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: robert.king@yale.edu

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 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 3

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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.vi Contents CLINICAL STUDIES Karen Gilmore Play in the Psychoanalytic Setting: Ego Capacity. Blum Psychoanalytic Reconstruction and Reintegration Cornelis Heijn On Foresight Index 213 239 263 295 312 335 . Bell A Girl’s Experience of Congenital Trauma: The Healing Function of Psychoanalysis in the Adolescent Years PSYCHOANALYTIC PERSPECTIVES ON THE FUTURE AND THE PAST Harold P.

INFANT-PARENT RESEARCH AND INTERVENTION .

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When Peter Wolff (1959) described infant states. Samuel Abrams. 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. including The Psychoanalytic Study of the Child 60. The findings of this research gradually made it possible to move beyond wellmeant but fundamentally authoritarian recommendations for infant care. copyright © 2005 by Robert A. There is universal agreement that such studies yield a goldmine of data. 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. and A. fateful consequences for the reactions they elicited in their caretakers. King.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. Peter B. Peter B. At about the same time. Samuel Abrams. Robert A. Scott Dowling). and A. Scott Dowling (Yale University Press. 3 . Neubauer. One area in which these data might be applied is that of parent-infant intervention. Many of the pioneers in advocating such intervention. ed. 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. the stage was set for the burgeoning field of infancy research. Neubauer. King. there is less agreement about the interpretation of the data and their significance for development and functioning in later childhood and adulthood.

will stimulate a productive dialogue concerning both clinical and theoretical aspects of providing assistance to infants and their parents. with the findings of infant developmental research. often combining drive/defense and object relations theories in their techniques. adversity.org/). such as Beebe. What the indications are for each of these forms of intervention (and what talents are required of the therapist) remain to be studied. emphasizing the central place of relationships in human development. To varying degrees the papers also acknowledge or assume integration of psychoanalytic concepts with Piagetian psychology. The practitioners of parent-infant intervention are pragmatic integrationists as they strive to reach the goal of clinical effectiveness in promoting developmental competence. alongside the commonality of their broad psychoanalytic orientation. It is our hope that these differing ideas. presented together. with others from psychology and social work (and with the support of dedicated philanthropists). of Zero to Three. It is a mark of the ferment and creativity of the papers published here that. others.zerotothree. From a practical point of view.. some of the interventions. recent findings in neuroscience. Albert Solnit. and. 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. the foremost interdisciplinary advocacy organization for early childhood mental health (www. and trauma. such as Slade et al.4 Introduction Sally Provence. focused interventions with better functioning mothers who sensed that their relationship with their infant had become derailed in some important way. 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. and in their specific techniques of intervention. and Selma Fraiberg. the authors show wide variation in their techniques of studying infant-parent interaction. . present short. were grounded in psychoanalytic earth. above all. involve long-term work with quite troubled mothers who also struggle with poverty. Peter Neubauer. One expression of their interest was the founding. in their conceptualization of the clinical task of intervention. as well as determining the longer-term impact of the different modalities. systems theory. Two authors explicitly demonstrate the benefit of combining elements of modern attachment theory with psychoanalytic developmental theory.

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. and how they might be re-experienced and accessed in the transference or counter-transference are all important unanswered questions. 1978. the five papers collectively raise provocative questions about the fashion in which the second-to-second interactions of parents and their young children. to the study of parents in interaction with their young children. shape each dyad’s enduring patterns of mutual influence and relating. These five papers are the beginning of a continuing dialogue in these pages concerning interventions with parents and their young children. defense. and characteristic modes of coping with various forms of instinctual arousal. drive/defense (“structural”). The ongoing empirical study of these processes promises to deepen our understanding of the links between psychoanalysis and developmental psychopathology. affective and cognitive self-regulation. Ritvo & Solnit. 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. 1958). . multifaceted nature of empathic attunement (and the potential derailments thereof ). researchers interested in infant development and in parent-infant interaction have made extensive use of video recordings.Introduction 5 Issues of therapeutic efficacy aside. 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. 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”). how they interact with temperament to shape drive. 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. developed in infant research. often on a non-verbal level outside of conscious awareness. For a number of years. and structure the child’s internal object representations. sometimes reviewed in frame-by-frame detail. and interpersonal (“object relations”) perspectives in our understanding of human psychology. and character. these studies reveal the subtle.

Wolff. . E. (1986) Temperament in Clinical Practice. Journal of the American Academy of Child Psychiatry. H. S. Psychoanalytic Study of the Child. V. & Shapiro.. Psychoanalysis and the History of the Individual. P. (1975) Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Ritvo S. (1958) Influences of early mother child interaction on identification processes. S. 14:387– 421. New Haven: Yale University Press. Loewald. 21: 110 –118. 13:64 – 91. Fraiberg.. W. A. & Solnit A.6 Introduction BIBLIOGRAPHY Chess. Adelson. & Thomas. (1978). New York: Guilford Press. (1959) Observation on newborn infants. Psychosomatic Med. J.

Ilene Lefcourt. I am grateful for the help of my research team: Caroline Flaster. King. Lisa Marquette. Joseph Jaffe has been an invaluable consultant and advisor. Adrienne Lapidous. Faculty.U. Michelle Lee. Peter B. Scott Dowling (Yale University Press. and the Laura Benedek Infant Research Fund. Barbara Kane. the Kohler Stiftung. Nina Finkel. Lin Reicher. and A. Columbia University Psychoanalytic Center. Stanley Feldstein and Donald Ross. Tammy Kaminer.Y.Mother-Infant Research Informs Mother-Infant Treatment* BEATRICE BEEBE. Hwee Sze Lim. Sandy Seal. Postdoctoral Program in Psychotherapy and Psychoanalysis. Alan Phalen. King. In the first. ed. I thank my statistical team. Samuel Abrams. *Winner of the Albert J. Nancy Freeman. Peter B. Juliet Hopkins. Columbia University. Sandra Triggs Kano. 2005 A brief mother-infant treatment approach using “video feedback” is described. Phyllis Ackman. Howard Andrews. Marina Koulomzin. Helen Demetriades. Faculty. Nicholas Seivert. Mary Sue Moore. Faculty. Lauren Ellman. Institute for the Psychoanalytic Study of Subjectivity. 7 . This work was partially supported by NIMH grant R01-MH41675. Jillian Miller. and Marina Tasopoulos. Rhonda Davis. Michael Ritter.C. Scott Dowling). Columbia Psychoanalytic Center Parent-Infant Program. Robert A. descriptions of the Clinical Professor of Psychology in Psychiatry. Jane Roth. The Psychoanalytic Study of the Child 60. Paulette Landesman. Faculty. This approach is informed both by psychoanalysis and by research on mother-infant face-to-face interaction using video microanalysis. Limor Kaufman-Balamuth. Patricia Cohen. Michaela Hager-Budny.D. Lauren Cooper. Stephen Ruffins. N. Greg Kushnick. Jill Putterman. Ph. George Downing. Henian Chen. Karen Buck. the Edward Aldwell Fund. Tina Lupi. Irena Milentejevic. Patricia Goodman. Wendy Olesker. Solnit Award. Samuel Abrams. Sara Markese. Sandra Triggs Kano. Donna Demetri-Friedman. I thank Frank Lachmann. Danielle Phalen. Allyson Hentel. Phyllis Cohen. and A. Shanee Stepakoff.Y. and Johanna Tabin for their clinical consultations. Claudia Andrei. Sara Hahn-Burke. Emily Brodie. Neubauer. Matthew Kirkpatrick. Elizabeth Helbraun. Two cases are presented. N. the Fund for Psychoanalytic Research of the American Psychoanalytic Association. copyright © 2005 by Robert A. Neubauer.. Lotte Kohler.

Our attempts together to translate the action-sequences into words facilitates the mother’s ability to “see” and to “remember. proce- . Maternal unresolved mourning has been specifically linked to infant and childhood disorganized attachment. the video interaction. Whereas the implicit. 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. But even highly competent parents can become destabilized under the impact of illness. Two cases are presented. & Jaffe. Cecil. In addition to maternal contributions. such as the loss of the husbands of 100 pregnant women from the 9/11 World Trade Center tragedy (Beebe. mother-infant interaction. even though videotaping was not an option. infants may also bring their own difficulties to the relationship. and the parent’s own upbringing are linked. descriptions of the videotaped interactions which informed the interventions are included. 2002). I show how knowledge of mother-infant microanalysis research can inform a treatment even when videotaping is not an option. Cohen. Golding. In the first. based on constitutional or developmental factors. Beveridge. or other traumas. 1997). In this paper I describe a brief mother-infant treatment approach using “video feedback. At times parental distress stems from longstanding character psycho-pathology. Maternal prenatal anxiety has been shown to predict behavior problems in the children at age 4 years (O’Connor. In the second.8 Beatrice Beebe videotaped interactions which informed the interventions are presented. Nicole. knowledge of mother-infant microanalysis research informed the treatment. Heron. 1998). & Glover. loss. Research on depressed mothers and their infants shows that these infants are at risk for insecure attachments and compromised cognitive outcomes (Murray & Cooper. The mother has a powerful experience during the video feedback of watching herself and her baby interact. Introduction more than two decades of research on maternal distress. The respective “stories” of the presenting complaints. and infant and child developmental outcomes have shown that infants suffer when a parent is distressed.” This approach is informed both by psychoanalysis and by research on mother-infant face-to-face interaction using video microanalysis. In the second.” fostering a rapid integration of implicit and explicit modes of processing. 2002). a form of insecure attachment that predicts childhood psychopathology (Lyons-Ruth.

1996. and Paulina Kernberg understood the importance of intervention in the first years of life. Fraiberg (1971. declarative mode refers to our symbolic. Marvin. Hofacker & Papousek. Lebovici (1983). 1990). and major depression were still in distress. 1994. Our approach to mother-infant treatment integrates psychodynamic and interactional approaches within the context of feedback on videotaped interactions. among others. Many different kinds of mother-infant therapies have been shown to predict positive outcomes (Cramer et al. 1993. Cohen & Muir. Psychoanalytic pioneers such as Anna Freud. 2003). Ferholt and Provence (1976). even though the mothers reported improvement of their own symptoms with medication and individual psychotherapy. Some mothers.. Murray & Cooper. facilitates the mother’s ability to “see” and to “remember. Field et al. and Weil (1970). Spitz (1965). 1997. Melanie Klein.. Stern. van den Boom. . 1995. I suggest that the mother’s experience during the video feedback of watching herself and her baby interact. Fraiberg.Mother-Infant Research and Treatment 9 dural mode of exchange addresses behavioral transactions which are usually out of awareness. the explicit. 1994. & Powell. 1980. 2002). Greenacre (1971). 1992. Nevertheless. however. Margaret Mahler.” stimulating a rapid integration of procedural and declarative modes of processing (see Beebe.. 2002. Hoffman. 1998. 1996. Fred Pine. Lieberman & Pawl (1993). Anni Bergman. Weinberg and Tronick (1998) documented by video microanalysis that the infants of mothers with panic disorder. Seligman. Cooper. 1980). Call (1963). verbalized narrative. and our joint attempts to translate the action-sequences into words. even in current approaches to mother-infant treatment. obsessive-compulsive disorder. 1998). 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. Although therapeutic interventions are widely available for young children. We address the mother’s representations of and transferences to the infant as well as mother-infant interaction patterns visible on videotape. 1994. Greenspan (1981). In the discussion. spearheaded by Adelson and Shapiro (1975). Hopkins. McDonough. mother-infant treatment remains less available. The last decade has shown great progress in conceptualizing methods of intervention with parents and infants. Weinberg & Tronick. Parent-infant therapy specifically has been known for several decades. the infant is in danger of being the “forgotten patient” (see Lojkasek. Malphurs et al. require more extensive treatment (see Cohen & Beebe. 1995).

Lester. Face-to-Face Interaction Research The video feedback treatment method attends to specific patterns of mother and infant self. Beebe & Lachmann. Sander. This research provides a rich resource for the parent-infant clinician.10 Beatrice Beebe Microanalytic research describing face-to-face patterns has been extensively reviewed (see Beebe 2003. 2002). 1995. and each form of regulation affects the other (Gianino & Tronick. 1989). 1995). Because each person must both monitor the partner and regulate inner state. facial expression. A “dyadic systems view” of face-to-face communication informs our approach to this research (Beebe. bringing remarkable capacities to seek and avoid engagement (Beebe & Lachmann. 1977. 1985. Interactive regulation is defined as bi-directional contingencies in which each partner’s behavioral stream can be predicted from that of the other. Beebe & Lachmann. 1989). 2000. Stern. 1997. 1990. Matias. Rovine. 1977. 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 . It is a “co-constructed” process in which each partner makes moment-by-moment adjustments to the other’s shifts in behaviors. Two treatment cases informed by mircroanalytic research have previously been presented in Beebe (2003) and Cohen and Beebe (2002). Beebe & Stern. Campbell. Tronick. 1989. but has nevertheless remained strikingly under-utilized. the infant is a very active participant in this exchange. 2002. & Brazelton. & Hopkins. 1985. Stern. 1985. Martin. 1985. & Taylor. 1971. 1988. 1981. and body and vocal rhythms. This work focuses on face-to-face interaction rather than the regulation of feeding and sleep (but see as an exception Sander. The importance of mother-infant face-to-face interaction for social and cognitive development is extensively documented (see Belsky. in this view all interactions are a simultaneous product of self. Hoffman. Scholmerich. 1977) and is most relevant for infants 3 to 12 months. Jaffe. Lewis & Feiring. Field. Tronick. 1984. Both the individual and the dyad contribute to the organization of behavior and experience. see also Freeman (2001). 2002. Stern. touch. Fracasso. 1989. such as gaze.. Thomas & Malone. 1988. Leyendecker. & Larson. Lamb.and interactive regulation which have been documented by three decades of video microanalysis research. orientation.and interactive regulation. 1992. & Lachmann. vocal quality. 1979). Cohn & Tronick. Although the mother has the greater capacity and range of resources. Malatesta et al. Cohn.

they are “nonconscious. infants perceive durations of events and temporal sequences (DeCasper & Carstens. Lachmann. 1982. but aversive interactions such as “chase and dodge” are also co-constructed. contingency detection. each partner must simultaneously regulate his or her inner state. Gergeley & Watson. Cohn & Beebe. when most of this research is conducted. 1985).” and “how you affect me. although again. 1997. for example. These capacities enable the infant to anticipate how each partner changes predictably in relation to the other’s changes. 1989). The interactions we study are extremely rapid. 1998). Beebe. 1997. 1980). organizing “expectancies” of “how I affect you. Tronick.. 1985. and the anticipation of events underlie the generation of procedural. & Jaffe. with individual behaviors lasting on the average 1/4 to 1/3 of a second. By the time infants are 3 to 4 months. Thus many aspects of these interactions occur out of awareness. Hazan. From birth and even in utero. Self-regulation is just as important as interactive regulation. Mutuality usually connotes a positive interchange.” These infant capacities for the perception of sequence. Stern. presymbolic representations of interactive sequences (Beebe & Stern.” rather than dynamically “unconscious” (see Lyons-Ruth. we no longer use these terms because neither “mutuality” nor “influence” in their usual meanings is accurate. Both infant and parent bring constitutional proclivities such as temperamental dispositions and . 1990. 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. often subliminally. Thus we prefer the more neutral terms “bi-directional regulation” or “coordination” to describe these contingency analyses. 1977). 2001. Stern. Although the terms “mutual influence” or “mutual regulation” are often used to describe the co-construction of interactive regulation. the parent has many dynamically unconscious motivations as well. in the sense that each partner’s behavioral stream can be predicted from that of the other (Beebe & Stern.Mother-Infant Research and Treatment 11 the other. 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. While participating in the interactive exchange. 1988. Jaffe et al. in maternal intrusiveness or in infant temperament difficulty. Watson. infants perceive the existence and magnitude of contingencies and can anticipate when events will occur (Haith. 1971). 1977. & Goodman.

associated with particular self-regulation processes. and there is no one optimal mode of interaction. Hofacker & Papousek.” and of becoming aware of the ways the parent may respond. 1998. Malphurs et al. Videotape played in slowed time. Video feedback is introduced to the parent as a way of learning about the infant’s “nonverbal language. Cramer & Stern.” and this research is still in progress. Cooper. Whereas one meaning of “co-construction” is that each partner contributes to the interactive regulation. have been using variations of this technique for over a decade (for current work see for example Bakermans-Kranenberg. Infant expectancies of different patterns of self. it helps the parent to see how both infant and parent affect each other. It is difficult for anyone to be aware of his or her nonverbal behavior.12 Beatrice Beebe arousal regulation styles which affect self-regulation. Each partner’s self-regulation capacity and style affects the nature of the interactive regulation. Hoffman. 1996. 2002. 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. Marvin. van den Boom. Video feedback is a remarkable clinical tool in the hands of an experienced “baby watcher” who is also a sensitive clinician. or frameby-frame.” revealing subtleties and subliminal details of interactions which are too rapid and complex to grasp with the naked eye in ongoing time. despite the fact that Stern (1995. If the video feedback is handled with great care to protect the parent’s self-esteem. 1998). McDonough (1993). Tutors (1991). & van Ijzendoorn. 1995). Despite extensive research predicting developmental outcomes from face-to-face interaction patterns.. Juffer. mo- . In applying this research to treatment. 1988). All dyads use problematic patterns at some moments. acts like a “social microscope. & Powell. and Downing (2004). it is important to recognize that ranges of “normal” interactions are more ambiguous than extremes of difficulty.and interactive regulation provide one process by which parental distress can be transmitted to the infant and alter the trajectory of development. among others. Thus both partners come to expect particular interactive patterns. as adaptive modes of coping and defense in the context of specific interactive dilemmas. there are no official “norms. and vice-versa. a second meaning is that inner and relational processes are co-constructed (see Beebe & Lachmann. 1998.

following the infant’s gaze aversion. and decreasing stimulation as the infant looks away. as well as the successful ones (Fonagy. and then the infant returns to gazing at mother’s face. Jurist. Until 9 to 12 months. generate a split-screen view of the pair interacting. fleeting details of the mother-infant action language. Two cameras. 1996. Beebe & Stern. one on each partner’s face and upper torso. 1971. Kozlowski. stimulating more as the infant looks. 1970). & Target. The infant’s repertoire during a face-to-face exchange is complex.Mother-Infant Research and Treatment 13 ment-by-moment. or avoid a face-to-face encounter (Stern. 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. disrupt. Although these are typical patterns. Brazelton. and it is the infant who typically engages in a looklook away cycle. The mother is instructed to play with the infant as she would at home. Video feedback provides an opportunity for the parent to process and reflect on the difficult moments in the interaction. Gergely. Microanalysis Teaches Us to Observe Video microanalysis can teach us to observe the subtle. 1974). we do not provide toys. who is seated in the same plane. gaze We begin by observing gaze. we have also noted a pattern of mutual “eye love” (Beebe. Mothers tend to look at the infant’s face most of the time. The infant is placed in an infant seat opposite the mother. and Main (1974) first showed that mothers typically pace the amount of stimulation according to this gaze cycle. 1973. looking at mother’s face for a period of time. looking away. maintain. 2002). 1977) in which mothers and infants can sustain prolonged mutual gaze for up . As the ethologists note. and then looking back (Stern. most animals do not sustain long periods of such looking unless they are about to fight or make love (Chance & Larsen. looking into the face of a partner can be very stimulating. heart rate decreases back down to baseline within the next 5 seconds. Field (1981) verified that infants organize their look-look away cycle to regulate degree of arousal. Thus infant gaze aversion is an important aspect of infant self-regulation. There is a remarkable range of behaviors at the infant’s disposal to initiate. EiblEibesfeldt. 1971. 1985).

the infant’s head is tucked into the chin. the infant then requires more time to regulate arousal down sufficiently to return to gazing at mother. freezing (described by Fraiberg.14 Beatrice Beebe to 100 seconds during periods of positive affect. or arching. 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. pull the infant’s hand. 1972). As the infant turns away up to about 60 degrees. however. increasing rather than decreasing the amount of stimulation. McGrew. of course. bi-lateral interactive regula- . Maternal difficulty in tolerating momentary infant gaze aversion is one of the most common pictures observed in mothers and infants who present for treatment. In relation to the maternal “chase” behaviors above. 1982). Maternal “chase” behavior is counterproductive. If the mother feels that her infant does not like her or is not interested in her. the infant will rapidly re-engage. or in rare instances actually attempt to force the infant’s head to get the infant to look. as the infant monitored her every movement through peripheral vision. she may pursue the infant. that every parent loves. trusting her infant to return to her. retaining access to rapid visual re-engagement with minimal effort. head orientation We next observe infant head orientation to the mother: is the head oriented vis-à-vis. 60. direction. or displaced in the horizontal plane approximately 30. by 90 degrees away. if the mother can be helped to give the baby a “time-out” to re-regulate. or going limp and giving up tonus. “cooling it” when the infant looks away. Instead. which takes considerable energy. he can still monitor the mother with his peripheral vision (tracking presence. and intensity of movement). In her pursuit or “chase. the infant may “dodge” with increasing degrees of head aversion. These are the moments. as well as arching back. They are “read” by the partner as active initiations of disengagement. or 90 degrees away? In the 90-degree aversion. but infant dodges also predicted maternal chase behaviors.” mother may call the infant’s name. a reciprocal. he may lose peripheral visual monitoring of her movements. 1962. More usual gaze aversions retain head orientation within an approximately 30-degree angle from the vis-à-vis. Beebe and Stern (1977) described split-second sequences of “chase and dodge” in which maternal chase movements predicted infant dodges. first described by Stern (1971).

