gazes were not sustained. But Mrs. N. had a direct, powerful experience of getting some more response from her baby. She could see that she was getting somewhere. She expressed relief and gratitude that I had validated that something was wrong. I reminded her of the many things that were right as well: she had a very gentle and affectionate capacity to hold Nicole and to feed her, she did have some games she played with the infant, and most of all, she wanted more contact with her. Ten days later we had a telephone session. “Now I make it totally Nicole’s time when I get home. If I can slow down, we can connect better. By the end of the week I feel totally disconnected from her. When the Nanny leaves, she is used to her. I have to be careful: I expect her to demonstrate affection and attachment. When I don’t get it, I get worried. Sometimes she does not make any sounds, so I can’t mimic her.” I asked her if she could start it with occasional sounds of her own. “My husband can walk in the room and connect with her right away. He is like the Pied Piper. It is hard for me. I feel bad that I don’t connect the way he does. If I don’t get a lot of feedback, I feel unliked.” I asked if there was then a danger that she would feel rejected and withdraw. She agreed, yes, very much. She then reported that Nicole is not as avoidant as she was: “She looks at me, she



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watches, though she does not smile. She can concentrate on my face though, that’s new.” She told me that Nicole was right there with her, looking at her face right now. I suggested she try a mock surprise expression right now, and she did. I waited a moment while Mrs. N. played with her. She reported that Nicole looks but she does not smile. “She will watch me now if I do interesting things with my face. But I noticed that if I’m tense I close my face up.” I said that it was wonderful that she was trying to engage her child with her face, and that Nicole was clearly beginning to respond. I congratulated her on becoming so aware of her own face, and able to notice when she closes it up. “When Nicole looks at my husband, she gets this glow; will it always be this way? In the morning I am terrible with her. I’m trying to get ready, I’m in a hurry, and I do a dancing conversation in front of her face, all speeded up.” I commented on Mrs. N.’s increasing ability to notice what she does and to see if it is disturbing Nicole’s ability to connect with her. She then asked, “Have I lost my chance? When I left you, I felt so bad, and angry; I missed my chance. I should have stayed home and not worked.” Without waiting for me to respond, she immediately told me that Nicole was looking at her right now, and Mrs. N. began to make sounds. We practiced the “sinusoidal”shaped “hello,” she and I saying it to each other, and she reported that Nicole was looking constantly at her while she made the sinusoidal sounds. Then I asked her about feeling angry. She said that she was angry her husband wasn’t encouraging her to quit work, and she was angry that no one had been agreeing with her that something was wrong. She felt that finally I had validated her. “I would be devastated if I do not have a good relationship with Nicole. She lights up for my husband. She is so responsive to the Nanny. But what you are saying to me is, it’s not too late for me to connect. I’ve never felt so insecure in my life.” I empathized with her fear and distress. Then I told her how terrific it was that she was holding on to her hope to connect with Nicole, and that she and I could both see progress. A telephone message two weeks after the initial three-hour session in person: Mrs. N. was canceling our tentative appointment to see each other in person because she and Nicole were doing so well: “I am getting so much feedback from her, I am relaxing a little. She smiles more, looks more. I don’t feel crazy anymore. All of a sudden she has started really vocalizing. The biggest thing you said was, focus on her. When I’m with her, I’m just giving her all my attention.” A telephone session one month after the initial three hour session



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in person: “She’s wonderful, she’s happy, she’s more vocal, more expressive, she’s really relating to me. Occasionally we have a bad evening. But I’m more comfortable around her. I may be doing more of her language. I try to slow it down for her. If I’m rushing, I notice it. Then I just hand her to the Nanny, because I don’t want her to sense it. I imitate her sounds, but not all the time. If she initiates, and I respond, and make it even bigger, then she laughs.” I tell her how wonderful all this is, how thrilled I am that things are so much better. “I think we’re doing a lot better. When I come home, I get a greeting. She looks, she smiles, she kicks.” Then she asked me if it was a mistake not to come for a second consultation in person, and I said no, I didn’t think so, because things were going so much better. We agreed that she would call me if she had any more concerns. She thanked me profusely. I told her that it was so remarkable how quickly she and Nicole were able to turn things around. discussion of the n. case This pair illustrates an absence of maternal provision of the usual “infantized” facial and vocal behaviors that engage infants in face-to-face play. Presumably the more adequate “provision” of the Nanny and the father had to this point safeguarded the overall social development of Nicole. The mother’s frozen face and inhibition of maternal “play” behavior required me to figure out how to get the actionsequences going, how to “prime the pump.” Mrs. N.’s immediate transference to me in the first telephone contact as having a beautiful voice set the stage for me to “provide” something that seemed to have been absent for her. By teaching her specific ways of engaging the infant, that is, vocal rhythm matching, vocal contouring, facial mirroring, and “cooling it” when the baby looked away, it is possible that she experienced a “provision” from me. I was also admiring of her willingness to try these new behaviors, and of her increasing ability to engage Nicole, as she tried it, over the phone. The key to unlocking Mrs. N.’s capacity to mother Nicole was the discovery of her traumatic reaction to her own mother’s face, which was then “carried” in a procedural form through her inhibition of her own face with Nicole. In retrospect, the vocal modality proved to be easier for Mrs. N. to develop with Nicole. Since the vocal modality did not require Nicole to look, it was initially easier to reach Nicole this way. But Mrs. N. had also been so responsive to my voice, from the very first contact, and she carried on most of her relationship



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with me over the telephone. It may be that the voice was a “non-traumatized” mode for Mrs. N., compared to the face (M.S. Moore, personal communication, August 18, 1999). Discussion Many different approaches to mother-infant treatment yield dramatic progress (see for example Cramer et al., 1990; Fraiberg, 1980; Seligman, 1994; Stern, 1995) (but note that controlled clinical trials are rare). Although the use of video feedback is growing, three decades of microanalysis research on the mother-infant face-to-face exchange is surprisingly under-utilized in current treatment approaches. Microanalysis of behavior allows us to perceive the details of interactions which are usually too rapid to grasp with the naked eye. These details provide the clinician with the ability to translate the parent’s presenting complaints into specific behaviors which can then be understood as an unfolding “story” of the relationship. With the additional perspective of the dyadic systems view of communication (despite the mother’s obviously greater ability and range of resources) the clinician can continually attempt to understand how each partner contributes to the exchange, how each affects the other. And the clinician can notice how the self-regulation strategies and styles of both partners affect and are affected by the nature of the interactive exchange. With this perspective, for example, negative interactions such as “chase and dodge” or “mutually escalating over-arousal” can be seen as reciprocally responsive co-constructed forms of engagement. This systems view helps us remain empathic to how each partner is affected by the other. However, video microanalysis of the interaction from a systems view can only richly set the stage for the treatment. A clinician’s sensitive ability to construct jointly with the parent a description of the exchange, to help the parent use the behavioral details of the video drama as a springboard for memories and associations, and to link the stories of the presenting complaints and the parent’s own history to the video drama, form the core of the treatment. The clinician’s careful attention to the parent’s self-esteem, particularly feelings of shame and humiliation, is essential. The video feedback method does not disturb the dyad while they interact. Later, when the parent and I view the videotape, it is simultaneously “immediate” and visually concrete, as well as somewhat “distant” and safer, in that it is not happening right now (Lefcourt, personal communication, July 7, 1998). In the video replay we can



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concentrate on a particular modality, and slow it down, whereas in the live interaction all modalities, as well as words, flood the senses. Since the visual information speaks on its own, the therapist is free to emphasize different aspects, to underscore the positive elements as well as identify derailments (Tabin, personal communication, September 10, 1998). Because the mother is usually so motivated to engage her infant, she can make an effort to overcome any natural awkwardness at seeing herself. We rarely know what we really look like as we interact. Seeing oneself on videotape may operate like a “shock” to the unconscious, “perturbing” the system (Milyentijevic, personal communication, June 26, 1998; Kohler, personal communication, October 23, 1998). This “shock” may be part of the emotional power of the video feedback method. The therapeutic viewing promotes a capacity to observe oneself in interaction, to think about the emotions seen in the video, and to reorganize representations (Beebe, 2003, p. 45).



Both parents in the two cases presented felt that the treatment validated their sense that “something was wrong.” Mrs. N. was able to persist in trusting her discomfort even though her husband did not think there was a problem. This vague discomfort is the parent’s ability to sense the impact of the implicit procedural mode and enables the parent to seek treatment. But the meaning of this discomfort is not usually recognizable without help (Tabin, personal communication, September 10, 1998). Procedurally organized interactive memories that are unrecognized and unsymbolized often come to play a role in shaping the action-language of our intimate interactions as well as the representations of our intimate partners. The psychoanalytically oriented video feedback method goes directly to the core interactional dynamic that is out of awareness and provides a safe format in which this dynamic can be verbalized and reflected on. The parent can become more aware of the infant’s “mind” as well as her own (Fonagy et al., 2002). In this process implicit, procedural aspects of the parent’s mode of relating to the infant which have remained out of awareness can be translated into explicit, narrative forms of understanding.



BIBLIOGRAPHY Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, N.J.: Lawrence Erlbaum Press. Bakermans-Kranenburg, M., Juffer, F., van Ijzendoorn, M. (1998). Interventions with video feedback and attachment discussions: Does type of



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maternal insecurity make a difference? Infant Mental Health Journal, 19 (2), 202–219. Beebe, B. (1973). Ontogeny of positive affect in the third and fourth months of the life of one infant. Dissertation Abstracts International, 35 (2), 1014B. Beebe, B. (1982). Micro-timing in mother-infant communication. In M. R. Key (Ed.), Nonverbal communication today. Series Edited by Joshua Fishman, Contributions to the sociology of language. Volume 33. New York: Mouton. Beebe, B. (2000). Co-constructing mother-infant distress. Psychoanalytic Inquiry, 20, 421–440. Beebe, B. (2003). Brief mother-infant treatment using psychoanalytically informed video microanalysis. Infant Mental Health Journal, 24 (1), 24 – 52. Beebe, B., Jaffe, J. & Cohen, P. (2002). Support groups and video-bonding consultations for mothers and infants of 9–11. Manuscript, NYSPI, April, 2002. FEMA Liberty Fund; Robin Hood Foundation. Beebe, B., Jaffe, J., & Lachmann, F. (1992). A dyadic systems view of communication. In Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 61–81). Hillsdale, N.J.: Analytic Press. Beebe, B., Jaffe, J., Lachmann, F., Feldstein, S., Crown, C., & Jasnow, J. (2000). Systems models in development and psychoanalysis: The case of vocal rhythm coordination and attachment. Infant Mental Health Journal, 21, 99 –122. Beebe, B., Jaffe, J., Buck, K., Chen, H., Cohen, P., Feldstein, S., & Andrews. (in press). Maternal depression at 6 weeks postpartum and mother-infant 4-month self- and interactive regulation. Infant Mental Health Journal. Beebe, B., Jaffe, J., Chen, H., Cohen, P., Buck, K., & Feldstein, S. (2004). Mother and infant self- and interactive regulation across modalities: A systems view. Manuscript submitted for publication, N.Y.S. Psychiatric Institute. Beebe, B., Jaffe, J., Chen, H., Cohen, P., Buck, K., Feldstein, S., et al. (2003). Mother and infant self- and interactive regulation and distress: Maternal distressed states of mind, mother and infant behavioral distress patterns, and infant attachment. Report submitted to NIMH, R01MH41675, November 1. Beebe, B., & Lachmann, F. (1994). Representation and internalization in infancy: Three principles of salience. Psychoanalytic Psychology, 11 (2), 127– 165. Beebe, B., & Lachmann, F. (2002). Infant research and adult treatment: Co-constructing interactions. Hillsdale, N.J.: Analytic Press. Beebe, B., Lachmann, F., & Jaffe, J. (1997). Mother-infant interaction structures and presymbolic self and object representations. Psychoanalytic Dialogues, 7 (2), 133–182. Beebe, B., & Stern, D. (1977). Engagement-disengagement and early object experiences. 1n N. Freedman & S. Grand (Eds.), Communicative structures and psychic structures (pp. 35 –55). New York: Plenum. Bennett, S. L. (1971). Infant-caretaker interaction. Journal of the American Academy of Child Psychiatry. 10:321– 335.



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Fogel, A. (1993). Two principles of communication: Co-Regulation and framing. In J. Nadel & L. Camaioni (Eds.), New perspectives in early communicative development (pp. 9–22). London: Routledge. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of self. New York: Other Press. Fraiberg, S. (1980). Clinical studies in infant mental health: The first year of life. New York: Basic Books. Gergely, G., & Watson, J. (1997). The social biofeedback theory of parental affect-mirroring. The International Journal of Psycho-Analysis, 77, 1181–1212. Gottman, J. (1981). Time-series analysis. Cambridge: Cambridge University Press. Greenacre, P. (1971). Emotional growth. New York: International Universities Press. Greenspan, S. (1981). Psychopathology and adaptation in infancy and early childhood: Principles of clinical diagnosis and preventive intervention. New York: International Universities Press. Hofacker, N., & Papousek, M. (1998). Disorders of excessive crying, feeding, and sleeping: The Munich interdisciplinary research and intervention program. Infant Mental Health Journal, 19 (2), 180–201. Hopkins, J. (1992). Infant and parent psychotherapy. Journal of Child Psychotherapy, 18 (1), 5–19. Isabella, R., & Belsky, J. (1991). Interactional synchrony and the origins of infant-mother attachment: A replication study. Child Development, 62, 373 – 384. Jaffe, J., Beebe, B., Feldstein, S., Crown, C., & Jasnow, M. (2001). Rhythms of dialogue in infancy (pp. 1–132) Monographs of the Society for Research in Child Development, 66, (2, Serial No. 265). Keener, M., Zeanah, C., & Anders, T. (1989). Infant temperament, sleep organization and nighttime parental interventions. Annual Progress Child Psychiatry & Child Development, 257–274. Korner, A., & Grobstein, R. (1977). Individual differences at birth. In E. Rexford, L. Sander, T. Shapiro (Eds.), Infant Psychiatry (pp. 69 –78). New Haven: Yale University Press. Korner, A., & Thoman, E. B. (1972). The relative efficacy of contact and vertibular- proprioceptive stimulation in soothing neonates. Child Development, 43, 443 –453. Landry, S. (1996). Effects of maternal scaffolding during joint toy play with preterm and fullterm infants. Merrill-Palmer-Quarterly, 42 (2), 177–199. Lebovici, S. (1983). Le nourrison, la mere, et le psychoanalyste: Les interventions precoces. Paris: Le Centurion. Lester, B. M., Hoffman, J., & Brazelton, T. B. (1985). The rythmic structure of mother-infant interaction in term and preterm infants. Child Development, 56, 15 –27. Lewis, M., & Feiring, C. (1989). Infant, mother, and mother-infant behavior and subsequent attachment. Child Development, 60, 831– 837.



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“What Is Genuine Maternal Love?” Clinical Considerations and Technique in Psychoanalytic Parent-Infant Psychotherapy TESSA BARADON



The question of what is genuine maternal love was posed by a mother struggling to understand and value the nature of her bond with her small baby. The question surfaced time and again in the context of this dyad’s long-term parent-infant psychotherapy and has challenged me to examine my thinking and, indeed, has produced impassioned discussions within the Parent Infant Project team at The Anna Freud Centre. In this paper I will address this question through sessional material of this mother and baby and discuss issues of technique in response to it, including my countertransference and conceptualization.



Trained in child analysis and psychotherapy at The Anna Freud Centre, London. Developed and manages the Parent Infant Project (clinical services, training, and research) at the Centre; practicing therapist and supervisor, and writes and lectures on applied psychoanalysis and parent-infant psychotherapy. Member of the Association of Child Psychotherapists and the Association of Child Psychoanalysis, Inc. The Parent Infant Project team—Carol Broughton, Jessica James, Angela Joyce, and Judith Woodhead—have provided valued collegial consultation during the course of this work and on the paper. I also want to thank Dilys Daws for her interesting comments. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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asked about her position on the different heuristic models of the mind, Anna Freud replied: “I definitely belong to the people who feel free to fall back on the topographical aspects whenever convenient and to leave them aside and speak purely structurally when that is convenient” (Sandler with Anna Freud, 1981). Parent-infant psychotherapy is a meeting point for the different disciplines addressing infant development: psychoanalysis, attachment, and neurobiological research. In facilitating our understanding of the ebb and flow of the therapeutic construction, Anna Freud’s advocacy of conceptual flexibility in the aid of clinical expediency is often helpful. The therapist working with young babies growing up in an environment of intergenerational deficits needs to understand the quality of mothering and the baby’s predicament. Psychoanalytic concepts of “good enough parenting” and maternal failure, attachment paradigms of “security” and “disorganization,” and neuropsychological discussion of relational trauma are useful frames of reference. Yet there is an additional ingredient to do with love, captured by the patient in her question: How can we integrate love into scientific and clinical discussion? “Genuine maternal love” for the mother who asked the question was defined by selflessness. My clinical work has convinced me that the love of a mother for her infant and of a baby for his mother needs both measure and passion. It contains the temperate—that is, regulated kernels of love and responsivity, and passionate appetite, ownership of the other and capacity to be consumed by the other. These latter rest upon the mother’s narcissistic love of herself in the baby, her adoration of “His Majesty the Baby” (Freud 1914), and her capacity to tolerate her hatred of her “bondage” to him (Winnicott 1949). Thus, her identification with her baby and yet her ability to differentiate between herself and her baby and allow individuation (Mahler et al. 1975) are required. Only then is the baby able to safely love his mother, in the sense of moving from relating to object-use (Winnicott 1969) and development of a sense of self as real. At the same time, “love” is not a static concept. In this paper I attempt to describe the development of this mother’s love, matched by changes in her baby’s expressed love for her, and the interventions that may have contributed to this process. “Maternal failure” in psychoanalysis refers to intrapsychic processes in the mother which violate their infant’s state of going-onbeing, such as projection and attribution resulting in distortion of self (Silverman and Lieberman 1999), failure to protect the infant from impingements (Winnicott 1962), inability to contain the infant



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through “maternal reverie” (Bion 1962). “Disorganized” attachment describes a collapse of adaptive strategy when the infant is frightened, seen to develop in the context of mother’s unresolved trauma and lack of reflective functioning thereof (Lyons-Ruth 1999, Fonagy 2001). “Relational trauma” depicts the neuropsychological disregulation of the infant in a situation in which danger emanates from the attachment relationship wherein the mother (a) disregulates the infant and (b) withdraws repair functions (Schore 2001, Perry et al. 1995, Tronick and Gianino 1986), leaving the baby in an “intensely disruptive psychobiological state” for extended periods of time (Schore 2001, p. 209). In this paper I consider those aspects of maternal “failure” and relational trauma that resulted from the mother’s inability to meet her baby with passion and reverie. This included the negation of herself in him, dis-identification with his state of dependency, and projection into him with consequent distortion of self and object boundaries and impingements on individuation. What is the experience of an infant within a primary relationship that fails to respond appropriately to his personal and intersubjective needs? From the observation of babies in this predicament, this maternal failure appears catastrophic. The infant patient, so dangerously dependent on his mother’s/caretaker’s capacity to identify and understand, expresses extreme anxiety, fragmentation and, finally, retreat. Because the anxiety is embedded in their relationship—often underpinned and driven by intergenerational patterns of relating—it is enduring. Therefore the concept of cumulative trauma (Khan 1963), the repeated breaching of the adaptive and defensive structures available to the immature ego, is pertinent. Extreme maternal depression can constitute a situation of relational trauma. Green (1986) discusses a situation where there is a mutative transformation of the mother from a live, vital presence to a dead detachment from her infant, and the trauma this inflicts on the baby. This is a particular situation where the infant has had an early period of resonance and lost it in the face of maternal loss and depression. But what of those infants who have been born, so to speak, into a relationship with a “dead mother”? The psychotherapeutic work informs us about the experience and the developmental endeavors of babies in this predicament. Psychically they display the “dead baby complex”—a decathexis of the maternal object and apparent identification with the dead mother (Bollas 1999). These babies lie slumped and blank. They seem careless of the maternal presence or non-presence beside them and appear non-present in their own bodies. Their precocious defenses of avoid-



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ance of emotional engagement with the mother, freezing and disassociation (Fraiberg 1982, Perry 1997, Schore 1994) put them in a state of unrailed/derailed development. I suggest that this was the predicament of the baby in the case to be discussed. Parent-infant psychotherapy intervenes in the parent-infant system to achieve the best accommodations that can be made between a parent and baby for the baby’s development. As an applied technique within the psychoanalytic framework it has its roots in the groundbreaking work of Selma Fraiberg and her colleagues (Fraiberg 1980, Lieberman and Pawl 1999). In recent years a model has been developed at the Anna Freud Centre (Baradon 2002, Baradon et al 2005, James 2003, Woodhead 2004), the defining feature of which is the use of the analytic mind to scaffold the affective experiences and representations of parent and infant in relation to each other. Intervening at the procedural as well as declarative levels of self organization, the aim is to create meaning through validating and cohering the parent’s experience and responding to the baby’s requirement for an attentive, adult mind to meet his developmental and attachment needs. In our model, the therapist straddles numerous roles in relation to her patients, both individually and collectively. She is a clinical “observer” (Rustin 1989), using observation as a mental stance and a technique to inform her understanding of the parent’s and baby’s (emergent) mental models of attachment relationships. She is, in parallel, an analytic therapist, employing psychoanalytic frames of reference and techniques in the work with what is manifest and conscious in the room and with the hypothesised unconscious fantasies and defenses underpinning these. Inevitably, she is a transference figure for the parent, sometimes benign but also at times perceived as hostile and/or persecutory. The therapist is a “new object” (Hurry 1998), offering a revitalizing attachment experience to parent and infant. As a new object for the baby, the therapist is also a “developmentalist,” supporting the infant’s development through providing contingent responses, stimulation, and regulation where the parent, at least temporarily, is unable to. In cases of severe maternal depression and withdrawal the therapist may also be the only “live company” (Alvarez 1992) for the child, providing the functions of “enlivening, alerting, claiming and reclaiming” (p. 197). Having the therapist to love, until the mother is able to receive and scaffold his love, may be pivotal for the baby’s psychic survival. And finally, the therapist is an external affect regulator of the patients’ disregulated



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states, particularly crucial in light of research suggesting that external regulation of the infant’s immature developing emotional systems during critical periods may influence the experience-dependent structuralization of the brain (Panskepp 2001, Cirulli et al. 2003). Parent-infant psychotherapy poses countertransference dilemmas particular to this method of intervention. Primitive emotions and projections are the fabric of infancy and parenting and invariably resonate with the therapist’s past and present attachments. The actual presence of an infant in the room intensifies the sense of immediacy and clinical (and of course legal) responsibility toward the baby. With at least two, and often three, patients present—infant, mother, and father—the therapist’s attention and receptivity are often pulled in different directions and her identifications may shift between the infant and parent, challenging the analytic stance. As always, the therapist’s countertransference is used and must be watched—her own hopes and despair, riven identifications between mother and baby, and her rescue fantasies. Above all, the therapist needs to maintain sufficient emotional resonance with the mother, in the face of the acute emotional pain and helplessness of her infant. Without this there is no way for mother to empathically recognize the real infant as opposed to the infant within her whom she often treats with cruelty. In the case under discussion, where the baby’s early attachment needs were thwarted by his mother’s failure to embrace him with “genuine” love, considerations of clinical process and technique were particularly charged. On the one hand, mother sought the ascetic and altruistic (A. Freud 1937) virtue of “genuine” love, devoid of all narcissistic investment and reward, and her severe depression was compounded by a sense of failing her own standards. On the other hand, her infant son was starved for the maternal appetite of ownership and adoration, and his experiences of going-on-being were distorted by her projections and hostility. These experiences of trauma for both baby and mother required ongoing scaffolding and regulation from me, the therapist, and I needed to be alert to the challenge to my capacities for “reverie” in my various roles and from within. Thus the matrix of intersubjectivity, transference, and countertransference was extremely complex. It raised minute-by-minute questions of technique. Which patient/what material should be privileged at any given time, and in what domain of relational knowing



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(Stern et al. 1998)—procedural (psychological acts) or symbolic (psychological words)—would the communication be most effective? Clinical Material Ms G was referred by her obstetrician just before her baby was due, with concerns about her depressive mood. A psychiatric report attached to the referral mentioned a long-standing history of eating disorders and self harm, and a number of attempted suicides requiring hospitalizations, the latest one year previously. Consequent upon the concern about this troubled young mother and her baby, a network of health and social service support was put in place. Ms G was in a stable relationship with D, the baby’s father. However, Ms G requested to attend without her partner, explaining that D reassured her that she is a good mother and that she needed her fears to be heard and not brushed aside. Although we ask to include fathers in the therapy where possible, I decided it was important to enable this mother to indeed be “heard” in her request and to explore the possibility of including the father after we had established a therapeutic alliance. In the course of the therapy father did become involved, but in this paper I will not discuss the work done with the triad. Mother, baby, and I met once a week for a period of two years. This paper focuses on the first year of therapy. tentative beginnings: mother, baby, and therapist In the event, although I was in telephone contact with Ms G from the time of referral, we only met 3 weeks after baby Ethan was born. A vulnerable baby, he had required special care in the early postnatal weeks and Ms G stayed in hospital with him. In the first session Ethan, still a fragile newborn, was asleep when they arrived. His painfully thin and pale mother sat sideways to me with her face averted. She spoke in a near whisper, her low voice and withdrawn facial expression camouflaging much of the terribleness of what she was saying. Ms G explained that she had never thought she would have children as she was afraid that she would damage them. I wondered whether at the same time as being afraid to have a baby she had also perhaps hoped for one. Ms G thought not. She explained that the likelihood of conception was low as she has irregular periods because of her eating disorder. I asked how she had felt in her pregnancy and she said she had not wanted it, and had continued smoking and bingeing.



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She had felt that the fetus was a parasite. She felt very guilty about this. I asked whether these kinds of thoughts were continuing. At this question Ms G became distressed, saying that she feels that she is “forced by him into an artificial position . . . of trying to be a good mother, who loves her child and takes care of him.” Ms G said she does not feel like that much of the time. She added that she would not harm him physically. Somewhere early in this conversation Ethan fretted a bit. Ms G immediately picked him up with extreme care and held him to her, his little body slumped against the palm of her hand. She checked with me whether she could feed him. She snuck him under her shirt, careful to keep her breast hidden. The “feed” was quickly over and Ethan went on sleeping. Ms G removed him from the breast and covered herself up. We spoke about attending parent-infant psychotherapy. I wondered what she was hoping to get. She replied that she wanted a “filter” so that her feelings don’t all come out on Ethan. I noted that I would not have been able to tell from her facial expressions and tone of voice when disturbing thoughts toward Ethan intruded during the session, and that from this I could tell that she was really trying to keep a tight grip on her feelings. Ms G reiterated her fear of damaging him through her depression as her mother, too, had been depressed and unavailable. I suggested that we would attend to both the good things that happen between her and Ethan, such as her gentle stroking of him that I had observed even when she was upset, and to her bad feelings and thoughts. Ms G hugged Ethan to her.



I felt that the central verbal and affective communication to me in this session was Ms G’s sense of being damaged herself and, through her very being with her baby, of damaging him. Her state of primary maternal preoccupation had a particular quality to it: hypersensitive to the baby via herself, it seemed that projection did not aid her to “feel herself into her infant’s place” (Winnicott 1956, p. 304) but that the infant was equated with her, as a disturbed extension of herself (King 1978). Moreover, his critical early hospitalization, in which her dread of damaging a child was actualized and exposed, seemed to have been a trauma which confirmed a psychic equation between her inner and external worlds (Fonagy and Target 1996; Target and Fonagy 1996). In turn, I experienced Ms G and Ethan, separately and as a dyad, as extremely fragile and needing both to be reached out to and to be handled with care. On the one hand, I struggled with my own need to establish some contact with her averted face, as I strained to hear her whispers. I felt responsible for her very life, as I imagine rescue workers feel in response to the sounds of life after disaster. In this



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process of projective identification I assumed the omnipotence attributed to the “caregiver” in relation to the infantile self. At the same time I was acutely aware of the danger-in-contact ricocheting between us during the session, manifested in her whispers and cautious handling of Ethan. My association was to a sea of shards in which any movement could be calamitous. Only later did I realize how her history of self-cutting had penetrated my subconscious. Thus, from the beginning this was a dyad with whom I engaged in an intense and worried way, responding perhaps to her unconscious invitation to assume this mantle. In the second session Ethan, now 4 weeks old, was awake, a tiny little thing with big blue eyes and a peaky face. Initially he slept on his mother’s lap, fists tightly clenched. Ms G stroked his hands but he did not relax his fists. A few times she pried them open and stroked his palms. Ethan’s eyes flicked open when he heard a door slam and he started crying. He seemed to move quickly into a loud cry, with no fretting or working up toward the upset. He cried hard. Ms G put him to the breast and he sucked, then fell asleep. She put him on the mat and he opened his eyes. I spoke to him about his experience being in a big room and hearing my stranger voice and not knowing where it came from. Ethan stared fixedly toward the ceiling lights above him. After a while he turned his head slightly in his mother’s direction, and I confirmed that that was where his mummy was.



As I observed this tense baby, I wondered whether there was heightened sensitivity to invasive stimuli (lights, noise), carried over from the weeks in the special care baby unit. I also wondered whether he was already reacting to the conflicted and disregulated quality of maternal emotion, transmitted and received through the ministrations of care. His ordinary going-on-being seemed to be punctuated with periods of disassociation—as expressed in fixing on the lights, and “falling forever”—as expressed in his urgent cries. Again my own emotional responses were strong. This time the pull was toward Ethan, so desperately in need of enveloping in maternal love. We had 6 more sessions over the following 6 weeks leading to the first break. The sessions acquired form and pace. Ms G sometimes looked my way and I found it less of a strain to hear her. Ethan moved between brief periods of wakefulness and prolonged periods of sleep. I found myself accommodating to their muted tone, characteristic of depressed mothers and their infants (Bettes 1988), by dampening my spontaneity, speaking slowly, riding the silences. But in-



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creasingly I also found my way to address the affects expressed verbally and in behaviors. Wary of the sadism of her superego and the masochism of her submission to it, I took care to acknowledge negative affect as conflictual, and positive interactions were noted without hollow reassurance that she was doing well. With Ethan I was relatively active, representing his mental states and communications, offering contingent responses, linking him up with his mother. I tried to balance offering myself to him for use as “live company” with awareness of Ms G’s envy of what she perceived I had to give Ethan, and which she had never received. At times indeed I felt rich in resources, but at other times I felt dull and drained. the meanings of dependency When I collected Ms G and Ethan, now 12 weeks of age, from the waiting room after the 2 week break, Ms G gave me a very quick glance of tenuous pleasure and then turned away with an avoidance of my gaze and bodily withdrawal. I felt I had become dangerous again during the break, even more so as I believed from her darting pleasure that she had missed me. Ethan woke up as she put him on floor beside her. He looked bewildered. We settled on the carpet and Ms G placed Ethan against her feet, facing me. I thought she was in some way offering him as a “transitional object” for reengagement. I adjusted my position so that Ethan could see my face directly. In so doing, I was also placing myself in Ms G’s range of vision should she chose to raise her eyes. I spoke to Ethan: “You’re not quite sure where you are, are you? . . . you haven’t been here for a while . . . have you?” He murmured. I asked him if it all right to wake up in this room now, and Ms G reminded me that the last time he was quite upset. I acknowledged this. Ms G asked Ethan if he wanted to sit down and placed him on her lap. I said, “that way you are with mummy and can still see me . . . and still give these gorgeous little smiles.” Ms G whispered, “yeh.” Ethan relaxed into her lap and looked back to me and made a gurgling noise. He gave a big smile and looked into my eyes for a few seconds, then looked away. Then he looked back, pursing his lips, and eventually produced a rolling sound. In a lilting voice (“motherese”) I to him, “It’s a little conversation, isn’t it?” His face opened and he smiled again, then looked away. I waited. After a few seconds he turned back to me. I said, “Are you ready to chat again? Hey . . . yes . . . yes . . . and when you’ve had enough you look away for a while, don’t you?” Ethan gurgled again. Ms G looked down at Ethan and said, “He can be quite coquettish, sometimes he turns his head



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Tessa Baradon and looks from the corners of his eyes.” I replied to Ethan, “mmm . . . hmm . . . I guess you’re taking a breather then, aren’t you, we adults do the same. Yah . . . Take a little break in a conversation, ah, otherwise it gets too much, doesn’t it?”



Ms G’s response to me in the waiting room suggested that the break had been experienced as an abandonment, in which I failed her as her primary figures had, and left her to struggle alone with disintegration. Yet, she allowed me access to Ethan (suggesting some goodness was retained) and through him, to herself. In talking to Ethan I was engaging in a process of emotional regulation through scaffolding his efforts at regulation (looking away) and placing them in the intersubjective domain. Using Ethan as a displacement, I could model for Ms G the process of ordinary, developmental selfand interactive- regulation (Beebe et al. 2003) in the pacing of an interaction. I was struck that the coquettishness she attributed to him in fact described her own conflict between engaging with me and withdrawing (e.g. when it “got too much”). Later in the session Ethan was sleeping, with Ms G stroking his head and hand. She related a visit by friends who played with Ethan. She asserted that he was happier when with them. I wondered whether she had felt the same when I was talking with Ethan earlier? Ms G prevaricated, “I couldn’t see the expression on his face so I don’t . . . he does smile at me, but he often spends a lot of time seemingly just staring at me with quite a pensive look on his face. . . .” I noted his looking to her earlier. She replied that she worried: “Should he be smiling at me more? Obviously he does smile at me and not something behind my shoulder that’s taken his interest.” I asked, “What are you like with people, do you carefully observe their expressions, maybe sensitive to what feelings they’re communicating towards you?” Ms G said that she was trained from an early age to be aware of what somebody’s going to need or want. I asked whether she was afraid sometimes of what he might see in her face. Ms G answered slowly, “I’m sure . . . that . . . that in my face there’ll be the ambivalence that I often feel towards him . . . or my own difficult feelings that may have nothing to do with him.”



In my experience, a mother questioning her baby’s love for her is attributing her own conflicts to the baby. Ms G’s fear that Ethan already preferred the company of others seemed multilayered, containing the fear of his rejection of her, a projection of her wish to get away from him, and the rivalry with him over me. At this point I was unsure whether words alleviated or intensified her conflict and I also felt that the urgency of Ethan’s need for her was overriding. I, there-



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fore, chose not to follow the route of interpretation and simply commented that he had been looking at her. Ms G was able to make use of my validation of Ethan’s desire for her to express her conundrum—can she allow personalization: “Should he be smiling at me more?” This offered an opportunity to explore what Ethan might be avoiding. I learned that Ms G habitually scanned the object for their affective communications/demands and that, since Ethan’s needs and wants evoked her hatred, it felt dangerous for him to look into her face/mind as he may see those emotions in it. I was aware that she had not related to Ethan for some length of time and asked whether she was feeling ambivalent about Ethan there and then in the session? Ms G said she was not sure . . . perhaps her instinct was to touch him but she did not want him to feel smothered by her. She wondered if she is not perhaps too disengaged with him. I suggested that, on the contrary, I thought she was very engaged with him but that she is protecting him from the toxicity that she felt was passed to her by her mother and which she fears she may pass to Ethan. Ms G nodded. She said she wanted to make it clear that her mother did the best she could at the time and added that of course she feels that it wasn’t good enough. I rushed in too quickly at this point, saying that perhaps in her attempts to protect Ethan she was keeping a distance between them that prevented them from spontaneous exchanges, such as laughing and playing together. Ms G replied that Ethan may in years to come experience her as in a state of severe depression or absent from him. Almost under her breath she murmured that if she were to leave through dying she would not come back. Ms G was quite tearful and picked Ethan up, caressing him. Then she said that she is not sure whether she’s holding Ethan because he is a soft, comforting thing . . . and she put him down on the floor, on his side facing away from her, and at a distance. He sucked hard on his hand and just lay there, looking into space.



The whole interaction was extremely painful as baby and mother seemed quite unable to come together. The essential elements of adoration and appetite for the baby were missing from Ms G’s love. It seemed that his dependency, need, and desire for her resonated with the representation of him as parasitic during pregnancy—depleting her of self-hood. The transference to Ethan was thus of a consuming object like the mother of her childhood. This dilemma is likely to have been accentuated by her feelings of abandonment by me during the break. In an identification with the aggressor (myself), feelings of dependency and need in herself and in her baby were denied. At the same time, Ms G cared intensely that her child should not experience the maternal toxicity or disappointment in the object that



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she suffered. In this way, distancing him was an act of love as well as cruelty. Ethan, to my concern, veered between disintegration and precocious defense. I felt caught in the middle and responsible for the devastation, as though during the break the therapy had replicated the hollow maternal stance—the offer of dependency withdrawn. Thus my maternal “best” was in fact toxic also for Ethan via the impact it had on his mother. Certainly my “too quick” response contained a veiled criticism (also reversing the attack on me): in protecting Ethan from damage you are in fact killing off a live relationship. Obviously, I may have responded from the countertransferential reserves of my own tetchy narcissism. We also know from clinical experience that past relational trauma can be reproduced in the present therapeutic situation, in the transference-countertransference transactions. Yet I think I was also “nudged” into the patient’s unconscious wish-gratifying role (Sandler 1976), as Ms G went on to speak of Ethan’s (and of course my) possible future loss of herself. The habitual solution to overwhelming dependency and inevitable disappointment was destruction of self and object. With my therapeutic goods thus spoilt, resonating her emptied state, I was unable to protect Ethan, who was put down and away from us. As he lay rigidly on his side looking into space, I felt I was witnessing his emergent identification with the dead mother (Bollas 1999)—a kind of dying in situ. good enough loving and impingements “I am trying to understand,” said Ms G two months into treatment, “what is genuine maternal love?” She feared that when she did experience maternal feelings it was because of her “delight in his need (for her)” and that, therefore, her “motives are suspect.” She weighed her gratification about his complete dependency on her against her wish to walk away. “I have to keep asking myself what is this about? Is it about me? About Ethan?” She dismissed my suggestion that it may be about both of them, and I commented on her fantasy that the ideal mother is selfless. Ms G confirmed this ascetic representation of the genuinely loving mother and said that the “ideal mother could understand all the baby’s needs,” thus rearing “emotionally, mentally and physically strong children.” She said she was humbled now when she saw others managing to do this. Ms G’s repudiation of gratification as a constituent of the maternal bond could be traced to her grievance with her mother, past and pre-



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sent, in which she felt “used” by her mother for her own narcissistic needs. Moreover, she held her parents responsible for her damaged mental state and, even as an adult, had no real sense of volition to modify the childhood feelings of helplessness. Yet, despite the relentless grip of the past, I observed her handling of Ethan extend to more animated exchanges. Ethan responded to these tentative “protoconversations” with widened eyes, excited kicking, and large smiles. He seemed to gain efficacy as a partner; for example when he lost her attention he would call her back by looking at her and cooing. When I pointed this out, Ms G said that friends visiting had commented that Ethan’s eyes followed her wherever she is—tracking her voice when he could not see her. As the months progressed the sessions felt safer, more predictable, encompassing a broader range of feelings, allowing Ms G to offer less ambivalent parenting and Ethan aspects of “good enough” relatedness, and thus also development. Indeed, during this period in the therapy, there were times in the sessions in which Ethan was a contented little baby. However, these quiet periods of regulated positive affect were also the backdrop to rapid transition into states of inconsolable crying. I noted that sometimes Ms G reached out to Ethan, and he, in the process of being attended to, became distressed. His tiny body became rigid and he clawed at his mother’s body. At such times Ms G moved through a repertoire of feeding, winding, rocking, walking—seeming to act promptly and contingently to effect “interactive repair” (Tronick and Weinberg, 1997). Four months into treatment. Ms G raised the question: Why is it so hard to soothe Ethan? Was he damaged at birth, would another mother get it right? I tried to explore with her what happens to her when he cries. Ms G confirmed that she gets very upset. I suggested that sometimes Ethan’s cries feel like her own. Ms G became tearful and then reprimanded herself for not always acting the adult with him. I said that when they are both crying she no longer feels the mother. I also spoke about the rage that she feels when he triggers her pain. Ms G whispered that she feels so guilty and ashamed.



Thus, it was becoming clearer the extent to which Ethan was the barometer of her own emotional state. When his needs did not resonate with her own conflicts, Ms G was able to respond. Unpredictably, however, his ordinary infantile needs could trigger or link in with her own volatility. This is another aspect of relational trauma— where the quality of affective communication with the baby imparts trauma from the mother’s internal world to that of the baby.



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Through the most careful observation of their affective interaction and of my own countertransference, I came to understand a particular quality of interaction that was perilous to both. Ethan’s cries retraumatized Ms G as her own unconsoled state as a small child came flooding back. At this point he became the frightening child to his mother, re-evoking her own disorganized attachments (Main and Hesse 1990). Unconscious conflict then permeated her ordinary maternal ministrations of feeding, changing, and soothing, and Ethan was disregulated by his mother’s care. Balint (1992) describes this as “unconscious communication”—direct communication between the unconscious mind of a mother and her infant, in which the baby perceives and internalizes aspects of the mother’s life of which she is herself unaware. And just as the meaning of her own affective state was unrecognizable to Ms G, so Ethan’s communications could not be understood and contained. Their distress ricocheted between them, escalating to the point of collapse. What could I model in the sessions in terms of a holding response? (session continued) . . . When Ethan got restless I spoke to him. He responded with attentive pleasure. At one point he cooed extra loudly and drowned out Ms G’s soft voice. I said playfully, “I couldn’t hear your mummy there, do you mind!” Ethan kicked gleefully in response to my crooning voice and smiles at him. Ms G became very tearful. She said it was the ease with which I relate to Ethan and she has to try so hard. I thought that addressing her envy would undermine her further, but perhaps she was ready to perceive his desire for her. I therefore asked what could help her recognize the cues from Ethan about good things he gets from her. Ms G’s face became very tense. I felt I had suddenly frightened her. I wondered whether Ethan’s love and dependency were difficult to recognize? Perhaps because she could not have these experiences as a child, as her mother was too depressed to be able to tolerate such feelings in her? Ms G whispered she did not want to repeat what had been her experience. I said that I thought she was struggling between her wish for Ethan to have a better experience and her fear of recognizing her importance in this and thus his dependency on her. Ms G said forcefully that other people’s dependency on her was enormously difficult. By this time Ethan was fretting and I wondered whether he needed his mummy again. Ms G sat Ethan between her legs and he looked at her. I said to him that he had called his mummy and she had gathered him up. Ethan sucked and chewed on his mother’s fingers. This was the first time, I think, that he did not have a feed in the session.



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felt diminished by this, I was in a conundrum: to embrace the one seemed to be a rejection of the other. It was as though I had to experience the possibility that only one of the dyad could survive. If I was unconsciously being faced with the choice between them I, equally unconsciously, resisted it by replacing Ms G as the object of her son’s love. Perhaps I hoped that Ms G would allow herself the experience of Ethan’s giving her pleasure and making her proud. Because she was more able to respond to cues of distress but not those of joy in relation to her, he was missing out on swathes of exchanges around emotional sharing, crucial for his development (Stern 1985, Trevarthen 2001). Indeed in this sense Ms G was not able to facilitate Ethan’s development as an “emotionally, mentally, and physically strong child.” Yet, as the therapy progressed, it seemed that by my modeling more playful exchanges with Ethan while emphasizing my “notmother” status, Ms G was sometimes able to respond contingently and offer herself to be used by him. separation-individuation In the course of a longer-term therapy the infant naturally moves from a state of total dependency on the mother toward the beginning of separation-individuation. This offers opportunity to work with the mother’s conflicts as they impact on her baby at each developmental phase. In the treatment of Ethan and Ms G there were hints from the beginning that separation, like dependency, was an area of extreme difficulty. Ms G’s history held no personal experience of moderated separation, only that of violent, mutually destructive rupture. The risk for this dyad was that separation-individuation would plunge mother into narcissistic despair and rage. Sleeping and feeding were ubiquitous arenas for expression of conflicts over separation in Ms G’s history and were, perhaps inevitably, the areas in which the conflicts were played out with Ethan. In the early weeks Ms G reported that Ethan would fall asleep only when lying on her chest. This meant that any movement of his woke her up. She moved Ethan to his Moses basket at her side, but kept vigil through the night. She recalled childhood fears of the dark and of sleeping alone and felt unable to tolerate Ethan’s cries when put into a cot. At the same she felt driven to madness and despair by lack of sleep. D, with his own difficulties in this area, was unable to offer support, and soon Ethan was restored to the parental bed. Ms G’s chronic insomnia was thereafter channeled into nightime rumina-



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tions as she waited for dawn so as to escape from the bed to a strong coffee and cigarette. With Ethan waking hourly, sleep disturbances became woven into the conflicts around feeding and weaning. Ms G repeatedly expressed her feelings that feeding was the sole good thing she could give him and admitted her gratification that only she could provide this. However, these feelings also came into conflict with her experience of his dependency as depleting. In the sessions I observed feeding encompass many regulatory functions, so that Ethan was put to the breast when he cried, when he was tired, when they were both at a loss as to play. With feeding used to meet such a variety of situations, it became difficult to tell when he was hungry. At around 5 months of age, Ethan’s weight began to drop and professional concerns about failure to thrive emerged. Medical opinion moved toward supplementary feeds, with a bottle also offering a possibility of respite from the hourly feeds at night. Ms G came under increasing pressure to achieve some measure of weaning. Her internal split was thus effectively externalized, with the medical network and her partner now carrying for her the thrust for forced separation, while she maintained the ubiquitous place of breast-feeding. It seemed important that at that point I did not ‘know’ what would be best, and held neither a wish for Ms G to wean nor for her to continue feeding. During this period, Ethan 6 –9 months, many threads in the therapy seemed to coalesce around the question of closeness versus distance and the losses implied in each. Week by week Ms G described her dread of the long days with Ethan while D was at work. She felt mired by his wish for her presence, for example crying when she left the room, and her inability to let him cry. She said that before Ethan was born she spent much of the time alone. I wondered if that was her way of keeping her emotions on an even keel and she confirmed this. I suggested that having Ethan with her all the time meant that she has no means of regaining her “emotional balance” (her words). Thus the closeness was experienced as loss of self, provoking rage. Getting away was a relief at that level, but it also brought with it the fear that she could disappear from their lives and it would not matter. As Ethan became more mobile he could initiate movement toward and away from his mother. 7 months into treatment. I noted how Ethan seemed to want to be close to her today. Ms G said she did not know if she wanted him close or not. She said her guilt at not really wanting his “relentless”



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closeness makes her try harder. I then witnessed this as Ms G finally allowed Ethan—who had been struggling for a while to get into her lap—to find a place there. He crowed and cooed and bounced. From the outside their little “reunion” seemed pleasurable and yet Ms G was talking about times when she feels she cannot go on. I asked whether those were times when she harmed herself. She was silent. Ethan seemed to get extremely boisterous in her embrace— sucking on her arm and blowing raspberries. He appeared to be both kissing and biting her and I said this to him. My thought was that they both moved between intimacy to destructiveness with confusing rapidity and that, despite being with them, I could not tell what felt good and what bad.



It is interesting that at age 8 months, when biting could be considered as a normal expression of desire (incorporation) and/or exploration, I attributed destructiveness to Ethan’s biting of his mother. Was I taking on Ms G’s attributions? In which case Ethan was subject to my projections as well as his mother’s. Was I picking up on an aggressive quality of relating in Ethan that indeed would be a pointer to derailed development at this age? If so, why did I not follow this through with an explication of his aggression as reactive to his mother’s unresolved ambivalence? Certainly, addressing his predicament would then need to have been privileged. In retrospect, I think that my shifting identifications with mother and with baby were enacted here through muddled, partial interpretations. Just as imaging the baby’s ordinary movement toward separateness was not available to Ms G, she was also not able to manage a normal loss through establishing the triad of mother, father and baby (Daws 1999). I noticed in the sessions that I felt increasingly forced to relate to Ethan, with Ms G watching and withdrawn, or to Ms G—with Ethan either observing or dis-engaged. Thus, the father/therapist was seen not as a gain but as a threat to the symbiotic tie. In the issue of weaning, the bottle symbolically represented the competent, third object, and there was a concrete idea that the bottle would deliver Ethan to his father. With this came powerful statements from Ms G that D and Ethan were doing so well together. There was affective undertone of not being needed anymore, and I was left with a concern that intense pressure on her to wean could precipitate a crisis, primarily in terms of her desire to stay alive. My anxiety about a possible suicide attempt was high, and I checked that the network was in place. In retrospect, I believe I was also caught up in powerful projections around loss of myself, as we were approaching another break (9 months into treatment).



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Anticipating this loss Ms G thought she and Ethan would miss their sessions with me, but she continued to insist that the solution was disengagement and self-sufficiency. Separation, as an intrapsychic process leading to growth, still felt beyond our reach. enacting rupture On their return after the holiday, Ms G appeared terribly thin and wan, while Ethan seemed to have gained bulk and weight. My first thought was “he’s feeding off her!” He also looked strikingly like his father, as though fulfilling her fears of losing him to D. They each responded to me with a measure of reserve. Ethan took his time before he approached me: gazing at me from a distance and looking worried. After a while he gave me a smile and I smiled back and asked whether he was beginning to forgive me for the summer break. Ms G told me that on their holiday everyone had adored Ethan and that he had gone easily to the men but not to the women who wanted to pick him up. I wondered whether she was linking Ethan’s reserve with me to this. She shrugged. I asked her what she made of her observation. She said, “It’s like being run over by a red car and then not liking red cars afterwards.” I said it seems to have reinforced her fear that she was not a good mother and as a result all women were like red cars to Ethan. Again she shrugged, this time seemingly in agreement. Ethan was crawling about—initially energetically but then looking lost. A number of times he headed toward his mother and then veered away. When he absolutely ran out of resources he crawled to her and tried to clamber onto her lap. Ms G held him loosely, pulling away a bit and getting her hair out of his clasp. She then abruptly stood up muttering that he needs a climbing frame, carried him over to one of the chairs and stood him there. Ethan looked tiny and forlorn across the room. I felt shocked. She came back to her place on the cushion. I said she was equating herself with the chair, as though it was not her—his mother specifically—that he needed. She replied that she does not want him to depend on her for his happiness. Feeling very anxious about what I was about to say, I asked whether she wanted him to be independent of her so that she could do away with herself if she felt she needed to. Ms G looked pale. She whispered that this was very selfish. I said perhaps she thought that in order to continue living she needed to feel that she could kill herself. Ms G said everybody had their escape routes. Ethan had crawled back to our vicinity and was searching Ms G’s bag. He pulled out a plastic container with food. We watched as he struggled to get an apple out. I accompanied him with words: is he wanting the apple, can he get to it? He managed to extract the apple



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and tried to bite into it. I asked him if he can eat it, is it too big? I said maybe Ms G thought I was fussing too much. She moved closer to him and asked him if he needed her to cut it for him, but Ethan had in the meantime made indentations with his teeth. He chewed on the apple for a while and then tried to get the bottle of baby food out. Ms G watched him closely and I found it agonizing that she did not capitalize on his interest. When she finally, tentatively offered him some food, he spat it out. She immediately put the bottle of food away. Shortly after this he began to cry. Ms G told me that at D’s insistence she had taken Ethan to a nursery that morning. I asked how they had felt about it. She said Ethan had choked on a brick during his visit. She conveyed immense sadness. I said she seemed torn between loving Ethan and wanting his love for her, and her fear that this dependency in both of them would take away her escape route. I suggested that the long break had probably also brought up these feelings in relation to me. Ethan was getting more upset and when picked up by Ms G he clung to her strongly. I said to him that he was showing his mummy how much he needed her and how frightened he gets when she thinks about leaving him. Ms G carried him over to the windowsill and sat him on it so he could look out. Ethan calmed, and soon after this it was time to end. Ms G fled the room clutching Ethan in her arms.



The story of the holiday could have been taken entirely as a transference communication: I had “run over” her dependence on me and left her, prematurely, to feed herself. Thus forsaken, she felt driven toward her habitual escape routes of self-denigration and selfharming, both to rid herself of her shaming infantile needs and as a retaliatory attack on me. Her rage with me was communicated in the narrative of the red car and enacted in substitution of climbing frame/chair for self, that is, in her refusal to embrace Ethan—again, an identification with the aggressor. A central dilemma in parent-infant psychotherapy is when to take up the transference to the therapist? Certainly the negative transference was in the forefront and needed addressing. However, my initial attempt to relate to my perceived dangerousness (via Ethan’s avoidance of me) was shrugged off. I reckoned that to pursue the transference and/or her defenses could be experienced by Ms G as retaliation on my part (Steiner 1994). In retrospect, it is the displacements that perhaps could have been taken up for it is there that the experience of cruelty lay. Addressing her rage with me may have relieved Ethan from the burden of carrying it. With the rupture (break) with me unsufficiently reflected upon, what followed was Ethan’s performing a transference enactment of



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failed self-feeding while the intergenerationally depriving mother stood by. By this point I was able to address the struggle to manage alone, but although Ms G carefully watched Ethan, her active intervention came too late (like mine) and was rejected. I wondered whether in fact Ms G experienced me as empathic toward Ethan when I had been withholding toward her, and this perhaps contributed to her not helping him feed. I also thought she was possibly punishing me through forcing me to witness her abandonment of her child (which was painful to watch). In a similar vein, going to nursery was experienced as forced upon them, with life-threatening consequences. However, Ms G’s sadness was here undefended and it gave coherence to the preceding narratives. Acknowledging the need and the pain allowed some movement—by the end of the session Ethan was ensconced in Ms G’s embrace. The following session Ethan was unusually free and playful, particularly in relation to the apple. He held it, bit into it, he lay on the apple and rolled around. I noted Ethan’s playfulness and Ms G said she too had noticed it—it was so different from his clinging. I suggested that he might be picking up that she and I were trying to work something out and it was a relief to him. Ms G said, “maybe he is being trustful.” “falling in love” as reparation In one of her earliest sessions Ms G asked, “When does one know that reparation has taken place?” “Reparation” was her choice of word, denoting making up for her destructiveness. Toward the end of the first year of treatment we came back to this theme. It was a period of creativity following the enactment of rupture, described above. In the sessions there was a shift, with Ms G taking a slightly more reflective stance (i.e. less rumination and self reproach) than hitherto. In the core relationship toward Ethan, so dominated previously by her ambivalence, there seemed to be a flowering of love. Between them there was a more robust link, which enabled Ethan to move to and from his mother and to refuel from a distance through gaze. Ethan also established his own little routine in the sessions. He would start by checking out the toys and re-establishing himself with me—little smiles, crawling over to me, gradually climbing up to explore me. Then he would go over to Ms G’s large bag and get out his food parcel—an apple and berries in a plastic bag. He had to work hard to get his hand into the bag, but Ms G



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monitored his endeavors and encouraged him. Ethan then ate his fruit, swallowing some and spitting some out. Gradually eating and playing/exploring became somewhat more integrated, and he moved between the activities and us. He approached his 1st birthday and this preoccupied Ms G. She said she still had not found the perfect present. She mentioned a cloth she’d had as a comforter which had worn away—she wished she still had it to give to Ethan. I said it sounded that she was wanting to protect and comfort him for the years to come. She replied that she had a lot to make up. I said this made me think of the perfect present as representing a wish to make good their very difficult early beginning. Ms G spoke of reparation and I thought she was also repairing something for herself. Her emphasis was on her wish to protect Ethan’s trust and expectations that people will respond to him kindly. I suggested she may have felt unprotected and that cruelty hit her abruptly as a child. Ms G spoke about her mother doing her best, but that it was not good enough. She added that her mother does a lot of charitable work but she wishes she could have given the same to her children. I said that perhaps she feels that sometimes both her parents didn’t really do their best and that some of the cruelty she experienced came from them—and this is what is so hard for her. Ms G struggled with this, though she did not deny it. Ethan had finished eating and messing and was exploring under the table where he discovered the telephone wire and plug. Ms G initially asked him not to play with the cord and then went over and picked him up. Ethan gleefully crawled back to the table and Ms G became firmer in her tone of voice. I spoke about what was happening between them, reflecting that he really enjoyed being gathered up by his mother and had found a hide and seek game which he could play with her.



This session was characterized by a sense of calmness and reflection between Ms G and myself, the adults, and playful exploration on Ethan’s part. It felt that I was allowed to hold a position of the benign “third,” and this was perceived to be containing to both baby and mother. The quest for the perfect present seemed to capture Ms G’s regrets about the lacks of their beginning together, and her wish to celebrate their coming together through the love she had discovered within herself for her child. In wishing to extend the “comforter” from her childhood to him, she also had begun to mourn the lonely childhood she had, and to relinquish some of the envy of her child for the maternal comfort he could still have in his. Ethan’s play with the tele-



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phone cord seemed to represent hope for more genuine, encompassing communication between them through which he could be gathered up and contained. Discussion Ethan’s first birthday also heralded the end of our first year of work together—a good time to take stock. The wish, and failure as yet, to find a “perfect present” seemed symbolic of what had been achieved and of that which still needed to be addressed. Ms G had approached parent-infant psychotherapy with the wish for a “filter” to protect her baby from the transmission of damage she felt had been done to her by the parenting she had received. In equal measure, although more hidden, was the fear of being damaged by her baby. This mutual threat was created through their very existences in relation to each other. As Ms G said, “Can one damage one’s baby just by being available?” In the transference I was also often a source of danger, most spectacularly around breaks when my unavailability confronted Ms G with her the extent of her dependency on me and my maternal failure to hold it. Ethan’s post-natal vulnerability—his smallness, sensitivity to lights and noise, seemingly low threshold to “unpleasurable” experiences and the difficulties in comforting him—intensified the sense of fragility and risk. My countertransference fantasy that we were constructing the therapeutic space within a sea of shards highlighted the power of the emotions, projections and enactments. In the course of the first year of the therapy there were some changes in the quality of the relationship between Ms G and Ethan. The most significant was the expanding sense of maternal love for Ethan. In the early months Ms G’s fear of, and guilty hatred for, her baby’s dependency overrode her ability to accept more benign feelings in herself. She defensively adopted an ideal of altruism that negated not only her passions but also his. Ethan was forced into precocious inhibition of attachment behaviors toward his mother. His turning from her, and her failure to meet her ascetic standards, compounded her depression. In the course of the first year of therapy there was a lessening of Ms G’s preoccupation with the question of “genuine” maternal love and a move toward more ordinary, at times “good enough,” mothering. She seemed more able to acknowledge and tolerate her wish to be central to Ethan and, albeit less consistently, her importance to him. Her gaze and facial expressions conveyed growing adoration of him. What facilitated these changes?



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Perhaps “falling in love” could start to take root only after there was some measure of surviving the destruction and despair brought from her past primary relationships into her present ones. By the third quarter of the year Ethan, although delayed, was making up the early impingements and developmental tests confirmed he was on track. Thus Ms G’s psychic reality of the inevitability of damage could, sometimes, be challenged by a different, external voice. Ethan, for his part, seemed to capitalize on the openings in their relationship and became more forward in expressing his desire for her. This, too, was a positive reinforcement which Ms G could at times perceive. In the transference relationship with me I, too, was surviving her destructiveness and was not retaliating with narcissistic demands of my own. Thus Ms G was meeting with a different “motherhood constellation” (Stern 1995) from the persecutory internal one, one in which the intergenerational mother could be experienced as containing and repairing of the damaged child. The clinical process, as the sessional material indicates, took place in the procedural and symbolic domains. Interpretations—using words as a means of giving meaning—were important to this mother, as were verbal (vocal, tonal) representations of his mind to Ethan. The procedural processes seemed to cohere more slowly. At first, the misattuned emotional “dance” between mother and baby was repeated in the interactions between the three of us. In time, I became better at matching and repair of the spontaneous gestures and affects that constitute “authentic person-to-person connection” (Stern et al. 1998, p. 904) and this then framed the developing relationships between mother and baby and myself. Because so much in the earliest transactions between Ms G and Ethan was driven by her negative transference to him, offering myself as someone who could simply be with mother and baby and could reflect on them in relation to each other without fear of damage, seems to have been important. For quite some time it seemed that only in my mind could their survival as a dyad be contemplated. This raised the question of which patient should be privileged from moment to moment—Ethan, mother, father (present or absent), the relationships? At times I left a session feeling that more work should have been done with Ethan, for example to enhance his efficacy in engaging his mother. At other times I felt that the focus should stay with Ms G, to address her depression and the defenses and distortions that constituted her zone of safety but also derailed the relationship with Ethan. Despite the compelling nature of Ms G’s narrative, it was cru-



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cial to keep Ethan in my mind at all times, so as not to slip into individual therapy in the presence of the baby. These issues were all the more urgent given Ethan’s young age and the chronicity of Ms G’s difficulties, spanning critical periods in his development. Alongside the changes that marked the achievements of our first year together there remained areas of great vulnerability in their relationship. It seemed that the quality of love Ms G was able to offer Ethan was contingent on her emotional state at any given time and the extent of preoccupation with herself. Often Ethan had to make do with the crumbs of emotional availability that penetrated her depression and withdrawal. Not able to love herself in her baby, or to allow his appeallingness to reflect on her, Ms G could not really entertain exuberant passion and appetite in her relationship with Ethan. Moreover, to be “consumed by the other” was only too real a threat and to be avoided at all costs. Thus Ethan was not able to safely experience himself as an object of hatred as well as of love. His own actions directed at separation-individuation were still, at times, subject to transferential attributions that frightened Ms G and evoked her rejection of him. In turn, Ms G’s fluctuating emotional state, and particularly when she became extremely depressed, could be frightening for Ethan, betrayed initially in disintegrative crying, and later in occasional veering away in the midst of approach or a momentary freezing when mother seemed annoyed. These thoughts about clinical process are relevant to the question of whether “genuine maternal love” exists. It seems to me that what Ms G captured in this term was the affective quality of her love for her baby as described above. In presenting the question she was disclosing her knowledge that something was going very wrong for them. At the same time, bringing the question into the therapy also underlined Ms G’s commitment to do better by her baby: whatever her state of mind, however conflicted she was about the therapy, Ms G and Ethan attended their sessions without fail. In using the therapeutic space to risk intimacy, Ms G and Ethan were constructing their particular version of “genuine” love—somewhat more measured and a little more vibrant at the end of the year than at the beginning. For myself—I was intrigued by this question in the context of my work with attachment disorders. It seems an important concept to hold in mind in the course of the therapy with mothers and babies. In the face of conscientious maternal care, it provides a framework for understanding a particular quality of “maternal failure” and ensuing relational trauma for the baby. It also suggests an outline of the



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clinical process that may be needed to free up object hunger and to encourage the risks of appetite and dependency, identification, and individuation in a dyad.



BIBLIOGRAPHY Alvarez, A. (1992) Live Company. London: Tavistock/Routledge. Balint, E. (1992) Before I Was I. New York: Guilford Press. Baradon, T. (2002) Psychotherapeutic work with parents and infants. In V. Green (ed), Emotional Development in Psychoanalysis, Attachment Theory and Neuroscience. London: Brunner-Routledge (2003), pp. 129–143. Baradon, T. with Broughton, C., Gibbs, I., James, J., Joyce, A. & Woodhead, J. (2005) The Practice of Psychoanalytic Parent-Infant Psychotherapy. London: Routledge (in press). Beebe, B., Rustin, J., Sorter, D., & Knoblauch, S. (2003) An expanded view on intersubjectivity in infancy and its application to psychoanalysis. Psychoanalytic Dialogues, 13, 805 –841. Bettes, B. A. (1988) Maternal depression and motherese: Temporal and intonational features. Child Development, 59, 1089 –1096. Bion, W. (1962) A theory of thinking. Int. J. of Psycho-Anal. 43, 306 – 310. Bollas, C. (1999) Dead mother, dead child. In C. Bollas, The Mystery of Things. London: Routledge, pp 106–126. Cirulli, F., Berry, A., & Alleva, E. (2003) Early disruption of the motherinfant relationship: Effects on brain plasticity and implications for psychopathology. Neuroscience and Behavioural Reviews, 27, 73 – 82. Daws, D. (1999) Parent-infant psychotherapy: Remembering the Oedipus complex. Psychoanalytic Inquiry, 19, 267–278. Fonagy, P. (2001) Attachment Theory and Psychoanalysis. New York: Other Press. Fonagy, P. & Target, M. (1996) Playing with reality: I. Theory of mind and the normal development of psychic reality. Int. J. Psycho-Anal. 77, 217–233. Fraiberg, S. (1980) Clinical Studies in Infant Mental Health: The First Year of Life. New York: Basic Books. Fraiberg, S. (1982) Pathological defences in infancy. Psychoanalytic Quarterly, 1(1): 612–635. Freud, A. (1937, reprinted 1942) The Ego and Mechanisms of Defence. London: Hogarth Press and Institute of Psycho-Analysis. Freud, A. (1981)—see J. Sandler with A. Freud. Freud, S. (1914) On narcissism: An introduction. Standard Edition, 14, 69– 102 (1957). Green, A. (1986) The dead mother. In A. Green, On Private Madness. London: Hogarth, pp 142–173. Hurry, A. (1998) Psychoanalysis and Developmental Therapy. London: Karnac Books.



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James, J. (2002) Developing a culture for change in group analytic psychotherapy for mothers and babies. British Journal of Psychotherapy, 19(1), 77– 91. Khan, M. M. R. (1963) The concept of cumulative trauma. Psychoanalytic Study of the Child, 18, 286 –306. King, P. (1978) Affective response of the analyst to the patient’s communications. Int. J. Psycho-Anal. 59, 329 – 334. Lieberman, A. & Pawl, J. H. (1993) Infant-parent psychotherapy. In C. Zeannah (ed), Handbook of Infant Mental Health. New York: Guilford Press. Lyons-Ruth, K. & Jacobvitz, D. (1999) Attachment disorganisation, unresolved loss, relational violence, and lapses in behavioural and attentional strategies. In J. Cassidy and P. Shaver (eds), Handbook of Attachment: Theory, Research and Clinical Implications. New York: Guilford Press, pp 520 – 554. Mahler, M. S., Pine, F., & Bergman, A. (1975) The Psychological Birth of the Human Infant. London: Hutchinson & Co. Main, M., & Hesse, E. (1990) Parents’ unresolved traumatic experiences are related to infant disorganised status: Is frightened and/or frightening parental behaviour the linking mechanism? In M. Greenberg, D. Cicchetti, and M. Cummings (eds), Attachment in the Preschool Years. Chicago: University of Chicago Press, pp 161–182. Panskepp, J. (2001) The long-term psychobiological consequences of infant emotions: prescriptions for the twenty-first century. Neuro-Psychoanalysis, 3(2) 149–178. Perry, B. (1997) Incubated in terror: Neurodevelopmental factors in the “cycle of violence.” In J. Osofsky (ed), Children in a Violent Society. New York: Guilford Press, pp 124 –149. Perry, B., Pollard, R. A., Blakely, T. L., Baker, W. L., & Vigilante, D. (1995) Childhood trauma, the neurobiology of adaptation, and “usedependent” development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. Rustin, M. (1989) Observing infants: Reflections on methods. In L. Miller, M. Rustin, M. Rustin and J. Shuttleworth (eds), Closely Observed Infants. London: Duckworth, pp 52–75. Sandler, J. (1976) Countertransference and role-responsiveness. Int. Rev. Psycho-Anal. 3, 43 –47 Sandler, J. (1993) On communication from patient to analyst: Not everything is projective identification. Int. J. Psycho-Anal. 74, 1097–1107. Sandler, J., with Freud, A. (1981) Discussions in the Hampstead Index on “The Ego and Mechanisms of Defence”: ll. The application of analytic technique to the study of the psychic institutions. Bulletin of the Hampstead Clinic, 4(5), 5–30. Schore, A. N. (1994) Affect Regulation and the Origin of the Self. New Jersey: Lawrence Erlbaum Associates. Schore, A. N. (2001) The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1–2), 201–269.



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Silverman, R. C., & Lieberman, A. F. (1999) Negative maternal attributions, projective identification, and the intergenerational transmission of violent relational patterns. Psychoanalytic Dialogues, 9(2), 161–186. Steiner, J. (1994) Patient-centred and analyst-centred interpretations: Some implications of containment and counter-transference. Psychoanalytic Inquiry, 14, 406 –422. Stern, D. N. (1985) The Interpersonal World of the Infant. New York: Basic Books. Stern, D. N. (1995) The Motherhood Constellation. New York: Basic Books. Stern, D. N., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan, A. C., Bruschweiler-Stern, N., & Tronick, E. Z. (1998) Non-interpretative mechanisms in psychoanalytic therapy. Int. J. PsychoAnal. 79, 903 –921. Target, M. & Fonagy, P. (1996) Playing with reality II: The development of psychic reality from a theoretical perspective. Int. J. Psycho-Anal. 77, 459 – 479. Trevarthen, C. (2001) Intrinsic motives for companionship in understanding: Their origin, development, and significance for infant mental health. Infant Mental Health Journal, 22(1–2), 95 –131. Tronick, E. Z., & Gianino, A. F. (1986) The transmission of maternal disturbance to the infant. In E. Z.Tronick and T. Field (eds). Maternal Depression and Infant Disturbance. New Directions for Child Development, no 34. San Francisco: Jossey-Bass. Tronick, E. Z., & Weinberg, M. K. (1997) Depressed mothers and infants: Failure to form dyadic states of consciousness. In L. Murray and P. J. Cooper et al. (eds), Postpartum Depression and Child Development, New York: Guilford Press, pp. 54–81. Winnicott, D. W. (1949) Hate in the countertransference. Int. J. of PsychoAnal. 30, 69 –74. Winnicot, D. W. (1956) Primary maternal preoccupation. In D. W. Winnicott, Collected Papers: Through Paediatrics to Psycho-Analysis. London: Tavistock Publications Ltd. Winnicott, D. W. (1962) Ego integration in child development. In D. W. Winnocott, The Maturational Processes and the Facilitating Environment, London: IPA Library, pp 56 –63. Winnicott, D. W. (1969) Use of an object and relating through identifications. Int. J. of Psycho-Anal. 50, 711–716. Woodhead, J. (2004) “Shifting triangles: Images of father in sequences from parent-infant psychotherapy.” The International Journal of Infant Observation, 7 (2&3), pp. 76 –90.



Minding the Baby A Reflective Parenting Program ARIETTA SLADE, Ph.D., LOIS SADLER, Ph.D., R.N., CHERYL DE DIOS-KENN, L.C.S.W., DENISE WEBB, M.S.N., P.N.P, JANICE CURRIER-EZEPCHICK, L.C.S.W., and LINDA MAYES, M.D.