During these periods. Through increasing head aversions. 1971). a greater likelihood of rapid rematch (within 2 seconds) predicts secure attachment at one year. this infant had a remarkable “veto power” over the possibility of a sustained. 1985). particularly when infants are distressed. (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. increasing and decreasing together (Beebe et al. The infant’s opening and closing of the mouth is a powerful and continuous form of communication. or complementing (Trevarthen. Malatesta et al. Elaboration (Fogel. In general. the full display of facial expression emerges only gradually from 2 to 4 months. with closed lips. It is unusual for mothers to display no facial matching at all.” Tronick and Cohn (1989) have shown that a more flexible process of match. or are in exact “synch. a fully opened mouth (“neutral gape”) is highly evocative (Beebe. echo. sadness). Furthermore. and re-match (disruption and repair) characterizes the exchange. frowning. 1973. Even without any hint of widening or smiling. We construe these patterns as “failures of facial empathy.” . mothers and infants tend to match the direction of the other’s positive-to-negative affective change. Although the innervation of the facial musculature is myelinated before the infant is born. 1977) are better metaphors than matching or imitation (Stern. As increasing degrees of mouth opening are added to a smile. 1985. periods of sustained mutual gaze with infant vis-à-vis orientation can be enjoyed.Mother-Infant Research and Treatment 15 tion. mismatch. Stern. is only moderately positive. mutual gaze encounter. Often both partners excitedly vocalize at such moments. arching. Tronick. further increasing the intensity (see Beebe.. Rarely is there an exact match of expression. 1973. so that both build to a peak of positive facial excitement. Instead of the more romanticized notion that mothers and infants exactly match. 2004).” hugely exciting for both partners. positive affect increases up and up into the fully opened “gape smile. face If mother and infant together manage the infant’s look-look away cycle so that the infant can comfortably regulate arousal. Bennett. or going limp. 2002. 1993). 1989). Beebe & Lachmann. A fully widened smile by itself. Mothers intuitively roughly match the infant’s increments. facial and vocal communication take center stage. By 3 to 4 months there is a flowering of the infant’s social capacity.

. In the Ainsworth “Strange Situation” attachment test. a sinusoidal shape indicates approval and a rightward falling shape disapproval (Fernald. mothers who are silent partners can disturb the development of vocal turn-taking. but cannot be comforted by mother’s return and does not easily return to play (Ainsworth et al. Both partners contribute to turn-taking by matching the brief “switching pause” as turns are exchanged. or abuse (Lyons-Ruth et al. an essential building block of language. avoids mother at reunion. insecure-anxious-resistant. & Wall. and matching the intonation of the infant’s sounds. and reunions (Ainsworth. 1999. mourning. 1978). The insecure-disorganized infant simultaneously approaches and avoids the mother.” 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. Vocal contours refer to the “shape” of the sound. When infants present for treatment with difficulty in sustaining mutual gaze and the face-to-face encounter. Waters. . The insecure-anxious-resistant infant is very distressed at separation. Across cultures. insecure-avoidant. separations. mother and infant go through periods of free play. such as opening the door for her but then sharply ignoring her. and typically has a history of unresolved loss. mothers who prattle continuously do not permit this.16 Beatrice Beebe vocalization A key feature of the vocal exchange is a turn-taking structure. 1993). Mothers also optimally pause sufficiently to give the infant a turn. 1978). Mothers contribute by slowing their speech rhythms. using mother as a secure base while being able to explore the environment. The mother herself acts frightened or frightening. Because the infant does not have to orient or to look. The insecure-avoidant infant shows little distress at separation. and continues to play on his own. individual infants can be classified as having a secure. providing a great deal of repetition. 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. Blehar. matching the infant’s vocal contours and rhythms can be an effective way to make contact with the infant.. Based on the infant’s reactions. or disorganized attachment style. On the one hand. The secure infant can easily be comforted by mother and return to play. on the other hand.

1990). school performance. 2000) predicted 12-month attachment outcomes from 4month vocal rhythm coordination. both partners are behaving relatively independently of the other. and Jasnow (2001. as well as less psychopathology in childhood and adolescence (Sroufe. assessed with a technique that samples behavior every quarter of a second. Feldstein. Disorganized attachment at 1 to 2 years is associated with oppositional. Bronfman & Parsons. Crown. using global assessments and clinical ratings (see van Ijzendorn. Although infants typically vocalize only about 10% of the time at 4 months. and two poles defined by very high (excessive) or very low (withdrawn) monitoring of the partner. Beebe et al. we still lack a full understanding of the origins of attachment. fearful and disorganized behavior. and capacity to regulate emotions. a substantial body of work examining both high and low poles is now converging on an “optimum midrange model” . Edelstein. construed as a coping strategy elicited by the uncertainty or threat experienced by both mother and infant. hostile-aggressive. and cognitive difficulties in childhood (Lyons-Ruth. Beebe. interpreted as a withdrawal or inhibition of interpersonal monitoring. 1994). Jacobson. its modes of transmission. secure attachment at 1 year is associated with better peer relations. 1997 for a review).Mother-Infant Research and Treatment 17 Main & Hesse. Although much research literature concentrates on the concept that lowered interactive coordination is a risk condition for infant development. This work led us to conceptualize interactive regulation on a continuum. As each individual shortens or elongates the durations of sounds and silences. 1999. In contrast. low selfesteem. High coordination increases the predictability of the interaction. 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. and the role of the infant (and infant temperament) in this process. Nevertheless. very high and very low degrees of coordination predicted insecure attachment classifications. with an optimal midrange. & Hofmann. Jaffe. vocalization is such a central means of communication that the way mothers and infants coordinate their vocal rhythms predicts infant attachment. 1983). At the very low pole of coordination. Fewer than a dozen studies have used microanalysis of videotape to predict attachment outcomes.. 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.

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

1994). or a history of head-banging (Tronick. 1989). By the time infants are assessed in the face-to-face situation. or touch. state regulation has stabilized and fluctuations in the management of an alert state have receded with maturation of the nervous system. Disturbances of infant self-regulation can be noted in patterns of autonomic distress (hiccupping.. 1995). Greenspan.. Greenspan. typically at 3 to 6 months of age. in a community sample. using brief videotape-assisted clinical interventions (Beebe et al. some infants with difficult temperaments do not tolerate a great deal of touch (see DiGangi et al. smell.Mother-Infant Research and Treatment 19 of self. as well as pulling the hair or ear. including sleep. Although maternal touch is a primary means of soothing a distressed infant. Neonates differ in their ability to regulate state (see for example Korner and Grobstein. self-regulation From birth onward. 1972). 1977. or special sensitivities to sound. which may then prevent later insecure infant attachment outcomes. Di Pietro. 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. arousal difficulties. The implication is that. 1998). feeding. Korner & Grobstein. the ability to dampen positive or negative arousal in the face of over-stimulation. 1981. 2002).and interactive regulation at 4 months. it was the quality of the 4-month mother-infant face-to-face interaction itself that predicted infant attachment outcomes. 1991). are an important area of inquiry in the treatment (see DeGangi. Such an effort is currently underway with the 9/11 widowed mothers and their infants. self-regulation refers to the management of arousal. 1991. Infant temperament patterns. van den Boom. and the capacity to inhibit behavior (Beebe & Lachmann. Instead. and extra handling is associated with diminished irritability (Korner & Thoman. vomiting) and disorganized visual scanning. the maintenance of alertness. Brazelton. At this point it is difficult to distinguish between infant constitutional processing difficulties that may have existed at birth from problematic interactive patterns. but did not predict infant attachment outcomes at 1 year. Infant temperament and self-regulation are already intertwined with interactive regulation difficulties (see also Hofacker & Papousek. & Porges. This study provides a further rationale for therapeutically supporting the quality of the mother-infant face-to-face interaction when mothers are distressed. 2002). 1977. For this .

” where each ups the ante. with “woe face” and associated vocal “woe” contours (vocal empathy). In contrast. 1985). Both partners bring capacities to soothe and dampen as opposed to escalate distress. Stern. Gergeley & Watson. Obviously the mother has greater range and resources in this process. 2001) and to discriminate treatment and control dyads (Weinberg & Tronick. Anderson. (3) decreased range of facial expression. and maternal management of infant distress. 2000. in contrast to “stable” (lasting 2 seconds or more). was illustrated above. Before the end of the first year. the stranger as partner Identical to our research lab assessment. and then gradually slowed down (Beebe. so that infant gaze at mother occurred while head was “cocked for escape”.. (4) a disruption of the capacity to coordinate gaze and head orientation into a stable posture while smiling. infant self-regulation is both a property of the individual and of the dyad. the rhythm (but not the volume or intensity) of the crying is matched. 1998). with constriction toward a predominance of neutral. and (5) more “labile” behaviors (lasting one second). An examination of the mother’s contribution to the interactive process is planned.20 Beatrice Beebe reason. & Jaffe. followed by infant and stranger. an effective form of distress regulation is a partial or loosely coordinated “joining” or matching of the infant’s fuss or cry rhythm. The pattern of “mutually escalating over-arousal. in our treatment cases mother and infant first play face-to-face. These future “avoidant” 4-month infants showed: (1) more self touch. distress regulation Dyads show important differences in infant ability to manage moments of heightened distress. This study describes infant self-regulation patterns that are directly useful for identifying infants who are at risk for avoidant attachment. 1997. In this process. 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. The stranger-infant interaction has been shown to be a sensitive predictor of infant attachment outcomes (Jaffe et al. Beebe. when some infants de- . (2) the necessity to self-touch while looking at mother in order to look for durations comparable to those of secure infants. 2002).

if the interaction is stressful with the mother. We assess the infant’s capacity to engage the stranger and. Or. If a longer treatment is indicated. stranger. I start with an office visit. and possibly nanny are videotaped in face-to-face interaction. father.” the stranger is both a novel challenge and at the same time an intensely interesting new partner. 2003).Mother-Infant Research and Treatment 21 velop “stranger anxiety. p. However if the parent prefers. On the other hand. 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. most 4-month infants are very sociable with the stranger. The degree to which the stranger feels at ease with the infant vs. two therapists . 2003. The format of the lab visit for a treatment pair is identical to that for a research pair. 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. 34). Three orienting questions organize our approach: (1) In the procedural bi-directional “action-dialogue. feels “wary” or needs to be “careful” not to over-arouse the infant is also noted. the same basic method is applicable. because I can “see” more with the aid of the videotaped interaction. The parent is instructed to play with the infant as she or he would at home. infant with mother. some infants are wary with the stranger. for example the infants of the treatment dyads in Weinberg and Tronick’s (1998) study. as in the first case presented below (see also Beebe. and the parent’s own childhood history. If a brief treatment is indicated. and the ways in which the infant affects the parent? (3) Are there ways in which the parent’s representation of the infant. two to four lab visits and accompanying feedback sessions may be adequate. and it fosters a greater integration between the two modes” (Beebe. can the parent verbally describe any of the ways in which he or she affects the infant. I explain my videotape approach and my preference that the first meeting be a lab visit.” how does each individual’s patterns of behavior affect those of the partner? (2) In the declarative mode. On the one hand. the infant’s ability to “repair” with the stranger. This treatment format is extremely flexible. to the point where often the stranger has an initial advantage over the mother. in the case of a more serious situation. In the lab. Each lab visit is followed within a few weeks by a two-hour feedback session in my psychotherapy office.

I consider that one of my most important functions is to admire the parent-infant pair wherever possible. is itself a powerful therapeutic intervention. This initial psychoanalytically informed conversation is a critical background to our ability to understand the “story” that unfolds in the videotape. is usually included in each treatment. greatly facilitates the work of the feedback session. enjoys each other. and negotiates repairs. and I simply used my own microanalysis to inform the interventions. My goal is to give . An Ainsworth attachment test. or increased a smile by opening the mouth or reaching the head forward. Together we view the videotape slowly. Other important aspects of the parent’s history usually emerge during or after watching the videotape together. I try to help the parent identify the exact moments where the parent responds to the infant and the infant responds to the parent. cooed. often at the beginning of the interaction. usually two hours. based on a psychoanalytically informed view of the meaning of the parent’s complaints in relation to his or her own functioning and history. Nonverbal interactions are highly repetitive. Bringing into awareness the ways in which this dyad already “finds” each other. attempting to construct with the parent the “stories” of the presenting complaints and the parent’s own history. and similar patterns can be discerned over and over. smiled. trying to see exactly when and how and in what sequence each partner oriented. somewhere between 12 and 18 months. I have reviewed the videotape in detail prior to the session. copes with disruptions. and based on my understanding of any temperament or arousal-regulation difficulties the infant may have. In only two of approximately 50 cases that I have seen have a parent refused.22 Beatrice Beebe may easily collaborate. using this example as an entry into learning to observe the small micro-moments of the interaction. coded by someone blind to the infant’s status. (It is extremely rare for a parent to refuse to view the videotape. usually is sufficient. and one functioning in the role of the consultant for the video feedback consultations (see Cohen & Beebe. A long session. described above. 2002). Viewing a small portion of videotape. informed by the patterns of regulation documented by research microanalyses. looked. In those cases I understood the refusal as an index of the level of trauma. In the session I follow the parent’s lead. one proceeding with a standard individual treatment.) In viewing the videotape I attempt to translate specific details of interaction patterns revealed by microanalytic research into terms that the parent can use. My first goal is to point out a successful moment.

Together we try to observe the effects of each partner’s behaviors on the other in these difficult moments. and the parent’s childhood history. at least once in slow-motion. to slow down. and ways the pair manage moments of infant distress. Wherever possible I like to use research findings. I suggest slower rhythms. how the parent paces and pauses. I encourage the parent to put into words what he or she is feeling. moments when the parent matches the infant’s vocal contours. I again inquire into what the parent felt. and more “waiting” when the infant looks away. Very likely I will play this positive portion several times. but nevertheless identifiable. shifting attention away from “the right way to do it” to infants’ remarkable capacities. . what the parent thinks the infant felt. 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. in an effort to understand what may interfere with the parent’s ability to “see” the infant and the interaction. It is here that the parent is likely to have a spontaneous insight into the problem. 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. and what the infant may be feeling. facilitating the infant “taking a turn. with an infant who easily becomes overaroused and irritable. more repetition.” I note infant self-regulation and self-soothing behaviors. Another videotaped assessment is scheduled in another month or two. behaviors. My role is often to give permission to do less. I will also have selected one or two central difficult interaction patterns that I would like the parent to be able to see. As we proceed I illustrate how evocative minute infant facial expressions can be. For example. and the meaning these moments have for the parent. they are identified. I emphasize what this particular infant needs to stay optimally engaged. illustrating with a drawing. I attempt to link the “stories” of the presenting complaint. At the end of the session the parent is encouraged to trust what has been learned. longer pauses. to help parents understand the infant’s behavior. as they occur in the interaction. the video drama.Mother-Infant Research and Treatment 23 the parent “new eyes” to see the infant’s remarkable nonverbal language. to wait. and to try not to be too self-conscious. Having studied the videotape in detail in advance. and the infant’s ability to respond to minute. Together we try to describe what we see. finding a “new language” for their exchange as well.

He seems more connected to the babysitter than to me. letting him go when he looked away. cecil 10 months In the lab mother and infant were asked to sit face-to-face. Cecil made very good eye contact with me. C. The older son had always been easier and had seemed to match the mother’s temperament. but Cecil emerged from the blanket momentarily dazed. was warm.” Mrs. C. and waiting until he initiated gaze before trying to engage him. said this was typical. The standard instructions to the mother are to . and even had moments of a “gape smile. As the blanket came off. Cecil never even looked at her. over the phone she told me that she had an eight-year-old son and a 9-month-old baby boy. then tried a peek-aboo game. so that I could try to see more of the details of the interaction.24 Beatrice Beebe The Case of Cecil may: first contact In my first contact with Mrs. Instead of trying to force more contact through high arousal games. tried to play with him face-to-face.” The mother then took Cecil. and could not get Cecil to engage. with excited positive affect. I explained that looking away is the baby’s natural method of re-regulating his arousal when it has become a little too high. and seemed quite relaxed. From what I could observe in the office. she wondered. Cecil looks past me. The first consultation occurred in my office. Mrs. Cecil. He then smiled at his mother briefly. He seems happier by himself. C. thought that perhaps Cecil needed a higher level of stimulation. My suggestion in this initial meeting was that although the peek-aboo game did have a moment of “built-in” eye contact. Mrs. This second baby had been different from the beginning. Or perhaps she herself had disturbed the relationship initially. Or maybe she had never given Cecil sufficient eye-contact and intimate engagement during nursing. I had difficulty understanding in more detail why the infant was so avoidant with his mother. but he is not focused on me when I play with him. “He is a friendly baby. there was a moment of brief eye contact. and looked away. We agreed to do a split-screen lab videotaping. C. I suspected she would have more success if she followed Cecil’s lead for eye-contact. with a sober look. it did not seem to engage Cecil. with the infant in a high chair. Mrs. by talking to her older son while nursing Cecil. june: first lab videotaping. putting the blanket over Cecil’s head. C. unless I energetically try to engage him. friendly.