Minding the Baby, an interdisciplinary, relationship based home visiting program, was initiated to help young, at-risk new mothers keep their babies (and themselves) “in mind” in a variety of ways. The intervention—delivered by a team that includes a nurse practitioner and clinical social worker—uses a mentalization based approach;



Arietta Slade, City University of New York, Yale Child Study Center; Lois Sadler, Yale University School of Medicine; Cheryl de Dios-Kenn, Yale Child Study Center; Denise Webb, Yale Child Study Center; Janice Currier-Ezepchick, Connecticut Department of Children and Families; and Linda Mayes, Yale Child Study Center. This work was supported by a generous grant from the Irving B. Harris Foundation, and grew out of a collaborative effort between the Yale Child Study Center, the Yale School of Nursing, and the Fair Haven Community Health Center. Other members of the research team who have been essential to our progress are Michelle Patterson, Betsy Houser, Megan Lyons, and Alex Meier-Tomkins. We would also like to thank Jean Adnopoz, the Director of Family Support Services at the Yale Child Study Center, as well as Sean Truman, both of whom were instrumental in getting the program off the ground. Finally, we wish to thank the administration and staff at Fair Haven Community Health Center, particularly Katrina Clark, Kate Mitcheom, Karen Klein, and Laurel Shader, who along with many other members of the pediatric and obstetric services gave Minding the Baby a home. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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that is, we work with mothers and babies in a variety of ways to develop mothers’ reflective capacities. This approach—which is an adaptation of both nurse home visiting and infant-parent psychotherapy models—seems particularly well suited to highly traumatized mothers and their families, as it is aimed at addressing the particular relationship disruptions that stem from mothers’ early trauma and derailed attachment history. We discuss the history of psychoanalytically oriented and attachment based mother-infant intervention, the theoretical assumptions of mentalization theory, and provide an overview of the Minding the Baby program. The treatments of two teenage mothers and their infants are described. Sometimes my daughter is just really nice and generous, and she likes giving me hugs and stuff . . . sometimes, just for nothing, she’ll walk up to me and hug me so tight in my neck and it feels so good . . . ’cause I never had that when I was little . . . She probably doesn’t understand why she’s getting me mad. ‘Cause she’s so tiny she probably doesn’t understand. But, that’s kind of what I think about, you know, you can’t compare your capacity to hers, ’cause she’s still so small, she doesn’t understand what she’s doing wrong. I usually try to hide my anger. I try not to let anyone see those feelings. I did that for a long time before Denise and Cheryl came along. That’s when I started opening up and talking to them. Because I had so much built in I couldn’t hold it anymore. —Iliana, 19, mother of Lucia, age 13 months I look at this tape of me and Noni, and she’s so little . . . I can’t believe she’s so big now . . . It’s so hard to watch this . . . I see now that maybe her crying was to tell me she’d had enough . . . here I can see her face sad trying to tell me what I didn’t know, that she may have been hungry or sleepy. The whole time she cried, I had no idea what she wanted. —Mia, age 19, mother of Noni, age 14 months



these young mothers are struggling to find words for the inner life—their baby’s and their own; tentatively, poignantly, they glimpse the other, and themselves. They look for ways to describe what is inside, what can be known, what can be held in mind, and what can be contained. They hold the past next to the present, the



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self next to the other. And as they discover their babies, they are discovering themselves for the first time. Mia and Iliana joined Minding the Baby—a relationship based mother-infant intervention program—in their third trimester of pregnancy. Both had been in different ways abandoned and betrayed by their own mothers when they were but babies themselves. They had lived their whole lives against the backdrop of trauma, within their own families and within the culture of their violent, impoverished, and chaotic communities. Knowing others and their minds had been fraught with terror, disappointment, and rage. And now they were faced with the enormous challenge of holding their own children in mind, children who had been born at a time when they were still children themselves. The crucial human capacity to understand the mind of the other, to make meaning of behavior—one’s own and others—in light of underlying mental states and intentions, is essential to the development of social relationships, and most particularly intimate relationships (Fonagy, Gergely, Jurist, & Target, 2002). Fonagy and his colleagues have referred to this interpersonal and intrapersonal capacity as the reflective function, and they suggest that it is essential to affect modulation and regulation; experiences that can be known and understood, held in mind without defensive distortion, can be integrated and contained. The capacity to mentalize, or envision mental states in the self and other, emerges out of early interpersonal experience, particularly the experience of being known and understood by one’s caregivers. The child discovers himself in the eyes and mind of his caregivers, and derives a sense of security and wholeness from that understanding (Fonagy et al., 2002; Fonagy, Steele, Steele, Leigh, Kennedy, Mattoon, & Target, 1995; Fonagy & Target, 1998). The child’s discovery of himself depends largely upon the caregiver’s capacity to hold, tolerate, and re-present the range of his diverse and contradictory mental states. Thus, a parent’s reflective awareness is inherently regulating and containing for the child. Importantly, though, it is also regulating and containing for his caregiver. Parenting is a fraught and complex enterprise, and without developed capacities for reflective functioning, parents are vastly more prone to impulsivity, disorganization, and dysregulation in relation to their child (Slade, 2002, in press, 2005). Trauma interferes in a number of profound ways with the development of reflective capacities (Fonagy et al., 1995, 2002). Parents who have been traumatized find their children’s needs and fears over-



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whelming and profoundly evocative, and as a result often find it difficult to read the most basic cues without distortion or misattribution (Fraiberg, 1981; Lieberman, 1997). At a most basic level, the defensive processes enlisted in the face of trauma fragment the development of stable, coherent representations of the self and other. What we see in the words of the mothers quoted above are tentative efforts to form such representations, and allow themselves moments of knowing the self and the other. Mia’s evaluation of her own failure to understand what her 4 month old infant was feeling provides a clear example of how difficult this can be. Minding the Baby, a relationship based home visiting program developed out of an interdisciplinary collaboration between the Yale Child Study Center and the Yale University School of Nursing, was initiated in 2002 to help young, at-risk new mothers keep their babies (and themselves) in mind in a variety of ways. We began with the assumption that—in addition to being relationship based and interdisciplinary—our program would focus on the development of mothers’ mentalizing capacities. Based on Fonagy and his colleagues’ work of the last decade (see Fonagy et al., 2002, for a review), we knew that—by virtue of early relationship histories that were universally characterized by attachment disruption and trauma—the reflective capacities of these women would be compromised. Furthermore, we believed that addressing the deficits and defenses that had led to such disrupted functioning would be vital to the development of healthy mother-child relationships. Obviously, while parenting is not the only factor contributing to the regularity and evenness of infant development (temperament and biology being but two of the myriad endogenous and exogenous factors that can affect development), we believed that enhancing parental reflective functioning would help mothers facilitate their children’s development in crucial ways. This approach is in line with what Fonagy and his colleagues have termed “mentalization based therapies” (Bateman & Fonagy, 2004); this term refers to treatments that directly address and target the development of reflective functioning or mentalizing capacities. In essence, these approaches—which Fonagy and Bateman have most extensively developed for work with borderline patients—are designed to very explicitly help patients make sense of mental states. It is this model that has informed the development of Minding the Baby. We also began with the assumption that when working with infants, containment and regulation take place not just at a mental level, but



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at a physical level as well. The knowledge of mental states, thought so crucial to responsive caregiving, is preceded and indeed founded upon an understanding of physical states. As Freud pointed out, “The ego is first and foremost a bodily ego” (1923, p. 6). Winnicott (1965) made a similar point: In healthy development at this stage the infant retains the capacity for re-experiencing unintegrated states, but this depends on the continuation of reliable maternal care or on the build-up in the infant of memories of maternal care beginning gradually to be perceived as such . . . The infant becomes a person, an individual in his own right. Associated with this attainment is the infant’s psychosomatic existence, which begins to take on a personal pattern; I have referred to this as the psyche indwelling in the soma . . . the infant comes to have an inside and an outside, and a body-scheme. In this way meaning comes to the function of intake and output; moreover, it gradually becomes meaningful to postulate a personal or inner psychic reality for the infant. (p. 45)



In other words, the child comes to know his body through the hands of his mother. As we can see from Mia’s reflections on her inability to acknowledge her baby’s most essential needs for sleep or food, even the recognition of physical states can be compromised in traumatized mothers whose own bodies have in a variety of ways often been a source of trauma. Thus, we wanted to help our mothers come to feel safe and confident in knowing their babies’ bodies as well as their minds, to feel that they could contain and regulate their babies’ physical states, and then slowly, with time, come to know their babies’ mental states. In the sections below, we will begin by briefly describing the essential principles and methods of Minding the Baby, as the program has evolved from its original inception three years ago. We will then present two cases in an effort to exemplify the approach intrinsic to our reflective parenting program. Mother-Infant Intervention: A Brief Overview Thanks to the remarkable and groundbreaking work of Selma Fraiberg, clinicians have been working in a psychoanalytic way with mothers and babies for more than 30 years (Heinicke, Fineman, Ponce, & Guthrie, 1999; Heinicke, Fineman, Ruth, Recchia, Guthrie, & Rodning, 1999; Lieberman, Silverman, & Pawl, 1999; Lieberman, Weston, & Pawl, 1991; Seligman, 1994; Stern, 1995). Infant-parent psychotherapy is today a highly valued and legitimate mode of psy-



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choanalytically based treatment, and the infant mental health movement—reflected in the emergence of organizations such Zero to Three, The National Center for Infants, Toddlers, and Families, and the World Association of Infant Mental Health—is well established both in the United States and abroad. And, as attested to by all of the papers in this section, neither the fact of the child’s age, nor the fact that the dyad presents for treatment are considered in any way impediments to analytic intervention. Indeed, the age of the child and the mother’s active participation in the work are seen as crucial to progress and early structural change (Fraiberg, 1981). And, in contrast to traditional notions of psychoanalytic work, infant-parent psychotherapists routinely work in situations of risk and trauma, where little about the environment can be contained or easily modulated. Circumstances once considered “unconventional” (Seligman, 1994) are now considered normative, albeit challenging, opportunities for analytically oriented work. Essential to the infant-parent psychotherapy model is the notion that in a disrupted mother-baby relationship there is some basic distortion of the mother’s capacity to represent the baby in a coherent and positive way. Fraiberg introduced an idea that now underlies virtually all infant-parent work, namely that in troubled dyads the mother’s representation of the baby has been distorted by unmetabolized and unintegrated affects stemming from her own early and usually traumatic relationship experiences. The goal of infant-parent psychotherapy is to disentangle these affects from the relationship with the baby. And, as in all psychoanalytic treatments, it is the relationship with the therapist that leads to shifts in the mother’s representational world, and the ultimate “freeing” of the baby from the mother’s traumatic projections. The parent-therapist relationship in an infant-parent psychotherapy is—from a traditional psychoanalytic perspective—somewhat unusual, primarily because of the concrete supports and guidance that are offered by the clinician within this setting. At the same time, the notion of transference is crucial to understanding how this relationship unfolds, and in anticipating the pitfalls inherent in the mother’s coming to trust and rely upon the clinician. Ultimately, and optimally, the therapist provides a crucial and transforming alternative to the mother’s previous relationships with caregivers; the experience of being heard and valued by the clinician frees her and the baby as well. Fraiberg’s work was to have an enormous impact outside of psychoanalysis as well. Beginning with the publication of her seminal papers, home visiting—although widely practiced in Great Britain and



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other Western countries since World War II, and in the tenements of New York in the early 1900s by public health nurses (Wald, 1915)— has become one of the most common approaches to improving psychological and developmental outcomes in high-risk mothers and babies across most of the United States. Certainly David Olds and his colleagues’ Nurse Home Visitation program is the most effective and valid of the many home visiting programs described in the literature (Kitzman, Olds, Henderson, et al., 1997; Kitzman, Olds, Sidora, et al., 2000; Olds, 2002; Olds, Hill, Robinson, Song, & Little, 2000). In Olds’ model, experienced public health nurses conduct frequent home visits to first-time high-risk mothers and their infants beginning in the end of the second trimester of pregnancy and proceeding to the child’s second birthday. Like Fraiberg and her colleagues, Olds emphasized that the development of a therapeutic relationship with the home visitor is key to a number of positive mother and child outcomes. Olds chose to use nurses rather than mental health professionals for a variety of reasons, the most central being his belief that they are perceived by families as highly informed and helpful, and are free of the stigma of mental health service providers. When Olds first began his work, nurse home visitors did not receive any training specific to mental health concerns; however, as the program has evolved over the past twenty years, and the mental health needs of families have emerged with great clarity, nurses have received increasingly specific training regarding what might be called “psychoanalytic concerns,” namely how to think about and work with the sequelae of severe trauma and relationship disruptions (Robinson, Emde, & Korfmacher, 1997; Boris, Nagle, Larrieu, Zeanah, & Zeanah, 2002). While the infant-parent psychotherapy and NHV approaches differ in emphasis, they are nevertheless rooted in the fundamental notion that changing the quality of the mother-child relationship through a transforming relationship with a clinician is key to improving outcomes for child and mother. In addition, both approaches provide a range of ego supports for the mother, so as to improve the chances that—by completing her education, delaying further childbearing, and gaining secure employment—she will be in the best position to surmount the multiple stresses associated with urban poverty, and she will be able to serve as a secure base and facilitating environment for her child. What the NHV program adds to the psychoanalytic model of parent-infant work, however, is the emphasis on the body and on physical care; despite the fact that the issues of the body played a central role in classical psychoanalytic theory, this is an



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aspect of development and of the mother-child relationship that has not been effectively integrated into psychoanalytically based infantparent work. It is abundantly clear from the past two decades’ research that early trauma is profoundly disruptive to the developing individual’s sense of physical integrity and wholeness (Herman, 1992). Mind and body become inextricably intertwined, and the pathology of biology, arousal, and self-care cannot easily be distinguished from disruptions at an internal, psychological level. For that reason, we believed that it was essential to integrate the nursing model with the infant-parent psychotherapy model into a singular, unified model. We did this by creating a home visiting team that included both a pediatric nurse practitioner and clinical social worker. The enhancement of reflective functioning was a central goal of both the nursing and mental health aspects of the program. Thus, we used a variety of techniques—drawn from both nursing and infantparent psychotherapy approaches—to deepen a mother’s understanding and awareness of her baby’s mind, her baby’s body, her own mind and body, and the exquisite and complex interrelationship amongst all of these bodies and minds (Slade, 2002; Slade, Sadler, & Mayes, in press). Minding the Baby The best way to describe Minding the Baby is through example, which we will provide in the form of case material in the sections below. These cases1 will be used to describe some of the particular techniques we use to enhance reflective functioning within our model. Before turning to the cases, however, we will describe the program and its methods in a general way. Minding the Baby is based in an urban community health center that provides health care for an underserved population of families, most of whom live at or below the poverty line, and are of diverse cultural and ethnic heritages, including African American, Caribbean American, Puerto Rican, Mexican, and El Salvadoran. This link to community health care services is crucial, because programs that are not adequately linked to services provided by local health providers and other community agencies risk becoming isolated and less effective. In addition, Minding the Baby services are provided by master’s level clinicians; we see this level of advanced training as crucial in preparing clinicians to be able to assess and manage the complex 1. We have created composite cases for reasons of confidentiality.



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clinical issues involved in working with highly disadvantaged and traumatized populations. First time mothers are recruited from prenatal care groups offered at the health center. The Minding the Baby team is made up of a pediatric nurse practitioner and a clinical social worker; both are involved in the recruitment and initial evaluation process, and both see mothers on a regular basis. Typically they alternate visits, beginning in the last trimester of pregnancy. Families are seen weekly until the baby’s first birthday, at which point visits are tapered to every other week through the child’s second birthday.2 In some cases, the mother may be visited by both clinicians in one week, or by one visitor consecutively when there are physical or mental health crises. In various times of crisis, visits may last hours, and—when the home is too chaotic or disrupted—take place in locations as diverse as the neighborhood library or a fast food restaurant. Prior to beginning the intervention, the clinicians receive extensive training in reflective functioning; this includes exposure to relevant background materials in psychoanalysis and attachment theory, a comprehensive review of Fonagy’s work, and in vivo training in recognizing and identifying different levels and types of reflective functioning. This training is offered jointly, so that the nursing and mental health approaches are always unified when considering the mother and baby. Since many of the families served by the program include adolescent mothers, the clinical team also receives extensive training and supervision regarding the particular developmental and behavioral characteristics of teen parents (Sadler, Anderson, & Sabatelli, 2001; Sadler & Cowlin, 2003). Because thorough evaluation is crucial to testing the efficacy of Minding the Baby, mothers and babies are assessed at regular intervals over the course of their participation in the program using a range of standard psychological, psychiatric, health, and developmental measures (see Slade et al.). Data from these assessments allow us to evaluate change in a systematic way. While space restrictions prohibit our elaborating the content and process of home visits, (these are more fully described in Slade et al. 2005, and in Slade, Sadler, Mayes, Currier-Ezepchick, de Dios-Kenn, Webb, Klein, Mitcheom, & Shader, 2004), we will briefly describe what we see as the essential features of a reflective parenting program (see too Goyette-Ewing, Slade, Knoebber, Gilliam, Truman, & Mayes, 2. This schedule of visits is determined largely by funding and personnel constraints, although extra visits are routinely offered in times of crisis or intensified demand.



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2003; Grienenberger, Popek, Stein, Solow, Morrow, Levine, Alexander, Ibarra, Wilson, Thompson, & Lehman, 2004; Slade, 2002). Our ultimate goal is to help mothers acknowledge that the baby has a body and a mind of his own, and to learn—as a function of this awareness—to tolerate and regulate the child’s internal states. The work almost always begins in the therapeutic relationship, with the clinician holding the mother in mind so that she can begin to know herself, only then slowly coming to know the child. We have found that it is our clinicians’ willingness to witness the mother’s world, to witness her emotions and her body, to hold these in a safe way in the here and now, that makes the mother feel heard and ready to know the baby in all his complexity. This process—and its various permutations—is manifest in the cases below. Fonagy and his colleagues have described reflective functioning or mentalization as occurring along a continuum, from an absence or denial of mental states, to a simple capacity to recognize basic feelings and thoughts, to the emergence of true reflective awareness, namely the capacity to understand behavior in terms of mental states, and to understand both the nature and dynamic interplay of mental states (Fonagy, Target, Steele, & Steele, 1998; Slade, Grienenberger, Bernbach, Levy, & Locker, 2004). Minding the Baby tries to help mothers develop this capacity, with each of the clinicians doing so in distinct, but complementary ways. The nurse provides ongoing help in relation to physical health and caregiving, while the social worker provides infant and parent mental health services and social service support. At the same time, however, their roles overlap in a number of ways, with both providing developmental guidance, crisis intervention, parenting support, and a range of concrete supports such as rides to work, emergency food, medical supplies, and the like. As has been described again and again in the infant-parent psychotherapy literature, the very real needs of high-risk families require that they be helped at many levels at the same time; this demands constant flexibility and collaboration on the part of the treatment team (Lieberman, 2003; Seligman, 1994). As is true of all analytically based work, the development of a therapeutic relationship is at the heart of all parent-infant interventions. However, establishing productive alliances with abandoned and traumatized women and their families is not easy. These alliances are regularly disrupted by powerful and elemental transferential reactions on the part of mothers who have been betrayed and hurt by those who cared for them. The home visitors are repeatedly inundated with demands and crises (eviction, food shortage, domestic violence)



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that require immediate action. So often clinicians struggle with rescue fantasies as well as feelings of futility and helplessness; often they are intensely dysregulated by reports of violence to mothers and babies alike. The clinical team’s ability to keep the “infant in mind” is often challenged by the chaos, maternal pathology, and levels of extreme deprivation experienced by the family. Consistency—the bedrock of any therapeutic work—is difficult to achieve even at the level of maintaining regularly scheduled visits. Add to all these complexities the fact that the multidisciplinary team—while sharing common beliefs and values—does not always share a common language. Although the construct of reflective functioning provides common ground for discussion, as do the guiding principles of our model, there are nevertheless crucial differences in approach that must be managed against the backdrop of families prone to splitting and disorganization. The supervisory relationship—which sets the tone and parallels developing therapeutic relationships—becomes critical to managing these multiple levels of complexity. In Minding the Baby, the pediatric nursing specialist and clinical social worker are supervised jointly; we see this approach as crucial to exploring the myriad diversions that threaten the clinical work. As a team, supervision is used to set priorities, identify barriers, and explore alternative routes to enhance reflective capacities while addressing the concrete and physical needs of the family. Without supervision that is both clinically focused and personally validating, the team’s own reflective capacities are challenged and even diminished. In the following sections, we will describe our work with Mia, Iliana, and their babies. In some ways, theirs are similar stories: both had babies as teenagers, and both of their childhoods were characterized by loss, trauma, and abandonment. At the same time, their stories are different in important ways: they began the program with different strengths and resources, and with very different openness to internal experience. They differed in the degree to which they had developed capacities for reflective functioning, in levels of ego and self organization, and they struggled with different kinds and depths of vulnerabilities; equally important, they had different levels of support within their families and communities. Unsurprisingly, their progress in a number of areas can be charted quite differently; most important for our purposes in this paper are differences in the development of mentalizing capacities in these two women. Both have made—relative to their status at the beginning of the program— enormous progress. And yet both stories convey how complex and



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vulnerable progress is for women living with such enormous external and internal burdens. Both stories also convey how such complexity invariably requires multiple and flexible levels of care, care that we feel is best provided by the integrated, multidisciplinary model offered by Minding the Baby. mia We first met Mia at age seventeen when she was seven and a half months pregnant. Mia and her boyfriend Jay—who was eight years her senior—were living with his family in a situation that was both chaotic and overwhelming. Mia had been forced to move out of her home when her mother discovered Mia was pregnant. Mia had been the great hope of her family; she had done extremely well in high school, and was hoping to be the first member of her extended family’s generation to go to college. But Mia’s hopes for the future had been dashed by the conception of her unplanned baby. She dropped out just months before her graduation from high school. The baby solidified Mia’s already estranged status from her single mother, who had disapproved of her boyfriend, whom she saw as certain to derail her hopes and dreams for her daughter; as she put it: “You’re just another teen mother statistic.” Mia recalled, “This never was supposed to happen. I’m breaking everyone’s hearts.” What Mia’s solemn pregnancy story evoked but omitted in her whispery voice was that perhaps her heart, too, was broken. When we met Mia, we found a young woman struggling to disavow the reality of the baby and of her internal world on many levels. She was doing everything she could NOT to think about her baby, and was awkward, distracted, and almost dissociated when asked about the baby. “Oh . . . That.” While there were small glimmers of anticipation of a new relationship—“I talk to my belly,” Mia could scarcely invest in this possibility. “I just hope I still have it by the time it’s five.” (Her own mother had lost custody of her when she was five.) At the same time, Mia showed a number of indices of what we might call latent capacities for reflective functioning. While these were scarcely manifest in relation to her thinking about the baby, she was able to reflect upon her initial denial of her pregnancy, and in so doing to suggest a shift in her capacity to hold her complex emotions in mind: “I was in denial even up to my fifth month. I couldn’t sleep, saying, ‘I know I’m not pregnant.’ . . . I didn’t know what to do.” More striking was her ability to describe her own complex fears and worries about becoming a mother, and—in particular—her feelings of being lost



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and overwhelmed. The depth and quality of her language, and her capacity to vividly describe her pain led us to feel that as little as she was able to imagine the baby, and keep any kind of a representation of a relationship in mind as she prepared for motherhood, she was able to give voice to her own anxieties and sense of confusion. This proved to be a resource that was of great value to her once the baby was born. Both of our home visitors worked hard during the third trimester to help the mother “make room” for the baby (Mayes & Cohen, 2001): preparing the room, planning for childcare, thinking through labor and delivery. Mia had little conception of the child’s concrete, physical needs, and when encouraged, for instance, to wash a baby doll in preparation for caring for her own child, she giggled uncomfortably and abandoned the activity, embarrassed. Signs of depression—which were to become far more pronounced after she gave birth—were evident. Mia gave birth to a healthy girl, Noni. While she had begun to make amends with her own mother toward the end of her pregnancy, she was still living with her boyfriend’s family. The home was dirty and crowded with multiple relatives. The adults in the home were intrusive and often inappropriate; Mia had to guard her and the baby’s food carefully. TVs blared and there was the din of the distant conversation. The progress that she had begun to make in pregnancy— reconciling a bit with her mother, beginning to give voice to her fears—began to slip away, as Jay became disinterested in being with the new mother and baby. Her baby appeared well-cared for but Mia did not touch her readily, and Noni remained alone in her crib. Mia muttered, “Shut up,” under her breath when Noni cried. Her movements were perfunctory and task-based. She admitted to crying daily, bathing less, and not bothering to get dressed unless she had to go out. Mia was often pale, her eyes puffy from crying. She spoke with eyes downcast, disgusted with her isolation and feeling of uselessness. Within one month post-partum, the team felt that her depression had reached a critical level (likely as a function of biological as well as other factors). As is very typical of the mothers we are working with, Mia was averse to seeking psychiatric treatment, leaving us with little choice but to address her severe depression in a way that respected her pace, needs, and expressed wishes, but at the same time kept clearly in focus the very real possible risks to the baby. We decided that the social worker should see Mia weekly, so as to provide the level of mental



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health services appropriate to the level of the psychiatric emergency. At the same time, we did not decrease nursing visits, which she was starting to use in a limited way. The last thing we wanted to do was give her less of anything, and we felt that the nursing visits’ focus on developmental guidance and parenting support—keeping the baby alive for her in the here and now—was a crucial balance to the work of uncovering and discovering the pain of her past. With this shift, Mia began to find words for her despair, and she began to tell her story. While we had learned pieces of the story during the evaluation period and the first months of the intervention, it was only now, with the baby real, and Mia’s fragile denial and determination shattered under the weight of reality, that she began to tell us about herself in a more detailed and—finally coherent—way. Mia, an only child, was born to a heroin addicted mother who was herself a teenage mother. Mia’s father died of a drug overdose when she was two; Mia was with her mother when she found him. When she was five, following years of neglect, she was removed from her mother’s care and placed in foster care for two years. Remarkably, her mother managed to get clean and bring Mia back to live with her. Despite her own drug problems, Mia’s mother was a strong, determined woman of enormous intelligence and perseverance who in her own way communicated a fierce loyalty and love for Mia. In many ways, Mia’s mother’s dreams had propelled her forward; at the same time, however, Mia sabotaged and bridled at these dreams (the pregnancy being a very clear example), and longed for the uncomplicated love she had never had. Over the course of the next few months, Mia began to forge a relationship with the social worker, giving voice to her feelings, and allowing herself to remember and describe moments and fears long forgotten. Week after week came the small but significant indications that the capacity to identify and reflect upon her internal states had begun to take root. She could not talk about the baby, but she could talk about her childhood experiences; slowly she found words for the terror that was associated with these remembrances, and for her own needs for comfort and support. These were feelings she had all but deleted from her awareness. First came the memories, and the feelings, and then came the effort to make meaning. She began to create a narrative, a story line that she could reflect upon, making meaning of the present in light of the past. The social worker worried that delving into such memories would be too painful and overwhelming for Mia, and she watched vigilantly for signs of traumatic stress. She



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did not push, but instead remained gently present, watching for Mia’s glazing over, the sign that she had remembered and described all that she could. At four months of age, Noni was an attractive and communicative baby, who in many ways managed to ignite Mia’s maternal capacities. On occasion, she could elicit maternal traits in Mia such as affection, playfulness, and pride. Mia’s competence and efforts to attend to the routine care, if not the emotional care, of the infant, were highlighted and validated. “There’s no one else that can comfort her like you. Look how she’s gazing right at you as if to say ‘thanks.’” This kind of comment, repeated multiple times over multiple home visits, fed Mia on many levels, and acknowledged her importance to the baby in ways that she herself could not yet recognize. Despite being unable to recognize her baby’s experience, she was, however, able to express complex feelings about her: “I don’t regret the baby, but I wish I didn’t have her so young.” At the same time that Mia could care for Noni competently and sometimes lovingly, she could also be quite aggressive and harsh with her. She had at this point no capacity to recognize or tolerate fear or distress in her baby (having not yet been able to articulate her own fears and need for comfort), especially fear and distress that she herself generated. Mia’s game of choice was to startle her infant, which she would do in a variety of ways. She would loom into the baby’s face quickly, smiling in a threatening way as she approached menacingly, or she would shove a shrill squeaking toy intrusively in her face. Mia delighted in this game, oblivious to Noni’s startled grimace and frozen expression. Noni would attempt a false, scared smile, as if she needed to placate Mia and keep her at bay. Repeatedly, Mia raised the threshold for tension, but did little to soothe the frightened baby, re-enacting her own helplessness as a child. This scary experience was repeated again and again, with the other adults’ finding similar pleasure in startling and overwhelming Noni. Equally disturbing was the fact that not only did Mia fail to recognize Noni’s fear, but that she viewed Noni’s response as false and manipulative. Whenever Noni would become distressed—not only with the startle game, but at times when she took a tumble or hurt herself—Mia would respond indignantly with some version of the following: “Faker! Big fake-crier! You don’t fool anyone.” Thus, Noni’s self-experience was both disavowed and distorted within the context of her mother’s response; it is these kinds of early relational experiences that Fonagy and his colleagues (2002) so richly describe as fundamental to a child’s developing an abiding feeling of alien-



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ation and emptiness. Even in these early months we could see Noni dissociated and frightened in interaction with her mother. The next task was clearly to help Mia recognize her baby’s fear and distress, feelings that were at this juncture too threatening for Mia to see, even in her own history. We began by trying to elicit curiosity about the baby’s intent, “Why is she fake-crying? What could she want by calling out to you?” Focusing on the baby’s intentions helped Mia slowly attend to the cues or events that led up to the baby’s distress. It also served as a chance to allow Mia to reflect upon her own experience of the crying. “How does it feel when you think Noni is trying to trick you into paying attention to her?” Her responses opened up a discussion about the “street’s” code of emanating fearlessness, denying needs, and feeling excited by fear. After revisiting these themes many times over, Mia began to explore the times in which she felt afraid, alone and/or felt like no one was taking her needs seriously. Mia admitted that indeed her own obvious cries for help in dealing with the overwhelming demands of straddling adolescence and motherhood were not being heard. As the intervention proceeded, we did not approach these deficits in Mia’s mentalizing capacities directly, of course, but rather began by using the therapeutic relationship with the home visitors to give voice to her own experiences of fear and distress. These therapeutic relationships then became the platform from which she could view the baby’s experience—her intentions and affects—with increasing accuracy and clarity, without needing to distort or misinterpret as a means of protecting her own fragile sense of self. Mia’s willingness to hold the baby in mind was quite tenuous and fleeting at first, and had to be nurtured in a variety of ways at all times, because her tendency to slip out of reflective awareness was so strong. Slowly, she began to be able to step out of automatic reactions and timidly observe her child’s feelings. Noni began to be able to express a more extended range of emotions toward her now more available mother. When the baby was thirteen months old, Mia moved back into her mother’s home. She made the choice to move away from the father of the baby because she believed it was a better environment for a baby. When asked, “Why now?” she replied, “She’s much happier. In the other home, she’d hold her hands over her ears, it was too much for her . . . I wanted to for her. It was an easy decision.” Mia was making links between the baby’s behavior (holding her hands over her ears) and internal dysregulation (too much for her), and she saw herself as instrumental in protecting the baby and providing her with a more regulating and containing environment.



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tachment (Main & Solomon, 1986), but showed many signs of a secure attachment; this is a crucial marker of developmental and relational consolidation. Mia is still an adolescent, one who has suffered a range of traumas in her short life. And yet, over the course of home visits, we see the effects of these traumas diminishing in her day-today interactions with Noni. She finds pleasure in her, she plays with her, she inhibits her own instincts to frighten and overwhelm. She comforts her child and tolerates her distress. For the most part, Mia can hold Noni in mind. Despite Mia’s continuing struggles, when we contrast her behavior with Noni at 4 months with the responsive and “good enough” mother we see now, it seems evident that the slow effort to help Mia keep Noni in mind has been successful, and we can feel somewhat confident that there are protective factors in place for both Mia and Noni that will make a big difference in both of their developments. This in sharp contrast to Iliana, whose case we turn to next. iliana We met Iliana, 19 years old, at a group prenatal class in the second trimester of her pregnancy. She was accompanied by the father of her baby, a 20-year-old man with a previous history of substance abuse and incarceration. During the two-hour class Iliana remained attentive but maintained a skeptical distance from others in the group. Indeed, distance and anger were to characterize Iliana’s central struggles, both as they were manifested internally and in relation to the team. In contrast to Mia, who from the beginning had some capacity to hold complex mental states in mind, Iliana was overtly more angry, more defended, and much less able to tolerate and describe her internal world. She had survived a childhood deeply marred by chaos, poverty, and violence. Her mother had left the family when Iliana was five. Her father, deeply involved in drugs and alcohol, erratic and sometimes violent, had been her sole caregiver. She was sexually abused by her grandfather. However, the abandonment by her mother—of whom she spoke with bitterness and rage—was a defining moment for Iliana, a scar that would not heal. Iliana’s defense against pain was to threaten and push away anyone who got close to her. She was proud of her toughness, her readiness to fight and establish her dominance on the street. She readily described herself as the kind of person who would act before she thought, and was clearly pleased at her capacity to frighten and intimidate people. At the same time, though, impending motherhood had stimulated—as it so



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often does—the wish to mother differently than she herself had been mothered. Iliana wondered aloud if she could learn to be the kind of mother the baby could count on. “I know I’ve got to change and not just walk away or not talk when I’m mad. It’s not just me and what I want anymore.” This snippet of mentalization, in which she linked her behavior to internal experience and recognized that her own intentions and desires were changing, was brief and fleeting. This was all we had to work with. When Iliana revealed her pregnancy to her father and sisters she was told that she was “not fit to be a parent and was on her own.” She had only known the father of the baby for several months and the pregnancy was unplanned. Their relationship was evidently troubled, although it was not until much later in the work that we knew just how troubled. She had little expectation of support from him (“maybe he’ll buy diapers”) and obviously felt let down and alone. Despite leaving high school during 10th grade, Iliana was—like Mia—clearly an intelligent and articulate young woman. Also like Mia, she longed for work that would give her a sense of purpose and meaning. Unsurprisingly, it was very difficult to establish a therapeutic relationship with Iliana. Her armor—manifested in her attitude—was thick and tough. During the prenatal phase, she routinely failed to show up for appointments. She never called to cancel, but when phoned to reschedule, she always appeared interested in setting up another meeting. We viewed this ambivalence in a positive light (at least she was ambivalent), and she continued to reschedule appointments, well aware that she would fail to keep more than half of them. We hoped that our continued presence signaled a willingness to meet and work with her as she became ready and more trusting of us. This was but the first sign of resistance that was to manifest itself continuously as treatment proceeded, and the first of many times that our clinicians would have to remind themselves that her resistance was based in fear rather than an outright rejection of intimacy. Not surprisingly, the fear of closeness to others was reflected in her relationship to her baby during pregnancy. “I talk to it sometimes, but I don’t know why,” she remarked. In this circumstance it was hard to make baby “real” to the young mother-to-be, except as the reason she had to stop “hanging out at clubs.” To stimulate her thoughts and feelings we looked at pictures of newborns and discussed common infant behavior that is often of concern for new parents. Looking at the life-sized photo of a brand new baby, Iliana was finally able to speak of her fears. “It’s hard to picture the baby. I’ve never held a lit-



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tle baby. They are so small they look like they can break. And when the baby cries—I might get mad or nervous and just walk away!” Embedded in these comments were signs of another set of difficulties that were to recur throughout all phases of the treatment, namely Iliana’s profoundly disrupted sense of her body. The new and frightening bodily sensations and discomforts of pregnancy made her feel out of control and angry. She was terrified of labor, and particularly frightened of the feelings of powerlessness and vulnerability that it would engender; these feelings can be especially poignant in women who have been sexually abused and who find labor retraumatizing. As might be expected, Iliana’s feelings about her own body were to later define her feelings about and insensitivity to her baby’s body. Giving birth was an empowering experience for Iliana. Anticipating the terror she would feel giving birth, the nurse practitioner developed a labor plan with Iliana that allowed her to make choices ahead of time about medication, restraint, and other aspects of the delivery (Simkins, 2002). The labor was difficult, but the labor plan—which was supported fully by the midwifery team—allowed Iliana to feel in control of her experience. She was extremely proud of herself, and her daughter was easy to feed and console. The new mother held the baby—a girl named Lucia—closely, gazing warmly into her eyes and imitating her facial expressions. We pointed out how she was able to make the baby feel safe by holding her close and how she was learning to read the infant’s cues to comfort her. Iliana was enormously pleased that she could regulate the baby’s states to reduce her crying episodes without becoming overwhelmed herself. Given Iliana’s tough veneer, and her enormous resistance to treatment, we had not allowed ourselves to hope for such an auspicious beginning. But as so often happens, Iliana got an important developmental nudge from her easy little girl. This positive beginning helped Iliana become more open to developing a relationship with the Minding the Baby team; however, unlike Mia—who was able to form a relationship that allowed her to move toward reflective understanding in relation to her baby—Iliana and her relationship to us was defined by her concrete needs and demands on the one hand and by her angry resistance on the other. On the one hand, there were moments when she could be tender toward her daughter. At these times, however, Iliana was also reminded of her own loss, of not having been nurtured and protected by her own mother. Iliana said she longed to “be a little girl all over again. Not to have the childhood I did have, but to have someone take care of me.” As a consequence, she often could not tolerate the baby’s need for



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care and comfort, and experienced Lucia as demanding and needy. The baby’s distress irritated her, and she would handle her abruptly and speak to her harshly. We observed her roughly awaken the baby to change her diaper or harshly tell the baby to “shut up” when she whimpered. She misattributed the baby’s facial expressions of discomfort as anger with her. It seemed quite evident that any sign of distress in the baby aroused her own feelings of sadness and helplessness and were thus intolerable. It was very hard to help her at these moments, most likely because our giving voice to the baby’s feelings made them even more unbearable. She took our “talking for the baby” as criticism, and responded with surly adolescent mumbling. Any hint of “correction” on our part (try though we might to remain benign and nonjudgmental) would trigger Iliana’s hostility and defensiveness. At such moments, she was extremely resistant to new ideas or ways of interacting with the baby. We had to work around her defenses. Iliana’s profoundly disrupted sense of her own body also interfered with her ability to see the baby’s needs as reasonable and separate from her own. Many times we would come to the home to find her disheveled, her hair uncombed, wearing her torn nightclothes. There were signs of neglect. Lucia was basically healthy, fed, and clean, but Iliana routinely failed to follow through on caring for what should have been routine physical care for her child. Lucia had eczema, and on several occasions both mother and child had advanced cases of ringworm. With her eczema untreated, the baby often had a number of raised, scaly patches of skin and was irritable and uncomfortable, which she would scratch continuously. Ignoring the baby’s distress, Iliana instead complained of her own numerous physical complaints, and reprimanded her daughter for scratching. In thinking about how to help Iliana become more sensitive to her child’s bodily needs, we remembered that her relationship with the midwife during her pregnancy allowed her to feel someone cared for and she respected her body for the first time in her life. We wanted to build on this new experience and find ways to demonstrate acceptance of the mother’s body (and, therefore, her whole being) in a caring way during home visits. Addressing Iliana’s needs first, the nurse practitioner spent time at each visit asking about her symptoms, using questions about her past and current activities, nutrition, and abuse, to help the young woman make tentative connections between her feelings, symptoms, and self-care. We found that the more the young mother’s pain was acknowledged, “heard,” by the clinicians, the more able she was to understand her daughter’s needs and experience.



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Unlike Mia, who from the start could—at least in a limited way— engage in the struggle to understand her history, her relationships, and her emotional experience, we had to approach Iliana through her body, and through her concrete needs. She could not work at a metaphoric or abstract level. When we tried to talk to her about her feelings about her life experience, she would become enormously sleepy and actually appear to doze off. Mentalization could only take place at a very concrete, protosymbolic level (Werner & Kaplan, 1963). But as we did this, she began to involve us more directly in helping her. It turned out that Lucia’s father had been abusing Iliana throughout the pregnancy, and he was now continuing to physically threaten her. This was the other side of Iliana’s toughness: the paralyzed victim. Once she disclosed his abuse to us, she was able to use us to help her obtain an order of protection, and to support her desire to protect her baby. At this time she became more overtly dependent upon the home visitors, and in particular needed a great deal of social service help to obtain a place to live as well as a variety of social service benefits. Her extreme neediness was experienced by the home visitors as a continuing volley of demands, within the context of which they had to continuously work to keep the baby in mind for Iliana. These demands only increased when we decreased the number of regular home visits when Lucia turned one (a standard transition in the Minding the Baby protocol). She responded with overt indifference and appeared to pull sharply away, but she began to call us nearly daily with minor and major crises. Iliana the tough and defended young woman who needed no one could not get enough of us. Over time Iliana has slowly become more aware of her baby’s experience. When Lucia was 15 months old, Iliana, her new boyfriend, and the baby moved into a tiny apartment of their own. Iliana complained that the toddler was “always in the way. Always trying to do what I am doing. It makes me crazy!” The nurse practitioner brought over a small plastic tub and a few containers for the little girl to play in, and asked the mother to follow the baby’s lead while she herself washed the dishes. Imitating her child’s actions, Iliana suddenly “saw” what the child was doing. In imitating her daughter’s splashes and play with soap bubbles, she laughed and exclaimed, “Oh! This is fun!” She had a sense of the child’s internal experience at that moment and recognized that the sharing of the experience brought them closer together. She was able to express this feeling to her child by having a short conversation about what they were doing. This realization has sometimes spilled over into other parts of their life together. Recently Iliana laughingly described her daughter as “being



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her own little self.” Iliana had been outside watering the flowers in the garden, and—anticipating her child’s desire to be included— had dressed her in a swimsuit. She had understood and accepted her baby’s desire to be nearby and involved with her, as well as to explore her expanding world. The child’s jubilant response served to reinforce and build on her mother’s new capacities. These moments of seeing the baby and taking pleasure in her have been accompanied by other shifts as well. Iliana now uses her community health center for routine medical care instead of going to the ER. She has a relationship with her primary care providers, facilitated by the nurse practitioner, who has served as a bridge between clinic and mother in an ongoing way. For Iliana, who has in the past tried to control her body and that of her baby’s as a means of regulating her fragile sense of self, the willingness to allow others to care for her and her body is crucial. As is captured in Iliana’s own words at the opening of this paper, we also began to see signs of limited reflective functioning across a number of domains. While significantly less widespread and deeply held than Mia’s capacity to understand and hold her baby in mind, there were signs that she had begun to understand that there was a baby to be known. She tentatively acknowledged that she had begun to allow the home visitors to get to know her, and to witness her experience. She has acknowledged the power of her mother’s abandonment and her own unrequited longings for love and simple care. She began to talk about her child’s needs and understanding as being different from her own. Thus, even though these reflective capacities can easily disappear in an instant when she becomes angry or threatened, it is nevertheless becoming more natural to her to think about the baby in this way. At the same time, it is important to acknowledge that there are profound limitations to Iliana’s reflective capacities, even after nearly two years of treatment. Unlike Mia, Iliana has not been able to develop and rely upon a narrative—a story of herself—that helps her to contain and make sense of her complex emotional experience. The understanding she does have often fragments under the intensity of her feelings. These kinds of phenomena have been described by Fonagy (2000) as typical of individuals who have suffered extensive trauma and who would be diagnosed with a borderline personality disorder. This is certainly a meaningful way to describe Iliana. She can still be openly neglectful of Lucia, and very harsh with her, although now she yells instead of slaps. Nevertheless, we worry that we will have to get child protective services involved, as there continue



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to be multiple signs that Lucia is often in danger, either from Iliana’s neglect or for Iliana herself. We understand the limitations of Iliana’s availability to treatment as a function of multiple factors, most prominent being past and ongoing trauma and the lack of a stable, loving caregiver. In addition, Iliana had endured continuous disruptions in her sense of bodily integrity and wholeness; often, these assaults had been at the hands of those who were responsible for caring for her. Discussion As she approaches her child’s second birthday, Mia has begun to hold her child in mind. Iliana’s abilities to do this are far more compromised and fragmented, although she too has discovered reservoirs of pleasure in and identification with her child that are crucial and even miraculous. Developmentally, these young women began Minding the Baby with significantly different capacities for reflective functioning and mentalization, with Mia—while quite defended— the more ready of the two to think in a complex way about her interior life, and about the dynamic relationship between her feelings and actions. While certainly no stranger to trauma, Mia had managed to escape the physical trauma and abandonment that had devastated Iliana, and had found crucial comfort and safety in her relationship with her mother, who in her own narcissistic fashion kept her daughter in mind. From the standpoint of reflective functioning, Iliana began the program without any evidence of such capacities, and Mia began with at least rudimentary openness to acknowledging mental states, and occasionally holding their interconnectedness in mind. Our multidisciplinary model allowed us to approach these differences in a flexible way, to balance the nursing and infant-parent psychotherapy approaches in response to different kinds of supports these mothers needed at different times. Mia was more ready to make use of a more traditionally therapeutic relationship with the home visitors; the first real shift in her treatment came in beginning to tell her own story to the social worker. She required relatively little help with physical care, but instead relied upon the nurse practitioner’s expertise in parenting and child development. Iliana, on the other hand, needed a great deal of practical help from the nurse practitioner, and only when she had established an almost physical dependency upon this concrete level of mothering from the team was she able to begin to take in any developmental guidance or parenting support. She used the social worker to help her obtain social



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services, again needing this kind of very concrete help to support any reflective capacity whatsoever. We think that the progress made by the mothers and babies in our program has come—finally—from our home visitors’ capacity to hold their bodies and feelings in mind, to witness their pain and their anger without dysregulation and retribution, and to keep the baby alive for the mother in the face of relentless chaos and uncertainty. As we hope we have been able to convey in our description of a mentalization based, multidisciplinary mother-infant intervention program, this is complex work indeed. BIBLIOGRAPHY Ainsworth, M. D. S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, N.J.: Lawrence Erlbaum. Bateman, A. W. & Fonagy, P. (2004). Psychotherapy for borderline personality disorders: Mentalization based treatment. Oxford: Oxford University Press. Boris, N., Nagle, G., Larrieu, J. A., Zeanah, P. D., & Zeanah, C. H. (2002). An innovative approach to addressing mental health issues in a nurse home visiting program. Paper presented at the Tulane University Health Sciences Center, New Orleans. Fonagy, P. (2000). Attachment and borderline personality disorder. Journal of the American Psychoanalytic Association 48:1129 –1146. Fonagy P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization,and the development of the self. New York: Other Books. Fonagy, P., Steele, M., Moran, G., Steele, H., & Higgitt, A. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 13, 200 –217. Fonagy, P., Steele, M., & Steele, H. (1991). Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age. Child Development, 62, 891– 905. Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Mattoon, G., & Target, M. (1995). Attachment, the reflective self, and borderline states: The predictive specificity of the Adult Attachment Interview and pathological emotional development. In Attachment Theory: Social, Developmental and Clinical Perspectives, ed. S. Goldberg, R. Muir, & J. Kerr. Hillsdale, N.J.: Analytic Press, pp. 223 –279. Fonagy, P., & Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues 8:87–114. Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective functioning manual, version 5.0, for application to adult attachment interviews. London: University College London.



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When Noni was 14 months old, 17 months after Mia’s entry into the program, the social worker reviewed a videotape that had been made of Noni and Mia interacting when Noni was 4 months old. Mia was obviously troubled in watching the tape, and noted readily how insensitive she had been to Noni’s cues—“I had no idea what she wanted, I couldn’t read her . . . I see now that her crying was to tell me she’d had enough . . . here I can see her face sad telling me what I didn’t know, that she may have been hungry or sleepy . . . She’s trying to tell me she’s scared, and I’m just in her face, scaring her.” While Mia tried throughout the sessions to minimize and deflect some of the guilt she felt in recognizing her failure to hold Noni in mind, she was nevertheless fully cognizant of the fact that she was ignoring signs of distress that she was readily able to identify in retrospect. This reaction signified crucial progress to the treatment team. The central focus of the work of both home visitors was to make Noni and her internal world real to Mia, slowly and in a way she could tolerate. At the same time, it is important to highlight the fact that the work was taking place on many other levels as well. Mia was overwhelmed by her living situation, and we worked in a variety of ways to help her make Jay’s family home safer for the baby. This meant she first had to recognize that the baby required safety and that she could participate in providing that. Filters were provided that protected the baby from the smoke in an environment where everyone smoked cigarettes. She needed help with travel to and from school, with birth control, with obtaining food for the baby, and with basic caretaking skills. We brought toys and baby books, and taught her how to play with the baby. She had several frightening blow ups with Jay (who had a history of violence), which required our help in sorting out. All reflective work took place against this backdrop of concrete support and education: help in stress reduction, vocational planning, safety procedures, medical care, and the like. Without these levels of support, the therapeutic work would have been utterly impossible. Noni is now 20 months old, and Mia is living in her mother’s clean and orderly home. Jay is still firmly in the picture; indeed, he is often present at home visits, and is proud of his understanding of development, as well as the mutual feelings of love and attachment that he and Noni obviously have for each other. Noni is clearly a loved child, cherished by the extended family on both sides. When seen in the Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978), a laboratory based separation procedure that is used to assess infant attachment status, Noni was not classified as disorganized in relation to at-



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home visiting for pregnant women and parents of young children. Current Problems in Pediatrics, 30,109 –141. Olds, D., Robinson, J., O’Brien, R., Luckey, D., Pettitt, L., Henderson, C., Ng, R., Sheff, K., Korfmacher, J., Hiatt, S., & Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized controlled trial. Pediatrics, 110, 486 – 496. Robinson, J., Emde, R., & Korfmacher, J. (1997). Integrating an emotional regulation perspective in a program of prenatal and early childhood home visitation. Journal of Community Psychology, 25, 59 –75. Sadler, L. S., Anderson, S. A., & Sabatelli, R. M. (2001). Parental competence among African American adolescent mothers and grandmothers. Journal of Pediatric Nursing, 16, 217–233. Sadler, L. S., & Cowlin, A. (2003). Moving into parenthood: A program for new adolescent mothers combining parent education with creative physical activity. Journal of Specialists in Pediatric Nursing, 8, 62–70. Seligman, S. (1994). Applying psychoanalysis in an unconventional context: Adapting infant-parent psychotherapy to a changing population. Psychoanalytic Study of the Child, 49, 481– 500. Simkin, P. (1992). Overcoming the legacy of childhood sexual abuse: The role of caregivers and childbirth educators. Birth, 19, 224 –225. Slade, A. (2002). Keeping the baby in mind: A critical factor in perinatal mental health. In a Special Issue on Perinatal Mental Health, A. Slade, L. Mayes, & N. Epperson, Eds. Zero to Three, June/July 2002, 10 –16. Slade, A. (in press 2005). Parental reflective functioning: An introduction. Attachment and Human Development. Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2003). Addendum to the reflective functioning scoring manual for use with the Parent Development Interview. New York: City University of New York. Slade, A., Sadler, L. S., & Mayes, L. (2005). Minding the Baby: Enhancing reflective functioning in a nursing/mental health home visiting program. In L. Berlin, M. Cummings, & Y. Ziv, Eds. Enhancing early attachments, pp. 152–177. New York: Guilford Publications. Slade, A., Sadler, L. Mayes, L., Ezepchick, J., Webb, D., De Dios-Kenn, C., Klein, K., Mitcheom, K. & Shader, L. (2004). Minding the baby: A working manual. New Haven, Conn.: Yale Child Study Center. Stern, D. N. (1995). The motherhood constellation: A unified view of parent-infant psychotherapy. New York: Basic Books. Wald, L. (1915). The house on Henry Street. New York: Henry Holt and Company, Inc. Werner, H., & Kaplan, B. (1963). Symbol formation. New York: Wiley. Winnicott, D. W. (1965). Maturational processes and the facilitating environment. New York: International Universities Press.



“In a Black Hole”: The (Negative) Space Between Longing and Dread Home-Based Psychotherapy with a Traumatized Mother and Her Infant Son JUDITH ARONS, LICSW



This paper offers fragments from the first year of a home-based motherbaby psychotherapy, in which I attempted to help a traumatized and dissociated mother to emotionally engage with her infant son. The treatment was organized in part around certain developmental objectives common to both attachment and psychoanalytic theory. These include: The ability to name and metabolize feelings, to evoke a soothing maternal introject, and to relate to the partner’s mind as a separate, understandable center of initiative and intention. In addition, attachment theory, with its emphasis on the critical psychobiological role of containing fear and distress in infancy, was a useful guide in formulating the treatment. The paper reviews research findings on motherSenior faculty member of the Infant-Parent Training Institute at Jewish Family and Children’s Service of Waltham, Massachusetts, and a lecturer at Simmons Graduate School of Social Work, and member of the Boston Psychoanalytic Society and Institute and the Massachusetts Institute for Psychoanalysis. I gratefully acknowledge Karlen Lyons-Ruth, Ph.D., for her invaluable clinical and editorial input, George Ganick Fishman, M.D., for his untiring support, Sarah Birss, M.D., and Ann Epstein, M.D., for teaching me so well, the Center for Early Relationship Support at the Jewish Family and Children’s Service of Waltham Massachusetts, for making it possible, and Mary and John for showing me the way. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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infant pairs described as frightened-disorganized, discusses some of the challenges encountered in home-based mother-infant psychotherapy and then discusses the case of Mary and John. The case illustrates how mother-infant psychotherapy may interrupt the intergenerational transmission of disorganized attachment by working within the couple to name, metabolize and flexibly respond to painful, dissociated or frightening experiences. this paper offers fragments from the first year of a motherbaby psychotherapy in which I attempted to help a traumatized and dissociated mother to emotionally engage with her infant son. My work with Mary and John was organized in part around certain developmental objectives common to both attachment and psychoanalytic theory. These include: the ability to recognize, to name, and to metabolize feelings; the ability to evoke a soothing maternal introject to aid in containment and integration of self states; and the ability to be aware of and to relate to the partner’s mind as a separate, understandable center of initiative and intention. Attachment theory, with its emphasis on the critical psychobiological role of modulating and containing fear and distress in infancy, was a useful guide in formulating the treatment with this terrified mother and her emotionally disorganized son. In this first year of our work we attempted to expand emotional communication and to enhance feelings of security and reliability both within the mother-baby couple and between mother and therapist. The clinical cornerstone of my approach was to track carefully to each individual’s emotional state and to how each of us co-regulated our present intersubjective experience (Stern, 2004). Whenever possible we attended in the moment to the relationship between mother and baby, mother and therapist, baby and therapist, and baby, mother, and therapist together. This attention to relating in the present included my assumption that past and deeply private psychic experiences were summoned by and also helped to shape the current moment. The paper begins with a review of research findings on mother-infant pairs in which the infant’s attachment is described as disorganized and the mother’s caregiving as frightened or helpless. I will briefly describe some of the challenges of home-based mother-infant psychotherapy and then move on to the case and discussion. There are relatively few case studies describing the psychoanalytically informed treatment of frightened/disorganized mother-infant couples, and we have little clinical data documenting the therapeutic outcomes of such interventions. It is my belief that within fright-



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ened/disorganized dyads, mother-infant psychotherapy may interrupt the intergenerational transmission of disorganized attachment by working within the couple to name, metabolize, and flexibly respond to painful, dissociated or frightening affective experiences. The resulting increase in mother and baby’s affective competence (Russell, 1998) paves the way for further growth of intersubjective relating between them. The Infant’s Experience of Disorganized Attachment: Research Findings Disorganized attachment in infants is defined as the child’s inability under stress to maintain a consistent strategy that engages the primary caregiver in the service of regulating arousal and receiving comfort and protection (Main and Hesse, 1990a). The baby’s relational strategy breaks down or cannot form, due to an irreconcilable emotional paradox within the caregiving dyad: his primary attachment figure is at once the source of his fear and his refuge from it (Main and Hesse, 1990a). In the research lab, stressful separationreunion experiences of the Strange Situation highlight the contradictory behaviors indicative of disorganized attachment. Despite upset during her absence, the infant, upon reunion with mother, appears to be dysphoric, apprehensive, or helpless, and he exhibits conflicted behaviors that include wandering in a disoriented state, making slowmotion underwater movements, and approach-avoidance or stilling/ freezing in a dissociative-like response (Lyons-Ruth, Bronfman and Atwood, 1999b, Lyons-Ruth and Jacobvitz, 1999a, Main and Hesse, 1990a, Main and Solomon, 1990b). Sometimes the infant exhibits an unusual combination of attempts at approach coupled with odd or inexplicable gestures (Lyons-Ruth and Jacobvitz, 1999a). Frightened Mothers of Disorganized Infants: Research Findings Mothers who struggle with unresolved trauma and loss are at high risk for unwittingly engendering attachment pathology in their infants. Researchers have categorized these mothers as hostile/helpless or frightened/frightening, and link mother’s “unresolved” state of mind with regard to trauma and loss to the formation of disorganized attachment in her infant (Main and Hesse, 1990a, Lyons-Ruth, Bronfman, and Atwood 1999b). While researchers agree that there is a correlation between mother’s unresolved state and her ability to



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provide responsive and consistent infant care, there is disagreement on the mode of transmission of disorganized attachment. For example, Main and Hesse hypothesize that “The traumatized adult’s continuing state of fear together with its interactive/behavioral concomitants (frightened/frightening behavior) is the mechanism linking unresolved trauma to the infant’s display of disorganized/ disoriented behavior” (1990a, p. 163). They speculate that when mother is frightened or helpless her emotional withdrawal leads to dysregulation in her infant. Taking a slightly different tack, LyonsRuth and colleagues speculate that the infant’s inability to maintain a cohesive attachment strategy is actually the echo of his mother’s contradictor affective cues (personal communication, 2002). My discussion will focus on the frightened/disorganized subgroup of mothers and their infants. Unlike mothers who display overt hostile or intrusive behaviors toward their babies, frightened mothers appear dissociated, preoccupied, and tentative. On the behavioral level mother’s responses to the Strange Situation demonstrate subtle, contradictory reactions to the child’s bid for comfort and care, like stepping away while speaking in a soothing tone (Lyons-Ruth, Bronfman and Atwood, 1999b, Schuengel and Bakermans-Kranenberg et al., 1999). Her emotional cues are incongruent or non-responsive sometimes with sudden loss of affect (Lyons-Ruth and Jacobvitz, 1999a, Schuengel and Bakermans-Kranenberg et al., 1999). She may appear disoriented or confused by the child’s behavior, or react to baby in a helpless, frightened, deferential, or sexualized manner (Main and Hesse, 1990a, Schuengel and Bakermans-Kranenberg et al., 1999). On the representational level, mother’s performance on the Adult Attachment Interview reveals unmonitored lapses of reason and coherence in discourse, affective incongruence, intrusion into consciousness of dissociated material, and multiple and discontinuous inner representations (Lyons-Ruth and Jacobvitz, 1999a, Main and Hesse, 1990a). Liotti’s work has noted the similarity of these responses to dissociative processes in adults (1999, 1992). From a clinical perspective, mother’s caretaking appears parent centered and organized around her defensive exclusion of painful feelings (Schuengel and Bakermans-Kranenberg et al., 1999, LyonsRuth, Bronfman and Atwood, 1999b). Along with unintegrated internal representations and difficulty regulating her own affect, mother’s unresolved state of mind impairs her ability to respond to baby’s cues in a sensitive and non-conflicted way (Schuengel, and BakermansKranenberg et al., 1999) and impedes her capacity to repair affective disruptions within the dyad (Lyons-Ruth et al., 1999). Mother de-



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fends herself against the threat of her baby’s fearful expressions and his need for comfort by restricting her awareness of his state (LyonsRuth, and Jacobvitz et al., 1999a). She is hindered in providing the adequately attuned affective envelope that would instill an experience of “felt security” in her baby. Mother also shows impairment in self-reflective functioning and in her ability to reflect upon her child as a separate individual with a unique inner life. Self-reflective capacities are thought to be among the key mediators in the transmission of secure attachment (Fonagy, 2001, Fonagy and Target, 1997, Fonagy and Steele, et al., 1991). Frightened/disorganized mother-infant dyads teach us of the profound impact of attachment disturbance and chronic fear upon the development of psychological processes and psychic integration. Disorganized attachment places infants at serious risk for impaired affect regulation and right brain development (Siegel, 1999, Schore, 2001a&b), the onset of dissociation in adolescence and adulthood (Lyons-Ruth and Jacobvitz, 1999a, Lyons-Ruth, Bronfman and Atwood et al., 1999b, Liotti, 1999 & 1992, Bleiberg, 2002), excessively caretaking, controling, or frankly aggressive behaviors (Lyons-Ruth and Jacobvitz, 1999a, Lyons-Ruth, Bronfman and Atwood, 1999b, Lyons-Ruth, Alpern and Rapacholi, 1993, Jacobvitz and Hazen, 1999, Solomon, George, and DeJong, 1995), chaotic internal representations (Fonagy and Gergely, et al., 2002, Fonagy and Target, 1997, Liotti, 1999 & 1992, Main, 1991), impairment of mastery motivation, autonomous exploration, and problem-solving (Bretherton and Waters, 1985), poor self-reflective functioning (Fonagy and Target, 1997, Fonagy and Steele, et al., 1991) and compromised cognitive functioning (Moss and St. Laurent, et al., 1999). Chronic and unresolved fear leaves its indelible imprint upon neurological and psychological functioning. The impact of chronic fear on brain development and functioning, stress arousal systems, and physical and mental health has been well documented. Negative sequelae of Type Two (chronic) trauma in childhood include relational disturbances, dissociation, profound affect dysregulation, inner fragmentation and compromised cognitive functioning, and living with sickening dread or unremitting sorrow (Terr, 1991). Some Challenges Encountered in Mother-Infant Psychotherapy Before discussing the specifics of therapeutic work with frightened/ disorganized dyads, I will broadly describe some of the challenges en-



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countered in mother-infant work. Home-based mother-infant psychotherapy provides a “living laboratory” in which to substantiate or to disprove the rich data generated in the infant research lab. Unlike the relatively controlled conditions of the infant lab, mother-infant intervention takes place in the freewheeling realm of the home. It makes therapeutic use of improvisation and surprise. The work requires a holistic, versatile, and dialectical approach buttressed by all that we have learned from relational, developmental, neurological, and biological systems theories. This is couples treatment in which one member is wordless and communicates through the language of body and affect. Baby’s nonverbal communication drives the therapeutic triad deeply into the affective, implicit domains of experience, while also stimulating exploration within the reflective, symbolized domains. Home-based mother-infant treatment parallels the work that parents do daily in raising their children: We attempt to feel what it is that baby is expressing, as we also try to name it, give it meaning, and hold it in mind. Of course we also attempt to feel what the baby stimulates in his mother, name it and hold it in mind, but this is a more familiar aspect of psychoanalytic work with adults. The therapist’s experience is one of joining a constantly shifting relational system that moves between poles of repetition and transformation (Lachmann, 2001). This system and the treatment are filled with paradox. There is the infant’s press to develop, to accommodate, and to emerge as an individual within the mother’s more fixed psychic system. There is mother’s need to be recognized as the individual she is. She struggles with this need in the midst of her own negative representations and in face of her baby’s real and constant demands. Mother’s childhood experiences tie her to the past, even as she struggles to break these ties and move into the future with her child. Her relationship with baby lays bare her difficulty in developing those processes that would help to contain painful feelings and maintain consistent and sympathetic attachments. She longs to give her child a better life, but is mired in chronic difficulties that take time to recognize and to rework. For the therapist, the responsibility of intervening in the life of a very small child is great. She must live within the paradoxes of acting versus waiting, proscribing behaviors versus enabling them to emerge, moving into the future while honoring the past. Baby’s needs are such that he cannot wait for his mother to change. His presence in the session coupled with his developmental dynamism and very real dependency exert tremendous pressure upon both



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mother and therapist. This pressure stimulates intense transferencecountertransference responses, and lends transformative power to mother-infant work. The Frightened/Disorganized Dyad: A Clinical Perspective Frightened/disorganized mother-infant pairs can present a confusing clinical picture and each dyad is unique. The pathogenic interactions that occur are more difficult to see than the easily observed hostile-coercive behaviors found in other disorganized couples. One observes a number of positive mother-baby interactions and few overt fear-inducing behaviors. In many cases one initially senses a subtle climate of misattunement. The extent to which this climate reflects disorganization takes time to assess. The frightened mother’s eagerness for professional help can inflate assessment of her capacity for relatedness. In the home one begins to notice mother-baby interactions that are shaped according to which emotions mother can tolerate. It is often the infant who is responsible for approaching her. Careful observation reveals a mixed picture of maternal gentleness and sensitivity combined with affective miscommunications, or sudden loss of affect and attention. When mother struggles with dissociative states or impaired relatedness, she will be unable to consistently keep her baby in mind. Emotional blank spaces or “black holes” may exist within the dyad. These pockets of emptiness can be hard to observe in a rapidly moving relational scenario that also contains positive mother-baby relating. Unlike hostile mothers who may overwhelm baby with their intrusive and undifferentiated responses to his distress, frightened mothers may miss the distressed baby’s cues altogether, or respond in a contradictory, deferential, or helpless manner. This failure to provide consistent affect regulation can send the infant into emotional freefall. During these moments he may be overwhelmed by uncontained or unmirrored experience. Mother and baby interact differently in the various domains of care, which take time to observe and to assess. Negative or dysphoric exchanges may stress mother’s capacity to remain sensitively engaged more than interactions that are positive or neutral. The distressed baby who makes an intense emotional bid for his mother’s comfort and protection arouses different emotions in her than the baby who rubs dinner in his hair or joyfully shares a toy. When difficult emotions or painful memories are aroused, mother may appear passive, preoccupied, and unable to scaffold her baby’s experiences.



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On the other hand, some of mother’s responses are relaxed and flowing. Sometimes she responds positively to her infant’s desire to connect and interacts warmly and spontaneously. At other times she is able to react positively to baby’s attempts to structure their interactions, taking his lead and responding with appropriate feeling. The infants of frightened/disorganized mothers may show relatively subtle signs of disorganization themselves. In situations where mother and child do engage in some attuned interactions, the child continues to request comfort and care. Disorganized attachment research indicates that the infants of frightened mothers may show a superficially secure attachment strategy when stressed, but that unusual behaviors exist in conjunction with more normative ones. Sometimes the disorganized baby’s approach-avoidance behaviors can look more like ambivalence than the absence of a consistent attachment strategy. The mothers of disorganized infants may present within a wide spectrum of psychological functioning (Lyons-Ruth, personal communication, 2002), leading one to speculate that diagnosis and treatment may involve a sophisticated and subtle assessment of motherbaby interactions. In the following case vignette mother’s severe trauma history, her cognitively and affectively disjointed manner of relating this history, her dual diagnosis of alcoholism and bi-polar disorder, and her alienation from herself and her son are all consistent with the more severe spectrum of the disorganized dyads described in infant research. On the other hand, mother and son related to one another in a fair number of loving and mutually attuned ways that were surprising in light of such a troubled history. Mary and John: Initial Impressions Mary, a thirty-two-year-old married mother of a twelve-month-old son, was referred to The Center for Early Relationship Support by her psychopharmacologist, after her recent discharge from an alcohol detox program. The Center for Early Relationship Support is part of the Jewish Family and Children’s Service of Waltham, Massachusetts, and offers a variety of therapeutic services to parents and infants, including home-based parent-infant psychotherapy. At the time of referral Mary and John were also being followed by Child Protective Services. Mary had been diagnosed with PTSD, alcoholism, post-partum psychosis, and bi-polar disorder. At our first meeting she said, “I want to be a good mother, to give my son more than I got, but I don’t know how. I had horrible mothering, no role models. I am a drunk and a loser. I don’t even feel that much for my



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son. I don’t know who I am or what I’m doing here.” Mary was unable to claim her son or to acknowledge her motherhood, “I can’t call myself his mother, I don’t deserve him. Sometimes I think he hates me and would be better off with someone else.” Mary had been sober for only twenty-eight days. My visits to the home revealed Mary to be a sweet and tentative mother who was struggling to stay sober and to care for her child. John was a beautiful twelve-month-old with a shock of curly blond hair and ice-blue eyes. He was cheerful, curious, and engaging. He approached his mother for help and to share his toys, and they would laugh or be silly together at his prompting. I observed Mary and John sharing moments of pleasure, joy, and hilarity. Mary responded well to the structure afforded by particular aspects of John’s daily care. She showed sensitivity to his cues around eating and being diapered. In these domains John was never made to feel passive, ignored, or intruded upon by his mother’s agenda. Mary would wait patiently for John to signal the next spoonful or when it was time to continue diapering or dressing him. These interactions included much mutual gazing, turn-taking, and playful physical contact. Mary could also be attentive and natural in her responses to John’s ebullient expressions, and he regularly looked at her and reached for her to help him. As John interjected himself into the adults’ conversation Mary would encourage him proudly and speak of what a good and beautiful boy he was. But coupled with these positive behaviors were more ominous interactions. John often crawled around the house with the pet dog, dangerously unsupervised. He had difficulty focusing in on toys or play, but could spend an hour amusing himself alone in his crib. In these early home visits John would sometimes cry from the other room in the middle of some mishap, as Mary, in a world of her own, spoke to me of her terrible childhood experiences, her guilt, and her urge to drink. Mary asked, “Is it o.k. for him to play alone so much? I don’t want him to grow up with a black hole in the middle of him like I have.” Mary’s eyes spoke volumes of her fearful inner world, but her narrative tone was one of disorienting cheer. In our first interview she revealed the depth of her alienation, “I wake up in the morning and I wonder, whose baby is this, whose house is this, whose life is this?” Throughout our initial meetings Mary revealed her painful story. Her narrative was filled with contradictions, lapses in reasoning, and affective incongruence. Sequencing of events was so confused that I was unclear exactly what had happened to her and when. Mary’s intense self-absorption and dissociated states initially placed



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John on the periphery of our conjoint work. I observed that she did not seek John out as an emotional companion; it was he who initiated this type of contact. From time to time he could successfully engage her but I wondered how much work he had to do to make this possible. Mary could not consistently help John transform his negative states to positive or neutral ones. When he was distressed she would pick him up, but then put him down before he was sufficiently calmed. Toys were often offered as comfort instead of her body or voice. Mary often allowed John to get into highly charged emotional states that were on the verge of decompensation. She was unable to play with him; there were few spontaneous gestures of affection, and she often asked if he would like to go up to bed. I was uncomfortable with how little we included John in our initial sessions. He was continuing to do all the reaching out for contact, and I was caught between the imperative need to include him and my concern that doing so would cause Mary to feel ashamed or overwhelmed. History After John’s traumatic birth (a mishandled forceps delivery resulting in a subdural hematoma and seizures), Mary plunged into a post-partum psychosis, started to hear voices, and began to drink heavily. Some months into the treatment I learned that for the first eight months of his life, John was neglected and left alone for long periods of time in his crib without food or diaper change. Mary would drink and go to bed, “covering my head so that I couldn’t hear his cries.” For these first eight months Mary was living with her husband Peter and his parents, all of whom were at work during the day. Peter was unable to offer adequate protection or containment for his wife and son. He was aware of Mary’s drinking, but desperate to keep his job and needed to deny a drinking problem of his own. Then when John was about three months, Peter demanded that Mary enter a detox program, which she did. There were two unsuccessful hospitalizations during this time. A year into our treatment Mary shared that she often cared for John in drunken blackout states, and lived in terror that she had physically injured him. During his first eight months, John responded well to the evening return of his father and grandparents, but there was tension between Mary and her parentsin law. When John was nine months Mary and Peter moved with him into a home of their own. The move allowed Mary to be closer to her father (a twenty years sober alcoholic), and enabled Mary to attend



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Fraiberg, S. (1980). Clinical studies in infant mental health. New York: Basic Books. Freud, S. (1923). The ego and the id. S.E., v. XIX, p. 26. Goyette-Ewing, M., Slade, A., Knoebber, K., Gilliam, W., Truman, S. & Mayes, L. (2002) Parents first: A developmental parenting program. Unpublished Manuscript, Yale Child Study Center. Grienenberger, J., Popek, P., Stein, S., Solow, J., Morrow, M., Levine, N., Alexandre, D., Ibarra, M., Wilson, A., Thompson, J. & Lehman, J. (2004). The Wright Institute Reflective Parenting Program workshop training manual. Unpublished manual, The Wright Institute, Los Angeles. Heinicke, C., Fineman, N., Ruth, G., Recchia, L, Guthrie, D., & Rodning, C. (1999). Relationship-based intervention with at-risk first time mothers: Outcome in the first year of life. Infant Mental Health Journal, 20, 349 – 374. Heinicke, C., Fineman, N. R., Ponce, V. A., & Guthrie, D. (2001). Relation based intervention with at-risk mothers: Outcomes in the second year of life. Infant Mental Health Journal, 22, 431– 462. Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. Kitzman, H., Olds, D., Henderson, C., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries and repeated childbearing. JAMA, 278, 644 –652. Kitzman, H., Olds, D., Sidora, K., Henderson, C. R., Hanks, C., Cole, R., Luckey, D. W., Bondy, J., Cole, K., & Glazner, J. (2000). Enduring effects of nurse home visitation on maternal life course. JAMA, 283, 1983 – 1989. Korfmacher, J., O’Brien, R., Hiatt, S., & Olds, D. (1999). Differences in program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: A randomized trial. American Journal of Public Health, 89, 1847–1851. Lieberman, A. F. (1997). Toddlers’ internalizations of maternal attributions as a factor in quality of attachment. In Attachment and Psychopathology, eds., K. Zucker & L. Atkinson. New York: Guilford, pp. 277–290. Lieberman, A. F. (2003). Starting early: Prenatal and infant intervention. Paper presented at Irving B. Harris Festschrift, Chicago, May 12, 2003. Lieberman, A. F., Weston, D., & Pawl, J. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199 – 209. Lieberman, A., Silverman, R., & Pawl, J. (1999). Infant-parent psychotherapy: Core concepts and current approaches. In Zeanah, C. H. (Ed.) Handbook of Infant Mental Health, pp. 472–485. New York: Guilford Press. Mayes, L. C., & Cohen, D. (2002). The Yale Child Study Center guide to understanding your child. New York: Little Brown. Olds, D. (2002). Prenatal and infancy home visiting by nurses: From randomized trials to community replication. Prevention Science, 3, 153 –172. Olds, D., Hill, P., Robinson, J., Song, N., & Little, C. (2000). Update on



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twice daily AA meetings. At that time Mary was frantic and depressed about John’s behavior toward her. Until he was eleven months, John rejected his mother’s attempts to connect. He screamed when she held him, would not gaze into her eyes, and would not smile at or reach for her. One month into Mary’s sobriety John began to reach out to her for comfort and to track her visually, but at thirteen months he developed a strange rolling eye movement in her presence. John had been followed neurologically since birth and there had been no sequelae from his early seizures or hematoma. The strange eye movement was determined to be non-organic in nature. Mary’s own childhood had been devastating. When she was a one year old her schizophrenic mother attempted to drown her in the bath and she required resuscitation. Mother then abandoned the family and was in and out of young Mary’s life. For a time Mary was passed among relatives so that her father could work. When father remarried three years later (Mary was four) she lived through cruel and degrading neglect at the hands of her stepmother, who locked her in her room each day, refusing to feed her or allow her to use the toilet. She was often locked outside of the house while her stepsiblings had after-school snack. In winter the kindness of an elderly neighbor sheltered Mary from the cold. Mary began to drink at age fourteen. But despite the depth of her difficulties, during adolescence Mary felt she had the love of her paternal grandparents and recently sober father. She lost her fear of her “evil stepmother” and became provocative and oppositional. She successfully completed high school and college and went on to have several interesting and responsible jobs. She fell in love with a gentle if troubled young man, and married into a large family. Formulating the Treatment The initial treatment plan was to offer weekly mother-infant sessions in the home in conjunction with twice daily AA meetings. But two months into our work Mary began to reveal the depth of John’s neglect and the severity of her childhood trauma. Our mother-baby work was heightening Mary’s affective numbing and flooding, and she was struggling to stay sober. It became clear that weekly conjoint sessions would not provide adequate containment to safely explore Mary’s issues. With some concern about the complexity of combining therapeutic modalities, I offered her additional weekly individual meetings in my office and telephone sessions as needed. Mary and John each needed to feel held, known, and remem-



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bered. But how to provide a relationship in which this would be possible? How to untie this Gordian knot of longing and dread? Mary had been brutalized and overlooked in childhood. Her subsequent difficulties establishing evocative constancy, affect regulation, and reflective capacity meant that she would not have attained the level of symbolic thought, verbal self-awareness, or affect tolerance necessary to fully engage in a conventional interpretive psychotherapy. I envisioned the individual work and mother-infant sessions as existing in a figure-ground relationship. My objective was to develop a therapeutic relationship that would provide mother and son with the experience of containment and safety. I hypothesized that as her fear and distress diminished in her relationship to me, Mary would become more capable of recognizing and naming her own feelings and of evoking a calming maternal introject to soothe herself and her son. I hoped that Mary’s growing attachment to me (and my holistic vision for her) would take integrative hold and help bridge the gap between her current level of functioning and her emerging potential. The gains we made in individual and conjoint sessions informed and reinforced one another and were articulated within the context of mother’s and son’s developmental strivings. In his book The Motherhood Constellation (1995), Stern describes the dynamic interplay between representation and behavior: change in one area affects change in the other. I hoped that in this urgent situation the combination of individual with conjoint sessions would maximize impact in both representational and behavioral domains and modify the pathogenic enactive representations that crippled Mary’s psychic functioning. Home-based mother-infant work offers a rich tableau of implicit interaction and a profound sense of intimacy. It integrates traditional psychoanalytic approaches with interventions designed to have immediate impact upon mother and child’s relating. Combining immediacy with enactment would afford us the opportunity to hold painful experiences in the moment, even as we “practiced” new forms of relating. Within individual and conjoint sessions we could unpack those interactions in which older and more troubled patterns held sway. In addition, Mary’s developmental strides within our dyadic relationship could be transferred to the immediate interactive realm of mother and son. But the developmental pathway we traveled was rocky and uncharted. Initially we did not know that the journey would require our living through repeated painful and overwhelming states of desperation and danger.