While he was still looking down. hi. After a brief interruption to get the seating and the camera angles right. and do you know what else?” This vocal contour is usually reserved for greeting. “gheh!” At each maternal movement. moved his head down. We have come to view such loss of postural tonus as a coping strategy in the face of overstimulation. mother found a new toy. as if the stimulation was just a bit too much for him. just at this moment. In my microanalysis of the face-to-face play interaction.” However. Cecil’s face took on a negative frown expression. dolly. and offered it with a “sinusoidal” shaped vocal contour (the contour of approval and flirtation): “Hello. While Cecil was still hanging over the side of the chair. moved his head farther down. I observed that the mother continuously gave Cecil toy after toy. hello. “Look what’s here. “What’s that!” showing the toy. Cecil. limp. Mother then moved into. with abrupt. Cecil” and gently tapped Cecil on the head with the toy. Cecil. producing a splitscreen view. look at her. Simultaneously with the collapsing tonus mother said. “Say hello. One camera is focused on the mother’s face.” Cecil’s face showed a hint of a slight mouth opening. Microanalysis of First Two Minutes of Mother-Infant Interaction In the opening moments of the interaction. not looking. the dolly. and to pay attention to the new toy. baby. It was successful in getting Cecil to look at mother. and Cecil’s face showed a hint of a smile. Cecil then looked down and away. mother asked Cecil to look at the toy. Cecil briefly glanced at his mother with a neutral face. once eye contact has already been made. Cecil blinked. and he looked down. “gurooom!” and got Cecil’s attention. then averted. and then uttered a fussy sound. with mild startles. mother shook the toy toward Cecil. as mother continued. in which both partners can be simultaneously observed. 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. rapid movements. each accompanied by a strong sound. and then receded into his more characteristic neutral expression. and one on the infant’s face. Then mother made an interesting noise. . then shifted his body and hung over the side of the chair. each accompanied by a strong sound.Mother-Infant Research and Treatment 25 play with the infant as she would at home. As mother continued with. At each Cecil blinked. making a series of “ooooh” sounds. look at her. and then looked down. Cecil’s head collapsed further into his stomach. Finally he gave up body tonus and collapsed his head into his stomach. but Cecil stayed with his head down. “Hello.

Those babies who . or over the side of the chair. Periodically Cecil continued to collapse. Occasionally there were some moments of eye contact. and thus she disrupted the baby’s initiative. in the rest of the ten-minute session there were nice moments of mutual gaze. and then “chasing” the baby when he averted gaze. Several times Cecil showed intense interest and vocal excitement in a toy. 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. started to cry and shake his body. Cecil did not respond. and yet another. averting gaze. However. throwing to the floor all the toys that mother handed him. and mother gently tapped him on the head with the toy. or sounds. very fussy. The infant’s ability to engage with a trained novel partner is a critical aspect of the assessment. and mother joined the excited sounds. When Cecil became fussy. offering one toy after another. But she did not give the baby a chance to respond. Overall. Cecil began to get fussy. while mother never paused. Cecil was low-key. By the end Cecil was openly protesting the level of stimulation. Cecil did not smile. while the mother watched the interaction over a TV monitor from another room. Cecil got even fussier. facial mirroring. and the mother beautifully matched the contours of Cecil’s sounds. mother offered Cecil another toy. However. but at the expense of the social engagement. often without pausing in her movements. and some interest on Cecil’s part in the toys mother offered. Toward the end of the ten-minute interaction. Mother then called to Cecil in the “sinusoidal” vocal contour usually reserved for greeting. At a more global level of description. into his stomach. orienting away. She also disrupted the baby’s arousal regulation. and following the infant’s line of regard to an object of interest. with his face mostly neutral. there were nice long strings of vocal exchanges. mother offered more toys. When the play was more successful. and some nice low positive moments. stranger-infant interaction Following the interaction with mother. further increasing the intensity of the stimulation. Mother took a rattle and began to shake it. over-arousing the baby by never pausing. Mother showed excellent capacity for vocal rhythm matching. or to organize an interest in the toys on his own.26 Beatrice Beebe This is a detailed description of approximately the first two minutes of the interaction. I played with Cecil for three minutes.

” a new ability to observe the details of interaction. I admired her facial empathy. I suggested that as we watched the tape. 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. When I handed Cecil a toy. which elicited the response from the baby that she wanted.Mother-Infant Research and Treatment 27 can “repair” the engagement with a novel partner are generally more resilient. body tonus collapsed. My overall impression was that he easily over-aroused. The mother had already watched the tape and she felt bad. 1988). Cecil was very physically active. and exactly what the infant did. and then hanging limp. sideways over the chair. turning around in his chair a lot. In essence. and then immediately became negative and averted. Each brief gaze encounter was followed by a sequence of immediate averting. as if to both self-stimulate and self-soothe. looking down on the floor at an object.. Each time I waited. In evaluating this interaction. She realized that she was “trying too hard” and it was not working. but these were very brief. On the other hand. mild negative facial expression. Eventually Cecil began to bang his own body gently against the seat. and this was repeated over and over. as each responded to the other. She was also surprised to see me point out very subtle facial expres- . we could try to make quite specific just what she was doing when she felt she was “trying too hard. as well as to notice what did not work for her baby. and he came back into the engagement on his own. Once he looked. But then Cecil became fussy. her vocal responsiveness. with a positive expression. I noted that my tempo was noticeably slower than that of the mother. and her well-modulated vocal contouring (see McDonough. with midrange positive affect. he became slightly excited. In this process my goal was to help her confirm what she did quite beautifully. he had the capacity to re-engage on his own when I waited. he quickly smiled broadly. quieter. In the process. There were then a few moments of eye contact with me. looking down.” My own goal was to help the mother notice exactly what she did. he quickly threw it on the floor. 1993). I waited for Cecil to look at me before I attempted to engage him. When he did look. in response to her abrupt movements with the toys. She saw me as smoother. She was quite surprised when I pointed out the infant’s blinks and startles at the beginning of the interaction. I wanted to give her new “eyes. whereas those who generalize the difficulty to a novel partner are in more difficulty (see Field et al.

just when she was feeling more and more desperate to reach Cecil. hints of shifts in cheek tonus.” Mrs.’s feeling state as a child. as a way of reaching him.. my hypothesis that Cecil dampened his face. Her mother was never attuned. C. had never been able to sense Mrs. distant. C. even when the infant is not smiling. which can be expressions of interest and involvement. said that all of a sudden she saw Cecil’s face as like that of her own mother. C. We both empathized with how hard it must have been for Mrs.’s own difficult childhood. averted gaze. lowered his arousal. and I showed her again a section of the videotape illustrating it. Now “seeing” Cecil’s neutral face seemed to trigger her procedural “motor memory” of her own mother’s face. and calling the infant in a “greeting” contour at moments when the infant was clearly not receptive. 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. hard to reach. hard to read. as she had when her own mother had been so difficult to read. And how counterintuitive it was to lower the stimulation. as Cecil seemed to become more and more un-readable. and that she could be seeing Cecil as like her own difficult and removed mother. to “try less hard. could see that she was doing the same thing with Cecil—setting the pace. C. She saw that she now felt the same way about Cecil—that Cecil was hard to read. who had always appeared impassive. In this interaction.” irrespective of where she was emotionally or what she needed. then told me that her own mother was rigid.28 Beatrice Beebe sions of slight mouth openings. Mrs. and never knew “where she was at. and the aspects of it that entered into her interactions with Cecil. hard to reach. We succeeded in defining the mother’s “trying too hard” as lack of pausing in movement or voice. Mrs. like her mother. And now Mrs. controlling. How natural it was to keep trying harder.” to be slower and calmer. C. We then discussed my description of Cecil’s face as too neutral. I reenacted for her the face I saw in the baby. We both felt sad over Mrs. C. and setting it too fast for him. although she had managed to work. 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. and turned away. and try harder with Cecil. I told Mrs. as self-regulation strategies in the face of feeling over-stimulated. to wait.’s mother had “set the pace. trying to get the infant’s attention when he was turned away. and quite depressed. And she saw that she would become anxious. C. C. But as we .

slow. and mother showed him another toy. and it was more sustained. while mother held it quietly. Even without such delays. fussing. The mother was gentle. Microanalysis of First Two Minutes of Mother-Infant Interaction As the videotape began. explaining the noise. held it close to his body. and was asked if she wanted to continue the filming. There was clearly more room for Cecil’s own initiative. The interruption disturbed Cecil. and she paused in between her movements and her vocalizations. We agreed to continue. Mother was told that the sound was now working. C. Cecil made more eye contact. I suggested that she try to trust herself with what she had learned. we see Cecil rocking his body back and forth in the chair. Mother then tried some puppet play. After a few minutes. holding his hand up in an appeal to be picked up. again while mother waited quietly. moving the puppet very slowly. and technical difficulty delayed the beginning of the filming. and stated that she thought she could shift what she was doing with Cecil now. We agreed to do a follow-up split-screen videotaping and an Ainsworth “separation test” in a couple of months. instead Cecil himself took a toy and explored it.” joining the infant’s distress. Cecil concentrated on it. and mother joined his line of regard. sitting in a high chair for ten minutes is hard for any active 12-month toddler. and held him. Mother then showed Cecil a doll. Cecil collapsed into his stomach. In evaluating the interaction. Cecil took the toy. Mother then rocked her own body a bit too. Then Cecil was distracted by the sound of the camera moving. august: second filming. Cecil lost interest. Mrs. and mother was able to wait. felt very positive about the experience. and Cecil briefly engaged. explored it. 12 months There had been a long wait in the lab. Without the sound in this section. . but without taking him out of the chair. Cecil was tired. and mother matched the distress sounds. and now he very much wanted to get out of the seat. Then there was an interruption at the door. I observed that the mother was slower and softer.Mother-Infant Research and Treatment 29 parted we both felt encouraged by understanding what the difficulty was. Mother made a “woe face. and was very sorry that Cecil couldn’t get out yet. without becoming overly self-conscious or self-critical. Cecil then made another bid to get out. He had been there a long time. matching the rhythm. there was no sound track for a couple of minutes. Once we got started. waiting for us to get going. The mother did not push toys at Cecil.

Although he had been having a spirited. turn taking di- . and giggled. I tried making the “la-ler” sound. Since this form of engagement does not require the child to be visually engaged. There was nothing the mother did in this second filming that seemed to interfere with the infant’s capacity to play and to respond. Immediately I matched this sound. He was silent. and sustained the positive affect. and threw any toys on the floor. Describing the rest of the session. stranger-infant interaction We then attempted a stranger-infant filming. Then Cecil was briefly quiet. All of a sudden the whole tenor of the interaction had changed. Cecil emerged smiling. And right away he looked at me and made another. Toward the end of the interaction Cecil began to be tired. since he was crying hard. and every toy that I tried to engage him with was immediately thrown on the floor. He cried loudly. and it came out as “la-ler. Finally we organized a set-up in which Cecil sat in mother’s lap. As we continued to match and elaborate on each other’s sounds. Cecil had been enormously responsive to my matching his vocalization.” He was intensely visually engaged. after a few minutes mother did a peek-a-boo game. it can potentially provide a less intrusive or demanding means of making contact. made no eye contact. Three different attempts by me to play with Cecil had to be aborted. “where is Cecil?” This time the quality was totally different: slower and very successful. His own willingness to elaborate on the jointly formed patterns was critical to the success of the dialogue. at some point he finally made a vocalization. similar one. and mother was instructed to “be the chair. Cecil was disengaged. at some point Cecil began to move his tongue as he made the sounds.30 Beatrice Beebe and mother joined Cecil’s vocal distress with similar sounds. and waited. covering Cecil’s face with her hands and saying. Cecil then heard the noise of the camera again. and this time I stopped the filming after seven minutes. and we were engaged in a fascinating vocal dialogue. a “spit” sound. Variations on this rich vocal dialogue continued for the next four minutes. at times elated.” not to help or respond. and mother waited. at a more global level. la-ler. and mother joined his line of regard. angrily. Now Cecil wanted to get out again. but Cecil would have none of it. For the first five minutes of the interaction. However. and held him close. and we both burst into big smiles.

I intuitively knew that I was not being with him or being emotionally re- . charming. He is an absolutely delicious. No surprise. having discovered Cecil. November A letter: “You have played an absolutely pivotal role in my life. . funny. you helped me relax and see him. he wants mommy only. I’m enjoying how different he is from his brother. Cecil. He is more bonded with me too. stopped comparing him to his brother. . our connection is deep and easy and full of joy. when he began to get tired. But then he was able to keep coming back to me. This laboratory filming ended with a brief discussion with the mother that her interaction with Cecil was going extremely well now. So. I stopped my agendas. Cecil was doing well. To begin with. He seems terrific. . I totally relaxed with Cecil. These movements away from me were his own self-regulatory efforts to manage his arousal within a comfortable range. . I had seen this side of him from time to time. The success of his self-regulation efforts could be seen in his continuing ability to re-engage me. but now it has really come out. Beebe & Lachmann. We made a decision not to pursue the attachment test since the visit had already been too long. It was a demonstration of a way to make contact without forcing. very loving little person.Mother-Infant Research and Treatment 31 alogue with me (as he sat in his mother’s lap). 1994). . . He is a delightful baby. . In retrospect. . he arched away into his mother’s body. and to continue the rhythm of the vocal exchange. I stopped focusing on who he was not and on how he and I were not. he is now so social. in cycles of vocal dialogue. . I fell in love with Cecil. . and avoided me. we are just charmed by him. 1989. . disruption. or chasing. . intruding. . We were on vacation for three weeks and we had a lot of time to spend . follow-up contacts September A telephone conversation: “Things are just great. This aspect of the interaction with me was used as part of the therapy. and all we needed to do was to watch to be sure he continued to be fine. It also vividly showed the power of vocal rhythm matching in making contact. . I got to know him better. my feeling of self-reproach was based on some accurately sensed stuff. since the child does not have to make eye contact. and then repair (see Tronick.

continually offering toys. who had “set the pace.’s ability to observe and verbalize both sides of the bilateral effects of each partner on the other. for example. C. Mrs. the difference is not minor. C.” discussion of the c. had as a little girl. C. Thus she and her infant had “re-enacted” an aspect of her own history. Addressing the infant’s impact on the mother. Often various representations of the infant disturb this process further. or inhibit initiation with toys. how does each partner affect the other? (2) In the explicit narrative mode.” Addressing the mother’s impact on her infant. to “withdraw. Our three orienting questions provide a framework for conceptualizing the treatment: (1) In the implicit mode of action-sequences. C.32 Beatrice Beebe sponsive to him anywhere near as much as I can be. look away. Mrs. She acted like her own mother. however. to startle.” Her own “setting the pace” behaviors (not pausing. rapidly moving into the face. “my baby does not smile at me. the mother who sets the pace and the child who withdraws.” or “my baby does not look at me. was aware that her infant was withdrawing from her. Mrs. Identifying these specific behaviors enabled Mrs. 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. Mrs. C. to observe the moments in which they influenced the infant to disengage.” But it is harder to observe one’s own behaviors which affect the infant. continually offering toys) were out of her awareness. had not been aware of the specific behaviors that we were able to describe together. When asked how she would respond to this. 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. such as. for example. could observe as well as verbalize that her infant often did not look at her. was vague: “I try harder. but she was not aware of how similar her infant’s behavior was to that of her own in childhood.” and her infant seemed to act like Mrs. and let me tell you. that is. collapse into the stomach. Now I am. C. We were able to identify some of the “transferences” to the infant that seemed to disturb Mrs.” or “He needs more stimulation. or smile at her. not pausing. . C.

tolerate the infant’s disengagement without “chasing. and to remember. C. and vocal behaviors.” very contingently responsive to the infant’s every move. so that they did not seem “excessive. This work allows the mother to shift her representation.’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. Presumably the similarity of this interaction with ones in her childhood interfered with Mrs. C. At the outset of the treatment. showing lowered level of arousal. in an arena that has been out of awareness due to some kind of unresolved pain. but interacting with levels of stimulation that were too high. neutral. since the infant had an “impassive” face. impossible to read. less vigilantly responsive to every infant move. Moments of matching were interspersed with “waiting” for the infant’s own moves (of self-regulation.Mother-Infant Research and Treatment 33 Similarly. which reminded Mrs. for example. more midrange in facial responsivity with both positive and negative expressions rather than a predominance of . with excellent facial-mirroring and vocal rhythm matching. vividly of her own mother’s face. The infant for his part shifted from a “low-coordinator” and became more “midrange” in his level of contingent tracking of the mother.to more “midrange” coordination.” tolerate the infant’s distress. or initiative). the infant seemed to act like Mrs. Being presented with the procedural level of action sequences which are out of the mother’s awareness. C. the mother was able to move from high. that is. that disturbed the infant’s initiative. with patterns that were spatially intrusive. and with his initiative shut down.” or imposed. Mrs. C. Following the videotape intervention. Cecil could be described as preoccupied with self-regulation (looking away. constricting the range of the face).’s ability to see that her “trying harder” was just pushing her infant farther away from her. with lowered levels of contingent coordination with mother’s behaviors through facial. facilitates the mother’s ability to see. do less. The optimum midrange model of regulation described above is useful as a framework for evaluating the progress of the treatment. She was able to pause more. and give the infant space to initiate play. wait. Mother could be described as a “high coordinator. from the baby rejecting her. The mother is being asked to make a unique integration of procedural and declarative information. presumably because they are connected to painful childhood experiences. These transferences were identified in the process of watching the videotape. body collapsed. to become anxious and to try harder.’s own mother. to the baby as over-stimulated and attempting to dampen his arousal. visual.

But what will it do to her in the long-term? I feel like she does not love me. and I happened to be traveling nearby. but rather in an office. She smiles more to my husband and the Nanny than to me. I envisioned a different reaction to me. N. and they were only seen in person for one extended three-hour evaluation. illustrates a maternal “absence of provision.” “I have never seen myself as a mother. Since the problem turned out to be an absence of intimate engagement. In the case of Nicole. Mrs. more visually engaged. Mrs. it was a case in which a detailed videotape evaluation was luckily not essential. strongly involved in her hard-driving career. Nicole. that I’m not good as a mother. In the Cecil case. I take Fridays off. N. My husband does not think it is anything to worry about. rather than a complex misregulation of engagement between infant and mother. and she had requested a consultation with an infant “expert. The first contact was a telephone session. probably had difficulty giving focused attention to her daughter because she had never gotten much herself. The Case of Nicole The case of Nicole is a useful counterpoint to the Cecil case. I was not able to detect the problem without the videotape microanalysis. and it takes her quite a while to warm up.” Because this family was from a distant city. had become worried that her five-month-old baby was not as responsive to her as she was to the Nanny. but it does not . Now I want to pick back up the domestic side. but she resented it. I was little ‘Miss Career.’ My mother was domestic.34 Beatrice Beebe neutral. together with a number of follow-up telephone consultations.” The therapist suggested that Mrs. and much more active in initiating play with objects. We were toys and dolls to her. the mother-infant pair was not evaluated in my lab. N. How much I need her love. “I’ve been going 100 miles per hour all day. who described her as an anxious new mother. Mrs. and Nicole has been with someone laid back with nothing to do but to be with her. knowledge of the microanalysis research was nevertheless essential to the treatment. but Nicole would not even look at her. was referred by her therapist. N. felt “disconnected” from her daughter. on the other hand. which illustrates mild maternal intrusion coupled with some temperament and arousal regulation difficulty in the infant. I’m not as natural as the Nanny. She described feeling crushed when she arrived home to see her daughter laughing and giggling with the Nanny.