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Attachment Crisis in the Treatment One month after adding individual sessions, I took my first vacation. This precipitated a profound crisis for Mary. Leading up to the interruption she was dismissive of suggestions that we explore the possible impact upon her of our separation. A few days before our break, Mary called me in an inebriated and near blackout state. Her voice was that of a desperate and confused little girl. As she spoke I could hear John playing near her. “I’m sorry, I can’t go on; I’m such a loser. Everyone is better off without me. They’ll be angry at me for a while and then they will forget. I am holding a knife and I don’t think I can control myself. I want to cut myself. I want to die. No I don’t, please, please, help me . . . can you help me? I am so scared . . . No, it’s too late for me, I am hopeless, it’s all hopeless.” Mary felt that John was better off without her and that he would soon “forget her,” as no doubt she thought I had also done. Despite my efforts during that phone call, she was unable to use me as a soothing presence; it appeared that all our work was lost. Mary placed the phone down as I listened in utter helplessness, trying to discern if John was all right and what had happened to his mother. I called 911 on my cell phone and did not hang up until I heard the EMTs arrive. Mary had passed out on the couch with John playing quietly at her feet. Usually an active child, fourteen-month-old John had apparently understood that something dangerous was happening and that he should stay by his mother. During those moments I understood the terror and isolation that Mary must have felt so often in childhood. Caught in a transferencecountertransference storm, I had become the abandoning mother who filled her with uncontainable and terrifying feelings. Mary felt compelled to enact this role with her son. In contradiction to the malevolent power that I unwittingly possessed, my helplessness made me feel that I did not really exist. Mary could not remember either John or myself and was sure that we would soon forget her. I wondered how often John might feel similar chaotic states of victim-victimizer, of absolute destructive power and utter non-existence. Waiting in silence on the phone, I struggled through my own fear to keep all of us alive within my mind. Later on I understood that it had been my role to bear witness to and to memorialize a dangerous attachment crisis for which Mary and John would have no explicit memory or language. Mary had delivered into our threesome the nameless dread of her infancy; that



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she would be the victim/perpetrator of abandonment or murder. I came to accept that if we were to work deeply enough to stimulate growth, the shadow of deadliness would have to fall across our relationship. We three had survived the specter of Mary’s past trauma and its fearful visitation upon the next generation. Mary’s near death as a wordless one year old had returned as her possible suicide in front of John and myself. She spent our first interruption in a psychiatric hospital. Living through this crisis marked a turning point. We had glimpsed the gaping black hole of Mary’s longing and terror and could now begin to build bridges across it. The following vignette, taken from a mother-infant session three weeks after my return and Mary’s discharge from hospital, illustrates how mother and son allowed me into their anxious and disorganized relating. It also demonstrates my attempts to enhance their communication by combining traditional psychodynamic approaches with interventions on an immediate interactive level. Process Vignette I arrive for a session in the home. John has just returned from daycare and seems tired and cranky. He is standing in front of the refrigerator yelling “more cheese!” over and over. He is spinning out of control. He reaches up for his mother. Mother: (stepping away from him and speaking sweetly.) “You’ve had enough cheese, soon its dinnertime, let’s go in the living room.” (She turns to walk into the living room. She appears tuned out, unable to hear or notice him.) John starts to scream, and throws himself on the floor sobbing. “Cheese, mama, more cheese!” (His eyes are glassy, his face red and puffy with exertion, it’s all I can do not to pick him up.) Mother: (with false sympathy) “No more cheese, sorry.” (angrily) “You have to learn not to get so upset. I’m getting frustrated.” John is up off the floor and asking to be held by mother. She picks him up but puts him down before he can settle. He asks again to be held and then strikes her in the face as she reaches for him. She puts him down again, more forcefully. John staggers away while pitifully crying for his mother. He begins to wander aimlessly around the house, stumbling over his toys. He suddenly lies down on the rug and becomes very quiet. Mother looks at me, frightened. Therapist: “O.K., lets try to figure out what’s going on and what each one of you is feeling right now.” (I sit by John, as he lies exhausted on the rug.) Mother: “I feel frustrated and helpless to make him feel better. I’m not a good mother. I don’t know how to handle this stuff. He confuses me, I try one thing and another but nothing helps.”



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Therapist: “Hard to handle this confusion and helplessness . . . When you can’t help him it must make you feel bad about yourself, and upset with him. You probably want to get away from it all . . .” Mother: “He makes me so frustrated, like I can’t do anything right, and then he hits me . . . am I raising him to be spoiled? I just tune out, try to stay away from him. I go upstairs and lock the stair gate, or come into the kitchen to be alone. He cries and cries. Sometimes I try to help him but it doesn’t make any difference.” Therapist: “Tell me about tuning out . . . what’s that like, where do you go?” Mother: “I don’t know, somewhere else. To a place where I don’t feel much . . . always hated it when there was arguing in my house, hated all the upset. I could never please the “evil stepmother” anyway. No one really cared how I felt, but I could check out . . .” Therapist: “This must be so hard for you. As a child never pleasing anyone, now feeling you can’t make John happy either . . . No one helped you to manage your feelings when you were a child, scared and alone. You must have handled it by tuning out . . . Kids have pretty strong feelings . . .” Mother: “He doesn’t know how to let me help him. I don’t know how to do it . . .” John has soothed himself a bit with a toy. As mother sits down, he asks for her lap. As she again begins to hold him, he stiffens and arches away from her. She makes a move to put him down again. Therapist: “You’re both upset and confused, but could we try to stay in this upset place for a moment more, just to see what might happen next?” (Mother continues to hold him and John squirms but remains with her. I come and sit on the couch very close them, almost touching Mary.) Mother: (tentatively) “I don’t know if I should say something to him . . .” Therapist: “Would you like to? What do you think he might need to hear?” Mother: (speaking with real sympathy to John and holding him closer as they begin to look at one another.) “I know you are angry about no more cheese, I’m sorry you’re angry, but soon I will make your dinner. Now you are starting to feel a bit better.” Therapist: “Maybe John doesn’t know how to get the help he needs when he’s angry or frustrated . . . maybe he gets scared . . . I thought you looked scared too, a few minutes ago . . .” John relaxes in mother’s lap and asks for his favorite stuffed animal, which I retrieve. Now John has his mother’s lap, his thumb and his transitional object. Both mother and son sit quietly together as the affect storm passes. Their bodies relax into one another. Therapist: “Hard work today you guys! You had some good ideas about how to calm him with your voice and your body. You let him know that you could feel his anger, and that there might be a way back from that with your help. Look at how he relaxes when you gather him in like this. I can see that he feels safe and calm, how do you feel now?”



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Mother: “Maybe I can help him . . . Maybe I don’t have to dread being with him if there are things that I can do to help him to be happy and grow.”



The Frightened/Disorganized Mother-Infant Paradigm as Illustrated in the Vignette The vignette illustrates how Mary’s dissociation and contradictory behaviors leave John feeling confused and uncontained. Mary’s initial unpredictable loss of affect makes John feel scared that he cannot find his mother. She inadvertently renders him helpless to find the way back from distress, because he can find no context for her inexplicable (endogenous) and non-contingent responses. With no reliable way to re-connect, John has no means of resolving his frightening lack of containment. In more attuned circumstances, he would learn to know himself through sensitive connection to the one who knew him. In the current relational context his alternatives are either to exist alone within an unmirrored and inchoate psychic state, or to join his mother in an alien one. John’s disorganized attempts to engage his mother are also inexplicable and frightening to her. His behavior renders her helpless to comfort him. Mary feels persecuted by John’s inconsolable demands and the specter of her abusive stepmother. She escapes into a dissociated and withdrawn state. Anxiously preoccupied and coping with the powerful affects that John arouses, Mary must get away from him, she must abandon John in her mind. At moments like this he is in emotional free fall, out of control and alone, just as Mary must have been, just as she remains. In these intense emotional exchanges around John’s need for comfort and protection, Mary both fears and dreads the baby who arouses in her the raw feelings and traumatic memories that are the legacy of her own childhood. John has become the message and not the messenger, the “ghost” of her own past (Fraiberg, 1975). Over time John will internalize both sides of these repeated and confused interactive sequences, just as his mother did (Lyons-Ruth et al., 1999, Liotti, 1999, Main and Hesse, 1990a). While it is difficult to predict developmental pathways, it is likely that John would come to experience himself as one who is both a persecutor and a victim. Repeated exposure to traumatic affect levels would likely impede his capacity to attain “personal synthesis” and to make meaning of experience, resulting in multiple and discontinuous inner representations (Liotti, 1999). John’s vitality, self-assertion, and depth of feeling could become a source of fear rather than of self-confidence. His mother’s inability to consistently respond to his basic needs for com-



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fort and protection leave John vulnerable to feelings of shame, rage, anxiety, and emotional confusion. With no way to make restitution, he is perpetually without agency. His options include excessively controlling behavior and/or living in a state of chronic mourning (Socarides and Stolorow, 1984). Interventions Illustrated in the Vignette I attempted to offer in-the-moment engagement with mother and baby as they negotiated highly charged and discordant interactions. While both positive and negative interactive patterns were reflected upon, the emphasis was on finding what worked and supporting mother’s positive role. Articulation of mother’s constructive engagement offers her support as well as an increasing capacity to observe the interaction. (“You let him know that you could feel he was angry . . . you had some good ideas about how to calm him . . .”) When asked, a therapist may make suggestions around behaviors but the focus is not educational or directive. Over time, observing and naming repetitive interactive patterns as they occurred helped to enhance Mary’s feelings of mastery. Her increasing sensitivity and consistency toward John’s need for comfort also allowed him to feel more competent and less frightened. Mary was eventually able to see for herself that when she avoided John or dissociated in his presence, his behavior grew more disorganized. Predicting that which triggers interactive patterns renders them knowable and containable. It also offers the possibility that some new way of relating may be possible. We worked to promote an atmosphere in which our threesome could experiment with improvising behaviors and then watch what might emerge between us. We attempted to make manifest the separate emotional experiences of mother and baby as the interaction unfolded. With time we were able to introduce John as a continuous presence in his mother’s mind, while simultaneously articulating how difficult this was for her to bear. We clarified Mary’s defensive need to escape, and to reject or minimize John’s needs. The initial interaction was driven by Mary’s defensive exclusion of John’s escalating bids for comfort. I empathized with Mary, explored her dissociated response to John, related these responses to her childhood experiences, and gently clarified her projections onto her son. In his vulnerability and need John had become Mary’s enraging and menacing parent and her frightened/frightening and uncontainable self. John was the source of Mary’s guilt, the attacking other who persecuted her with his relentless demands. It was difficult not



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to comfort John in his distress, but I believe that this would have shamed his mother. Feeling for Mary’s and John’s affective states and developmental capacities within each interaction provided direction for the improvisation of new “relational moves” (Stern and Sander, et al., 1998). Improvisation addresses experience and change within the procedural domain, and it provides an interactive format in which to modify compulsive role assignments and to model containment. It is enhanced by the baby’s natural dynamism. It makes use of mother’s open sharing of feelings and fantasies, along with the baby’s emotional expressions, as they are experienced in the moment. Mary’s softening of tone and defensive stance (He doesn’t know how to let me comfort him. I don’t know how to do it . . .) signaled her readiness to let me into her confusion around how to interact with John. I began to wonder if something new could happen between us. I believe that it was the lending of my physical presence (moving back and forth between them) that offered the following unspoken response to Mary: “I can empathize with and hold both of your emotional states. I am free to move within your compulsive and confused enactment. You can use me to bridge the gap between your current level of interacting and something that will be more complex and new.” As I sat close to Mary and John on the couch, Mary continued to relax her defended stance. Tentatively she mused, “I don’t know if I should say something to him.” At this point in the interaction a new developmental level of relating was about to emerge. Combining Individual Adult Work with Mother-Baby Sessions Mary’s suicidal crisis lent great urgency to our top priority: To establish a therapeutic relationship that would offer open and responsive emotional contact and modulation of fear. Mary’s suicidal gesture had delivered into our relationship all the uncontained emotions of her childhood. I believed that we were going to have to feel our way through the therapy and live through the unnamed terrors, giving narrative voice to the process when we could. In the words of Phillips, sometimes, “stories are lived before they are told” (quoted in Holmes, 1996, p. 167). giving voice Mary struggled to put words to feelings and experiences. In the mother-baby sessions at home I had began to gently draw her into my



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curiosity about John’s behavior and motivations. In individual sessions I expressed a similar curiosity about Mary. Together we created a lexicon that captured the unique experiences of mother and baby. It has been hypothesized that within the adult narrative lies the blueprint of early attachment experiences (Slade, 2001). The linguistic structure of adult narrative traces the range of affective communication permitted within the earliest relationship and the child’s need to adapt to the attachment figure’s defensive constraints upon relating. Factual and affective incongruencies, unmonitored lapses in reason and logic, paucity of affectively charged descriptions and defensive idealizations, or minimization of cruelty and neglect indicate an insecure and emotionally constricted attachment relationship (Main and Hesse, 1990a, Slade, 2001, Holmes, 1996). I believe that the act of creating a lexicon, coupled with capturing the specific experiences of mother and baby, helped to expand Mary’s emotional communication and her reflective functioning. Our widening conversation implied an increasing ability to express and to hold deep feelings. Over time our shared language offered Mary a way to name her own complex internal states and to feel more in control. It enabled her to speculate about and to feel for the inner life of her child. During intense emotional exchanges between mother and son our familiar phrases were a source of comfort and orientation for Mary. We found it particularly helpful at such times to use expressions that conveyed active containment, such as “getting your arms around” a feeling, “gathering in” a disorganized baby, or “finding the way back” to a quiet and connected state. metabolizing fear Mary was afraid of everything. Her terrors had derailed her efforts after mastery and psychic wholeness. Toxic levels of fear occluded her ability to create and to synthesize (inter)personal meaning. Fear had interrupted her ability to attend or even to maintain a consistent state of consciousness. Abuse and neglect had taught Mary to expect that her feelings would be forgotten or obliterated. Frequently slipping into dissociated or empty states, Mary often did not know what she felt. We set out to explore the “black hole” left by Mary’s trauma, and the overwhelming feelings and contradictory inner representations it had spawned. With each frightening memory or state delivered into the treatment we entered a new interpersonal negotiation. We asked, how could Mary contain her upset around John? What feel-



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ings did he arouse in her? How could she use her relationships (with me, her husband, and her AA sponsors) for soothing and containment? Mary and I paid careful attention to how we made contact, and related this to patterns of emotional communication between mother and son. Her initial requests to connect were subtle, often overridden by an expectation that she did not matter and could not be known or contained by another. Mary had covered her childhood devastation with an avoidant style and disorienting cheer, punctuated by states of panic and emptiness. Her affective cues were as confusing to me as they must have been to John. But eventually we were able to frame our miscommunications within the context of Mary’s longing to have her attachment needs met and her dread that I would rebuff her. Gianino and Tronick, (1988) link the ability to repair affective mismatches in infancy to the establishment of the attachment figure as reliable and trustworthy. Experiences of disruption and repair also contribute to the infant’s sense of mastery and control and to the development of a positive emotional core. I believe that within the transference Mary’s increasingly secure attachment to me offered her similar gains. Her diminishing fear led to an increased sense of agency and inner cohesion and to a budding capacity to make reparation to her son. Mary and I were able to name her intense feeling states (or absence of feeling), and give voice and shape to her chaotic inner representations. We observed the ways in which she dissociated during powerful emotional eruptions around John, her confusing responses to his need for comfort, and his disorganization in response. Consistent inquiry into Mary’s inner states introduced the notion that I could know and remember her. At the same time we observed the ways in which Mary’s intense and confusing experiences impeded her ability to keep John in mind and to represent him as a separate being. As her affect tolerance and self-reflective abilities increased, Mary and I could more deeply explore the relational context in which powerful feelings or defenses against them emerged. She struggled to share her private terror, anger, and emptiness with me, while valiantly attempting to make loving contact with her son. Our conversations signaled to Mary that she could use our relationship to hold and metabolize her confusion and fear and to gather in the disavowed parts of herself. As demonstrated in the vignette, genetic material was used to promote compassionate understanding and personal perspective. Within the first year of our work, Mary minimized or dismissed transference interpretations, and they



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did little to enhance our relating. But each new aspect of Mary’s experience, no matter how disturbing, was offered a place in our conversation. She began to send me e-mail messages about fantasies that scared her. These messages I saved for her until she felt safe enough to address them in person. We then began to anticipate the emergence of the “evil stepmother’s” cruel and degrading voice within Mary. We called this frightening figure out of the shadows, stared her down, and told her that her days as a saboteur were numbered. Mary’s need to defend against the feelings John aroused coupled with her cognitive dysregulation (dissociation and transient thought disorder) had rendered her unable to consistently attend to their relationship. In mother-baby sessions we worked to enhance responsive relating by containing the fear and anger aroused by John’s need for comfort. In individual sessions we explored how Mary’s attachment needs within the transference paralleled those of her son. Mary was the mother of a child she could not comfort and a child herself in need of comfort. Over time, as we co-constructed the scope and pace of what emerged between us, Mary’s inner representations (terrifying mother and terrified/enraged child, idealized rescuer and cruel saboteur) existed side by side with a budding new way of our being together: We became a collaborative therapeutic team. Less constricted by her own defensive exclusion of painful affects, Mary developed freer access to her own inner world and to the emotional world of her son. As she began to release John from her malevolent projections and her need to control the fear he aroused, he emerged as a positive force of nature, a baby to be loved and understood. Conclusion In cases of frightened/disorganized mother-infant couples, the combination of individual adult work along with mother-infant sessions can significantly enhance the development of responsive emotional communication and intersubjective sharing within the dyad. During the first year of our work, Mary was able to transfer her growing security of attachment to me onto her relationship with John. The process has been slow and painful however. During our first year of treatment there were several bouts of drinking, psychosis, and suicidality, stimulated each time by my taking a vacation. But Mary has been increasingly able to remain connected to me during our interruptions, with fewer overwhelming states of abandonment or deadly nothingness. She is feeling more at home in the fluid psy-



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chic space that encircles attachment and separation. With the help of psychotherapy, pharmacotherapy, and AA, she has not had a drink in fourteen months. Mary continues to use our relationship to hold her fear and her rage. The frightening inner representations and emotions that inhabit her psychic landscape have emerged in full force. She has addressed violent fantasies of throwing her son out the window or slashing his face with a knife. She has been able to use me as a secure base around disorienting and psychotic flashbacks. Having partly freed the mother-child relationship from the toxic intrusion of intolerable affects, we continue to address the need to name and to metabolize such feelings in all areas of Mary’s life. We continue to explore the emotional impact of mother and son upon one another and their patterns of communication. Sometimes I am rocked by Mary’s vacillating experiences of flooding and deadness. I continue to worry and wonder about the impact of John’s early life upon his future development. But the projections, dissociation, and affective misattunements, so prevalent in Mary’s early relationship with John, have abated. Although prone to regression around his mother’s psychic upsets, John has responded beautifully to her increasing sensitivity and reliability. Much work remains to be done, but John now looks consistently to his mother for soothing and protection. His requests for care and protection are not conflicted; they are the expressions of a child who anticipates that comfort and aid will be forthcoming. Mary feels more connected to herself and to her son. She takes great pride in how John is developing as an individual, and the important role she has played in this. While an in-depth analysis of the multiple transferences of trauma survivors is extremely relevant to this case, it exceeds the scope of my discussion. Several authors have written about the fluid and unintegrated inner representations and discontinuous transferences of victim, victimizer, and rescuer in trauma survivors (Davies and Frawley, 1991, Liotti, 1999). It remains unclear whether Mary will be able to analyze her murderous maternal transference toward me, or if this is even advisable. It may be that in cases of severe early loss and trauma, rage in the transference represents too great a threat to the therapeutic relationship and requires metabolizing and repair in displacement. To date, Mary has very much needed to keep me as a “good enough mother.” The difficulties in depicting mother-infant psychotherapy are similar to those one faces in describing human relating and development



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in general. The case discussion must illuminate both intrapsychic and interpersonal phenomenon. It must describe recursive and potentially emergent relational processes within a format that is predominantly linear, narrative, and deterministic. It should discuss both implicit and explicit modes of relating, remembering, and meaningmaking as developmental constructs and as mutative factors within the psychotherapy itself (Lachmann, 2001, Stern and Sander, et al., 1998). To further complicate matters, the thousands of non-verbal gestures, and affectively nuanced communications that would provide the reader with critical information, remain out of the participants’ awareness and cannot be recorded. But despite all these imperfections, case studies can bring to life the depth and complexity of our work. Finally, another difficulty in writing case material is that in an effort to create a narrative out of what is essentially a kaleidoscopic interpersonal experience, the case is rendered too neat and organized. I understood the process of my work with Mary and John both prospectively and retrospectively. Some concepts came to me before or during the time they emerged within the treatment, most did not come to life conceptually until I had already acted intuitively and improvisationally. My application of concepts from attachment theory and psychoanalysis helped shape the treatment, but is not intended to impose a privileged position over other useful and creative approaches to mother-infant work. I have offered vignettes from a mother-baby psychotherapy in which I applied principles from attachment theory and psychoanalysis to help a troubled mother emotionally engage with her infant son. A major function of the attachment system is to buffer the infant’s stress so that he is free to grow within himself and secure in the exploration of his world. Mary and John’s relationship, colored by chronic states of fear and emptiness, was the legacy of Mary’s childhood attachment trauma. Without interventions designed to respond to the attachment needs of both mother and son, they would have had little opportunity to explore sensitive emotional relating or creative and meaningful engagement. In addition, attachment theory enhanced my understanding of mother’s developmental deficits and baby’s incipient developmental stressors, and provided a logic to the interplay between my individual work with mother and my work with mother and baby together. Central to my work with Mary and John was the development of three interrelated functions that any “ordinary devoted” mother (or other caregiving figure) provides for her child: responsive engagement in



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regulating her baby’s affect, her own capacity to evoke a compassionate and soothing maternal introject, and her ability to reflect upon baby’s experience, to keep him continuously in mind. While these concepts are not new to psychoanalysis, they nest nicely within attachment theory, which operationalizes them and grounds them in empirical research. Post Script Recently, Mary and I were reviewing the progress that she and John have made (John is now two and a half). She related that while packing up some of his infant clothes she had been overwhelmed with how vulnerable John had been as a small baby, how he had needed her, and she wasn’t there. She remembered with great sorrow and remorse leaving him for long spells alone in his crib. Then she related this story: After school yesterday John and I were playing together in his room, like I am trying to do more with him these days. He began a new game: he put me in his big boy bed, covered me with his favorite blanket, kissed me goodnight and went out of the room, closing the door. Without thinking about it I began to cry, “Mama! Mama, I am scared, Mama!” He rushed into the room, snuggled me with the blanket, and kissed me softy, whispering, “o.k. baby, don’t cry baby, don’t cry,” and went out. We repeated this game several times; each time he came in and comforted me. Then it was his turn. He wanted to be in his bed with the covers. I kissed him, said goodnight, and left the room. He pretended to cry, “Mama, come, Mama!” I rushed in as he had done, kissed him, and cozied him up with the blankets, telling him that everything was all right. After doing this several times he became quite relaxed and quiet. He looked so peaceful lying snugly in his blankets. And then, as I sat there on the edge of his bed, I experienced a moment of grace. I realized that I can comfort my child!



The child who no longer arouses intolerable feelings resides more securely in his mother’s heart and mind.



BIBLIOGRAPHY Beebe, B. & Lachmann, F. M. (2002). Infant research and adult treatment. Hillsdale, N.J.: Analytic Press. Bleiberg, E. (2002). Attachment, trauma and self-reflection: Implications for later psychopathology. In J. Martin Maldonado-Duran (Ed.), Infant



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and toddler mental health (pp. 33 –56), Washington D.C.: American Psychiatric Publishing. Bretherton, I. & Waters, E. (1985). Growing points of attachment theory and research. Monographs for the Society for Research in Child Development, 50(1–2). Davies, J. M. & Frawley, G. F. (1991). Dissociative processes and transference-countertransference paradigms in the psychoanalytically oriented treatment of adult survivors of childhood sexual abuse. Psychoanalytic Dialogues, 2 (1), 5–36. Fonagy P. (2001). Attachment and psychoanalysis. New York: Other Press. Fonagy, P. & Target, M. (1997). Attachment and reflective function: Their role in self-organization. Development and Psychopathology, 9, 679 –700. Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). The roots of borderline personality disorder in disorganized attachment. In P. Fonagy, G. Gergely, E. L. Jurist, & M. Target (Eds.), Affect regulation, mentalization and the development of the self (pp. 343 –372). New York: Other Press. Fonagy, P., Steele, H., Moran, G., Steele, M., & Higgitt, A. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 13, 200 –217. Fraiberg, S. & Shapiro, V. (1975). Ghosts in the nursery. Journal of the American Academy of Child Psychiatry, 14, 387– 421. Furman, E. (1992). On feeling and being felt with. Psychoanalytic Study of the Child, 47, 67–84. Gianino, A., and Tronick, E. (1988). The mutual regulation model: The infant’s self and interactive regulation. In T. Field, P. McCabe & N. Schneiderman (Eds.), Stress and coping across development (pp. 47– 68), Hillsdale, N.J.: Erlbaum. Holmes, J. (1996). Attachment, intimacy and autonomy: Using attachment theory in adult psychotherapy. Northvale, N.J.: Jason Aronson. Jacobvitz, D., & Hazen, N. (1999). Developmental pathways from infant disorganization to childhood peer relationships. In J. Solomon & C. George (Eds.), Attachment disorganization (pp. 127–159). New York: Guilford Press. Lachmann, F. M. (2001). Some contributions of empirical infant research to adult psychoanalysis: What have we learned? Psychoanalytic Dialogues, 11 (2), 167–186. Ledoux, J. E. (1996). The emotional brain: The mysterious underpinning of emotional life. New York: Simon and Schuster. Liotti, G. (1999). Disorganization of attachment as a model for understanding dissociative pathology. In J. Solomon & C. George (Eds.), Attachment disorganization (pp. 291–317). New York: Guilford Press. Liotti, G. (1992). Disorganized/disoriented attachment in the etiology of dissociative disorders. Dissociation, 5, 196 –204. Lyons-Ruth, K. (2001). Hostile-helpless relationships and disorganized attachment. Division 39 Newsletter.



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Lyons-Ruth, K. (1999). The two-person unconscious: Intersubjective dialogue, enactive relational representation, and the emergence of new forms of relational organization. Psychoanalytic Inquiry, 19 (4), 577– 617. Lyons-Ruth, K. (1998). Implicit relational knowing: Its role in development and in psychoanalytic process. Infant Mental Health Journal, 19 (3), 282–289. Lyons-Ruth, K. & Jacobvitz, D. (1999a). Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral and attentional strategies. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 520 –554). New York: Guilford Press. Lyons-Ruth, K., Bronfman, E. & Atwood, G. (1999b). A relational diathesis model of hostile-helpless states of mind: Expressions in mother-infant interaction. In J. Solomon & C. George (Eds.), Attachment disorganization (pp. 33 –70). New York: Guilford Press. Lyons-Ruth, K. Alpern, L., & Rapacholi, B. (1993). Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the pre-school classroom. Child Development, 64, 572–585. Main, M. (1991). Metacognitive knowledge, metacognitive monitoring and singular (coherent) vs. multiple (incoherent) models of attachment: Findings and directions for future research. In J. Stevenson-Hinde & P. Marris (Eds.), Attachment across the life cycle (pp. 127–157). London: Routledge. Main, M. & Hesse, E. (1990a). Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In M. Greenberg, D. Cicchetti & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research and intervention (pp. 161–184). Chicago: University of Chicago Press. Main, M. & Solomon, J. (1990b). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. Greenberg, D. Cicchetti & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research and intervention (pp. 121–160). Chicago: University of Chicago Press. Moss, E., St. Laurent, D., & Parent, S. (1999). Disorganized attachment and developmental risk at school age. In J. Solomon & C. George (Eds.), Attachment disorganization (pp. 160 –186). New York: Guilford Press. Phillips, A. (1987). Winnicott. London: Fontana. Russell, P. L. (1998). Trauma and the cognitive function of affects. In J. G. Teicholz & D. Kriegman (Eds.), Trauma, repetition and affect regulation: The work of Paul Russell (pp. 23 –47). New York: Other Press. Schore, A. (2001a). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22 (1), 7–66. Schore, A. (2001b). The effects of early relational trauma on right brain de-



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velopment, affect regulation and infant mental health. Infant Mental Health Journal, 22 (1), 201–269. Schore, A. (1994). Affect regulation and the origin of the self. Hillsdale, N. J.: Erlbaum. Schuengel, L. C., Bakermans-Kranenberg, M. J., van Ijzendoorn, M. H. & Blom, M. (1999). Unresolved loss and infant disorganization: Links to frightening maternal behavior. In J. Solomon & C. George (Eds.), Attachment disorganization (pp. 71–94). New York: Guilford Press. Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press. Slade, A. (2001). The development and organization of attachment: Implications for psychoanalysis. Journal of the American Psychoanalytic Association, 48 (4), 1147–1160. Socarides, D. & Stolorow, R. D. (1984). Affects and self-objects. The Annual of Psychoanalysis, 12/13, 105 –120. Solomon, J., George, C., & Dejong, A. (1995). Children classified as controlling at age six: Evidence of disorganized representational strategies and aggression at home and at school. Development and Psychopathology, 2, 31–46. Stern, D. (2004). The present moment in psychotherapy and in everyday life. New York: W. W. Norton and Company. Stern, D. (1995). The motherhood constellation. New York: Basic Books. Stern, D. (1985). The interpersonal world of the infant. New York: Basic Books. Stern, D., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan, A. C., Bruschweiler, N., & Tronick, E. Z. (1998). Non-interpretive mechanisms in psychoanalytic therapy: The “something more” than interpretation. International Journal of Psycho-Analysis, 79, 903 – 921. Stolorow, R. (1997). Dynamic, dyadic, intersubjective systems: An evolving paradigm for psychoanalysis. Psychoanalytic Psychology, 14 (3), 337– 346. Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148 (1) 10 –20. Tronick, E. Z. (1989). Emotions and emotional communication in infants. American Psychologist, Feb. 112–119. Winnicott, D. W. (1996). Babies and their mothers. London: Free Association Press. Winnicott, D. W. (1975). Through pediatrics to psychoanalysis. New York: Basic Books. Winnicott, D. W. (1971). Playing and reality. London: Routledge.



Herding the Animals into the Barn A Parent Consultation Model ALEXANDRA MURRAY HARRISON, M.D.



Initial assessments of children with psychological problems are important both to develop appropriate diagnoses and to provide the basis for productive discussions with parents on treatment alternatives. This paper develops an assessment method referred to as the Parent Consultation Model (PCM) that emphasizes the use of videotape micro-analysis and developmental theory to provide critical information to parents as well as to the clinician in this important initial stage. The paper provides a description of the PCM and an expanded example of the use of the PCM, including illustrations of how these methods can be used to organize information and engage parents in the initial consultation. The paper concludes with some observations on the role of new techniques and ideas in psychotherapy and psychoanalysis.



Introduction I receive a telephone call from a mother who sounds distressed. She says, “We have a problem and we hope you can help.” Training and Supervising Analyst, Boston Psychoanalytic Society and Institute. I owe substantial debts to the following individuals for their insights and comments on previous drafts of this paper: E. Z. Tronick, Elisabeth Fivaz-Depeursinge, George Downing, Louis Sander, Beatrice Beebe, and Dawn Skorcewski. I also would like to express my appreciation to the Boston Process of Change Study Group; my years of participation in the Group inspired the development of many ideas in this paper. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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She explains that her 4-year-old son is disruptive at school and does not follow directions. At home he is fearful, demanding of her attention, and constantly picking on his little brother. In the past, my initial interactions with the mother and father would have been relatively brief, primarily designed to provide background on the problem as a prelude to seeing the child in individual sessions—first in a diagnostic session and then, if therapy appeared warranted, as a patient in psychotherapy or psychoanalysis. I would of course discuss my initial observations and recommendations with the parents, and get information from them about major constitutional and environmental factors that affect their son; but the tools I had to obtain that important information would be limited to my own observations of the child and parents in the initial sessions and the parents’ own descriptions of key events and circumstances. I describe my past interactions with parents and potential child patients in this initial diagnostic stage, because over the past ten years I have changed my approach to the initial evaluation of children with psychological problems. This shift in approach is the result of learning from key techniques used by infant researchers and developmental psychologists—particularly their use of micro-analysis of videotapes and certain organizing ideas—and parallels a shift in the tools I use in the evaluation of potential cases for psychotherapy and psychoanalysis. Micro-analysis of videotapes of family meetings or of therapeutic sessions allows one to uncover key verbal and non-verbal interactions that simply could not be discovered without the benefit of detailed ex post analysis. Developmental theories provide a means of organizing these detailed observations into coherent patterns. Colleagues and I have recently discussed the ways in which these techniques can be useful in psychotherapy and psychoanalysis (Harrison 2003, Harrison and Tronick, forthcoming). This paper discusses the ways in which these same tools of videotape micro-analysis and developmental theory can be used in the initial assessment and discussions with parents regarding therapeutic interventions. Indeed, I refer to this method as a Parent Consultation Model (PCM), to emphasize the importance of providing critical information to the parents as well as to the clinician in this key initial stage. Moreover, this collaborative or interactive model can usefully be continued beyond the initial diagnostic stage and become part of the ongoing process of engaging parents in their child’s psychological development. The next section of this paper provides an overview of the PCM, including contrasts to more “standard” child psychiatric or psychoana-



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lytic evaluations. The following section provides an overview of several methods that have been developed by developmental researchers to organize the information that can be developed from detailed observation of videotaped sessions. The next section then provides an expanded example of the use of the PCM, including illustrations of how these methods can be used to organize information and engage parents in the initial consultation. The final section provides some concluding observations on the role of new techniques and ideas in psychotherapy and psychoanalysis. The Parent Consultation Model It is useful to begin a description of the PCM by considering the “traditional” child clinical evaluation and two elements that seem relatively poorly handled in the traditional approach—the clarity of the role of the clinician in relation to the parents in the evaluation, and the observation of family patterns. These elements set the stage for a description of the PCM and some of the key conceptual frameworks I have found useful in organizing diagnostic information. what i did then: the traditional child clinical evaluation Ten years ago, when I began to use videotape and other tools of infant researchers, I was already an experienced child psychiatrist and psychoanalyst in private practice, and a teacher of child psychiatry fellows and analytic candidates. My methods for the evaluation of child cases were typical of most child therapists. I would first see the parents to hear their concerns about their child and to obtain some of the developmental and family history, and I would then see the child at least twice in individual sessions. I believe this general approach is still typical among many child psychiatrists and child analysts—and other clinicians—but I have come to appreciate its limitations in the light of the relatively new tool of videotape micro-analysis. In particular, although present in the traditional approach, two elements come to the fore when one begins to use videotape microanalysis and the observational techniques it makes possible. The first element is adopting the role as consultant to the parents, a role that provides a clearer structure for interactions with the family and for developing—that is, obtaining and transforming into a usable form—information to address parents’ concerns. The second element is the use of micro-analysis of family interactive patterns as the basis for formulations concerning the child’s psychological problems.



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role of the clinician as a consultant in evaluating children with behavior problems Parents come to the clinician with a problem, asking for help. Yet, in the typical method of child psychological evaluation, there is no clear delineation of the role of the clinician in relation to the parents. The child psychoanalytic and psychotherapy literature has of course long acknowledged the importance of work with the parents in a child psychotherapy or analytic case (Burlingham, 1951, Furman, 1957, Bernstein, 1995, Richmond, 1992). Yet, the role the clinician should assume in work with parents is often a matter of confusion. I have concluded that it is useful to think of the therapist as a consultant to the parents, particularly in the initial evaluation. I use “consultant” here in the sense defined by psychoanalytic group theory, as elaborated by the A. K. Rice Institute and Tavistock Clinic model of group dynamics (Shapiro, 1978, 1991). In this context, the clinician uses his or her knowledge and information to answer parents’ questions and make recommendations that respond to parents’ concerns. The clinician as consultant does not purport to know what is best for the child in this initial stage, but rather attempts to help parents make decisions about their child in accordance with their values and circumstances. This role is respectful to the parents as decision makers regarding their child and establishes the position of the child clinician as supporting, or scaffolding, the parents in their active role as parents. It also implicitly acknowledges—what I believe to be the truth—that there is no one answer to questions of etiology and treatment of childhood psychological problems. Another advantage of assuming the role of a consultant to the parents is that it makes it possible to delineate a clear boundary between the evaluation and the subsequent therapy. In contrast, the “traditional” model often does not provide a clear differentiation between the evaluation and the therapy, especially if the “evaluation” includes multiple individual sessions with the child. This ambiguity about the boundary between evaluation and therapy may stem in part from the difficulty that psychoanalytically oriented clinicians sometimes have in formulating clearly what they can offer, and why the parents should choose psychotherapy or psychoanalysis rather than some other form of treatment or assistance (Tuckett, 2004). micro-analysis of family patterns Once the clinician assumes the role of consultant to the parents, the task is to answer the parents’ questions and make recommendations



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responsive to the parents’ concerns. To accomplish these tasks, the clinician needs to acquire relevant data and to use some theory or conceptual approach to make sense of those data. In the past, the data I used were mainly observations of the child’s play, and my clinical theory was based on psychodynamic theory. In contrast, my data for evaluations now comes largely from videotaped family play sessions, and my psychoanalytic interpretations of the data are augmented by micro-analytic technique and dynamic systems theory. Using videotape micro-analysis technique and dynamic systems theory, current developmental research has demonstrated the powerful contribution of family interaction patterns to the developmental process, and therefore to the child’s adaptive behavior (Fivaz, 1999, Fivaz, 1994, Stern, J., 1996, Beebe, 1994, 1997, Jaffe, 2001, Fogel, 1993, Tronick, 1989, Tronick, 1998, Stern, D., 1985, 1998). However, these valuable resources are not usually part of the clinician’s repertoire. Although child clinicians will often note the parent’s (usually the mother’s) behavior with the child in the waiting room, or the behavior of the parents in the parent sessions, observation of family interaction is not done in a systematic manner. Yet, these theoretical and technical tools—so useful to infant researchers—can also be available to child clinicians. The shifts in the sources of my data and their effects on my technical and theoretical tools has significantly changed what I see when I evaluate troubled children, and how I intervene to help them and their families. My previous method of evaluating children did not include a family meeting. Without a videotaped family meeting, I did not have the data to “unpack” the complex interactive patterns that underlie a child’s symptomatic behavior. Without dynamic systems theory as a theoretical framework, I could not understand the relationship between certain interactive patterns and the child’s problems. For example, I could not relate the child’s self-regulatory problems—such as temper tantrums or fears—to particular failures in mutual regulation between the child and his parents. And, I could not appreciate the connection between the child’s problems and difficulties negotiating agency in the family, such as in patterns of overcontrol or withdrawal. Knowing in general terms that patterns such as over-control or withdrawal exist in families of children with psychological problems is helpful. Yet, the usefulness of that knowledge is limited in terms of helping parents. It is not helpful, for example, to tell parents—as clinicians sometimes do—to “be less controlling.” In videotape micro-analysis, on the other hand, the data are visual. For that reason



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and because it includes otherwise invisible observations of the child’s behavior in interaction with his family, this information is more immediately relevant to parents than experience-distant psychodynamic formulations, and easier to use in answering their questions about their child. what i do now: the parent consultation model of the evaluation of psychological problems in young children1 As a means of describing the PCM, let me return to the phone call from the mother I will call Mrs. R. After Mrs. R tells me her concerns about her son, whom I will call “Sean,” I say, “Let me tell you how I work, and you can see if it fits what you are looking for.” She agrees. I tell her that I offer parents a consultation in three sessions. The first session is for parents alone, so that I can hear their concerns about their child, find out some facts about their child’s development and the family situation, and—particularly important—help the parents generate questions for me as their “consultant” about children. The second session is a family meeting with every family member present, not just Sean. It is a play session, and its major purpose is to provide opportunities for me to gather data that I can use to answer the parents’ questions as their consultant. To provide the optimum means of developing this information, the family meeting is videotaped. The organization of the family meeting is designed to give me a glimpse of every relationship in the family and the way various family members work together, as well as how the entire family functions. The family meeting also allows me to observe Sean’s capacity for pretend play, and the meanings he makes of his experience as it is represented in the play. The third meeting is for parents alone in which I answer their questions and make recommendations regarding treatment and other matters. I illustrate my impressions of the family with video clips from the session. The three meetings are 45– 50 minute appointments, though I usually schedule the third, the second parent meeting, at a time when I can extend the meeting if desirable. After describing the PCM approach, I give Mrs. R a chance to tell me what she thinks of the general method. She says that it sounds interesting to her. I give her a chance to ask me questions. At this point she has only one: “What do we do in the family meeting? It would be 1. I now use the PCM for all my child evaluations, regardless of age or presenting problem of the child. In evaluations of older children I use a family discussion instead of play format.



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hard for him (Sean) to have his problems discussed in front of his brother. He is easily shamed.” I tell her that the play session is intended to be a pleasant experience. Usually I would not discuss Sean’s problems directly. The information I need to answer Mr. and Mrs. R’s questions will show up in the play. I say that I will direct the session and take care not to let anyone be put on the spot. At the beginning of the session, I will explain that we are going to “play in partners,” that Sean will begin as Dad’s partner, and his brother as Mom’s partner. After five to ten minutes, I will tell everybody to switch partners. Then after a similar time period, I will tell everybody to play altogether. After another ten minutes of playing together, I will tell everybody that Mom and Dad are going to sit in the two chairs and have a conversation with each other while Sean and his brother continue to play. This section is the last part of the play session. After this, I announce the end of the playtime, and we all pick up the toys and say goodbye. The entire family play session takes about 45 minutes. Mrs. R says that she thinks this approach is just what she and her husband are looking for. She then notes that she and her husband are also concerned about the toll the family situation is taking on Sean’s little brother, Mattie, and considering the whole family will give them an opportunity to take Mattie’s needs into account. I suggest that she talk to her husband about the approach I have described and get back to me about whether they would like to move forward with the consultation. If they choose to carry on, we will schedule the meetings. In suggesting that Mrs. and Mr. R talk about the consultation together, I am putting the emphasis of the decisionmaking back on the parental couple. I am also giving them a chance to reflect on the approach. The next day, Mrs. R calls and says that she and her husband have decided they would like the consultation. We schedule the first meeting. conceptual framework I have found it to be critical to have some conceptual framework for evaluating the wealth of information available in the videotaped sessions used in the evaluation. Indeed, without some framework, the material tends to be overwhelming. I have found conceptual frameworks developed by two developmental psychologists particularly helpful—Elisabeth Fivaz-Depeursinge and George Downing—both of whom I have studied for some time. Although these conceptual



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frameworks work for me, it is possible that the choice of a particular framework is less important than finding some useful means of making order from the extraordinarily rich material in videotapes of family sessions. Lausanne Triadic Play Model The specific organizational structure in the PCM is inspired by the work of Elisabeth Fivaz-Depeursinge and colleagues (Fivaz et al., 1994, Stern et al., 1996, Fivaz et al., 1999). The triangular framework of the LTP includes observations of the famly at multiple levels of interaction—participation, role, joint attention, and affective contact. Particularly important from the point of view of the PCM is the capacity of the LTP to organize observations of the non-verbal communications in the family system in a systematic way. The triangular framework of the LTP includes observations of the family at multiple levels of interaction—the level of interaction involving the lower body, the upper body, the orientation of face and gaze, and affective expression. These observations lead to the description of various crucial functions in the family interaction—those of participation, role, joint attention, and affective contact. Fivaz and colleagues explain various functions of family interaction as “embedded” in one another, such that the orientation of the lower body is a basic requirement for participation, making possible the orientation of the upper body as a definition of role, which in turn leads to the capacity for joint shared attention through movement of the head and gaze, and finally the establishment of affective contact through the communication of emotions in facial expression and tone of voice. In addition to providing a framework for the observation of family interactions in a four-step family play session, Fivaz and colleagues also describe how to go about making observations. The first specific focus of observation is the body position of the family members. Next, the orientation of the face and the facial expression is noted, and finally the orientation of the gaze (1999, pp. 11–14). The observer also notes the affect expressed by family members. Is the affect communicated by each family member happy, sad, or angry? Do family members exhibit a full range of affect, or is affective expression constrained or inhibited? Is affect well modulated, or is it explosive or tightly contained? The observer also notes examples of self and mutual regulating behaviors, such as gaze aversion, self-touching, and other body movements. How do the parents comfort their infant? How do they comfort each other and themselves, and how does the



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infant comfort herself? Finally, how do the parents collaborate with each other in the comforting and playing with their child?2 Video Micro-Analysis (George Downing) A second useful framework for interpreting material as part of the development of the PCM is the clinical work of George Downing and his technique of video microanalysis. (Downing, 2000, 2005a, 2005b). Downing provides means of organizing information from videotapes from the point of view of five domains of clinical observation: (1) connection; (2) autonomy; (3) organization of time and space; (4) language; and (5) boundaries. Downing focuses his observations on multiple ways of interacting—using body, face, and voice. (1) In terms of connection, he notes the various ways the family members make a connection with one another, using their bodies, their faces, and their voices. He notes body positions and their function in the interaction, for example, orientation of body in relation to one another. He will consider the interactional function of the orientation, such as whether the partners make a play space between them with their bodies. (2) In relation to autonomy, he notes the parent’s style of encouraging the child’s development of autonomy. For example, he asks whether the child takes initiative in the play, and whether the parent supports that initiative, or on the other hand, whether the parent is inattentive to the child’s expression of initiative or tries to control it. (3) From the point of view of organization of space and time, he notes how the families utilize the space of the room, and how they manage the time constraints of the interview. Does the family use the large space designated as the play area, or do they limit themselves to a corner of the room? Do they settle down to play right away, or do they spend so much time negotiating the setting up that they have little time to play? (4) In terms of boundaries, he notes how the family members respect one another’s boundaries, and how they manage the boundaries of the play interview. Do the parents respect the child’s personal boundaries, or do they intrude into them by touch2. The differences between the LTP, in which a structured seating arrangement of the family members is part of the experimental design, and the PCM, which involves a free-play situation, result in different ways of analyzing the observational data. For example, observations about body position in the PCM cannot be reliably coded, as they can in the LTP. Yet, these observations may still be clinically useful. The observations of mother-child, father-child play, sibling play, and parent conversation in the PCM are actually observations made of sub-systems of the family rather than as observations of “dyadic relationships.” However, clinically relevant observations about the relationships in these subsystems can be made.



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ing the child or by moving the child’s play objects without an invitation? Do the family members respect the play space presented to them, or does the child stray into the part of the room where the computer and the video equipment is? Does the parent make a clear boundary between playtime and time to stop and pick up the toys? (5) Apropos language, how is language used in the play session—to promote the play, to comfort, to criticize, or to control? What kind of language does the parent use—primarily descriptive language such as, “Oh, you are putting that there” or prescriptive language such as, “Put that there.” Downing’s model is based on developmental theory but is designed primarily as a clinical theory. In that sense, particularly, it has been an important influence on my work on the PCM. I also owe much of my skill in making observations about families and analyzing them to the consultations and discussions I have had with Downing during the past five years. Other Theoretical Influences The PCM as I have developed it derives from other aspects of developmental research, including the mini-reunion experience created by the order of the partner play, in which the identified problem child plays with the father first. This order offers the opportunity to observe a “mini reunion” of the child with the mother. The PCM does not, of course, replicate the experimental conditions related to the “strange situation” of Attachment Theory. Nonetheless, my experience suggests that this design can elicit interesting observations about the mother-child relationship corresponding in some way to the findings of the strange situation test (Lyons-Ruth, 1991). Finally, because it is a play session designed for preschool and early school age children, the PCM also offers the opportunity to evaluate the quality of the child’s play and uses psychoanalytic theory to identify and make sense of symbolic representations in the play. Psychoanalytic theory and developmental theory are thus both instrumental in informing the observations obtained from the PCM. In sum, the PCM draws primarily from developmental theory— particularly the observational research of Fivaz and colleagues and the clinical model of Downing—to make a number of important assessments. It offers a quick clinical assessment of the father-child relationship, the mother-child relationship, the sibling relationship, and the marital relationship. The PCM also offers an assessment of the way the family functions as a unit, the way the family makes transitions, the impact of the children on the marital relationship, and fea-



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tures of the child’s play. The time spent in the family session is short, but videotape transcription makes possible the recognition of repeated patterns on a micro level, contributing to the larger level behaviors that constitute an adaptation. clinical case illustration of pcm: first step—first parent meeting Mr. and Mrs. R come in for the first parent meeting. They are an attractive couple in their late 30s. Mrs. R in particular looks tired and stressed. Mr. R works in a demanding professional job. Mrs. R had a comparable job before Sean’s two-year younger brother, Mattie, was born but left her job at that point to become a full-time mother. They explain that Sean was “high maintenance” from the beginning, but that they didn’t recognize it as a problem because they “didn’t know what to expect” from their first baby. They could tell that he was very bright. They first realized that he had a problem when he was rejected from all the private elementary schools they applied to for 4year-old pre-kindergarten. The teachers in his preschool confirmed that he had trouble paying attention and was disruptive during circle time, but said that he was sweet, enthusiastic, and loved to learn. At home, he was very dependent on his mother and anxious about being separated from her. He insisted on following her from one floor of the house to another. He envied Mattie’s possessions and competed fiercely with him for his parents’ attention, but he also played happily with him for long periods. Play usually ended with Sean’s teasing Mattie, or with his aggressive physical attacks on him. Sean also complained about lumpy food, tags on the back of his shirts, strong smells, and loud noises. Both parents agree that they are noticing Sean’s immature behavior more now than they had even a year ago. As Sean gets older, the discrepancy between his behavior and that of his peers, and even that of his little brother, becomes more apparent. I ask about family stressors, and the Rs respond that the main stresses are Sean’s behavior and the pressure of Mr. R’s job, which often keeps him at the office until the children are in bed. Family neuro-psychiatric and developmental history is positive for mild to moderate learning disabilities on the paternal side, acting out in adolescence and depression in one of Mrs. R’s siblings, and anxiety both in maternal grandmother and in Mrs. R. The generation of consultation questions is the crucial part of the first meeting. Although Mr. R tends to defer to Mrs. R, I insist that



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both give me at least two questions. I write the questions down verbatim and put the paper where I can retrieve it for the final meeting. Mrs. R asks, “How to relieve his anxiety—he is fearful and anxious, and how to develop strategies to deal with his behavior problems, e.g. constant picking on his little brother.” Mr. R asks, “How to deal with his negative effect on the family—he wears his mother down.” Mrs. R adds, “How do I get this kid motivated to do the things he needs to do, like get himself dressed in the morning or go to the bathroom by himself?” Mr. R concludes, “How do we help him with his confidence, self-esteem?” Although sometimes I find I am able to answer some of the parents’ questions immediately, in this case I think that a family meeting is essential, and I tell the Rs that a family meeting will help me answer their questions. We discuss the family meeting. I repeat the description of the family meeting to Mr. and Mrs. R, concluding with a discussion of what to tell the children about the meeting. After hearing Mr. and Mrs. R’s ideas about how to best present the idea to their children, I suggest that they refer to me by my first name rather than as “doctor,” so as not to unnecessarily alarm the children, and suggest that they refer to me as “a lady who knows a lot about children and families and who gives families ideas about how they can get along better together.” Then I suggest adding, “And the way she does that is to have families come and play at her house, and then go home again. She also uses a camera to take a film so that she can remember what happened after the meeting.” We schedule a meeting time. second step—family meeting At the time of the family meeting, I arrange the room with toys appropriate for children of Sean’s and Mattie’s ages—a barn with farm animals, a garage with cars and people, building blocks, and puzzles. I meet the family in the waiting room and show them into the office. Mr. R coaches the children to greet me politely, and they do. The boys are very attractive children. Sean leads the way into the office. He is excited and eager to see my toys. Mattie holds his mother’s hand. In the office I remind the family of the plan for the meeting. I repeat the different parts of the meeting including the parents’ conversation and the camera. The camera is a small video camera that I place on my lap; the monitor can be viewed in a brief downward glance. I point out the camera to the family. Openness about the filming of the meeting is particularly important from the point of view of modeling trustworthy behavior in the family consultation. I



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tell them that in the beginning, Sean will be Dad’s partner and Mattie will be Mom’s partner. Child and Father Play Sean chooses the barn with farm animals, and he and Mr. R establish themselves in front of the barn. Sean says to Mr. R, “Let’s herd them into the barn, because there is a big storm coming!” Mr. R asks, “Which ones? Which ones?” and starts to pick up the animals. The two of them are smiling and obviously happy to be together. They are picking up the animals and talking about them. Interestingly, the animals do not get herded into the barn by the time of my call to “change partners,” about five minutes later. The next transition goes smoothly, with Mrs. R calling out to Sean, “Change buddies! You’re my buddy, Sean!” and walking over to him, while she helps Mattie and Mr. R find the toy garage. Sean calls out to Mrs. R, “We’re going to herd the animals into the barn.” Mrs. R says, “O.K.,” sits down beside the barn, and listens to Sean explain again about herding the animals. Sean and Mrs. R also play together well, though they both look somewhat uncomfortable and constrained. Mrs. R does not look as if she is enjoying herself and is sitting back with her hands folded most of the time. Again, in this seven-minute play sequence, despite much talking about it, the animals do not get herded into the barn. When I call for the family to play together, the family makes another smooth transition, with Mrs. R making suggestions about how they might combine the two types of play. They begin to play with the garage and some of the farm animals. Mattie, Mr. R, and Mrs. R cluster around the garage and play with it for the entire period. Sean plays on the periphery, connecting vehicles with their trailers, periodically joining the others and then removing himself again from the central family play. Finally, I ask for the family to make the transition of Mr. and Mrs. R to the two chairs, so that they might have a conversation with each other. Mr. and Mrs. R move to the chairs, and the boys continue their play. Mattie goes to play with the barn, and Sean continues playing with the cars and trailers. The parents are able to have a conversation with each other, though now and then they are distracted and turn their attention to the boys. They seem to anticipate a problem that they must be ready to manage. Then Mattie says, “We have to herd the animals into the barn. There’s a big storm coming.” He begins to put the animals into the barn. Sean comes over to the barn and starts to help him, but he is



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more erratic in his attention and his movements than his little brother. Numerous times he grabs a toy away from Mattie; sometimes Mattie objects, sometimes he does not. At one point, Sean declares, “The storm is over now,” but Mattie responds, “No, it’s not,” and continues his work of herding. Sean moves back and forth from the barn, to the activity of hooking up the cars and trailers. Finally, Mattie declares, “Now they’re all inside—safe and sound.” In a dramatic conclusion to the course of events, Sean’s little brother is able to implement Sean’s stated agenda more effectively than either parent is able to do alone with Sean. How can we understand this interesting eventuality? As I consider this question, I am thinking of the powerful metaphor of herding the animals into the barn to find protection from the impending storm, which I take to signify Sean’s dysregulated behavior and its effect on the family. The whole family seems to resonate with this symbolic theme. The conclusion of the family play is to find a safe place for all the animals inside the barn, yet this is accomplished in an unexpected way. It is only when the constraining behavior patterns Sean and his parents have created together are relegated to the background, and the parents allow the children to exercise their own agency, that Sean’s agenda can be constructively engaged.3 Yet, a full answer to the question must wait until later, since we must first return to the model as a practical way of answering the parents’ questions. third step—interviewer viewing the tape In this step, I view the tape alone. Initially I transcribed small tapes from my digital video camera onto a VHS tape and viewed them on my television monitor. I used my remote control to look at certain sequences in slow motion. Now, I capture clips from the digital videotape on my computer, using the program of final cut express. While time consuming on my part, it makes the showing of the film to the parents more efficient, since it isolates small sequences of the tape that are immediately available for viewing. Also, the computer program allows for frame (about one thirtieth of a second) by frame viewing easily. As I observe the tape, I look for patterns of behavior in



3. Sander’s work has been extremely influential to my thinking and clinical work. Both in his writings and in our discussions, Sander’s conceptualization of agency as emerging from the mutual regulatory competency of the dyadic system has been central to my understanding of children like Sean (Sander, 1985, 1995, personal communication, 2004).



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the different sections of the interview. Here I make use of Downing’s technique of video micro-analysis to evaluate the play sequences of father-Sean, mother-Sean, family together, and parental couple with siblings. Although at first I would spend more time capturing the clips and viewing the tapes than the duration of the family meeting, now I can complete the process in about 30 minutes. The initial transition into the play room is accomplished smoothly. In this transition, the family values are demonstrated in Mr. R’s reminding the children of the rules of courtesy in greeting and the boys’ willingness to comply. Sean’s capacity for enthusiastic engagement with a new situation is also clear. Mrs. R takes up the rear, perhaps showing a tendency toward reticence. Mattie stays back with her; he could be expressing his own timidity, or “taking care of” his mother. Father-Child Play Sequence 1. Connection—Mr. R and Sean express their enjoyment at being with each other in their facial expressions, their tone of voice, and their affectionate physical contact. At one point, Sean leans comfortably against his father’s leg, and at another point, Mr. R puts his hand on Sean’s shoulder. Father is oriented to Sean, but Sean’s body is at a ninety-degree angle to his father. This seems to indicate some difficulty making contact. There is little visual monitoring of each other. 2. Organization of time and space—Father is lying on the floor next to Sean, and Sean is seated next to the barn, using the play space in a comfortable manner. They use the play space available, and they begin and end at the time I direct them to play and then to change. 3. Boundaries—Neither seems to intrude on the other’s space, nor to take control from the other. However, an interesting pattern is created when Mr. R is showing Sean two animals, and Sean reaches over his father’s extended arm to reach into the barn, glancing at the animals over his own arm. This unusual arrangement of bodies is more evident in split second viewing and again seems to illustrate some avoidance of direct connection. 4. Language—When Mr. R speaks to Sean, he does not use prescriptive language; in other words, he does not give him orders. He primarily communicates his ideas as they come up in the play, for example reminding Sean of an animal they saw together on a family trip. 5. Autonomy—In spite of their mutual pleasure in the play, Sean’s expressed agenda of getting the animals into the barn is not implemented. This seems to be because Mr. R does not attend to Sean’s repeated requests that they do this. When I count, Sean refers to the agenda of herding the animals into the barn six times in a one-minute film clip, before his father begins to put the animals into the barn.



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The transition to the mother-child play sequence is also smooth. I announce the transition, and each family member responds in a characteristic way. Sean turns away from the activity, bending over farther toward the barn, as if to manage the confusing and stimulating experience of the transition. Mr. R turns smoothly away from Sean and toward Mattie, whose small hand can be viewed in the crook of his father’s arm as he guides his father into his new position as his partner. Mrs. R supports my directive and helps manage the transition, saying—“Change buddies! You’re my buddy, Sean!” Sean calls out to her as she crosses the room, “We’re herding the animals into the barn!” and then turns away again, bending over the toy. As she approaches him, Mrs. R displays a pattern similar to Sean’s, though subtler. She turns toward Mr. R and Mattie, pointing out an interesting toy to them as she moves toward Sean and sits down before him. It is not until after she completes this communication that she turns to Sean and focuses on him intently, as he repeats his wish to herd the animals into the barn. Mother-Child Play Sequence 1. Connection—Sean and Mrs. R are seated at a greater distance from each other than Sean and his father had been, and there is a sense of anxious constraint in their behavior. After Mrs. R’s careful attention to Sean when she looks directly at him as he explains his agenda, there is little eye contact between them. Sean expresses enthusiasm about the play in his face and voice, but Mrs. R expresses little positive affect, presenting a look of earnest concern, instead. They do not touch each other. 2. Organization of time and space—Mrs. R quickly initiates an organizing activity, taking the animals and in orderly fashion placing them according species in front of the barn. She inquires what kind of animal Sean wants to herd into the barn, further assisting him in organizing his intention. Mrs. R and Sean make a good play space between them. 3. Boundaries—Mrs. R and Sean seem to be particularly attentive about maintaining adequate distance between them. In fact, they express anxiety about physical closeness. For much of the play sequence Mrs. R sits with her hands clasped, and Sean frequently pulls his hands back out of the play space, at one time sitting on his hands. Micro-analysis of the videotape demonstrates a moment lasting a fraction of a second in which Sean extends his arm suddenly, making a grabbing motion toward his mother and the animal she is holding. This movement is not apparent during normal time; it is very quick, and Sean’s hand remains empty. However, it is after this movement that Sean pulls his hands way back and Mrs. R puts down the animal and clasps her hands. No gaze is exchanged during this event.



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4. Language—Mrs. R does not use prescriptive language to Sean, but once she talks in an educative way to Sean about the difference in appearance between dairy cattle and beef cattle. This communication is in response to Sean asking, “Is that a deer?” when Mrs. R is moving an animal toward the barn. She also demonstrates a unusual vocal turn-taking pattern that involves beginning her vocal turn immediately after Sean finishes his, a pattern associated with anxious overcontrol (Beebe, 1999). 5. Autonomy—Mrs. R demonstrates a clear intention to support Sean’s autonomy. She listens intently when he explains his plan to her. She helps him with the set-up of the plan and encourages him to implement it. In response to Sean’s remonstrance, “You have to help me!” she begins to put the animals into the barn. Yet, at several points, Mrs. R expresses her skepticism about the potential success of the agenda, framing it in terms of fitting all the animals into the barn, and by the end of the ten-minute play sequence, just a few of the animals have been put into the barn. Mrs. R seems to have anticipated failure in the enterprise, and her negative expectation has been fulfilled.



When I announce the transition to the whole family playing together, Mrs. R, Sean, and Mattie look up at me. Mrs. R immediately says, “O.K.,” and begins to assist in the transition. Sean says, “Yeah! Daddy can play with the farm!,” Mrs. R repeats that they are going to look for “a group activity,” something they can “all do together,” and Mr. R suggests that Sean can bring some of his animals to the garage if they can’t all fit in the barn. Sean initially rejects this idea, but when Mattie moves over to the barn, Sean grabs it away from Mattie and declares it “locked,” saying, “Let’s use the garage for another barn.” He again grabs the barn from Mattie’s grasp and pushes Mattie’s arm away from the barn. Just after Sean’s aggressive moves toward Mattie, Mr. and Mrs. R both simultaneously turn their faces away from Sean and begin to orient their bodies toward the garage. At the same time, Mattie turns away from the barn and also moves toward the garage. It seems clear that the family is attempting to avoid conflict by complying with Sean’s demands. Yet, as they comply, they in unison move away from him, leaving him alone. Family Play Sequence 1. Connection—Mr. and Mrs. R and Mattie begin arranging the animals on the different floors of the garage. They communicate positive affect with their facial expressions and tone of voice. Sean plays on the outskirts of the group. He has found several vehicle-trailer pairs, and he occupies himself with trying to connect them. Now and then, he joins the family group for a brief period, but then he returns



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to the cars. It seems clear that Sean attempts to regulate himself by frequent, periodic distancing from the family group. He uses the repetitive motor activity of hooking up the truck and trailer as another regulating activity. This activity also has the symbolic meaning of “connecting.” After a few initial attempts, his family members do not actively try to engage him in what they are doing. As a result, he remains relatively disconnected from the family group. 2. Organization of time and space—The family organizes itself in a small space, without much freedom to move about the floor. While this was also true during the “partner play sequences,” it is more obvious with the whole family playing together. The family is able to begin, elaborate, and complete a play sequence within the time offered. 3. Boundaries—The boundaries between interacting members of the threesome including Mr. R, Mrs. R, and Mattie seem comfortable. There is affectionate physical contact but not intrusiveness and control. The boundary between Sean and the family group is strikingly different. He intrudes into Mattie’s attempted play with the barn, and when he enters the family group play, he bursts into it. When Mr. R invites Sean to bring his animal into the family play, Sean moves his cow to the garage with one hand while pushing his father’s hand out of the way with the other, though it is not apparent that his father’s hand was in the way. 4. Language—The family uses language appropriately in a descriptive or suggestive manner. However, sometimes Sean uses language to control his family members, for example when he tells the others what the cow is “supposed to” do, and when he tells them, “Put it here!” In response to his commands, Mrs. R, Mr. R, and Mattie say, “O.K.” 5. Autonomy—In the family play, Sean seems to intrude on Mattie’s agency, in particular. Frequently, he takes toys away from Mattie or gives him orders about what to do. Mr. and Mrs. R have two ways of responding to this behavior. They allow Mattie to comply with Sean’s commands, or they move to minimize the amount of control Sean can exercise. An example of the former is when they turn to the garage in response to Sean’s claiming possession of the barn at the beginning of the family play. An example of the latter is when Mrs. R takes the cow that Mattie has been playing with, and that Sean has just grabbed from him, and replaces it where Mattie can reach it. Mrs. R seems to be maintaining constant vigilance over Sean’s controlling behavior. Sean takes the initiative at several points in the play, and the family makes efforts to respond to his ideas. Frequently, however, he interrupts his participation in the group play and turn to connecting the vehicle and trailer. The other family members allow him to do so without explicit recognition. It seems that the family has difficulty supporting the agency of both boys—Mattie, because



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of Sean’s intrusive behavior toward him, and Sean, because of his difficulty maintaining a focus of joint attention and other regulatory difficulties and because of the family’s response to his controlling behavior.



The transition to the parents sitting together to have a conversation also goes smoothly. Mrs. R notifies the boys of what they are going to do. Neither boy objects. Mr. and Mrs. R sit in the chairs and begin to talk. This part of the session in particular demonstrates important strengths of the family—the parents’ capacity to constitute a wellfunctioning relationship of their own, and the siblings’ ability to play together creatively, despite Sean’s regulatory difficulties. Sean continues his regulating play with the vehicles and trailers. Mattie moves to the barn, which is on the other side of the room and which he has not played with before. He says, using Sean’s exact words and tone of voice, “We have to herd the animals into the barn, because a big storm is coming!”4 He is oriented away from Sean, and he speaks apparently to himself. Sean, however, approaches him and attempts to join his play. Without looking at Sean, Mattie continues to put animals into the barn. His attention is more focused and his actions smoother and better coordinated than Sean’s. In ignoring Sean, it is as if he recognizes that Sean could introduce a significant disruption in his plan. When about half the animals have been put back in the barn, Sean pronounces, “The storm is over now.” Without looking up or changing his position, Mattie responds, “No, it’s not,” and continues putting animals into the barn. Sean, after a hesitation, leaves the cars and joins him. Finally, the animals are in the barn. Leaning back, Mattie surveys the barn and says, “Now they are all in the barn, safe and sound.” It is remarkable to me observing the tape, as it was when I was observing the meeting itself, how Mattie is able to accomplish Sean’s agenda by the end of the meeting. In fact, it is now clear that although initially articulated by Sean, it is a family agenda and all the family members—Mr. and Mrs. R also, by allowing the boys to play uninterrupted—cooperate in its accomplishment. the second parents’ meeting: the third of the three meetings In this meeting, I take out the paper on which I have written Mr. and Mrs. R’s questions about Sean. I intend to answer them in simple, 4. This observation gives evidence for the influence all family members have on one another while playing in the same room at the same time, whether they are playing in “dyads” or all together.



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practical answers that lend themselves to recommendations for action. First, however, I am going to give them my impressions of the family meeting. I get out the tape. I show Mr. and Mrs. R the transition into the playroom. I acknowledge the attractiveness of the family and the expression of their family values in the polite greeting. I point out the friendliness of Sean and his interest and eagerness to engage in this new situation. Then I show the clip of Mr. R and Sean. Again, I first address the positive features of the obvious pleasure the two of them take in playing together and the affectionate and supportive attitude of Mr. R toward Sean. I note Sean’s significant strengths in being able to create and express such a compelling metaphor as “herding the animals into the barn” to avoid an impending storm. I also point out Sean’s difficulties in coordination, including the way he drops the animals, and his tendency to get distracted. Next, I note the multiple statements of Sean indicating his agenda to herd the animals into the barn and Mr. R’s inattentiveness to them. This is a powerful moment in the meeting. Mr. R is deeply moved. He is astonished to appreciate this observation and wonders how he could have failed to attend to Sean in this way. The next clip I show them is that of Mother and Sean. I first point out the evidence of Mrs. R’s devotion and sensitivity to her children, including her helpful preparation of Sean and Mattie for the transition and her attentiveness as Sean is explaining his agenda to her. Then, however, I note her obvious anticipation of failure in this activity with Sean. I suggest that this sad, discouraged reaction of hers may not be an uncommon one. Mrs. R is also very moved. In contrast to her husband, she is not at all surprised by my observation and agrees that with Sean she often expects to fail. I explain to Mr. and Mrs. R a little about self-regulation, especially in the domains of motor activity, attention, and affect. I remind them of what they have told me about Sean’s sensitivity to loud noises, irregular textures in his food, and scratchy things against his skin and point out that these sensitivities are associated with regulatory difficulties such as the ones demonstrated in the film. I tell them that it is clear that Sean is a child challenged by problems regulating himself, but that I think the film gives us some ideas about how to help him learn to regulate himself better and how to support him in his development. These ideas include learning ways of attending to him more carefully and finding cause for hope in his getting better and developing in a healthy way. Toward the goal of elaborating these ideas about how to help, we turn to their original consultation questions.



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(1) The first question is Mom’s: “How to relieve his anxiety—he is fearful and anxious.” I answer, “Right now Sean tends to be an all or nothing kind of guy. We would like to teach him new, more flexible ways of making sense of his world.” This, of course, is neither a complete answer, nor does it lead directly to a discrete intervention. However, it communicates a new perspective on Sean’s anxiety and his demanding behavior, and it indicates a direction toward constructive action—teaching him ways of being more flexible. We have seen the positive feature of his persistence in the agenda of herding the animals into the barn. We would now like to help him find other, more flexible ways of working on his agenda so that he could feel confidence in their successful accomplishment. And we would like to find ways of helping his parents support him in his agenda. (2) The second question is also Mom’s: “How to develop strategies to deal with his behavior problems, e.g. constant picking on his little brother.” I answer, “We need to come up with new limit setting strategies.” This answer focuses on managing Sean’s aggression and impulsivity through regulating his high arousal states and his negative affect. It also stresses the need to change the controlling effect Sean has on the rest of the family. This answer is also neither comprehensive nor specific. However, it leads toward a practical way of changing the family relationship patterns that are not working and suggests that I am available to help the parents make those changes. In this answer, I am also addressing Mrs. R’s exhaustion in her efforts to manage the boys’ aggression, as well as Mr. R’s sense of helplessness about how to support his wife when he arrives on the scene of a sibling conflict after having been at work all day. Mrs. R might be able to give up her role as the family manager if both she and Mr. R could find more effective ways of helping Sean regulate his behavior. (3) The third question is Dad’s: “How to deal with his negative effect on the family. He wears his mother down.” I point out that Mrs. R identifies herself as a “problem solver,” but that this problem is not the kind that can be “solved” by one person. For her to take this on her own shoulders is too great a burden. I also point out that Mr. R seems to withdraw into his work and feel helpless. I suggest that we find new ways of the parents working together to make things better. (4) The fourth question is Mom’s: “How do I get this kid motivated to do the things he needs to do?” Mrs. R explains that Sean is unable to dress himself or take on other age-appropriate skills of autonomy, and she has been unsuccessful in helping him learn. I agree with the Rs about how Sean needs experiences of mastery. Neuro-developmental disabilities have interfered with his achieving certain compe-



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tencies necessary for age-appropriate autonomy. I explain, also, that his difficulty managing strong feelings makes it hard for him to take risks that threaten him with disappointment and frustration. We need to find special ways of supporting him in achieving mastery of skills of independence. The Rs are thoughtful and interested in my answers to their questions. They ask for recommendations about how to implement some of my ideas. I tell them that I think they need help working on these changes, and that I would be glad to help them. Since the problems are interfering with Sean’s development in a significant way, I recommend a therapeutic intervention that includes working with Sean directly—either continued parent consultation with family meetings or individual therapy. Mr. and Mrs. R say that they are interested in trying to change the way the family members behave in relation to one another, including their parenting behaviors, and that they would prefer to continue to work with me in family consultation. I agree, and we set a first meeting. key differences in the consultation You will notice that my comments to Mr. and Mrs. R include neither a diagnosis nor an explicit formulation of Sean’s difficulties. That is because those issues are not included in their consultation questions to me. In this case, my initial formulation of Sean as a child with neurodevelopmental disorders complicated by family patterns of difficulty regulating him and supporting his agenda, informs my answers to the questions they do ask me. I know that Sean has made sense of his life experience and that the sense he has made includes rigid, all-or-nothing meanings that underlie his separation anxiety and his other fears. At this point, I know that these meanings include that of a destructive “storm” that threatens the living creatures of the farm, and I know that Sean and his whole family fear that they might not find the means to keep the “animals” safe. The storm is the focal point of the meeting, to which the family members return again and again. It has important symbolic meaning, demonstrated in each family member’s reaction to the threat of the storm. Sean is afraid of the storm, but so is everybody else. His mother, father, and brother either keep a distance from Sean or comply with his demands, in an effort to avoid the storm of his temper outbursts. Fear of the storm helps explain Mr. R’s choice of more immediate subjects of joint attention rather than Sean’s main agenda. It helps understand Mrs. R’s withdrawal and anxious efforts to manage



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the family. It informs the observations of Sean’s sitting on his hands to avoid potential grabbing movements. It explains Mattie’s accommodation to Sean’s refusal to share the toys with him. Yet, my fuller understanding of Sean’s problems depends on the micro-analysis of the family meeting. Had Sean, in an individual session, represented his experience in the metaphor of the storm—less likely, perhaps, were he not in the midst of his family—I would have interpreted the storm as Sean’s aggressive behavior and his fear of the consequences of this behavior on his important relationships. I would not, though, have seen evidence of crucial features of this behavior. I would not have appreciated the degree to which and the ways in which Sean’s problems regulating his attention, his motor activity, and his affects contributed to the creation of the “storm.” These observations are harder to make when the clinician is playing with the child one on one. The family meeting illustrated—in the micro-process with each parent, and in the sibling play—the extreme struggle Sean exerts to regulate his behavior. The storminess of his affective state and his attentional state underscores his impulsive grabbing. I also would not have seen how each individual family member responds—how the family as a whole responds—to the threat of the storm. The family meeting illustrated the way his parents and brother contributed to Sean’s dilemma by symbolically leaving him outside the barn, when they felt helpless to deal with the storm. I would not have understood in what ways the family system has created adaptations to the challenge of Sean’s behavior that backfire, and make it even harder for them to help him grow. I would not have seen Mattie’s valiant efforts to recuperate the plan of herding the animals in order to save his family from the storm. Finally, I would not have seen the significant strengths of the family, strengths that will be essential in their attempts to achieve their goals. The PCM includes valuable tools derived from infant observation research to use in my clinical work. With videotape I can observe the exchange between the child and the world of his family. However, I cannot observe the child’s inner world with videotape. His private world is the territory of psychoanalysis. The opportunity to put together these two complementary views of the child—the inside and outside views—is an exciting opportunity. Often, the PCM evaluations go on to become psychotherapies, and sometimes—as in the case of Sean—psychoanalyses. Once the child is in individual therapy or psychoanalysis, transference issues usually make family meetings



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impossible. Beginning the evaluation with the PCM often gives me the only chance I will have to capture this “outside view.” Concluding Remarks I would like to conclude by considering analogies between the quest for useful means of helping troubled children and their families, and Sean’s desire to herd the animals into the barn. Through his attempts to get the animals into the barn, Sean is drawing his family’s attention and my attention to the storminess of his internal world, and to how that storm sometimes provokes him to behave. But as I have pondered Sean’s stormy world, I have also thought about the storm in psychoanalysis and recent efforts to bring together information from infant research and developmental theory into something that is useful for the theory and practice of psychoanalysis and psychotherapy. The technical and theoretical tools that infant research provide have enormous potential but must be integrated into psychoanalytic theory and technique in order for me and other clinicians to be able to make use of them in practice. My work as a child psychiatrist and analyst for almost three decades has shown me that the ways children grow and change are extremely complex. No linear theory of causality is sufficient. Moreover, the plurality of contemporary psychoanalytic theories lacks the necessary coherence to provide the clinician with what he or she needs to make sense of clinical material. Dynamic systems theory—a theory that provides a broad umbrella theory for therapeutic and developmental change—includes in its general principles coherence, as well as complexity. These considerations suggest that psychoanalysts and other clinicians should attempt to provide coherence by developing useful integrations. Indeed, the PCM that I have described in this paper represents one effort to develop a useful integration of techniques and theory to help children and their parents in the initial—and important—diagnostic phase. Sean and his family are searching for greater flexibility in the meanings they make of their experience together and apart. They are trying to support each family member’s agency in their efforts at creative elaboration of their private meanings, yet at the same time striving to find ways of regulating themselves and also the family system, so that it does not come apart. In a similar way, analysts and other clinicians would be well advised to be flexible, open to alternative perspectives, without fearing the loss of familiar concepts. The



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self-organizing properties of dynamic systems suggest that there are many ways of understanding the challenges of developmental processes, including those we engage in our work with patients. The search is for ways of embracing complexity, while developing and maintaining the coherence of our theories. In Sean’s metaphor, we search for means of “herding the animals into the barn”—bringing the complexity of developmental processes into a coherent framework of psychoanalytic theory. BIBLIOGRAPHY Alvarez, A., & Reid, S., eds. (1999). Autism and Personality: Findings from the Tavistock Autism Workshop. London: Routledge Press. Beebe, B., & Lachmann, F. (1994). Co-constructing inner and relational processes: Self and mutual regulation in infant research and adult treatment. Psychoanalytic Psychology 11(2), 127–265. Beebe, B. & Lachmann, F. (2002). Infant Research and Adult Treatment: CoConstructing Interactions. Hillsdale, N.J.: Analytic Press. Beebe, B., Lachmann, F., & Jaffe, J. (1997). Mother-infant interaction structures and presymbolic self- and object representations. Psychoanalytic Dialogues 7(2), 133–182. Bernstein, I. (1995). The importance of characteristics of the parents in deciding on child analysis. J. Amer. Psychoanal. 6, 71–78. Burlingham, D. (1951). Present trends in handling the mother-child relationship during the therapeutic process. Psychoanal. Study of the Child, 6, 31– 37. Downing, G. (2000). Emotion theory reconsidered. In Wrathall, M., and Malpas, J., eds. Heidegger, Coping and Cognitive Science. Cambridge, Mass.: MIT Press, pp. 245 –270. Downing, G. (2005a, [in press]). A different way to help: Position paper for the council on human development. Downing, G. (2005b). Emotion, body, and parent-infant interaction. In Nadel, J., and Muir, D., eds., Emotional Development: Recent Research Advances. Oxford: Oxford University Press. Fivaz-Depeursinge, E., & Corboz-Warnery, A. (1999). The Primary Triangle. A Developmental Systems View of Mothers, Fathers, and Infants. New York: Basic Books. Fivaz-Depeursinge, E., Stern, D., Corboz-Warnery, A., Lamour, M., & Lebovici, S. (1994). The dynamics of interfaces: Seven authors in search of encounters across levels of description of an event involving a mother, father, and baby. Infant Mental Health Journal 15(1), 69 – 89. Fogel, Al. (1993). Two principles of communication: Co-regulation and framing. In Nadel, J., and Camaioni, L., eds., New Perspectives in Early Communicative Development. London: Routledge.



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Furman, E. (1957). Treatment of under-fives by way of parents. Psychoanal. Study of the Child, 12, 250 –62. Harrison, A. (2003). Change in psychoanalysis: Getting from A to B. Journal of the Amer. Psychoanal. Assoc. 51(1), 221–257. Harrison, A., & Tronick, E. (submitted for publication). Now we have a playground: Emerging new ideas of therapeutic action. Jaffe, J., Beebe, B., Feldstein, S., Crown, C., & Jasnow, M. (2001). Rhythms of Dialogue in Infancy. Monograph Series of the Society for Research in Child Development, 66, (2, Serial No. 265), 1–132. Lyons-Ruth, K. (1991). Rapprochment of approachment: Mahler’s theory reconsidered from the vantage point of recent research on early attachment relationships. Psychoanalytic Psychology, 8, 1–23. Nichols, M., & Schwartz, R. (1995). Family Therapy, Concepts and Methods. Boston: Allyn and Bacon. Sander, L. (1983). Polarity, paradox, and the organizing process in development. In Call, J. D., Galenson, E., and Tyson, R., eds., Frontiers of Infant Psychiatry. New York: Basic Books, 315–327. Sander, L. (1985). Towards a logic of organization in psycho-biological development. In Klar, K., and Siever, S., eds., Biological Response Styles: Clinical Implications, pp. 20 –36. Washington D.C.: Monograph Series, American Psychiatric Press. Sander, L. (1995). Identity and the experience of specificity in a process of recognition. Psychoanalytic Dialogues 5, 579 – 593. Shapiro, E. (1978). Research on family dynamics: Clinical implications for the family of the borderline adolescent. Adolescent Psychiatry, 6, 360 – 376. Shapiro, E., & Carr, A. W. (1991). Lost in Familiar Places. New Haven: Yale University Press. Stern, D. (1985). The Interpersonal World of the Infant. New York: Basic Books. Stern, D., Sander, L., Nahum, J., Harrison, A., Bruschweiler-Stern, N., Lyons-Ruth, K., Morgan, A. (1998). Non-interpretive mechanisms in psychoanalytic therapy. International Journal of Psycho-Analysis, 79, 903 – 921. Stern, J., Fivaz-Depeursinge, E., de Roten, Y., Corboz-Warnery, A., & Darwish, J. (1996). Transitions and the sharing of interactional affective events. Swiss Journal of Psychology 55(4), 204–212. Tronick, E. (1989). Emotion and emotional communication in infants. American Psychologist 44(2), 112–119. Tronick, E. (1998). Dyadically expanded states of conscious and the process of therapeutic change. Infant Mental Health Journal, 19, 290 –299. Tuckett, D. (2004). Opening Plenary Address, EPF Conference, Helsinki.



PSYCHOANALY TIC RESEARCH



Recollections of Being in Child Psychoanalysis A Qualitative Study of a Long-Term Follow-Up Project NICK MIDGLEY, PsychD, and MARY TARGET, PhD



To date there has been very little research looking at how former child analytic patients have made sense of the experience of being in psychoanalytic treatment as children. Based on semi-structured interviews with twenty-seven people who, as children, had been in intensive psychoanalysis at the Anna Freud Centre, London, between 1952 and 1980, this study uses a qualitative methodology to explore two central themes: “attitudes toward being in therapy” and “memories of therapy and the therapist.” This report presents the findings of the study in narrative form, and argues that the recollections of former child analytic patients are an important, but under-used, source of knowledge for an understanding of the psychoanalytic process. In 1922, thirteen years after he published his first account of the psychoanalytic treatment of a child, the case study of “Little Hans,” Freud added a short postscript. In it he described a “strapping youth of nineteen” who approached him and introduced himself as the same person whom Freud had met when he was only five. He told



Nick Midgley, Anna Freud Centre, London, and Mary Target, Anna Freud Centre and University College London. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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Freud that he “was perfectly well, and suffered from no troubles or inhibitions.” He had apparently “come through his puberty without any damage,” despite the severest of ordeals, including the divorce of his parents. Most remarkable of all, he told Freud that, even when he read the case history, he could remember nothing of the analysis itself or anything described in the pages of Freud’s work (1909:304). Freud suggested that Hans’ memories were no longer available to consciousness because of the repression barrier that had blocked any recall of both his early childhood and, more specifically, of the analytic work undertaken by Hans’ father under the “supervision” of Freud. Perhaps it was Hans’ lack of memory that has encouraged psychoanalysts (and researchers) to assume that former child analytic patients will have little or no memory of their early experience of analysis, leading to an almost complete absence in the professional literature of any accounts of child analysis from the point of view of the former patient him or herself. Yet when we turn to the general child analytic literature, we discover that in many treatments some form of spontaneous followup—like that of Freud and little Hans—does take place, and that in a few instances some indications of how the child analysis has been remembered is recorded. Far from suggesting that all memories are over-taken by the repression barrier, there are hints that the child analysis—and the figure of the analyst in particular—retain some place in the memories of these adults. For example, in Koch’s (1973) review of twenty cases of follow-up contact with former child patients, he reports that former child patients made some reference to their experiences of analysis, but with little specificity and some distortion of memory. Some spoke of it as being “helpful,” or remembered some aspect of the treatment room or particular events (often connected to provocative or acting-out episodes) but that much of the children’s experiences had “receded into the oblivion of the repressed” (238). The only exception is one child who, at follow-up, “dwelt at some length on his experience, vividly recalling his anger at the therapist for not understanding what he was trying to communicate when enraged” (238). In a similar review, Beiser (1995) writes that of the thirteen intensive child analyses she carried out during her analytic career, in ten cases follow-up data was available, in some cases up to forty years after termination. But in only one case does Beiser explicitly report the former child patient’s own memories of therapy: a boy who remembers playing Fox and Hounds with his therapist, while naming each animal with an affect—depression, envy, anger, and happiness. The



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man also reports his memory of an incident when his analyst “told him it was unacceptable to put his feet or chocolate-smeared hands on [the therapist’s] desk” (117). Although she gives no other examples, Beiser observes that many of the memories of therapy that these former patients retain were related to experiences of limit-setting by the analyst, and she wonders whether the experience of gratification and frustration, inherent to the analytic experience itself, encourages the process of internalization. She also notes that several of her former patients had entered professions involving the care of children, and that they often retained an “attitude of inquiry as to the meaning of behavior and feelings” which the analyst had herself promoted (119). The psychoanalytic literature also contains several case studies of former child patients who have returned to analysis as adults (e.g. Adatto 1966, Ritvo 1966, Ritvo and Rosenbaum 1983, Ostow 1993, Babatzanis 1997, McDevitt 1995, Colarusso 2000, Parsons 2000, Rosenbaum 2000). Most of these studies have been attempts to show how “core aspects of character seem to be continuous from childhood to adulthood” (Cohen and Cohler 2000:9), so they have not focused primarily on the former child patients’ memories of therapy. Nevertheless, a number of these case reports do remark on the place the child analyst appears to have retained in the former patient’s mind. In a review of several cases, Ritvo suggests that many of these adults have maintained an internal representation of the child analyst as a “source of self-awareness and self-understanding to which they turned at times of internal crisis” (1996:375), as well as an awareness that “understanding the workings of the mind was the way to resolve their difficulties, and that the analyst was someone who knows how to help them” (2000:344). While the focus of much of this follow-up literature is elsewhere, the few glimpses we are given of the former patients’ memories of their analyses are tantalizing: Ms B, who “recalled many aspects of her first analysis, especially in connection with her analyst’s interpretation of wishes to have a baby” (Ritvo and Rosenbaum 1983:686); “Richard,” in analysis with Melanie Klein as a young child, who almost forty years later remembers her as “dear old Melanie,” “short, dumpy, with big floppy feet,” and with “a strong interest in genitalia” (Grosskurth 1987:272–73); the young woman who felt that, as an adolescent in analysis, she had been able to “get better because [the analyst] was kind like her father,” and who recalled particularly a painting on the wall of the analyst’s office (Adatto 1966:500); and “Evelyne,” who, in a follow-up interview at the age of thirty-four, re-



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ported “that she learned the art of good listening and communicating from her former analyst” (Ritvo 1996:374). To our knowledge, the only description of a child analysis written by a former child patient her or himself is Peter Heller’s A Child Analysis with Anna Freud (1990). The book includes a reproduction of the very sketchy process notes made by Anna Freud on Heller’s childhood analysis in Vienna, which she sent to him a few years before her own death. Heller chose to publish these, together with an account of his own memories of his childhood in Vienna and his “free associations” to reading Anna Freud’s notes. In his introductory chapter, where Heller writes of his family and his childhood, Heller expresses with great force his deep but ambivalent feelings toward Anna Freud and his analysis with her, which was carried out in quite unusual circumstances. (Heller also attended a special school run by Anna Freud and his later life was closely tied up with that of Anna Freud and her circle). He describes his memories of Anna Freud’s “kindly severity” (xxii) as she sat behind the couch on which he lay (between the ages of nine and twelve), knitting or crocheting. He remembers that his analysis focused on the loss of his mother and his “problematic” relationship to his father (xlvi), and he describes how as a child he “loved and revered [Anna Freud] above all other humans” (xxvii). Yet Heller is deeply ambivalent about the experience: he explains how, “in analysis I wanted to be loved . . . and like so many patients, I did not think I was loved enough” (xxvii). Heller’s account of his child analysis hints at the depth of feeling he still retains about this period in his early life, and suggests that former child analytic patients can provide us with another point of view on the psychoanalytic process, one which would complement the many accounts of child treatments from the analyst’s point of view. More particularly, they could provide us with the opportunity to discover how former analysands felt about being in therapy as children, what they understood about why they were taken to see someone, and what specific memories of the experience they have retained. The desire to know more about this remarkably unexplored area was what led us to carry out the current study. Rationale and Aims of the Study The research reported here is part of a larger project on the longterm outcome of child psychoanalysis (Target and Fonagy 2002), which attempted to follow up all adults who were referred as chil-



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dren to the Anna Freud Centre between 1952 and 1980. In total, twenty-seven adults who had been in intensive psychoanalysis as children were interviewed as part of this project (see Appendix One). These interviews were extremely wide-ranging and in-depth, exploring all aspects of adult life and functioning as well as memories of childhood generally and the child analysis more specifically. Out of this huge amount of data, this study makes use of only one small part—the interviews which focused specifically on memories of being in child analysis (Barth 1999). The approach chosen to analyze these interviews was broadly-speaking “qualitative.” The relatively small sample (twenty-seven participants), the nature of the data (verbatim transcripts of semi-structured interviews focusing on the subjective accounts of personal experience), and the topic itself (a relatively unexplored area where an exploratory approach is probably more appropriate than a hypothesis-testing one) are all features that have been widely recognized as appropriate for qualitative studies (McLeod 1999). Inevitably the detail and depth of memory retained by the participants of their child analyses varies enormously. Some of those interviewed had been as young as three and a half when they had been referred to the Centre; others were in late adolescence. Likewise the period of time since the analysis had ended varied a great deal— from eighteen years to forty-two years, with the average length of time being twenty-seven years. Some people refer to specific, but quite major gaps in their memory, like being unable to remember anything about starting or ending therapy, or whether they saw one or two different therapists, or how often or for how long a period they came. Only two people (aged four and a half and five at the time of their respective referrals) claimed to have no memory at all of the experience. Perhaps unsurprisingly, those whose memories were less clear tended to be the ones who had been referred for therapy when they were six or under, although this was not always the case. For example, one person who had been in therapy at the age of three and a half for about two years, had quite clear memories of his therapy and his therapist. Results In the course of the analysis of the data, a wide range of analytic themes were generated (see Midgley 2003; Midgley, Target and Smith, in press), and this paper will present only part of the findings—those which were related to the participants’ attitudes to-



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ward being in child analysis, their memories of what actually took place, and their feelings about the figure of the analyst him or herself. In the presentation of the material, verbatim excerpts from the transcripts are included in order to convey the tone and complexity of the individual narratives, and to give a more vivid sense of what the interviewees’ experiences involved. Although not given in exact quantifiable terms, some sense will also be given of whether the themes that emerged were common across many interviews, or were quite particular to the experience of one or two interviewees; or whether certain themes were especially common among men rather than women, or those who had been in analysis at a certain age. The excerpts will be referenced in the following way: (Anthony, 10.10), meaning that the quotation is from the interview with “Anthony” (all names are changed), age ten years and ten months at the time of being referred for analysis. attitudes toward being in therapy A number of participants in the research suggested that being in psychoanalysis as a child was a relief because they were aware that things were difficult, although few were specific about the nature of the difficulties. Five of the interviewees (all latency age or older at the time of referral) spoke of their own sense that they needed to be in therapy, or the relief they felt that something was being done to make things better, although most of them are not specific (in this interview, at least) about what they felt their difficulty was at the time. As one puts it: You know I’d obviously—something had gone wrong and I was unhappy and everything, and I thought maybe, maybe this will make things better, so really I was pretty determined to do it because I thought I needed to. (Richard, 10.10)



About half of the interviewees (evenly spread across the age range) commented that they did not really understand why they were taken to therapy as children, and they described feeling that nobody had really explained this to them. “I was never really told why I was going there” (Susannah, 12.3) is a comment that recurs several times in different interviews, although the way different interviewees feel about this varies. In some cases the interviewees indicate that nobody had explained to them why they were going, but this does not seem to have been a difficulty for them, as they were able to make sense of it for themselves (e.g. Anna, 8.11). In several other cases, however, especially



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among those who had been in therapy as adolescents, the fact that they did not feel they understood why they were coming to the Anna Freud Centre was a more serious obstacle, and made it harder for them to make use of the therapy itself. In one woman’s case, her difficulty in understanding why she had been referred for therapy led to a more negative attitude toward being in therapy: I think that it would have been very helpful if it had been all explained to me if everything, the whole treatment was explained to me . . . why I was there, the necessity of her to react to me in the way she did . . . as I say at eleven I didn’t have any choice about going. I didn’t choose to go and it was never explained—or as far as I remember it was never explained. (Tamsin, 12.6)



For another interviewee, who came into therapy as an adolescent, this issue of not understanding why she was coming to therapy was felt to be almost the main topic of the therapy itself: It’s strange because I didn’t understand why I was there—my childhood wasn’t brilliant, my adolescence wasn’t brilliant, I wasn’t getting on well with my parents, and I can only think—but nobody got on well with their parents, I really didn’t understand why I was there, and that theme went on throughout the year, it was the constant, major theme of “why am I here?” (Heather, 17.5)



Of those who described this sense of not understanding why they had come to therapy, a number expressed a wish that they had been consulted more, that there was “a negotiating kind of process, about what’s going to happen” (Daniella, 13.9), or that they had been given more information, at the time. “I think at thirteen a bit more information would be useful,” says one woman, thinking back to her experience (Susannah, 12.3), while another woman remembers feeling that “we never sort of assessed as we went along how it might have be helping [. . .] and it might have been helpful for her to say ‘Let’s see how you progress, let’s see what value has been in it, let’s see perhaps let’s talk to your parents together’” (Tamsin, 12.6). Without such a process, being in therapy could feel as if it were actually a “punishment” for doing something wrong: It felt, you know, I was like being punished every day and I didn’t understand what good it was doing. (Tamsin, 12.6)



Commentary From her earliest writings Anna Freud recognized that one of the greatest differences between child and adult psychoanalysis was the



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child’s attitude toward being in therapy. Adults who have an emotional difficulty may sometimes decide to see a therapist; children rarely do. If they do see a therapist, it is probably because they have been asked (or told) to go by a teacher, a doctor, or a parent. Children may not be as troubled by their “symptom” as the adults around them are; they may lack the same motivation to engage with the analytic process, and they are more likely to seek an external solution to their difficulties (A. Freud 1965). All of these issues raise very specific questions—perhaps even concerns—about what the child’s attitude toward being in therapy will be. To a considerable degree, these concerns are confirmed by the findings of this study. While there were a small number of participants in this study who described a sense that they “needed” to be in therapy, and spoke of the “relief” they felt when their difficulties were finally being addressed, very few referred to specific difficulties or worries that led them to be in analysis; a large number of participants (about half) in retrospect described some feeling of not knowing why they were taken to therapy as children. It is interesting that of those who expressed this feeling, a greater proportion had either been under six or adolescent at the time of their referral. It may be that for those who were referred at a very young age their lack of understanding about why they had been in therapy was more related to lack of memory or lack of understanding at the time, whereas for those who were in adolescence the meaning of these statements was different. This might seem to be confirmed by the fact that it was predominantly the adolescent group for whom this lack of understanding was seen (retrospectively) as having been an obstacle to their engagement in therapy. Of course the problem of engaging adolescents in psychotherapy is a notorious one (Meeks 1971), and in general outpatient psychotherapy, it is generally accepted that there is a 40 to 60 percent drop-out rate for this age group (Kazdin 1995, Wierzbicki and Pekarik 1993). What comes across very powerfully from this data, however, is a sense that these participants did not feel as if they had been given enough information about why they were in therapy, what was expected of them, and how the process worked—a finding that replicates recent studies into adolescents’ experiences of therapeutic inpatient units (Street and Svanberg 2003). Although we have no “objective” data about what information these young people had actually received at the time, this finding seems to confirm some research suggesting that lack of preparation can be an obstacle to children engaging in psychotherapy (Holmes



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and Urie 1975) and that helping adolescents to understand why they are coming, and how therapy is supposed to help them, is of great importance (Griffiths 2003). The need to attend to the child’s understanding of why they are in therapy—not just at the beginning, but as an on-going process—is perhaps one of the most important findings of this study, given the degree to which these former child analytic patients report a lack of understanding in this respect. memories of therapy and the therapist Among the twenty-seven people who took part in this study, there was a fairly even spread between those who remember feeling predominantly positive about going to therapy, those who felt mixed, and those who felt largely negative. Interestingly, of those who spoke about coming for therapy at the Anna Freud Centre in the most positive terms, the largest number tended to come from the adults who had been in therapy as very young or latency-age children, rather than as adolescents. This group spoke about how “it was fun, it was brilliant” (Angela, 7.10), that it was “a good feeling” to go (Phil, 9.3), or that they “enjoyed spending time with [the therapist]” (Rupert, 3.9). For these people the emphasis is often on the enjoyment they got from having this quite unique experience. When describing the experience of being in therapy itself, most people described it in terms of two main activities: playing and talking. Not surprisingly, those who describe the therapy in terms of “talking” tended to be those who were referred at an older age, whereas those who spoke in terms of “playing” were younger when they had been referred for therapy. Of those who remember coming to therapy in terms of “playing,” the memories tend to be rather vague and generalized: painting, playing with dolls or bricks, bits of plasticine or a book kept in a special cupboard. Several people describe some uncertainty about what the purpose of the play was, and only in one case is the play described in very positive terms as characterizing the essence of the experience of being in analysis as a young child: I saw it, you know, as my time to be with someone who was there to play with me and sort of do whatever I wanted to do, and that was hugely enjoyable. (Rupert, 3.9)



For several of the participants, the feeling that they could talk about—or do—whatever they wanted was what characterized being in therapy, and this opportunity is described several times with a sense of surprise and pleasure:



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I think, initially, I think I liked the fact that it was one to one and the—I could do things here like art and craft that I couldn’t do at home or at school, and that seemingly you could do anything you wanted. So it was like fun, it was brilliant, it was so, you know, whatever I wanted to do, I wanted to talk about, that was what I could do. (Angela, 7.10)



For this particular woman the emphasis is on both being able to do and to say whatever she wanted, but for others (again, mostly those who were slightly older children when they came to therapy) it is more specifically the opportunity to talk that characterizes their experience of therapy: “I’d just chat away about anything and everything” (Susannah, 12.3); “I just remember talking and things” (Lillian, 5.10); “talking about things, how it affected me” (Phil, 9.3). As one interviewee makes very clear, this “talking” was not the same as the “talking” that might go on elsewhere; not only was the content sometimes different, but so too the way in which the talking evolved: And sometimes I would just sit there [laughs] and not say anything for about ten minutes and then, he would just say “well,” you know, and then I’d start talking about anything that came to my mind, you know, it’s very, very difficult, it’s really difficult. (Mark, 16)



While recognizing the difficulty of this process, this interviewee and others acknowledged that it enabled them to talk in a way that was quite different to other situations with other people. A number of people refer specifically to the fact that they were able to talk about “secret” thoughts and feelings, and emphasize that they would not be able to speak like this elsewhere, or that they would not be listened to in the same way: Yeah, it was like a chance to go through things which, which I couldn’t go through with other people, because nobody had the patience or the time [laughs] to sit down and to listen to what was on my mind so, to be able to do that was a privilege, it was something very special. (Phil, 9.3)



While the quotation above describes the therapist’s attentive listening as helpful in its own right, others talk about things that the therapist did more actively. Although they do not use the word itself, several interviewees refer to something their therapist did which we might understand as “making an interpretation.” In some cases, this is a rather general comment about how the therapist would comment or “mould” what the child had said or done in their play (e.g. Eva, 9.8) or would “offer solutions to possible problems” (Anthony,



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10.10). One man talks about the way his therapist would “mould” things and “talks about things I’d been talking about, like dreams or whatever” (Mark, 16) and goes on to describe what this felt like: Sometimes, sometimes he came out with, I’m pretty sure he would come out with some very interesting sort of links, you know with what I was saying, like, and I’d say “hey hang on a minute,” that’s absolutely right, you know. (Mark, 16)



Another woman refers to the “comments” that her therapist used to make, and remarks on how, “20, 30 years later I can remember little comments [the therapist] made to something I said that she may not have even thought was important,” describing this as a “powerful” experience (Heather, 17.5). In some cases, the therapist’s “interpretation” seems less about what the therapist said, and more related to what the therapist did, a particular action or response which had significance. One man remembers how he used to make things in his sessions, and that his therapist used to “dutifully walk down stairs” and get whatever he needed: And then on some occasions I’ll forget to ask her for something and I’ll say “could you go and get me this” and she had to go all the way back down again [laughs]. I’m sure I used to deliberately kind of just see, you know, boundary again, just kind of see how far I could push her and you know, she always used to go until there came a point where she said “I’m not going to do that” and I was like “oh, why not?,” and she said something like “because I don’t want to.” Uh, OK . . . So my memory is quite fond of her, you know. (Neil, 10.4)



This man indicates that his own behavior was a kind of testing of boundaries, and that his experience of the therapist setting limits was an important one, and leads directly into his comment about his “fond” feelings for the therapist. When asked explicitly, about two thirds of those interviewed described some kind of positive feelings toward their therapist, and this was especially true of those who came into therapy as young children. A large number said simply that they “liked” their therapist, without elaborating greatly on this. Others spoke about their therapist being “warm and friendly” (Elaine, 6.4), or being “a sympathetic person” (Jason, 7.1) and of themselves having “real feelings of warmth” toward the therapist (Neil, 10.4). Among those who spoke about their therapist in these positive terms, a few people expressed a more specific sense that they felt accepted, looked after, and listened to by their therapist. One man



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spoke about how he “appreciated the attention” that his therapist gave him (Bobby, 14.11), while a couple of the participants also describe, with obvious warmth, the sense of their having a unique relationship to their therapist, quite different from those with their parents, teachers, or other adult figures. One says: I didn’t really have any relationship with anyone else, but my therapist I was very close to. I felt I could tell her anything and she wouldn’t be cross. And everything I told my parents made them cross. So that was quite nice. I felt accepted. (Marigold, 11.8)



In a similar way, another man describes his relationship to his therapist with the following words: I felt I could be more relaxed, if you know what I mean, I mean open, where I was not able to be relaxed with people in general. It was almost like I could feel, like, comfortable with her, like at ease with [my therapist] yes, and, and also she wasn’t in a position—you see in a lot of, especially with teachers . . . they tend to judge the children so, so I was safe from judgement. (Phil, 9.3)



In contrast, several participants in the research describe feelings about being in therapy which were often quite mixed and even contradictory. One woman describes her feelings about her therapist as a “typical sort of love-hate relationship” (Angela, 7.10). Others speak of the way that they liked their therapist, but felt hostile toward him or her when they felt under pressure or were going through a difficult period in the therapy. One man describes particularly well the way in which his feelings about the therapist could change depending on what was happening in the therapy, while also recognizing that the hostile feelings were ultimately related to the difficulties of the therapy, not the person of the therapist herself. He says: I remember liking her, but I also remember being frustrated about specific conversations and things, when she would query whether I was feeling in a particular way or whatever, and you know, at the time I felt it was a useless line of conversation, and then feeling annoyed about that. But I seem to recall my overall feelings was that I liked her [. . .] Sometimes, if I reacted adversely to a particular type of conversation, sometimes my feelings about that spilled over onto her personally, for a period of time. (Peter, 7.8)



While this man describes different feelings toward his therapist depending on what was happening in the therapy at the time, others describe the way their feelings toward the therapist changed over time. In some cases, an initial dislike gave way to more positive feelings:



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I didn’t like him at first, or I was scared of a man, [the therapist] was strict and wouldn’t do what I asked [. . .] And later I was very fond of him, I remember later saying to him “I think I might, I think I might want do what you do for a living,” some real feeling of warmth toward him toward the end. (Neil, 10.4)



In contrast, for a significant minority of interviewees (just under a quarter of the total, mostly latency-age or adolescent at the time of therapy, and almost all women) their description of the therapy is characterized by their non-engagement with the therapy. “I wasn’t really sharing anything with him. I was very closed” (Joanne, 7.9); “I didn’t talk about anything—sometimes things were really hard at home” (Dominique, 7.6); “I’d never open up, I’d tell whopping great lies because I didn’t want her to know what I was really thinking or feeling” (Susannah, 12.3); “I didn’t really talk to her—I used to sit counting squirrels out of the window” (Eva, 9.8). Memories about non-engagement in therapy tended to be linked with negative feelings about the therapist him or herself. Overall, about one third of those who took part in the research expressed some negative feelings about their therapist as a person. Interestingly, all of these people had been in therapy when they were either latency-age or adolescent, and none of those in therapy as young children spoke about their therapists in negative terms. Most commonly among this group, interviewees spoke about a sense that their therapist did not understand them. Whereas some spoke about feeling not understood in a global sense, others suggested that there were only particular times when they did not feel understood (e.g. Richard, 10.10). As one woman puts it: I think, yeah, I felt he understood certain things but I think that, I think I felt that maybe his priorities were not my priorities like, you know, to him it seemed really important about my particular bodily function, and to me it was “why on earth is he interested in that?” You know, in that respect he wouldn’t understand. (Angela, 7.10)



For two others, one of whom will be described further in the next section, they felt the central issue that their therapist did not understand was the question of “am I mad?” As one of them puts it: I felt, I think she said something like, well I think she said something like—“you’re coming here, isn’t there something wrong?” or something. I think that maybe we were at cross-purposes or something. Because I suppose on some level I was talking about whether I was completely bats and maybe she didn’t realise that. (Daniella, 13.9)



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For a number of interviewees, the negative feelings they had about the therapy and the therapist were connected with the experience of being asked questions: “they asked me questions that I didn’t want to answer” (Neil, 10.4), says one, while another remembers how the therapist “tried to pressure me to look at things I didn’t want to look at” (Bobby, 14.11). One woman gives a more particular description of this experience: I think I liked [the therapist] but I think I found him really annoying because he would ask me all these questions which I didn’t necessarily want to answer [. . .] he used to ask me a lot of questions about my bowel movements—or that’s certainly what sticks in my mind [laughs]—so in my mind, it’s probably a complete distortion, but in my mind I think he was a bit obsessed by my bowel movements but [laughs] I don’t know . . . (Angela, 7.10)



While these people describe feeling that these questions forced them to think about things that may have been uncomfortable, others describe the experience as more negative, or as giving them a sense that they did not know why they were being asked all these questions. “I thought she was interrogating me half the time” (Susannah, 12.3), says one interviewee, while several refer to their uncertainty about what all the questions were for. One woman describes her memory of “being asked loads of questions and not knowing the reason,” and she remembers that some of the questions seemed to have “sexual overtones” which she felt confused about (Elaine, 6.4); another remembers how she used to wonder “why they were asking me all these questions,” because I would stand there and I would be playing with a doll or something and then I would think “why are they asking me this?” (Lillian, 5.10). For a small number of those interviewed, the therapist’s questions, together with their sense that the therapist refused to respond to their own questions, led them to experience the setting and the therapist in more explicitly negative terms. One participant put this especially clearly: You see, I totally resented the process which was basically—presumably it’s still the same, I don’t know—but she used to just sit and wait for me to say something and I just resented that so much, and I got so angry about it all that I don’t think she—my feeling was “how could she ever know anything about me because she never asked any questions” [. . .] You see if I didn’t talk then she didn’t talk so we just sat there sometimes for the whole session not saying anything at all, and I loathed it. (Susannah, 12.3)



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A little later in the interview, however, the same woman described how her therapist did ask questions, but that this was equally unsatisfactory: She would ask me questions, and I would sort of think I knew what she was trying to—I thought she was interrogating me half the time [. . .] I’d tell whopping great lies because I didn’t want her to know what I was really thinking or feeling [. . .] And I felt she was prying, I didn’t want her to know—when she did ask the questions [laughs]. (Susannah, 12.3)



While several participants describe some negative feelings about their therapy and their therapist as a person, the woman above is one of a group of about six interviewees, almost all women who came into therapy as latency-age children or in early adolescence, who describe much more explicit, active feelings of dislike toward their therapists. “I thought he was revolting,” says one (Joanne, 7.9), “she drove me demented,” says another (Eva, 9.8), while another states that she simply “hated” her therapist (Anna 14, 8.11). Interestingly, none of them elaborate that much on what it was they hated about their therapists. One of them simply says it was “because he was a man” (Joanne, 7.9), while another speaks about simply disliking “everything” about her therapist. Those in this same group also describe feeling that they were not understood by their therapists, that they were not able (or did not want) to share anything with their therapists, and that they did not wish to be there. They all describe how they felt using quite similar language: “I just didn’t want to go” (Joanne, 7.9), “I hated it” (Susannah, 12.3), “I was resentful about having to go, having to be there every day” (Dominique, 7.6), “I didn’t like it . . . I thought it was invading my own privacy” (Sarah, 9.1). One woman gives a fuller description of how she felt and why: I can’t remember sharing my feelings with her; it was always resisting sharing my feelings with her. I kept thinking it was a waste of time and I kept trying to provoke her and I couldn’t understand why I had this little cupboard where I had some toys and crayons and I couldn’t understand why I had to go there and draw pictures or play with dolls. Or I just thought that it was just meaningless, not understanding that what I was doing was being interpreted because I didn’t have any concept that behaviour could be interpreted. I just thought it was—I didn’t feel any better after going. (Tamsin, 12.6)



For this woman, as for some others, her negative feelings about the therapy eventually led her to end her treatment prematurely.



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It appears from this study that those who remembered their child analyses in the most positive way were often in analysis as quite young children, although they may have had only a vague idea of what the analysis was about. In The Technique of Child Psychoanalysis, Sandler et al. acknowledge that “for the young child the positive tie to the therapist probably forms the main basis for the therapeutic work” (1980:47), and the fact that those who were in analysis as small children almost all described it in terms of “fun” and as an opportunity to play with an interested adult figure seems to confirm this. The view of Sandler et al. seems to be confirmed by the findings of this study: To a child, analysis probably seems simply to be another one of those strange activities that grown-ups enter into with children, responding to whatever is put to them. The child’s experience in treatment gradually enables him to sort out the meaningful differences [. . .] even if he speaks of treatment as “play.” (1980:156)



But this study also tells us something more specific about what aspects of the experience of being in analysis as children were felt to be important. For some participants in this research, there is a powerful sense that the experience of being able to talk about whatever they wanted to, in the presence of a sympathetic, non-judgmental listener, was the essence of the therapeutic experience. The emphasis on the experience of being accepted, listened to, and looked after by a therapist who is “warm” and “non-judgmental” appears to confirm once again what Sandler et al. have written: The child in analysis has a novel experience in that the therapist is an adult who takes his feelings and expressions seriously over a significant period of time. This has the result that the therapist raises the self-esteem of the child by saying, in effect, “I regard you as someone to be considered important, and I am not going to dismiss you out of hand. I will listen to what you have to say.” (1980:112/13)



This emphasis on being listened to and understood echoes much of the research into patients’ views of adult psychotherapy, in which the interpersonal qualities of the relationship are seen as considerably more important than any particular thing that the therapist said or did (e.g. Llewelyn and Hume 1979). However the current study also suggests that former child analytic patients remembered, and valued, some of the particular “comments” or “links” that their analyst had said, indicating that a “significant interpretation” (Sandler et



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al., Chapter 18) made in childhood can be remembered and valued more than twenty years later in life. However, for a considerable minority (about a quarter of the participants) the child therapy is remembered predominantly in terms of their own non-engagement with the analytic process (“counting squirrels out of the window”). This non-engagement is associated with two factors in particular: a sense of being questioned, or even interrogated, by the analyst, whose questions did not seem to make sense or did not give the child a sense of being “understood”; and in a smaller number of cases, a general resentment of the analytic process itself, experienced as “insulting,” because the analyst was distant and unresponsive and the child was left feeling misunderstood and dis-empowered. While in some cases these feelings were associated with a period of the analysis when the child was being “forced” to confront things they preferred to avoid, in other cases the feelings are more intense and on-going, associated with a general non-engagement with therapy, a feeling of frustration about the analytic process. In a few cases, especially among those who had been adolescents at the time of their analysis, this led to intensely negative feelings both about being in therapy and about the therapist as a person. Analysts in the Anna Freudian tradition have also recognized that the development of the negative transference in psychotherapy with adolescents is particularly common, and especially likely to end in premature termination of treatment (Meeks 1971:133). Moses Laufer has written extensively about the particular difficulty when the adolescent patient re-experiences the developmental breakdown within the transference itself (Laufer 1989). The accounts by some participants in this research of their intensely negative feelings are an important reminder that the psychoanalytic approach is not always successful or even appropriate. While in some cases the negative feelings appear to have been transitory and part and parcel of the therapeutic work, in other cases the feelings were on-going and unresolved, even at the end of therapy. Whether such feelings were an aspect of the child him or herself or were due to the nature of the analytic setting or failures on the part of the analyst, it is not possible to be sure. But since, in some cases, the feelings appear to have continued right through to the end of the analysis, it appears as if such negative feelings could not always be understood and used as part of the analytic process, and they often led to premature termination and unsatisfactory outcome. This finding is an important reminder to child psychoanalysts that technique



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needs to be geared carefully to the developmental level of the child, especially how the treatment is introduced and the way that its aims are presented. Concluding Comments By the very nature of being a long-term follow-up of child psychoanalysis, the participants in this study were describing experiences that had happened to them at quite a young age and many years previously. Memory itself, as psychoanalysis knows only too well, is a complex and over-determined process, and to what degree these memories accurately “reflect” what happened in their child analyses is open to question. There is a great likelihood that quite significant aspects of the child analysis—such as its duration, or whether more than one analyst was seen, or how the treatment ended—would be described quite differently in the child case notes, and the difference between these contemporary notes and the retrospective accounts would be fascinating to compare and contrast. Future studies based on the follow-up data already collected will attempt to compare these participants’ memories of therapy with the clinical case-notes kept at the Anna Freud Centre, as well as looking at smaller sub-groups (such as those who were most or least happy with their experience of child analysis) and comparing them using data related to initial diagnosis, outcome, current representations of attachment relationships, and general adult functioning and mental health. But although future studies may well complicate and enrich our understanding, the uncertainties about the status of the memories described in this study should not prevent us from attending to the former child patients’ memories themselves. The voice of former child analytic patients has been so strikingly absent in the clinical and research literature, that we believe it is important to simply register this voice first, before we go on to further research that would allow us to explore the status of such accounts of the past within a broader context. Most importantly, the current study appears to indicate that former child analytic patients, for the great part, do have memories of certain aspects of their therapies (sometimes very clear ones) and are able to give accounts of their analyses (sometimes very eloquently). Since these accounts are in some important ways different from those of child psychoanalysts themselves, they are worth attending to for what they can teach us about the process and outcome of child psychoanalysis.



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Appendix. Participants in the Follow-up Study



NAME Bobby Daniella Elsa Richard Tracy Angela Rupert Marigold Nathan Sarah Neil Jason Peter Elaine Heather Phil Eva Anna Anthony Sheila Dominique Susannah Mark Lillian Kevin Joanne Tamsin



AGE AT REFERRAL (Years, months)



LENGTH OF ANALYSIS (Years, months)



AGE AT FOLLOW-UP



14.11 13. 9 5.2 10.10 6.11 7.10 3.9 11.8 4.8 9.1 10.4 7.1 7.8 6.4 17.5 9.3 9.8 8.11 10.10 4.0 7.6 12.3 16 5.10 11.11 7.9 12.6



3.8 4.2 2.2 4.6 1.2 1.10 2.0 3.1 1.5 3.3 3.1 3.9 2 .10 2 .0 0.9 4 .6 1.6 2.10 2.9 1.9 3.9 Missing data 3.10 3.4 5.3 1.6 1.8



42 36 36 29 29 32 34 31 41 29 33 45 32 39 42 33 29 34 37 46 41 39 40 36 39 35 35



BIBLIOGRAPHY Adatto, C. (1966). On the metamorphosis from adolescence into adulthood. J. Amer. Psychoanal. Assoc. 14:485 – 509. Babatzanis, G. (1997). The analysis of a pre-homosexual child with a twelve-year developmental follow-up. Psychoanal. St. Child 52:159 –189. Beiser, H. (1995). A follow-up of child analysis. Psychoanal. St. Child 50:106 – 121.



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Cohen, J. & Cohler, B. (eds.). (2000). The Psychoanalytic Treatment of Lives over Time. (San Diego: Academic Press). Colarusso, C. (2000). A child-analytic case report: A 17-year follow up. In Cohen, J. and Cohler, B. (eds.), The Psychoanalytic Treatment of Lives over Time (San Diego: Academic Press). Freud, A. (1965). Normality and Pathology in Childhood. (New York: Int. Univ. Press). Freud, S. (1909). Analysis of a phobia in a five year old boy. In J. Strachey (ed.), The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 10. (London: Hogarth Press). Griffiths, M. (2003). Terms of engagement. Reaching hard to reach adolescents. Young Minds, 62:23 –26. Grosskurth, P. (1986). Melanie Klein. Her World and Her Work. (New York: Knopf ). Heller, P. (1990). A Child Analysis with Anna Freud. (Madison: Int. Univ. Press). Holmes, D. & Urie, R. (1975). Effects of preparing children for psychotherapy. J. Cons. and Clin. Psychology, 43:311– 318. Kazdin, A. (1995). Bridging child, adolescent and adult psychotherapy: Directions for research. Psychotherapy Research, 5:258 –277. Koch, E. (1973). Observations on follow-up contacts with former child analytic patients. J. Amer. Acad. Child Psychiatry, 12:223 –246. Laufer, M. (1989). Why psychoanalytic treatment for these adolescents? In Laufer, M. and Laufer, E. (eds.), Developmental Breakdown and Psychoanalytic Treatment in Adolescence: Clinical Studies. (New Haven: Yale University Press). Llewelyn, S. & Hume, W. (1979). The patient’s view of therapy. Br. J. of Med. Psychology, 52/1. McDevitt, J. (1995). A childhood gender identity disorder: Analysis, preoedipal determinants, and therapy in adolescence. Psychoanal. St. Child 50:79 –105. McLeod, J. (1999). Practicioner Research in Counselling. (London: Sage). Meeks, J. (1971). The Fragile Alliance: An Orientation to the Outpatient Psychotherapy of the Adolescent. (Baltimore: Williams and Wilkins). Midgley, N. (2003). Memories of Therapy: A Qualitative Study of the Retrospective Accounts of Child Psychoanalysis. Unpublished D.Psych dissertation, University College London. Midgley, N., Target, M. & Smith, J. (in press). ‘The outcome of child psychoanalysis from the patient’s point of view: A qualitative analysis of a long-term follow-up study’. Psychology and Psychotherapy: Theory, Practice, Research. Ostow, M. (1993). Play, dream, fantasy and enactment in Bornstein’s “obsessional child,” then and now. In Cohen, D., Neubauer, P. and Solnit, A. (eds.), The Many Meanings of Play: A Psychoanalytic Perspective. (New Haven: Yale University Press). Parsons, M. (2000). The search for a good-enough self: From fragmenta-



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tion toward cohesion in a young adult’s second analysis. In Cohen, J. and Cohler, B. (eds.), The Psychoanalytic Treatment of Lives over Time. (San Diego: Academic Press). Ritvo, S. (1966). Correlation of a childhood and adult neurosis: Based on the adult analysis of a reported childhood case. Int. J. Psychoanal. 47:130 – 131. Ritvo, S. (1996). Observations on the long-term effects of child analysis. Psychoanal. St. Child, 51:365 –385. Ritvo, S. (2000). Double-dipping: Child analysands return as young adults, In Cohen, J. and Cohler, B. (eds.). The Psychoanalytic Treatment of Lives over Time (San Diego: Academic Press). Ritvo, S. & Rosenbaum, A. (1983). Reanalysis of child analytic patients. J. Amer. Psychoanal. Assn. 31:677–688. Rosenbaum, A. (2000). The case of Charlie: Analysis during transition. In Cohen, J. and Cohler, B. (eds.). The Psychoanalytic Treatment of Lives over Time. (San Diego: Academic Press). Sandler, J., Kennedy, H., & Tyson, R. (1980). The Technique of Child Psychoanalysis: Discussions with Anna Freud. (Cambridge, Mass.: Harvard University Press). Street, C. & Svanberg, J. (2003). Room for improvement: Adolescents’ views on impatient care. Young Minds, 62:27. Target, M. & Fonagy, P. (2002). The history and current status of outcome research at the Anna Freud Centre. Psychoanal. St. Child, 57:27– 59. Wierzbicki, M. & Pekarik, G. (1993). A metaanalysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24:190 –195.



The Process of Attachment and Autonomy in Latency A Longitudinal Study of Ten Children RONA KNIGHT, Ph.D.



The findings in this clinical, longitudinal study describe the process of attachment and autonomy as it unfolds during the latency period of development. Ten normal boys and girls were studied from ages six through eleven. A separate timetable of latency development for boys and girls is suggested. The differences in the boys’ and girls’ separation responses, which include feelings of a lack of self-coherence, loss, anger, neediness, movement toward peers and defense functioning, are delineated and discussed. every psychoanalytic theory must have at its base a developmental framework in order to give meaning to the ideas it proposes and the psychopathology it attempts to explain. Freud (1905) proposed a timetable of sexual and aggressive instinctual development



Child, Adolescent, and Adult Psychoanalyst; Founding Member and Senior Faculty at the Berkshire Psychoanalytic Institute; Faculty at the Boston Psychoanalytic Institute; Supervising Analyst at the Massachusetts Institute of Psychoanalysis. I want to express my gratitude to the children and parents who participated in this study. I am indebted to Lillian Schwartz, Ph.D., who volunteered her time and considerable knowledge to help me score and evaluate all the psychological testing and for her thoughtful contributions to this paper. I would like to thank Dr. Anna Wolff for her many thoughtful readings of this paper, the IPA Research Program (1998) for their advice and encouragement, and Drs. A. Scott Dowling, Anton Kris, Samuel Abrams, Peter Neubauer, and Paul Brinich for their helpful suggestions. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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in infancy through adolescence to support his theory of the mind. In “The Three Essays” Freud (1905) concluded that the phase of childhood between the Oedipus complex and adolescence was a latency period: a lull between the two sexual waves of development, a time in which sexuality advances no further and the sexual instincts are diminished in strength and repressed. He conceptualized latency as a period of dynamic defense, noting the uses of sublimation, reaction formation, repression, and whole body responses as a way of redirecting the activity of the child’s sexual and aggressive impulses. In this same paper, Freud also regarded the latency period as very important in determining adolescent object choice. He viewed the development of object choice as diphasic: the first wave occurring from age two to five, and the second occurring in puberty, with latency as the middle ground during which time the sexual object choice and the sexual aims underlying it are transformed into relationships based on affection, admiration, and respect (1905, p. 200). Over the years he added fantasy formation (1911) and regression (1916) as defenses used in the latency period. Freud had different ideas, at different times, as to the actual cause of latency. As early as 1905 he wrote: “this development is organically determined and fixed by heredity” (p. 177). The idea of latency as a defensive reaction to the events of the Oedipus complex and as a preordained, biological, and hereditary developmental phase exist side by side in The Dissolution of the Oedipus Complex (1924), and Freud wrote that “The justice of both these views cannot be disputed. Moreover, they are compatible” (p. 173). Anna Freud (1936) wrote that by the age of seven years, the latency child has all the major defenses available as coping mechanisms, noting fantasy as a significant defense in latency. Her concept of developmental lines (1963) that are separate but also intertwine—weaving together a complex intermingling of id, ego, superego, self and object structures, biological growth, and environmental influences at each stage of development—provided the first complex framework for psychoanalytic thinking about development and paved the way for more modern, integrated thinking about children’s development. A more complex examination of the latency age child’s play, fantasy, and cognitive development has helped make us more aware of the wealth of psychological issues which the six- to eleven-year-old child must experience and master in the areas of psychosexual development, object relations, separation, autonomy, and ego and superego development. Piaget (1932, 1967) and Kohlberg (1963) helped



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map out the development of cognition and moral judgment in this age group. Sullivan (1940) focused on the interpersonal shift to peer relations in latency and spoke of a “juvenile era” which, as Freud had proposed, had lasting importance in terms of future adolescent and adult relationships. Shapiro and Perry (1976) presented evidence of the ways physiological growth promotes autonomous cognitive functioning that allows for more mature ego functioning in latency. Charles Sarnoff (1976) examined the interplay of psychosexual and cognitive development in the latency age child. The stages and phases of latency have been discussed in the literature in different ways. Erikson (1950) considered latency as an era of industry in which cognitive and physical skill development become important factors in shaping the child’s positive sense of self and forming successful relationships with peers. Bornstein (1951) divided latency into two phases tied to superego functioning. Williams (1972) divided latency into three stages according to id, ego, and superego development and dominance. Sarnoff (1976) divided latency into three cognitive organizing periods. Renewed interest in object relations theories raised interesting questions concerning the ways in which latency age children continue to confront and resolve developmental issues pertaining to object relationships within the realms of attachment and autonomy (Oremland, 1973; Glenn, 1991). Kohut (1984) described the twinship self-object experience during latency as a need to feel a sense of sameness with others as the school-aged child ventures out of the home more and into the world of peers, and Freedman (1996) corroborated that clinical finding in her study of latency children. Although Blos (1967) described adolescence as “the second phase of separation-individuation,” the results of this study suggest that the development of separation-individuation is a process that continues through the latency period. Taking up Anna Freud’s (1965) challenge to continue the study of the many complex factors that contribute to a child’s development, psychoanalysts working in development (Sander, 1980, 2002; Mayes, 2001; Abrams & Solnit, 1998; Tyson & Tyson, 1990; Stern, 1985; Emde, 1984, 1988; Galatzer-Levy, 2004; and others) have begun to think of development as both continuous and discontinuous, with the development of discontinuities “occurring within a series of progressively differentiated hierarchical psychological organizations that arise over time” (Abrams, 2003, p. 175). This view of development requires an understanding of the individual parts as well as the interweaving of the many different structures of the mind.



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This research is an attempt to understand the complexity of development as applied to the six- to eleven-year-old child. This contribution is the first in a series of papers that will report and discuss the findings of a clinical, hypothesis generating, longitudinal study of ten normal children who were evaluated yearly from the ages six through eleven. The purpose of this study was to begin to better understand the development of the inner world of the normal latency age child, informed by psychoanalytic concepts and theories. The present paper focuses on attachment and the separation process that leads to autonomy in latency, thus the selection of data intentionally highlights this theme, although other aspects of development are entwined with it. While there are research advantages of focusing on a single element of development, as I have done with attachment and autonomy, a comprehensive understanding and integration of all aspects of development is essential to achieve a balanced view. I hope to be able to provide that as I continue to analyze all the data from this study. Method Subjects: Four boys and six girls participated in this study. Each child was followed from age six through age eleven, for a total of six years for each child. Only children who fell within the normal range of psychological functioning at age six were chosen. A determination of normal psychological functioning was made using the following criteria: 1) a normal six-year-old profile on psychological testing (WISCR, Rorschach, TAT, Bender Gestalt, Figure Drawings); 2) chronological age and phase behavior of a six-year-old based on a clinical interview with the child. The initial diagnostic clinical interview followed the framework outlined by Greenspan (1981) as well as his formulations for normal six-year-old psychological development. Children were selected from the suburban Boston area and were in the middle to upper-middle, white socioeconomic class. To be in the study a child must have had an intact family unit at age six, no history of severe or moderate psychological problems requiring professional help, no physical abnormalities, chronic illness, or significant learning disability. Only children whose families could be expected to stay in the Boston area and whose parents had no chronic illness, physical disabilities, or moderate to severe psychological problems were selected. All the families remained intact throughout the study. The children who participated in the study were extremely bright and very verbally expressive. Their average I.Q. was 134 at age six. A



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small, homogeneous group of children was specifically chosen so that they could be studied in depth as well as provide internal validity within the subject group. Instruments: A multiple measures design was chosen to measure indepth conscious and unconscious thoughts and feelings between children and within each child for each age as well as over the entire six year period studied. Psychological Testing: A battery of psychological tests including the Rorschach, Thematic Apperception Test (TAT), Wechsler Intelligence Scale for Children—Revised Edition (WISC-R), Bender-Gestalt, and House-Tree-Person Drawings was used to assess each child’s personality profile annually for six years. The principal investigator (a child and adult psychologist and psychoanalyst) administered the test battery. The tests were scored and evaluated by the principal investigator and a psychoanalytically oriented senior psychologist who was an expert in child testing. Each year of the children’s testing was scored separately and only after all the years of testing were completed, in an attempt to keep tester and rater bias to a minimum. Interrater reliability using the Pearson correlation coefficient ranged from 0.81 to 0.93 for all measures and was 0.87 for the separation measures discussed in this paper. Using Wechsler’s, Klopfer’s and Schafer’s scoring systems and analysis for cognitive and projective data, each psychologist was asked to make clinical evaluations along ten dimensions based on each child’s responses on the test battery: 1) quality of interpersonal relatedness, 2) self-esteem, 3) ego ideals, 4) body image, 5) degree of narcissism, 6) conscious and unconscious feelings and their discharge, 7) defensive functioning, 8) cognitive functioning, 9) gender identity, and 10) degree and kind of experienced intrapsychic conflict. Each of these dimensions was rated on a five-point scale as well as descriptively. They were chosen to gain information about this age group that would elucidate developmental aspects of psychosexual and structural theory, object relations theory, and self-psychology. At the time of administration of the testing and during the scoring, neither of the two psychologists were aware of the hypotheses that resulted from examining the present findings after all the years of testing were scored and evaluated. The Rorschach and TAT tests were used because they tap into unconscious fantasies and processes (Schafer, 1954). The Rorschach was scored using the Klopfer (1962) scoring system and an object relations and ego function scoring system that I adapted for children and which combines those used by Blatt (1976; 1988), Burke, Friedman, Gorlitz (1988), Kantrowitz (1975; 1989), and other psychoana-



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lytic researchers who have documented reliability and validity for the systematic investigation of these Rorschach measures. Both the Rorschach and TAT were also evaluated using Schafer’s sequence analysis (1954). Projective testing has traditionally been used in psychoanalytic research and has been proven to be a very effective clinical measure (Holt & Luborsky, 1955). One aspect of the Rorschach testing presented in this paper evaluated the children’s level and quality of object relationships. On the Rorschach, the level of object relatedness was based on the subject’s ability to differentiate boundaries between objects, ranging from merged to separate (Table I). Rating is based on the degree to which an object’s boundaries are described as distinct or separate from one another. Merged responses indicate that the subject does not feel himself as separate from “the other,” or yearns for an undifferentiated closeness. Separated responses indicate that the subject experiences herself as separate and distinct from “the other.” Ledwith (1960) and Ames et al. (1974) have published many similar



TABLE I Psychoanalytic Rorschach Profile SCALE



LEVELS



SAMPLE RESPONSE



Object Relations Differentiation



1. Merged



Monsters attached with two heads. Siamese monkeys.



2. Merged to Separating



A wall that is split open but still attached to the ground.



3. Separate but Connected



Connecting chairs. Two crabs stuck together.



4. Separating/ Touching But Distinct



Two animals back to back about to go away from each other



5. Separate



Two people dancing together. Two rabbits playing.



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TABLE II Psychoanalytic Rorschach Profile SCALE



LEVELS



SAMPLE RESPONSE



EGO STABILITY



1. Death



A dead cat; A dead flower



2. Fragmentation



Crumbled rocks A cup broken in pieces Example of One Boy’s Sequence: Age 5—People Age 6—Two shoes, two knees, two chins Age 7—Two ladies smashing pumpkins Age 8—People



THOUGHT PROCESSES



3. Incipient Fragmentation



Decaying leaf Humpty-Dumpty falling



4. Enduring and Solid



Person; Bear; A cooking pot



Contamination



Chinese dancers. Dogs playing patty-cake. Chinese dog dancers.



Anthropomorphism Rabbits wearing their Easter hats having a tea party. A frog in a bow tie going to a ball.



Rorschach responses in their normal children’s protocols for this age group. A second aspect of the Rorschach testing appraised the integrity of the child’s self structure, which was evaluated by the degree to which the object remained whole, intact, or alive (Table II). A fragmentation response on the Rorschach implies that the subject is in an unconscious feeling state of dis-integration. We usually think of frag-



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mentation as indicative of a severe problem with self and object integrity. Its presence in these normal children during certain phases of development suggests a normal, temporary break-down in the antecedent mode of object-connection and the concomitant establishment of self-coherence, indicative of a change from an enduring state to one that is experienced as not yet integrated. Fragmentation in normal latency children’s protocols also appears in Ledwith (1960).1 Clinical Interview: Each child was administered a semi-structured clinical interview, developed for this research to gather information about the following: 1) self-esteem, 2) ego ideal, 3) body image, 4) quality of interpersonal relatedness, 5) narcissism, 6) conscious and unconscious feelings and their discharge, and 7) coping mechanisms and their functioning. The principal investigator administered the clinical interview. Each interview was tape recorded and transcribed. The clinical interviews were not scored for this research paper; the children’s responses were used to confirm and deepen the understanding of the test data. Parent Questionnaire: Every four to six months the parents of each child were asked to complete a 16-page parent questionnaire developed for this research. The questionnaire elicited information about the child’s ongoing feelings and attitudes about him/herself, fantasy and dream material, general mood, relationships with family and friends, behavior and performance in school, parents’ feelings and behavior toward the child, and information about the parents’ feelings about themselves. The child’s mother was asked to fill out the entire questionnaire. The child’s father was encouraged to contribute information for this questionnaire, and he was required to fill out the part of the questionnaire that concerned his feelings and attitudes about the child and himself. Responses from the questionnaire have not been scored as yet but were used anecdotally to further our understanding of the test data. Observation of Child in Play with Peers: Each child was observed annually and videotaped for 1–2 hours in free play with a friend in the child’s house. This information was not used in the present study. Teacher Questionnaire: Two thirds of the way through the school year, each child’s teacher was asked to complete a questionnaire about the



1. Bibring (1959) also found a dramatic difference between the disturbed Rorschach responses of pregnant women and their everyday good functioning in the real world.



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child. The teacher questionnaire elicited the teacher’s evaluation of the child’s general mood, school performance and behavior, and relatedness to peers, using a five-point rating scale, which was primarily used in this paper to see how well the children were functioning in school. Procedure: The above measures were administered each year to each child and their parents and teachers for the six-year period that each child was studied. Results early latency: ages six to eight years This clinical study delineates the processes of attachment and autonomy that occurred during the latency age period in these ten children. At age six years in the boys, and at age seven years in the girls, the children began to develop an unconscious sense of being separate from their parents in a way that they had not experienced previously. This sense of separation was related to the denouement of the oedipal period and their feeling pushed out into the world outside their home. Along with this new sense of separateness came feelings of disconnection, sadness, and anger. Although both sexes experienced this development, they had different timetables—the boys entered this phase one year earlier than the girls. Boys: At age six, a sense of separateness and lack of cohesion first appeared in the boys’ responses. Three of the boys had Rorschach testing at age five and were judged as not yet feeling separated and had no fragmentation responses. However, between ages six to eight all the boys were judged to be feeling separated from their objects. All four boys had fragmentation responses on the Rorschach at age six, which were less intense at age seven and were completely gone by age eight. Typical of the advent and waning of a feeling of fragmentation was one boy’s responses to Card III on the Rorschach: at age five he saw two whole people; at age six he saw two heads, two chins, legs or knees, and shoes; at age seven he saw two ladies smashing pumpkins together; and at age eight he saw two people. Table III shows the process of fragmentation and separation responses in the six- to eight-year-old boys and girls. At age six the boys had feelings of being alone, abandoned, and not nurtured in the big world. TAT stories about feeling lost and without parents were typical. Feeling little and damaged, they had concerns about whether they could make it on their own, feeling in-



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TABLE III Rorschach Fragmentation and Separation Responses For Five- to Eight-Year-Old Children BOYS AGE FIVE



AGE SIX



AGE SEVEN



AGE EIGHT



Solid



All Fragmented



Some Fragmentation



Solid



Not Separated



Separated



Separated



Separated



GIRLS AGE SIX



AGE SEVEN



AGE EIGHT



Solid



Fragmented



early 8: some fragmentation late 8: Solid



Not Separated



Separated



Separated



sufficiently supported by their parents. These responses were present on the TAT and were also expressed in the conscious fears and dreams these boys reported in the clinical interview. One boy worried about getting hit by a car while walking to school without a parent, and another dreamt about a dog that broke loose from his leash, wound up with a bad family, and needed rescuing. The six-year-old boys felt very angry and sad about being left alone to fend for themselves. They associated separation with the death of their parents. In the clinical interview they expressed fears about people in their families getting hurt and killed and reported dreams about their parents dying. One boy’s story to a TAT picture of a girl leaving for school expresses these feelings: “Somebody got killed in her family. The grandfather. Then the father died and everyone else in the family died, and so she’s gonna get adopted. They just all died cause they were real old, like 100 years old. (How old is the girl?) She’s 19.” These boys also experienced guilt about their underlying fantasy that separation will lead to the death of their parents, which



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often increased their worries. One boy’s dream at age six illustrates this conflict: “There is a monster coming to the house and I run out. I worry about what will happen to the family when I run away from the house.” Oedipal defeat and the resulting narcissistic injury added to the six-year-old boys’ feeling rejected by their mother and not nurtured by her. Mothers were often pictured as dead or hurt. The boys were sad and angry about their loss and unconsciously expressed their depression in explosive discharge. The main defenses they used to cope with all these affects were intellectual and obsessive-compulsive defenses. Their ego control, judging from their teacher’s high ratings of their concentration and behavior, was good enough to hold these feelings at bay during school hours; however, parents reported that the boys’ behavior at home was often aggressive and difficult to manage. At age seven, the boys sense of oedipal defeat and their concommitant oedipal feelings continued. Most of the boys still made the connection between separation and the death of their parents. The boys felt a push to be independent but were scared about being lost or in danger on their own. They found two ways to cope with their anxiety about still feeling little and being able to manage on their own in the world. The boys started to see their fathers as very human, capable of making mistakes, but also able to help and/or protect their sons from danger. They also began to use the defense of magic to help them cope with their fears of getting lost in this new, larger, more dangerous world. One boy’s TAT story at age seven describes his faith in his father: “A boy is sitting there with nothing to do. . . . He goes bird watching and gets lost. Then his father was coming home and he found him and brang him home. The boy felt scared when he was lost and good when his father found him.” His story to a TAT card with no picture on it shows his use of magic: “There’s a boy right here and he’s lost in the woods so the forest animals lead him home. He feels relieved that the forest animals know where his home is. The mother and father thank the forest animals.” The boys’ developmental push for independence at age seven led to their feeling much more independent at age eight. The boys experienced a conflict over feeling more independent because they still had the same worries and needs they felt the year before. Separation was still experienced as getting lost in a big world and still included the total loss of parental objects. One boy showed some regression back to more typical six-year-old responses on the Rorschach after the death of his uncle, which increased his anxiety over parental loss.



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Girls: While the six-year-old girls were all beginning to feel pushed out into the big world by both their parents and their own drive toward separation, they were not yet as separated as the boys were at this age. Their Rorschach protocols included responses like animals and monsters with two heads, and a wall that split open but is still attached at the ground. Separating was associated with parents’ dying. The following TAT story told at age six is representative of their separation concerns: “The girl is going to school and she’s staring at some Indians coming. So she’s going to run back to her family and tell her family to run. She’s worried about the Indians killing her. Her parents are going to run but they get killed and she survives.” None of the girls had any fragmentation responses on a Rorschach at age six. They were all still in the throes of the Oedipus complex, with the attendant concerns about body damage and death related to the oedipal struggle. By age seven, five girls were feeling a lack of cohesion, with many fragmentation responses in their Rorschach protocols. Five of the seven-year-old girls showed evidence of having made a separation based on their Rorschach responses and their TAT stories. They had fantasies about going out into the world alone and having their own houses. Their dreams and their conscious worries were about being forcibly taken away from their homes by ghosts, monsters, and kidnappers, and separation often was associated with parental death. The following TAT story told at age seven illustrates the girls’ feelings of loss, sadness, and conflict around separating: “This is a person crying ’cause her parents just died. And she came back to the house and she dropped the keys on the floor and she started crying. She feels sad, and she’s thinking she wished she never moved away from her parents’ home. At the end she finds out that this is a time that people have to die.” One girl had not achieved a sense of separation and also had no fragmentation responses on the Rorschach. The absence of unconscious feelings of a lack of integration and separation was paradoxical; for this girl separation meant total abandonment that led to her own death, making her too anxious to tolerate a complete separation. While she was able to achieve appropriate separation in her day-to-day life (based on teacher and parent questionnaires and clinical interviews), her responses on the projective testing indicated persistent unconscious difficulty in this area. The seven-year-old girls were frequently preoccupied with pervasive loss, deprivation, and a need for nurturance. Like the boys, they felt little in a big world. Oedipal defeat added to the girls’ sense of loss. Stories in which men were perceived as dead, hurt, or deni-



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grated were frequent. The anger that the girls felt about their loss took the forms of oppositional behavior and aggression turned against the self and siblings. The girls defended against these feelings by denying and avoiding strong aggressive and libidinal feelings. Some girls used repression and/or intellectual and obsessive-compulsive defenses to close off or constrict their feelings and impulses. Their increased anxiety around aggressive impulses led them to a conflict over good and bad behavior, exemplified by the following TAT story told at this age: “The girl is sad. Her mother sent her to her room because she had been bad. ‘I have been a nasty little girl,’ she thought. And she went to her room and fell asleep on the bed. (What had she done?) She hurt her little brother. She hit him.” Despite strong aggressive feelings, they do not have the sense of these impulses getting as out of control that the eight-year-old boys experience. By age eight, the girls who had separated felt psychically impoverished and felt they had to work hard to perform, leaving all of them feeling tired but hopeful of becoming more competent as they got older. Like the boys at seven, the eight-year-old girls use benevolent magic to manage their anxiety about their separation and scary independence in the big world. Nurturance needs continued to increase at age eight, which added to their conflict between wanting to stay little and wanting to grow up. One girl’s TAT story nicely describes the need and the conflict: “This is a little boy, and he’s sitting on the step of a barn door sucking his fingers watching his father feed the animals. And he’s thinking that he doesn’t want to grow up. He wants to stay little ’cause his mother just read him Peter Pan. . . .” Table IV outlines the findings for the six- to eight-year-old girls and boys. middle latency—age nine years By age nine, the latency separation process converges for both the boys and the girls. They felt both an external push to grow up from their parents and an internal push to grow up. Both the boys and the girls were made extremely anxious by their newfound separateness. Projective tests at this age showed a breakdown of defenses. Contamination and anthropomorphic responses appear frequently on the Rorschach as well as a reporting of visual and/or auditory responses not actually present on the Rorschach or TAT cards. For example, one girl saw “talking and hearing vibrations” on the Rorschach. The high degree of anxiety and emotional disturbance seen on the



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TABLE IV Summary of Findings for Ages Six to Eight Years BOYS AGE 6



1. Feeling separate and fragmented 2. Feeling pushed out into the world 3. Separation equated with the death of both parents 4. Feeling alone and abandoned 5. Sad about being alone and mad about being kicked out 6. Depressed with explosive discharge, defended against with intellectual and obsessive-compulsive defenses 7. Aggressive and difficult to manage at home 8. Concern about being able to make it on their own 9. Feeling little and damaged 10. Oedipal defeat; mothers seen as dead or hurt 11. Feeling not nurtured



AGE 7



1. Push to be independent 2. Concern about danger or getting lost in the big world 3. Separation equated with the death of both parents 4. Sense of damage 5. Oedipal defeat; mother experienced as dead 6. Sad and mad about loss of mother 7. Fear of explosive discharge; oppositional behavior at home 8. Nurturance needs



GIRLS 1. Not separated 2. Feeling pushed out into the world 3. Separation equated with the death of both parents 4. Concern about body damage and death 5. Strong Oedipus Complex



1. Feeling separate and fragmented 2. Feeling rejected and pushed out into the world 3. Separation equated with the death of both parents 4. Sad about the loss; sense of deprivation 5. Oedipal defeat; Men seen as hurt, denigrated or dead 6. Feeling little and damaged 7. Nurturance needs 8. Oppositional behavior at home; aggression turned on the self and siblings continued



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TABLE IV Summary of Findings for Ages Six to Eight Years BOYS 9. Magic used as defense



10. Fathers seen as helping sons in world AGE 8



1. Conflict over independence 2. Feeling small and damaged 3. Nurturance needs strong 4. Concerns about getting lost in the big world 5. Separation equated with the death of both parents 6. Concern that aggression leads to death 7. Oedipal concerns very present



GIRLS 9. Aggressive feelings defended against with denial, avoidance, repression, intellectual and obsessivecompulsive defenses 10. Conflict over good and bad behavior 1. Conflict over growing up 2. Feeling small and damaged 3. Nurturance needs continue to increase 4. Feeling psychically impoverished; having to work hard to perform 5. Oedipal concerns; denigrating men 6. Fear of parental loss 7. Magic used as a defense



Rorschach is not manifested in the children’s typical conscious state and functioning as described by teachers and in the clinical interview. Mothers of the boys, however, did describe more fighting with their siblings during this age. Girls: The nine-year-old girls became much more concerned with moving away from their parents and toward their peers, exemplified in the following TAT story: “This girl is crying ’cause her family is going away on a trip, and she wants to go to her friend’s birthday party. She’s gonna get to go to the sleepover party, and her parents and brother will go away for the weekend, and she will get to sleep at her friend’s house an extra day.” The girls responded to the anxiety they felt around their newfound separateness and autonomy with an increased need for nurturance and a yearning for an idealized childhood. While they all had a desire to grow up, they were very conflicted about it and had an intense wish to be taken care of like a



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much younger child. The external pressure to grow up that they experienced made them very angry and anxious about their ability to function on their own and resulted in lowered self-esteem. One girl’s dream illustrates the anxiety at this age: “I am on a bridge with my friends. I have just left my mother on one side, and me and my friends are going to the other side. As I am crossing the bridge it begins to unsnap, and I am terrified me and my friends will fall. My friend’s parents are on the other side, and they snap the bridge back together again, and we can safely get across.” Their concern about not getting enough nurturance and their yearning for it can be seen in the following TAT story: “This boy is sitting here waiting ’cause his mother is out shopping, and he’s really hungry. They’re poor. He feels really hungry ’cause his mother is taking so long. (What is going to happen?) His mother is going to come home with a lot of food, and he is going to eat lots.” Boys: The nine-year-old boys’ responses tended to have a more separate, alone quality. They made a point of noting that the people they saw on the Rorschach were separating or separate. This more developed sense of separation and autonomy often made them feel a sense of isolation and disconnection from people. This TAT story exemplifies the cold, isolating quality of the boys’ sense of separateness: “One day there was a blizzard. And a man got locked out of his house in the blizzard. By the time someone found him he was in a coma. The person that found him took him to the hospital. Then his father came and tried to wake him up, but he couldn’t. The next day he came out of his coma and lived happily ever after. (How did he get to be so alone outside?) He was locked out in the wilderness and he didn’t live near anyone. Someone going down a road saw him.” While they expressed an unconscious sense of separateness and isolation, they were able to maintain very caring relationships with their peers. The boys at age nine responded to their sense of separateness with either a constriction that held their affects at bay but kept them isolated, or maintained a connection at the expense of feeling anxious. Two boys were able to stay connected while feeling separate, although they were both disturbed sufficiently to see and hear things that weren’t there during times when they were experiencing separation. This could be seen in the flow of associations through several TAT cards. For example, one boy’s response to TAT Card 4 was a story about a wife and husband who separate and divorce. When the next card (TAT Card 3BM) was presented to him, he told a story about a boy who has amnesia and a case of seeing things that aren’t



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there. The boy is scared by what is happening to him. His story to the next card presented (TAT Card 7BM) was about a boy who is separating from his father to go off to college. Responses on the Rorschach also show the boys’ disturbance around separating: “It looks like two Chinese dancers or people of some kind. They are separate. Maybe two big dogs playing patty cake with their back feet and their front feet. Maybe two big Chinese dog dancers. They just finished clapping and are about to separate and then it looks like they are about to collide. They are slapping so hard the red stuff is the noise. The red and the sharpness look like noise.” Concurrent with the boys’ feelings of separation, projective testing showed that their aggressive and sexual feelings can feel intense and out of control because their autonomous defenses do not hold as well as before. At times these feelings actually got out of control. Parents reported an increase in the boys’ fighting with their siblings at this age. Table V shows the findings for the nine-year-old girls and boys.