But now she’s not so happy about it. I commented on how aware she was that she needed to try to relax and slow down to be with Nicole. I pulled up a footstool and sat halfway between the two of them. The baby played with the toy. he declined to be involved. I tell myself. Instead of being able to relax. Nicole at 5 1/2 months was a big girl. and she’s trying to help herself change it. Mrs. quite placid and self-sufficient. I’m on the phone. As she was settling Nicole in. home life. this is her time. This was the only contact in which I actually saw them in person because of the extremely long distance involved. don’t pick up the phone. and that she was struggling to find a way to slow down to be with Nicole. but I want her to love me more. but the infant will not look at her. nor did she look around the room.” As she told me this. I don’t mind if she loves the Nanny. It’s my nature to be doing three things at once. and heavy. Mrs. and that she had been stupid. It was very understandable that it would be hard for her to learn.” 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. “I don’t measure up to the Nanny. I said that we needed to find a way of re-righting this without blaming. N. “Maybe it’s because I always had the phone in my ear when she was nursing. She lamented that she did not do it right.” And then she cried.” I said that evidently she had learned to be like her mother in this. She responded that I had a beautiful voice. We then discussed exactly what happens when she comes home from work. and take the time to be with her. while her mother talked to me about her work schedule and her dilemma of work vs. I told her how important it was that she had taken the step of calling me. . and perhaps it had been a way of being close to her own mother. putting each different part of it in her mouth. I feel like my mother when she’s running around like crazy and can’t get organized. I sensed the rapid clip of her speech. “I don’t like myself when I am with her. She nurses Nicole when she comes in.Mother-Infant Research and Treatment 35 come naturally. propped her up at one end of the couch with a toy. then sat at the other end of the couch. N. Although the father came as well. and that she felt smart for trying to get help. she knows exactly what to do. 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. She never looked at her mother or at me. The second contact was a three-hour consultation with the mother and baby. I empathized with her agony over feeling that she had disturbed her relationship with Nicole. the infant’s body arched away from her.

N. N. She had a large bowel movement. anticipating the moves with her body. but without smiling. Nicole chortled. and returned some of Mrs. showed me a “pull-to-sit” game that she plays with Nicole. what will be the effect. N. I explained that first I needed to play with her to try to see her range of responsiveness. I coached the sounds from the sidelines. This was the nicest connection they made. as much as finding a way to make a connection with Nicole.’s sounds were thin and squeaky. N. She was marvelously socially engaged. N. I tried to get her to move her face in ways similar to the ways I moved mine (small increments of open mouth. N. Mrs. The baby clearly knew the game. and she did not put any words to the sounds. with high positive affect. She did not seem to know how to play. The first thing I taught her was vocal rhythm “matching. pitch. N. solicitous. slow. Eventually the sounds she made were adequate to make some contact with the baby. and Mrs. was gentle. I said that I did not think the issue was the amount of time that she worked. her face showed no animation. I then tried to teach Mrs. will she know her own mother. a game that her friend had taught her. Mrs. But Nicole did not look at her mother. then a little more. and at the last moment before attaining the sitting position. and managed it well. Mrs. I then set about trying to teach Mrs. She did not give the sounds a robust prosody. After about an hour. I suggested that we start to see how we could help her engage Nicole more. Now Mother and Nicole were together on the couch. mock surprise). sustaining long gazes with me. and rhythm. she could not elaborate on them.” making sounds contingent on the baby’s sounds. both bodies relaxed. both matching and elaborating on the intonation. Nicole oriented to her a bit more.’s sounds with her own. both looking at the other. Noting how flat her face was as she interacted with Nicole. but she did not look at her mother. then began to talk about how terrible she felt: “Have I hurt her. From this interaction it was clear that the difficulty was not an incapacity on the part of the infant. beginning a rudimentary vocal dialogue. her head oriented up and 30 degrees away from the vis-à-vis. by having her roughly match some of my faces (gape smile. moving . should I stop working?” She cried during most of this discussion. open a little more. facial mirroring. I chose this first because the child does not have to make eye contact in this mode of relating. Mrs.36 Beatrice Beebe Nicole then needed her diaper changed. how to engage Nicole. then held Nicole lying across her lap on the infant’s back. N. Evidently. the social engagements with her Nanny and her father were going well.

I feel bad that I don’t connect the way he does. In this process she had an association to her mother’s angry.” I asked her if she could start it with occasional sounds of her own. If I can slow down. and to do vocal rhythm matching if Nicole made any sound. her face was tight. Gradually I taught Mrs. The attention to the behavioral details of the procedural level. We then moved to an attempt at face-to-face interaction between mother and baby. She was receptive and felt sobered by this idea. “My husband can walk in the room and connect with her right away. She agreed. and unvarying.” I asked if there was then a danger that she would feel rejected and withdraw. N. powerful experience of getting some more response from her baby.” Nicole began looking a bit more. But Mrs. 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. If I don’t get a lot of feedback. She then reported that Nicole is not as avoidant as she was: “She looks at me. she wanted more contact with her. When the Nanny leaves. She was unable to play with her face. to slow down and to make some slow rhythmic sounds. she . had a direct. Sometimes she does not make any sounds. “Now I make it totally Nicole’s time when I get home. and she became a little teary. I taught her to “cool it. N. she is used to her. we can connect better. she did have some games she played with the infant. seemed to trigger her representation. I suggested that her reaction to her mother’s angry face was expressed in her own facial tightness and constriction. The gazes were not sustained.Mother-Infant Research and Treatment 37 the upper lip in and out of a purse etc. He is like the Pied Piper. 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 instant the infant looked away. By the end of the week I feel totally disconnected from her. It is hard for me. I feel unliked. tight face. I have to be careful: I expect her to demonstrate affection and attachment. I taught her to give an exaggerated mock surprise greeting. which we could then address and elaborate at the symbolic level. The infant made absolutely no eye contact. and how to massage her face. She agreed. so I can’t mimic her. I get worried. Ten days later we had a telephone session. She expressed relief and gratitude that I had validated that something was wrong. When I don’t get it. yes. At first Nicole was very gaze avoidant and her whole body arched away from her mother. She could see that she was getting somewhere. flat. very much. I then had the idea of showing her how to unlock her jaw. and most of all. I asked her if she would be interested in trying this. When the infant would give her a darting glance. particularly the constriction.

I am relaxing a little. I don’t feel crazy anymore. she gets this glow. I’m trying to get ready.’s increasing ability to notice what she does and to see if it is disturbing Nicole’s ability to connect with her. all speeded up. All of a sudden she has started really vocalizing. “She will watch me now if I do interesting things with my face. N. I’m in a hurry. looks more. We practiced the “sinusoidal”shaped “hello. I missed my chance. She reported that Nicole looks but she does not smile. But I noticed that if I’m tense I close my face up. and angry. When I’m with her. The biggest thing you said was.” I empathized with her fear and distress. A telephone message two weeks after the initial three-hour session in person: Mrs. I suggested she try a mock surprise expression right now. “Have I lost my chance? When I left you.” A telephone session one month after the initial three hour session . She said that she was angry her husband wasn’t encouraging her to quit work. 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. played with her. I’m just giving her all my attention. and Mrs. I waited a moment while Mrs. N. But what you are saying to me is. I’ve never felt so insecure in my life.” She told me that Nicole was right there with her. N. She lights up for my husband. She can concentrate on my face though. and that Nicole was clearly beginning to respond. I should have stayed home and not worked. “I would be devastated if I do not have a good relationship with Nicole. and I do a dancing conversation in front of her face. though she does not smile. that’s new. She smiles more. Then I asked her about feeling angry. she immediately told me that Nicole was looking at her right now. and able to notice when she closes it up. I felt so bad. focus on her. looking at her face right now. I congratulated her on becoming so aware of her own face. N. began to make sounds. “When Nicole looks at my husband. She then asked. and she did.” Without waiting for me to respond.” she and I saying it to each other. it’s not too late for me to connect. Then I told her how terrific it was that she was holding on to her hope to connect with Nicole.38 Beatrice Beebe watches. and she was angry that no one had been agreeing with her that something was wrong.” I commented on Mrs. and she reported that Nicole was looking constantly at her while she made the sinusoidal sounds.” I said that it was wonderful that she was trying to engage her child with her face. and that she and I could both see progress. She felt that finally I had validated her. will it always be this way? In the morning I am terrible with her. She is so responsive to the Nanny.

the vocal modality proved to be easier for Mrs. to develop with Nicole. how to “prime the pump. N. she’s happy. that is. and “cooling it” when the baby looked away.” Then she asked me if it was a mistake not to come for a second consultation in person. facial mirroring. She looks. The key to unlocking Mrs. When I come home. because I don’t want her to sense it. N. and I respond. Then I just hand her to the Nanny. Presumably the more adequate “provision” of the Nanny and the father had to this point safeguarded the overall social development of Nicole. I get a greeting. over the phone. because things were going so much better.’s capacity to mother Nicole was the discovery of her traumatic reaction to her own mother’s face.” Mrs. Occasionally we have a bad evening. and she carried on most of her relationship . The mother’s frozen face and inhibition of maternal “play” behavior required me to figure out how to get the actionsequences going. how thrilled I am that things are so much better.” I tell her how wonderful all this is. which was then “carried” in a procedural form through her inhibition of her own face with Nicole. If she initiates. I notice it. But Mrs. and I said no. If I’m rushing. But I’m more comfortable around her. and make it even bigger. it was initially easier to reach Nicole this way. vocal rhythm matching. She thanked me profusely. I didn’t think so. By teaching her specific ways of engaging the infant. I told her that it was so remarkable how quickly she and Nicole were able to turn things around. N. but not all the time. I may be doing more of her language. discussion of the n. “I think we’re doing a lot better. she’s really relating to me. and of her increasing ability to engage Nicole. then she laughs. she’s more vocal. from the very first contact. vocal contouring. N.Mother-Infant Research and Treatment 39 in person: “She’s wonderful. Since the vocal modality did not require Nicole to look. she smiles. I try to slow it down for her. it is possible that she experienced a “provision” from me.’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. I was also admiring of her willingness to try these new behaviors. In retrospect. 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. as she tried it. had also been so responsive to my voice. I imitate her sounds. she kicks. more expressive. We agreed that she would call me if she had any more concerns.

how each affects the other. Discussion Many different approaches to mother-infant treatment yield dramatic progress (see for example Cramer et al.. Moore. 1998). It may be that the voice was a “non-traumatized” mode for Mrs. particularly feelings of shame and humiliation. and to link the stories of the presenting complaints and the parent’s own history to the video drama. Fraiberg. Microanalysis of behavior allows us to perceive the details of interactions which are usually too rapid to grasp with the naked eye. 1995) (but note that controlled clinical trials are rare). compared to the face (M. In the video replay we can . personal communication. 1994. This systems view helps us remain empathic to how each partner is affected by the other. 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. Stern. With this perspective. to help the parent use the behavioral details of the video drama as a springboard for memories and associations. form the core of the treatment. N. Seligman. Although the use of video feedback is growing.40 Beatrice Beebe with me over the telephone. 1999). However. A clinician’s sensitive ability to construct jointly with the parent a description of the exchange. personal communication. for example. in that it is not happening right now (Lefcourt. July 7. negative interactions such as “chase and dodge” or “mutually escalating over-arousal” can be seen as reciprocally responsive co-constructed forms of engagement. three decades of microanalysis research on the mother-infant face-to-face exchange is surprisingly under-utilized in current treatment approaches.S. when the parent and I view the videotape. August 18. Later. The clinician’s careful attention to the parent’s self-esteem. as well as somewhat “distant” and safer. 1980. 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 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. The video feedback method does not disturb the dyad while they interact. it is simultaneously “immediate” and visually concrete. video microanalysis of the interaction from a systems view can only richly set the stage for the treatment. 1990.. is essential.

flood the senses. procedural aspects of the parent’s mode of relating to the infant which have remained out of awareness can be translated into explicit. We rarely know what we really look like as we interact. van Ijzendoorn. This “shock” may be part of the emotional power of the video feedback method. Kohler. 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. Seeing oneself on videotape may operate like a “shock” to the unconscious. and to reorganize representations (Beebe. M. 1998). M. 1998). In this process implicit. September 10.: Lawrence Erlbaum Press. N. 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. Because the mother is usually so motivated to engage her infant... The parent can become more aware of the infant’s “mind” as well as her own (Fonagy et al. E. October 23. Hillsdale. BIBLIOGRAPHY Ainsworth. September 10. M.J. & Wall.. N. 45). personal communication. 41 Both parents in the two cases presented felt that the treatment validated their sense that “something was wrong. S. June 26. Since the visual information speaks on its own. (1998).. This vague discomfort is the parent’s ability to sense the impact of the implicit procedural mode and enables the parent to seek treatment. 1998. the therapist is free to emphasize different aspects.” Mrs. was able to persist in trusting her discomfort even though her husband did not think there was a problem. But the meaning of this discomfort is not usually recognizable without help (Tabin. The therapeutic viewing promotes a capacity to observe oneself in interaction. Bakermans-Kranenburg. Patterns of attachment. personal communication. F. “perturbing” the system (Milyentijevic.Mother-Infant Research and Treatment concentrate on a particular modality. (1978). whereas in the live interaction all modalities. she can make an effort to overcome any natural awkwardness at seeing herself. personal communication. Waters. narrative forms of understanding. Interventions with video feedback and attachment discussions: Does type of . 2002). to underscore the positive elements as well as identify derailments (Tabin. M.. 1998). p. Blehar.. Juffer. to think about the emotions seen in the video. as well as words. personal communication. 2003. and slow it down.

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

regulated kernels of love and responsivity. in the sense of moving from relating to object-use (Winnicott 1969) and development of a sense of self as real. her adoration of “His Majesty the Baby” (Freud 1914). At the same time. Yet there is an additional ingredient to do with love. “Maternal failure” in psychoanalysis refers to intrapsychic processes in the mother which violate their infant’s state of going-onbeing. attachment paradigms of “security” and “disorganization. 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. 1975) are required. 1981). 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. Thus. and neurobiological research. In this paper I attempt to describe the development of this mother’s love. ownership of the other and capacity to be consumed by the other. failure to protect the infant from impingements (Winnicott 1962). her identification with her baby and yet her ability to differentiate between herself and her baby and allow individuation (Mahler et al. Psychoanalytic concepts of “good enough parenting” and maternal failure. and passionate appetite. Anna Freud’s advocacy of conceptual flexibility in the aid of clinical expediency is often helpful. such as projection and attribution resulting in distortion of self (Silverman and Lieberman 1999). These latter rest upon the mother’s narcissistic love of herself in the baby. Only then is the baby able to safely love his mother. inability to contain the infant . In facilitating our understanding of the ebb and flow of the therapeutic construction. matched by changes in her baby’s expressed love for her. 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. “love” is not a static concept.” and neuropsychological discussion of relational trauma are useful frames of reference.48 Tessa Baradon asked about her position on the different heuristic models of the mind. Parent-infant psychotherapy is a meeting point for the different disciplines addressing infant development: psychoanalysis. It contains the temperate—that is. and the interventions that may have contributed to this process. 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. attachment. and her capacity to tolerate her hatred of her “bondage” to him (Winnicott 1949).

so dangerously dependent on his mother’s/caretaker’s capacity to identify and understand. this maternal failure appears catastrophic. Tronick and Gianino 1986). fragmentation and. Perry et al. “Disorganized” attachment describes a collapse of adaptive strategy when the infant is frightened. vital presence to a dead detachment from her infant. leaving the baby in an “intensely disruptive psychobiological state” for extended periods of time (Schore 2001. into a relationship with a “dead mother”? The psychotherapeutic work informs us about the experience and the developmental endeavors of babies in this predicament. so to speak. 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. expresses extreme anxiety. 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. 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. They seem careless of the maternal presence or non-presence beside them and appear non-present in their own bodies. Fonagy 2001). finally. This included the negation of herself in him. 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. “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. the repeated breaching of the adaptive and defensive structures available to the immature ego. 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. Because the anxiety is embedded in their relationship—often underpinned and driven by intergenerational patterns of relating—it is enduring. 209).“What Is Genuine Maternal Love?” 49 through “maternal reverie” (Bion 1962). retreat. But what of those infants who have been born. 1995. p. Their precocious defenses of avoid- . and projection into him with consequent distortion of self and object boundaries and impingements on individuation. seen to develop in the context of mother’s unresolved trauma and lack of reflective functioning thereof (Lyons-Ruth 1999. is pertinent. The infant patient. dis-identification with his state of dependency. Therefore the concept of cumulative trauma (Khan 1963).

The therapist is a “new object” (Hurry 1998). Baradon et al 2005.50 Tessa Baradon ance of emotional engagement with the mother. James 2003. Schore 1994) put them in a state of unrailed/derailed development. Inevitably.” supporting the infant’s development through providing contingent responses. sometimes benign but also at times perceived as hostile and/or persecutory. at least temporarily. she is a transference figure for the parent. She is a clinical “observer” (Rustin 1989). In recent years a model has been developed at the Anna Freud Centre (Baradon 2002. the therapist is also a “developmentalist. 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. 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. She is. may be pivotal for the baby’s psychic survival. alerting. In our model. As an applied technique within the psychoanalytic framework it has its roots in the groundbreaking work of Selma Fraiberg and her colleagues (Fraiberg 1980. the therapist is an external affect regulator of the patients’ disregulated . 197). the therapist straddles numerous roles in relation to her patients. offering a revitalizing attachment experience to parent and infant. Perry 1997. until the mother is able to receive and scaffold his love. and regulation where the parent. 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. in parallel. 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. an analytic therapist. And finally. stimulation. As a new object for the baby. the aim is to create meaning through validating and cohering the parent’s experience and responding to the baby’s requirement for an attentive. is unable to. Having the therapist to love. Woodhead 2004). claiming and reclaiming” (p. I suggest that this was the predicament of the baby in the case to be discussed. freezing and disassociation (Fraiberg 1982. providing the functions of “enlivening. Intervening at the procedural as well as declarative levels of self organization. In cases of severe maternal depression and withdrawal the therapist may also be the only “live company” (Alvarez 1992) for the child. both individually and collectively. adult mind to meet his developmental and attachment needs. Lieberman and Pawl 1999).

where the baby’s early attachment needs were thwarted by his mother’s failure to embrace him with “genuine” love. challenging the analytic stance.“What Is Genuine Maternal Love?” 51 states. and her rescue fantasies. Cirulli et al. the therapist’s countertransference is used and must be watched—her own hopes and despair. 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. On the one hand. It raised minute-by-minute questions of technique. Above all. and countertransference was extremely complex. 2003). The actual presence of an infant in the room intensifies the sense of immediacy and clinical (and of course legal) responsibility toward the baby. On the other hand. Which patient/what material should be privileged at any given time. These experiences of trauma for both baby and mother required ongoing scaffolding and regulation from me. considerations of clinical process and technique were particularly charged. and I needed to be alert to the challenge to my capacities for “reverie” in my various roles and from within. With at least two. patients present—infant. and father—the therapist’s attention and receptivity are often pulled in different directions and her identifications may shift between the infant and parent. 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. Thus the matrix of intersubjectivity. transference. Parent-infant psychotherapy poses countertransference dilemmas particular to this method of intervention. and often three. devoid of all narcissistic investment and reward. Freud 1937) virtue of “genuine” love. her infant son was starved for the maternal appetite of ownership and adoration. and in what domain of relational knowing . Primitive emotions and projections are the fabric of infancy and parenting and invariably resonate with the therapist’s past and present attachments. and his experiences of going-on-being were distorted by her projections and hostility. and her severe depression was compounded by a sense of failing her own standards. the therapist. in the face of the acute emotional pain and helplessness of her infant. In the case under discussion. As always. riven identifications between mother and baby. mother. mother sought the ascetic and altruistic (A. the therapist needs to maintain sufficient emotional resonance with the mother.

and had continued smoking and bingeing. her low voice and withdrawn facial expression camouflaging much of the terribleness of what she was saying. explaining that D reassured her that she is a good mother and that she needed her fears to be heard and not brushed aside. but in this paper I will not discuss the work done with the triad. Ms G thought not. Consequent upon the concern about this troubled young mother and her baby. Mother. a network of health and social service support was put in place. was asleep when they arrived. This paper focuses on the first year of therapy. His painfully thin and pale mother sat sideways to me with her face averted. . I asked how she had felt in her pregnancy and she said she had not wanted it. A vulnerable baby. A psychiatric report attached to the referral mentioned a long-standing history of eating disorders and self harm. and therapist In the event. baby.52 Tessa Baradon (Stern et al. baby. tentative beginnings: mother. the baby’s father. I wondered whether at the same time as being afraid to have a baby she had also perhaps hoped for one. the latest one year previously. 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. 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. with concerns about her depressive mood. still a fragile newborn. In the first session Ethan. However. She explained that the likelihood of conception was low as she has irregular periods because of her eating disorder. although I was in telephone contact with Ms G from the time of referral. and a number of attempted suicides requiring hospitalizations. and I met once a week for a period of two years. Ms G was in a stable relationship with D. She spoke in a near whisper. we only met 3 weeks after baby Ethan was born. In the course of the therapy father did become involved. he had required special care in the early postnatal weeks and Ms G stayed in hospital with him. Ms G requested to attend without her partner. Although we ask to include fathers in the therapy where possible. Ms G explained that she had never thought she would have children as she was afraid that she would damage them.

Ms G immediately picked him up with extreme care and held him to her. On the one hand. such as her gentle stroking of him that I had observed even when she was upset. it seemed that projection did not aid her to “feel herself into her infant’s place” (Winnicott 1956. The “feed” was quickly over and Ethan went on sleeping. in which her dread of damaging a child was actualized and exposed. too. In this .” Ms G said she does not feel like that much of the time. Target and Fonagy 1996). Her state of primary maternal preoccupation had a particular quality to it: hypersensitive to the baby via herself. Somewhere early in this conversation Ethan fretted a bit. his little body slumped against the palm of her hand. Moreover. 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. of damaging him. who loves her child and takes care of him. I wondered what she was hoping to get. seemed to have been a trauma which confirmed a psychic equation between her inner and external worlds (Fonagy and Target 1996. and to her bad feelings and thoughts. I felt responsible for her very life. as I imagine rescue workers feel in response to the sounds of life after disaster. She added that she would not harm him physically. She snuck him under her shirt. In turn. I suggested that we would attend to both the good things that happen between her and Ethan. She checked with me whether she could feed him. 304) but that the infant was equated with her. We spoke about attending parent-infant psychotherapy. p. 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. At this question Ms G became distressed. Ms G removed him from the breast and covered herself up. Ms G hugged Ethan to her. his critical early hospitalization. She replied that she wanted a “filter” so that her feelings don’t all come out on Ethan. She felt very guilty about this. of trying to be a good mother. as I strained to hear her whispers. separately and as a dyad. . I experienced Ms G and Ethan. through her very being with her baby. .“What Is Genuine Maternal Love?” She had felt that the fetus was a parasite. I asked whether these kinds of thoughts were continuing. I struggled with my own need to establish some contact with her averted face. as a disturbed extension of herself (King 1978). saying that she feels that she is “forced by him into an artificial position . 53 I felt that the central verbal and affective communication to me in this session was Ms G’s sense of being damaged herself and. as extremely fragile and needing both to be reached out to and to be handled with care. had been depressed and unavailable. careful to keep her breast hidden.

and “falling forever”—as expressed in his urgent cries. As I observed this tense baby. We had 6 more sessions over the following 6 weeks leading to the first break. I wondered whether there was heightened sensitivity to invasive stimuli (lights. This time the pull was toward Ethan. Ethan moved between brief periods of wakefulness and prolonged periods of sleep. In the second session Ethan. speaking slowly. I spoke to him about his experience being in a big room and hearing my stranger voice and not knowing where it came from. I found myself accommodating to their muted tone. now 4 weeks old. was awake. She put him on the mat and he opened his eyes. a tiny little thing with big blue eyes and a peaky face. with no fretting or working up toward the upset. Again my own emotional responses were strong. But in- . He cried hard. Ms G stroked his hands but he did not relax his fists. Ethan’s eyes flicked open when he heard a door slam and he started crying. Ms G put him to the breast and he sucked. He seemed to move quickly into a loud cry. fists tightly clenched. manifested in her whispers and cautious handling of Ethan. transmitted and received through the ministrations of care. I also wondered whether he was already reacting to the conflicted and disregulated quality of maternal emotion. 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. Ms G sometimes looked my way and I found it less of a strain to hear her. so desperately in need of enveloping in maternal love. Initially he slept on his mother’s lap. His ordinary going-on-being seemed to be punctuated with periods of disassociation—as expressed in fixing on the lights. At the same time I was acutely aware of the danger-in-contact ricocheting between us during the session. Only later did I realize how her history of self-cutting had penetrated my subconscious. characteristic of depressed mothers and their infants (Bettes 1988). Thus. by dampening my spontaneity. carried over from the weeks in the special care baby unit. A few times she pried them open and stroked his palms. After a while he turned his head slightly in his mother’s direction. Ethan stared fixedly toward the ceiling lights above him.54 Tessa Baradon process of projective identification I assumed the omnipotence attributed to the “caregiver” in relation to the infantile self. The sessions acquired form and pace. and I confirmed that that was where his mummy was. My association was to a sea of shards in which any movement could be calamitous. riding the silences. noise). then fell asleep.

“that way you are with mummy and can still see me . . “Are you ready to chat again? Hey . With Ethan I was relatively active. representing his mental states and communications. I took care to acknowledge negative affect as conflictual. “It’s a little conversation. . I said. . 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 positive interactions were noted without hollow reassurance that she was doing well. the meanings of dependency When I collected Ms G and Ethan. I asked him if it all right to wake up in this room now. even more so as I believed from her darting pleasure that she had missed me. facing me. Ms G gave me a very quick glance of tenuous pleasure and then turned away with an avoidance of my gaze and bodily withdrawal. . . linking him up with his mother. I felt I had become dangerous again during the break. then looked away. Ethan woke up as she put him on floor beside her. He gave a big smile and looked into my eyes for a few seconds. then looked away. I said. At times indeed I felt rich in resources. . and still give these gorgeous little smiles. We settled on the carpet and Ms G placed Ethan against her feet. After a few seconds he turned back to me. . Ms G looked down at Ethan and said. “yeh. . In a lilting voice (“motherese”) I to him. Then he looked back. He looked bewildered. I waited. In so doing. . I spoke to Ethan: “You’re not quite sure where you are. “He can be quite coquettish. have you?” He murmured. sometimes he turns his head . . you haven’t been here for a while . but at other times I felt dull and drained. isn’t it?” His face opened and he smiled again. . I acknowledged this.” Ms G whispered. .“What Is Genuine Maternal Love?” 55 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. and Ms G reminded me that the last time he was quite upset. and eventually produced a rolling sound. I adjusted my position so that Ethan could see my face directly. yes . don’t you?” Ethan gurgled again. and when you’ve had enough you look away for a while. I thought she was in some way offering him as a “transitional object” for reengagement. are you? . yes . offering contingent responses.” Ethan relaxed into her lap and looked back to me and made a gurgling noise. I was also placing myself in Ms G’s range of vision should she chose to raise her eyes. pursing his lips. now 12 weeks of age. Ms G asked Ethan if he wanted to sit down and placed him on her lap. and which she had never received. from the waiting room after the 2 week break.

Later in the session Ethan was sleeping. . containing the fear of his rejection of her. doesn’t it?” Ms G’s response to me in the waiting room suggested that the break had been experienced as an abandonment. developmental selfand interactive. otherwise it gets too much. do you carefully observe their expressions. in which I failed her as her primary figures had. a mother questioning her baby’s love for her is attributing her own conflicts to the baby. we adults do the same. . Take a little break in a conversation. there- . “mmm . . Ms G’s fear that Ethan already preferred the company of others seemed multilayered. I asked whether she was afraid sometimes of what he might see in her face. . . but he often spends a lot of time seemingly just staring at me with quite a pensive look on his face. 2003) in the pacing of an interaction. I could model for Ms G the process of ordinary. 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.” I noted his looking to her earlier. with Ms G stroking his head and hand. aren’t you. and left her to struggle alone with disintegration. . or my own difficult feelings that may have nothing to do with him.regulation (Beebe et al. . Ms G answered slowly. she allowed me access to Ethan (suggesting some goodness was retained) and through him.” In my experience. when it “got too much”). “I’m sure . .” I asked. . “What are you like with people. “I couldn’t see the expression on his face so I don’t . . . . 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 wondered whether she had felt the same when I was talking with Ethan earlier? Ms G prevaricated. She asserted that he was happier when with them. hmm .g. Yet. . to herself. that in my face there’ll be the ambivalence that I often feel towards him .56 Tessa Baradon and looks from the corners of his eyes. and the rivalry with him over me. .” I replied to Ethan. . Using Ethan as a displacement. a projection of her wish to get away from him. I. . ah. that . . 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. he does smile at me. Yah . 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. She related a visit by friends who played with Ethan. I guess you’re taking a breather then. I was struck that the coquettishness she attributed to him in fact described her own conflict between engaging with me and withdrawing (e.

. The whole interaction was extremely painful as baby and mother seemed quite unable to come together. chose not to follow the route of interpretation and simply commented that he had been looking at her. He sucked hard on his hand and just lay there. comforting thing . . Ms G cared intensely that her child should not experience the maternal toxicity or disappointment in the object that . such as laughing and playing together. need. on the contrary. and she put him down on the floor. and at a distance. . I suggested that. 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 . caressing him. Ms G replied that Ethan may in years to come experience her as in a state of severe depression or absent from him. She wondered if she is not perhaps too disengaged with him. 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. Ms G was quite tearful and picked Ethan up. Then she said that she is not sure whether she’s holding Ethan because he is a soft. It seemed that his dependency. it felt dangerous for him to look into her face/mind as he may see those emotions in it. feelings of dependency and need in herself and in her baby were denied. This dilemma is likely to have been accentuated by her feelings of abandonment by me during the break. 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. perhaps her instinct was to touch him but she did not want him to feel smothered by her. saying that perhaps in her attempts to protect Ethan she was keeping a distance between them that prevented them from spontaneous exchanges. The transference to Ethan was thus of a consuming object like the mother of her childhood. on his side facing away from her. In an identification with the aggressor (myself). since Ethan’s needs and wants evoked her hatred. and desire for her resonated with the representation of him as parasitic during pregnancy—depleting her of self-hood. At the same time. Almost under her breath she murmured that if she were to leave through dying she would not come back. I learned that Ms G habitually scanned the object for their affective communications/demands and that. 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.“What Is Genuine Maternal Love?” 57 fore. . The essential elements of adoration and appetite for the baby were missing from Ms G’s love. looking into space. I rushed in too quickly at this point. Ms G nodded.

” thus rearing “emotionally. We also know from clinical experience that past relational trauma can be reproduced in the present therapeutic situation. Thus my maternal “best” was in fact toxic also for Ethan via the impact it had on his mother. “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.” She weighed her gratification about his complete dependency on her against her wish to walk away. to my concern. Obviously. Ms G confirmed this ascetic representation of the genuinely loving mother and said that the “ideal mother could understand all the baby’s needs.58 Tessa Baradon she suffered. I was unable to protect Ethan. mentally and physically strong children. veered between disintegration and precocious defense. past and pre- . as though during the break the therapy had replicated the hollow maternal stance—the offer of dependency withdrawn. Ethan. and I commented on her fantasy that the ideal mother is selfless. “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. I felt I was witnessing his emergent identification with the dead mother (Bollas 1999)—a kind of dying in situ. 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. distancing him was an act of love as well as cruelty. Yet I think I was also “nudged” into the patient’s unconscious wish-gratifying role (Sandler 1976). The habitual solution to overwhelming dependency and inevitable disappointment was destruction of self and object. Ms G’s repudiation of gratification as a constituent of the maternal bond could be traced to her grievance with her mother. I may have responded from the countertransferential reserves of my own tetchy narcissism. who was put down and away from us. With my therapeutic goods thus spoilt. in the transference-countertransference transactions. As he lay rigidly on his side looking into space.” said Ms G two months into treatment. therefore. her “motives are suspect. In this way. resonating her emptied state. as Ms G went on to speak of Ethan’s (and of course my) possible future loss of herself.” She said she was humbled now when she saw others managing to do this. I felt caught in the middle and responsible for the devastation. good enough loving and impingements “I am trying to understand.

these quiet periods of regulated positive affect were also the backdrop to rapid transition into states of inconsolable crying. however. had no real sense of volition to modify the childhood feelings of helplessness. his ordinary infantile needs could trigger or link in with her own volatility. in which she felt “used” by her mother for her own narcissistic needs. Thus.“What Is Genuine Maternal Love?” 59 sent. . despite the relentless grip of the past. 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. rocking. Unpredictably. excited kicking. Ms G was able to respond. I said that when they are both crying she no longer feels the mother. even as an adult. Ms G confirmed that she gets very upset. He seemed to gain efficacy as a partner. it was becoming clearer the extent to which Ethan was the barometer of her own emotional state. When I pointed this out. winding. Yet. walking—seeming to act promptly and contingently to effect “interactive repair” (Tronick and Weinberg. more predictable. His tiny body became rigid and he clawed at his mother’s body. 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. Ms G whispered that she feels so guilty and ashamed. I observed her handling of Ethan extend to more animated exchanges. I suggested that sometimes Ethan’s cries feel like her own. in the process of being attended to. during this period in the therapy. would another mother get it right? I tried to explore with her what happens to her when he cries. and he. became distressed. allowing Ms G to offer less ambivalent parenting and Ethan aspects of “good enough” relatedness. Moreover. I also spoke about the rage that she feels when he triggers her pain. When his needs did not resonate with her own conflicts. Ms G became tearful and then reprimanded herself for not always acting the adult with him. encompassing a broader range of feelings. there were times in the sessions in which Ethan was a contented little baby. As the months progressed the sessions felt safer. However. Ethan responded to these tentative “protoconversations” with widened eyes. Ms G raised the question: Why is it so hard to soothe Ethan? Was he damaged at birth. for example when he lost her attention he would call her back by looking at her and cooing. she held her parents responsible for her damaged mental state and. and thus also development. and large smiles. Indeed. Four months into treatment. I noted that sometimes Ms G reached out to Ethan. At such times Ms G moved through a repertoire of feeding. 1997).

I thought that addressing her envy would undermine her further. I wondered whether Ethan’s love and dependency were difficult to recognize? Perhaps because she could not have these experiences as a child. And just as the meaning of her own affective state was unrecognizable to Ms G. and Ethan was disregulated by his mother’s care. I think. . Ms G sat Ethan between her legs and he looked at her. By this time Ethan was fretting and I wondered whether he needed his mummy again. I said playfully. Unconscious conflict then permeated her ordinary maternal ministrations of feeding. but perhaps she was ready to perceive his desire for her. Ms G’s face became very tense. that he did not have a feed in the session. so Ethan’s communications could not be understood and contained. Balint (1992) describes this as “unconscious communication”—direct communication between the unconscious mind of a mother and her infant. 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. “I couldn’t hear your mummy there. 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. At one point he cooed extra loudly and drowned out Ms G’s soft voice. in which the baby perceives and internalizes aspects of the mother’s life of which she is herself unaware. When Ethan got restless I spoke to him. What could I model in the sessions in terms of a holding response? (session continued) . At this point he became the frightening child to his mother. escalating to the point of collapse. I said to him that he had called his mummy and she had gathered him up. This was the first time. do you mind!” Ethan kicked gleefully in response to my crooning voice and smiles at him. Their distress ricocheted between them. He responded with attentive pleasure. Ethan’s cries retraumatized Ms G as her own unconsoled state as a small child came flooding back. . Ms G became very tearful. Ms G said forcefully that other people’s dependency on her was enormously difficult. I therefore asked what could help her recognize the cues from Ethan about good things he gets from her. I felt I had suddenly frightened her. changing.60 Tessa Baradon Through the most careful observation of their affective interaction and of my own countertransference. and soothing. She said it was the ease with which I relate to Ethan and she has to try so hard. Ethan sucked and chewed on his mother’s fingers. I came to understand a particular quality of interaction that was perilous to both. and a mother who . re-evoking her own disorganized attachments (Main and Hesse 1990). Faced with a baby responding with joy to interactions with me (in the absence of such exchanges with his mother).

Sleeping and feeding were ubiquitous arenas for expression of conflicts over separation in Ms G’s history and were. If I was unconsciously being faced with the choice between them I. and soon Ethan was restored to the parental bed. Ms G was sometimes able to respond contingently and offer herself to be used by him. She moved Ethan to his Moses basket at her side. Ms G’s chronic insomnia was thereafter channeled into nightime rumina- . 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. the areas in which the conflicts were played out with Ethan. It was as though I had to experience the possibility that only one of the dyad could survive. Ms G’s history held no personal experience of moderated separation. At the same she felt driven to madness and despair by lack of sleep. was unable to offer support. was an area of extreme difficulty. perhaps inevitably. The risk for this dyad was that separation-individuation would plunge mother into narcissistic despair and rage. In the treatment of Ethan and Ms G there were hints from the beginning that separation. it seemed that by my modeling more playful exchanges with Ethan while emphasizing my “notmother” status. mentally. I was in a conundrum: to embrace the one seemed to be a rejection of the other. This offers opportunity to work with the mother’s conflicts as they impact on her baby at each developmental phase. as the therapy progressed. equally unconsciously. crucial for his development (Stern 1985.” Yet. and physically strong child. mutually destructive rupture. Because she was more able to respond to cues of distress but not those of joy in relation to her. resisted it by replacing Ms G as the object of her son’s love. only that of violent. he was missing out on swathes of exchanges around emotional sharing. Indeed in this sense Ms G was not able to facilitate Ethan’s development as an “emotionally.“What Is Genuine Maternal Love?” 61 felt diminished by this. with his own difficulties in this area. Perhaps I hoped that Ms G would allow herself the experience of Ethan’s giving her pleasure and making her proud. This meant that any movement of his woke her up. In the early weeks Ms G reported that Ethan would fall asleep only when lying on her chest. 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. D. like dependency. Trevarthen 2001).