TABLE V Summary of Findings for Age Nine Years BOYS 1. Intense feelings of separation 2. Sense of aloneness and isolation in the separateness 3. Weakened defenses 3. Anxiety about separation 4. Constriction of affect in aloneness—two boys Anxiety in connectedness—two boys 5. Aggressive and sexual feelings that can feel out of control; increased fighting with siblings 6. Caring relationships with friends



GIRLS 1. Intense feelings of separation 2. Push toward peers 3. Weakened defenses 4. Anger about being pushed to grow up 5. Anxiety about being able to function independently 6. Lowered self esteem 7. Increased nurturance needs 8. Conflict over growing up



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late latency—preadolescence At ages ten and eleven another phase of separation and autonomy begins to develop. This sense of separation is related to the hormonal/biological and cognitive changes occurring in preadolescence as well as attributable to the continued development of the children’s feelings and experiences of attachment and separation experienced with their family and their peers. In this next phase, the boys and girls diverge significantly, with the girls taking the lead in the developmental process this time. Girls Ages 10 and 11: The early latency phase of attachment and autonomy was revived and incorporated into this next phase of separation. At ages ten through eleven, concerns about connection and separation re-occurred as the now late latency/preadolescent girls began to experience the beginning of the adolescent separation-individuation phase described by Blos (1967). Typical responses on the Rorschach were: two horseshoe crabs stuck together, two boys as the same person going out on Halloween, and two animals back to back about to go away from each other. This is a response that Ames et al. (1974) also reported with their population of normal ten-year-olds. Once again, fragmentation responses on the Rorschach appeared as frequently as they did at age seven. This sense of a lack of integration appeared in four out of the six girls’ Rorschach protocols at age ten, and in five of the six girls’ protocols at age eleven. The one girl who had no fragmentation responses at age seven, once again did not have any. The variation of timing in this next separation phase suggests that this is a process that may occur over a longer period for some children, and one that depends on the psychological, cognitive, hormonal, and physiological development of the individual child. Based on mothers’ reports, five of the six girls were at Stage Two of Tanner’s pubertal staging (1962) by age eleven, and one girl had reached menarche at age ten years. For the ten-and eleven-year-old girls, attachment and autonomy meant a moving away from home base to create a life and world of their own, with a knowledge that they could still return when they wanted to or were needed at home. This is a very different scenario from that of the seven-year-old’s picture of separation, which entails parental death. The following TAT story is an example of the different tone of this next phase: “The lady’s just thinking about her friends and family, ’cause she just moved here, and she misses them. She needs to find a job, but she doesn’t know what kind of job she is good at. Finally she decides she’s going to be a shopkeeper. She



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thought she was old enough to move away so she moved. She will start her own store and it will be okay.” Frequently teachers were seen as helping the girls achieve their goals, replacing parents, and friends also filled in for family. The importance of the peer group for the girls is demonstrated by the following story to the blank TAT card: “Gabrielle, age eleven, was starting to go to a new camp this year. She was nervous. As she rode in the bus, she almost cried. But then she thought of all her friends from school and cheered up. As it turned out, it was the best summer of her life—for friends, creativity, and happiness. It was one of the best summers of her life, and she couldn’t wait ’til next summer.” This next phase of separation was not entirely free of fears and conflicts. Three of the six girls had very real concerns about death, which they applied to themselves and their loved ones. One girl had the following dream about the possibility of death following separation: “A week or two after we got our kitten, I had this dream that she drowned. My friend dropped Lizzy [in the water] and we cried, ‘She’s drowned!’ I started diving underneath the water, and she was at the bottom. I brought it up and started squeezing all the water out. My friend appeared with the mother cat, and that made her feel better ’cause she was missing her mother.” Conflicts fused with anxiety about growing up were exceptionally strong at ages ten and eleven. Contamination and anthropomorphic responses were present in all of the girls’ Rorschach protocols, while at the same time they were telling TAT stories about going off to college and being on their own. While change and separation were experienced as scary, these girls had a sense that they would survive it and even fare well in the world. They didn’t defend against these feelings but tolerated the anxiety and sadness that comes with the separation, bolstering themselves with a hope for a wonderful outcome. The one girl whose concern about separation was problematic when she was seven was still concerned that she would not fare well and described visions of homelessness, drudgery, and neglect, which may be why she did not experience the more intense disconnection that the other girls showed. Along with this newfound sense of autonomy and its concomitant feelings, oedipal concerns were more present again, and the girls experienced a surge of aggressive and sexual feelings that at times would break through their defenses and overwhelm them. The girls’ conflict about growing up at this point was also a response to their anxiety about their intense sexual and aggressive feelings at this age. They felt a need to be taken care of and nurtured by their mothers,



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whom they often experienced as either weak or unable to help them in the following arenas: 1) out in the world, 2) with their very strong and conflictual instinctual feelings, and 3) with their feelings about their changing bodies. Boys Ages 10 and 11: Three of the ten-year-old boys showed no evidence of entering another phase of separation and autonomy. These boys had no fragmentation responses and there was no common theme concerning separation. Based on their mothers’ reports, these boys were predominantly in Tanner’s Stage I. Only one ten-year-old boy had entered a new phase of separation. While he had fragmentation responses on the Rorschach, he did not have the connected responses that were characteristic of the girls who had fragmentation responses at this age. At ten, this boy was clearly in Tanner’s Stage II of early puberty, suggesting that this next phase and process of attachment and separation may also have a biological clock that is later in boys than in girls. At age eleven, images of both connection and separation appeared in all the boy’s Rorschach responses, despite their still early Tanner staging. The boys once again felt that the only way to separate was either to kill their parents or never see them again. Their early latency feelings and fantasies about separation were revived and incorporated into this phase of separation. These feelings were mixed with aggression, an intensification of oedipal wishes, and a longing to remain connected. The following TAT story demonstrates their longing to remain connected during complete separation: “There was a son [who] left his house when he was eighteen and didn’t talk to either of his parents for around twenty years. And then he came back and was thinking what to say to his mom so that she would believe it was him. And after a while he still couldn’t think of anything. He just left. He wrote a letter to her explaining everything, and she was still mad at him. He was sad because he really wanted to come back to his family. He never did, and he wrote a lot of letters all the time.” The boys’ resurgence of oedipal feelings is evident in one boy’s TAT story: “There is this girl in high school. And she likes this guy here. And she wants to marry him, and he wants to marry her. But this lady—this guy is a slave to her, and she won’t let them get married. So the girl is thinking, ‘What can I do to get rid of this lady?’ So then one day she takes a knife and kills her, and they live happily ever after. (Who was the lady?) His owner.” Their mounting sexual and aggressive feelings worried all four boys. Three of the four boys had concerns about the death of themselves and their loved ones in their Rorschach and TAT responses at



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TABLE VI Summary of findings for Ages Ten and Eleven Years GIRLS



BOYS



Feeling fragmented—five out of six girls Images of connection and breaking apart Separation means moving away from home Suicidal ideation and concerns about death Teachers and friends replace family Conflict over growing up Nurturance needs Strong aggressive and sexual feelings; oedipal concerns



Not feeling fragmented—three out of four boys 11-year-olds: images of connection and breaking apart Separation means killing parents or never seeing them again Suicidal ideation and concerns about death



Strong aggressive and sexual feelings; oedipal concerns



this age. While this appears related to their sexual and aggressive feelings, there is also a quality of a wish to return to lost oedipal objects. The following TAT story expresses this wish: “This lady was the wife of the guy who got in the car accident. He died and so did her kid and then she lost her job. So she got really depressed and she committed suicide ’cause that’s a gun right there.” Table VI summarizes the findings for the ten- and eleven-year-old boys and girls. Discussion Analysis of the responses of these ten children outlines a process of attachment and autonomy that occurred in two waves, one during early latency and another in preadolescence. In both waves there is evidence of a change in the antecedent mode of object connection and the concomitant breakdown of self-coherence. The developmental task of negotiating dyadic and triadic relationships—attachment as well as separation and autonomy—is an ongoing process that starts in infancy and continues throughout the life cycle. It is emphasized in latency when children must negotiate another level of internal separation and independence from their family as they join the world of their peers.



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their early latency children for after-school activities like scouts, sports, dance, karate, after school programs, etc., keeping them away from the home many afternoons until dinner time and requiring them to enter into a world of peers for most of their day. This new sense of separation leads to feeling a lack of integration and disconnection that is experienced unconsciously. A sense of an unconscious, internal lack of integration may be a necessary part of the separation process. The one girl who did not have any fragmentation responses had difficulties managing separation in her adolescence. One might hypothesize that each successive phase of separation along this developmental line has a period of wishing to merge and a breaking apart that marks its inception. This corroborates the analytic assumption that the development of an autonomous self requires a repeated process of identification and de-identification with significant objects, as well as object removal and deidealization, all of which can feel destabilizing. This normal latency state of experiencing a lack of self-cohesion may be a more advanced state similar to the one Stern (1985) described when he discusses the lack of organization the infant first experiences in the emergent sense of self, and Sander (1980) described at the beginning of the mother-infant regulatory system that gets established in the neonatal period. Kohut (1971) also theorized a regression to a state of feeling fragmented when the child experiences an absence of the narcissistically invested lost object, along with attempts to re-establish the union through visual fusion and other archaic forms of identification. Feeling a lack of self-cohesion may also be a response to the conflict of independence. Experiencing a lack of integration is consciously expressed during normal developmental periods of separation. One mother reported that her seven-year-old daughter, during a crying episode, screamed, “I feel all in pieces!” I have heard several thirteen-year-olds, another developmental period of growing autonomy, describe their mothers as “the tape that holds me together when I feel in pieces (or unglued).” When working with children and adolescents in analysis, their expression of feeling a lack of selfcoherence may indicate that they are entering a period of transformation in development. While these latency separation concerns are clearly tinged with oedipal wishes, as they similarly are in early adolescence, they are also about a yearning to merge, a desire to be attached and connected that has roots in the earliest phase of infancy (Pine, 1985; Sander, 1980; Tyson and Tyson, 1990; Bowlby, 1969). This yearning



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for a merged closeness is well described by Homer (1992, p. 41): “The wish for closeness and intimacy is the effective motivating force serving the individual’s attempt to close the open space that is inherent in relationships throughout the lifespan, starting with the embryo and continuing, transformed, at birth.” For both the boys and the girls in this study, separating in early latency had connected to it an idea of both parents being dead. The theme of parents who have either died or abandoned the latency-age child has frequently been expressed in literature read by latency age children, most notably in the fictional lives of characters such as Pippi Longstocking, Peter Pan, Superman, Luke Skywalker, and Harry Potter. This theme is the fantasized expression of the internal object loss that the children are unconsciously experiencing in this phase of separation and a necessary step in the development of a separate sense of self. Loewald (1979) has described the separation process at the end of the oedipal period as one in which the child must murder and mourn the “incestuous ties” in order to achieve a more separate sense of self. Modell (1984) has described the guilt that ensues as a result of the underlying fantasies that separation will lead to the death or damage of a parent. Because of this underlying fantasy and the guilt that it produces, an actual death of a parent during this period can severely impede the process of separation, which often becomes clinically noticeable during adolescence and early adulthood. When working with latency children in analysis, it is helpful to specifically delineate the content and context of their attachment and separation wishes and fears in order to more appropriately interpret them and provide empathy to our analysand’s inner experience of attachment and separation at each moment in time within the analytic process and relationship. the management of anger in latency The boys and girls experienced their anger in different ways, although the resulting fantasy of parental death may be the same. Both genders exhibited oppositional behavior at home, as reported by the parents. But on the projective testing, the girls consistently turned their anger against themselves and their siblings while the boys mostly directed it outward toward people and objects. This is consistent with Olesker’s (1984) findings of gender differences in the expression of aggression in the first phase of separation-individuation. Both her findings and mine suggest that through the process of iden-



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tification and cultural handling, boys and girls develop different styles of processing and expressing aggression at a very early age. The need to defend against anger by turning it on the self may account for the drop in self-esteem the girls showed beginning at age nine. These findings may also be an additional reason for the drop in selfesteem that Gilligan (1982) found in her study of preadolescent girls. Both the boys and the girls used the defense of aggression turned against the self as they began to enter their early preadolescent separation phase; however, it sometimes had a quality of being a fantasized way to return or reunite with a lost object. This feeling was clearly expressed in analysis by a young man with separation difficulties: “Suicide and my mother are like the same thing; it’s a way out. It’s a moment when it seems like all of your problems are removed from you and you don’t have to grow up. I feel like I can get it any time. I feel like there is an easier way.” A further elaboration of the suicide theme expressed by the girls at times was the feeling that to lose your mother could mean the loss of one’s own self, suggesting the strong internal ties the girls have with their mothers. This study suggests that suicidal ideation—very real thoughts and concerns about death applied to oneself during the preadolescent phase of separation-individuation—is part of a normative process that is not pathological or pathognomonic. The responses of the children in this study suggest that the latency and pre-pubertal phases of attachment and separation are filled with intense experiences and feelings that can lead to significant disruption in self-coherence and ego functioning and to suicidal ideation— all derivatives of a normative process. Evaluating children in this age group requires an understanding of the complexity of their normal development in order to then determine pathology in a latency or preadolescent child. coping with separation The children’s feeling of separation leading to more autonomous functioning at the beginning of latency is enhanced by the development of concrete operational thinking, a higher level of cognition (Piaget, 1967). This cognitive maturation allows the child to decenter and measure himself/herself against others and experience the world as bigger and more challenging, leading to anxiety about going out into the world of school and peers, where they really are the smallest, least knowledgeable children in that larger world. All the children used fantasy and magic to help them cope with



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fears of managing on their own as they felt more separated and alone in the larger, challenging world. This supports Anna Freud’s (1936) and Sarnoff’s (1976) finding that fantasy is used as a major defense in the latency period, and the use of magic within that defense is significant. The boys in this study also felt they could rely on their fathers to help them manage difficulties in the world outside the family. One interesting finding was that the girls in the study did not feel they could rely on their parents in the same way as the boys, and demonstrated an oral neediness that grows in intensity throughout the latency period as well as a sense of being tired at times by the task of growing up. These findings are illustrated in the “Harry Potter” stories (Rowling, 1998–2003). Harry has his god-father, his friend Ron’s father and brothers, and several male teachers to help him avoid dangers as he grows up in the magical world of Hogwarts. Hermione, by contrast, has parents that are of no help to her, and she has to study magic very hard (sometimes taking two classes at the same time), relying on her wits to help her and Harry along the way (Harry relies on her ). The cultural and psychological implications that allow boys to see their fathers as helping figures while girls cannot use their mothers (or fathers) in a similar way during this phase of identification with the same sex parent must be considered. All of the girls’ mothers worked part-time in professional positions, yet the girls could not imagine their mothers as helping figures in the world outside of the home in their fantasy. One possible explanation for the different reactions of the boys and girls has to do with gender identification processes in early latency. Mahler (1981) addressed the gender difference in the first separation phase, noting that the boy has his father to support and maintain his personal and gender identity, while the girl, in her separation from the post-infancy mother, has a much more difficult and complicated task to attain and maintain her sense of self because her relationship with her mother “carries the burden of threatening regressions.” In latency, boys identify with their fathers and their sense of their fathers’ more competent position in the outside world. The girls’ TAT stories often expressed a sense of tiredness related to independent functioning in the world. The girls in this study may have identified with their mothers’ tiredness from having to maintain two jobs— work and family care, and/or their mothers’ overriding maternal function of being the main caretaker of the basic needs of the home and children. Stephen King (1983) nicely expressed this male-female



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role dichotomy: “What your mother leaves you is mostly good hardheaded practical advice—if you cut your toenails twice a month you won’t get so many holes in your socks; put that down you don’t know where it’s been . . . but it’s from your father that you get the magic, the talismans, the words of power” (p. 36). This component of the girls’ identification with their mothers, when combined with their lowered self-esteem, may sometimes leave them feeling that they are not competent enough to be completely out in the world. Another explanation for this gender difference may be found in the remains of the late oedipal phase conflict. In this study, the early latency boys unconsciously experienced their mothers as dead to them, while the girls unconsciously experienced their fathers in this same way. In their effort to break their oedipal tie to their fathers, the girls need to distance themselves internally from their fathers, and therefore do not have them as available as the boys do to help them in their fantasy working through of the present stage of separation. This might make the girls feel they have to bank on their own resources, which would increase nurturance needs in the face of moving out in the world without the internal reliance on their fathers. Their increased need to rely more on their own resources may add to their feelings of lowered self-esteem by the age of nine. Two of the boys felt an intense sense of disconnection at age nine that the girls didn’t have. It is interesting to note that the two boys who retained a sense of connection at age nine both had mild learning difficulties, requiring them to remain more dependent on their mothers for help with their school work and the structuralization of their environment. Chodorow (1989) suggested that the masculine personality is founded on the denial of relational needs out of the difference in social attachments that evolve out of the oedipal configuration, requiring the boy to more fully repress his primary relationship and, consequently, the degree of dependency attached to it. While this finding supports her theoretical position, the relational picture is more complicated. The nine- to eleven-year-old boys in this study, while feeling internally disconnected and isolated, maintained caring peer relationships. Their unconscious feelings of disconnection seemed to be a response to their internal experience of separation, but did not necessarily lead to a denial of relational needs in their peer relationships. Their attachment and loyalty to a primary, close male friend was much more constant than the girls’ friendships were during these years. However, the quality of the connection did seem to be dif-



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Because of the small number of homogeneous subjects who were studied in depth, this study can only generate hypotheses about the developmental process for all children in this age group; however, the convergence of data from a variety of sources makes the results compelling and ring true with our analytic observations. While there is value in small N studies (Jones, 1993), additional studies on large numbers of children from different cultural, racial, and socioeconomic groups are necessary to validate the ideas proposed in this paper. Therefore, these findings can only be applied cautiously to a more varied cultural, cognitive, or socioeconomic group. At the beginning of latency, the children in this study began to develop an unconscious sense of being separate from their parents in a way that they had not experienced previously. Although both sexes experienced this development, they had different timetables—the boys entering this phase one year earlier than the girls. Several possibilities could account for the gender difference in the latency process of the development of attachment and autonomy. Olesker (1990), studying separating toddlers, reported that mothers were more likely to push boys toward independent behavior and keep girls closer longer. She suggested that this might lead the girls to enter the oedipal period less well separated from their mothers than the boys. In addition, boys may enter the latency separation period with a history of a more established separation than the girls may because they have had to establish a predominantly male gender identity that is different from that of their mother. This forces them into a differentiation pattern earlier than the girls and may promote earlier development of separation and independence. Buxbaum (1980) suggested another factor that may influence this developmental difference. She proposed that the girl’s oedipal phase might not be as “violent” as the boy’s, in that girls don’t have to give up their original love object. This may explain why the girls may have a different timetable, allowing them to remain in the oedipal phase for a longer, more comfortable period. The mothers of the early latency age boys and girls described what felt like an instinctual desire to push their children out into the world. One mother characterized her feelings of pushing her daughter into activities outside the home: “I feel like a mother bird pushing her out of the nest.” The biological clock (Shapiro and Perry, 1976) that gives latency its start may also be present in the parents’ responsive need to push their children out into the world of peers. Although both parents and children were ambivalent about this new phase of separation and autonomy, all of these parents registered



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ferent—the girls talked to each other more and shared fantasies in play; the boys did a lot of physical activity together but talked less. consolidation of autonomy With a sense of separateness comes a sense of autonomy and a restructuralization of the ego as the latency child develops new levels of cognition, physical abilities, socialization, and the autonomous use of defense functioning. By age nine all of the children had consolidated the latency phase of separation and autonomy. Their higher levels of autonomous and internalized defense functioning and their newly developed cognitive functions were not yet sufficiently established to protect them from their strong feelings, which were in greater power than their defenses at this point, resulting in the breakdown of defense functioning and the considerable distress that can be seen on their Rorschach protocols. Ames et al. (1974) noted that the nineyear-olds on the Rorschach protocol look “neurotic or disturbed.” She and her co-workers also found a large number of responses reported by their ten-year-old subjects but not actually present on the Rorschach card, similar to the talking and hearing vibrations one girl in this study reported. The age difference between her subjects and these children may be due to the fact that the children in the present study were more intellectually advanced and so experienced this breakdown in ego functioning somewhat earlier than the average child might. That such a breakdown of defenses at age nine occurs after consolidation of separation and a more autonomous self and ego structure at age eight is consistent with the idea that the most recently developed functions are the first to show vulnerability during a maturational change that also includes a surge of strong feelings (A. Freud, 1966; Piaget, 1967). It is also compatible with Blos’s (1967) description of adolescent separation in which ego impoverishment follows the sense of internal object loss. late latency/preadolescent attachment and autonomy At age ten there starts to be another clear distinction between the boys’ and girls’ development. Between the ages of ten and eleven, all the girls’ Rorschach protocols once again had fragmentation responses along with concerns about merging and breaking apart, very similar to their seven-year-old protocols. Ames et al. (1974) also reported a similarity between the ten- and seven-year-old Rorschach protocols. This return to the seven-year-old subjects’ feelings was



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nicely expressed by one ten-year-old girl’s response to the blank TAT card; she told a story about a seven-year-old-girl having a birthday party during which the children played pin the tail on the donkey (note the disconnected donkey). The disturbance in defense functioning seen at age nine continued, as the girls’ newly established ego functions were further bombarded by their drives and the additional stress of a new phase of separation. Mahler (1972) has reported the defensive use of rageful, distancing behaviors in girls toward their mother during separation. This time parents reported that their girls “had become very difficult,” were easily angered, easily had hurt feelings and became upset, had frequent mood swings, and mothers reported a significant increase in mother-daughter confrontations. The girls did manage to maintain their high functioning in school, as teachers continued to praise their abilities and behavior. This preadolescent phase of separation is certainly related to a biological clock driven by a major change in hormonal functioning, which starts earlier for girls than for boys. While only one boy was clearly in early puberty and showed fragmentation responses at ages ten and eleven, all of the boys were internally preoccupied with connection and separation, just as the girls were. Because data collection in the present study stopped after age eleven, it is not possible to know when the other three boys would have felt the same breakdown in self-coherence that the girls did at ages ten and eleven. One may assume that this next phase of separation is biologically driven, since the one boy who did feel fragmented was in early puberty, while the others still looked like latency boys at age eleven. This finding suggests that boys tend to remain in a late latency/prepubertal stage of development longer than girls do. The biological time-table that contributes to these two waves suggests a discontinuous process of attachment and autonomy separate from underlying dynamic conflicts, albeit not unaffected by them. stages and phases of latency The stages and phases of latency have been described in the literature in many different ways, as discussed in the introduction to this paper. The results of this study suggest another theoretical addition to the phases of latency related to the development of attachment and autonomy. In the proposed model, the early latency phase would be between six and eight years in boys and seven to eight years in girls, when the latency child begins a new phase of separation and autonomy from his/her primary objects. Middle latency would occur at



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age nine, when both boys and girls consolidate their more independent and autonomous functioning. Late latency/preadolescence would begin at age ten in girls and ten/twelve⫹ years in boys, when another phase of separation and autonomy begins. If this theoretical hypothesis holds true, then girls have a much shorter period of latency development than most boys do, and consequently don’t have as much time to consolidate their growth during this developmental phase before they have to cope with another major developmental shift to preadolescence. BIBLIOGRAPHY Abrams, S., & Solnit, A. (1998). Development and analytic technique. Journal of the American Psychoanalytic Association, 46:85:104. ——— (2003). Looking forwards and backwards. Psychoanalytic Study of the Child, 58:172–186. Ames, L., Metraux, R., Rodell, J., & Walker, R. (1974). Child Rorschach Responses. New York: Bruner Mazel. Bibring, G. (1959). Some considerations of the psychological processes in pregnancy. Psychoanalytic Study of the Child, 14:113 –121. Blatt, S. (1988). The assessment of change during the intensive treatment of borderline and schizophrenic young adults. Psychoanalytic Psychology, 5:127–158. Blatt, S. et al. (1976). Normal development and psychopathological impairment of the concept of the object on the Rorschach. Journal of Abnormal Psychology, 85:364 –373. Blos, P. (1967). The second individuation process of adolescence. Psychoanalytic Study of the Child, 22:162–186. Bornstein, B. (1951). On latency. Psychoanalytic Study of the Child, 6:279 – 285. Bowlby, J. (1969). Attachment. New York: Basic Books. Burke, W., Friedman, G., & Gorlitz, P. (1988). The psychoanalytic Rorschach profile: An integration of drive, ego, and object relations. Psychoanalytic Psychology, 5:194 –212. Buxbaum, E. (1980). Between the Oedipus complex and adolescence: The “quiet” time. In The Course of Life. Volume II: Latency, Adolescence and Youth, Eds. S. I. Greenspan & G. H. Pollock. Washington, D.C.: U.S. Government Printing Office, pp. 121–135. Chodorow, N. J. (1989). Feminism and Psychoanalytic Theory. New Haven: Yale University Press. Cramer, B. (1975). Outstanding developmental progression in three boys: A longitudinal study. Psychoanalytic Study of the Child, 30:15 – 48. Emde, R. N. (1988). Development terminable and interminable. Considera-



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tions for theory and therapy. International Journal of Psychoanalysis, 69:283 – 296. Emde, R., & Harmon, R. (Eds.) (1984). Continuities and Discontinuities in Development. New York: Plenum Press. Fonagy, P., Steele, M., Moran, G., & Steele, H. (1993). Measuring the ghosts in the nursery: An empirical study of the relation between parents’ mental representations of childhood experiences and their infants’ security of attachment. Journal of the American Psychoanalytic Association, 41:957– 989. Freedman, S. (1996). Role of self-object experiences in affective development during latency. Psychoanalytic Psychology, 13:101–127. Freud, A. (1963). The concept of developmental lines. The Writings of Anna Freud Vol. VI. New York: International Universities Press. ——— (1966). The ego and the mechanisms of defense. The Writings of Anna Freud Volume II. New York: International Universities Press. Freud, S. (1905). Three essays of the theory of sexuality. Standard Edition XII: 123 –243. ——— (1911). Formulations on the two principles of mental functioning. Standard Edition XII: 218 –230. ——— (1916). The development of the libido and the sexual organizations. Standard Edition XVI: 320 –338. ——— (1924). The dissolution of the Oedipus complex. Standard Edition XIX: 173 –179. ——— (1933). New introductory lectures on psychoanalysis. Standard Edition XXII: 112–135. Galatzer-Levy, R. (2004). Chaotic possibilities: Toward a new model of development. International Journal of Psychoanalysis, 85:419 – 442. Gilligan, C. (1982). In a Different Voice. Cambridge, MA: Harvard University Press. Glenn, J. (1991). Transformations in normal and pathological latency. In Beyond the Symbiotic Orbit: Advances in Separation-Individuation Theory. Eds. S. Akhtar & H. Parents. Hillsdale, NJ: The Analytic Press, pp.171–187. Greenspan, S. (1981). The Clinical Interview of the Child. New York: McGrawHill. Holt, R., & Luborsky, L. (1955). The selection of candidates for psychoanalytic training: On the use of interviews and psychological tests. Journal of the American Psychoanalytic Association, 111:666 – 681. Homer, T. (1992). The origin of the symbiotic wish. Psychoanalytic Psychology, 9:2548. Jones, E. (1993). How will psychoanalysis study itself ? Journal of the American Psychoanalytic Association, 41:91–108. Kantrowitz, J. L. et al. (1975). Suitability for psychoanalysis: The role of psychological testing. Psychoanalytic Quarterly, 44:371– 391. ——— (1989). Patient-analyst match and outcome of psychoanalysis: A pilot study. Journal of the American Psychoanalytic Association, 37:893 – 920. King, S. (1983). Christine. New York: Penguin Group.



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Klopfer, B. & Davidson, H. (1962). The Rorschach Technique: An Introductory Manual. New York: Harcourt, Brace & World, Inc. Kohlberg, L. (1963). Moral development and identification. National Society for the Study of Education Yearbook, 62:277– 332. Kohut, H. (1971). The Analysis of the Self. New York: International Universities Press. ——— (1984). How Does Analysis Cure? Chicago: University of Chicago Press. Ledwith, N. (1960). A Rorschach Study of Child Development. Pittsburgh: University of Pittsburgh Press. Loewald, H. W. (1962). Internalization, separation, mourning, and the superego. Psychoanalytic Quarterly, 31:483 – 504. ——— (1979). The waning of the Oedipus complex. Journal of the American Psychoanalytic Association, 27:751–776. Mahler, M. S. (1972). On the first three subphases of separation-individuation process. International Journal of Psychoanalysis, 53:333 – 338. ——— (1981). Aggression in the service of separation-individuation: Case study of a mother-daughter relationship. Psychoanalytic Quarterly, 50:625 – 638. Mahler, M., Pine, F., & Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books. Mayes, L. (1999). Clocks, engines, quarks-love, dreams, genes: What makes development. Psychoanalytic Study of the Child, 54:169 –192. ——— (2001). The twin poles of order and chaos. Psychoanalytic Study of the Child, 56:137–170. Modell, A. H. (1984). Self preservation and the preservation of the self. Annals of Psychoanalysis, 12:69 –86. Olesker, W. (1984). Sex differences in 2- and 3-year-olds: Mother-child relations, peer relations, and peer play. Psychoanalytic Psychology, 1:269 –288. ——— (1990). Sex differences during the early separation-individuation process: Implications for gender identity formation. Journal of the American Psychoanalytic Association, 38:325 –346. Oremland, J. (1973). The jinx game: A ritualized expression of separationindividuation. Psychoanalytic Study of the Child, 28:419 – 432. Piaget, J. (1932). The Moral Development of the Child. London: Kegan Paul. ——— (1967). Six Psychological Studies. New York: Random House. Pine, F. (1975). Developmental Theory and Clinical Process. New Haven: Yale University Press. Rothstein, A. (1998). Discussion of this paper. The Boston Psychoanalytic Society and Institute Annual Beata Rank Child Analysis Lecture, Boston, Massachusetts. Rowling, J. K. (1998 –2003). The Harry Potter Series: Books 1– 5. New York: Scholastic Press. Sander, L. (2002). Thinking differently: Principles of process in living systems and the specificity of being known. Psychoanalytic Dialogues, 12:11– 42. ——— (1980). Investigation of the infant and its caregiving environment as a biological system. In The Course of Life. Volume I: Infancy and Early Child-



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hood. Eds. S. I. Greenspan & G. H. Pollock. Washington, D.C.: U.S. Government Printing Office, pp. 177–202. Sarnoff, C. (1976). Latency. New York: Aronson. Schafer, R. (1954). Psychoanalytic Interpretation in Rorschach Testing. New York: Grune & Stratton. Shapiro, T., & Perry, R. (1976). Latency revisited: The age 7 plus or minus 1. Psychoanalytic Study of the Child, 31:79 –106. Simon, B. (1991). Is the Oedipus complex still the cornerstone of psychoanalysis? Journal of the American Psychoanalytic Association, 39:641– 668. Stern, D. (1985). The Interpersonal World of the Infant. New York: Basic Books. Tanner, J. M. (1962). Growth at Adolescence, 2nd Edition. Oxford: Blackwell Scientific Publications. Tyson, P., & Tyson, R. (1990). Psychoanalytic Theories of Development: An Integration. New Haven: Yale University Press. Williams, M. (1972). Problems of technique during latency. Psychoanalytic Study of the Child, 27:598 –620.



CLINICAL STUDIES



Play in the Psychoanalytic Setting Ego Capacity, Ego State, and Vehicle for Intersubjective Exchange KAREN GILMORE, M.D.



The psychoanalysis of an 8-year-old boy who does not play is presented to illustrate the centrality of the “state of playing” for meaning-making and communication in treatment. Developmental research links affect regulation, narcissistic balance, and the capacity for make-believe to the early intersubjective exchange between mother and infant. The intersubjective dialogue between patient and analyst in the “state of playing” is a crucial component of child analysis and its absence both reflects and compounds ego vulnerability in the child and presents a daunting technical challenge to the analyst. So—here I am in the dark alone, There’s nobody here to see: I think to myself, I play to myself, And nobody knows what I say to myself; Here I am in the dark alone, What is it going to be? I can think whatever I like to think, I can play whatever I like to play,



Training and supervising analyst and Head of Child Division, Columbia University Center for Psychoanalytic Training and Research. Presented as the Robert Kabcenell Memorial Lecture, New York Psychoanalytic Institute, March 9 2004. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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in this communication, i describe my efforts to understand a latency age boy, Andy, whose analysis has been remarkable in my experience because of its absence of thematic content and emergent “intersubjective exchange” in the form of play (Birch 1997). Through discussion of one boy’s particular difficulties, I hope to demonstrate how analytic work with prepubertal children is facilitated by the child’s capacity to achieve a shared “state of play” where meaning making, affect modulation, and mental representation of intolerable psychic experience becomes bearable and achieves therapeutic effect. The absence of play creates formidable obstacles to therapeutic progress and indicates serious ego-impairment in the child. Play in Psychoanalysis In child work, the evaluation of child’s capacity to play and the process of playing typically yield an invaluable trove of information about the individual’s psychological and cognitive development, dynamics, diagnosis, and interpersonal relatedness. The child clinician expects that, despite possible inhibitions and constrictions, pseudomaturity or chaotic impulsivity which may deform the playing function, the child patient will usually produce some form of play that can serve as a shared “intermediate region,” (a term borrowed from Freud’s 1914 metaphor of the “transference as playground”) where the action of the analysis can safely unfold. Play has been addressed extensively in the analytic literature even before Freud’s immortal description of the “Fort-da” game (1920); with the advent of ego psychology and observational studies of infants and children, it has been increasingly privileged as serving a central role in child development. No longer reduced to merely a discharge or wish-gratifying phenomenon, it is conceptualized as a complex normative growthpromoting capacity that evolves with cognitive and psychological development (Marans et al. 1993, Solnit 1987). Its crucial position in the analytic treatment of children has also been described extensively in the clinical literature where it has been analogized to the transference (Battin 1993), termed a “creative workshop for action” (Mahon 1993), and yet distinguished from the enactments that directly draw the analyst into a dramatization of unconscious fantasy, which, of course, are also prevalent in child analysis (Chused 1991).



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Child analysts are very well acquainted with the “coercive” as well as the “generative” effects (Ogden 2004) that accompany playing out a child patient’s narrative. Like enactments, i.e. “symbolic interactions between analyst and patient which have unconscious meaning to both” (Chused 1991), play typically reveals that the analyst is both “playing a role in, and serving as author of, someone else’s unconscious fantasy” (Ogden 2004) that inevitably reverberates with her own. However, play differs from enactments in that it is, either implicitly or explicitly, “make-believe.” Playing in the analytic setting establishes a space “without real consequences” (Freud 1917) where communication between the child and analyst can occur at the developmental level of the child in a state that is demarcated as meaningful and yet not real. While both action and verbalization are involved, what is optimally achieved is an intersubjective exchange in the mutual state of playing where transformation of the child’s anxieties and defenses can be accomplished by the analyst’s clarifications, reciprocal engagement, and interpretive work. This phenomenon is comparable to “the analytic third” as conceptualized by Ogden (2003) or by Bromberg as “space for thinking between and about the patient and the analyst” (1999) in adult work. In child analysis, this state is concretely anchored to favored play objects endowed with layers of meaning, both explicit and unconscious (Abrams 1988), and it is represented in the idiosyncratic play themes that emerge and evolve as a product of the child and the analyst’s conscious and unconscious communication in the course of an analysis. But more fundamental than these tangible artifacts is the intersubjective “mutual state of playing” that characterizes each patient/analyst relationship and that sustains and is in turn transformed through the metaphors of the evolving play narratives and props. Because the playing analyst, to be truly effective, must fully engage in playing (Birch 1997, Yanof 1996, Cohen and Cohen 1993), the play is inevitably co-created and contains elements from the unconscious of both patient and analyst, although the patient’s contribution is privileged by the nature of the endeavor. Beyond mastering the typical countertransference anxieties around regression and instinctual discharge, child analysts ideally have remastered the capacity to play without condescension or self-consciousness and to maintain a consciousness divided between the analytic and the playing function wherein the analyst is tuned into that particular child’s inner life. In child work where playing is prominent, there are layers of diagnostic, dynamic, and transference meanings within the play, as well as



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in the freedom with which the child reveals his personal “state of playing” and in the manner with which the child draws the analyst into the play and allows the emergence of an intimate dialogue. I believe that the child analyst, more than any other professional who works with children, most consistently attempts to enter the child’s inner world and go beyond the typical array of self-protective barriers that children present to grown-ups. Both child patient and analyst must be willing to engage wholeheartedly (Birch 1999, Yanof 1996) in the “conceptual world” (Cohen and Cohen 1993) that the childwith-the-analyst creates. Over time, the analyst readily launches herself into the singular world of her patient’s “state of playing,” a world whose rhythms, rules, and rituals as well as opportunities for therapeutic work are unique and to some extent idiosyncratic to the particular individual and the dyad; among these are the pathological adaptations that can be addressed best by being in that world with the child. This state includes unconscious communication and intuitive leaps that can result in dramatic shifts in the child’s tolerance for affects and rejected self-representations. As for the child patient, even young children know, within a short time, that playing with an analyst is a very different business from playing alone or even with another child or adult. Playing with the analyst is all at once revealing the self, drawing the other into a private world, and tolerating an openness to a dialogue which now subjects his psychic experience to modification and “mentalization” here used to mean the establishment of links between drive-affect and mental representation that are gradually identified and elaborated verbally (Lecours and Bouchard 1997). Of course, children differ a great deal in their guardedness around this threshold, but bridging it is a crucial moment in the treatment. This is the moment where the child admits the analyst into his private world, by no means without its own resistances and defensive organizations, but the juncture marks a point where the treatment relationship reaches, to borrow a favorite video game metaphor, the next level. Insights from Developmental Studies Before describing the work with Andy, I will frame the discussion against a backdrop of a selective review of some pertinent formulations of how early experience within the mother-baby relationship serves as the birthplace for shared intersubjectivity which in turn stimulates the interrelated set of ego-capacities that are at question here, allowing a more informed speculation about how Andy’s par-



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ticular history and endowment disadvantaged him. While much of Andy’s relevant personal early history was indistinct due to his parents’ relative lack of awareness, the absence of imaginary play and even typical infantile play (such as peek-a-boo) with either parent was noteworthy. Findings from allied disciplines underscore the importance of the earliest relationship for many facets of future development. The vast research and theoretical literature that has sprung up around infant observation and the developmental sciences underscore the importance of the mother-infant relationship and intersubjectivity for the establishment of very fundamental ego capacities, such as affect regulation, symbolic capacity, self-experience, and implicit procedures that characterize object-relatedness. Infant observers and cognitivedevelopmental scientists have been able to illuminate the steps in the emergence of affect recognition, mutual regulation, self-reflective and symbolic capacity in the context of the earliest interaction with the caretaker, demonstrating the significant contribution of the environmental surround (Stern 1985). Given the nature of our contemporary child patient population, which, like Andy, is distinguished by a variety of disorders alternately called “developmental,” “regulatory” and the like, these findings provide fascinating corroborative data and suggest new ways of thinking about and addressing these fundamental deformations that clearly predate the Oedipus and profoundly affect its unfolding. A number of seminal papers written by psychoanalysts and psychoanalytically informed baby watchers from previous decades, such as Anna Freud, Winnicott, Weil, Mahler, Sander, Emde, Pine, and Shapiro, adumbrate these contemporary conceptualizations and facilitate their contextualization within our psychoanalytic metapsychology. All of these writers observed and privileged “the interaction between the infant’s equipment and early experiential factors—an interaction that aggravates or attenuates initial tendencies” (Weil 1970). Weil termed this the “basic core” which establishes the earliest “regulatory stability;” this regulatory stability—or relative lack of stability—contains directional trends for all later functioning” (p. 242– 43, my italics). Neurotic conflict is ubiquitous but rests on a substructure that predates its appearance and does not originate in conflict but rather represents a transactional adaptation. This idea and its variants rephrase in concrete ego psychological terms Winnicott’s principle: “there is no such thing as an infant,” that is, “the infant and the maternal care together form a unit” (1960). Winnicott’s work elaborates the notion that the “inherited



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potential of the infant cannot become an infant” without the maternal care, which in infancy is guided predominantly by “maternal empathy.” This maternal matrix facilitates the tolerance of anxiety, structured integration of the personality, the “dawn of intelligence and the beginning of the mind” (p. 45). Winnicott’s ideas also underscore the fact that neurotic conflict as it emerges in childhood occurs in a mind already stamped by its interaction with its particular environment, the product of a complex transaction that begins within the first days of life. As the study of the self began to eclipse the ego in the literature, the emergence of the self as a developmental accomplishment increasingly occupied infant observers and researchers (Mahler and McDevitt 1982, Stern and Sander 1980, Emde 1983, Pine 1982). In 1985, Stern drew upon his infant observational studies to posit that a very early existential sense of self, or rather a number of “senses of self,” predate language development and self-reflective capacities and are both revealed by subsequent development and transformed by it. Among the senses he identified are the “senses of agency, of physical cohesion, of continuity in time, of having intentions in mind . . . the sense of a subjective self that can achieve intersubjectivity with another, the senses of creating organization and the sense of transmitting meaning” (pp. 6–7). The presence of the other is crucial for self-regulation of affect and somatic experience and indeed has a central role in defining the infant’s primary self-state. Between seven and nine months, the human infant discovers that the other has a mind of her own and that that mind can be engaged in sharing subjective experience. Indeed, infancy research offers a series of elegantly simple paradigms, such as Tronick’s still face, the visual cliff, and theory of mind studies, that underscore the parallel strands of the infant’s and young child’s expectation of mutuality and engagement with the significant other even as he is increasingly able to realize the fundamental separateness of the other’s mental state, ranging from beliefs and desires to available mental contents that inform him about the world. The notion that the same interpersonal process that produces emotional recognition and regulation, reflective function, and self and object constancy also is central for the birth of symbolic capacity and imaginary play began with Anna Freud’s Normality and Pathology in Childhood (1965). The very young infant “neither distinguishes self from object nor is able to manipulate symbols and . . . the emergence of each process is importantly interrelated with that of the other” (Drucker 1979). For example, social referencing referred to above,



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i.e. looking at the mother’s face for affective guidance, is a developmental milestone that highlights the presence of self-other differentiation. Moreover, it shows that the infant is available to receive the attribution of meanings to objects and circumstances from the mother, an essential step in the development of symbolic capacity and imagination. “The infant relates not only to the world as perceptually specified, but also to someone else’s psychological relation to that same world . . . [More important than mere information about the world], this configuration of experience affords an infant the opportunity to learn that given objects and events can have multiple, person-related meanings. The meaning-for-me is not necessarily the meaning-for-her” (Hobson 1993). This remarkably rich developmental moment captures as in a freeze-frame the complex process whereby the infant learns to use the mother’s affective signal to guide both his own affect and his actions, a process which, when internalized, provides a key component of future self-regulation of affect. In addition, this same moment illuminates the infant’s recognition of separateness, the intersubjectivity of his mental state as he obtains the required affective guidance from his mother’s expression, and the process through which meanings of things are conferred by minds. With these developments comes the possibility that objects and their meaning can be assigned and transformed by creative invention on a personal, interpersonal, or cultural level. Thus, the child achieves the developmental level required for symbolic play. Another tradition within infant observational studies underscores the crucial role of contingency detection, an infant capacity that is demonstrable within the first months of life. Interestingly, this capacity has also been shown to figure as a key component in the development of narcissistic integrity and the capacity for make-believe. Broucek, reviewing the relevant research prior to 1979, observes that the infant’s discovery that a contingency exists between his own activity and the occurrence of external events is a fundamental building block in the infant’s development of “self-feeling” and narcissistic integrity; violations of contingency expectation early in life can instigate withdrawal and avoidance, infantile defenses against traumatic helplessness and impotence. This is beautifully demonstrated in Tronick’s still-face experiment where violation of the infant’s expectations that his mother’s facial expression will vary in response to his own communicative expressiveness results in disorganization and withdrawal (Gergely and Watson 1996). In more recent studies, Gergely (1996) calls upon the infant’s sen-



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sitivity to the contingency structure of face-to-face interaction and the “species-specific propensity for the facial and vocal reflection of the infant’s emotion-expressive displays during affect-regulative interactions” to explicate how the infant develops awareness of his own affects, recognizes the nature of his mother’s affects, learns to selfregulate his emotional state based on parental mirroring, and comes to distinguish real affect from pretend (i.e. “marked”) affect. This very detailed study suggests that the interaction with the parent around emotional displays is midwife to both the infant’s self-regulatory capacities and the infant’s entry into the world of make-believe. Even as the infant is distinguishing between his mother’s face “reflecting what she sees” (Winnicott 1965) in his own face and his mother’s face expressing her own affect, he achieves the associated developmental milestone of distinguishing, by their markedness, mock displays of emotion, those playful exaggerated expressions of surprise, fear, delight, and so on, from real ones. With these miraculous achievements, the infant engages in the excited interplay of emotional expression with the parent, correctly interpreting mock surprise, anger, and sadness and ultimate re-creating these “play” affects. This, of course, constitutes a vital step toward symbolization and the world of make-believe. In tandem with the increasing emphasis on the crucial interpersonal context of the infant’s developing capacities—to recognize and regulate his own affective states (Gergely and Watson 1996), to appreciate and distinguish the mind of his caretaker from his own, to identify his unique intentionality and agency (Fonagy and Target 1998), and to freely access the developmentally crucial world of make-believe where mentalization can occur—there is a growing accumulation of data to suggest biological and genetically based sources of psychopathology. Many of the children we see today have been examined systematically in terms of their ego equipment and their genetic pedigrees, and we often face the conundrum of understanding their psychopathology in the context of contributions from markedly uneven ego functioning which is developing in a complex transaction with conflict. While the stability of findings from neuropsychiatric testing is variable depending on the age of the child, as well as on dynamic and educational factors, there is no doubt that these variations feed into, as well as reflect, psychopathology and color the interchange with the environment throughout life. I believe that the impact of these features are far more powerful in presentations in childhood than in adulthood for a number of reasons, including the obvious one that adults have developed more stable



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ego organization and adaptations and are rarely called upon to perform in as many diverse arenas as the average school child. The adult will presumably manifest less distress and symptomatology around chronic exposure to impossible environmental demands and can avoid confrontation with areas of relative weakness by his choice of profession and pastimes. The child analyst thus faces a diagnostic and clinical challenge where the multiple transactions among nature, nurture, history, on-going development, and environmental expectations and demands are all intermingled and clearly contribute to the child’s suffering. In the following, I will tell you more about Andy who, despite early indications to the contrary, fell within what I consider to be the usual contemporary range of analyzable childhood psychopathology, i.e. he fell within the spectrum of neurotic/developmentally uneven/ dysregulated patients who are the staple of contemporary child analytic practice. The degree to which his psychology was influenced by a documented developmental strain due to markedly uneven cognitive and physical maturation is, I believe, both considerable and commonplace. Elsewhere, I and others (Gilmore 2000, Greenspan 1989, Cohen 1991) have suggested that our current thinking, enhanced by our greatly improved assessment techniques, allows us to take into account the impact of developmental idiosyncrasy on the evolving structure of the mind; that is, we are able to identify and consider the way that the unique individual developmental profile shapes and organizes the evolving personality and defines its potential. I would speculate that Andy’s extraordinary degree of uneven ego endowment, with marked delays in coordination, visuo-spatial integration, and sustained alert attentiveness, and his low thresholds for frustration and stimulation tolerance impacted his sense of efficacy and his availability for easy interpersonal exchange from the outset. His vulnerabilities diminished his opportunities for the early repeated experience of joy, self-satisfaction, and parental admiration in the routine fine and gross motor accomplishments of early childhood. These considerations, plus the report of maternal depression in the first year of life and his parents’ orientation toward emotionality in general, support hypotheses about the complex bio-psycho-social underpinnings of this boy’s particular difficulties when he presented in early latency, which included the absence of unstructured play, intolerance of affect, impulsivity, and a markedly constricted inner life. The working hypotheses which thus guided Andy’s treatment accumulated over the course of my work with him. I offer them here in advance to show the interweaving of the developmental, diagnostic,



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and dynamic issues as they served to light the way in what sometimes seemed a discouraging darkness. To my way of thinking, they represent a complex series of interacting influences which determined, exacerbated, triggered, and were recruited by each other: 1. Andy did not play because innate constitutional factors, especially his limited capacity to sustain quiet alertness and focus (ADHD) and his reduced proclivity toward object relatedness (non-verbal learning disability), diminished his availability for early engagement with his mother, where affect regulation and imaginary play find their origins. 2. Andy did not play because his mother was depressed during the crucial first year of life and was unable to engage her “hard-to-engage” child. 3. Andy did not play because his sense of personal agency and his pleasure in his own productions were compromised by his motor and visuo-motor deficits. 4. Andy did not play because ego weaknesses, interference in maternal attunement, and, possibly, constitutional factors, heightened his fear of his affects and his difficulty developing signal function. 5. Andy did not play because his narcissistic fragility and sense of internal impoverishment inhibited the development of fantasy and the expression of creativity. 6. Andy did not play because affective expression was devalued in his family and precocious intellectuality was strongly prized. Obsessional defenses against his constitutionally determined impulsivity were reinforced by his intellectual, “workaholic” parents; coupled with his perfectionism and his fear of his own affects, these defenses further squelched his freedom to play creatively.



Over the course of the two years of treatment to date, I came to conceptualize the core of Andy’s pathology as a complex disturbance in his ego organization, one that remained as an on-going (although also evolving and transforming) limitation in his development. His clinical presentation, corroborated by his history, showed that he had on-going difficulty establishing and maintaining an intersubjective state where self-discovery, emotional exploration, and creativity are engendered, where his inner world can be made manifest without crippling self-consciousness, a state that we rely on as child analysts and that we usually get to experience directly or sometimes only indirectly, as with highly oppositional children. His analysis has indeed been marked by fierce resistance, behind which lay anguished loneliness, narcissistic fragility, and mistrust of adults—all attributable to the factors outlined above. Furthermore, Andy used his constitutionally based tendency to “tune out” as a powerfully opaque



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ego-state of pseudo-autonomy, resistance, and disengagement; these factors conspired against Andy’s experiencing an open exchange with me. Andy When Andy’s parents first sought consultation, he was just short of 8 years old and had been on stimulant medication for about 6 months. Consistent with his parents’ orientation toward cognitive approaches, he had had no prior contact with a child psychiatrist; when his school had urged his parents to seek an evaluation for his hyperactivity, distractibility, and fine and gross motor delays, his parents consulted a pediatric neurologist. Neuropsychiatric test results corroborated an extraordinary degree of developmental unevenness with a 41 point difference in his superior verbal and low average performance IQ; most significantly depressed were the scores on tasks that required visuo-motor integration and visual memory. His attentional lapses and difficulties with organization were felt to impair his capacities across the board, but with most damaging effect on his weak performance scores. Attention deficit disorder, grapho-motor delays, and visuomotor learning disability were diagnosed; his affect dysregulation and low frustration tolerance were attributed primarily to the combined impact of these disorders. Andy’s distractibility and hypermotility were viewed as serious impediments to his learning and medication was recommended and begun. However, despite his teacher’s report of significant improvements in his learning, Andy’s overall state worsened over the year to the point that there was now an urgent need for psychiatric input. On stimulants, Andy was more impulsive, rather than less, and his emotional instability was becoming unmanageable. New and peculiar behaviors included his refusal to swallow his saliva, which he retained in his mouth and spat out at intervals. His behavior at recess was increasingly reclusive; he removed himself from contact with other children, paced, and twirled about, seemingly lost in fantasy. His meltdowns and impulsivity spilled over to the classroom, to the point where his teachers felt that they needed extra help dealing with him in class. His nighttime enuresis, typically occurring once or twice per week, had increased and he also began wetting and soiling at school. At home his “oversensitivity” to slights and misunderstandings, his frustration with homework, and his insomnia were all worsening. Talk of suicide and reckless behaviors finally frightened his parents; the consultation with me was arranged after Andy bolted from home



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one night and ran several blocks, across busy intersections, before being apprehended by a policeman. What was most striking in my conversation with his concerned parents was their lack of awareness of Andy’s mental life or, for that matter, of subjective or interpersonal experience in general. Well educated, well intentioned, and exceedingly busy professionals, they conveyed bewildered sympathy for their son’s situation, reacting with dismay tinged with a kind of abashed perplexity and frustration, but at the same time suggesting that everyone was exaggerating the seriousness of his disturbance. They complied with the school’s insistence on a “shadow teacher” but viewed it as alarmist. This posture previewed their reaction to the recommendation for analysis. Later in the first year of treatment, Andy’s mother, who was herself in an on-going treatment, acknowledged her own significant depression during Andy’s first year of life precipitated by her father’s death. She also articulated a tension between herself and her husband and indeed his entire extended family. She had come to recognize that as she increasingly gave voice to her feelings, she felt peripheralized as an excessive worrier, a “mother hen,” in a culture characterized by a casual but somewhat implacable denial of danger and distress and a humorous disregard for anyone who was frightened or who visibly emoted. The mother seemed unable to sustain her position in the face of this attitude, lapsing into a kind of hapless posture, as if, Woody Allen-like, she was just being “neurotic.” This quality in Andy’s parents highlighted to me how much we as analysts rely on parents to provide a context for our growing understanding of their child. The idiosyncrasies of their own dynamics and the dynamics of their relationship as it emerges willy-nilly in the consulting room, their reflections on their own psychologies and their personal histories, their complaints about each other or their child, their blind spots, kindnesses, and cruelties accrue in our experience of the parents and facilitate our capacity to understand our patient’s experience. In meeting with parents, I am often aware of a process of identification with my child patient, which emerges as a reverie about what it feels like to be both the present-day child and the very young infant of these people: what are the rituals of interaction, the shared assumptions, the unspoken expectations about engagement, the “ease and continuity” of on-going experience (Pine 1982)? Parents’ transparency in terms of their representation of themselves, their relationship, and the portrait of their child that develops in the course of the work reflects their willingness to openly engage with the analyst in helping their child; to some extent this corre-



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sponds to their own self-reflective capacity, as well as to the particularities of their individual dynamics and psychopathology. As suggested above, the parents’ own “reflective function” has been robustly linked to secure attachment (Main and Hesse 2000) and to the child’s capacity to experience his drives and affects as mental contents (Lecours and Brouchard 1997) and to maintain a “theory of mind.” Andy’s parents’ opacity adumbrated the powerful interference within the analysis, that is, the absence of the medium of play. Work with the parents over the course of Andy’s treatment involved a process of establishing an arena of communication which capitalized on their considerable intellect and investment in his cognitive development. For example, at one point, his mother observed that she was able to reinvigorate his father’s commitment to the treatment by reminding him of how much Andy’s fine motor skills had improved, presumably because we drew together. Early in our relationship, Andy announced: “I’m an oxymoron,” proof of which, he suggested, was his “wish to die, while everyone wanted just the opposite” for him. He then proceeded to demonstrate his global determination to “do the opposite”; for example, he insisted that any activity he agreed to participate in must be done lefthanded and claimed to be left-handed, which he is not. He did not play and he seemed most emphatically unwilling to talk, even about the mundane facts of his life. When I tried to explore any topic, especially one that bore on him and his mind, he would silence me by saying, “Stop talking, I’m trying to think . . .” and then, after multiple false starts that seemed to lack specific content, he insisted that he couldn’t explain what he was thinking and besides, “you wouldn’t understand.” He spat surreptitiously into the garbage can. He attempted some drawing and coloring, but in such microscopic dimensions that he became agitated and inconsolable as his attempts proved unsatisfactory. On other occasions he would simply stand stock-still and stare at the clock. Even after Andy settled into the routine of treatment, he consistently began our sessions by flopping himself upside down on a chair or floor cushion with his buttocks in the air facing me, a posture I have suggested is his “opposite” way of declaring that I’m the “butt-face.” While this behavior ultimately yielded to interpretation, there is no doubt that Andy relied on oppositionality as a defense against the variety of encroachments that beset him when he first presented and which continued to threaten his tenuous narcissistic balance, among which I include myself. But as his oppositionality alternated with a worrisome potential for compliance, also expressed in presenting his butt submissively to me, I recognized the



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polar manifestations of his oppositional defense against exposure of a poorly developed sense of self, a threatened sense of agency and a personal agenda that is organized primarily around maintaining his fragile narcissistic balance. Andy relied on the other as a form to submit to, to mold to, or to repulse, but he could not seem to use the other for mutuality and progressive development. He repeatedly retreated from the establishment of mutual engagement and, despite his considerable intelligence and verbal agility, he shrank from the opportunity to establish better internal regulation through bringing his experiences under the modulating influence of metaphorical and/or verbal symbolization in playing, an activity that is, of course, the sine qua non of child analysis. Andy’s resistance during this introductory phase reached a peak of anguish and despondency when he spent a session wedged into the small entry hall of the office, refusing to go farther and bellowing for his mother who was sitting in the waiting room 10 feet away. His nonstop screaming brought the neighbors to my door in alarm! When his mother repeated, “Andy, just come in here, I’m here waiting for you,” he finally replied, “Something in me wants to do that, but another part says I can’t after all this; I won’t let me.” What more vivid demonstration of his sense of aloneness and his inability to make use of his mother in his struggle with affects! This episode came to epitomize for me the great divide between Andy and his mother around the communication and translation of overwhelming emotion into manageable experience. It also illuminated how his oppositionality had hardened within the breach into a monument of stony isolation. The assessment period did not auger well for analytic work: indeed, it seemed to me as if he had come to experience everything coming from a supposedly helpful person as a poisonous, murderous, or disintegrating intrusion; understandably, he was desperate to refuse and resist. One issue seemed obvious: Andy deeply resented and was determined to expel the hated medication and the implication of severe disturbance that he read into it and that it seemed to have the power to create. In this initial phase of the treatment then, my goal was to “listen” to Andy’s action and find a better solution to his medication problem. While not perfect, a marked improvement was achieved by changing his stimulant and adding an SSRI, since his agitation seemed driven by anxiety and despondency, although it remained unclear whether I was medicating an iatrogenic or endogenous disorder. In the following 3 months, I saw Andy twice per week, with a very gradual diminution of his symptoms, but without a better sense of his



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inner life. When he told me in response to a question, that he couldn’t talk about certain things with me “yet” because he didn’t know me well, I felt more optimistic, because such a statement implied a less rigid and guarded stance and supported the hope that he might be able to feel safe with me. But he remained aimless and profoundly impaired in his capacity to play. It was not that his play was primitive, perseverative, stereotypic, chaotic, or lacked key features, such as characterizations and narratives, upon which the dynamic child clinician typically depends in order to diagnose, explore conflict, and analyze. It was not that he relied on the typical rote play of the well-defended latency child. He only very rarely resorted to the use of prepackaged games, board games or cards, and mostly at my instigation; those moments were, with Andy, treasured opportunities to view his management of competitive feelings. But they were few and far between. In most sessions, Andy just seemed stymied, unable to sustain the pretend mode in any form. What was there, deep within Andy? This remained puzzling to me. I was strongly in agreement with his parents’ wish to taper him off medication as the summer approached so that we could reassess Andy without the distorting effect of both the stimulant and the SSRI. After the medications were removed and with an increased frequency of sessions that I proposed as a trial, my experience of Andy continued to be curiously blank, as if I were in the company of a highly mobile, courteous spinning top. The Andy that gradually emerged was manifestly far less disturbed, dysphoric, and remote but remained unable to generate any play. Andy seemed to acquiesce to our sessions and his self-described “oxymoronic” behavior, with its reflexive oppositional stance, abated; the only hint of oppositional feeling remaining was in his momentary hesitation in putting down his book in the waiting room when I beckoned him into the playroom. When I addressed this whisper of resentment, he seemed eager to spare my feelings and to attribute his reluctance to his absorption in reading. I later understood that any allusion to feeling on my part, even in the remote form of “I see you are still letting me know you aren’t so happy to be here” worried him. It was as if both of us had to be affect-neutral to maintain Andy’s equilibrium. In general, despite his earlier presentation, Andy seemed exceedingly careful and polite, quickly undoing the rare and minimal expressions of anger or hostility by his characteristic phrase, “I’m only kidding.” Whereas the Andy of the past seemed to define himself by anger, refusal, and resistance, the Andy of the present, apparently divested of oppositionality, seemed shapeless and aimless,



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with little or no affective expression. Once in the playroom, he would rock on the rocking chair, wheel about on the wheeled chair, or jump free-form about the room, often colliding into various projects of other children but without a discernable intent to destroy, usually quite apparent in the palpable rivalries of our child patients. The content of the hours was almost impossible to recount; there was conversation but the evolution of themes that could knit our work together was curiously absent. Moreover, the atmosphere in the sessions, formerly distinguished by passionate refusal, frustration, and despondency, was now curiously flat. The dramatic opening presentation of desperate expulsion of poisonous intrusions gave way to an implicit demand for me to fill him up and enliven him. He said with some resentment that since I did not “give him ideas,” I was of no value as a playmate. My presence did not even promise the simple advantage of a compliant other “at his service,” i.e. with no play agenda but Andy’s own. Indeed by not providing a play agenda, I denied him the necessary borrowed scaffolding (or content) for what Andy called “playing” to take place. While I did not minimize the potentially inhibiting impact of my “other” agenda, that of knowing him, developing a relationship with him, and in this way, gaining understanding for both of us, I came to feel that the apparent paucity of internal resources was pervasive in Andy’s experience. It often found expression in his lament that my playroom (which is rather overloaded with play material for all ages) was too small and had nothing in it worth doing (Anna Freud 1965). Even worse, I began to sense that the paucity of “ideas” that Andy manifested had colonized my mind. I had the demoralizing impression that I had no ideas about him dynamically, I had no insights or hunches; I began to feel that I complained about his not playing with me the way he did, although much less often, about my office. To reiterate the absence of the usual culprits: Andy seemed, at least superficially, less depressed than he had been on antidepressant medication, he did not appear grossly inhibited in any obvious way, he did not appear chaotic, he was no longer adamantly oppositional and resistant, and he was able to play with peers when they provided direction. For example, he reported great enjoyment of role-playinggames (RPG’s) but said he was a poor “dungeon master” (i.e. he could not direct the play) and was therefore unable to import such play into our sessions. At home, his “play” consisted almost exclusively of video and computer games whose complex story lines he would “borrow” on rare occasions, in order to attempt an RPG with me. These petered out quickly and never got carried over to the next



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day. In fact it was the rare exception that a motif generated one day was taken up the next; there was none of the often preemptory drivenness of the child patient who is playing out important thematic conflicts in displacement, who comes in knowing just where the play left off and easily reestablishes continuity. Andy returned to school without any medication and when 4 months later, Strattera, a new non-stimulant ADHD medication, was finally introduced, his parents and I agreed to try it. I hoped that Andy would accept this medicine because it had an initial sedative effect and could provide relief for his chronic sleep onset insomnia. Overall, on a relatively low dose of Strattera, Andy’s insomnia, marked hyperkinesis, and restlessness improved; moreover, the Strattera seemed to have little effect on Andy’s conscious experience, and therefore did not generate the same resistant response that he was able to mount to the stimulants. Nonetheless he told me some time later that while he appreciated the improved sleep, he didn’t like the idea of medicine, whether he actually noticed it or not. Andy’s progress in the past two years of treatment has been considerable, with a dramatic cessation of disruptive meltdowns, improvement in frustration tolerance and in overall functioning. But the analytic relationship continues to feel to him like a judgment of “abnormality” and a deprivation because I do not provide “ideas” for play and do not assert my personal agenda beyond the attempt to know him. I began to think about Andy’s quality of relatedness, his transference in the broad sense, and to consider how rarely I experienced intersubjectivity (Birch 1997) or even a sense of his desire for joint visual attention (Scaife and Bruner 1975), that typical developmental marker of the infant who is just beginning to appreciate the idea that mother’s mind differs from his own and must be actively engaged. In the assessment period, he frequently responded to my interest in what was on his mind as if I were, like the intrusive medication, trying to disrupt his control of his thoughts. While this seemed to improve to the extent that he did not forcibly attempt to silence me, he was unable to generate any activity where we engaged in mutual discovery and elaboration of meaning. Often, when he engaged in some motor task like tracing a picture, I would realize that he had gradually turned his back to me. Other activities he proposed, often in response to my observation of his disengagement, were attempts to trick me, by definition an avoidance of a shared mental state. Without my intervention, Andy most readily lapsed into his default position, his “tuning out” state of mind, a state as closed to introspection



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as it was to my inspection, but which protected him from any experience of interpersonal desire or vulnerability. I regularly observed Andy’s use of this “tuning out” to slip into an ego-state unavailable for communication and intersubjectivity; at times this appeared as a visible shift in his attention which in some children marks the intrusion of inner fantasy or preoccupation. While I initially approached these “disappearances” with the confidence that he was internally occupied, I came to realize that Andy’s access to his inner life was also compromised; he described a frustrated, stymied feeling, a sense of pressure, and an absence of specific content. Andy certainly was not eager to engage in an open communication with me, but this was at least in part because he simply did not have the tools to do so. In order to even establish contact I had to break through his self-absorbed inwardness with my increasingly plaintive refrain, “Play with me!” Over time, I was able to show Andy how he made me the left-out little one in this passive to active enactment where I was yearning to make contact with someone so withdrawn or preoccupied that I was quite unnoticed. I could also sample the frustration and anger that this neglect engendered. While Andy concurred with the “fact” of this connection by saying, “My parents never play with me; that’s why I don’t know how to play with you,” he demurred about the associated affect, once again denying his loneliness and distress. It was clear that for Andy, emotional expression was fraught with potentially catastrophic narcissistic consequences. As mentioned earlier, he interpreted any sign of intensity in me with alarm and did his best to neutralize his own emotions. Only unmodulated disruptive affects (Lecours and Bouchard 1997) could force themselves into full expression, as in his so-called “melt-downs,” those inarticulate chaotic tantrums, which at this point were rare events and hardly ever occurred in my view. Affects that were better contained and potentially verbalizable were apparently experienced as intolerably demeaning, and were vigorously disavowed. I was struck over and over again by Andy’s effort to be objective and to eschew the range of emotion that most people experience. In fact, in the treatment relationship, his mirroring my neutrality was far more successful than my capacity to maintain it! In one session, I recalled his apparent willingness to be wildly out of control in the opening months of our acquaintance; but, when the dust settled, he admitted to almost no emotions at all. To this he replied, “maybe other people have more, but I just have two ‘big emotions’: frustration and embarrassment.” Andy’s stance was clearly an identification with and an attempt to please his father, but this identification had a far-reaching impact on



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his ego functioning: it amounted to a wholesale disavowal of a range of affect and it exacerbated Andy’s constitutional difficulties with affect-regulation and the integration of affect into his self-representation. Certainly Andy experienced many other feelings, some of them quite obvious to me, such as anxiety, pride, jealousy, hurt, and loneliness, to name a few, but he vigorously and elaborately denied these feelings, as if they diminished him. For example, he struggled to disguise his visible deflation upon losing a game and with somewhat less determination, tried to subdue his joy upon winning. He insisted that his brother shared everything with him and therefore never made him feel envious or excluded in the blatantly contradictory context of a reported meltdown on his brother’s birthday. Despite my first-hand knowledge of his rages, he undid even the mildest hostility by the “I’m only kidding” mantra, and denied his anger in moments when he was clearly angry; he far preferred a victimized posture which he seemed to willingly embrace. He even denied curiosity about sex, certainly not atypical of his age group, but increasingly noteworthy as his peers showed more excited interest from which he anxiously retreated. It became apparent that Andy’s urgent need to be “an oxymoron,” that is, an original, also contributed to this disavowal of feelings, and further impeded his capacity to name them and understand them; his ideal was a caricature of his father who was so remarkably unflappable. The same narcissistic pressure impeded verbalization and thought in other arenas. Its impact in regard to his academic performance was onerous, because he was unable to rest until he was sure of producing work that was extraordinary. His parents reported that any time something “special” was called for at school, even something as banal as an “interesting sentence” using a new spelling word, Andy would fall into an anxious and paralyzed state that extended the activity for hours. While he demanded his parent’s presence in these struggles, he could not use them to “brainstorm,” since any input from others immediately threatened his originality. The fragility of his ideas and of his sense of ownership of them was so great that Andy could not use an adult’s mind as scaffolding for his own invention. Over the course of the work, the global disavowal of ordinary emotions in his transaction with the world outside the office gradually remitted as I strenuously addressed his defense and linked his altered state to his denial and fear of emotion. Andy’s capacity for sophisticated humor was a great asset here, as he could tolerate my musings about his extraordinary absence of feelings and what I, a mere mor-



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tal, might feel in his shoes. As I examined the responses he tried to elicit in me by his remarkable “absence in my presence,” he was able to identify and admit to more feelings and more nuance of feelings. The intensity of his competitive dynamic, wherein his aggressive wish to triumph and lord it over his opponent was in perpetual struggle with his anxiety about maintaining the relationship and consequent submissiveness, was clearly present in this struggle with me over affect expression, and we were gradually able to recognize it in relation to a range of narcissistic and oedipal conflicts. I was also able to suggest my dynamic hypothesis about the premium placed on affectneutrality as representing Andy’s identification with his father and a position of masculine strength within the family. Despite this work, the competitive struggle with me made him veer away from openly depending on me to sort out painful feelings; instead, he would transpose his feelings of loss and/or anxiety into a diatribe about treatment, my lack of forthrightness about myself, and the implicit accusation of “abnormality” that the treatment comprised. It was almost as if Andy intuited that a transference complaint, no matter how stereotypic, would lure me away from seeing the hot spot where he was acutely suffering at that moment; he thus substituted friction with me to indirectly achieve his shameful wish for closeness, a pattern demonstrated outside of the treatment in his relationships with his mother and brother. For example, on one occasion, I addressed his palpable suffering while his brother was at camp and his parents were traveling for work. It was clear to me that Andy was enduring even greater loneliness than usual. He adamantly denied my observation and attributed his tears to his frustration at having to see me so often. This was all the more striking because our schedule had been disrupted by his day camp and we had met only once that week. On another occasion, when he was bereft at the painful yearly change of au pair, he shifted way from acknowledging his loss and resumed his litany of reproaches to me. In one fascinating hour when Andy (I fear accurately) read my attempts to connect as a critical complaint, he said with considerable bitterness, that in fact, he was with me just like I was with him: “You don’t give your ideas, so I won’t give mine. You see as much of me as I see of you. If you don’t tell me anything about you and if you don’t start anything, if you don’t show your feelings, why should I?” Here again his oppositionality seemed pronounced, taking the form of an imitative pseudo-analytic stance; but I sensed behind that a painful sense of deficiency and a deep narcissistic wound created by our differing status in the treatment and his conflicted wish that I love him and pur-



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sue him. The transference meanings of his complaint, i.e. its history in his relationship to his father, was less available than its defensive function in the here and now. I had ample opportunity to see that this posture protected him against the frightening feeling that he couldn’t think of anything, that his thoughts and intentions seemed to drift out of his mind, that his attempts at creativity were strained and empty, and that he was just an ordinary sad and lonely kid, and therefore unlovable. Not unexpectedly, these rare moments of openly expressed resentment toward me, which of course were at once displacements of painful states experienced in relation to others, expressions of on-going transference themes, and a way to engage with me and keep me at a distance all at once, were typically followed by a rapprochement which was certainly motivated in part by guilt and anxiety. When I observed once more how difficult it was for him to talk about feelings with me and to feel comfortable having feelings about me, he said with great poignancy, One is the loneliest number that you’ll ever do (But) Two can be as bad as one, It’s the loneliest number since the number one. (From “One,” by Three Dog Night)



Without the precious medium of the playing state, it is a challenge indeed to represent these many layered issues to such a child in a way that usefully examines his oedipal and sibling rivalries, narcissistic injury, and shameful sense of inadequacy, while recognizing his real disabilities arising from his maturational unevenness as well as their role in his developmental lag in tolerance of intersubjectivity and affective expression. Discussion While the psychoanalytic view of play acknowledges its importance in the elucidation of the child’s inner world and mental conflicts in the treatment, there is at least an equal emphasis (A. Freud 1965, Neubauer 1994, Solnit 1987, Abrams 1993, Mayes and Cohen 1993, Friedman and Downey 2000) on its crucial role in development, since play provides the opportunity to try on identifications, to practice gender roles, to master developmental challenges and personal trauma, to overcome helplessness, to modulate drive derivatives, and so on. A child who does not play is not only manifesting a symptom, he is suffering from an on-going developmental handicap that has widespread reverberations. The ability to play is a developmentally



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determined capacity with strong biological foundations serving a range of social, interpersonal, and intrapsychic functions, and observable in the young of all human cultures, mammals, and birds (Friedman and Downey 2000). Although my intention here is not to iterate the mental building blocks of this complex function, I draw your attention to just a few: the “regression in the service of the ego” that affects all the agencies of the mind and permits greater access to irrational fantasy content, the displacement in the service of the ego, the willing suspension of a number of ego and superego functions such as reality testing, critical self-consciousness and censorship, the associated tolerance of otherwise unacceptable impulses and affects, and, of course, the array of cognitive and motor capacities required to enact the roles or manipulate the props of the play. These features differ in prominence and amplitude depending on the developmental phase and the psychology of the individual child. In emphasizing the crucial and ubiquitous development-promoting features of the capacity to play, I believe that the many excellent psychoanalytic contributions on the subject have underemphasized the unique nature of play in the psychoanalytic setting. Just as Lewin (1955) observed that there are several types of free association depending on the context and intention, so there are differences in play from one setting to another; the play with a peer, the play with a parent, and the play of the child alone all share many features but differ from playing with the analyst, in that the latter is a communication and an invitation into the child’s subjective experience addressed to a person whose declared goal is to learn about that world for the purpose of understanding and helping the child to understand himself. While this circumstance may bear complex relationships to transference and resistance, it exists as fundamental premise in any session in which the child is playing. As child clinicians well know, there are some children who play in life but refuse, for brief or sustained periods, to play in our playrooms, and some children who play nowhere but with the analyst. These variations reflect the child’s posture toward the threshold of engagement with the analyst, variously understood to be affected by disturbances in attachment history, oppositionality and overt resistance, profound narcissistic vulnerability, shame, or superego severity. But the child’s capacity to play with the analyst also reflects his freedom to achieve, in the presence of his particular analyst, a state of playing that is intrinsic to some of its components but is more than the sum of those parts; it is an altered state of consciousness (Birch 1997) with a much closer relationship to unconscious mentation, more like the secondary elabo-



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ration of a dream with a less exacting requirement for logic and reality, even in latency-age children fully capable of concrete operational thought. Moreover, this state is more or less porous to the analyst’s playing participation, as the child dictates how much input the analyst is permitted, and the analyst assumes a playing state informed by her growing knowledge of the patient and her appreciation of the boundaries of play in its interface with direct expression of drive derivatives and consequential action. Inevitably, the analyst’s play state is also informed by her own unconscious mentation and her countertransference toward the particular patient. The resilience and stability of the playing state are unique to the individual child and his relationship to the specific analyst, because once the state of playing is produced in the treatment it becomes an intersubjective medium with its own conventions and its objects, whose historical meanings are gradually transformed as they become incorporated into the history of this new relationship, just as transference paradigms and historical memories show plasticity and evolution in the course of adult analysis (Rizzuto 2003). In regard to this evolution, I believe that despite the considerable controversy about the therapeutic value of playing in and of itself (Mayes and Cohen 1993, Scott 1998, Cohen and Solnit 1993), the transformation that child analysis facilitates and which the child patient anticipates, is achieved primarily through verbalization while in the state of playing. Child analytic literature certainly abounds with clinical reports where a significant therapeutic benefit is gained by the facilitation of previously inhibited or chaotic playing without explicit interpretation of conflict (Birch 1997, Mayes and Cohen 1993, Slade 1994). Nonetheless, in all such instances, the analyst’s verbalizations are a central, transforming element, much like the mother’s transformation of the infant’s chaotic experience into discrete affects, recognizable self-states, and familiar interpersonal exchange by her naming and dialogical prosody. As Rizzuto (2003) declared in a recent paper on the transformation of self-experience in adult treatment, “Analysis is the second instance in life in which another person tries persistently to ascertain the internal experiences and needs of the subject by naming, describing and interpreting them with his or her own speech.” (p. 293) I believe that the same process occurs in the play dialogue of child analysis; in a comparable way, narratives about the self are made coherent, disavowed self-representations are clarified and modified to permit reintegration, nameless and disorganizing anxieties are named and organized, and dissociated self-states are open to contact both



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intrapsychically and interpersonally through the analyst’s participation and verbalizations within the state of playing.