She said her guilt at not really wanting his “relentless” . Week by week Ms G described her dread of the long days with Ethan while D was at work. I suggested that having Ethan with her all the time meant that she has no means of regaining her “emotional balance” (her words). In the sessions I observed feeding encompass many regulatory functions. so that Ethan was put to the breast when he cried. 7 months into treatment. She felt mired by his wish for her presence. when he was tired. provoking rage. these feelings also came into conflict with her experience of his dependency as depleting. when they were both at a loss as to play. I wondered if that was her way of keeping her emotions on an even keel and she confirmed this. it became difficult to tell when he was hungry. 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. Ethan’s weight began to drop and professional concerns about failure to thrive emerged. with the medical network and her partner now carrying for her the thrust for forced separation. However. Ms G said she did not know if she wanted him close or not. With Ethan waking hourly. and her inability to let him cry. It seemed important that at that point I did not ‘know’ what would be best. Ms G came under increasing pressure to achieve some measure of weaning. With feeding used to meet such a variety of situations. Ethan 6 –9 months. but it also brought with it the fear that she could disappear from their lives and it would not matter. I noted how Ethan seemed to want to be close to her today. Thus the closeness was experienced as loss of self. Medical opinion moved toward supplementary feeds. At around 5 months of age. sleep disturbances became woven into the conflicts around feeding and weaning. As Ethan became more mobile he could initiate movement toward and away from his mother. During this period. many threads in the therapy seemed to coalesce around the question of closeness versus distance and the losses implied in each. She said that before Ethan was born she spent much of the time alone. with a bottle also offering a possibility of respite from the hourly feeds at night. for example crying when she left the room. Getting away was a relief at that level. while she maintained the ubiquitous place of breast-feeding. Her internal split was thus effectively externalized.62 Tessa Baradon tions as she waited for dawn so as to escape from the bed to a strong coffee and cigarette. and held neither a wish for Ms G to wean nor for her to continue feeding.

third object. and there was a concrete idea that the bottle would deliver Ethan to his father. the bottle symbolically represented the competent. 63 It is interesting that at age 8 months. I believe I was also caught up in powerful projections around loss of myself. the father/therapist was seen not as a gain but as a threat to the symbiotic tie. My thought was that they both moved between intimacy to destructiveness with confusing rapidity and that. she was also not able to manage a normal loss through establishing the triad of mother. My anxiety about a possible suicide attempt was high. addressing his predicament would then need to have been privileged. He crowed and cooed and bounced. and I was left with a concern that intense pressure on her to wean could precipitate a crisis. father and baby (Daws 1999). when biting could be considered as a normal expression of desire (incorporation) and/or exploration. and I checked that the network was in place. With this came powerful statements from Ms G that D and Ethan were doing so well together. partial interpretations. why did I not follow this through with an explication of his aggression as reactive to his mother’s unresolved ambivalence? Certainly. He appeared to be both kissing and biting her and I said this to him. There was affective undertone of not being needed anymore. She was silent. Was I taking on Ms G’s attributions? In which case Ethan was subject to my projections as well as his mother’s. I could not tell what felt good and what bad. Just as imaging the baby’s ordinary movement toward separateness was not available to Ms G. In the issue of weaning.“What Is Genuine Maternal Love?” closeness makes her try harder. Thus. In retrospect. Ethan seemed to get extremely boisterous in her embrace— sucking on her arm and blowing raspberries. as we were approaching another break (9 months into treatment). primarily in terms of her desire to stay alive. In retrospect. I asked whether those were times when she harmed herself. . with Ms G watching and withdrawn. From the outside their little “reunion” seemed pleasurable and yet Ms G was talking about times when she feels she cannot go on. 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. I think that my shifting identifications with mother and with baby were enacted here through muddled. 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. despite being with them. or to Ms G—with Ethan either observing or dis-engaged. I noticed in the sessions that I felt increasingly forced to relate to Ethan. I attributed destructiveness to Ethan’s biting of his mother.

can he get to it? He managed to extract the apple . She said. Separation. but she continued to insist that the solution was disengagement and self-sufficiency. They each responded to me with a measure of reserve. Feeling very anxious about what I was about to say. pulling away a bit and getting her hair out of his clasp. as though it was not her—his mother specifically—that he needed. carried him over to one of the chairs and stood him there. He pulled out a plastic container with food. “It’s like being run over by a red car and then not liking red cars afterwards. Again she shrugged. Ms G said everybody had their escape routes. When he absolutely ran out of resources he crawled to her and tried to clamber onto her lap. Ms G appeared terribly thin and wan. She whispered that this was very selfish. as though fulfilling her fears of losing him to D. 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. Ethan took his time before he approached me: gazing at me from a distance and looking worried. I said she was equating herself with the chair. I said perhaps she thought that in order to continue living she needed to feel that she could kill herself. Ms G looked pale. Ms G held him loosely.64 Tessa Baradon Anticipating this loss Ms G thought she and Ethan would miss their sessions with me.” 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. as an intrapsychic process leading to growth. 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. She shrugged. She came back to her place on the cushion. I felt shocked. My first thought was “he’s feeding off her!” He also looked strikingly like his father. while Ethan seemed to have gained bulk and weight. She then abruptly stood up muttering that he needs a climbing frame. Ethan had crawled back to our vicinity and was searching Ms G’s bag. I wondered whether she was linking Ethan’s reserve with me to this. A number of times he headed toward his mother and then veered away. still felt beyond our reach. We watched as he struggled to get an apple out. Ethan was crawling about—initially energetically but then looking lost. She replied that she does not want him to depend on her for his happiness. I asked her what she made of her observation. enacting rupture On their return after the holiday. Ethan looked tiny and forlorn across the room. I accompanied him with words: is he wanting the apple. 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. this time seemingly in agreement.

and her fear that this dependency in both of them would take away her escape route. She said Ethan had choked on a brick during his visit. 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. an identification with the aggressor. Addressing her rage with me may have relieved Ethan from the burden of carrying it. With the rupture (break) with me unsufficiently reflected upon. Ms G watched him closely and I found it agonizing that she did not capitalize on his interest. Ethan was getting more upset and when picked up by Ms G he clung to her strongly. Ms G fled the room clutching Ethan in her arms. prematurely. is it too big? I said maybe Ms G thought I was fussing too much. my initial attempt to relate to my perceived dangerousness (via Ethan’s avoidance of me) was shrugged off. Ethan calmed. what followed was Ethan’s performing a transference enactment of . I reckoned that to pursue the transference and/or her defenses could be experienced by Ms G as retaliation on my part (Steiner 1994). I said she seemed torn between loving Ethan and wanting his love for her. in her refusal to embrace Ethan—again. 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. 65 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. to feed herself. and soon after this it was time to end. She conveyed immense sadness. it is the displacements that perhaps could have been taken up for it is there that the experience of cruelty lay. 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. I suggested that the long break had probably also brought up these feelings in relation to me. that is. When she finally. he spat it out. He chewed on the apple for a while and then tried to get the bottle of baby food out. Ms G told me that at D’s insistence she had taken Ethan to a nursery that morning. In retrospect. I asked how they had felt about it. I asked him if he can eat it. Her rage with me was communicated in the narrative of the red car and enacted in substitution of climbing frame/chair for self. tentatively offered him some food. Ms G carried him over to the windowsill and sat him on it so he could look out. 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. Thus forsaken.“What Is Genuine Maternal Love?” and tried to bite into it. Shortly after this he began to cry. She immediately put the bottle of food away. However.

I also thought she was possibly punishing me through forcing me to witness her abandonment of her child (which was painful to watch). Acknowledging the need and the pain allowed some movement—by the end of the session Ethan was ensconced in Ms G’s embrace. In the sessions there was a shift. and this perhaps contributed to her not helping him feed.” “falling in love” as reparation In one of her earliest sessions Ms G asked. he lay on the apple and rolled around. He held it. In a similar vein. By this point I was able to address the struggle to manage alone. which enabled Ethan to move to and from his mother and to refuel from a distance through gaze. Ms G said. However. but although Ms G carefully watched Ethan. denoting making up for her destructiveness.66 Tessa Baradon failed self-feeding while the intergenerationally depriving mother stood by. Between them there was a more robust link. but Ms G . there seemed to be a flowering of love. bit into it. 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. I noted Ethan’s playfulness and Ms G said she too had noticed it—it was so different from his clinging. less rumination and self reproach) than hitherto. Ethan also established his own little routine in the sessions. her active intervention came too late (like mine) and was rejected. with life-threatening consequences. crawling over to me. with Ms G taking a slightly more reflective stance (i. 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. In the core relationship toward Ethan. 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. “When does one know that reparation has taken place?” “Reparation” was her choice of word. described above. He would start by checking out the toys and re-establishing himself with me—little smiles. so dominated previously by her ambivalence. I wondered whether in fact Ms G experienced me as empathic toward Ethan when I had been withholding toward her. He had to work hard to get his hand into the bag. The following session Ethan was unusually free and playful. Ms G’s sadness was here undefended and it gave coherence to the preceding narratives. particularly in relation to the apple. gradually climbing up to explore me.e. going to nursery was experienced as forced upon them. “maybe he is being trustful.

It felt that I was allowed to hold a position of the benign “third. I suggested she may have felt unprotected and that cruelty hit her abruptly as a child. She added that her mother does a lot of charitable work but she wishes she could have given the same to her children. and to relinquish some of the envy of her child for the maternal comfort he could still have in his. I said it sounded that she was wanting to protect and comfort him for the years to come.“What Is Genuine Maternal Love?” 67 monitored his endeavors and encouraged him. 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. swallowing some and spitting some out. Ms G spoke about her mother doing her best. This session was characterized by a sense of calmness and reflection between Ms G and myself. and playful exploration on Ethan’s part. and he moved between the activities and us. Gradually eating and playing/exploring became somewhat more integrated. and her wish to celebrate their coming together through the love she had discovered within herself for her child. I said this made me think of the perfect present as representing a wish to make good their very difficult early beginning. She replied that she had a lot to make 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. but that it was not good enough. 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 initially asked him not to play with the cord and then went over and picked him up. she also had begun to mourn the lonely childhood she had. Ethan’s play with the tele- . Her emphasis was on her wish to protect Ethan’s trust and expectations that people will respond to him kindly. 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. Ms G struggled with this. He approached his 1st birthday and this preoccupied Ms G. In wishing to extend the “comforter” from her childhood to him. Ms G spoke of reparation and I thought she was also repairing something for herself. the adults. though she did not deny it. Ethan then ate his fruit. Ethan had finished eating and messing and was exploring under the table where he discovered the telephone wire and plug.” 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.

albeit less consistently. Discussion Ethan’s first birthday also heralded the end of our first year of work together—a good time to take stock. and failure as yet. her importance to him. As Ms G said. The wish. “Can one damage one’s baby just by being available?” In the transference I was also often a source of danger. 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. 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. her baby’s dependency overrode her ability to accept more benign feelings in herself. seemingly low threshold to “unpleasurable” experiences and the difficulties in comforting him—intensified the sense of fragility and risk. and guilty hatred for. and her failure to meet her ascetic standards. This mutual threat was created through their very existences in relation to each other. His turning from her. Ethan was forced into precocious inhibition of attachment behaviors toward his mother. She defensively adopted an ideal of altruism that negated not only her passions but also his.” mothering. although more hidden. encompassing communication between them through which he could be gathered up and contained. She seemed more able to acknowledge and tolerate her wish to be central to Ethan and.68 Tessa Baradon phone cord seemed to represent hope for more genuine. at times “good enough. Ethan’s post-natal vulnerability—his smallness. Her gaze and facial expressions conveyed growing adoration of him. In the early months Ms G’s fear of. 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. What facilitated these changes? . 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. My countertransference fantasy that we were constructing the therapeutic space within a sea of shards highlighted the power of the emotions. sensitivity to lights and noise. In equal measure. to find a “perfect present” seemed symbolic of what had been achieved and of that which still needed to be addressed. The most significant was the expanding sense of maternal love for Ethan. was the fear of being damaged by her baby. compounded her depression. projections and enactments.

This raised the question of which patient should be privileged from moment to moment—Ethan. mother.“What Is Genuine Maternal Love?” 69 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. was making up the early impingements and developmental tests confirmed he was on track. to address her depression and the defenses and distortions that constituted her zone of safety but also derailed the relationship with Ethan. seemed to capitalize on the openings in their relationship and became more forward in expressing his desire for her. sometimes. At other times I felt that the focus should stay with Ms G. was a positive reinforcement which Ms G could at times perceive. 904) and this then framed the developing relationships between mother and baby and myself. tonal) representations of his mind to Ethan. The clinical process. At first. Ethan. For quite some time it seemed that only in my mind could their survival as a dyad be contemplated. was surviving her destructiveness and was not retaliating with narcissistic demands of my own. as were verbal (vocal. 1998. the relationships? At times I left a session feeling that more work should have been done with Ethan. The procedural processes seemed to cohere more slowly. p. one in which the intergenerational mother could be experienced as containing and repairing of the damaged child. Interpretations—using words as a means of giving meaning—were important to this mother. took place in the procedural and symbolic domains. By the third quarter of the year Ethan. as the sessional material indicates. This. seems to have been important. it was cru- . be challenged by a different. Thus Ms G’s psychic reality of the inevitability of damage could. father (present or absent). Thus Ms G was meeting with a different “motherhood constellation” (Stern 1995) from the persecutory internal one. Because so much in the earliest transactions between Ms G and Ethan was driven by her negative transference to him. In time. 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. external voice. for example to enhance his efficacy in engaging his mother. I became better at matching and repair of the spontaneous gestures and affects that constitute “authentic person-to-person connection” (Stern et al. the misattuned emotional “dance” between mother and baby was repeated in the interactions between the three of us. for his part. too. Despite the compelling nature of Ms G’s narrative. too. In the transference relationship with me I. although delayed.

Alongside the changes that marked the achievements of our first year together there remained areas of great vulnerability in their relationship. In the face of conscientious maternal care. 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. 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. Thus Ethan was not able to safely experience himself as an object of hatred as well as of love. and particularly when she became extremely depressed. His own actions directed at separation-individuation were still. For myself—I was intrigued by this question in the context of my work with attachment disorders. Not able to love herself in her baby. 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. so as not to slip into individual therapy in the presence of the baby. and later in occasional veering away in the midst of approach or a momentary freezing when mother seemed annoyed. Moreover. Ms G and Ethan attended their sessions without fail. betrayed initially in disintegrative crying. In presenting the question she was disclosing her knowledge that something was going very wrong for them. or to allow his appeallingness to reflect on her. subject to transferential attributions that frightened Ms G and evoked her rejection of him. These issues were all the more urgent given Ethan’s young age and the chronicity of Ms G’s difficulties. Ms G’s fluctuating emotional state. At the same time. Ms G could not really entertain exuberant passion and appetite in her relationship with Ethan. to be “consumed by the other” was only too real a threat and to be avoided at all costs. It also suggests an outline of the . These thoughts about clinical process are relevant to the question of whether “genuine maternal love” exists.70 Tessa Baradon cial to keep Ethan in my mind at all times. it provides a framework for understanding a particular quality of “maternal failure” and ensuing relational trauma for the baby. Often Ethan had to make do with the crumbs of emotional availability that penetrated her depression and withdrawal. 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. In using the therapeutic space to risk intimacy. In turn. spanning critical periods in his development. It seems an important concept to hold in mind in the course of the therapy with mothers and babies. at times. could be frightening for Ethan.

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Kate Mitcheom. City University of New York. JANICE CURRIER-EZEPCHICK. copyright © 2005 by Robert A. Megan Lyons. King. we wish to thank the administration and staff at Fair Haven Community Health Center. King.D. Yale Child Study Center. the Yale School of Nursing..W. as well as Sean Truman. and grew out of a collaborative effort between the Yale Child Study Center. the Director of Family Support Services at the Yale Child Study Center. and the Fair Haven Community Health Center.D. P.. Connecticut Department of Children and Families. 74 .C. Minding the Baby. DENISE WEBB. who along with many other members of the pediatric and obstetric services gave Minding the Baby a home. and A. ed.W..P.S. Yale Child Study Center. Denise Webb.N. Betsy Houser. Yale University School of Medicine. Lois Sadler. Peter B.S. Peter B.N. was initiated to help young. L.. Neubauer. and A. Samuel Abrams. Finally. Other members of the research team who have been essential to our progress are Michelle Patterson. Neubauer. and Laurel Shader. Harris Foundation. both of whom were instrumental in getting the program off the ground. Arietta Slade. Ph. Karen Klein. Scott Dowling (Yale University Press. This work was supported by a generous grant from the Irving B. Yale Child Study Center.D. Robert A. and Alex Meier-Tomkins. at-risk new mothers keep their babies (and themselves) “in mind” in a variety of ways. Cheryl de Dios-Kenn.. and LINDA MAYES. R. M. CHERYL DE DIOS-KENN. Janice Currier-Ezepchick. The intervention—delivered by a team that includes a nurse practitioner and clinical social worker—uses a mentalization based approach. LOIS SADLER. Samuel Abrams. L.S. Ph. and Linda Mayes. relationship based home visiting program. particularly Katrina Clark. The Psychoanalytic Study of the Child 60. Scott Dowling).Minding the Baby A Reflective Parenting Program ARIETTA SLADE.N. Yale Child Study Center. We would also like to thank Jean Adnopoz. an interdisciplinary..C. M.

just for nothing. 19. as it is aimed at addressing the particular relationship disruptions that stem from mothers’ early trauma and derailed attachment history. . . Because I had so much built in I couldn’t hold it anymore. . I see now that maybe her crying was to tell me she’d had enough . what can be known. mother of Lucia. and she likes giving me hugs and stuff . tentatively. I try not to let anyone see those feelings. mother of Noni. I can’t believe she’s so big now . They look for ways to describe what is inside. I had no idea what she wanted. poignantly. It’s so hard to watch this . I usually try to hide my anger. what can be held in mind. we work with mothers and babies in a variety of ways to develop mothers’ reflective capacities. and she’s so little . . . 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. . They hold the past next to the present.Minding the Baby that is. . you can’t compare your capacity to hers. ’cause I never had that when I was little . you know. age 13 months I look at this tape of me and Noni. the . ’cause she’s still so small. the theoretical assumptions of mentalization theory. age 19. . . —Iliana. She probably doesn’t understand why she’s getting me mad. Sometimes my daughter is just really nice and generous. age 14 months 75 these young mothers are struggling to find words for the inner life—their baby’s and their own. she doesn’t understand what she’s doing wrong. and provide an overview of the Minding the Baby program. . and themselves. sometimes. —Mia. here I can see her face sad trying to tell me what I didn’t know. . ‘Cause she’s so tiny she probably doesn’t understand. That’s when I started opening up and talking to them. The whole time she cried. I did that for a long time before Denise and Cheryl came along. . . and what can be contained. they glimpse the other. We discuss the history of psychoanalytically oriented and attachment based mother-infant intervention. that’s kind of what I think about. she’ll walk up to me and hug me so tight in my neck and it feels so good . that she may have been hungry or sleepy. The treatments of two teenage mothers and their infants are described. But. .

Knowing others and their minds had been fraught with terror. and they suggest that it is essential to affect modulation and regulation. Parents who have been traumatized find their children’s needs and fears over- . disorganization. The child’s discovery of himself depends largely upon the caregiver’s capacity to hold. Jurist. they are discovering themselves for the first time. & Target. though. can be integrated and contained. and dysregulation in relation to their child (Slade. and most particularly intimate relationships (Fonagy. 2002. And as they discover their babies. Fonagy & Target. Mia and Iliana joined Minding the Baby—a relationship based mother-infant intervention program—in their third trimester of pregnancy. is essential to the development of social relationships. Trauma interferes in a number of profound ways with the development of reflective capacities (Fonagy et al. Parenting is a fraught and complex enterprise. held in mind without defensive distortion. Steele. Both had been in different ways abandoned and betrayed by their own mothers when they were but babies themselves.. disappointment. it is also regulating and containing for his caregiver. 2002). Mattoon. 1995. Gergely.76 Arietta Slade and others self next to the other. and re-present the range of his diverse and contradictory mental states. within their own families and within the culture of their violent. impoverished. Fonagy. And now they were faced with the enormous challenge of holding their own children in mind. The crucial human capacity to understand the mind of the other. Leigh. 1998). 1995. Fonagy and his colleagues have referred to this interpersonal and intrapersonal capacity as the reflective function. The capacity to mentalize. Importantly. experiences that can be known and understood. 2002. parents are vastly more prone to impulsivity. Thus. Kennedy. a parent’s reflective awareness is inherently regulating and containing for the child. The child discovers himself in the eyes and mind of his caregivers. They had lived their whole lives against the backdrop of trauma. or envision mental states in the self and other. Steele. and without developed capacities for reflective functioning. particularly the experience of being known and understood by one’s caregivers. emerges out of early interpersonal experience. and chaotic communities. and rage. & Target. to make meaning of behavior—one’s own and others—in light of underlying mental states and intentions. 2005). and derives a sense of security and wholeness from that understanding (Fonagy et al. children who had been born at a time when they were still children themselves. 2002).. tolerate. in press.

but . was initiated in 2002 to help young. At a most basic level. at-risk new mothers keep their babies (and themselves) in mind in a variety of ways. It is this model that has informed the development of Minding the Baby. 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. 2002. 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). What we see in the words of the mothers quoted above are tentative efforts to form such representations. 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. for a review). 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. coherent representations of the self and other.Minding the Baby 77 whelming and profoundly evocative. Furthermore. containment and regulation take place not just at a mental level. Minding the Baby. 1997). We also began with the assumption that when working with infants. Obviously. In essence. This approach is in line with what Fonagy and his colleagues have termed “mentalization based therapies” (Bateman & Fonagy.. 2004). 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. Lieberman. the defensive processes enlisted in the face of trauma fragment the development of stable. Based on Fonagy and his colleagues’ work of the last decade (see Fonagy et al. and as a result often find it difficult to read the most basic cues without distortion or misattribution (Fraiberg. we believed that enhancing parental reflective functioning would help mothers facilitate their children’s development in crucial ways. 1981. 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. this term refers to treatments that directly address and target the development of reflective functioning or mentalizing capacities. 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.