BIBLIOGRAPHY Abrams, S. 1988. The Psychoanalytic Process in Adults and Children. Psychoanal. St. Child, 43:245 –261. ——— 1993. The Developmental Dimensions of Play during Treatment: Conceptual Overview. In, The Many Meanings of Play, ed. Solnit et al., New Haven: Yale University Press, pp. 221–228. Birch, Marian. 1997. In the Land of Counterpane: Travels in the Realm of Play. Psychoanal. St. Child, 52:57–75. Bromberg, P. 1996. Standing in the Spaces: The Multiplicity of Self and the Psychoanalytic Relationship. Contemp. Psychoanal., 32:509 – 535. Broucek, F. (1979) Efficacy in Infancy: A Review of Some Experimental Studies and Their Possible Implications for Clinical Theory. Int. J. PsychoAnal., 60:311–316. Chused, J. F. 1991. The Evocative Power of Enactments. J. Amer. Psychoanal. Assn., 39:615 –639. ——— 2000. Discussion: A Clinician’s View of Attachment Theory. J. Amer. Psychoanal. Assn., 48, pp. 1175 –1188. Clyman, R. 1991. The Procedural Organization of Emotions: A Contribution from Cognitive Science to the Psychoanalytic Theory of Therapeutic Action.J. Amer. Psychoanal. Assn., 39S:349 – 382. Cohen, D. 1991. Tourette’s Syndrome: A Model Disorder for Integrating Psychoanalysis and Biological Perspectives. Int. R. Psycho-Anal., 18:195–208. Cohen, P. & Cohen, M. 1993. Conceptual Worlds: Play, Theatre, and Child Psychoanalysis. In, The Many Meanings of Play, ed. A. J. Solnit, D. J. Cohen, P. B. Neubauer. New Haven: Yale University Press, pp. 75 – 98. Cohen, P. & Solnit, A. 1993. Play and Therapeutic Action. Psychoanal. St. Child, 48:49 –63. Drucker, J. 1979. The Affective Context and Psychodynamics of First Symbolization. In, Symbolic Functioning in Childhood, ed. N. Smith and M. Franklin. Hillsdale, N.J.: Lawrence Erlbaum Publishers, pp. 27– 40. Emde, R. 1983. The Prerepresentational Self and Its Affective Core. Psychoanal. St. Child 38:165 –182. Fonagy, P. & Moran, G. 1991. Understanding Psychic Change in Child Psychoanalysis. Int. J. Psycho-Anal., 72:15 –22 Fonagy, P., Moran, G., & Target, M. 1998. An Interpersonal View of the Infant. In Psychoanalysis and Developmental Therapy, ed. Anne Hurry. Psychoanalytic Monograph No, 3, Madison, Conn.: IUP, pp. 3– 31. Freud, A. 1965. Normality and Pathology in Childhood: Assessments of Development. The Writings of Anna Freud Volume VI. New York: Int. Univ. Press (1970).



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Freud, S. 1914. Remembering, Repeating, Working Through. SE 12: pp. 145– 156. ——— 1920. Beyond the Pleasure Principle. SE 20: pp. 1– 64. Friedman, R. & Downey, J. 2000. The Psychobiology of Late Childhood: Significance for Psychoanalytic Developmental Theory and Clinical Practice. Am. Ac. Psychoan., 28:431–448. Gergely, G. & Watson, J. 1996. The Social Biofeedback Theory of Parental Affect-Mirroring: The Development of Emotional Self-Awareness and SelfControl in Infancy. Int. J. Psycho-Anal., 77:1181–1212. Gilmore, K. 2000. A Psychoanalytic Perspective on Attention Deficit/Hyperactivity Disorder. J. Amer. Psychoanal. Assn., 48:1259 –1294. Greenspan, S. 1989. The Development of the Ego: Biological and Environmental Specificity in the Psychopathological Developmental Process and the Selection and Construction of Ego Defenses. J. Amer. Psychoanal. Assn., 37:605 – 638. Hobson, R. P. 1993. The Intersubjective Domain: Approaches from a Developmental Psychopathology. J. Amer. Psychoanal. Assn., 41S:167–192. Knight, R. 2003. Margo and Me II: The Role of Narrative Building in Child Analytic Technique. Psychoanal. Study Child, 58:133 –164. Lecours, S. & Bouchard, M. 1997. Dimensions of Mentalisation: Outlining Levels of Psychic Transformation. Int. J. Psycho-Anal., 78:855 – 875. Lewin, B. 1973. Dream Psychology and the Analytic Situation. In, Selected Writings of Bertram D. Lewin, ed. J. Arlow. New York: The Psychoan. Q. Inc, pp. 248–263. (1955). Lyons-Ruth, K. 1999. The Two Person Unconscious: Intersubjective Dialogue, Enactive Relationship Representation and the Emergence of New Forms of Relational Organization. Psych. Inq., Vol. 19, No. 4:576– 617. Mahler, M. & McDevitt, J. 1982. Thoughts on the Emergence of the Sense of Self, with Particular Emphasis on the Body Self. J. Amer. Psychoanal. Assn., 30:827–848. Mayes, L. & Cohen, D. 1993. Playing and Therapeutic Action in Child Analysis. Int. J. Psa., 74:1235 –1244. Neubauer, P. 1994. The Role of Displacement in Psychoanalysis. Psychoanal. St. Child, 49:107–119. Ogden, T. 2004. The Analytic Third: Implications for Psychoanalytic Theory and Technique. Psychoan. Q., LXXIII, pp. 167–195. Pine, F. 1982. The Experience of Self—Aspects of its Formation, Expansion, and Vulnerability. Psychoanal. Study Child, 37:143 –167. Rizzuto, A. 2003. Psychoanalysis: The Transformation of the Subject by the Spoken Word. Psychoan. Q., LXXII, pp. 287– 324. Scott, M. 1998. Play and Therapeutic Action: Multiple Perspectives. Psychoanal. Study Child, 53:94 –101. Shapiro, T. 1977. Oedipal Distortions in Severe Character Pathologies Developmental and Theoretical Considerations. Psychoanal. Q., 46:559 – 579. Slade, A. 1994. Making Meaning and Making Believe: Their Role in the Clinical Process. In, Children at Play: Clinical and Developmental Approaches to



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Meaning and Representation, ed. A. Slade and D. Wolf. New York: Oxford University Press, pp. 81–110. Solnit, A. 1987. A Psychoanalytic View of Play. Psychoanal. Study Child, 42:205 – 219. Sorce, J. & Emde, R. N. 1981. Mother’s Presence Is Not Enough: Effect of Emotional Availability on Infant Exploration. Developmental Psychol., 17:737– 745. ——— 1985. Maternal Emotional Signaling: Its Effect on the Visual Cliff Behavior of 1-year-olds. Devel. Psychol., 21:195 –200. Stern, D. & Sander, L. (1980) New Knowledge about the Infant from Current Research: Implications for Psychoanalysis. J. Amer. Psychoanal. Assn., 28:181–198. Sugarman, A. 2003. A New Model for Conceptualizing Insightfulness in the Psychoanalysis of Young Children. Psychoan. Q., LXXII, pp. 325 – 354. Tronick, E., Als, H., Adamson, L., Wise, S., & Brazelton, T. B. 1978. The Infant’s Response to Entrapment between Contradictory Messages in Face-to-Face Interaction. J. Amer. Acad. Child Psychiat. 7:1–13. Weil, A. 1970. The Basic Core. Psychoanal. Study Child, 25:442– 460. Winnicott, D. 1960. The Theory of the Parent-Infant Relationship. Int. J. Psycho-Anal., 41:585 –595. ——— 1965. The Maturational Process and the Facilitating Environment. London: Hogarth Press. Yanof, J. 1996. Language, Communication, and Transference in Child Analysis I. Selective Mutism: The Medium Is the Message II. Is Child Analysis Really Analysis? J. Amer. Psychoanal. Assn., 44:79 –116.



Psychoanalysis As Cognitive Remediation Dynamic and Vygotskian Perspectives in the Analysis of an Early Adolescent Dyslexic Girl LISSA WEINSTEIN, Ph.D., and LAURENCE SAUL, M.D.



The interface of neurocognitive problems and dynamic concerns are examined in the treatment of an early adolescent dyslexic girl. Despite previous intensive remediation, she had been unable to master reading and spelling, but made remarkable progress after a relatively brief period of psychoanalysis. Psychoanalytic and Vygotskian perspectives are integrated to provide a model of how play, within the analytic context, is mutative for learning disabled children. Through the process of reexteriorization in the transference, play allows for the interpretation and resolution of traumatic situations which have become associated



Dr. Weinstein is an Assistant Professor in the Clinical Psychology doctoral program of the City University of New York, lecturer on the faculty of the Columbia Center for Psychoanalytic Research and Training, and a graduate of the New York Psychoanalytic Institute. Dr. Saul is a Clinical Instructor in Psychiatry at the Weill Medical College of Cornell University and an Attending Psychiatrist at New York Presbyterian Hospital. He is a faculty member of the Columbia Center for Psychoanalytic Research and Training. An earlier version of this paper was given on June 16, 2001, at the New Paltz, New York conference: “Brainstorms: Psychoanalysis Meets Neurobiology in Development,” sponsored by the Association for Psychoanalytic Medicine. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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with learning. As the act of learning becomes separate from the personal and affective context in which it took place, the child gains access to other, more normative, functions of play. These functions include the development of the capacity to separate meaning from action and the ability to understand words as generalized categories which represent objects, rather than being part of the specific object named. These two capacities, fundamental to the development of abstract thought, will support reflective awareness and help modulate affective states. The abilities furthered in play also act to remediate one component of dyslexia—the difficulty separating context from more abstract bits of knowledge. Finally, the child learns to “play at reality,” often trying on the new role of “student.” As Vygotsky notes, play is essential in allowing the child to become aware of what she knows. For a dyslexic child, for whom reading may never become completely a part of procedural memory, becoming conscious of what he knows may also enhance mastery of the skills of phonological processing, albeit more slowly than normally developing readers. The pleasure in play and the repetition it generates aids the internalization of the task and the development of automaticity.



Introduction the emotional problems of learning disabled children often bring them to psychoanalytic treatment, and in recent years the view that analysis is not the treatment of choice for children with neurocognitive difficulties (Giffin, 1968) has gradually shifted (Arkowitz, 2000; Garber, 1988, 1989; Migden, 1998; Rothstein & Glenn, 1998). The existing clinical papers often fail to precisely delineate the nature of the neurocogntive problems, eventuating in a hodgepodge of diagnoses lumped under the rubric of learning disabilities, even though the factors that make analysis helpful to children with language based learning problems may be quite different from the mechanisms that are mutative for children whose problems in processing perceptual stimuli form the core of their difficulties (Rourke, 1985). Lacking a clear rationale for why analysis might be helpful, it becomes impossible to evaluate the necessity for any changes in technique. With few exceptions (e.g. Cohen & Solnit, 1993), papers focus on the affective difficulties rather than the manner in which analysis alters or enhances ego functions which support learning. The current paper examines the interface of neurocognitive problems and dynamic concerns in the analysis of an early adolescent dyslexic girl and tries to specify those aspects in the analytic context



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which were mutative. Developmental dyslexia, the most common neurobehavioral disorder affecting children, seems an ideal starting point for a discussion of the interactions of neurocognition, dynamics and development, because its organic basis is clearly demonstrated by significant differences in the temporo-parieto-occiptal brain regions between people with dyslexia and those who are not reading impaired (McCandless & Noble, 2003; Shaywitz, 2003). Natalie was 12¹⁄₂ years old when she was referred for psychoanalysis to address long standing disturbances in her sense of self and others which stemmed from her learning difficulties and traumatic history. No effort will be made to examine the entire complex of dynamic factors in her analysis; nor is it our intention to present an “ideal” analytic treatment, as a rocky course may be inevitable in the treatment of learning disabled children (Rothstein & Glenn, 1998). Instead, the focus of examination will be one curious fact—despite intensive cognitive remediation prior to beginning analysis, Natalie continued to have difficulties with spelling, reading, and school performance. After a relatively brief period of analytic treatment, she was increasingly able to access reading and spelling skills that everyone had assumed she did not possess. Natalie made this remarkable progress despite the fact that she was not currently being tutored in reading. Before embarking on the case material, analytic perspectives on play will be briefly reviewed. The case presentation will first document the nature of Natalie’s early speech and language delays and her learning problems in order to support the diagnosis of specific reading disability before attempting to articulate Natalie’s unconscious associations to her dyslexia as they emerged in the transference. In the discussion, a multifactor model is proposed to explain how psychoanalysis, a treatment not directed at cognitive change, can enhance the capacity to learn even in cases of clearly documented neurologically based deficits. The necessity for the interpretation of unconscious conflict is integrated with the work of Lev Vygotsky, a Russian constructivist thinker and early member of the Russian Psychoanalytic society, who noted play’s dual role in helping the child to restructure cognition and embrace the constraints of reality. Review of the Literature The psychoanalytic theory of play has focused heavily on content and why only certain events (often unpleasant ones) are chosen for reproduction. Relying on Freud’s (1918) notion of the repetition compulsion as a way to bind traumatic overstimulation, Waelder (1933), defining trauma operationally as “an onslaught of more events in a



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relatively brief period of time than the immature ego can handle,” suggested that children, being passive, must suffer experiences that they cannot absorb and which they attempt to master through repetition. In addition to the disappointments of reality, play also helps the child cope with trauma generated internally, either by the upsurges of the drives or via the heightened pressures of the superego. Play aids mastery by turning passive to active. It allows the child to alter the outcome of the experience or to change his role. Rather than a suffering victim or an anxious onlooker, the child can instead be a world creator. In addition, the reenactment of an experience in itself constitutes a switch from passive to active. The observed repetitions in play allow for the fact that the child’s weak ego can master reality only a little bit at a time and are necessitated by the child’s limited capacity for verbalization and his inability to link thoughts together through cognitive work. The actual play is a compromise formation. By offering the most satisfying solution between the desire for pleasure, the demands of reality, and the conscience, play strives to make up for anxieties and deficiencies at a minimum risk of danger. Although popular notions oppose play and reality, from Freud (1918) onward (e.g. Plaut, 1979; Oremland, 1997, 1998; Ostow, 1998; Solnit, 1987) analytic writers have recognized the role of reality in shaping play. Winnicott’s (1974) notion of transitional space also suggests a role for play in the structuring of external and internal reality in addition to the interpretation of play which focuses on meaning. More recently, theorists have noted the contribution of play in the creation of new representations, suggesting that play in itself acts as a force in getting development back on track (Mayes & Cohen, 1993; Neubauer, 1993; Scott, 1998; Slade, 1994). Although this structuring role of play has been noted particularly in children with ego deficits (Cohen & Solnit, 1993), cognition and its relationship to play has been largely ignored in the psychoanalytic literature with only a few exceptions (e.g. Santstefano, 1978) Case Presentation presenting problem Natalie’s mother sought psychological testing at age 12 years and two months because of Natalie’s worsening irritable, withdrawn, and aggressive behavior both at home and at school. Natalie frequently screamed, cried, hit, and kicked. She directed these outbursts mainly at her sister, who was 3 years her junior, but also at her parents and



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peers. Shortly prior to the start of treatment, Natalie threw a butcher knife toward her sister, missing her. Natalie’s interactions with her peers at school, although far less dramatic, provoked them into antagonizing and ostracizing her. Testing resulted in a recommendation for psychoanalysis. Natalie was highly opposed to psychopharmacological intervention. developmental history Natalie was the product of a planned, uncomplicated pregnancy with an induced delivery at 41 weeks that required forceps. Fine and gross motor milestones were within normal limits, but there was a notable delay in language. Natalie did not speak her first words until 18 months or speak in full sentences until 4 years of age. Speech therapy was begun at 4 years and continued until she was 11. From early in childhood, Natalie struggled with articulating her thoughts and feelings and she was described as a highly anxious child who was needy of her mother’s attention. Psychological testing at age 8 years, initiated because of her distress over not reading, led to transfer to a specialized school for learning disabled youngsters. Medical history was significant only for seasonal environmental allergies. Menarche was at age 11 years and 10 months. Two weeks after Natalie’s birth, Natalie’s mother returned to her career full time. Natalie’s paternal grandmother moved from Eastern Europe to become Natalie’s primary caretaker, as her mother often did not arrive home until 10:00 p.m. This non-English speaking woman was stern and cold but reliable. Natalie’s father was also a constant presence. Although highly intelligent, he was an alcoholic who was unable to keep a job. Particularly close with Natalie, her father read her Greek mythology and studied American Civil War tactics and strategy with her. Natalie frequently witnessed her father vomiting and passing out in a drunken stupor. She also regularly witnessed verbally and physically violent altercations between her parents. Once, when Natalie was 7 years old, her father lay down in front of his family, held a steak knife to his throat, and threatened to kill himself. Natalie saw her mother sustain a fractured arm and, at another point, a subdural hemorrhage from father’s beatings. Father also frequently exhibited bruises his wife had inflicted on him. Natalie’s sister attempted to break up the battles by getting physically between her parents while Natalie, in sharp contrast, would run to her room and remain under her bed covers.



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When Natalie was 11 years old, her mother had the police remove Natalie’s intoxicated father and placed an order of protection against him because of verbal threats. Natalie never asked to see him. Visitations were started 6 months later because Natalie’s sister requested to see him, and visitations continued sporadically. A few months after Natalie’s father was removed from the home, Natalie’s paternal grandmother died. Therefore, she suffered two major losses simultaneously. These apparent precipitants closely preceded Natalie’s increasingly withdrawn, intermittently violent, and hypersensitive behavior which led to her mother seeking help. psychological testing Several evaluations provided ample evidence for the diagnosis of developmental dyslexia. An educational evaluation completed at age 8 demonstrated receptive and expressive linguistic difficulties rather than oromotor problems. Natalie failed to initiate a lot of language, had trouble sequencing her thoughts, and had difficulty with word retrieval and naming. Phonological processing was impaired. This skill (the ability to hear and sequence the sounds within words) is the central deficit found in reading disorders (Morris et al., 1998; Shaywitz, 2003). Natalie had poor auditory discrimination, could not identify medial vowel sounds, and had poor memory for phonemes. While she needed the scaffolding provided by a listener in order to organize her thoughts, the more object related and para-verbal aspects of communicative language (prosody, eye contact, and turn taking) were intact. In sum, Natalie met the criteria for double deficit dyslexia (Wolfe, 1999), a term used to identify children who show problems in both rapid automatized naming and phonological processing, and who, typically, are very difficult to remediate. A second evaluation, completed at age 12 years, 2 months when Natalie was in 7th grade, supported the earlier impression of a dyslexic child of average to high average intelligence, with a fairly focalized language disorder. The WISC III yielded a Full Scale IQ of 103, with a Verbal IQ of 106, and a Performance IQ of 99. The subtest scores were as follows: Verbal Scale Information Similarities Arithmetic Vocabulary Comprehension Digit Span



11 10 12 12 10 7



Performance Scale Picture Completion Picture Arrangement Block Design Object Assembly Coding



10 14 11 9 5



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Despite the apparent evenness of the major subscale scores, there was considerable variability amongst her abilities. While verbal skills ranged from the average to high average, visual perceptual and visual spatial performance skills varied from a defective performance on a task of cross modal integration to a very superior performance on a task where she has to sequence cartoon pictures of interpersonal interactions. Thus, Natalie’s ability to understand the motivational states of others, as well as to process complex perceptual material was intact. In structured settings, Natalie’s oral language was not impaired. Voice quality, pitch rate, volume, and fluency were within normal limits. Natalie’s ability to follow complex multipart directions were within the average range and her lexicon, as measured by her ability to form word classes, was average. She had no trouble processing semantic relationships and was able to answer questions about paragraphs that had been read to her. Tests of reasoning and problem solving were in the superior range. Informal assessments of oral expression were deemed normal for her age. Reading/decoding skills were several grade levels below average, as was mathematical computation, a finding compatible with a diagnosis of dyslexia as computations (unlike mathematical concepts) often tap semantic/linguistic abilities rather than the visual-spatial skills. Reading comprehension was above grade level, suggesting that the act of decoding was what barred the way to comprehension in timed settings. The qualitative nature of Natalie’s performance, her tendency to misread or skip small function words (such as the, was, or but) which are not directly representational, also spoke to the presence of a developmental reading disorder. A writing sample showed a difficulty using vowel sounds, poor punctuation, poor sequencing of sounds within words (“breath day” for birth day), and omission of sounds (“presten” for present). In short, the testing provided strong evidence of classic dyslexia with problems in decoding, spelling, and written expression. Natalie’s functioning was more compromised in ambiguous situations than in structured ones and her sparse, ten response Rorschach showed her difficulty in mobilizing her cognitive equipment in new situations. None of her responses involved a sophisticated integration of the components. The lack of human movement responses suggested that it was difficult for Natalie to utilize internalized images of others which might serve as templates for behavior or support her ability to delay her impulses. Instead, Natalie’s Rorschach resembled that of a much younger child with few content categories,



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little ability to integrate her emotional responses to a situation with a more cognitive viewpoint, and a tendency to become emotionally overwhelmed and cognitively impaired in situations of stress. course of treatment Natalie began treatment at age 12¹⁄₂. Literally within the first few minutes of treatment with her male analyst, Natalie introduced a transference theme that would be continually elaborated throughout her analysis: her need to maintain distance (particularly from men) in order to feel safe. The early manifestation of this theme took place primarily in the behavioral realm: Natalie kept her coat on during the first session, claiming she didn’t want to see a psychoanalyst because she had “other things [she] wanted to do . . . like kick boxing.” In a dramatic demonstration of her wish to be the aggressor, rather than a victim, Natalie punched her sister in the mouth on the way home from her second analytic session. Shifting identifications between victim and victimizer reverberated in her fantasy life as well, as Natalie described a music video where men on strings were manipulated by a woman puppeteer and another video where a woman who tries to leave her boyfriend is beaten to death. The analyst tied these two videos together, noting that “women better maintain control of men or they’ll end up dead.” Continuing her posture of “not getting involved” Natalie kept her coat on for the first weeks of treatment, refusing to discuss “personal stuff.” Similarly, she isolated herself with peers, voicing a desire to be unique and different from the “boring popular crowd.” When speaking of her family, Natalie expressed both despair and a wish to remain distant. For example, she claimed July fourth as a favorite holiday because “the fireworks are like paint in the sky bursting, and you don’t know what it’s going to look like.” This contrasted to all the family based holidays she hated like Thanksgiving, where “you just get a big stomach ache,” Christmas “where there’s so much pressure to get the right gift,” or the absolute worst holiday, Valentine’s Day, with its associated themes of love and kisses. Natalie then decided that she would write an article for the school newspaper entitled, “X Valentine’s Day.” She added that she wanted to “X” dating, marriage, and having babies as well. Natalie agreed with the offered interpretation that “up close, those things had not worked out so well for her.” After the third week, Natalie took off her coat, but continued to struggle against becoming absorbed in the analytic relationship. In response to an observation that she didn’t like showing off, she



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agreed that she preferred to blend into a crowd and did not like to be closely observed, alluding to her fears of being seen in the analytic encounter. During sessions, turning passive to active, she would pull her hat over her head, turn away from the analyst, or even sleep. Natalie alternated between attempts at contact and a need to lessen the amount of experienced stimulation through physical distance. She chose to sit in the analyst’s swivel chair which allowed her to sit very close by him and quickly turn away when necessary. She alternated between talking engagingly and playing catch or being by herself, remaining silent for entire sessions during which she would refuse to respond, even to direct questions. Often, “silent” sessions followed ones in which she had been particularly talkative. The analyst’s countertransference responses illuminated the nature of the conflicts aroused. He felt relieved when Natalie talked and careful not to confront her or her anger, as well as worried that he had caused her periods of retreat by being too aggressive with his interpretations. That the highly charged feelings emerging in the treatment contained sexual fantasies of seduction and pursuit was made clear when after 6 months in treatment, an analogous situation surfaced in Natalie’s school life. She excitedly reported being “stalked” by two boys in her class. When the analyst wondered out loud whether the incident might be flattering as well as scary, Natalie threw a ball harder and harder toward the analyst until it was impossible to catch. The analyst’s premature interpretation of Natalie’s underlying sexual wishes led to the fortification of her defensive strategies and a regression to action where violent, castrating wishes were expressed directly. In the following session, Natalie found a spare tie in the analyst’s closet and put it around her own neck. Gleaming with pleasure, Natalie threatened to “cut the tie” in a highly condensed metaphorical statement which included elements of castration as well as her efforts to defend against her dependency. It is also noteworthy that in moments of high affective intensity, words did not “hold” her and she quickly moved to highly symbolic and expressive actions to regulate her feelings. In addition to action, Natalie would also remove herself from the more passionate arena of verbal interaction and seek solace in a calmer visual perceptual world, painting vivid scenes of serene, inanimate content. Usually ill at ease with her desires to be seen, Natalie began to express an interest in acting. She performed Shakespeare soliloquies for her analyst and simultaneously blushed and smiled with pride at the applause he would give. At this point, Natalie’s exhibitionistic desires were not interpreted. Rather, the analyst allowed Natalie to ex-



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perience that wishes could be expressed and contained in the analytic situation without dire consequences. This stance seemed to support Natalie’s ability to tolerate previously disavowed affects. Several months later, at her beach club, Natalie began taking photographs of a 15-year-old boy she had a “crush” on. She then sold the prints for $5 each to girls at the art school where she was taking classes during the week. The analyst, exclaimed, “Now, you’re doing the stalking!” She brought in prints of this boy, drooled over them, and drew portrait after portrait of him. She was frustrated with this boy’s lack of enthusiasm with her but was determined not to let this fact get in the way of her talking and thinking about him incessantly. The analyst pointed out that it appeared as if it didn’t matter what this boy thought of Natalie. “You are the stalker. You are in control.” Natalie replied jokingly, “Hey, don’t spoil my fun.” While Natalie felt freer to express her sexual and voyeuristic interest in a peer, she remained defended against recognition of any excitement about her analyst. The reasons for this became obvious as Natalie’s experience of herself in relation to her father in particular and men in general continued to be further elaborated in the analysis in the transference. Upon returning from a vacation, the analyst was asked by Natalie to go back to Iraq where she imagined he had been playing pool and drinking beers with “your good friend Haddam Hussein . . . You’re buddies.” The analyst said, “I guess you want to keep a safe distance from a dangerous, beer guzzling, take over the world kind of guy like me.” In later sessions, she imagined the analyst was plotting with Hussein to blow up some countries. The analyst noted how untrustworthy and dangerous he seemed to her. Natalie responded. “You’re not Hussein, you’re Barney,” referring to the goofy pre-school TV character who teaches the letters of the alphabet. He was too adorable and clearly inept: “Do you see purple dinosaurs on Wall Street or at a desk getting a fax?” Natalie quipped. It was at this juncture that Natalie’s conflict around men being either dangerously abusive and exciting, or harmlessly castrated and ineffective crystallized in the transference. In another variation upon this same theme, over a year into the analysis, Natalie complained of being “stuck with ‘Mr. Tingle,’” a male version of a comedy movie character, Mrs. Tingle, a sadistic high school teacher. Natalie went on to say that she felt “You’re poking at me. Looking at me under a microscope.” The analyst said, “So I’m the teacher from hell. Forcing you to talk about things you don’t want to.” Natalie retorted, “Yeah, Mr. Tingle, and I don’t want to!”



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Natalie’s excitement became intolerable to her and she swiftly emasculated the therapist, turning him back into the ineffectual dinosaur: “Or you could be Barney, just add a tail.” A few months later, Natalie began to describe how she had always been scared of her current 8th grade male teacher because of his reputation as strict and demanding. The analyst noted that when he thought of a scary man for Natalie, her father came to mind. Natalie remarked, “I hate my father! But he’s not scary. He’s just a moron . . .” The analyst replied, “In the same way that you call your father names, you’ve called me a few.” Natalie said, “Yea, Mr. Tingle and yea, Barney.” The analyst remarked, “There seems to be two sides to me for you, this scary teacher or this wimpy dinosaur.” Natalie retorted, “You’re not scary, you’re just chubby. You’re a chubby, chubby man.” The analyst became acutely aware of feeling emasculated and pointed out, “So now you’re having more fun—at my expense, of course—with me being chubby—the wimpy Barney side of me.” Natalie laughed. The analyst further mused, “Perhaps you feel safer around my possible scary side by turning me into a chubby and bumbling dinosaur.” Natalie grinned. A year and a half into the analysis, in the context of angrily calling the analyst names, Natalie began to articulately reveal how her mother degraded her father. For example, while mother and daughters went to a beach spot during summer weekends, mother had father do menial jobs for her like walk the dogs and clean the bathtub to earn money so that he could take out his daughters with the money. Natalie got worked up thinking about how her “jackass father can’t even work at Barnes and Noble to help us out.” He’s a “goodfor-nothing drunk.” As the historical roots of her bivalent attitudes toward her father were becoming more conscious, Natalie’s mother reported that Natalie was expressing a new desire for physical contact, affection, and comfort. This contrasted sharply with her lifelong pattern of physical avoidance, withdrawal, and difficulty being soothed. In school as well, Natalie’s teacher reported that she was “blossoming,” with decreasing moodiness and impulsivity, and a lessening tendency to provoke attacks from peers. Even more curious was her teacher’s report that Natalie was beginning to absorb academic material in a new way, given that scholastic performance had not been a focus of treatment to date. As her fear and excitement about being with a man continued to be evoked, tolerated, and addressed in the relatively calm context of the therapeutic relationship, a new aspect of Natalie’s relationship to



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her father began to manifest in the transference. She started to use the analyst as a teacher, albeit this time one who remained more separate from the frightening aspects of her teacher/father. She brought schoolwork into the sessions, using the analyst as a homework helper or stayed after sessions to complete her assignments in his presence. She increasingly viewed the analyst as the nurturing father who read to her and acted as a comforting, organizing, and soothing physical presence who would sit with her quietly observing while she worked. She asked to be quizzed on vocabulary words or geographical locations. The studying was, of course, used to regulate the comfortable space between her and the analyst, helping her to defend against awareness of sexual excitement by taking an active stance. However, it was a far more productive compromise formation than merely keeping her coat on, as it incorporated elements of sublimation and identification rather than just turning passive to active. It is equally important that the studying served the adaptive purposes of learning. In short, Natalie had begun to play “the student.” In behavior typical of the “teacher game” (Ross, 1965), common in early school development, Natalie frequently switched roles and began actively examining being the “teacher” as well as the student. She would test her analyst, taking particular sadistic pleasure if he didn’t know an answer. In her outside academic life, Natalie began to shine, making particular strides in the area of written language and speech. Natalie was moved to the most challenging reading group, and other children asked to be in her group, because she was the best speller. She was chosen to represent her class at 8th grade graduation by giving the senior speech. At this point, (1¹⁄₂ years into treatment), Natalie did not hold back the excitement of her triumph at being chosen and not only practiced the speech before her analyst, but went into a blow by blow account of the audience responses. Natalie had also gradually became quite comfortable in the transference with her desires to do the “looking.” Toward the end of treatment, over 2 years into the analysis, Natalie began to avidly use the analyst as a model (primarily his hands) for her drafting class assignments. She acknowledged that this was a way of remembering her analyst. In this example, it is interesting that Natalie’s mode of internalizing the analyst still involved a concrete representation, rather than the analyst’s words or the function of reflection. However, Natalie also became increasingly able to symbolize and take a reflective stance about her learning problems. In describing George Orwell’s novel, Animal Farm, Natalie focused on Clover the horse, “who had strong feelings but couldn’t figure out how to put



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those feelings into words.” When her analyst made the analogy between herself and Clover, she was able to say that problems learning “really suck.” While Natalie was able to voice these feelings after having some academic success, clearly her analysis had been instrumental in making her educational interventions increasingly assessable. Natalie was accepted to several mainstream private schools and ultimately attended a competitive public school specialized for the arts. Natalie was very proud that she was one of the few students with learning disabilities admitted. Because of financial difficulty, Natalie’s mother requested that treatment be terminated after 2¹⁄₂ years. Natalie was thriving at school both academically and with peers. Although there was certainly more analytic work to be done around her conflicts with her mother and father, Natalie was developmentally back on track. In the final weeks of analysis, Natalie requested that the analyst teach her how to play poker. This was pleasurable for both analysand and analyst as Natalie had become a “model student.” She anticipated missing “our homework sessions.” Particularly determined to learn to shuffle, before the last session Natalie was an expert. At 12¹⁄₂ years of age, Natalie presented as a young adolescent with affective symptomatology, an oppositional defiant disorder, learning problems and a history of traumatic overstimulation. Her symptoms resulted from three interweaving factors: a biologically based learning disorder and alterations in the timing of the maturation of her speech and language, her chronically traumatic home life, and her entrance into adolescence. Exposed to a greater than normal degree of aggressive stimulation, these traumatic experiences shaped the way she perceived herself and interacted in relationships, for example via identification with the aggressor, and placed considerable strain on defenses already compromised by processing difficulties. Finally adolescence, with its heightened drive pressure further increased the demands on her stressed ego resources. Natalie’s language difficulties affected her not only in school, but throughout her development, making it harder for her to access words as a mediating force during critical periods (Migden, 1998). Offering new gratifications and connections, speech usually helps the child to master the waning symbiotic ties and the loss of the accompanying feelings of omnipotence and safety. Conceptualized thus, language is a central aspect of the separation process. For Natalie, early separation from her mother resulted both in object loss as well as the loss of an optimal linguistic environment because her English exposure was curtailed when she was cared for by a non-English



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speaking grandmother. In addition, without language, Natalie had a more limited array of impulse control mechanisms. Because she could not interpolate words as a form of trial action, it was harder for her to distance from the immediacy of a situation (Lewis, 1977). Finally, Natalie’s need for support in order to function cognitively intensified the relationship with her learning partner, her brilliant, but erratic, father. Her learning difficulties prolonged the necessity for an intimate relationship, slowed efforts at separation, and made the repression of oedipal impulses more difficult. All these factors made it more likely that the autonomous functions (Hartmann, 1954), in her case language and to a lesser degree perception, would be drawn into conflict. Given these complicating factors in Natalie’s development, how are we to understand the helpfulness of psychoanalytic intervention, particularly as it relates to her school performance? Discussion While developmental dyslexia can be conceptualized as a deficit (Winner, 2001), some children are able to make use of compensatory strategies and others are not. Psychoanalysis, with its unique observational vantage point on the question of motivation, potentially offers some answers that predictions based on the severity of neurocognitive deficits alone cannot. As analysts, we learn the specific connotations of the disability for the child by accessing the personal landscape and its presuppositions—how events, whether external ones such as the behavior of caretakers or internal ones such as the perception of bodily or intellectual processes, are woven into a web of meaning, which then become: the starting point for further causalities. Analysis is a science of subjective experience, and how one interprets neurophysiological events is imperfectly correlated with the events themselves. Like A. R. Luria (1979), who chose to humanize and make whole the most puzzling of neuropsychological entities, psychoanalysts are engaged in a “romantic science” that seeks not only to abstract general laws but to describe human ordinariness in all its glory and detail. To base an understanding of a dyslexic child solely on the delineation of the neural pathways that mediate the reading process falls prey to the same misconceptions as thinking that internal representations are isomorphic copies of real external events. Events in the outer world and those in the internal environment meld, with neurophysiology and the transactions around the developmental crises of childhood mutually influencing each other



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in a manner that is truly individual and not easily subject to regular laws. While it is possible to argue that Natalie’s improvement in reading was due to an increased ability to use contextual cues that accompanies adolescence, it is not usual for spelling skills to improve. Along with slow reading speed, spelling difficulties remain one of the indicators of compensated dyslexia. It is our argument that the analysis allowed Natalie to access skills that had been acquired during previous remediation efforts, but had remained dormant or blocked by conflict. The literature offers numerous general statements about the psychological functioning of dyslexic children. For example: they are more vulnerable to states of overstimulation which generates trouble with impulse control and difficulties with affect regulation (Arkowitz, 2000); suffer poor self esteem and alterations in their object relations (Migden, 2002); and have a tendency to rely on weaker or more primitive defensive structures (Rothstein & Glenn, 1998). All of the above general statements are to some degree true about Natalie, but what is more salient is that her inability to learn, or to retrieve what she knew, was also a way of warding off an affective awareness of the traumatic overstimulation of events with her father. the association of learning with conflict and the regulation of affective intensity While defending against sexual excitement with aggression is typical of early adolescence, in Natalie’s case, this defense was also supported by experiences with her father which had left her feeling that men were violent and untrustworthy and should be responded to in kind. For Natalie “knowing” became drawn into conflict when she saw her father (her teacher) act violently toward her mother. Learning became connected with sadomasochistic fantasies about sexuality. Additionally, his threatening to kill himself right around the time she was learning to read may have functioned as a specific trauma which further interfered with the development of automaticity in reading. Given the mind’s tendency to associate like-valenced affects, Natalie was unable to learn because of the disruptive effects of what she experienced as her father’s seductiveness, her own excitement, and her aggressive responses. As learning became libidinized, there was an inhibition of function, which led to her trouble with looking as well as with its opposite—exhibiting. She was able “not to know” and “not to see” because to know and to read would unconsciously lead to the relationship with her father,



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about which she wished to remain blind. The defensive efforts that interfered with retrieving memories of her father’s frightening violence and the painful affects they would arouse also interfered with other information that for associative reasons shared the same “address” (Westen & Gabbard, 2002). Although unconscious, the memories remained in a state of activation that accounted for their continuing effects. In Natalie’s case these events, associated with the process of learning, affected her motivation to learn. Natalie’s dyslexia came to function as an anlage, a model based on constitution around which the defenses can crystallize. Not knowing became a defense; in choosing it as a defense, she also turned passive to active. These dynamics were revealed when they were re-externalized in the transference which, because of its connection to affect, functions as a powerful anamnestic tool. In the analysis, Natalie was thrilled and repulsed by sexuality and furious at being reminded of her interest. The Janus faces of Mr. Tingle and Barney explicate Natalie’s repeated experience of intense excited attachment coupled with fears/desires of being attacked/attacking. Natalie experienced pleasure both as the terrorized girl and as the emasculating female. Of significance is that both Barney and Mr. Tingle were teachers, one sadistically drilling facts into her, the other an emasculated and useless wimp. Becoming a “student” and learning was either dangerously exciting or doomed to devastating disappointment. Natalie’s fusion of sexuality and aggression is determined by her age, but also by her history. “I don’t love you,” she says, as she kicks her male analyst. “I don’t love you,” she says to her father as she fails to learn to read. It was harder for Natalie to use language as a tool to abstract and distance herself from her experience. She alternated between excitement, talkativeness, and silence. When she could not talk, she withdrew into a world of art work. Natalie’s neurophysiological weakness left her with a tendency to focus on the non-linguistic aspects of the environment; she had a strong reaction to tone and prosody in language and maintained a strong attachment to the visual world where she could retreat when her affective stability was disrupted. She also regressed to action as a mode of expression. The analysis allowed Natalie to access language for what had been inchoate and in so doing to connect a variety of associated, previously unconscious memories into cognitive structures. When her conflicts with the father were repeated in the transference and interpreted, Natalie was able to “look” and to learn, to spell and to remember. She was helped, through the mechanism of the transfer-



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ence to work through the exhibitionistic and voyeuristic wishes that were tied into reading and learning. What was implicit memory became explicit. While part of the explanation is that she no longer needed to use so much of her available energy for defense, her improvement can be understood in other terms than as a transfer of energy within the ego system. a hole is to dig: play as a tool of cognitive structure Up until this point, our understanding of how analysis helped Natalie’s cognitive functioning has relied on an understanding of conflict and the use of interpretation to understand her play. Vygotsky (1933/1978) offers an additional perspective, suggesting that play aids structuralization by allowing a child to become less tied to situational constraints and to act independently of what he sees. To a young child, perception cannot be separated from meaning, motor activity, or motivation. Thus, an object is what it is used for, or even the context in which it has been used. One prosaic example: a 2¹⁄₂ year old child hears his mother curse when she accidentally dents her car by backing into a mail truck. The next day the child, sitting on his ride-on toy, curses as he pedals backward. Very matter of fact, he explains to his shocked nanny, “I’m backing up. I say ‘Fucking damn it’” as if the curse were simply part of going in reverse, rather than representing an angry feeling. This connection between an object and its context was more poetically articulated by Ruth Krauss and Maurice Sendak, when they tell us “A Hole is to Dig,” in their classic children’s book: A First Book of First Definitions. In play, however, objects will inevitably have novel uses and the same object will have multiple uses. Krauss and Sendak understood this developmental point as well. Over the course of their book a hole changes from something that is “to dig” to “something you could hide things in,” or “sit in” and “a place for a mouse to live in,” a thing “to look through,” and “when you step in it, you go down.” As multiple connections, varied perspectives, and experiences with objects accrue, they form new grids of meaning separate from any one action and there is a consequent shift from action to semantics. Vygotsky’s conception is virtually identical to Rappaport’s (1951) description of the shift from the drive-organization to the conceptual organization of memory. Initially, to a child, a word is part of the object it names: the word “ice cream” causes the child to see, to taste the food behind the sounds. In play, however, a dust mop can be “Black Beauty”; using the



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old object in a new way acts as a pivot to disentangle perceptual qualities or action done on the object from the meaning of the object. At first, the play object must share some similarities with the represented object (i.e. the mop is “Black Beauty” because you can ride it between your legs), but gradually, semantic qualities come to override perceptual ones and the word “horse,” which bears no similarity at all, even to the “Black Beauty” mop, can be used to represent horse in the creation of stories about horses. These shifts can be described at any one time as the product of a ratio between object/ meaning and action/ meaning. As the meaning of the object and its place in the play narrative becomes central and the perceptual qualities of the object become subordinate, the child becomes able to exist above the field for a moment, capable of stepping back. Vygotsky parallels this shift to the change in the child’s ability to observe his oral language after acquiring grammatical forms and written language. A vital transitional stage toward operating with meanings occurs when a child first acts with meanings as with objects (as when he acts with the stick as though it was a horse). Later, he carries out these acts consciously. This change is seen too, in the fact that before a child has acquired grammatical and written language, he knows how to do things, but does not know that he knows. . . . Thus, through play the child achieves a functional definition of concepts or objects and words become parts of a thing. (Vygotsky, 1978, p. 99)



In this way, play allows the meaning of a situation (both conscious and unconscious) to emerge more fully and then, translated into action, to become amenable to thought and self reflection. In their usual prescient manner, Krauss and Sendak end their book of first definitions with “A book is to look at,” thus intuiting the parallel that Vygotsky makes consciously between play and the acquisition of skills which allow for the extraction of meaning from text. In Natalie’s case, the process of learning is associated with the context of her excited, but threatening relationship with her father. When she begins the analysis (in itself a type of learning situation, which children frequently confuse with school) she reacts as she does to all men/teachers and is unable to take anything in from the analyst. She responds to his verbal interpretations in action; she cuts his tie, turns away from him, or hits out at others. The fact that the analyst does not respond to her provocations or collude with the underlying unconscious fantasies (i.e. that men will frighten and violate) allows the original context of her fears to emerge. She is helped by the relatively calm affective climate that develops as the analyst allows



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Natalie to titrate the level of stimulation so it remains tolerable to her. As Natalie begins to separate her image of the analyst from that of her father and gradually to separate the act of learning from the context in which it originally took place, she becomes able to use the analyst’s words in a new way. As language gains ascendancy over action, she is able to make increasing use of his interpretations. Natalie’s ability to use the analyst develops in tandem with a change in her play. Early on, Natalie is unable to symbolize. Emotion is expressed in action and there is no “as if ” quality to her involvement in the transference. Her defensive strategies consist mostly of instinctual vicissitudes such as turning active to passive and reversal. Over time, her responses become increasingly sublimated and distanced from her physical body, eventuating in her story about Clover, with whom she shares a partial identification as being unable to put his feelings into words. A second central point in Vygotsky’s work is that play is intimately tied to reality and the development of self regulation. Vygotksy would agree that symbolic play includes an aspect of wish fulfillment as play develops at the time that the child becomes aware of desires that can neither be immediately gratified nor forgotten. However, he was not focused on motivation in the psychoanalytic sense of hidden desire nor the need to deny reality through imagination. For Vygotsky, motivation is the bridge between a nascent developmental achievement and its final form. Because imaginative play evolves into play with rules, Vygotsky started his investigation searching for the origin of this trajectory, noting that in all play the child invokes rules—the rules of role based behaviors as the child has observed them. The child is literally “playing with reality” (Vygotsky, 1978), by trying on the actions that define important others, such as mother, dentist, teacher, or student. Only actions that fit these roles will be acceptable to the play. During the act of play, rules of behavior which are observed and imitated but not necessarily conscious or available to reflection are made conscious and explicit. They can then be internalized and used for self regulation and delay. Thus, play is instrumental in the acceptance of the demands of reality. In analytic terms, it promotes the development of the superego by furthering the creation of an internal agency which guides the child’s behavior so that prohibitions are no longer imposed only from the outside. While the child would not participate in play if it did not involve pleasure, now the child willingly subordinates himself to the rules of reality and renounces immediate gratification as a new form of desire develops—to act in accordance with the rules. Now



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the child’s desire centers on her role, on a fictitious “I” that relates to the rules of external reality and takes them in, making them her own. In Natalie’s analysis, this development is seen most clearly in her teacher play. As Ross (1965) notes, the teacher game allows both object cathexis (of the teacher by the student) and identification (with the teacher’s role) and employs these psychic mechanisms interchangeably. In this way the process of learning can be separated from fixed roles and internalized. In play, the child acts ahead of her average age. Thus, play exists in the child’s zone of proximal development, offering a measure of the difference between the child’s actual developmental level and her potential. In this zone, functions such as abstract thinking and the child’s relation to reality are in the process of maturing. The areas where play is essential, namely in the development of abstract, semantically dominant, and more emotionally distant attitudes, are also those which analytic writers have noted to be impaired in dyslexic children. Conclusion It is our contention that play in analysis functions in essentially two ways for language based learning disabled children. First, learning disabled children, with their increased need for external cognitive support and structure, find it more difficult to separate from figures that are associated with learning, and learning is more likely to become entwined with conflict. Undoubtedly, even in the absence of an aggressive father, learning is an everyday trauma inflicted by parents and teachers on a daily basis. Therefore, play in analysis must initially function in the transference to externalize and interpret conflicts associated with learning. If this task of working through in the transference is successful, then the child is able to make use of play for purposes of learning and for the development of cognitive structures where meaning is super ordinate to the immediate perceptual situation. This offers the opportunity to separate objects from the actions done upon them and ultimately to distinguish meaning from action, thus allowing the child to take an abstract attitude. This development, in itself, provides remediation for one aspect of the dyslexia, the difficulty separating context from more abstract bits of knowledge. Secondly, play in analysis functions to enable the child to join the analyst in becoming learning partners where roles of “student” and “teacher” are tried on, rehearsed, and eventually internalized. Several authors have noted this common type of play in learning dis-



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abled children, a play very close in nature to reality (Cohen & Solnit, 1993). It has been suggested that in addition to functioning as an object in the service of transference repetition, the analyst also functions in a role as a new object which has some overlap with teaching (Freud, 1974; Wilson & Weinstein, 1996; Weinstein, 2002). This teaching role allows for the internalization of insight. Both aspects of the analytic role are heightened and intertwined for the dyslexic child. As the analyst functions as an object in the service of repetition, conflicts around learning will be re-evoked as the traumatic situations accompanying learning come closer to consciousness. Once these conflicts are interpreted, as they were with Natalie, then the child can begin to use the analyst as a partner (new object) in play/learning. During this phase, interpretation is probably less required, as the child is finally able to make use of play for cognitive structuring and for developing a decontextualized abstract attitude. These skills are notably essential for learning to read as well as other modes of symbolization. Beyond the mutative aspects of interpretation, by allowing Natalie to titrate the level of stimulation, the analytic context also supported her ability to access knowledge she already possessed. Thus the analyst acted neither exclusively as a developmental new/real object nor as transference object, but as both depending on the context of the treatment at any one point. Although it is beyond the scope of this paper to offer technical prescriptions, some differences in the way play and the analytic context may function for learning disabled children should be highlighted. First, learning disabled children may need to play beyond the usual age than that of other children, both inside and outside of the analytic context. In the context of the analysis, play that might traditionally be considered resistance (i.e. doing homework in the sessions) may, in fact, be a sign of progress in the treatment and essential in the remediation of the learning problems. Third, although it would be impossible to judge whether the nonverbal aspects of the interaction are more salient than the interpretive ones, a possibility suggested by the Boston Change Process Study Group (2002), it is clear that the regulation of a tolerable state of affective stimulation becomes necessary before the analytic work can take place. Finally, interpretation is most successful if geared to the child’s cognitive abilities, either by adjusting one’s use of syntax, using shorter words, or even allowing for an enhanced role for action in the treatment. The necessity for factoring in the child’s level of cognitive development in the formulation of interpretations as well as the interrelationship be-



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tween language development and the child’s ability to reflect on her own actions and feelings has earlier been discussed by Lewis (1977), although he did not apply his findings directly to learning disabled children. Combining the analytic and the Vygotskian notions of play potentially offers a more comprehensive picture of the nature and utility of play for the learning disabled child. First: play is pleasurable. It allays anxiety by turning passive to active or by changing the outcome of traumatic situations through the transference. Second: play allows the learning disabled child the space to take in the reality of the outside world—to play the “student,” to learn the difficult spellings and phonemes. As part of the fictitious “I” in play, she can work hard at something without humiliation, she can begin to learn the part of “the student” “I” who can fight against great odds, by “borrowing” the strength of the characters in play. Through play, the transference sets up a new possibility for separating action from meaning. The tie between perception and meaning is ineluctable to a young child, and probably even in an older child under situations of stress or high affective tone, which engender regressions. Learning as an act can now be separated from its situational constraints. The child can begin to think about learning, to think about thinking. As the implicit meaning is analyzed, play can move from the pathological to the normative. BIBLIOGRAPHY Arkowitz, S. (2000). The overstimulated state of dyslexia. JAPA 48:1491– 1520. The Boston Change Process Study Group (2002). Explicating the implicit: The local level and the microprocess of change in the analytic situation. Int. J. Psychoanal, 83:1051–1062. Cohen, P. & Solnit, A. (1993). Play and therapeutic action. Psychoanal. Study Child, 48:49 –66. Freud, A. (1974). The Writings of Anna Freud, Vol. I. Introduction to Psychoanalysis. Lectures for Child Analysts and Teachers. New York: IUP. Freud, S. (1918/1955). Beyond the Pleasure Principle. S.E. 17. Garber, B. (1988). The emotional implications of learning disabilities: A theoretical integration. Annual of Psychoanalysis, 16:111–128. Garber, B. (1989). Deficits in empathy in the learning disabled child. In Learning and Education: Psychoanalytic Perspectives. K. Field, B. Coheler, F. Woo, eds. Madison, Conn.: IUP. Giffin, M. (1968). The role of child psychiatry in learning disabilities. In Progress in Learning Disabilities. New York: Grune & Stratton. 1:62– 82.



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Krauss, R. & Sendak, M. (1952). A Hole Is to Dig: A First Book of First Definitions. New York: Harper and Brothers. Lewis, M. (1977). Language, cognitive development and personality. J. Amer. Acad. Child Psychiatr., 16:646 –658. Luria, A. R. (1979) The Making of Mind: A Personal Account of Soviet Psychology. Cambridge, Mass.: Harvard University Press. Mayes, L. C. & Cohen, D. J. (1993). Playing and the therapeutic action in child analysis. Int. J. Psychoanal., 74:1235 –1244 McCandliss, B. & Noble, K. (2003). The development of reading impairment: A cognitive neuroscience model. Mental Retardation and Developmental Disabilities Research Reviews, 9:196 –204. Migden, S. (1998). Dyslexia and self control: An ego psychoanalytic perspective. Psychoanal. Study Child, 53:283 –289. Migden, S. (2002). Self-esteem and depression in adolescents with specific learning disability. Journal of Infant, Child and Adolescent Psychotherapy, 2:145 – 160. Morris, R., Stuebing, K., Fletcher, J., Shaywitz, S., Lyon, R. G., Shankweiler, D., Katz, L., Francis, D., & Shaywitz, B. (1998). Subtypes of reading disability: Variability around a phonological core. Journal of Educational Psychology, 90:347–373. Neubauer, P. B. (1993). Playing: Technical implications. In The Many Meanings of Play. A. J. Solnit, D. J. Cohen, & P. B. Neubauer, eds. New Haven: Yale University Press, pp. 44 –53. Oremland, J. (1997). The Origins and Psychodyanmics of Creativity: A Psychoanalytic Perspective. Madison, Conn.: IUP. Oremland, J. (1998). Play, dreams, and creativity. Psychoanal Study Child, 53:84 – 93. Plaut, A. (1979). Play and adaptation. Psychoanal Study Child, 34:217–231. Rappaport, D. (1951). The Organization and Pathology of Thought. New York: Columbia University Press. Ross, H. (1965). The teacher game. Psychoanal Study Child, 20:288 –297. Rothstein, A. & Glenn, J. (1998). Learning Disabilities and Psychoanalysis. New York: IUP. Rourke, B. P. (Ed.) (1985). Neuropsychology of Learning Disabilities: Advances in Subtype Analysis. New York: Guilford. Santostefano, S. (1978). A Biodevelopmental Approach to Clinical Child Psychology. New York: Wiley. Scott, M. (1998). Play and the therapeutic action: Multiple perspectives. Psychoanal Study Child. 53:94 –101. Shaywitz, S. (2003). Overcoming Dyslexia: A New and Complete Science-based Program for Reading Problems at Any Level. New York: Knopf. Slade, A. (1994). Making meaning and making believe: Their role in the clinical process. In Children at Play: Clinical and Developmental Approaches to Meaning and Representation. A. Slade and D. P. Wolf, eds. New York: Oxford University Press.



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Solnit, A. (1987). A psychoanalytic view of play. Psychoanal. Study Child, 42:205 –222. Vygotsky, L. (1933/1978). The role of play in development. In Mind in Society: The Development of Higher Psychological Process. Cambridge, Mass.: Harvard University Press. Waelder, R. (1933). The psychoanalytic theory of play. Psychoanal Q, 2:208 – 224. Weinstein, L. (2002). Transference and the developmental context. Psychoanal Study Child, 57:355 –376. Westen, D. & Gabbard, G. (2002). Developments in cognitive neuroscience: I. Conflict, compromise and connectionism. JAPA, 50:1– 97. Wilson, A. & Weinstein, L. (1996). The transference and the zone of proximal development, JAPA, 44:167–200. Winner, E., Von Karolyi, C., Malinsky, D., French, L., Seliger, C., Ross, E., & Weber, C. (2001). Dyslexia and visual-spatial talents: Compensation vs deficit model. Brain and Language, 76:81–110. Wolf, Maryanne (1999). What time may tell: Towards a new conceptualization of developmental dyslexia. Annals of Dyslexia, 49:3 –28.



A Girl’s Experience of Congenital Trauma The Healing Function of Psychoanalysis in the Adolescent Years SILVIA M. BELL, Ph.D.



This paper addresses the centrality of conflict in psychic trauma, as evidenced in the psychoanalytic treatment of an adolescent girl with a congenital life-threatening and disfiguring condition that necessitated multiple surgical procedures in early childhood. The focus is twofold: to elucidate certain characteristics of analysis in the adolescent phase that promote the integration of early trauma; and to shed light on the modes of therapeutic action of psychoanalysis. Case material is presented indicative of the psychic consequences of early medical traumata, including the impairment of the ego’s capacity to utilize anxiety as a signal function that mobilizes defense, the failure of repetition to effect mastery of the trauma, the predominant use of aggression in the interest of defense, and distortions in self and object representations. The author offers evidence to show that conflicts over aggression and oedipal desires, characteristic of adolescent girls who have not been subject to trauma, were involved in the defensive function of her paTraining and Supervising Analyst, and Associate Supervisor in Child and Adolescent Analysis, Baltimore-Washington Institute for Psychoanalysis; Clinical Assistant Professor of Psychiatry, University of Maryland School of Medicine. I gratefully acknowledge the invaluable contribution of my discussions with Dr. Alan B. Zients, whose insight and support were instrumental in my treatment of this patient. I thank also Drs. Boyd Burris and Charles Brenner for their thoughtful critique of an earlier version of this manuscript. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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tient’s pervasive sense of defectiveness. She postulates that the interpretation of conflict and defense is the analyst’s attuned response to the mind of the patient, and points to the resulting increase in the capacity to observe and to exercise volitional control over heretofore unconscious, automatic mental processes as evidence of the mutative function of dynamic interpretation. in a recent publication, harold blum (2003c) reminds us that psychoanalysis began with the concept of psychic trauma. The classic definition (Freud, 1926) emphasizes a psychic state that results when the ego has been flooded and overwhelmed by stimulation emanating from danger, be it internal or external. Psychic trauma, then, refers to the experience of the ego which is helpless to cope with a state of excitation that has annihilating power. Trauma can be caused by an exceptional event, taking place at a particular point in time, or it can be an ongoing life circumstance. In either case, it has an organizing effect. Memory of the trauma is registered both consciously and unconsciously. Blum states that it “has both verbal and non-verbal elements, the latter reflected in sensory, affective, motor, actingout, and somatic phenomena” (p. 418). When the trauma is imposed by congenital conditions, it inherently marks the development of the ego and of object relations. “It is important,” cautions Blum, “to differentiate the traumatic event, the internal traumatic situation, and posttraumatic sequelae” (p. 416). This speaks to the central role of the child’s internal experience of the trauma, which is represented in unconscious fantasy, as it marks subsequent development and affects adaptation. While the benefit of psychoanalytic treatment for patients with a history of trauma is unquestionable, the nature of therapeutic action in psychoanalysis has been the focus of active controversy. One aspect of disagreement that surfaced in a recent publication (IJP, 2003), centers around whether the mutative function is inherent in the analysis of transference and in “genetic interpretation and reconstruction of the unconscious conflicts and trauma of childhood” (Blum, 2003a, p. 500), or whether change results from the experience of “self with other,” where “the crucial component is the provision of a perspective or a frame for interpreting subjectivity” (Fonagy, 2003, p. 506). In the first, or traditional conceptualization, interpretation and reconstruction, though inexact, play a crucial role in the process of addressing “the best possible approximation to the patient’s unconscious fantasies and the traumatic realities of life” (Blum, 2003a, p. 512). While not excluding the therapeutic effect of



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the patient’s experience of safety as the trauma is revisited in the presence of the nonjudgmental figure of the analyst, the emphasis is on “the analysis of unconscious retarding and inhibiting forces” that are inherent consequences of trauma (ibid.). The second view, expounded by Fonagy (2003), emphasizes instead the “deep exploration of subjectivity from alternative perspectives” that the patient has heretofore not had “ready conscious access to apart from the analytic encounter” (p. 506). This view privileges the importance of implicit, that is, non-declarative, memory representations from past relationships. Dynamic (i.e., intrapsychic) conflict is not considered pathognomonic, and reconstruction of past trauma is significant only to the extent that it leads to generating a coherent historical self-narrative. The “curative” aspect of psychoanalytic treatment is ascribed to “the process of reworking current experiences in the context of other . . . perspectives”(ibid., emphasis mine), which results in “the active construction of a new way of experiencing self with other” (Fonagy, 1999, p. 218). Psychoanalysis works by effecting changes in implicit relational structures that represent “non-conscious” influences of the past on the present. It is the analyst’s “attention to the patient’s currently repudiated feelings in the analysis” (Fonagy, 2003, p. 507), rather than the interpretation of their unconscious derivatives, that promotes intrapsychic reorganization. This paper discusses the psychoanalytic treatment of an adolescent girl born with a life-threatening, disfiguring congenital condition that necessitated multiple surgical interventions in childhood. The focus is twofold: to elucidate certain characteristics of analysis in the adolescent phase that promote the integration of early trauma; and to shed light on the mutative aspects of a psychoanalytic intervention that focuses on the interpretation of conflict/compromise. Clinical Presentation I first met Beccah when she was 14. She came to our scheduled appointment dressed in Spandex running shorts and a sports bra. She approached me quickly with a broad smile when I greeted her in the waiting room, and made a point to bring her face very close to mine as she went past me to enter the consultation room. Before sitting down, she faced me and asked, “Can you tell?” “Tell?” I asked. “Yes, can you tell that I’ve had something wrong with my face?” In response, I said that that seemed to be very much on her mind. “Yes,” she said, “I’ve had surgery on my lip and my face many times, and a lot of work on my skin.” This launched her into a description of her



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history of many surgical interventions aimed at repairing and reconstructing her features as a result of disfiguring birth defects. Her initial, rather provocative “take charge” attitude, clearly a reaction to defend against the anxiety that our meeting stirred up in her, turned into a description of experiences of early trauma, that impressed me for its balance and forthrightness. She reflected on her fear of pain and hospitalizations (“I’ve had to weather it for my own good.”); on her endurance of rejection (“It’s amazing how much I’ve changed, and I still remember how it feels being looked at funny.”); and on the difficult relationship with her parents (“My parents don’t know how to work things out. My mother cries about me, and all I want is for her to feel proud of me”). She spoke, with embarrassment, about her concern that she “does not know how to handle boys,” and described her conflict about an intense neediness for attention that rendered her vulnerable (“I know that I need to please, especially boys, because it’s so important that they like me. So maybe if someone were to force himself on me, I might not be able to stop him.”) This rather dramatic first meeting, revealed key elements of Beccah’s adaptation that remained central considerations for the duration of our work. Beccah presented as an attractively built, vivacious adolescent whose pretty eyes and bright expression diverted attention away from the minor remnants of her previous deformities, now confined to relatively unobtrusive facial scarring and skin discoloration that she ameliorated with the skillful application of make-up. She behaved as an action-oriented young lady, who took charge of the session; in particular, of the impact she wanted her appearance to make on me. While there were no obvious physical signs of what had been, for much of her childhood, a salient appearance, now it was her manner and style that cut a striking figure. In this session, she gave a coherent autobiographical account that included the consciously stored aspects of her painful childhood, and she was self-reflecting enough to include observations about her feeling states and motivation—she had experienced fear and pain “for her own good.” She expressed a wish to confide in, even seek nurturing from me, as she spoke of her compromised sense of confidence in light of her early experiences of rejection. As feelings of defectiveness and hopelessness surfaced, she turned to chastising thoughts about her mother, who was not able to express a sense of pride in her, in a defensive maneuver that helped to regulate affect. In these respects, she was responding like a well-functioning adolescent. However, the exposure in her manner of dress and her confrontational style evinced a deeper struggle marked by self-conscious-



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ness, insecurity, and vulnerability to deep narcissistic hurt, that was revealed in her question, Can you tell? In fact, her actions upon first meeting me were an attempt to master anxiety that also expressed her conflict—she was exposing herself actively to avoid the pain she expected in the form of rejection from me, and masking her sadness and anger in a casual, yet “tough” demeanor. There was a readymade transference to me as “judge”—the female who, like the mother, would scrutinize her with a critical eye. She reacted by assuming a provocative, almost oppositional posture—she came dressed as she wished, not as she might be expected to look, rushing toward me, yet ready to run away. As we would discover together, there was a deeper meaning to her question about whether I could tell. Her question revealed her own confusion around internal representations, which rendered her vulnerable in relationships with others: she couldn’t tell. Beccah was aware that she couldn’t get away from “remembering how it feels being looked at funny.” Despite the cosmetic success that had changed her external appearance, unconscious aspects of her internal experience prevented her from integrating a healthier image of herself. She exposed her new female body, but she spoke of her sense of defectiveness and of her fear of sexuality. Her presentation communicated an almost desperate need to figure out what others thought of her now, as she sought to make sense of the confusing images of herself, past and present. In a shift expectable in adolescence, she made clear that her longing search for mother’s admiring gaze had now turned to seeking acceptance in the eyes of a boy. history Beccah was born in an Eastern European country, with facial deformities and serious birth defects, including complete cleft lip and palate, and multiple benign soft tissue tumors which involved the face, the vascular system, and obstructed the airways and bowel. Her parents, both professionals who had been educated in the United States and counted many friends and relatives here, recognized that her medical needs would be extensive, and took immediate action to relocate. Indeed, Beccah required multiple surgical interventions in the first four years of life, and her condition was considered life threatening. Her medical status stabilized after age five, and she was essentially healthy thereafter. However, she underwent staged periodic facial cosmetic surgery between the ages of five and twelve to approximate a normal appearance. These interventions became less



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invasive as she grew older but represented, nevertheless, an inescapable specter in her childhood experience. Infancy was a highly stressful period for mother and infant; Beccah had projectile vomiting, cried excessively and had poorly regulated sleep-wake cycles. As her rhythms stabilized in her second year, the relative respite from anxious concern over her status was periodically broken by emergency hospitalizations for various complications in vital organ systems. Despite Beccah’s medical history, the parents reported an otherwise normal accomplishment of developmental milestones. Beccah was a charming, active little girl in early childhood—a stoic patient who seemed to find the strength to maintain a sense of relatedness toward others, and the resilience to tolerate her hospitalizations. Periodically, however, she had angry outbursts, was demanding, and not easily soothed. A maternal aunt, who lived in close proximity, provided daytime care for her since infancy, given the mother’s decision to pursue her career. Beccah turned to her aunt for comfort, and experienced her as a refuge when she felt embattled with her parents. Beccah’s developmental history would have been considered unremarkable, were it not for the enormous achievement it represented for this little girl to function competently, academically, and socially, through the grammar school years. Beccah was the older of two children. Her brother, four years her junior, was described as healthy, aggressive, and irreverent like his father. Beccah took pride in being “the smart one,” whose academic accomplishments far surpassed his. The children shared an interest in sports, in identification with the father, and there were no obvious conflicts between them. The father was a self-acknowledged “no-nonsense person,” who wanted his children to be strong and active. Threatened by Beccah’s history of damage and suffering, he focused on his daughter’s present status and denied the psychological impact of her early appearance and medical vulnerability. His affirmation that there was “nothing the matter with Beccah now,” obviated what comfort this conflicted girl might have garnered from his seemingly supportive comment, since it was delivered by way of a complaint: “What is her problem? She looks fine!” He railed at his wife for “making too many excuses for her,” and it was clear that Beccah was at the center of marital conflict. The mother, more attuned to her daughter’s emotional distress, was the one seeking psychological help for her. She had the competent demeanor of one experienced in the handling of emergencies, but she could verbalize her awareness of underlying anxiety and conflicted feelings about this child who had “brought so much trauma”



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into their lives. She was undergoing psychotherapeutic treatment to address “a pervasive sense of guilt” that interfered with her relationship with her daughter. She felt close to Beccah, able to understand, nurture and comfort her, but also felt overwhelmed and entrapped by the requirements of her care. She acknowledged that she had returned to work as a respite from trauma; yet she had been available to support Beccah as she endured the uncertainties, repetitive invasive interventions, and frustrations of her medical condition. The mother was deeply pained by the undercurrent of anger which surfaced in periodic outbursts between them, and she expressed a wish to soothe and promote her daughter, whom she experienced as “masking pain with anger.” With the onset of prepubertal changes at age ten, Beccah’s behavior deteriorated. She became defiant at home, caused fights with and between her parents, and resisted doing her school work. After evaluation by the school psychologist, she underwent once-a-week psychotherapy for one year, with noticeable improvement in her mood and conduct. Since menarche at age 12, Beccah had once again become unmanageable. She was neglectful of her academic work, got into fights with her friends, and had become sexually provocative— she dressed in tight, revealing clothing, wore a lot of make-up, and “threw herself at boys.” Nevertheless, she continued to devote herself to her passion—horseback riding. In fact, she had demonstrated substantial equestrian ability and had won many ribbons in competition. However, the parents felt that she had no awareness of real danger, and she seemed constantly to put herself at risk. It was this recognition that lent urgency to their request for help once more. treatment An extended evaluation was undertaken, to explore Beccah’s capacity to tolerate anxiety and regression prior to the recommendation for analysis. As is characteristic of individuals who have suffered early trauma, Beccah experienced anxiety as a sudden and intense onrush of affect, which felt disorganizing. She defended against this feeling by taking counterphobic measures—that is, she exposed herself to the very situation she dreaded so she would not be surprised by it. The affect would be further moderated through primitive denial, or isolation—she would purport not to feel anything at all. I noted with concern, a pervasive tendency to repeat trauma by creating sadomasochistic relationships wherein she identified with the aggressor, but also experienced the victimization of being the object of abuse.



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She seemed to need to relieve a pervasive sense of defectiveness through impulsive action that imperiled her safety. It became clear that the nature of her conflicts required a more intensive intervention that would promote the development of her capacities for introspection, and provide her with the opportunity to integrate her chaotic early experience. Beccah had established a therapeutic alliance with me by the time that we started psychoanalytic treatment, ten months after our original meeting. Beccah responded to the intensification of the treatment by becoming more conversational and less introspective in a defensive maneuver to maintain distance from affect. My indication that we would meet four times per week felt like an increased interest in her—an approach that triggered anxiety at an unconscious level. In a displacement of the conflict, she developed a fascination with a boy. She had picked him up at the beach after he made “an obscene remark about her body.” In her sessions, she recounted the details of their interaction, which took place primarily over the phone. This behavior was a compromise that allowed her to counter the regressive pull generated by the analytic experience, as she talked excitedly to me, about him. She phoned him repeatedly, hounding him with demands for attention, and stimulating him with seductive stories about her provocative behavior. His tough manner and provocative sexual comebacks fascinated and terrified her, and triggered a defensive identification with the aggressor. She developed a verbally abusive stance towards him, demeaning his socioeconomic status and his academic ability. He became “a good-for-nothing, with no culture and no morals.” This relationship was an enactment of her experience of past relationships, which she expected would be repeated with me. Whereas she had often felt victim to surprise and hurt in response to the reaction of others, now she created a sadomasochistic entanglement in which she exacted and suffered pain and humiliation. The excitement generated in the interaction defended against her belief that “no nice boy” (or “nice doctor”) could genuinely like her, and against the dread that the wished-for closeness was inevitably linked to abuse. A relationship with a boy she regarded as more defective than she was, ameliorated the sense of being damaged and “bad” that was exacerbated by my recommendation to increase the frequency of our sessions. In fact, whilst she consciously regarded me as a trustworthy confidante, her relationship with this boy expressed in displacement her unconscious fear of what would happen between us—we would hurt and disappoint each other.



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These complex dynamics needed to be addressed gradually. My early interventions aimed to help her to observe her affect in relation to her actions, and to begin to consider her use of defense to regulate her internal state (turning passive into active, and identification with the aggressor). “When a boy notices you, something happens inside and you feel that you need to find out what he thinks of you. Maybe you rush to find out, to stop yourself from worrying.” She replied insightfully, “When I get attention, I don’t know what I feel; I can’t figure it out; I can’t make sense of myself or what is going on.” In this early period, rather than explore directly the nature of her fantasies and self- and other-representations, the interventions aimed to help her to consider her sense of confusion. We noted not only the disorganizing quality of her anxiety but also its genetic aspect: “Not knowing how you feel now may be showing us what it was like for you when you were little, and you couldn’t figure out what kind of attention you were getting.” Thinking about her experience in the past created a respite from the intense anxiety generated in the moment, and thus it facilitated her capacity to observe her internal state. Mindful of her observation in our first session that she had had to weather fear and pain for “her own good,” a statement referring to elective but “necessary” painful cosmetic surgery, I reconstructed that sometimes it was hard for her to distinguish whether the attention she gets is helpful or destructive, because in the past even good attention was tied up with so much bad feeling. She reflected, “I’ve had to put up with so much pain, I never know whether the pain is for my own good or not. Maybe I don’t want to think about it.” The internal confusion she experienced when she was the focus of attention was an automatic reaction based on past experiences that were encoded in implicit, non-verbal memory. However, Beccah was also inhibited by unconscious conflict pertaining to complex feelings about the need to subject her self to medical procedures and cosmetic changes in order to be “normal.” Beccah was caught up in impulsive externalization that defended against new and old reactions to her body that were exacerbated by adolescence—the painful sense of defectiveness of her childhood body and the frightening wishes related to her new female body. We noticed that focusing on what a boy thought of her, kept her from letting herself know more about what she was feeling. This led her to observe that “something happens inside when a boy is interested. I can’t let it go.” She reflected on not being able to tell me that her boyfriend had made a vulgar comment about her breasts, which she found pleasing and scary. Rushing at him with excitement, as she had



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done with me on our first appointment, she defended against feelings of vulnerability and helplessness that surfaced with his attention. She recognized that she felt attractive some times, but then doubted that anyone could find her attractive. With sadness, she added, “I’ve had such bad luck, born with all these birth defects I have to live with the rest of my life. I have this need to get attention from guys and then I let them abuse me. I’m so angry inside.” I noted to myself that she had turned to thoughts of pain and damage after she had allowed herself to acknowledge her new, attractive body, and her exciting, seductive behavior. Beccah’s traumatic history predisposed her to repetition, in an attempt at mastery where she had felt the helpless victim. When confronted with a situation that called up a sense of defectiveness, as in meeting someone new, she called attention to herself. She projected her sense of defectiveness and became provocative and aggressive to defend against the disappointment of not being lovable. She invited hurt through teasing, thus enacting her sadistic wishes, and then isolated the affective content of the interaction. Often, her behavior elicited the rejecting response she had dreaded in response to her appearance. Our work gradually elucidated the complex meaning of her feelings of defectiveness. On the one hand, the implicit record of painful experiences in face-to-face interaction now mobilized anxiety and depressive affect around looking at her self and being looked at. We learned, however, that feelings of defectiveness also surfaced as a defensive turning against the self in the service of maintaining equilibrium when sexual feelings, which she experienced as dangerous, came to the fore. As our work progressed, Beccah verbalized feelings more directly, and her tendency to enact became less ubiquitous. Sadness and despair, affects kept in abeyance by her aggressive stance, surfaced. She commented: “Only dirtballs are interested in me; I’m the one they abuse, but they choose somebody else for a girlfriend.” She told me of her recent encounter with her first grade teacher who, not having seen her in the intervening years, asked unfelicitously, “What happened to you?” In the safety of the analytic work, we explored Beccah’s painful experience of looking and being looked at. We reconstructed that she had learned from the look of others that her appearance could inflict an emotional response that elicited a reaction that was incongruous with what she was feeling, and caused her pain. While her provocative actions seemed to cry out “look at me!,” her manner was a defensive maneuver that startled and interfered with close scrutiny. Her salient behavior deflected the onlooker’s



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gaze away from her face. Looking and being looked at were highly charged affective moments, which mobilized fantasy and conflict. She began to recognize that her own looking was compromised—she looked to others as mirrors of herself, because she could not see the young woman in the mirror as herself. As our work progressed, we considered the meaning of her searching in my eyes, as she had done on our first meeting; a search that repeated her experience with her mother’s eyes. Beccah had enrolled in a course to make porcelain dolls, and she brought them to her sessions. She was critical of her work, and showed me that she could not get the face “quite right.” The connection with her wish to have the perfect face with a flawless complexion was unconscious. She did not recognize that her newfound interest represented her experience of remaking her own face. After sharing in her interest in porcelain dolls—that is, keeping our work in the displacement—I noted the unremitting quality of her concern about not getting the doll’s face “quite right,” and I asked her whether she was curious about it. She asked my opinion, what did I think about the face? I replied that her checking now how I felt about the doll’s face reminded me of her question, “can you tell?” We addressed her externalization; her checking what others felt kept her confusing feelings about herself temporarily out of mind. She connected with her anxiety upon meeting people, “I have this constant knot in the pit of my stomach; so much, that I don’t even know it’s there.” At our next appointment, she brought a porcelain baby doll. Now aware that her behavior had meaning beyond an interest in the hobby, she said, “I like babies. I worry about having babies in the future.” We explored her worry that she could not have a normal baby—a worry which, although connected to her pervasive sense of being damaged, was also an expression of normal conflicts about the dangers of growing up and being female. This work was also a harbinger of conflicted feelings about her mother, who had not passed on a normal body to her. The transference deepened, and Beccah’s response to the treatment setting gave us an added, unexpected opportunity to reconstruct the genetic aspects of her pervasive feelings of vulnerability. My office was located at the end of a U-shaped corridor in a suite with four other offices. After several months of treatment, I still often found her roaming the hallway. She seemed momentarily surprised, even startled at my presence, and then responded by assuming a casual, distracted demeanor that resolved into a broad smile denying deeper feeling. As I wondered with her whether she experienced a



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discomfort in the waiting room that compelled her to move around, she recognized a mounting feeling of anxiety as she waited for me passively, that compelled her to “check out the place.” Beccah became aware of an internal state of alarm, and she recognized that, despite her frequent checking, she felt confused and could not make sense of the office space. I considered that, in the regressive state promoted by the analytic process, Beccah was enacting an earlier, non-verbal memory. I interpreted that her experience in the office with me gave us further clues about what it might have been like for her as a little girl, when she repeatedly found herself in strange, frightening doctor’s spaces waiting for something to be done to her. Her anxiety, which must have felt intolerable then, now impelled her to take charge but still impaired her effective mastery of the situation. She recognized that waiting brought up fears that I would not come for her, and that a stranger with harmful intent might appear instead. She was abandoned and helpless. She responded to this insight by making a map of the office. She also started setting an alarm to signal the end of our appointments before the time was up. “I like to know when you’re going to tell me it’s time to go,” she stated. As Beccah understood that fantasies of rejection and abandonment were mobilized in the treatment, she felt increasingly able to take charge and this, in turn, furthered our exploration of her internal experience. As the transference deepened, she “remembered” an episode when her incision “opened up” after abdominal surgery when she was a toddler. She described, as if telling an exciting, funny story, her aunt’s panic and ensuing confusion, as she was alone to handle this emergency. Her account had the quality of bringing me into the family lore; it revealed how humor had been used to cope with trauma. I felt the importance of respecting the affective tenor of her communication, which defended against the traumatic impact of that moment. I commented, after acknowledging the humorous quality of her story, that remembering how her aunt had experienced this moment helped her to put aside what it had been like for her. She responded by disclosing her worry that someone could come through the window and attack us. As we explored this fear, she revealed her chronic difficulty sleeping in her bed at night. She slept on the floor, or on a sofa, with a TV on. In keeping with her massive denial and isolation of affect, this behavior was automatic and she was not aware of the feelings that necessitated her avoiding her bed. She recalled that, as a child, she needed to hear that there were people around her who could rescue her if she stopped breathing. She realized that



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she lived with a pervasive fear that she might die. We noted that she was worried about whether I would or could protect her from harm. Gradually, the fantasy that I might assault her, which was emerging in the transference, became amenable to interpretation. Beccah spoke of the comforting feeling of hearing the sound of voices from the TV at night; they helped her to feel safe. I had registered that her memories, which depicted her mother’s unavailability and her aunt’s helplessness, had triggered a fantasy of assault that elaborated on her feelings in the waiting room. I said: “Perhaps the sound of voices from the TV may even feel safer than a voice up close.” I interpreted that fearing that someone might come through the window to attack us had something to do with a fear about being alone with me. She reflected thoughtfully: “I tell you so much. You could do something that would hurt me.” In the months that followed, Beccah explored her confusion about her mother, who seemed to be in charge of her well-being and yet so helpless to protect her, and whose interventions she experienced both as life-saving and as murderous assaults. Her awareness of feeling vulnerable with me gave us an entry to explore her aggressive feelings. The fantasy of the intruder who would attack us, was a compromise that included the projected aspects of her rage at me, the powerful doctor-mother who, by providing treatment, exacerbated her feelings of being damaged. It was also a harbinger of the deepening paternal transference. As the treatment progressed, Beccah focused more actively in sports, and she brought evidence of her success, indeed her stellar performance, as recognized in newspaper clippings, ribbons, and citations. We noted, however, that she felt a great pressure to maintain an “unblemished” record. Every event was a new challenge, as if her previous success did not serve to ameliorate her blemished self-concept. She reported a worry that “people out there” wanted her to lose, a projection of her enviousness that also reflected her expectation of punishment. Winning was of paramount importance, yet fraught with conflict. Noting her anxiety prior to a particular equestrian competition, I wondered if these events recalled her experience of her cosmetic surgeries, so fraught with promise and risk. The exploration of her exaggerated sense that so much was riding on the outcome, led Beccah to recognize that she dreaded failure as evidence “that it was all her fault.” This insight allowed her to connect with her sadness about needing reconstructive surgery, and to recognize that, although her body had undergone a process of change, her old feelings of being faulty and at fault remained unchanged. She expressed anger at her mother who, in contrast to her athletic, aggres-



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sive father who “did not see anything wrong with her,” was felt as the mirror reflecting her defectiveness. Beccah accessed her conflicted feelings about her father before she could fully address the complexity of her reactions to her mother. Her bisexual conflict was openly manifest in this period in her analysis, as she focused on sports in an effort to identify with her father and disavow her dangerous, defective femininity. The identification with him did not offer lasting comfort, however. She reported “shouting matches” between them; he was insensitive and didn’t care about her feelings. “He is an angry person ready for a fight.” Beccah’s wishes for closeness with her father stimulated oedipal conflict and called forth the dual threats of rejection from father and abandonment from mother. We recognized that anger maintained closeness between them, and defended against intimacy and disappointment. She added, “I’m afraid that I’m just like him, and nobody will be able to set limits on me.” The identification with his intact image seemed to bolster a sense of hope about her own strength, also experienced in her horseback riding, and was a relief from the complex feelings in relation to her mother. However, it also promoted fantasies of unbridled impulse, which increased her sense of vulnerability. The intensification of Beccah’s feelings towards her father led to an increase in her nighttime fears. She revealed that she had asked her mother to sleep with her, as when she was a little girl. In the course of our exploration of her regressive response to oedipal pressures, she painfully uncovered her confusing feelings toward her mother. Sometimes she felt reassured of the much-needed mother’s love and approval. Often, she experienced mother as abandoning, helpless to create a haven of safety where she would feel protected. She developed a concern about her mother’s health and well-being. Her sense of defectiveness seemed to intensify with her fear of her destructive wishes toward her mother. “How can I be so angry with my mother when I have been the cause of so much pain?” she protested, and proceeded to turn against herself as the defective one. Being the damaged one also defended against the frightening wishes to surpass her mother by becoming the young woman with the beautiful body who would bear the healthy, porcelain-skin child. As our work progressed, Beccah’s appearance and demeanor changed. She began wearing age-appropriate, stylish outfits and joined the “preppy” crowd. There was a shift in the transference, and wishes for me as the oedipal father surfaced. She talked about being glad that I was not a male doctor. “I would worry what he might do to



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me; there are movies about this.” I commented that thinking about things that happened in the movies kept her from considering her thoughts about me, right here. Her fantasy of my sexual feelings toward her, manifested in sadomasochistic wishes, condensed oedipal components and a developmentally expectable erotic interest in me. I interpreted that the excitement of thinking about an abusive relationship between us distracted her from considering other feelings that surfaced as we worked together. I spoke to her excitement as a defense against her worry about feeling unloved, if I did not reciprocate her interest and longing for me. In conjunction with the process of object removal, which had been delayed by conflict, Beccah developed an idealized view of me that promoted her capacity to relinquish her mother. She became curious about my interests, my salary, my education, and admired that I had become my own boss. She imitated me in her manner of dress, identified with me in considering career choices; she felt that I was smart, reliable, and interested in her: “You never forget anything I say.” At a time when development required that she relinquish mother in order to attain a separate and independent sense of herself as female, I provided the necessary unblemished female substitute. Noticing an adult female patient who had left the office, Beccah pondered whether she used the couch, and asked “to try it.” The couch was “weird” but, as if it were a test of her readiness to face her growing up, she was determined to use it. She reacted against the relative restraining quality of it, as adolescents are prone to do, but I was aware of her unconscious association to a sick bed, and to her fears of dying, that led her mostly to sit in the middle of the couch with her back leaning against the wall. She told me about having set appropriate limits on a boy: “You’ll be proud of me when I tell you this!” I responded to the identification (“you are very pleased too, thinking that we share in that feeling”), while mindful of the defensive aspects of her remark. She came to one of her appointments dressed like a hippie and asked whether I had been one, thus revealing her burgeoning interest in my body and my sexuality as she tried to reconstruct and imitate me in my adolescence. She replied to herself, “Nah, you’re too conservative. I don’t think so. You go too much by the rules.” I wondered with her whether she thought of me in that way to feel safe from a worry that I might do something surprising and scary. She said: “It’s a relief.” She mentioned getting a learner’s permit, and jokingly added that we could go driving together. I commented that she was thinking about things we might do together outside of the office. She mused that it was good that it was just the two



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of us in the office—then she didn’t need to decide what to call me, whether by my title or by my first name. I said that by not calling me anything she wasn’t letting us know more about what made the choice difficult. We noted a sense of risk that prevented her from speaking freely about her wishes for a special closeness with me. She came to our next appointment wearing very high heels, and told me that her mother borrows them. “But she does not fit into my clothes. Do you like them?” she asked in a challenging tone. The erotic wishes from the previous session had given way to the lesser risk of the defiant stance. I replied that she wonders whether I like what she has and whether, like her mother, I might also want what she has. She exposed herself as she flipped over on the couch, sat up, and pranced around the room. Then she took off her shoes and picked her toenails, first littering and then cleaning up the debris from her body. She had brought greasy food that she spilled/contained/cleaned up; all the while as if she were oblivious to me. I felt this provocative behavior as action language that expressed the multiple dangers she experienced around her wish to become a woman, a wish that brought up closeness as well as competition between us. At this point in the transference, I was experienced as the longed-for, eroticized, dangerous witch-mother who could become malignant in my envy. Her messy, regressive behavior defended against the risks inherent in the wish to be the woman who might incur my retaliation; a risk fueled by her projected envy. She needed to remain the little girl who would incur my wrath for her messiness, so as to avoid my retaliation against her femaleness. In a subsequent session, Beccah reported that she had gotten good grades; then she pointed to a run in her brand new stockings. “I hate runs. I am so bothered by little things!” She showed me that it looked just like the hyperplastic scar on her abdomen, from one of her procedures. She told me she has many others like it. “I can’t wear a twopiece bathing suit; I will have to have more plastic surgery.” She started picking on a scab and said, “I’m lengthening the healing process. I know that. I’m attacking my skin.” I noted to myself that, as she was more in touch with her wishes to be like me and liked by me, her conflicted feelings about her self-representation were coming to the fore with an increase in depressive affect. While I was mindful of the defensive aspects of this behavior, I felt that, in light of her past history, the fantasies and realistic concerns about her “vulnerable femaleness” were surfacing in the image of the fragility of her stockings. Beccah was now aware of her feelings, and she was able to explore more directly her fears about being a woman. She spoke



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about the worry that her menstrual flow would not stop, and of her fear of dying in sexual intercourse, or in childbirth. Her past history of defectiveness accentuated the developmentally expectable concerns about her changing body, and stimulated the certainty of future trauma. As a little girl she had relied on her mother or her grandmother to take over her body in order to feel safe; becoming a woman meant giving up that tie to them, and taking charge of her own body—a body that had felt unreliable as a child, and was undergoing a risky process of change. Beccah’s behavior toward me became more erratic. She reported that her mother had commented on her progress—“we don’t fight any more”—but now she was angry with me. I was “weird” and out of touch with kids her age. She told me that she spoke on the phone with her boyfriend’s mother every day; “I’ve never met her. I don’t care what she thinks.” I pointed to the worry about letting her self tell me more because she might care too much about what I think. She became more resistant. “I don’t have the maturity for this analysis. You’re trying to connect things up. I don’t want to do that. I don’t want to remember.” Then she told me that there are pictures of her “back then” all over the house, and upsetting stories from her mother about how people used to react to her. Letting herself experience with me her wishes and worries about her femaleness had mobilized in the transference the manifestation of a fantasy that I, like her mother, wished to ensnare her in the past in order to keep her from moving forward. The work in this period gave us further access to the defensive function of the defective view of her self. Beccah was aware of still looking at other people’s reactions to her in order to get a clearer sense of her self, as if what she saw in the mirror was not convincing. She expressed despair about whether she would ever feel “good enough.” I ventured that she seemed aware that, no matter what image was reflected back, something was interfering with letting herself change the old picture in her mind. Maybe being her new, grown up self felt scary and she kept herself looking back. She brought an album of photographs of a recent family event and used each photograph to evaluate herself—her expression was weird in this one, there she looked deformed, her hair was not right on the next one. Then she found a “good one” and said, gleefully; “Look at my face there,” clearly taking pleasure and pride in her image. I clarified her ambivalent feelings: “Sometimes you can’t stand looking at yourself, and sometimes you like what you see.” As if my words had touched on something that brought up discomfort, she dismissed her pleasure



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and remarked: “There’s only one good one.” We were thus able to observe that expressing to me the feeling that she liked what she saw had mobilized a need to take the good feeling away. Beccah developed a relationship with a boy. Her boyfriend was “a nice guy, but he is adopted.” His adopted status fascinated her; she saw it as his secret defectiveness. In that sense, he was more defective than she—her parents had not given her up, she was valuable to them. The threat of abandonment and loss, so prominent in her thoughts about her boyfriend’s history, was also a central aspect in her conflict about growing up. Her relationship with this boy stimulated heterosexual feelings that signaled the potential disruption of her childhood tie to her mother, and resulted in an exacerbation of her anxiety. The impulse to call him repeatedly resurfaced; she felt miserable and sought his constant reassurance. One day she broke out in great anger at me: “Despite all this work, I still feel so insecure! What good is this analysis anyway? And how can I trust that you really like me when you didn’t know me back then?” I said, “You worry that something about my seeing you back then would change what I feel about you now.” Beccah came to her next session carrying the framed pictures of herself as a child that her mother displayed in the home. She propped them in front of me, all the while scrutinizing my face. “Can you understand,” she asked, “why it’s hard for me to make sense of how I look now? It’s like, to me, I’m the same, I’m me then and now.” I felt the poignancy of this moment. She had brought the childhood pictures to the office as if reclaiming ownership of her experience. I understood intuitively at that moment the importance of my role as trusted observer of her struggle, a struggle she was proclaiming and was determined to work through, albeit in the context of the analytic experience that granted me a vital role. She pointed to the many defects of old, and commented on the few vestiges that remained, symbols of past and present. I said, “You wonder whether I see an old you that’s not right, or a changed you that makes you acceptable, and how that makes me feel about you, the 16-year-old girl in front of me.” “I still don’t believe anyone could find me attractive,” she said. This session was powerful for both of us. Beccah exposed her vulnerability in the wish that she would feel undamaged as she displayed her defects, a gesture no longer masked and distorted by the defensive provocative stance she had displayed in our first meeting. I was moved by her presence, aware of feeling sorrow and pain for the little girl who had been subject to the experiences betrayed in the pic-



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tures. But, I was also responding to the strength and courage of the young person before me. I do not doubt that Beccah was impacted by the affective tenor of that session, in which I served as witness to her increasing appreciation and acceptance of her struggle (Poland, 2000). Beccah was now “telling herself.” However, in order to understand the psychic meaning of her action, it is necessary to place it in the rich context within which it manifested, and consider what compelled Beccah to bring the pictures to me at this point in her treatment. Beccah had been expressing openly her experience of being lovable in the context of the growing relationship with a boy. As those feelings, harbingers of her developing femininity, deepened, the threat of the loss of the childhood experience with mother mobilized intense conflict. Testing my response to her as a child at this time, a move which could be regarded to serve in the interest of acquiring a new way of “seeing herself with me,” was in effect a maneuver that put a halt, albeit temporarily, to dangerous developmental wishes to experience herself as a young woman in my presence. A stormy period ensued during which Beccah enacted the sadomasochistic fantasies pertaining to her early relationship with her mother. Fears about her vulnerability to illness became prominent. She worried that her immune system “was down,” and that her body could not fight infection. A simple cold triggered fears that she would not be able to breathe. She put down our work; talking was not doing anything. I was helpless and ineffectual. Her agitation switched to cool withdrawal. She came to the office barefoot. “My mother made a comment, Do you think it’s dangerous to walk around barefoot? I can decide what to do.” I said that maybe she wanted for me to worry about the danger, and then she wouldn’t have to worry about her decision. She reported that she had eaten her lunch during her biology lab. “We were dissecting a rat. The teacher said there was a possibility of bacterial contamination. If I get sick, I could pass it along.” Like the rat on the dissecting table, Beccah felt dangerous to herself and to others. While, on the one hand, she felt that her mother was responsible for her defectiveness, she also struggled with the fantasy that she was the one at fault, who hurt her mother with her defectiveness. She wanted me/mother to rescue her from herself because, without maternal controls, she could not trust that she could be safe. She assaulted me with my helplessness while exacerbating her own sense of vulnerability; she was thus enacting with me in the transference the sadomasochistic symbiotic fantasy that kept her locked in a sense of defectiveness.



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As these issues were addressed, Beccah gained in self-confidence; she started to face the end of high school and the move to college. Family discord had become greatly exacerbated, and her anxiety about separation intensified. “What good is this doing? So now I have a lot of fears!” she yelled at me. I interpreted that now that she was not doing so many exciting, scary things, she was more aware of other feelings. I added that maybe her fears had intensified as she was experiencing upset feelings towards me who, like her mother, seemed helpless to make things right for her. She said, “That’s right! And just as I get worse, I am going to have to stop with you!” I spoke about how scary it must feel to make plans to go away as she was feeling worse. Maybe she was looking for me to say we needed to continue our work because that would stop her from leaving, and would relieve her of her worry about making the decision to go. Beccah revealed a fantasy that her mother would not be there for her unless she needed her in sickness; it seemed inevitable that letting go, a signal of her health, would have destructive consequences. The regression ensured their closeness, but it engendered hostility in response to what felt like a requirement to succumb to mother. Fighting with me, as she had done with her mother, was an attempt to regulate the interpersonal distance between us, given the dependent longings and aggressive reaction that were stimulated in the transference. Her history of risk-taking behavior had come under close scrutiny in the analytic work. Creating a state of excitement and worry was her way not to know about complex difficult feelings about “being on her own” in light of her overwhelming experience of vulnerability as an infant and young child. Her behavior was a compromise that represented her wish to experience herself as invulnerable so she might dare let go of the mother, while it heightened her real susceptibility to damage, thus safeguarding her closeness to her mother. Leaving mother and me was a loss associated with death and harm. As Beccah connected with the affectively charged fantasies that pervaded her internal experience and observed her conflicts, she was able to address her present fears about going to college—feeling small and at risk, being subject to the old dread of meeting people that would inhibit her, being alone to meet life in its many challenges. She began actively to make plans to attend college away from home; she met with her college counselor, and she brought books to her sessions to discuss her college search. “My only requirement,” she said when considering schools, “is that it be a very big school, with all kinds of people and pretty buildings.” We both understood that this was an expression of her wish to feel “main stream,” and one among many



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people who displayed differences that made them uniquely pretty. I interpreted that thinking about “many people” was a way not to think about the worry about being all alone, now that our work would come to an end. The final weeks of the termination phase were stressful. She started to miss her sessions. She had taken a job and “was going to the lounge to talk with her friends.” I interpreted that she was leaving me before we terminated, because of the worry about what feelings might come up on our final good-bye. During her last sessions, she reflected thoughtfully on her reaction to ending: “It really did sink in that I’m going away to college. I was missing appointments here to try it out on my own, but I didn’t want to know about it.” As we worked through old and new feelings about being on her own, she reflected on her gains. “I’m proud of myself now; I told this guy off who was after me. I don’t chase guys any more, and I don’t have to have people prove they like me. I feel calmer all around. I have more esteem for myself.” While Beccah could have profited from further analytic work, she left for college rooted in a sense of being a young woman with much to offer, a view of her self that would stand her in good stead to meet the challenges ahead. Discussion This presentation details the analytic treatment in adolescence of a girl who suffered pervasive trauma, originating from a congenital condition that persisted for many years and necessitated multiple invasive medical interventions. Beccah’s history involved all of the elements common to trauma—repeated assaults of intolerable magnitude that inflicted pain, helplessness, and chaos on an ego incapable of mobilizing adequate defensive action. At the inception of the analysis, she functioned like a highly traumatized youngster. She tended to enact in order to defend against sudden, disorganizing anxiety, while sadness and rage locked her in a fixed view of herself as defective. She projected her hostile view of herself onto others, and her relationships became battlegrounds that expressed her inner turmoil. She went through a period of “action-filled adolescence,” where she acted outrageously to counteract worries about the dangers of adolescence. Blos (1962) describes the central role of regression in adolescence. The adolescent reworks the tie to the parents in the interest of individuation and disengagement from infantile dependency, a process that involves the need to solidify the image of one’s own personality



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as the parental figures are relinquished. Both Blos (1962) and Winnicott (1971) state that, because of the centrality of regression, adolescence is a phase that facilitates the opportunity to undo developmental arrests and promotes restructuralization. Earlier conflicts and fantasies that interfere with successful individuation, and can become further structuralized in pathological outcomes, now are uniquely available for observation. The data from Beccah’s analysis attests to the importance of the adolescent period as one that provides a propitious opportunity for psychoanalytic intervention. Experiences involving her new female body, and the intensification of drives that safeguard individuation, provided a context that promoted our exploration of the crippling conflicts that were interfering with the process of psychic differentiation. Given the mental capacities of adolescence—the ability to think beyond the concrete aspects of the present, to consider past, future, and the possible—Beccah was able to rework the governing childhood adaptations, and effectively utilize the forces that promote development. Accounts of female adolescent development (Dahl, 1995; Ritvo, 1984, 1989) attest to the vicissitudes of this phase, which were much exacerbated for Beccah given her past conflicts. The girl’s entry into adolescence is characterized by a resurgence of the preoedipal object tie to the mother; she responds to the major shifts in physical, and mental, functioning, as well as to the intensification of drive impulses, by seeking emotional closeness with the protective mother of early childhood. With the onset of menarche, there is a heightening of anxiety over the inability to control the body that intensifies the girl’s neediness of mother’s help with bodily care. These longings stimulate fears of passive submission to the mother, and reactivate earlier conflicts about merger with/engulfment by her. Beccah’s experience of life-death dependency on mother’s ministrations and protection was reactivated in this phase of development, and it threatened to keep her locked in a pervasive posture of defectiveness that defended against separateness. The immediacy of these feelings in the context of the concomitant drive toward separateness made the reworking of separation-individuation issues more accessible to analytic intervention The girl’s awareness that she is beginning to possess a body like the mother’s may further stimulate fantasies of merging with her (Ritvo, 1989). A replay of the struggles of the anal period can ensue, and oppositional feelings, aversion, and estrangement from the mother take over. When the resurgence of sadism is too powerful, the girl may defensively externalize the sadism onto her mother. Rather than



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fearing her own murderous impulses, she then feels endangered by the mother’s rage (Dahl, 1995). Competitive feelings may surface defensively to establish a more comfortable distance, but this can lead the girl to experience her development as a destructive surpassing of the mother (Dahl, 1995; Laufer, 1986). Moreover, the regressive pull to the mother who took care of the body is a harbinger of an erotic entanglement with her. The girl may ward off the homosexual danger by turning to precocious heterosexuality (Ritvo, 1984). However, the mother may remain fixed unconsciously as the erotically longedfor object the girl is inadequate to satisfy. In a projection, she experiences her mother as a “jealously possessive, envious, malignantly destructive witch-mother” who fascinates and imprisons her (Dahl, 1995, p. 196). In order to mask and protect her heterosexual longings, the girl regresses to a messy, disorganized presentation that safeguards her from a fantasized attack. Beccah’s focus on her body, and the nature of the conflicts around developmental progression that emerged in the analytic exploration, are in keeping with these expectable characteristics of adolescent development, albeit marked in specific ways by her history of early trauma. The analytic work with Beccah attests to the pervasive, ongoing power of annihilation fears and traumatic anxiety, as they influenced her internal experience. Fears of “being overwhelmed, merged, penetrated, fragmented and destroyed” (Hurvich, 2003, p. 579), characteristic in individuals who have experienced an insufficiency of safety (Sandler, 1960), were intrinsic to Beccah’s affective state. Laub and Lee (2003), referring primarily to the psychic consequence of acts of cruelty, state that trauma “creates a strong impulse to repeat destruction” (p. 460). Beccah understood on a conscious level that the trauma befalling her was not a premeditated act of cruelty. Nevertheless, she experienced it unconsciously as damaging actions against her body and self that had resulted because of her mother, and because of herself. In the state of total dependency of infancy and early childhood, her mother was the defective/intact mirror of her damaged self, a rescuing lifeline unable to provide a haven of safety, or to help her with the regulation of suffering. Now in adolescence, she experienced sadomasochistic fantasies about surpassing her mother, which interfered with the development of a view of herself as an attractive young woman. Several authors have demonstrated that self and object representations are crystallized around experiences of early medical trauma that lock mother and child in a sadomasochistic relationship. Kennedy (1986), describing the analysis of an adolescent boy who suf-



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fered from phimosis requiring surgery at age two, detailed how the perception of the mother as “a vicious attacker, whose longed-for attention and concern could be attained only by suffering and pain and by relinquishing his penis, absorbed, restructured and organized a whole range of earlier experiences and conflicts” (p. 217–218). Beccah’s “affect storms,” which she enacted in her relationships with others, can be conceptualized as expressions of her internal representation of self and objects—a “systematic repetition of the relationship between a persecutory, scolding, and derogatory object, and a rejected, depressed, and impotent self ” (Kernberg, 2003, p. 520). However, as Goldberger (1995) points out in her account of the analysis of a five-year-old-girl who suffered medical trauma, the picture is more complex. The child who, out of medical necessity, has experienced painful maternal ministrations, develops an attachment to being handled in painful ways; in fact, the gratification obtained from such relationships is “something which is feared, but also looked to have repeated” (p. 268) so as to prevent object-loss. The analytic work with Beccah revealed that sadistic fantasies around her early experience (that her mother caused/wished her trauma; that she damaged her mother through her defectiveness), and conflict (rooted in oedipal and pre-oedipal wishes wishes that mandated punishment) interfered with the appropriate restructuring of her internal representations, and kept her locked in a regressive posture of being the defective child. The excitement of her sadomasochistic entanglements, as well as the unconscious connections between health—loss of mother—abandonment/death, that interfered with the development of an adequate view of herself, required careful interpretation and working through. Hoffman (2003) comments on the prominent role of aggression in enactment and defense in the traumatized person, in particular the predominant use of “identification with the aggressor” and “turning passive into active.” A posture of “nonchalant bravado” is a characterologic defense in traumatized youngsters, serving to obscure intense object hunger, and passive libidinal object longings, as well as to ward off expectations of repeated rejection and loss (Steven Marans, as reported in Mazza, 2003). Goldberger (1995) comments that the incessant need to repeat the traumatic experience is a hallmark behavior of the victimized child. The data from Beccah’s analysis gives evidence of the pervasive nature, and complex function, of repetition. Repetition, which is a function we observe in play, provides normally a much-needed opportunity to re-experience a situation, this



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time as the active agent rather than helpless victim. This experience promotes the gradual assimilation and mastery of anxiety. When trauma is involved, however, the capacity to utilize anxiety as signal function is impaired. The ego is, once again, overwhelmed and cannot mobilize defense in response to the affect generated in the process of repetition. Loewald (1971) regards the revival of the experience in the analysis as “an active recreation on a higher organizing level which makes resolution of conflict possible” (Moore and Fine, 1990). Hence, one of the functions of the analytic intervention is the restoration of the ego’s capacity to utilize anxiety for adaptation (Yorke, 1986). Beccah’s treatment created an opportunity for contained repetition, where she was able to “take an affective sample of these basic danger situations, to experience them in miniature” (Yorke, 1986). Blum (2003c), underscoring the importance of genetic reconstruction, states that re-experiencing a trauma in the context of the safety of the analytic situation effects changes in adaptive capacity that are more congruous with present reality. As the record of Beccah’s treatment elucidates, reconstruction did not refer to the accurate recall of past events, nor to a simplistic ascription of causation between early factors and later pathology, but to the recovery of affective experiences which, when understood in light of what was known of “the relevant dimensions” of her childhood (i.e., within a genetic context), facilitated the capacity to distinguish between “reality and fantasy, past and present, cause and effect” (Blum, 2003a, p. 500). Certain authors who write about the impact of early trauma (cf. Mazza, 2003) stress that it interrupts the development of healthy omnipotence, prevents the establishment of self-soothing and self-regulating capacities, and disrupts the capacity to recognize mental states and to find meaning in one’s own and others’ behavior. Referring to Fonagy’s concept of “mentalization” (Fonagy et al., 2002), many assert that the major goal of treatment is to facilitate the development of the capacity to conceptualize and make sense of situations, affect and behavior. The clinical material elucidates that Beccah’s capacity for affect regulation was seriously compromised, and it had a disorganizing impact on her ability to comprehend her internal and external experience. In the early phase of our work, she experienced a resurgence of the traumatizing childhood feelings that accompanied her many overwhelming experiences pertaining to her medical needs. The affective impact of these experiences, which were recorded at a procedural (i.e., non-verbal) level, were actualized in the transference as she felt disoriented in my physical space, and she ex-



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perienced me as a dangerous intruder. My interventions aimed to help her to make sense of herself in the present, by promoting connections between relevant information that was known or inferred from her history, and her internal experience then and now, thus meaningfully integrating past and present at a conscious level. Beccah became less impulsive as she became more cognizant of her internal state, and she could begin to identify, and label her affects, and connect them with her thoughts and her behavior. This work took place in a context of safety, what Fonagy refers to as a therapeutic “secure base” (2003), and it promoted the development of a sense of containment, which facilitated the use of affect as signal function. While these interventions promoted mentalization, and provided her with a new experience of “self with other,” which Fonagy (2003) asserts are the mutative factors in psychoanalysis, the unfolding of the clinical material provides evidence of the persistence of the dynamic unconscious as manifested in the pathologic compromise formations that continued to inhibit the developmental process. Unconscious fantasy and conflict that were integral to her experience of childhood became increasingly highlighted as the central aspects of her misery. As the interpretive work addressed dynamic conflict, Beccah’s capacity to regress and access earlier fantasies and their related affects, deepened. Interpretations that focused her attention on the sense of danger attached to her excitement about her new female body, reactivated fantasies that ensnared her and her mother in irreparable defectiveness. Dahl (2002) states that conflicts over aggression and oedipal desires are defensively concealed by disguising oneself as little and devalued in relation to the hated, beloved, and feared archaic mother. Beccah began a complex enactment of the experience of being the defective child with mother by bringing her childhood image for me to see. This defensive reaction to the intensification of separation wishes and drive derivatives, brought her in contact with her inner-most feelings and earliest childhood fantasies. The immediate response to seeing the pictures with me was the resurgence of depressive affect. (“I still don’t believe anyone could find me attractive.”) Despite the fact that our work provided an opportunity for a corrective experience (implicit and explicit) to being looked at in childhood, Beccah would be unable to integrate a new image of herself until we had addressed the conflicts that surfaced more poignantly in subsequent sessions. Beccah enacted her sense of the utter unreliability of her body, of the helplessness and destructiveness of her mother, of her fantasy of herself as dangerous and damaging,



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which represented the affective experience of her early years and her adaptation to it. In the course of the analysis, Beccah came to appreciate that she experienced her developmentally appropriate wishes in a context of danger that reflected her earlier adaptation to her painful past. We uncovered that she adhered to a devalued view of herself for complex reasons intended to restrict her functioning. Because the meaning of this experience became accessible to interpretation in the context of our work, she was able to achieve a new integration that reworked the heretofore sadomasochistic aspects of her relationship with her mother, and relinquished the defensive use of defectiveness that interfered with adolescent development. As a result, her affect, her behavior, and the quality of her thought processes increasingly reflected changes indicative of a modification in the constellation of intrapsychic factors that determines adaptation. By the time treatment discontinued, she gave eloquent testimony about the differences she experienced in herself. The interpretive work functioned to promote insight, and permitted her to achieve “conscious solutions to those conflicts that, when they were unconscious, threatened to mobilize anxiety” (Gray, 1988, p. 44). Specifically, Beccah’s attention was directed to the defensive function of her sense of defectiveness, which could be observed by her as we noted her tendency to turn to disparaging images of herself in order to inhibit strivings that felt dangerous. While, as Gray emphasizes, profound unconscious changes take place as a result of the influence of the experience of the analyst-patient dyad, the therapeutic aim of a focus on the analysis of resistance, to quote Gray, is “to reduce the patient’s potential for anxiety, as differentiated from an aim that merely seeks to reduce the patient’s anxiety” (Gray, 1988, p. 41). In Beccah’s case, depressive affect was also a target, as it became involved in compromise formations that relied on turning aggression against her self in a depressive response intended to relieve anxiety (Brenner, 1982). Each instance when the patient can confirm the connection between their sense of danger and the activities of the mind intended to relieve that feeling strengthens the capacity to exercise volitional control over internal forces (Busch, 1999). For example, when Beccah recognized that her aggressiveness protected her from the worry about being overwhelmed by fear, she was better able to evaluate her anxiety and could establish more satisfying relationships with others; when she realized that she experienced being healthy as a harbinger of loss, and understood that thoughts of “defectiveness” kept her safe



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from strivings she experienced as dangerous, she was free to pursue her goals and wishes. Given that fantasy and conflict were pervasive and persistent at the inception of treatment, the significant changes in the patient’s psychic function subsequent to interpretations aimed at the pathologic aspects of compromise can be considered evidential criteria that validate the mutative action of dynamic interpretation in psychoanalysis (Boesky, 1988). The psychoanalytic method engages complex verbal and non-verbal processes of the mind. Analysis is an experience where the patient increasingly exposes these processes, about which he/she remains unaware pending intervention from the analyst. The psychoanalytic intervention requires a specific kind of matching between the mind of the analyst at work, as it facilitates the elaboration of the patient’s mental processes and elucidates them, and the mind of the patient at work, engaged in an “effort at self-healing” (Jacobs, 1988, p.66). The congruence of these processes creates a context that enhances the patient’s capacity for self observation, promotes the affective reliving of inner experience, and stimulates the integration of present in light of past experience that lends meaning to mental functioning. Beccah was able to look forward to leaving home to attend college, because she had gained insight into her inner reality, and a sense of her capacity for conscious management of internal impulses. BIBLIOGRAPHY Blos, P. (1962) On Adolescence: A Psychoanalytic Interpretation. New York: Free Press. Blum, H. (2003a) Psychoanalytic controversies: Repression, transference and reconstruction. In Int. J. Psychoanal., 84:497– 503. ——— (2003b) Response to Peter Fonagy. In Int. J. Psychoanal., 84:509 – 513. ——— (2003c) Psychic trauma and traumatic object loss. In JAPA, 51/2: 415 –432. Boesky, D. (1988) A discussion of evidential criteria for therapeutic change. In How Does Treatment Help?, A. Rothstein, ed. Madison, Conn.: Int. Univ. Press, pp. 171–180. Brenner, C. The Mind in Conflict. Madison, Conn.: Int. Univ. Press. Busch, F. (1999) Rethinking Clinical Technique. Northvale: Aronson. Dahl, E. K. (1995) Daughters and mothers: Aspects of the representational world during adolescence. In Psychoanal. Study Child, 50:187–204. ——— (2002) In her mother’s voice: Reflections on “femininity” and the superego. In Psychoanal. Study Child, 57:3 –26.



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Fonagy, P. (2003) Rejoinder to Harold Blum. In Int. J. Psychoanal., 84:503 – 509. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002) Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press. Freud, S. (1926) Inhibitions, symptoms and anxiety. SE, XX: 87–174. Goldberger, M. (1995) Enactment and play following medical trauma: An analytic case study. In Psychoanal. Study Child, 50:252–271. Gray, P. (1988) On the significance of influence and insight in the spectrum of psychoanalytic psychotherapies. In How Does Treatment Help?, A. Rothstein, ed. Madison, Conn.: Int. Univ. Press, pp. 41– 50. Hoffman, L. (2003) Vicissitudes of aggression: Theoretical and technical approaches to psychic trauma. In JAPA, 51/2:375– 380. Hurvich, M. (2003) The place of annihilation anxieties in psychoanalytic theory. In JAPA, 51/2:579–616. Int. J. Psychoanal. (2003) 84: part 3. Jacobs, T. (1988) Notes on the therapeutic process: Working with the young adult. In How Does Treatment Help?, A. Rothstein, ed. Madison, Conn.: Int. Univ. Press, pp. 61– 80. Kennedy, H. (1986) Trauma in childhood: Signs and sequelae as seen in the analysis of an adolescent. In Psychoanal. Study Child, 41:209 –219. Kernberg, O. (2003) The management of affect storms in the psychoanalytic psychotherapy of borderline patients. In JAPA, 51/2:517– 545. Laub, D. & Lee, S. (2003) Thanatos and massive psychic trauma: The impact of death instinct on knowing, remembering, and forgetting. In JAPA, 51/2: 433 – 464. Laufer, M. E. (1986) The female oedipus complex and the relationship to the body. In Psychoanal. Study Child, 41:259 –276. Mazza, D. (2003) Dangerous behavior in children and adolescents. In JAPA, 51/2:651– 666. Poland, W. (2000) The analyst’s witnessing and otherness. In JAPA, 48/1: 17–35. Ritvo, S. (1984). The image and uses of the body in psychic conflict. In Psychoanal. Study Child, 39:449 –468. ——— (1989). Mothers, daughters and eating disorders. In Fantasy, Myth and Reality: Essays in Honor of Jacob A. Arlow, Blum, Kramer, Richards, & Richards, eds. Madison, Conn.: Int. Univ. Press, pp. 371– 380. Sandler, J. (1960) The background of safety. In Internal. J. Psychoanal., 41:352– 365. Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books. Winnicott, D. (1971) Playing and Reality. New York: Basic Books. Yorke, C. (1986) Reflections on the problem of psychic trauma. In Psychoanal. Study Child, 41:221–236.



PSYCHOANALY TIC PERSPECTIVES ON THE FUTURE AND THE PAST



Psychoanalytic Reconstruction and Reintegration HAROLD P. BLUM, M.D.



Psychoanalytic reconstruction has declined in theoretical and clinical interest as greater attention has been directed to the here and now of the transference—counter-transference field and inter-subjectivity. Transference, however, is based upon childhood fantasy, and is a new edition of unconscious intra-psychic representation and relationships. In this paper transference is viewed as a guide to reconstruction, but transference itself is also an object of reconstruction. Reconstruction is a complementary agent of change, which integrates genetic interpretations and restores the continuity of the self. The patient’s childish traits, features, fixations, and irrational childish fantasies and behavior point to the necessity for reconstruction. Reconstruction organizes dissociated, fragmented memories, potentiating the further retrieval of repressed memories. Reconstruction is essential to the working through and attenuation of early traumatic experience. Recapture of the past is necessary to demonstrate and diminish the persistent influence of the past in the present, and to meaningfully connect past and present. A case is presented in which reconstruction had a central, vital role in the analytic process.



Clinical Professor of Psychiatry, New York University School of Medicine, Training and Supervising Analyst, New York University Psychoanalytic Institute. Given as the Freud Lecture, Germany, November 1, 2002, and originally published in German under the title “Psychoanalytische Rekonstruktion und Reintegration” in “Zeitschrift fur Psychoanalytische Theorie und Praxis/Journal for Psychoanalytic Theory and Practice” 2/2003 (XVIII) © 2003 Stroemfeld Verlag, Frankfurt am Main/ Basel, published here in English with the permission of Stroemfeld Verlag. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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in its second century, psychoanalysis has moved in many new directions, often with increasing distance from its origins and core formulations. Psychoanalytic reconstruction has been treated either with neglect or declining interest as attention has turned to other psychoanalytic issues and agents of change. Psychoanalysis itself is not regarded as particularly popular in many parts of the world today, and reconstruction has particularly fallen out of favor as there has been more immediate attention and emphasis on the here and now, inside and outside psychoanalysis. Actually, analysts and patients have pondered the question of where the patient was coming from, and how he or she got there. It is not only the adopted child who is curious about his/her origins, but all persons and peoples. Nations have legends about their origins, which are constructions compounded of fact and fantasy. Freud (1919, p. 83) asserted: “analytic work deserves to be recognized as genuine psychoanalysis only when it has succeeded in removing the amnesia which conceals from the adult his knowledge of his childhood . . . This cannot be said among analysts too emphatically or repeated too often . . . anyone who neglects childhood analysis is bound to fall into the most disastrous errors. The emphasis which is laid here upon the importance of the earliest experiences does not imply any under-estimation of the influence of later ones.” Extending my previous work on the theoretical and therapeutic value of reconstruction (Blum, 1980, 1994, 2000), this paper supports reconstruction as inherent to the psychoanalytic point of view and virtually all clinical work. In my view, reconstruction is not only reciprocal to transference interpretation in the present, but it is a complementary agent which guides and integrates interpretations and reorganizes and restores the continuity of the personality. Reconstruction for Freud was both a technique, a means toward the goal, and a goal of psychoanalysis. Experience such as the birth or death of a sibling had an impact on the patient’s life, permanently influencing the personality. Freud (1937, p. 26) illustrated such a prototypical reconstruction, “Up to your nth year you regarded yourself as the sole and unlimited possessor of your mother; then came another baby and brought you grave disillusionment. Your mother left you for some time; and even after her reappearance she was never devoted to you exclusively. Your feelings toward your mother became ambivalent, your father gained a new importance for you . . . and so on.” A genetic interpretation shows that a current symptom, behavior, thought, feeling, or trait is derived in some way from childhood. It is



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specific and focal, and it traces, for example adult obesity, to childhood conflicts concerning feeding and object loss. Genetic interpretations are fostered by the regressive character of free association and transference. Reconstruction would encompass broader considerations, e.g. of dependent relationships, concurrent parental regression, inability to mourn and accept loss, identification with the lost object, etc. Reduction of the transference to its childhood roots and the accumulated analytic data converge in a reconstruction, which in turn furthers the analytic process. Contrary to the current position in some analytic quarters, that such genetic data are co-determined by the analyst’s suggestion or countertransference, the childish character of the transference, the patient’s childish traits, features, fixations, and irrational childish fantasies point to the childhood locus of pathogenesis and the patient’s psychopathology. Although analytic work requires the reconstruction of childhood (Freud, 1937), this does not mean that any two reconstructions by two different analysts will be identical. Each analyst will select, organize, and interpret the data with some degree of theoretical and personal preference. The analyst’s countertransference may make it difficult to analyze the transference, or from another point of view, it may provide further insight into the patient’s conflicts, the transference, and the patient’s resistance in the analytic process. The analyst’s analytic attitude, self analysis, education, and experience should contain and limit the analyst’s human subjectivity, retaining “good enough objectivity.” Analytic theory does not derive entirely from adult regressive states, which do not reproduce earlier states unaltered, but has long been complemented by infant observational research and child analysis. The reconstruction of childhood takes into account affective, cognitive, and moral development. Reconstruction considers the overlap and sequence of developmental phases, and the unique quality of individual endowment and experience. Because of the theoretical implications of reconstruction, it has been used from the beginnings of psychoanalysis to propose, confirm, or challenge a theoretical or developmental hypothesis. As analysis proceeds, the wealth of associations, memories, transference reactions, etc. provide a foundation for the process of reconstruction. Usually there are a number and variety of reconstructions rather than one grand encompassing reconstruction. Like interpretation, reconstruction is neither arbitrary nor capricious nor dogmatic. All too often what is depicted as analysis in popular distortions and misconceptions is a parody of the psychoanalytic process. A cari-



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cature of the psychoanalyst as insensitive, insistent, robotic, and selfserving is deployed to defend against the authentic yet disturbing nature of analytic insights. Self-protection is preferred to self-knowledge. When a reconstruction is offered to the patient, it is a product of prior analytic work, tentative and always an approximation. Psychoanalysis and the process of reconstruction are not based on faith, dogma, or conjecture, but on evidence, inference, and further confirmation or alteration with new data. Fragmented, dissociated, and repressed memories emerge and have to be differentiated from screen memories and pseudo-memories. Screen memories are often similar to the patient’s constructions. Our knowledge of memory has significantly advanced in the recent decade. Bridges are under construction between psychoanalysis and neuroscience, and both disciplines should benefit. Several memory systems are now recognized. These systems appear to have their respective modes of registration, storage, and retrieval with interrelated functions and controls. Autobiographical memory is closely connected to declarative, explicit, usually conscious verbal memory for persons and places and general knowledge. Procedural, implicit memory for skills, e.g. riding a bicycle, playing the piano, is not conscious, though not repressed, and is not modified as a consequence of psychoanalysis. At this time the dynamic unconscious has not been definitely delineated within any specific memory system or configuration. Traumatic memory is an exception, however, and appears to be processed differently from other memory. Severe trauma alters the structure and the memory function of the hippocampus. Unconscious traumatic memory is essentially formed in the amygdala (Le Doux, 2002), which appears to instigate automatic fight-flight reactions to stress. These findings illuminate the complexity of memory and the necessity of reconstruction superseding the limitations of discrete memory. Patients sometimes offer reconstructions before the analyst. In any case, reconstruction will be invoked in analysis unless the past continues to be resisted and avoided. If the past and present have not been meaningfully interconnected, then the patient’s defenses have not been sufficiently diminished. The past will continue to influence the present, but the past may also defend against the present. A patient, for example, preferred to reconstruct her childhood strife with her mother, rather than scrutinize her derivative overprotection and over-indulgence of her daughter. Any confrontation with her daughter was to be strenuously avoided. The present as well as the childhood past may be viewed through a glass darkly. Before the reconstruction is verbalized and offered to the patient,



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the psychoanalyst has been building a mental construction of the patient’s childhood. Based on the patient’s presenting symptoms and character, the life history described by the patient, and the initial transference reactions of the patient along with the analyst’s countertransference responses, construction evolves. Construction is an initial preliminary formulation, which goes on silently in the analyst’s mind, particularly concerning the nature of the patient’s psychopathology and its relationship to pathogenesis. Construction is thus an initial set of hypotheses about the patient’s unconscious conflicts and character structure which is not shared with the patient and which develops during the opening phase of psychoanalysis (Greenacre, 1975; Blum, 1994). Differentiated here from construction, reconstruction is generally formulated after the opening phase of analysis and is shared and shaped with the patient. In the material that follows I shall focus primarily on reconstruction. This will allow a deeper understanding of the significance of the child that lives on within the adult, the persistence of childish features and fixations within the adult personality, and the revival of childhood in the patient’s regressive responses. This is not to say that the child in the adult is ever revived as he/she actually existed in childhood. Childish reactions in the adult may or may not serve their original defensive and adaptive functions, and there may have been developmental transformation of meaning and function. The adult’s present personality and life situation influences the form and content of childhood revivals. Reconstruction of the patient’s past is necessary to demonstrate the persistent influence of the childhood past in the present, but contemporary reconstruction also demonstrates the influence of the present in the way the past is revived, re-experienced, and understood. The archeological metaphor which Freud originally used in his description of reconstruction as reclaiming the buried past is still apt in many respects. “His work of construction, or if it is preferred, of reconstruction, resembles to a great extent an archeologist’s excavation of some dwelling-place that has been destroyed and buried or of some ancient edifice. . . . except that the analyst works under better conditions and has more material at his command to assist him, since what he is dealing with is not something destroyed but something that is still alive . . .” (Freud, 1937, p. 259). Patient and analyst develop rational conviction about a reconstruction based upon analytic knowledge, observations, inferences and their cohesive integration. Reconstructions have transference and counter-transference meaning, however, so a patient’s reaction to reconstruction becomes part of the analytic process. Some of the main features of clinical reconstruction will be illus-



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trated in the following clinical material. The primary case report is that of the analysis of a white male in his thirties who held an academic position. He was gaining increasing recognition and was developing a consulting practice, which made private psychoanalysis possible. He sought treatment because he suffered from intermittent depression with feelings of poor self-esteem. He was quite conflicted and indecisive with respect to their relationship. He felt that the analysis was necessary, and he anticipated it would be painful to expose his vulnerabilities. He hoped to develop a more positive confident self-image, and greater self-esteem and to become more successful in his life goals. He was completely naïve about analysis and at the same time, seemed to have an intuitive grasp of what was expected of him. He was fascinated with the idea of “everything means something.” During the first half year the patient remained interested, enthusiastic, and motivated. He was very intelligent and seemed very cooperative. This honeymoon period did not last and what then emerged was a person who expressed himself in two different ways, almost as if he were two different people. Frequently his language was crude, with poor grammar and frequent curses and obscenities. On the other hand, he would make frequent literary allusions, quoting Shakespeare, Proust, Joyce, and other authors. He was capable of using a very large excellent vocabulary and subtle expressions, just as he was capable of using crude language riddled with profanity. He alternated between curiosity and indifference regarding his two contrasting language styles. He also had two different ways of relating to the analyst, and similar expectations of how the analyst would relate to him. He expected his analyst to be in either a crude and uncontrolled dangerous closeness, or to be more distant and cultivated. He indicated that he was afraid he would become too dependent on the analyst and analytic process. The analysis had become one of the most important things in his life. The patient then revealed a secret, which he had withheld at the beginning of analysis. He not only had two languages, but there were two women in his life. While living with his girlfriend, presumably exclusively, he actually saw other women, primarily his ex-fiancee. His lover had resumed sexual relations with the patient during the time that he was living with his present girlfriend. He actually became closer to his former fiancee whom he began to visit regularly. He was afraid to reveal this to his girlfriend for fear that she would reject him. He was divided between his two conscious loves, his present and former girlfriend. This had now become intolerable. His divided love



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and loyalties, and his guilt toward these women, were major reasons for his seeking psychoanalysis. When his girlfriend learned about his “affair” with his former fiancee, she repeatedly told the patient that had hurt her deeply, and then she broke off all contact with him. Separation reactions activated in the transference. He was reluctant to leave sessions, and on Friday would cheerfully state, “have a nice weekend.” The intrigues in his personal life entered the analytic situation. He confessed guilt about reading a magazine report about a mass murder in the waiting room. Although he was afraid of getting caught, he had somehow left the magazine open to that page. He then recalled that in adolescence he had found his father’s pornographic pictures. Disgusted, but excited, he masturbated with these pictures. He was so afraid of being discovered that he replaced them exactly as he found them. He thought his parents were shameful hypocrites. When he had asked for the analyst’s card, he was unconsciously referring to his father’s pornography, wondering if the analyst were trustworthy or a lascivious hypocrite. This led to feelings about morality and specifically religion. He wondered if the analyst were Jewish. He had grown up in an antiSemitic milieu with contempt of Jews. In a Catholic college he had told a fellow that he had no use for any Jews and this person declared, “I’m Jewish.” The patient was stunned and mortified. In his view, though weaklings, Jews could be ruthless and they did the dirty work (like servants). Later he began to examine the many stereotypes of his childhood. He was unconsciously afraid that the possibly Jewish psychoanalyst would encourage immoral thoughts and acts. On the couch he was vulnerable; he felt feminine and was homophobic. The patient was dimly aware of his fear of all women and preferred to think of them as asexual Madonnas. As a child he had wondered about sounds coming from the thin partition of his parents’ bedroom, and as an adolescent he audited their sexual relations and was sexually aroused. His adolescence was burdened by guilt and fears of punishment. At this point the analyst could reconstruct the patient’s reactivated primal scene fantasy and sibling experience during his childhood and adolescence, which reflected in all his current relationships. He had slept in the same room as a sister until puberty, undressing together. His removal from their bedroom at puberty convinced him of his sinfulness and motivated his urge to confession in church and later in analysis. His masturbation while looking at the parental pornography was unconsciously incestuous, and he was fearful of the



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incestuous voyeurism, exhibitionism, and sibling sex play. He was guilty and anticipated punishment for his incestuous fantasies. The secret of his affair was tied to the secrecy of the primal scene, his sibling experience, and his unconscious fantasy of impregnating sister and mother. After this reconstruction he could understand his fear of intimacy. The patient spoke again of the hypocrisy of his parents, their own crude behavior, their not setting limits, and their implicit condoning of inappropriate sibling intimacy. His attention turned to his irrational fear of the analyst’s cruel and dirty impulses and then to recollections of parochial school. The priests and nuns were supposed to be kindly but they were frequently cruel. They too were unreliable hypocrites. He then described physical abuse, endless repetitions of prayers, and penance for minor infractions. He had despised the Jews in part as a defense against his ambivalence toward the Christian authorities of his childhood and adolescence. The analysis deepened in its middle phase after a vacation. The idealization of wealth was introduced when the patient had difficulty in paying the analyst, ostensibly because he did not have an envelope in which to enclose the check. The bare check would be nude, not proper, but pornographic. Payment led to associations about dirty money, greed, and the analyst becoming enriched through the patient’s efforts and expense. A very important childhood theme then affectively emerged in the center of analytic work. The patient had grown up in New England, mostly on large estates in which his parents worked as servants. He was the son of servants, within a socioeconomic class system. The analyst reconstructed the influence of the servant experience on his fear of being compliant and dependent, his fragile self-esteem and compensatory striving for social status and affluence. His father was a tyrant at home but deferential and subservient toward his rich employers. The patient too had to know his place. He recalled with humiliation and rage how his father made him walk to the back door, the servant’s entrance, and how he hated being a caddy, carrying golf clubs for affluent adults to earn extra money. The patient had played with a Jewish employer’s son, but they were not allowed to eat together in the main dining room, nor did he know proper etiquette. The primary house of his childhood was actually a cottage on an estate, servant’s quarters. He realized this accounted for the lack of boundaries and privacy since the few small rooms had flimsy walls. The two different styles of language and manners, which had appeared in the transference, could now be reconstructed as related to his early experience, that of observing two classes, his parents and the estate owners with different styles of lan-



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guage and dress. He identified with his parents of the servant class and also with the aristocratic parents. He had not been aware of his dual identifications, languages, and ambivalent attachments. He had lived in two worlds which were dissociated; ego integration was possible only after reconstruction of his childhood. Reconstruction elaborated how he and his family were filled with awe, envy, and resentment of the aristocrats. The “have-nots” attempted to devalue what they did not have. He should have been rich, and what a better life he would have if he were the son or adopted son of the nobility. Yet his identification with the cultivated, educated, refined aristocrats proved to be a very important factor in the patient seeking higher education and developing many cultural interests. He displayed the superficial accoutrements of affluence, and elegance but he knew that deep inside he had a servant mentality. Secrecy had also referred to the social devaluation of servants, which he regarded with shame and humiliation. Moreover, servants knew some of their employers’ secrets, and could know too much. Acting servile and submissive was unconsciously associated with being feminine, with being Jewish. Anything that reminded him, or was suggestive of being submissive or subjugated, enraged and frightened the patient. He transiently thought of quitting analysis rather than lying compliantly on the couch. He needed to be clean and neat, not only because of his guilt, but because of the dirty work of his parents. His father had done manual labor, and his mother probably served as a maid. He felt compassion and pity, but also contempt, for manual laborers and for the lower class. He identified not only with the values of the aristocracy but also with their condescending, haughty superiority toward their servants. He admired and idealized their prestige and power. He wanted to realize grandiose omnipotent fantasies and to never again be subjected to being humble and humiliated. A flood of painful memories returned, integrated in the reconstruction of the patient’s childhood as the son of servants. The wealthy estate owners had referred to his parents by their first names or without a name. The patient saw this as a lack of respect, treating his belittled parents as if they were children. He thought that one of the reasons they worked on different estates was that his parents had been summarily dismissed from some of their jobs. Apparently some of the estates were owned by descendents of the “Robber Barons,” influential individuals who inherited great wealth from the financial manipulations of their forebears. The estate owners, partially through projection, feared that their servants would engage in theft. The pa-



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tient had fantasies of acquiring great wealth by defrauding the rich. In the analysis he wondered about concealing his still rising income so that he would not have to raise the fee. In fantasy he was the greedy thief, the Robber Baron, a role formerly assigned to his analyst and Jews. He realized that he, his parents, and the aristocrats all had a common religion—they worshiped wealth. These various associations and interpretations were followed by further enlarged reconstruction to which the patient contributed. The analysis then veered further into the arena of shame, guilt, and humiliation. The analyst pointed out that the patient’s view of his servant parents was that they had to swallow their pride. As servants they had been fed and swallowed a steady diet of denigration. The patient had a fleeting coprophagic fantasy; he identified with his degraded parents, but also was hungry for money and its power. On one level he regarded his parents as shameless, but he identified with their silent compliant acceptance of shame and humiliation. The patient wanted to erase, reverse, and revenge the humiliations. The analyst reconstructed the patient’s organizing his life around overcoming any narcissistic injury, obtaining narcissistic supplies, and becoming an aggrandized aristocrat. As a consequence of the reconstruction, many of his disconnected thoughts, memories, and feelings were organized into a cohesive, coherent, meaningful constellation. He could reflect on the family life of servants. He had fantasized that he was not the child of the servants, but the masters. He was of, or destined to be, the nobility. The reconstruction unified what had been a double identity, prince and pauper, servant and master. He had two languages, two sets of parents, two women, and two polarized sets of attitudes toward people and society. His self and object world had been split between idealized and denigrated childish representations. In a parallel reconstruction, he had taken upon himself or had been delegated by his parents to redress their narcissistic mortification, to overcome the family shame, and turn humiliation into pride and glory. He rebelled against any idea of being subservient toward his analyst. He would not be treated with contempt by his analyst or any authority, but would rise to the superior status to which he was entitled, like the landed aristocracy. The patient could see that some memories defended against much more disturbing memories of his adolescence and childhood. The secrecy of his ex-wife’s illegitimate child, the secrecy of sibling sex play, the secrecy of the primal scene were associated with the child’s secrecy and confusion concerning his parents’ denigrated status. Why their job dismissals and moves? Servants had no job security and



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no status. Were they actually fired because they committed robberies? Frequently paid in cash, they avoided income tax. Did they deserve punishment? Were they without self-respect, and/or secretly enjoying humiliation? What had led to their becoming servants? Did his parents also idealize and identify with the aristocracy, basking in their reflected glory, while denying their own devaluation? Did they wish to be adopted as he did by the estate owners and analyst in a familial family romance just as he had, now manifest in wishes to be adopted by the analyst (Freud, 1909; Frosch, 1959)? The reconstruction gave him insight into his thoughts and feelings about the past and his plans for the future. It allowed greater access to the negative feelings of guilt, shame, and humiliation, his low self-esteem, his fear of failure, and his drive for success. The reconstruction elucidated to the patient’s intrapsychic fantasies and responses to his pre-adult experiences. He was less confused by his pendulum-like swings between his feeling affluent and indigent, aristocrat and servant, master and slave. The reconstruction did not compete with nor defend against transference interpretation, but advanced understanding of both transference and genetic interpretation. The recovery of dissociated, forgotten, and repressed memories reciprocally facilitated reconstruction. Although Freud noted that reconstruction may serve as a convincing surrogate for a memory that could not be retrieved from repression, his basic premise was developmental and dealt with a forgotten piece of childhood. Freud reconstructed a part of the analysand’s development, with pathogenic or progressive ramifications. Freud’s (1937) formulation went far beyond a single memory or element: “What we are in search of is a picture of the patient’s forgotten years that shall be alike trustworthy and in all essential respects complete” (p. 258). Freud added that the task of the analyst “is to make out what has been forgotten from the traces which it has left behind, or more correctly, to construct it.” Freud (1920) anticipated the contemporary developmental issues in reconstruction, and early differentiated between genetic and developmental perspectives. So long as we trace the development from its final outcome backwards, the chain of events appears continuous and we feel we have gained in insight, which is completely satisfactory or even exhaustive. But if we proceed the reverse way, if we start from the premises inferred from the analysis and try to follow these up to the final result, then we no longer get the impression of an inevitable sequence of events, which could not have been otherwise determined. We notice at once that there might have been another result, and that we might



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have been just as well able to understand and explain the latter. The synthesis is thus not so satisfactory as the analysis. (p. 167)



The problem of reconstructing developmental steps and sequences, of tracing the over-determined numerous factors of pathogenesis both evokes and challenges reconstruction. The issues of genetic fallacy and adultomorphic myth are further complicated by the possible confusion of pathological regression, normal development, and deviant development; by the number of factors and varied strength of forces involved; and by the discontinuities which have to be bridged. Reconstruction is made possible by the wealth of information provided by the analysis. But it is never a singular, veridical “red thread” of connections. The reconstructive inferences depend upon the totality of analytic data, and not just the transference alone, on the elaboration and remodeling of the reconstruction in the crucible of the analytic process. How could this patient understand his master-slave fantasies, his feelings of emasculation and inferiority, his overall preoccupation with narcissistic injury and self-aggrandizement without the affective reconstruction of his childhood? Some of the unresolved analytic issues in this case are of great interest. The genetic interpretations, and the reconstruction to which they were attached, did not fully explain the patient’s psychopathology. So far the classical explanation of the patient’s disorder was in terms of oedipal conflict. Were there not also primary narcissistic and pre-oedipal issues, which were important antecedents of later conflict? Of course the further back into the pre-oedipal period a reconstruction is attempted, the more speculative it inevitably becomes. The earlier the level of reconstruction, the greater the level of conjecture. What was his early experience with his mother? She was stoic in her menial work of cleaning and laundering. Some of the ambivalence toward his father may have been transferred and displaced from his mother. She was not described in warm terms and was regarded as rigid and unempathic. She was quite possibly depressed during his early childhood, hardly playful. It is likely that his feeding, sleeping, and toilet training were rigidly controlled. Was his mother the prototype of the rigid, insensitive, callous nun? Mother could be a Madonna-like figure who protected him from his own impulses, but also an exciting and emasculating prostitute. He stated, “I’m uncomfortable with cracks in the edifice I have created.” Women were cracked, tempting, and dangerous; they were split into degraded pairs of prostitutes and nuns. Only after more analysis could he admit that some of the clergy were dedicated and effective



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educators. There were few if any parties in his childhood, and holidays were not celebrated. He had never had a birthday party, though the patient was aware that the aristocrat’s children on the estate had such parties. His father was not sure about his son’s birthday. The atmosphere of home was somber. His parents’ relationship was not marked by overt affection and friendship, and they were little interested in their children’s feelings. If he did not like the food he was offered, he was expected to eat it without complaint, so that his preferences were largely ignored. In later childhood he was painfully ashamed of his parents and strenuously defended against feelings of shame. His parents conveyed their feelings of denigration to their son, but they and the aristocrats encouraged both his later achievement and entitlement. Transference analysis and reconstruction were synergistic rather than competitive or adversarial. The reconstruction was regarded as mutative, “making a decisive difference in clinical analysis . . . the past within the present is transformed forging a new vision of reality” (Blum, 1994, p. 150). In the process of reconstruction, self-representations as well as object representations from various phases of life are re-evaluated and reintegrated into new and more realistic representations. Not only were the defenses modified, but also the patient’s apperception of his/her inner and outer world. In clinical situations where there has been massive psychic trauma, there may be ego regression and damage to cognitive and affective processes. What the patient cannot remember and articulate has to be laboriously reconstructed. Somatization reactions and non-verbal communication may be at least initially of great importance. Reconstruction may contribute to the retrieval and reorganization of fragmented, distorted, memories, as well as filling in memory gaps. Without the reconstruction of memory what is indescribable and ineffable may be somatized, enacted, or acted-out through the children, the next generation. To avoid a collusion of silent avoidance, reconstruction is required of the trauma, terror, and panic, of the feelings of helplessness, and of the void of protecting or rescuing objects (Grubrich-Simitis, 1981; Krystal, 1991; Blum, 1994). An attempt is made to clarify the details of the traumatic situations, and when necessary, to uncover the intergenerational transmission of trauma, with analytic awareness of inevitable unknowns and ambiguities. Only then can traumatic reality and its fantasy elaboration be integrated into the relatively intact personality. The verbal reconstruction coalesces with step-by-step working-through of trauma and terror. This permits the massive trauma of the past, recalled and re-



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constructed, to belong to the past rather than the ever present. Further analytic reconstruction may encompass prior and subsequent traumatic experience, telescoped into the maelstrom of massive trauma. I shall now turn to the early facilitating value and integrative effects of reconstruction psychoanalysis and in insight oriented psychoanalytic psychotherapy. While it is true that reconstruction is not necessarily a part of psychotherapy as it is in psychoanalysis, reconstruction is often utilized to help the patient become aware of the power and persistence of childhood fantasy and experience into their adult lives. Transference and current reality may take precedence, but at the same time, reconstruction may be necessary to illuminate the transference and the current reality situation, which the patient has helped to create. A borderline patient, who is bitterly critical and contemptuous of the analyst, may not respond to the analyst’s attempts to show the patient that the attacks on the analyst are irrational and unjustified. The psychoanalyst regards the patient’s criticism as part of transference fantasy, whereas the patient believes that the analyst truly merits criticism. The analyst has a negative counter-transference, about which he is inwardly conflicted. The patient has succeeded in eliciting the psychotherapist’s hostility, justifying in his mind his criticism of the analyst. A transference-countertransference stalemate might ensue. There are different approaches to such thorny problems, but early reconstruction can be very helpful, to the psychoanalyst as well as to the patient. This is a departure from the general use of reconstruction after the initial phase of therapy. The exception here is not meant to detract from Freud’s (1940) counsel, “we never fail to make a distinction between our knowledge and his knowledge. We avoid telling him at once things we have often discovered at an early stage, and we avoid telling him the whole of what we think we have discovered. We reflect carefully over when we shall impart the knowledge of one of our constructions to him . . . which is not always easy to decide” (p. 178). Where the patient has experienced a pathogenic relationship with a parent involving regular overdoses of criticism, contempt, and disparagement, the therapist could point out that the patient had experienced withering criticism long before his treatment. His feelings of mistreatment derived not from the present, but predominantly from the past with his parent. The patient has identified with the aggressor and was treating the therapist to the same disparagement to which he was subjected. The patient had become the critical parent and the



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analyst is treated as the child whom the parent holds in contempt of court. Without this reconstruction of a piece of the patient’s childhood, it may not be possible for an ego impaired patient to distance himself from the transference as well as to understand and accept transference interpretation. Furthermore, the reality of a patient being contemptuous and insulting toward others in his life situation, may still be readily subjected to projection and rationalization that the others deserved his animosity. The adult woman who is seductive and exhibitionistic in an erotic transference may have similar dynamics. Seduced by an older brother into sibling sex play, she is now the active seducer. This would be a specific genetic interpretation. She gains control over the analyst in fantasy and unconsciously seeks not so much his falling in love with her, but his downfall. In this case the erotic transference recapitulates the sibling relationship, and defends against an underlying hostile fantasy of emasculating the analyst and destroying his reputation. The reconstruction integrates and explains her seductive behavior as repetition and revenge, weapon and defense, in analysis and in life. Is reconstruction important in the contemporary analytic process as Freud (1937) had earlier proposed? To my mind the reconstructions presented here were essential to the analytic and the therapeutic process and progress. It is difficult to understand how analytic experience without the insights enriched by reconstruction would significantly alter unconscious, unrealistic self and object representations, as proposed by inter-subjective theorists. An emphasis on the mutative effect of the here and now analytic experience takes account of the influence and effect of the analyst’s counter-transference and subjectivity, but with loss of balanced focus on childhood, and patient’s infantile neurotic fantasies and features. The analyst also engages in reciprocal self-examination and counter-transference analysis. The value of reconstruction is exemplified in the clinical material in which the past so prominently influences the present and impinges on the future. Without reconstruction, psychoanalysis tends to become a-historic, dissociated from the infantile unconscious, and the context and shaping of life experience. Reconstruction restores the continuity and cohesion of personal history, correcting personal myths while simultaneously fostering greater and more realistic self-awareness, knowledge, and insight. Spanning life experience, reconstruction integrates past and present, fantasy and reality, cause and effect. Reconstructions are selected from their alternatives on the basis of the convergence of analytic data and of the patient’s response to the



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reconstruction. Individual fantasy and experience may coalesce with universal fantasies and the universals of life experience, but there are always individual variations. This is exemplified in the family romance of the son of servants. A reconstruction should be internally consistent and cohesive, logical and lucid, and closely linked to the prevailing unconscious conflicts and analytic issues. While it may replace gaps in memory, reconstruction has a different contemporary position in the theory of technique, deriving from and applying the genetic and developmental points of view in clinical psychoanalysis. In contemporary psychoanalysis, reconstruction has largely supplanted reliance on the recovery of repressed memory. Patterns are more important in general than are single memories, with the major exception of shock trauma. Reconstruction also has an important current research dimension, testing and potentially integrating analytic data with the findings of infant developmental studies. Validation and conviction are not necessarily achieved. Either analyst, analysand, or researcher may be much more convinced of the validity of a reconstruction than the other persons. While Freud at times shifted positions concerning the relative importance of fantasy and real experience, he never relinquished the importance of trauma. Freud (1926) referred to the sometimes “irrefutable evidence that these occurrences which we inferred really did take place” and he then stated, “The correct reconstruction, you must know, of such forgotten experiences of childhood always has a great therapeutic effect, whether they permit of objective confirmation or not” (p. 216). Unlike the past when non-analytic data tended to be dismissed or scorned as impediments or contaminants in the analytic process, such concerns are no longer regarded as entirely appropriate. External confirmation can be analytically useful and contribute to rational validation and conviction of correct reconstruction (Good, 1998). Patients are stimulated to check and correct reconstructions whenever possible through objective evidence, e.g. of documents and the reports of relatives and witnesses. It is remarkable how often psychoanalytic reconstructions are confirmed and expanded with extra-analytic evidence. However, no source or selection of data is inherently free of distortion. The legal system has painfully learned that eyewitness reports may not be reliable. The past is not only rediscovered but is recreated in clinical psychoanalysis. Memory is remodeled. The past has taken on elaborate new meanings, which did not exist in childhood. Moreover, developmental transformations may not be retrievable in their pristine form. The “second look” (Novey, 1968) at childhood is through analytic



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eyes with the refraction of an adult lens. Though the analytic autobiography is further illuminated and integrated by a particular reconstruction, there are no guarantees in analysis of valid reconstruction or interpretation. Psychoanalysis requires tolerance and evaluation of alternative considerations. Ambiguity and perplexity are part of psychoanalytic work and the quest for greater insight. In addition to Freud’s (1911) two principles of mental function, the pleasure and reality principles, we live and work with the uncertainty principle (Heisenberg, 1958). BIBLIOGRAPHY Blum, H. (1980). The value of reconstruction in adult psychoanalysis. Internat. Psychoanal., 61:39 –54. ——— (1994). Reconstruction in Psychoanalysis. Childhood Revisited and Recreated. New York: International Universities Press. ——— (2000). The reconstruction of reminiscence. J. Amer. Psychoanal. Assn., 47:1125 –1144. Freud, S. (1909). Family romances. S.E., 9. ——— (1919). A child is being beaten. S.E., 17. ——— (1920). The psychogenesis of a case of homosexuality in a woman. S.E., 18. ——— (1926). The problem of lay analysis. S.E., 20. ——— (1937). Constructions in analysis. S.E., 23. ——— (1940). An outline of psychoanalysis. S.E., 23. Frosch, J. (1959). Transference derivatives of the family romance. J. Amer. Psychoanal. Assn., 7:503 –520. Good, M. (1998). Screen reconstructions: Traumatic memory, conviction, and the problem of verification. J. Amer. Psychoanal. Assn., 46:149 –183. Greenacre, P. (1975). On reconstruction. J. Amer. Psychoanal. Assn., 23:693 – 771. Grubrich-Simitis, I. (1981). Extreme traumatization as cumulative trauma: Psychoanalytic investigations of the effects of concentration camp experiences on survivors and their children. Psychoanal. Study Child, 36:415 – 450. Heisenberg, W. (1958). Physics and Philosophy. New York: Harper. Krystal, H. (1991). Integration and self-healing in post-traumatic states: A ten year retrospective. Amer. Imago, 48:93 –118. Laub, D. (1998). The empty circle: Children of survivors and the limits of reconstruction. J. Amer. Psychoanal. Assn., 46:508 – 529. LeDoux, J. (2002). Synaptic Self: How Our Brains Become Who We Are. New York: Viking. Novey, S. (1968). The Second Look. Baltimore: Johns Hopkins University Press.