. Seligman. moreover. we wanted to help our mothers come to feel safe and confident in knowing their babies’ bodies as well as their minds. and a body-scheme. the infant comes to have an inside and an outside. Silverman. 1991. Mother-Infant Intervention: A Brief Overview Thanks to the remarkable and groundbreaking work of Selma Fraiberg. Associated with this attainment is the infant’s psychosomatic existence. In this way meaning comes to the function of intake and output. 1999. it gradually becomes meaningful to postulate a personal or inner psychic reality for the infant. As we can see from Mia’s reflections on her inability to acknowledge her baby’s most essential needs for sleep or food. come to know their babies’ mental 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 . . 1999. is preceded and indeed founded upon an understanding of physical states. Fineman. As Freud pointed out. Infant-parent psychotherapy is today a highly valued and legitimate mode of psy- . Guthrie. 1994. as the program has evolved from its original inception three years ago. The knowledge of mental states. & Pawl. Weston. & Pawl. The infant becomes a person. Thus. “The ego is first and foremost a bodily ego” (1923. Winnicott (1965) made a similar point: In healthy development at this stage the infant retains the capacity for re-experiencing unintegrated states. 6). . 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. an individual in his own right. . to feel that they could contain and regulate their babies’ physical states. p. Recchia. Fineman. with time. I have referred to this as the psyche indwelling in the soma . In the sections below. the child comes to know his body through the hands of his mother. clinicians have been working in a psychoanalytic way with mothers and babies for more than 30 years (Heinicke. Lieberman.78 Arietta Slade and others at a physical level as well. and then slowly. (p. Stern. Heinicke. & Guthrie. 45) In other words. 1995). 1999. Ruth. Ponce. & Rodning. which begins to take on a personal pattern. we will begin by briefly describing the essential principles and methods of Minding the Baby. We will then present two cases in an effort to exemplify the approach intrinsic to our reflective parenting program. Lieberman. thought so crucial to responsive caregiving.

and the infant mental health movement—reflected in the emergence of organizations such Zero to Three. The goal of infant-parent psychotherapy is to disentangle these affects from the relationship with the baby. albeit challenging. nor the fact that the dyad presents for treatment are considered in any way impediments to analytic intervention. and Families. Beginning with the publication of her seminal papers. Toddlers. Indeed.Minding the Baby 79 choanalytically based treatment. primarily because of the concrete supports and guidance that are offered by the clinician within this setting. and optimally. Circumstances once considered “unconventional” (Seligman. and the ultimate “freeing” of the baby from the mother’s traumatic projections. 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. 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. and the World Association of Infant Mental Health—is well established both in the United States and abroad. it is the relationship with the therapist that leads to shifts in the mother’s representational world. the experience of being heard and valued by the clinician frees her and the baby as well. 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. And. And. as attested to by all of the papers in this section. the therapist provides a crucial and transforming alternative to the mother’s previous relationships with caregivers. 1994) are now considered normative. Fraiberg introduced an idea that now underlies virtually all infant-parent work. And. in contrast to traditional notions of psychoanalytic work. neither the fact of the child’s age. where little about the environment can be contained or easily modulated. Fraiberg’s work was to have an enormous impact outside of psychoanalysis as well. infant-parent psychotherapists routinely work in situations of risk and trauma. home visiting—although widely practiced in Great Britain and . 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. The National Center for Infants. The parent-therapist relationship in an infant-parent psychotherapy is—from a traditional psychoanalytic perspective—somewhat unusual. Ultimately. At the same time. 1981). as in all psychoanalytic treatments. opportunities for analytically oriented work.

and in the tenements of New York in the early 1900s by public health nurses (Wald. and are free of the stigma of mental health service providers. Sidora. Olds. Nagle. is the emphasis on the body and on physical care. & Zeanah. Larrieu.. Olds chose to use nurses rather than mental health professionals for a variety of reasons. Boris. Henderson. 1997. Olds. Like Fraiberg and her colleagues.. Olds. Olds emphasized that the development of a therapeutic relationship with the home visitor is key to a number of positive mother and child outcomes. as the program has evolved over the past twenty years. and the mental health needs of families have emerged with great clarity. Robinson. In addition.” namely how to think about and work with the sequelae of severe trauma and relationship disruptions (Robinson. Emde. nurses have received increasingly specific training regarding what might be called “psychoanalytic concerns. 1997. et al. 2000. 2002. Olds. 2002). however. & Little. the most central being his belief that they are perceived by families as highly informed and helpful. 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. Kitzman. & Korfmacher. 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. While the infant-parent psychotherapy and NHV approaches differ in emphasis. Hill. Song. delaying further childbearing. In Olds’ model. nurse home visitors did not receive any training specific to mental health concerns. both approaches provide a range of ego supports for the mother. despite the fact that the issues of the body played a central role in classical psychoanalytic theory. 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. and she will be able to serve as a secure base and facilitating environment for her child. Zeanah. 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. however. this is an . so as to improve the chances that—by completing her education. et al.80 Arietta Slade and others other Western countries since World War II. When Olds first began his work. and gaining secure employment—she will be in the best position to surmount the multiple stresses associated with urban poverty. What the NHV program adds to the psychoanalytic model of parent-infant work. 2000).

Slade. . These cases1 will be used to describe some of the particular techniques we use to enhance reflective functioning within our model. we will describe the program and its methods in a general way. Caribbean American. arousal. In addition. Minding the Baby is based in an urban community health center that provides health care for an underserved population of families. Sadler. her baby’s body. most of whom live at or below the poverty line. we see this level of advanced training as crucial in preparing clinicians to be able to assess and manage the complex 1. and the exquisite and complex interrelationship amongst all of these bodies and minds (Slade. and are of diverse cultural and ethnic heritages. We have created composite cases for reasons of confidentiality. Mind and body become inextricably intertwined. because programs that are not adequately linked to services provided by local health providers and other community agencies risk becoming isolated and less effective.Minding the Baby 81 aspect of development and of the mother-child relationship that has not been effectively integrated into psychoanalytically based infantparent work. unified model. Minding the Baby The best way to describe Minding the Baby is through example. Mexican. psychological level. This link to community health care services is crucial. her own mind and body. Minding the Baby services are provided by master’s level clinicians. including African American. 1992). We did this by creating a home visiting team that included both a pediatric nurse practitioner and clinical social worker. For that reason. 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. and the pathology of biology. Thus. and self-care cannot easily be distinguished from disruptions at an internal. The enhancement of reflective functioning was a central goal of both the nursing and mental health aspects of the program. we believed that it was essential to integrate the nursing model with the infant-parent psychotherapy model into a singular. 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. which we will provide in the form of case material in the sections below. 2002. Puerto Rican. however. and El Salvadoran. Before turning to the cases. in press). & Mayes.

the clinical team also receives extensive training and supervision regarding the particular developmental and behavioral characteristics of teen parents (Sadler. Data from these assessments allow us to evaluate change in a systematic way. the mother may be visited by both clinicians in one week.2 In some cases. health. This schedule of visits is determined largely by funding and personnel constraints. Knoebber. 2001. this includes exposure to relevant background materials in psychoanalysis and attachment theory. The Minding the Baby team is made up of a pediatric nurse practitioner and a clinical social worker. While space restrictions prohibit our elaborating the content and process of home visits. de Dios-Kenn. at which point visits are tapered to every other week through the child’s second birthday. and both see mothers on a regular basis. beginning in the last trimester of pregnancy. In various times of crisis. we will briefly describe what we see as the essential features of a reflective parenting program (see too Goyette-Ewing. and in Slade. Gilliam. & Mayes. although extra visits are routinely offered in times of crisis or intensified demand. 2005. Mayes.). Sadler & Cowlin. 2003). and in vivo training in recognizing and identifying different levels and types of reflective functioning. (these are more fully described in Slade et al. Currier-Ezepchick. Sadler. 2004). a comprehensive review of Fonagy’s work. psychiatric. 2. mothers and babies are assessed at regular intervals over the course of their participation in the program using a range of standard psychological. so that the nursing and mental health approaches are always unified when considering the mother and baby. Slade. Typically they alternate visits. visits may last hours. Klein. Because thorough evaluation is crucial to testing the efficacy of Minding the Baby. First time mothers are recruited from prenatal care groups offered at the health center. and developmental measures (see Slade et al. Prior to beginning the intervention. . Anderson.82 Arietta Slade and others clinical issues involved in working with highly disadvantaged and traumatized populations. Families are seen weekly until the baby’s first birthday. the clinicians receive extensive training in reflective functioning. & Sabatelli. Webb. or by one visitor consecutively when there are physical or mental health crises. both are involved in the recruitment and initial evaluation process. Truman. & Shader. Since many of the families served by the program include adolescent mothers. Mitcheom. This training is offered jointly. and—when the home is too chaotic or disrupted—take place in locations as diverse as the neighborhood library or a fast food restaurant.

However. this demands constant flexibility and collaboration on the part of the treatment team (Lieberman. Grienenberger. from an absence or denial of mental states. Levy. Our ultimate goal is to help mothers acknowledge that the baby has a body and a mind of his own. The home visitors are repeatedly inundated with demands and crises (eviction. Fonagy and his colleagues have described reflective functioning or mentalization as occurring along a continuum. & Locker. Wilson. The work almost always begins in the therapeutic relationship. This process—and its various permutations—is manifest in the cases below. food shortage. establishing productive alliances with abandoned and traumatized women and their families is not easy. Slade. 1998. with the clinician holding the mother in mind so that she can begin to know herself. 2003. to the emergence of true reflective awareness. As is true of all analytically based work. Minding the Baby tries to help mothers develop this capacity. Levine. Seligman. Morrow. with each of the clinicians doing so in distinct. Ibarra. their roles overlap in a number of ways. medical supplies. Alexander. emergency food. & Steele. Target. 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. We have found that it is our clinicians’ willingness to witness the mother’s world. that makes the mother feel heard and ready to know the baby in all his complexity. The nurse provides ongoing help in relation to physical health and caregiving. Stein. Slade. but complementary ways. parenting support. and to learn—as a function of this awareness—to tolerate and regulate the child’s internal states. & Lehman. and a range of concrete supports such as rides to work. crisis intervention. the development of a therapeutic relationship is at the heart of all parent-infant interventions. to witness her emotions and her body. Solow. 2004). domestic violence) . the very real needs of high-risk families require that they be helped at many levels at the same time. and the like. As has been described again and again in the infant-parent psychotherapy literature. At the same time. however. 2004. to a simple capacity to recognize basic feelings and thoughts. only then slowly coming to know the child. Thompson.Minding the Baby 83 2003. 2002). Bernbach. and to understand both the nature and dynamic interplay of mental states (Fonagy. to hold these in a safe way in the here and now. with both providing developmental guidance. Grienenberger. namely the capacity to understand behavior in terms of mental states. Popek. Steele. 1994). while the social worker provides infant and parent mental health services and social service support.

and explore alternative routes to enhance reflective capacities while addressing the concrete and physical needs of the family. identify barriers. In some ways. and both of their childhoods were characterized by loss. At the same time. trauma. They differed in the degree to which they had developed capacities for reflective functioning. we will describe our work with Mia. The supervisory relationship—which sets the tone and parallels developing therapeutic relationships—becomes critical to managing these multiple levels of complexity. Without supervision that is both clinically focused and personally validating. Both have made—relative to their status at the beginning of the program— enormous progress.84 Arietta Slade and others that require immediate action. Unsurprisingly. they had different levels of support within their families and communities. there are nevertheless crucial differences in approach that must be managed against the backdrop of families prone to splitting and disorganization. As a team. So often clinicians struggle with rescue fantasies as well as feelings of futility and helplessness. the team’s own reflective capacities are challenged and even diminished. their progress in a number of areas can be charted quite differently. In Minding the Baby. Add to all these complexities the fact that the multidisciplinary team—while sharing common beliefs and values—does not always share a common language. and abandonment. and levels of extreme deprivation experienced by the family. Although the construct of reflective functioning provides common ground for discussion. maternal pathology. Iliana. the pediatric nursing specialist and clinical social worker are supervised jointly. in levels of ego and self organization. as do the guiding principles of our model. theirs are similar stories: both had babies as teenagers. The clinical team’s ability to keep the “infant in mind” is often challenged by the chaos. And yet both stories convey how complex and . supervision is used to set priorities. Consistency—the bedrock of any therapeutic work—is difficult to achieve even at the level of maintaining regularly scheduled visits. equally important. In the following sections. most important for our purposes in this paper are differences in the development of mentalizing capacities in these two women. and their babies. we see this approach as crucial to exploring the myriad diversions that threaten the clinical work. and they struggled with different kinds and depths of vulnerabilities. their stories are different in important ways: they began the program with different strengths and resources. often they are intensely dysregulated by reports of violence to mothers and babies alike. and with very different openness to internal experience.

multidisciplinary model offered by Minding the Baby. . She dropped out just months before her graduation from high school. and was awkward.” More striking was her ability to describe her own complex fears and worries about becoming a mother. While these were scarcely manifest in relation to her thinking about the baby. as she put it: “You’re just another teen mother statistic. . But Mia’s hopes for the future had been dashed by the conception of her unplanned baby. distracted. and—in particular—her feelings of being lost .) At the same time. I didn’t know what to do.” (Her own mother had lost custody of her when she was five. 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. ‘I know I’m not pregnant. “Oh . care that we feel is best provided by the integrated. whom she saw as certain to derail her hopes and dreams for her daughter. too.” Mia could scarcely invest in this possibility. and was hoping to be the first member of her extended family’s generation to go to college. She was doing everything she could NOT to think about her baby.” While there were small glimmers of anticipation of a new relationship—“I talk to my belly. I couldn’t sleep. . Both stories also convey how such complexity invariably requires multiple and flexible levels of care. “This never was supposed to happen. The baby solidified Mia’s already estranged status from her single mother. saying. Mia showed a number of indices of what we might call latent capacities for reflective functioning. When we met Mia. . Mia had been the great hope of her family. Mia had been forced to move out of her home when her mother discovered Mia was pregnant. she had done extremely well in high school. mia We first met Mia at age seventeen when she was seven and a half months pregnant. we found a young woman struggling to disavow the reality of the baby and of her internal world on many levels.” Mia recalled. I’m breaking everyone’s hearts.’ .Minding the Baby 85 vulnerable progress is for women living with such enormous external and internal burdens. That. was broken. and almost dissociated when asked about the baby. she was able to reflect upon her initial denial of her pregnancy. “I just hope I still have it by the time it’s five.” What Mia’s solemn pregnancy story evoked but omitted in her whispery voice was that perhaps her heart. 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. who had disapproved of her boyfriend.

As is very typical of the mothers we are working with. “Shut up. so as to provide the level of mental . Mia was averse to seeking psychiatric treatment. and Noni remained alone in her crib. The progress that she had begun to make in pregnancy— reconciling a bit with her mother. Her movements were perfunctory and task-based.86 Arietta Slade and others and overwhelmed. Mia muttered. to wash a baby doll in preparation for caring for her own child. Noni. Mia was often pale. The home was dirty and crowded with multiple relatives. We decided that the social worker should see Mia weekly. she was able to give voice to her own anxieties and sense of confusion. but at the same time kept clearly in focus the very real possible risks to the baby. needs. She spoke with eyes downcast. Signs of depression—which were to become far more pronounced after she gave birth—were evident. Mia gave birth to a healthy girl. This proved to be a resource that was of great value to her once the baby was born. Within one month post-partum. planning for childcare. the team felt that her depression had reached a critical level (likely as a function of biological as well as other factors). The depth and quality of her language. and keep any kind of a representation of a relationship in mind as she prepared for motherhood. Mia had little conception of the child’s concrete. and not bothering to get dressed unless she had to go out. and her capacity to vividly describe her pain led us to feel that as little as she was able to imagine the baby. thinking through labor and delivery. and expressed wishes. her eyes puffy from crying. Mia had to guard her and the baby’s food carefully. for instance. she giggled uncomfortably and abandoned the activity. beginning to give voice to her fears—began to slip away. she was still living with her boyfriend’s family. as Jay became disinterested in being with the new mother and baby. bathing less. She admitted to crying daily. 2001): preparing the room. Both of our home visitors worked hard during the third trimester to help the mother “make room” for the baby (Mayes & Cohen. Her baby appeared well-cared for but Mia did not touch her readily. and when encouraged. TVs blared and there was the din of the distant conversation. leaving us with little choice but to address her severe depression in a way that respected her pace. The adults in the home were intrusive and often inappropriate. physical needs. disgusted with her isolation and feeling of uselessness. While she had begun to make amends with her own mother toward the end of her pregnancy. embarrassed.” under her breath when Noni cried.

Mia’s mother was a strong. Remarkably. Mia began to find words for her despair. and she began to tell her story.Minding the Baby 87 health services appropriate to the level of the psychiatric emergency. She . was born to a heroin addicted mother who was herself a teenage mother. which she was starting to use in a limited way. Mia began to forge a relationship with the social worker. 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. however. In many ways. at the same time. and the feelings. Over the course of the next few months. but she could talk about her childhood experiences. Mia. and Mia’s fragile denial and determination shattered under the weight of reality. With this shift. Mia’s mother’s dreams had propelled her forward. Despite her own drug problems. we did not decrease nursing visits. These were feelings she had all but deleted from her awareness. following years of neglect. and longed for the uncomplicated love she had never had. The social worker worried that delving into such memories would be too painful and overwhelming for Mia. While we had learned pieces of the story during the evaluation period and the first months of the intervention. The last thing we wanted to do was give her less of anything. and for her own needs for comfort and support. She began to create a narrative. that she began to tell us about herself in a more detailed and—finally coherent—way. giving voice to her feelings. she was removed from her mother’s care and placed in foster care for two years. making meaning of the present in light of the past. First came the memories. Mia was with her mother when she found him. When she was five. and she watched vigilantly for signs of traumatic stress. 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. determined woman of enormous intelligence and perseverance who in her own way communicated a fierce loyalty and love for Mia. a story line that she could reflect upon. Mia’s father died of a drug overdose when she was two. it was only now. and allowing herself to remember and describe moments and fears long forgotten. slowly she found words for the terror that was associated with these remembrances. with the baby real. her mother managed to get clean and bring Mia back to live with her. an only child. She could not talk about the baby. and then came the effort to make meaning. Mia sabotaged and bridled at these dreams (the pregnancy being a very clear example). At the same time.

scared smile. she could elicit maternal traits in Mia such as affection. This scary experience was repeated again and again. Noni’s self-experience was both disavowed and distorted within the context of her mother’s response. but instead remained gently present. Mia delighted in this game. she was. but that she viewed Noni’s response as false and manipulative. On occasion. Mia’s game of choice was to startle her infant. Noni would attempt a false. fed Mia on many levels. smiling in a threatening way as she approached menacingly. able to express complex feelings about her: “I don’t regret the baby. especially fear and distress that she herself generated. 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- . were highlighted and validated.88 Arietta Slade and others did not push. as if she needed to placate Mia and keep her at bay. Noni was an attractive and communicative baby. playfulness. Repeatedly. 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). or she would shove a shrill squeaking toy intrusively in her face. of the infant. with the other adults’ finding similar pleasure in startling and overwhelming Noni. Mia’s competence and efforts to attend to the routine care. 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. repeated multiple times over multiple home visits. “There’s no one else that can comfort her like you. and acknowledged her importance to the baby in ways that she herself could not yet recognize. watching for Mia’s glazing over. however. and pride. At four months of age. if not the emotional care. re-enacting her own helplessness as a child. but did little to soothe the frightened baby. the sign that she had remembered and described all that she could. Despite being unable to recognize her baby’s experience. which she would do in a variety of ways. but I wish I didn’t have her so young. oblivious to Noni’s startled grimace and frozen expression. Look how she’s gazing right at you as if to say ‘thanks. she could also be quite aggressive and harsh with her.” At the same time that Mia could care for Noni competently and sometimes lovingly. She would loom into the baby’s face quickly.” Thus. Whenever Noni would become distressed—not only with the startle game.’” This kind of comment. Equally disturbing was the fact that not only did Mia fail to recognize Noni’s fear. Mia raised the threshold for tension. who in many ways managed to ignite Mia’s maternal capacities.