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If a man carefully examines his thoughts he will be surprised to find how much he lives in the future. His well being is always ahead. —Ralph Waldo Emerson



it seems that only man imagines the “winter of his discontent,” or the “glorious summer.” No other living being can hold an imagined future before the mind, and has the responsibility of its opportunities and dangers. But we who have this comforting and tormenting companion of inner thought extending beyond the moment are never long distracted from glancing toward our horizon, whether in anxiety or hope, impassioned thought or quiet reverie. Even when not pondering in this vein with full deliberation, we often discover we’ve been quietly including the future anyway. The psychology of the future is less developed in psychoanalytic thought, however, than that of past.1 Although there are studies on related topics such as judgment and anticipation, and although attention to the future is implicit in much analytic writing, I found no papers on the specific concept of foresight in the analytic literature. Loewald states that it is the fear of molding the patient in our own image that has prevented analysts from coming to grips with the future. In addition, reconstruction of the past, and recovery of repressed, has been so useful a focus of clinical work. The neurotic part of us is in the grip of the past. In fact, one way to view neurosis is as a truncation of realistic foresight, as the past is repeated over and over again, which validates our imagined fears over and over again. The fact that foresight has often been the province of astrologers, seers, psychics, etc., may also have discouraged serious scientists from attention to the subject. This paper is an introductory effort to explore our concern about the future and to consider what might be reasonable possibilities and limitations of our attempts at foresight. It is not about knowing events in advance, about prediction of specifics, about foreknowledge. It is about forms of anticipation that do not transcend our senses, experience, and judgment. A mature imagination has much to contribute when its limitations are recognized. 1. Emde (1995) notes, “It is only very recently that our contemporary behavioral sciences have become aware that a future orientation in our psychology has been grossly neglected in the twentieth century. A multitude of studies have been done concerning the influence of present and past events on behavior, but we have neglected the influence of the future.”



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Freud observes the difficulties of prediction during the flow of analytic work: So long as we trace the development from its final outcome backwards, the chain of events appears continuous, and we feel we have gained insight which is completely satisfactory and even exhaustive. But if we proceed to reverse the way, if we start from the premises inferred from the analysis and try to follow these up to the final result, then we no longer have the impression of an inevitable sequence of events which could not have been otherwise determined . . . the chain of events can always be recognized with certainty if we follow the line of analysis, whereas to predict along the lines of synthesis is impossible. (Freud 1920)



However, in analysis we do often sense a direction, envision a horizon, and feel that some possibilities exist more than others. These delicate impressions, however, don’t elbow their way in to focused attention, often don’t come in verbal language, and are easily overlooked. They are more like a quiet breath, or a passing fantasy or fleeting image, but may be of surprising value when noted. Sometimes we have a fantasy or image, on the “edge of awareness”2 that later appears in the patient’s associations.3 Often, however, we pay little attention to such impressions. We feel that conscious, secondary process, deliberate thought is the locus of higher mental functions such as insight. The characteristics of conscious, secondary process thought work toward differentiating, separating, categorizing, analyzing, and focus, all processes that restrict the breadth of gaze while also removing us from full involvement. They objectify and detach us from what we study. Primary process thought blends and synthesizes, makes ideas collide, spill over, intermingle, come together, and influence each other over a wide field in a manner in which we remain immersed. One isolates, the other unites, one narrows, the other broadens. In one we step back and observe, in the other we find ourselves involved. Primary process, however, is in practice still viewed with more skepticism among us, and also is not as easily studied since it goes on in a silent realm, revealing its manifestations more than its workings. Secondary process, on the other hand, makes greater use of the lan2. Robert Gardner’s phrase suggests psychic events that one may easily attend to or not. This often depends on delicate circumstances of the moment, such as the state of the therapeutic alliance or the tactfulness of the analyst’s wonderings. 3. Bennett Simon, M.D., has made such an event the subject of an interesting article in Psychoanalytic Inquiry. See Bibliography.



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guage and symbols familiar in the logic and reasoning of conscious life and can be studied, criticized, evaluated, and its products then embraced or cast aside. These reflections begin with some examples from general medicine, psychoanalysis, poetry, and life that suggest the pervasive importance of our concern for the future. Many years ago, as consultant to a medical service, I saw an elderly man who was in the hospital after a stroke. His family had prospered in Germany for many generations, but he had foreseen the coming persecution of the Jews very early in the Nazi era, and moved here with his wife and children soon after Hitler came to power, leaving behind a considerable fortune. Unable to practice his profession here, he started a farm, did well, and was soon on to other ventures. Although we talked only once, his story left a lasting impression. His realism when most anguished, his foresight and ability to act upon it with the sureness of faith in his own judgment, his resilience and capacity for adaptive renunciation, and his gentleness, modesty and essential happiness all spoke of character evoking spontaneous respect. We see a less conscious type of foresight in analysis at times. It is not unusual to see a patient change as if by magic between the initial meeting and the beginning of analysis some time later. The patient is not aware that he or she is reacting to an unconscious assessment of what may happen in analysis, but the awful relationship he first complained about is happy now, the problems at work have been resolved. We learn that the patient has been anticipating, without consciously knowing it, an analytic experience of lost freedom, of insensitive control by an unempathic analyst, and we can expect some form of long negative, or false positive, transference. The patient is in the grip of the past and can hardly believe that today or tomorrow could be different. Much of the work of analysis is to free the future from such influences of the past, or in Loewald’s words, help “ghosts” become “ancestors,” and thus make possible realistic foresight. Unconscious foresight, if one can call it that, may be experienced as a sense of foreboding, or as a welling up of courage or hope, or, as noted earlier, an image on the “edge of awareness,” the surface feelings of deeper happenings. One of the great organizers of our lives is the certainty of time passing and of our own eventual death. We are often eager to modify this certainty, and much of the power of religion has come from promises of some kind of eternal life, or at least measures of consolation for life reaching its end. However, perhaps especially in a scientific age in



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which we doubt ideas of immortality, and religion has more trouble finding a relevant message, many of us have that event hovering in mind, and this influences how we view the future. Religion and poetry each aim at trying to make our present and future more meaningful and the inevitable end more tolerable. Love and death are often the subjects of poetry, and when talking of love the theme of time and perishing is close by, as in these few lines from the famous poem by Andrew Marvell “To His Coy Mistress.” But at my back I always hear Time’s winged chariot hurrying near: And yonder all before us lie Deserts of vast eternity. Thy beauty shall no more be found; Nor, in thy marble vault, shall sound My echoing song: then worms shall try That long preserved virginity, And your quaint honor turned to dust, And into ashes all my lust. The grave’s a fine and private place, But none, I think, do there embrace. Now therefore, while the youthful hue Sits on thy skin like morning dew, [. . .] (The Oxford Book of English Verse, 1902)



The message is not a complicated one. A lesser poet of our day might say something like “hey, let’s get with it babe,” but the arresting images of the poem bring a power and depth of meaning to the argument. Here words are used to evoke images, and the images side by side build a complex new meaning that neither image has alone. Poetry brings together what is usually unrelated, in this case love and death, beauty and perishing, and this synthetic act seems typical of mechanisms we think of as primary process. MacLeish writes, “One image is established by words which make it sensuous and vivid to the eyes or ears or touch—to any of the senses. Another image is put beside it. And a meaning appears which is neither the meaning of one image nor the meaning of the other nor even the sum of both but a consequence of both—a consequence of both in their conjunction, in their relation to each other.” And later, regarding the effect of coupled images, “To carry experience itself alive into the heart is an extraordinary achievement, an achievement neither science nor philosophy has accomplished” (MacLeish 1960, pp. 65, 67). This seems to be brought about by a process akin to condensation, but here it is used in the creation of new meaning rather than for disguise. Poetry



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seems a good example of our concerns about the future as well as the use of tools we would think of as belonging to the primary process: images, symbolization, condensation, displacement. Images carry affect in a way that other symbols cannot do.4 You will probably have imagined by now that I have been trying to suggest some of the ways that images and primary process modes of thought may be important in how we process information consciously and unconsciously. The emergence of images and primary process in regression of thought and for purposes of disguise has been emphasized and well developed in analytic thought, but this may be only an aspect of their importance. Perhaps a way to welcome primary process mechanisms that is more comprehensive and less tentative than “regression in the service of the ego” would extend our reach as analysts. In Keats, Frost, Emily Dickinson, Shakespeare we repeatedly feel the search for the eternal moment, the timelessness of the primary process, in the continually perishing beauty of the world. Paul Ricoeur writes: because history is tied to the contingent it misses the essential, whereas poetry, not being the slave of the real event, can address itself directly to the universal, ie: to what a certain kind of person would likely or necessarily say or do. (Ricoeur 1995)



Poetry has a truth arising from its ability to reach beyond the welter of daily events into the essence of things and the timelessness of the truth it finds seems to include some concern to help us bear the unbearable aspect of the future. As poetry leaps into what is timeless it includes essences of past, present, and future. “The Wasteland,” by T. S. Eliot had a profound impact not only as a statement of the present day but of ominous trends leading into the future. A Brief Diversion into History While the “contingent” events of history in themselves may miss the essential, or draw us away into details, we also do infer from these events some important truths. Machiavelli, in The Prince, discusses the disadvantages of using auxiliaries and mercenaries in warfare, and writes: 4. Pinchas Noy has written about the need to concretize in order to carry affect. The intellectualization of the obsessional bores us because of its distance from the moment of real experience.



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But man’s little foresight will initiate a project which at the start seems good, but it does not notice the poison that is underlying it: . . . And so whoever does not recognize evils when they arise in a principality is not truly wise, and this ability is given to few. [He goes on to describe causes leading to the overthrow of the Roman Empire—a principal one being the employment of Gothic mercenaries.] (Machiavelli, p. 177)



History provides many examples of the success and failure of foresight. We owe much to James Madison in the design of our Constitution. His profound knowledge of good and evil in human affairs, and his awareness that greed and power would be avidly sought unless contained, along with intensive study of the various structures of government that attempt to channel such motives, enabled him more than anyone to see the long-range implications of the various plans put forward at the Convention. Early in his career Napoleon had shown a high degree of foresight. Later, in the Russian campaign, when his army of 433,000 was destroyed and only 10,000 half-frozen and starving men escaped, we see many examples of the deterioration of this faculty, of valuable foresight ignored or rejected, and of foresight used to ultimate victory by the opposing General Kutuzov. This is described in the remarkable journal of General Caulaincourt, one of Napoleon’s closest aides. Once he had an idea implanted in his head, the Emperor was carried away by his own illusion. He cherished it, caressed it, became obsessed with it, one might say he exuded it from all his pores. . . . Never have a man’s reason and judgment been more misguided, more led astray, more the victim of his imagination and passion, than the reasoned judgment of the Emperor on certain questions. (Caulaincourt 1935, p. 28)



Caulaincourt anticipated the probable course of the campaign. He knew the vast area into which the Russians could withdraw, the fierce cold of the Russian winter, and the terrible revenge peasants would inflict on any stragglers. He describes the disastrous result of failing to provide for such small necessities as horseshoes with spikes, suitable for travel on ice. Horses were unable to haul wagons up frozen inclines and many supplies had to be abandoned. The Russian campaign was after Napoleon’s great successes but while he was still a relatively young man. He had been famous for his ability to visualize how a battle was likely to evolve the next day. But foresight is a fragile process, easily lost or perhaps disrupted by the



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hubris that may flower with success. Its loss was revealed in many ways in the months to come. . . . the Emperor could not or would not show a trace of foresight. There is no doubt that we should have preserved much more undamaged if we had made the necessary sacrifices in time. But to two or three unfortunate horses we allotted guns and waggons that needed six, and by not abandoning one or two guns and waggons at the proper time, we lost four or five a few days later. We planned for the day only; and because we refused, as the saying is, to give the devil his due, we paid heavily in the end to the enemy. (Caulaincourt, p. 208)



Although the focus of this paper is the concept and process of foresight, Napoleon’s campaigns suggest another subject of importance, that of the factors that influence its adaptational use. In one of her last books, The March of Folly, Barbara Tuchman describes how great events are often determined by people who cling, through vanity or what she calls “wooden-headedness,” to plans seen by others at the time to be unworkable. Britain’s loss of the American Colonies, the intransigence and corruption of the Renaissance Popes that led to the Reformation, the Vietnam war, the Japanese attack on Pearl Harbor, which someone described as “destined only to awaken a sleeping giant,” all took place when those in power would not listen to reasonable foresight. Her meticulous gathering of evidence is compelling, and one senses that she was doing what she could to awaken a world moving mindlessly toward great dangers.5 Toynbee emphasizes the need for a currently felt challenge to evoke creative response. Apparently he feels our imagination mostly slumbers when long-range adaptation is concerned, and this contributes to the rise and fall of civilizations. 5. Such problems envelop us today, as science and technology grow in power, controlled by an economic system that feeds on the demand for constant growth and ever increasing private profit, with little consideration of long range consequences to a finite and fragile world. So we see the problems of global warming, environmental destruction, genetic engineering, rapid transmission of world diseases, enormous inequality of wealth, loss of species, changes in family structure brought on by economic forces, all with little effective consideration of risks until they appear as crises. Science has been so triumphant that we may have lost perspective about its limitations, some of which lie particularly in the difficulty of applying the scientific method to highly complex interdependent systems in which small changes may have massive but often slowly developing effects. Yet in idealizing science we have also given up much of our reliance upon expert experience, and upon the foresight of wisdom. Thus we run great dangers with calmness.



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Lack of foresight makes us more merry. (Oxford English Dictionary) In warm climates, nature being bountiful, there is no need of foresight. (Oxford English Dictionary)



On a more optimistic note we have in the recent past the example of George Kennan. An article in the New York Review of Books, April 26, 2001, entitled “A Memorandum for the Minister” describes how in 1932 Kennan, then a 28-year-old member of the delegation at Riga, Latvia, analyzed the deficiencies of the radical Soviet policies then being implemented in Russia. It showed how destruction of the existing tradition and ideals that ground a coherence of life, on the one hand, and how the failure to provide new sources of psychological and moral elements necessary for a healthy society were likely to cause the eventual failure and collapse of the Russian-Communist system. This perspective became the basis of our containment policy, which reflected an understanding of these inherent deficiencies. As head of the policy planning group at the State Department when Marshall was Secretary, Kennan was also the primary architect of the Marshall Plan. It is hard to think of another person whose foresight and wisdom has had such a vast and benevolent effect on events of the last century. Analysts know the hazards of believing that we know what would be best for another person. Jane Austen illustrates the wisdom of humility in this regard with a beautiful passage from her last novel, Persuasion. Advised by a well-meaning aunt, Lady Russell, Anne had sacrificed a deep love when she was young. As the years went by, as the bloom of youth faded, but confidence in her own judgment grew, Anne felt she had made the most unfortunate mistake of her life. It is an all too common story. She would not give such advice in a similar situation. “How eloquent would Anne Eliot have been, how eloquent, at least, were her wishes on the side of early warm attachment, and a cheerful confidence in futurity, against the over-anxious caution which seems to insult exertion and distrust Providence!” (Austen, p. 34) Loewald also expressed faith in our ability to use our faculties with hopeful confidence, and places it at the very center of analytic work. He finds that the possibility of beneficial change springs from the analyst’s appreciation of the unknown, undeveloped potential, on the analyst’s vision of the patient’s future. The parent ideally is in an empathic relationship of understanding the child’s particular stage in development, yet ahead in his vision of



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the child’s future and mediating this vision to the child in his dealings with him . . . The child, by internalizing aspects of the parent, also internalizes the parent’s image of the child . . . (Loewald 1960, p. 20)



He comments on the many ways such interactions occur and writes: In analysis, if it is to be a process leading to structural changes, interactions of a comparable nature (comparable to parent-child interactions) have to take place . . . the analyst relates . . . always from the viewpoint of potential growth, that is, from the viewpoint of the future. (Loewald 1960, p. 21)



What a lovely project it would be to explore how we develop and communicate this vision of the patient’s future, how we come to see the potentials of character, of intellect and feeling, and nourish them while respecting their freedom, and how we responsibly imagine a small kernel of talent blossoming with maturity.6 It would take considerable artistry to provide examples because such interactions are subtle and complex. These examples are presented to suggest that we are deeply concerned about the future and that much of life is influenced in the light of our assessment of that great unknown. In addition, much remains to be learned about the functional properties of the image, the major medium of the primary process. It may be useful to consider more deeply the role of the primary process in addition to that of disguise and defensive regression. It seems likely that these three issues, the future, the function of the image in thought, and the primary process, are all related. The Form That Foresight Takes in Conscious Life How do we experience a view of what may become manifest in the future? The future is all tendency and possibility, but these are at least 6. James Engell, in a beautiful scholarly book The Creative Imagination, writes: “Coleridge deals with one of the most curious and fascinating properties of the imagination: it is even more powerful as an idea when described in its own terms.” If the imagination is a higher power than reason (as the Romantics said), and every higher power includes the lower power, then reason cannot express its comprehension of the imaginative power. He quotes Coleridge, “They and they only can acquire the philosophic imagination, the sacred power of self-intuition, who within themselves can interpret and understand the symbol, that the wings of the air-sylph are forming within the skin of the caterpillar: those only who feel in their own spirits the same instinct which impel the chrysalis of the horned-fly to leave room in its involucrum for antennae yet to come. They know and feel, that the potential works in them, even as the actual works on them.” (Engell 1981, pp. 346 – 47)



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in part expressions of what we know from the past and what we see today. To approach a vision of the future is to embrace in thought and feeling many variables that differ in weight and quality, to have easy access to different contexts, and to weigh facts that are constantly changing. What form may this take? As with so many human issues, Shakespeare provides a rich example. In Richard II, the King has neither consolidated his power nor gained the confidence of his subjects. His decisions vacillate. He has just banished a powerful Lord, and then gone to quell a rebellion in Ireland. The Queen feels disaster approaching, without being able to specify why, or what form it might take. Lord Bushy urges her to “lay aside life-harming heaviness.” Queen: “I cannot do it, yet I know no cause Why I should welcome such a guest as grief, . . .” Some unborn sorrow, ripe in fortune’s womb, Is coming towards me; and my inward soul With nothing trembles; at something it grieves.”



After some time news comes that the exiled Lord Bolingbroke has landed with an army and the other Lords are flocking to him. The King’s power is quickly evaporating. Queen: Now hath my soul brought forth her prodigy;7 And I, a gasping new-delivered mother, Have woe to woe, sorrow to sorrow join’d.’ Lord Bushy: “Despair not, Madam.’ Queen: “Who shall hinder me? I will despair, and be at enmity With cozening hope, he is a flatterer, A parasite, a keeper back of death.” (Shakespeare, p. 44)



The Queen is feeling disaster ahead without being able to name specific causes or outcome. Her realism, refusal to accept false hope, her trust in her own feelings without elaborating them into specific fantasied disasters as a paranoid person would do so exuberantly, all seem noteworthy. Her character seems comparable to that of Oedipus or Hamlet in its requirement that she see the world without illusions. She is sensing tendencies, directions that are probably in their essence if not predictable in their particulars, in a complex situation, at some level of thinking that is not logical in a way we could describe but that has validity even as it is nourished in unknown ways. Some 7. The Yale Shakespeare Edition of The Tragedy of King Richard the Second, edited by Robert T. Petersson, explains that prodigy as used here means “monster.”



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people would call it intuition but that tells us little about the processes involved. “Inward soul” suggests its central place, one that concerns us deeply. How can one approach thinking of this kind, and learn how it operates in our “inward soul”? It is elusive, and emerges from and recedes into silence. We often seem in awe of it, cautious, fascinated at times, aware of its power, skeptical of its reliability. We are sometimes glad in our uncertainty to defer to someone else, and astrologers, oracles, psychics, pundits, ‘authorities’ of all stripe abound and play upon the irreducible doubt that is realistically part of such an assessment.8 We also yearn to dismiss such ominous intimations as the Queen describes, or to welcome hopes unreasonably when they are pleasant, and are helped in both directions by well-meaning friends. Perhaps we trust such ‘thinking’ less in our scientific age, when conscious reasoning is valued most highly, and some incline to believe that everything should either be certain and scientifically proven or not entertained at all. Serious consideration of such thinking must ultimately involve some wager of faith, yet it is not blind faith, but faith in our reality sense and judgment. We can never remove all doubt, however, since we are often led astray by hopes and fears, hubris or timidity, and since contingencies that impinge on future events can never be eliminated. In analysis, I felt more grounded when I thought I was working like a Maine guide, or a coastal fisherman. A Maine guide is in a wilderness situation but still “knows” we may soon see a bear in the region, although he might not be able to give reasons. Perhaps it is the unusual quiet, or the nervousness of other animals, but through an absorption of multiple perceptions he has knowledge worth taking seriously. In analysis we sometimes have a similar sense of what may emerge. Perhaps our level of comfort is changing, or we become aware that a determined clock-watcher hasn’t mentioned time for several weeks, and realize that the middle phase is upon us with all its increased trust and greater terrors, or we notice that a patient occasionally talks about how things were earlier in analysis, using the past tense, and sense that the sadness and rebuke of termination is soon to come. These changes in analysis, small in all but significance, are like the snow-drop, the first tiny flower of late winter, coming up of8. American analysis has a long history of concern with what is referred to as “wild analysis,” and the ready association of “foresight” with unscientific modes of thought may have contributed to the lack of attention to this subject.



On Foresight CORNELIS HEIJN, M.D.



Examples of our interest in the future are drawn from poetry, religion, general medicine, and from the aims of psychoanalysis. The concept of foresight is taken as a focus for questions regarding the relative inattention to a psychology of the future in psychoanalytic thought. This inquiry leads to consideration of the varying constraints and potentials that are determined by the formal properties of verbal language and mental images, which are briefly compared and contrasted in regard to their usefulness in understanding complex dynamic systems such as psychoanalysis. The paper concludes with questions regarding the qualities of conscious and unconscious, and secondary and primary process thought, and with comments on technique. I stopped short in the woods today to admire how the trees grow up without forethought, regardless of the time and circumstances. They do not wait, as men do. Now is the golden age of the sapling: earth, air, sun, and rain are occasion enough. They were no better in primeval centuries. “The winter of their discontent” never comes. Witness the buds of the native poplar, standing gaily out to the frost, on the sides of its bare switches. They express a native confidence. —Thoreau’s Journal, January 2, 1841



Clinical Professor Emeritus, Tufts University School of Medicine. An earlier version of this paper was presented at the Western New England Institute and Society in November 2000. I have greatly benefited from the superb discussion there by Dr. David Carlson. The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).



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ten unnoticed through the snow itself, the harbinger of spring long before the great explosion of life in May. I find that I noticed these subtle changes more explicitly when hearing about a case in supervision than when involved as analyst, but I must have been potentially aware of them then as well, and were there time again would want to cultivate this delicate function of the “analyzing instrument.”9 These intimations may be compared with creative activity in other fields such as painting, poetry, or scientific discovery. All involve the arrival of new meaning before it is obvious and forced upon us. German Expressionist painting, for example, seems to embody forces and directions at work between the wars. Its dark and brooding quality, the inexorable sense of brutality and violence close at hand, seems to foreshadow the cruelty to come. Or Van Gogh’s late painting of crows over the wheatfields, with the road leading into emptiness, conveys, to this viewer at least, an aloneness beyond loneliness that makes his suicide seem understandable if not predictable.10 A few scientists have recognized the limitations of the scientific method, which at least apparently is dominated by the secondary process, for the study of complex dynamic living systems. convenient characteristics of physical nature bring it about that vast ranges of phenomena can be satisfactorily handled by linear algebraic or differential equations, often involving only one or two dependent variables; they also make the handling safe in the sense that small errors are unlikely to propagate, go wild and prove disastrous. Animate nature, on the other hand, presents highly complex and highly coupled systems—these are, in fact, dominant characteristics of what we call organisms. It takes a lot of variables to describe a man, or, for that matter, a virus; and you cannot often study these variables two at a time. Animate nature also exhibits very confusing instabilities, as students of history or the stock market, or genetics are well aware. (Weaver 1955, p. 1256)



(He might have included psychoanalysis as an example of highly complex, highly coupled systems.) 9. Often the conscious insight comes as the patient is leaving. How often have I wished to call a patient back when the meaning of an hour suddenly crystallizes. I saw this as a failure of my listening, now I see it more as a change in the state of the “analyzing instrument.” There is much evidence to suggest that creative insights often come during a transitional state between involvement and detachment. We analysts have “wax in the third ear” much of the time. 10. A friend has observed that the roads in Van Gogh’s painting, which I saw as leading nowhere, could also be seen as leading anywhere and everywhere. We need always to weigh the subjectivity of our judgments in such matters.



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Mathematics has begun to approach elucidation of dynamic systems through the development of catastrophe theory, and chaos and complexity theory, and may be coming closer to providing methods congenial to the study of psychoanalysis. It is interesting that each of these new theories makes extensive use of images to convey the essence of their concepts.11 Abstract Symbols and Images What might be some differences between the functional possibilities of various symbolic forms? For instance, if we compare and contrast mathematical symbols, words, and images, what tasks are best approached with which medium? Mathematical symbols have beautiful clarity and precision, and purity of form and meaning. A number, or a constant such as pi, or a function seem to mean precisely one thing and nothing else. It therefore has a universal, lifeless, and timeless meaning that seems to approach Plato’s ideal forms. It is, however, detached from the unique thing it is used to describe, and is impersonal. It deals with the relations between things rather than with the things themselves. Where what is being studied moves around and won’t sit still to be measured, mathematics has developed probability theory and statistics, so that without giving up the exactness of its tools it recognizes that unique things may differ, and so provides us with levels of confidence. While mathematics can help us predict and control many aspects of our surroundings and thus seems most closely allied with science as it has developed so far, it loses touch with the teeming activity of life. For most of us it resides in an ethereal world, and we cannot swear or make love mathematically, and rarely communicate with our friends by equations. With words we let in our passions, and our wish to communicate or mislead. They are the bridge to friend and enemy. Words have a relatively consensual meaning, although even dictionaries differ some, but their meaning can often change gradually, so a word once rich with meaning can become empty over time. The meaning of words is often highly dependent on context. Words also mean something different to each of us as our individual experiences get at11. If one considers the essence of science not only as it is embodies in the scientific method, but in the scientific conscience, with the ideal of putting aside wishes, fears, and pride in the search for truth, psychoanalysts systematically cultivate this scientific ideal, with more or less effect, in the analysis of counter-transference.



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tached to them, and their usefulness depends upon the degree of shared meaning. Words can reach deep down and evoke feeling or can stay in an airy realm as lifeless as mathematics, but rarely reach such a high degree of precision and universality. When a word does evoke a feeling it is often by touching upon an image. Ferenczi has written about “obscene words,” which are connected to emotion and to images, and some of us would agree that a word like “shit-head” has a different impact than “Mercy, Abigail” or “goodness-gracious.” Words are thus well suited to reveal or conceal as they move closer or further away from reality and from the depths. But in spite of the great flexibility of words they have limitations.12 The Taj Mahal, for example, could perhaps be accurately described in words and mathematical symbols, although this exercise would be lengthy and not very interesting, and its beauty and significance as a loving memorial would vanish. The image of the Taj Mahal has an economy, immediacy, and human meaning that is entirely different. In his poem The Study of Images, Wallace Stevens writes: in images we awake, within the very object that we seek. Participants of its being. (Collected Poems, p. 463)



So the image can achieve much of the precision and clarity of mathematical symbols, but also partakes directly of the thing itself. It is not as severe an abstraction, removed, but a depiction, involved; analog not digital. It is capable of infinite degrees of change and molding without loss of precision. However, we have whole disciplines of linguistics and mathematics but as yet little theory of the image. As Ricoeur writes: We are “. . . heirs of a tradition that sees the image as a residue of perception or as the trace of an impression” and the “old psychology of the image as a revivication of a perceptual trace resists the psychoanalytic discovery of the constructed character of the fantasm,” “. . . the universe of discourse appropriate to the analytic experience is not that of language but that of the image. Unfortunately, however, we do not yet possess a theory of the image and the imagination” (Ricoeur 1978).



12. A valuable study of the limitations of words in grasping reality, in reflecting our inner thought processes, and in communicating with others, is found in the book by Ben-Ami Scharfstein (1993).



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The Study of Mental Imagery David Hume asserted in the eighteenth century that a mental image was only the trace of a perception, not modified by processes of an active mind. The subject evoked little interest until William James ridiculed this view, and devoted several chapters in his great text on psychology to the functions of mental imagery in thinking and creativity. Later, however, Watson declared that only observable behavior was deserving of serious study, and such “airy nothings” as mental images were again neglected by psychology until the poverty of the strict behaviorist view became apparent. About thirty years ago a debate broke out over the question of how to define the basic elements of information storage and processing within the brain. One group, including many who were interested in the computer as a model, argued that there were no depictive, or image-like representations in the brain, and that images we experience are an epiphenomenon of information processing that is at the basic level propositional. Another group felt that images are not epiphenomena but are actively involved in memory and thought. A convergence of findings from many studies, and conclusively from Positron Emission Tomography, have shown that visual images are anatomically localized in the visual cortex, and similarly in other areas where vision is broken down and processed, in a pattern similar to their location on the retina, and these areas are used in reverse in the creation of mental images.13 So it seems that there are at least two anatomical systems for processing information, one involving the symbols, signs, and rules of language and the other, a more private and solitary one, for mental images. The Image in Analytic Thought Freud described the mechanisms of symbolization, condensation, and displacement which seem among his most important and enduring discoveries. His focus was on their role in the service of disguise of the conflicted and repressed, as these were believed to induce a regression to the visual. Analytic interest has subsequently been weighted toward the recovery of the repressed and interpretation of 13. This debate and its resolution are admirably described in Image and Brain, S. Kosslyn. It no longer seems beyond possibility that some day an external observer will be able to view another’s dreams.



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the latent content, which the manifest content was, according to this theory, structured to conceal. The value of these mechanisms for other purposes has rarely been explored, and sometimes disavowed. Greenberg and Pearlman, using as an example information from the Freud-Fleiss letters about the Irma dream, show that Freud was wrestling with the same issues in the manifest as in the latent content without recognizing that fact himself. They conclude that the “distinction between manifest and latent in the formation of dreams should be reconsidered” and “the concepts of dream censor and of drive discharge no longer seem necessary to our understanding of dream formation.” An implication seems to be that the image is a different way of placing our concerns before the mind but that the function of disguise is overdrawn (Greenberg and Pearlman 1978). The analytic literature emphasizes the primacy of conscious thought as a prerequisite to insight. (I am assuming a relationship between foresight and insight, an aspect of foresight being insight into hypothetical situations cast into the future.) Freud writes: It is misleading to say that dreams are concerned with the tasks of life before us or seek to find a solution for the problems of our daily work. Useful work of this sort is as remote from dreams as is any intention of conveying information to another person. When a dream deals with a problem of actual life, it solves it in the manner of an irrational wish and not in the manner of a reasonable reflection. The dream work is not simply more careless, more irrational, more forgetful and more incomplete than waking thought; it is completely different from it qualitatively and for that reason not comparable with it. It does not think, calculate or judge in anyway at all; it restricts itself to giving things a new form. (Freud 1931)



Many still accept this sharp parceling out of our mental functions as in this statement by Edward Joseph in his Presidential Plenary address at the American Psychoanalytic Association. “becoming conscious of a particular mental product is always a prerequisite to insight. The unanimity of psychoanalytic writers on this score was impressive” (Joseph 1987). Other authors: Rangell, Dorpat, Weiss express contrasting views, however, and include perception, reason, judgment, insight, realism in unconscious thought. Rangell (1989) writes, “While there is a widespread resistance to the idea of secondary process functioning in the unconscious, I am astonished and perplexed as to how a practicing psychoanalyst can do without it” (p. 197). And “Insight does not always, or promptly, or even eventually become conscious” (p. 198). He would extend our understanding of the workings of the unconscious to include evaluating, planning, problem solving, and executing action.



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Dorpat states that “most often reception, registration, and response to stimulation occur outside conscious awareness.” His “cognitive arrest theory” postulates arrest of perceptual and cognitive processes before the stage of conscious awareness but “the earlier phases of the transformations of the sensory information remain intact and unaffected by the action of denial,” and contradicts Freud’s idea that the denier first forms a normal, conscious percept and later disavows and distorts the percept. Evaluation, judgment, development of implications are going on in a pre-verbal mode of thinking out of consciousness (Dorpat 1985, p. 28). Joseph Weiss (1993) finds the “unconscious control hypothesis” most consistent with clinical experience. This assumes that a person is unconsciously able to use his higher mental functions and brings repressed contents to consciousness when he unconsciously decides he may safely experience them. This points away from emphasis of correct interpretation to emphasis on unconscious judgments of safety for release of repressed and clinical progress. These authors all seem convinced that higher mental functions operate in the unconscious. Although our age considers the scientist as the highest form of rational man, and the scientific method as the surest way to truth, scientific discovery, as distinct from method, appears often to rely on processes that are not conscious and deliberate, and that involve thinking with images. There are many anecdotes about this in biographies of scientists, sometimes told with embarrassment because dreaming is not always recognized by a serious scientist as an honorable way to think. One morning, as Einstein got out of bed, he imagined a man falling off the roof past his window, and realized that he could not tell from the percept alone whether the man was falling or the house was rising, an image including the concept of relativity. In response to an inquiry about his thought processes, he said, “The words of the language, as they are written or spoken, do not seem to play any role in my mechanism of thought. The physical entities which seem to serve as elements in thought are certain signs and more or less clear images which can be ‘voluntarily’ reproduced and combined. . . . Conventional words or other signs have to be sought for laboriously only in a secondary stage” (1974, pp. 25 –26). Edison, ever the inventor, invented a way to capture his hypnagogic hallucinations because he found they often contained the solution to a problem he had been pondering. He took frequent cat-naps in his chair, holding steel balls in his hands over metal plates on the floor. At the moment of sleep onset, when all the muscles relax, they



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would make a great clatter and wake him up while the hallucination was still vivid. Our thought when expressed in words is more open to our examination than is our thinking in images. How often do we inquire about the formal qualities of dreams, their skill and accuracy? Perhaps some of us dream with the fidelity of Vermeer, others with the skill of a Sunday painter. Books by Arthur Koestler and Harold Rugg outline steps in the creative process. This usually begins with intense study and conscious efforts to solve a problem, then follows a continuing sense of puzzlement, a feeling that things do not fit. Eventually there is a turning away from the problem, and at an unpredictable point what Rugg calls a “flash of insight” and Koestler the “Eureka phenomenon” ensues, usually during some not fully alert focused state, one that Rugg calls “trans-liminal.” 14 While there are many descriptions of the phenomenon, it is very difficult to study the underlying process. When we dwell in the secondary process we are aware that past and future exist and feel the affects of grief and hope that accompany awareness of time. When our experience is connected to primary process we feel no past or future in the same reflective sense, and people long gone may appear as they were. We dwell then outside of time or, as Loewald says, in eternity, the absence of time. Remote aspects from the full granary of related past experience may enter the present. The potentials of having at our aid all the related experience of our lives, fresh and vital in the immediate moment, to be felt and worked with in a plastic medium capable of an infinite variety of shades, forms, and intensities, all with deep involvement but without the distraction of troubling feelings of loss, disappointment, ambition, or the limitations of time, such as we feel when awake, would seem a great advantage for some issues, allowing integration of related experience, help from past experience. Perhaps wisdom, beyond intelligence and knowledge, depends upon such thinking involving the primary process. In the dream as in a good play we have this intense absorption in what is happening and the relevant events from all our life experience seem to be effortlessly before us, drawn together as by a magnet, in a fluid medium capable of infinite variation and great preci14. This immediacy of insight may have contributed to the belief that some people of genius seem to work effortlessly. In fact, while talent is needed, hard work and much preparation are essential preparation for creative work.



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sion. We have no sense of authorship even as we are the director, painter, and only audience of our dream. Awareness of today’s reality is in suspension, and we can’t step back from the dream reflectively and ask if our thinking partakes of our usual standards of logic, honesty, balance, and earnestness. That sort of detached critical thinking seems absent from the dream state. One man did remark on the exquisite beauty and realism of the women in his dreams, and on the blends of deep color that seemed to reflect mood as truly as in a Bergman film. The rational part of us, however, tends to dismiss the dream upon awakening. Why we would be so grasped and take so seriously something that we then may dismiss as “just a dream” is not entirely clear. A man prior to analysis had always dismissed his anxiety dreams as nightmares, and was glad to be removed from them on waking up. As he became more introspective he wondered if they were trying to warn him about something worth attending to. Eventually he thought they were wiser than he was. They seemed repeatedly to be trying to alert him to the possibility that he might continue to fritter away his precious time, indeed his life. They returned at moments of important choice to the theme of the undone thesis, the first major instance of avoidance due to anxiety, an avoidance that had resulted in a half-hearted and failed effort and lifelong regret. At times of potential achievement in later life his dreams might offer him a second chance at courses he had neglected, but then would show him forgetting to go to class or sleeping through the exams. He felt that his dreams kept him in touch with both the opportunities and danger in his current situation, the danger that he might again avoid a challenge. Finally, we might renew an inquiry into what standards of honesty, realism, and judgment can guide our thoughts when we think in images. It is true that the logical forms and structures of verbal language are lacking but this is inherent in the formal qualities of images, and is not in itself reason to question the integrity and balance, honesty or realism, of thought in this mode. Musings and Concluding Remarks Psychoanalysts and their patients know the difficulties of gaining insight, which never seems complete and is always subject to revision. In this arduous quest, however, the relevant facts are at least potentially available to the resourceful and determined inquirer since they all lie within the present or the past. Even so, with our varying per-



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ceptions, imperfect judgment, revision of memory, skill at self-deception, tendency to leap to theory or preconceived explanation, etc., the gaining of insight is full of difficulty and must always be tentative. Much understanding of life escapes our best efforts and remains a mystery. We know this well in analytic work but it is equally true of human behavior on the larger scale. Historical events are not only difficult to foresee but explanations after the fact often seem simplistic and inadequate, often following the personal predilections of the historian. Imagine then the added difficulty achieving reliable foresight, where the problem is still developing in a constantly changing world and some relevant facts have yet to be born. Here we sense the need for abilities and qualities of character in a new dimension of realism and imagination. I have gradually come to feel that some of the distinctions between consciousness and the unconscious, and between primary and secondary process lie more in the nature of the medium of thought than in the quality and validity of thought. It has been more useful clinically to work as if we can be as sane, honest, and integrated in our imagery as in our wordiness. The idea of the dream as a “normal psychosis” or as lacking in judgment leads us away from the positive value of the dream and other mental images. I think I worked better when I saw us all struggling to find meaning, and to reveal and conceal from others and ourselves in any of the modes we have available. I worked best when I thought of analysis not as a “science of suspicion” but as a science of discovery. To view the patient as split into such different portions as to require a science of suspicion leads to such notions as resistance, pleasure principle vs. reality principle, censor, dream work as disguise, and analyst as general, surgeon, hunter or trapper. To experience it as a science of discovery, while still with ample difficulty, leads to notions of acceptance rather than hard earned neutrality, to mutuality in the process of inquiry, to curiosity and wonder, and to the analyst as good traveling companion, gardener, wilderness guide, or assistant analyst to the patient who is the true analyst.15 One of my last patients said that her analysis had been like a “treasure hunt.” While pain, sorrow, and chance of tragedy cannot be eliminated, analysis can also be a joyous adventure.



15. The concept of analyst as assistant-analyst to the patient originated with Robert Gardner.



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BIBLIOGRAPHY Austen, J. (1933). Persuasion. Macmillan and Co. Limited. Caulaincourt. (1935). Ed. George Libaire. With Napoleon in Russia. William Morrow and Co. Inc. Dorpat, T. (1985). Denial and Defense in the Therapeutic Situation. Jason Aronson. Einstein, A. (1974). Ideas and Opinions. Bonanza Books. Emde, Robert N. (1995). Fantasy and Beyond. On Freud’s “Creative Writers and Day Dreaming.” Yale University Press. Engell, J. (1981). The Creative Imagination. Harvard University Press. Freud, S. (1920). A Case of Homosexuality in a Woman. S.E. 15:182. ——— (1933). The Interpretation of Dreams. Third English Revision, Basic Books, Avon Edition 1963. Greenberg, R. & Pearlman, C. (1978). If Freud Only Knew: A Reconsideration of Psychoanalytic Dream Theory. Int. Rev. Psychoanalysis. 5:71–76. James, W. (1890). The Principles of Psychology. Henry Holt and Co. Joseph, E. (1987). The Consciousness of Being Conscious. J.A.P.A. 35:5 –22. Koestler, A. (1964). The Act of Creation. Arkana Press. Kosslyn, S. (1994). Image and Brain. M.I.T. Press. Loewald, H. (1960). On the Therapeutic Action of Psychoanalysis. Int. Journal Psychoanalysis. XLI: 16 –33. Machiavelli, N. (1964). The Prince, translated and edited by Mark Musa. St. Martin’s Press. MacLeish, A. (1961). Poetry and Experience. Riverside Press, Houghton-Mifflin. Marvell, A. (1902). The Oxford Book of English Verse, chosen and edited by A. T. Quiller-Couch. Clarendon Press. Noy, P. (1978). Insight and Creativity. J.A.P.A. 26:717–748. Rangell, L. (1989). Action Theory within the Structural View. Int. J. Psychoanalysis, vol. 70:189 –203. Ricoeur, P. (1978). Image and Language in Psychoanalysis. Psychoanalysis and the Humanities. Ed. by J. H. Smith. Yale University Press. ——— (1995). Figuring the Sacred. Fortress Press. Rugg, H. (1963). Imagination. Harper and Row. Scharfstein, B. (1993). Ineffability: The Failure of Words in Philosophy and Religion. State University of New York Press. Selye, H. (1964). From Dream to Discovery: On Being a Scientist. McGraw Hill. Shakespeare, W. (1921). The Tragedy of King Richard the Second. Yale University Press. Simon, B. (1987). Confluence of Visual Image between Patient and Analyst; Communication or Failed Communication. Psychoanalytic Inquiry. 1:471– 488. Stevens, W. (1982). Study of Images I. The Collected Poems. Vintage Books Edition. Originally published by Alfred A. Knopf, Inc., 1954. Tuchman, B. (1984). The March of Folly. Knopf. Waelder, R. (1960). Basic Theory of Psychoanalysis. International Universities Press.



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Weaver, W. (1955). Science and People. Science. 122:1256. Charles Scribner’s Sons. Weiss, J. (1988). Testing Hypotheses about Unconscious Mental Functioning. Int. J. Psa. 69:87–95. ——— (1993). Empirical Studies of the Psychoanalytic Process. J.A.P.A. 41:7–30. West, T. (1997). In the Mind’s Eye: Visual Thinkers, Gifted People with Dyslexia and Other Learning Difficulties. Prometheus Books.



Index



Abandonment, 266, 269, 274 –276, 280 – 282, 286 Abusive behavior, 269 –270, 272, 302 Adolescents. See also Latency development: attitudes toward therapy, 164 –165, 169 – 171, 173; cognitive remediation, 239 – 260; latency development, 179 –180; neurocognitive problems, 239 –241; psychic trauma, 263 –290; relational trauma, 251 Adult Attachment Interview, 104 Adult narratives, 119 Aggressiveness: as defense mechanism, 263, 266 –267, 269 –272, 275 –276, 281– 283, 286, 288 –290; latency development, 179, 188, 190 –192, 194, 196 –198, 201– 202; Natalie (case study), 246 –250, 253 – 254 Ainsworth, M., 16 Alcoholism, 110 –111 Ames, L., 183, 195, 205 Analytic third, 215 Anger management, 201–202, 227, 231– 232, 267–269. See also Aggressiveness Animal Farm (Orwell), 250 –251 Anna Freud Centre, 50, 161 Anthropomorphism, 184, 190, 195–196 Anxiety. See also Death anxiety: Andy (case study), 232; as defense mechanism, 263, 266 –267, 269 –275, 287–290; latency development, 188 –194, 196; maternal distress, 8, 18; relational trauma, 49 – 50; Sean (case study), 138 –139; separationindividuation, 282–284 Attachment theory: frightened/disorganized attachment, 102–108, 120 –124; latency development, 178 –207; maternal love, 48–49; parent-infant interactions, 16–20; Strange Situation attachment test, 16, 90– 91, 103 –104, 137 Attention deficit hyperactivity disorder (ADHD), 222, 223 Austen, J., 320 Autobiographical memory, 298 Autonomy: consolidation process, 205; latency development, 178 –207; play ses-



sions, 136, 142, 144, 145 –146; Sean (case study), 148 –149 Aversion movements, 14–15, 135, 284 Balint, E., 60 Bateman, A. W., 77 Beebe, B., 14, 17 Behavior observations. See also Facial expressions: body orientation, 135 –136; gaze, 13–14, 135; head orientation, 14– 15; video microanalysis, 13–23, 40–41, 135 –137, 142–152; vocalizations, 16–18, 23, 26, 30–31, 36, 39 Beiser, H., 158 –159 Bender-Gestalt, 182 Bergman, A., 9 Bi-directional regulation, 11 Birth defects, effect of, 266 –268, 272–273, 278 –280, 289 –290 Black holes, 107, 119 Blatt, S., 182 Blos, P., 180, 195, 205, 283 –284 Blum, H., 264, 287 Body awareness, 93–97, 267, 271–272, 278 –279, 284 –285 Body orientation, 135 –136 Bornstein, B., 180 Boston Change Process Study Group, 259 Boundaries, 136 –137, 142, 143, 145 Brazelton, T. B., 13 Bromberg, P., 215 Broucek, F., 219 Burke, W., 182 Buxbaum, E., 199 Case studies: Andy, 221–233; Beccah, 265 – 290; Cecil, 24– 34; Ethan, 52–70; Iliana, 91– 97; Little Hans, 157–158; Mary and John, 108 –124; Mia, 85– 91; Natalie, 242–258; Nicole, 34– 40; Sean, 138 –152 Caulaincourt, A., 318 – 319 Center for Early Relationship Support, 108 Chase and dodge behavior, 14, 26, 33, 40 Chess, S., 3 Child Analysis with Anna Freud, A (Heller), 160



335



336



Index



Childhood analysis, 296 – 311 Chodorow, N. J., 204 Closeness versus distance, 62– 63 Cognitive development, 179 –180, 214, 258 –260 Coherence, 151, 185 –186, 198 –200, 206 Cohn, J., 15 Conceptual frameworks, 134 –138 Conflict/compromise interpretations, 264 –267, 270 –273, 275, 281–282, 284, 288 –289 Conflicts in learning, 258 –260 Congenital trauma, 263 –290 Conscious insight, 324, 328 – 332 Construction, 299 Contamination, 184, 190, 196 Contingency detection, 219 –220 Coping mechanisms, 179, 188, 202–205, 225 –226 Countertransference: Ethan (case study), 58, 68; Mary and John (case study), 113; Natalie (case study), 247; parent-infant interactions, 51; reconstruction process, 295 –311; state of playing, 215, 235; therapist’s role, 107 Creative Imagination, The (Engell), 321 Creativity, 324, 330 Crown, C., 17 Culver, C. See Malatesta, C. Dahl, E. K., 288 Dead baby complex, 49 – 50 Death anxiety, 187–192, 195 –198, 201–202 Dependency, 55– 66 Depression, 8, 18, 49– 54, 86– 87, 221–222, 300 Developmental theories, 129, 137 Disconnection, 34, 37, 145, 193, 200, 204 Disorganized attachment, 48– 49, 52– 54, 60, 102–108, 113 –117 Dissociation. See Frightened caregiving Dissolution of the Oedipus Complex, The (Freud), 179 Distress: infant distress, 60 – 61, 89 – 91, 94, 107; maternal distress, 8–9, 18–19, 60– 61, 88; regulation patterns, 89– 90 Distress regulation, 20 Dorpat, T., 329 Downing, G., 12, 134, 136 –137 Dreams, 328–332 Dyadic systems. See Parent-infant interactions Dynamic systems theory, 132, 151–152 Dyslexia, 239 –241, 244 –245, 252–254, 258 –259



Edison, T. A., 329 – 330 Ego: Andy (case study), 230 –231; capacities, 263 –264, 287; ego capacities, 216 – 217, 220 –223; and Freud, S., 78; latency development, 179 –180; reconstruction process, 303, 307; regression, 234; state of playing, 214, 216 –217, 242; uneven functioning, 220 –223, 230 –231 Einstein, A., 329 Eliot, T. S., 317 Emde, R., 217, 313 Emerson, R. W., 313 Emotional issues, 62, 68–70, 116 –123, 220 –221, 230 –233 Empathic attunement, 5 Enactments, 214 –215. See also Fantasy formation Engell, J., 321 Erikson, E., 180 Facial expressions: mirroring, 15, 26, 36– 37, 39; parent-infant interactions, 15, 23, 27–28, 135; separation-individuation, 218 –220; stranger-infant interactions, 26–27 Faith, 323 Family interaction patterns, 131–152 Fantasy formation: Andy (case study), 222; Beccah (case study), 271–273; conflict interpretations, 288; incestuous fantasies, 301– 302; latency development, 179, 187–189, 192–198, 201–203; Natalie (case study), 246 –247, 253; psychic trauma, 264; reconstruction process, 296 –297, 307, 309 – 310; separation-individuation, 282, 284, 288; sexuality, 276 – 281, 285 –286, 288; social status, 303 – 305; state of playing, 214 –215 Fear, 88–89, 92–93, 119 –121. See also Disorganized attachment; Frightened caregiving Feldstein, S., 17 Ferenczi, S., 326 Field, T., 13 First Book of First Definitions, A (Krauss and Sendak), 255 –256 Fivaz-Depeursinge, E., 134 –135, 137 Flexibility, 148, 151 Fonagy, P., 76, 77, 83, 265, 287–288 Foresight, 312– 332 Former child patients: attitudes toward therapy, 162–165; feelings about therapist, 166 –173; memories of therapy, 158 –162, 165 –174; non-engagement, 169, 173; participants, 175



Index Fragmentation, 184 –187, 189, 191–192, 195, 200, 205 –206 Fraiberg, S., 4, 50, 78–80 Freedman, S., 180 Freud, A.: attitudes toward therapy, 163– 164; fantasy formation, 203; and Heller, P., 160; infant psychoanalysis, 3, 9, 48; latency development, 179, 180, 203; parent-infant interactions, 217, 218 Freud, S.: ego, 78; imagery symbolism, 327–328; latency development, 178 – 179; prediction difficulties, 314; reconstruction process, 296 –297, 299, 305 – 306, 308 – 311; repetitive activities, 241; repression barrier, 157–158, 305; state of playing, 214 –215, 242 Friedman, G., 182 Frightened caregiving, 102–108, 113 –117. See also Fear Future, influence of, 312– 332 Gaze, 13–14, 135 Genuine maternal love, 47–71 Gergely, G., 219 –220. See also Fonagy, P. Gianino, A., 120 Gilligan, C., 202 Goldberger, M., 286 Gorlitz, P., 182 Green, A., 49 Greenberg, R., 328 Greenspan, S., 181 “Harry Potter” stories (Rowling), 203 Head orientation, 14–15 Heller, P., 160 Helpless caregiving. See Frightened caregiving Hesse, E., 104 Hoffman, L., 286 “Hole Is to Dig, A” (Krauss and Sendak), 255 Home-based mother-infant psychotherapy, 101–124 Homer, T., 201 Home visits, 79–82 House-Tree-Person Drawings, 182 Hume, D., 327 Hypersensitivity, 53– 54 Images, impact of, 316 –317, 326 – 331 Imaginary play. See Fantasy formation; Make-believe; Play Improvisation, 117–118 Interactive regulation, 11, 19, 56 Internalization, 159, 267, 274, 285, 287– 288



337



Interpersonal connections, 136, 142, 143, 144 –145 Intersubjective exchanges, 215 –219, 229 – 230, 235 Intuition, 322– 323 Irma dream, 328 Isolation, 193 –194, 204, 226, 232, 246, 269 Jaffe, J., 17 James, W., 327 Jasnow, M., 17 Jewish Family and Children’s Service, 108 Joseph, E., 328 Jurist, E. See Fonagy, P. Kantrowitz, J. L., 182 Kennan, G., 320 Kennedy, H., 285 –286. See also Sandler, J. Kernberg, P., 9 King, S., 203 –204 Klein, M., 9, 159 Klopfer, B., 182 Koch, E., 158 Koestler, A., 330 Kohlberg, L., 179 –180 Kohut, H., 180, 200 Kozlowski, B., 13 Krauss, R., 255 –256 Kutuzov, M., 318 Language usage: dyslexia, 244 –245, 252– 254; learning disabled children, 239 – 241; play sessions, 137, 142, 144, 145; relational trauma, 251–254 Latency development, 178 –207 Laub, D., 285 Laufer, M., 173 Lausanne Triadic Play Model, 135 –136 Learning disabled children, 239 –260 Ledwith, N., 183, 185 Lee, S., 285 Lewin, B., 234 Lewis, M., 260 Little Hans, 157–158 Loewald, H. W., 201, 287, 313, 320 – 321, 330 Longitudinal study of latency development: analytical discussion, 198 –201; anger management, 201–202; background information, 178 –181; early latency, 186 –190; gender differences, 186 –207; late latency, 195 –198, 205 – 206; methodology, 181–186; middle latency, 190 –194; results, 186 –198; timeline, 206 –207



338



Index



Long-term follow-up project of child analyses, 157–175 Loss, 186 –192, 232 Luria, A. R., 252 Lyons-Ruth, K., 104 Machiavelli, N., 317– 318 MacLeish, A., 316 Magic, use of, 188, 190, 192, 202–204 Mahler, M., 9, 203, 206, 217 Main, M., 13, 104 Make-believe, 215, 218 –220 Malatesta, C., 15 March of Folly, The (Tuchman), 319 Marshall, G. C., 320 Marvell, A., 316 Maternal failure, 48– 49 Maternal love, 47–71 Mathematics, 325 – 326 Memories of therapy, 158 –162, 165 –174 Memory, reconstruction process, 295 –311 Mental imagery, 327– 331 Mentalization theory: fantasy formation, 220; Iliana (case study), 95– 98; Mia (case study), 87– 90; Minding the Baby program, 81– 85; parent-infant interactions, 76–77; psychic trauma, 287–288; state of playing, 216 Metabolizing feelings, 112, 119 –122 Metraux, R. See Ames, L. Midrange regulation model, 33 Milne, A. A., 213 –214 Minding the Baby program, 74– 98 Mini-reunion experience, 137 Modell, A. H., 201 Motherhood Constellation, The (Stern), 112 Mutuality, 11, 218, 226 Napoleon I, Emperor of the French, 318 – 319 Narcissistic balance: Andy (case study), 222, 225 –226, 230 –233; contingency detection, 219; psychic trauma, 267; reconstruction process, 304, 306 National Center for Infants, Toddlers, and Families, The, 79 Neubauer, P., 4 Neurocognitive problems, 239–241 Neurotic conflict, 217–218 Non-engagement, 169, 173, 222–223, 228 – 230 Nonverbal language, 12–13, 21– 34, 106, 135, 247 Normality and Pathology in Childhood (Freud), 218



Noy, P., 317 Nurse Home Visitation program, 80 Nurturance, 186 –194, 196, 198, 204 Object relations theories, 179 –180, 183 – 185, 218 –219, 255 –256, 263 –264 Oedipus complex, 276 –277, 284 –286, 306. See also Latency development Ogden, T., 215 Olds, D., 80 Olesker, W., 199, 201 Oppositionality, 225 –227, 232, 267, 284 Orwell, G., 250 –251 Overstimulation, 19, 25–28, 40, 251, 253. See also Self-regulation Parental history: Beccah (case study), 267– 269; Cecil (case study), 28, 32– 35; Ethan (case study), 53, 58– 59; Iliana (case study), 91; Mary and John (case study), 110 –114; Mia (case study), 87; Natalie (case study), 243 –244, 253 –254; reconstruction process, 301–304, 306 –307; video microanalysis, 40 Parent Consultation Model (PCM), 128 – 152 Parent-infant interactions. See also Minding the Baby program: behavior observations, 13– 41, 135 –137, 142–152; Cecil (case study), 24– 34; ego capacities, 216 – 217, 220 –223; face-to-face interactions, 10–12, 18–20; frightened/disorganized attachment, 102–124; Iliana (case study), 91– 97; intersubjectivity exchanges, 217–220; intervention techniques, 3 – 5; Mary and John (case study), 108 –124; maternal love, 47–71; Mia (case study), 85– 91; mind-body awareness, 78– 81, 83; Nicole (case study), 34– 40; Parent Consultation Model (PCM), 128 –152; perception, 11; psychotherapy interventions, 48–71, 79– 98, 101–124; regulation patterns, 11–12, 19–20, 24– 34, 55– 56, 217–220; temperament, 3, 5, 19; treatment methodology, 21–23; video microanalysis, 7–13, 40–41, 129 – 138 Pearlman, C., 328 Pearson correlation coefficient, 182 Peer relationships, 180, 204 –205 Perry, R., 180 Persuasion (Austen), 320 Phonological processing, 244 Piaget, J., 179 –180 Pine, F., 9, 217



Index Play: lack of play, 221–233; learning disabled children, 239 –241, 258 –260; object relationships, 255 –256; regulation patterns, 257–258; state of playing, 213 – 236; therapeutic value, 233 –236, 241– 242, 258 –260 Play sessions, 133 –137, 139 –141 Poetry, 315, 316 – 317 Preadolescence, 195 –198, 202, 205 –206 Primary process thought, 314, 316 – 317, 330, 332 Prince, The (Machiavelli), 317– 318 Provence, S., 4 Psychic trauma, 76 –77, 263 –290, 298 – 311 Psychological testing, 181, 182–185, 244 – 246 Puberty, 195, 197, 206 Rangell, L., 328 Rappaport, D., 255 Reconstruction process, 295 – 311 Reflective awareness function: frightened/ disorganized attachment, 105; Iliana (case study), 95–98; Mary and John (case study), 119; Mia (case study), 87– 90; Minding the Baby program, 81– 85; parent-infant interactions, 76 –77; psychic trauma, 76–77; state of playing, 216, 218, 225 Regression, 179, 215, 254, 269, 282, 283 – 286 Rejection, 266 –267, 274. See also Abandonment Relational trauma: Beccah (case study), 270; Ethan (case study), 59– 60; Iliana (case study), 91–97; Mary and John (case study), 110 –123; Natalie (case study), 242–244, 249, 251, 253 –254; parent-infant interactions, 48 – 49, 51, 76–81, 104 –105 Reparation, 66–68, 120 Repetitive behavior, 269, 272, 286 –287 Representational/behavioral domains, 112 Repressed memories. See Reconstruction process Repression barrier, 158 Richard II (Shakespeare), 322 Ricoeur, P., 317, 326 Ritvo, S., 159 Rizzuto, A., 235 Rodell, J. See Ames, L. Rorschach tests, 182–190, 192–197, 205, 245 –246 Rowling, J. K., 203 Rugg, H., 330



339



Sadomasochism, 269 –270, 277, 281, 284 – 286, 289 Safety issues, 274 –275, 285 Sander, L., 200, 217 Sandler, J., 172–173 Sarnoff, C., 180, 203 Schafer, R., 183 Scientific method, 324 – 325, 329 Scoring systems, 182–183 Secondary process thought, 314 –315, 324, 329 –330, 332 Self-esteem: dyslexia, 253; latency development, 193, 194, 202, 204; parents, 40; reconstruction process, 300 Selflessness, 48 Self-other differentiation, 218 –220, 263 – 265, 271, 285 –286, 288 Self-regulation: aggressiveness, 266, 271; Cecil (case study), 24– 34; challenging behaviors, 145 –147; frightened/disorganized attachment, 105; importance, 11– 12; Mia (case study), 89–90; parent-infant interactions, 19–20, 24– 34, 55– 56, 135 –136; psychic trauma, 287; self-other differentiation, 217–220; state of playing, 257–258; traditional evaluation process, 132 Sendak, M., 255 –256 Separation-individuation: adolescence, 277; aggressiveness, 282–284, 288; Ethan (case study), 61– 64, 70; gender differences, 186 –207; latency development, 180 –183, 186 –207; parent-infant interactions, 218 –220 Sexuality: Beccah (case study), 267, 269 – 270, 272, 276 –279, 284 –285; as defense mechanism, 269 –270; fantasy formation, 284 –285, 288; latency development, 179, 194, 196 –198; Natalie (case study), 247– 250, 253 –254 Shakespeare, W., 322 Shapiro, T., 180, 217 Shepard, B. See Malatesta, C. Solnit, A., 4 Space/time organization, 136, 142, 143, 145 Stern, D., 14, 112, 200, 218 Stevens, W., 326 Stranger-infant interactions, 20–21, 26–27, 30 – 31 Strange Situation attachment test, 16, 90– 91, 103 –104, 137 Study of Images, The (Stevens), 326 Suicide. See Death anxiety Sullivan, H., 180



340



Index



Symbolism. See Images, impact of; Mathematics; Poetry Tanner, J. M., 195, 197 Target, M. See Fonagy, P. Teacher game, 250, 258 Technique of Child Psychoanalysis, The (Sandler et al.), 172–173 Teen parents, 82 Tesman, J. See Malatesta, C. Testing, psychological, 181, 182–185, 244 – 246 Thematic Apperception Test (TAT), 182– 183, 186 –190, 192–198, 203, 206 Therapist’s role: Ethan (case study), 53 – 71; Minding the Baby program, 82–84; state of playing, 214 –216, 234 –236, 258 – 260; traditional evaluation process, 130 – 133; transferences, 51, 79– 80, 106 –107 Thomas, A., 3 Thoreau, H., 312 “Three Essays, The” (Freud), 179 “To His Coy Mistress” (Marvell), 316 Toynbee, A., 319 – 320 Traditional evaluation process, 130 –133 Transferences: Cecil (case study), 32– 33; distance theme, 246 –250; erotic interpretations, 309; Ethan (case study), 57– 58, 64–70; Mary and John (case study), 113, 120 –122; negative transference, 173; Nicole (case study), 39; paternal/ maternal transferences, 32– 33, 275 –282; psychic trauma, 264 –265, 267, 273 –275, 287–288; reconstruction process, 295 – 311, 315; relationship issues, 246 –250, 254 –257; state of playing, 214 –216, 235, 258 –260; therapist’s role, 50– 51, 79, 106 –107; transference complaints, 232– 233 Traumatic memory. See Psychic trauma Triangular frameworks, 135 –136 Tronick, E., 9, 15, 120, 218, 219 Tronick’s still face experiment, 218, 219 Tuchman, B., 319



Turn-taking structure, 16, 23 Tutors, E., 12 Tyson, R. See Sandler, J. Unconscious communication, 60 Unconscious foresight, 314, 315, 329, 332 Verbalizations, 231, 235, 242 Video feedback techniques: behavior observations, 13– 34, 40– 41, 135 –137, 142–152; family interaction patterns, 131–152; microanalysis, 5, 40–41, 129 – 138; nonverbal language, 12–13; parentinfant interactions, 7–12; treatment methodology, 21–23 Vision. See Foresight Vocal rhythm coordination, 16–18, 23, 26, 30–31, 36, 39 Vulnerability, 266 –267, 268, 272–283 Vygotsky, L., 241, 255 –257 Waelder, R., 241–242 Walker, R. See Ames, L. “Wasteland, The” (Eliot), 317 Watson, J., 327 Wechsler Intelligence Scale for Children (WISC), 244 Wechsler Intelligence Scale for Children— Revised Edition (WISC-R), 182 Weil, A., 217 Weinberg, K., 9 Weiss, J., 329 Williams, M., 180 Winnicott, D. W., 78, 217–218, 242, 284 Wolff, P., 3 Words, impact of, 325 –326 World Association of Infant Mental Health, 79 Yale Child Study Center, 77 Yale University School of Nursing, 77 Yeats, W. B., 3 Zero to Three, 4, 79