In the other home. I wanted to for her. alone and/or felt like no one was taking her needs seriously. we did not approach these deficits in Mia’s mentalizing capacities directly. but rather began by using the therapeutic relationship with the home visitors to give voice to her own experiences of fear and distress. “She’s much happier. she’d hold her hands over her ears. It also served as a chance to allow Mia to reflect upon her own experience of the crying. because her tendency to slip out of reflective awareness was so strong. . After revisiting these themes many times over. The next task was clearly to help Mia recognize her baby’s fear and distress. “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. Even in these early months we could see Noni dissociated and frightened in interaction with her mother. it was too much for her . 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. she began to be able to step out of automatic reactions and timidly observe her child’s feelings. Slowly. feelings that were at this juncture too threatening for Mia to see. When asked. and feeling excited by fear. “Why now?” she replied. “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. and she saw herself as instrumental in protecting the baby and providing her with a more regulating and containing environment. Mia’s willingness to hold the baby in mind was quite tenuous and fleeting at first. . Mia moved back into her mother’s home. Mia began to explore the times in which she felt afraid. even in her own history. Noni began to be able to express a more extended range of emotions toward her now more available mother. 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. of course. It was an easy decision. When the baby was thirteen months old. We began by trying to elicit curiosity about the baby’s intent.” Mia was making links between the baby’s behavior (holding her hands over her ears) and internal dysregulation (too much for her). She made the choice to move away from the father of the baby because she believed it was a better environment for a baby. without needing to distort or misinterpret as a means of protecting her own fragile sense of self.Minding the Baby 89 ation and emptiness. . As the intervention proceeded. and had to be nurtured in a variety of ways at all times. denying needs.

Mia is still an adolescent. Despite Mia’s continuing struggles. it seems evident that the slow effort to help Mia keep Noni in mind has been successful. she plays with her. we see the effects of these traumas diminishing in her day-today interactions with Noni. had been her sole caregiver. erratic and sometimes violent. at a group prenatal class in the second trimester of her pregnancy. distance and anger were to characterize Iliana’s central struggles. She was sexually abused by her grandfather. She comforts her child and tolerates her distress. However. At the same time. though. she inhibits her own instincts to frighten and overwhelm. this is a crucial marker of developmental and relational consolidation. but showed many signs of a secure attachment. 19 years old. who from the beginning had some capacity to hold complex mental states in mind. During the two-hour class Iliana remained attentive but maintained a skeptical distance from others in the group. over the course of home visits. Iliana’s defense against pain was to threaten and push away anyone who got close to her. and violence. She finds pleasure in her. iliana We met Iliana. Her father. 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. Mia can hold Noni in mind. This in sharp contrast to Iliana. deeply involved in drugs and alcohol. impending motherhood had stimulated—as it so . poverty.Minding the Baby 91 tachment (Main & Solomon. a 20-year-old man with a previous history of substance abuse and incarceration. more defended. Iliana was overtly more angry. both as they were manifested internally and in relation to the team. She readily described herself as the kind of person who would act before she thought. For the most part. She was proud of her toughness. Her mother had left the family when Iliana was five. And yet. one who has suffered a range of traumas in her short life. a scar that would not heal. and much less able to tolerate and describe her internal world. 1986). the abandonment by her mother—of whom she spoke with bitterness and rage—was a defining moment for Iliana. She had survived a childhood deeply marred by chaos. She was accompanied by the father of her baby. In contrast to Mia. when we contrast her behavior with Noni at 4 months with the responsive and “good enough” mother we see now. her readiness to fight and establish her dominance on the street. Indeed. whose case we turn to next. and was clearly pleased at her capacity to frighten and intimidate people.

but when phoned to reschedule. Unsurprisingly. except as the reason she had to stop “hanging out at clubs. “I know I’ve got to change and not just walk away or not talk when I’m mad. We viewed this ambivalence in a positive light (at least she was ambivalent).” she remarked. Iliana wondered aloud if she could learn to be the kind of mother the baby could count on. Their relationship was evidently troubled.92 Arietta Slade and others often does—the wish to mother differently than she herself had been mothered. Iliana was—like Mia—clearly an intelligent and articulate young woman. During the prenatal phase. 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. she routinely failed to show up for appointments. she always appeared interested in setting up another meeting. in which she linked her behavior to internal experience and recognized that her own intentions and desires were changing. Looking at the life-sized photo of a brand new baby. but I don’t know why.” 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. She had little expectation of support from him (“maybe he’ll buy diapers”) and obviously felt let down and alone. Her armor—manifested in her attitude—was thick and tough.” She had only known the father of the baby for several months and the pregnancy was unplanned. she longed for work that would give her a sense of purpose and meaning.” This snippet of mentalization. We hoped that our continued presence signaled a willingness to meet and work with her as she became ready and more trusting of us. Also like Mia. although it was not until much later in the work that we knew just how troubled. was brief and fleeting. It’s not just me and what I want anymore. Iliana was finally able to speak of her fears. “I talk to it sometimes. This was but the first sign of resistance that was to manifest itself continuously as treatment proceeded. the fear of closeness to others was reflected in her relationship to her baby during pregnancy. 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 never called to cancel. well aware that she would fail to keep more than half of them. “It’s hard to picture the baby. In this circumstance it was hard to make baby “real” to the young mother-to-be. Not surprisingly. and she continued to reschedule appointments. it was very difficult to establish a therapeutic relationship with Iliana. Despite leaving high school during 10th grade. I’ve never held a lit- .

As might be expected. and her daughter was easy to feed and console. Iliana was enormously pleased that she could regulate the baby’s states to reduce her crying episodes without becoming overwhelmed herself. She was terrified of labor. Iliana said she longed to “be a little girl all over again. and particularly frightened of the feelings of powerlessness and vulnerability that it would engender. gazing warmly into her eyes and imitating her facial expressions. Iliana’s feelings about her own body were to later define her feelings about and insensitivity to her baby’s body. but to have someone take care of me. The labor was difficult. of not having been nurtured and protected by her own mother. the nurse practitioner developed a labor plan with Iliana that allowed her to make choices ahead of time about medication. 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. Anticipating the terror she would feel giving birth.” As a consequence. They are so small they look like they can break. these feelings can be especially poignant in women who have been sexually abused and who find labor retraumatizing. there were moments when she could be tender toward her daughter. 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. Not to have the childhood I did have. This positive beginning helped Iliana become more open to developing a relationship with the Minding the Baby team. At these times. Giving birth was an empowering experience for Iliana. she often could not tolerate the baby’s need for . namely Iliana’s profoundly disrupted sense of her body. restraint. Iliana was also reminded of her own loss. Iliana got an important developmental nudge from her easy little girl. but the labor plan—which was supported fully by the midwifery team—allowed Iliana to feel in control of her experience.Minding the Baby 93 tle baby. The new and frightening bodily sensations and discomforts of pregnancy made her feel out of control and angry. The new mother held the baby—a girl named Lucia—closely. But as so often happens. She was extremely proud of herself. 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. and her enormous resistance to treatment. 2002). however. we had not allowed ourselves to hope for such an auspicious beginning. however. Given Iliana’s tough veneer. and other aspects of the delivery (Simkins. On the one hand.

There were signs of neglect. fed. Many times we would come to the home to find her disheveled. In thinking about how to help Iliana become more sensitive to her child’s bodily needs. We wanted to build on this new experience and find ways to demonstrate acceptance of the mother’s body (and. her whole being) in a caring way during home visits. using questions about her past and current activities. therefore. and abuse. and on several occasions both mother and child had advanced cases of ringworm. the baby often had a number of raised. the more able she was to understand her daughter’s needs and experience. She took our “talking for the baby” as criticism.94 Arietta Slade and others care and comfort. With her eczema untreated. wearing her torn nightclothes. 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. Ignoring the baby’s distress. Lucia had eczema. her hair uncombed. We had to work around her defenses. which she would scratch continuously. At such moments. and she would handle her abruptly and speak to her harshly. and self-care. symptoms.” by the clinicians. and experienced Lucia as demanding and needy. nutrition. It seemed quite evident that any sign of distress in the baby aroused her own feelings of sadness and helplessness and were thus intolerable. most likely because our giving voice to the baby’s feelings made them even more unbearable. she was extremely resistant to new ideas or ways of interacting with the baby. scaly patches of skin and was irritable and uncomfortable. She misattributed the baby’s facial expressions of discomfort as anger with her. Lucia was basically healthy. Iliana instead complained of her own numerous physical complaints. and clean. to help the young woman make tentative connections between her feelings. The baby’s distress irritated her. the nurse practitioner spent time at each visit asking about her symptoms. We found that the more the young mother’s pain was acknowledged. and responded with surly adolescent mumbling. “heard. but Iliana routinely failed to follow through on caring for what should have been routine physical care for her child. Addressing Iliana’s needs first. 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. It was very hard to help her at these moments. Any hint of “correction” on our part (try though we might to remain benign and nonjudgmental) would trigger Iliana’s hostility and defensiveness. and reprimanded her daughter for scratching. . We observed her roughly awaken the baby to change her diaper or harshly tell the baby to “shut up” when she whimpered.

Iliana. and the baby moved into a tiny apartment of their own. and asked the mother to follow the baby’s lead while she herself washed the dishes. we had to approach Iliana through her body. “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. 1963). She was able to express this feeling to her child by having a short conversation about what they were doing. At this time she became more overtly dependent upon the home visitors. Her extreme neediness was experienced by the home visitors as a continuing volley of demands. Iliana complained that the toddler was “always in the way. It makes me crazy!” The nurse practitioner brought over a small plastic tub and a few containers for the little girl to play in. Always trying to do what I am doing. and through her concrete needs. She could not work at a metaphoric or abstract level. Mentalization could only take place at a very concrete. her new boyfriend. within the context of which they had to continuously work to keep the baby in mind for Iliana. 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. protosymbolic level (Werner & Kaplan. 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 was able to use us to help her obtain an order of protection. her relationships. When we tried to talk to her about her feelings about her life experience.Minding the Baby 95 Unlike Mia. Recently Iliana laughingly described her daughter as “being . In imitating her daughter’s splashes and play with soap bubbles. and he was now continuing to physically threaten her. She responded with overt indifference and appeared to pull sharply away. Iliana the tough and defended young woman who needed no one could not get enough of us. Once she disclosed his abuse to us. When Lucia was 15 months old. Imitating her child’s actions. and to support her desire to protect her baby. This realization has sometimes spilled over into other parts of their life together. Iliana suddenly “saw” what the child was doing. but she began to call us nearly daily with minor and major crises. It turned out that Lucia’s father had been abusing Iliana throughout the pregnancy. But as we did this. Over time Iliana has slowly become more aware of her baby’s experience. she laughed and exclaimed. This was the other side of Iliana’s toughness: the paralyzed victim. she would become enormously sleepy and actually appear to doze off. and her emotional experience. she began to involve us more directly in helping her. who from the start could—at least in a limited way— engage in the struggle to understand her history.

Iliana now uses her community health center for routine medical care instead of going to the ER. At the same time. it is nevertheless becoming more natural to her to think about the baby in this way. the willingness to allow others to care for her and her body is crucial. we worry that we will have to get child protective services involved. The child’s jubilant response served to reinforce and build on her mother’s new capacities. She can still be openly neglectful of Lucia. She has a relationship with her primary care providers. as there continue .” Iliana had been outside watering the flowers in the garden. who has served as a bridge between clinic and mother in an ongoing way. Nevertheless. Unlike Mia. 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. As is captured in Iliana’s own words at the opening of this paper. facilitated by the nurse practitioner. The understanding she does have often fragments under the intensity of her feelings. Thus. as well as to explore her expanding world. She began to talk about her child’s needs and understanding as being different from her own. This is certainly a meaningful way to describe Iliana. 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. and to witness her experience. While significantly less widespread and deeply held than Mia’s capacity to understand and hold her baby in mind. These moments of seeing the baby and taking pleasure in her have been accompanied by other shifts as well. we also began to see signs of limited reflective functioning across a number of domains.96 Arietta Slade and others her own little self. although now she yells instead of slaps. even though these reflective capacities can easily disappear in an instant when she becomes angry or threatened. She has acknowledged the power of her mother’s abandonment and her own unrequited longings for love and simple care. 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 very harsh with her. it is important to acknowledge that there are profound limitations to Iliana’s reflective capacities. She had understood and accepted her baby’s desire to be nearby and involved with her. even after nearly two years of treatment. and—anticipating her child’s desire to be included— had dressed her in a swimsuit. 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. For Iliana.

Our multidisciplinary model allowed us to approach these differences in a flexible way. Mia had managed to escape the physical trauma and abandonment that had devastated Iliana. and about the dynamic relationship between her feelings and actions. Iliana had endured continuous disruptions in her sense of bodily integrity and wholeness. and had found crucial comfort and safety in her relationship with her mother. and Mia began with at least rudimentary openness to acknowledging mental states. Iliana’s abilities to do this are far more compromised and fragmented. loving caregiver. these assaults had been at the hands of those who were responsible for caring for her. From the standpoint of reflective functioning. with Mia—while quite defended— the more ready of the two to think in a complex way about her interior life. although she too has discovered reservoirs of pleasure in and identification with her child that are crucial and even miraculous. these young women began Minding the Baby with significantly different capacities for reflective functioning and mentalization. Mia was more ready to make use of a more traditionally therapeutic relationship with the home visitors. Developmentally. Iliana. We understand the limitations of Iliana’s availability to treatment as a function of multiple factors. either from Iliana’s neglect or for Iliana herself. She used the social worker to help her obtain social . but instead relied upon the nurse practitioner’s expertise in parenting and child development.Minding the Baby 97 to be multiple signs that Lucia is often in danger. 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. most prominent being past and ongoing trauma and the lack of a stable. Discussion As she approaches her child’s second birthday. on the other hand. Mia has begun to hold her child in mind. and occasionally holding their interconnectedness in mind. often. Iliana began the program without any evidence of such capacities. While certainly no stranger to trauma. who in her own narcissistic fashion kept her daughter in mind. 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. to balance the nursing and infant-parent psychotherapy approaches in response to different kinds of supports these mothers needed at different times. In addition.

Gergely. N. M. M. 62. As we hope we have been able to convey in our description of a mentalization based. & Wall. Fonagy. H. (1998).. N. Mattoon.. Child Development. H. M. (1991).. Fonagy. Steele. version 5.. P. Patterns of attachment: A psychological study of the Strange Situation. Fonagy.. S. Steele.... P. H. A... Steele.. P. & Steele. Blehar.. T. In Attachment Theory: Social. multidisciplinary mother-infant intervention program.: Analytic Press.. Attachment and borderline personality disorder.. (2000). & Target. R. D. M. Steele. Affect regulation. Bateman. G. again needing this kind of very concrete help to support any reflective capacity whatsoever. P. Fonagy. P. & Steele. Zeanah.. Fonagy P. (1978). Muir. Goldberg. Psychoanalytic Dialogues 8:87–114. pp. G. ed. BIBLIOGRAPHY Ainsworth. D. Oxford: Oxford University Press. Infant Mental Health Journal.: Lawrence Erlbaum. (2002). Journal of the American Psychoanalytic Association 48:1129 –1146. . P. Waters.. & Zeanah. Fonagy. Paper presented at the Tulane University Health Sciences Center. this is complex work indeed. M... M. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. H.J. & Target. M. G. and borderline states: The predictive specificity of the Adult Attachment Interview and pathological emotional development. to witness their pain and their anger without dysregulation and retribution. Maternal representations of attachment during pregnancy predict the organization of infant-mother attachment at one year of age.. Jurist. New Orleans. Boris. London: University College London.J.. Fonagy. (2002). (1995). M. and to keep the baby alive for the mother in the face of relentless chaos and uncertainty. Leigh. H. W. Hillsdale. 13. R.0. (1991). Kerr. C. Larrieu.98 Arietta Slade and others services. S. (1998). Target. N. 223 –279... 891– 905. mentalization.. P. Moran. the reflective self. & Higgitt. Psychotherapy for borderline personality disorders: Mentalization based treatment. Attachment. J. 200 –217. A... A. E. S. Steele. M. Kennedy. Mentalization and the changing aims of child psychoanalysis. G. E.and the development of the self. (2004). An innovative approach to addressing mental health issues in a nurse home visiting program. & J. & Fonagy.. Reflective functioning manual. P. Steele. 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. M. & Target. Hillsdale. Nagle. for application to adult attachment interviews. New York: Other Books. Developmental and Clinical Perspectives.

cherished by the extended family on both sides. . safety procedures.90 Arietta Slade and others When Noni was 14 months old. the social worker reviewed a videotape that had been made of Noni and Mia interacting when Noni was 4 months old. slowly and in a way she could tolerate. Mia was overwhelmed by her living situation. . Waters. with birth control. When seen in the Strange Situation (Ainsworth. The central focus of the work of both home visitors was to make Noni and her internal world real to Mia. and taught her how to play with the baby. a laboratory based separation procedure that is used to assess infant attachment status. he is often present at home visits. & Wall. We brought toys and baby books. and the like. and Mia is living in her mother’s clean and orderly home.” 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. 17 months after Mia’s entry into the program. and is proud of his understanding of development. . This reaction signified crucial progress to the treatment team. and noted readily how insensitive she had been to Noni’s cues—“I had no idea what she wanted. She had several frightening blow ups with Jay (who had a history of violence). indeed. . it is important to highlight the fact that the work was taking place on many other levels as well. At the same time. and we worked in a variety of ways to help her make Jay’s family home safer for the baby. with obtaining food for the baby. Without these levels of support. 1978). scaring her. Noni was not classified as disorganized in relation to at- . vocational planning. medical care. Filters were provided that protected the baby from the smoke in an environment where everyone smoked cigarettes. and with basic caretaking skills. she was nevertheless fully cognizant of the fact that she was ignoring signs of distress that she was readily able to identify in retrospect. and I’m just in her face. the therapeutic work would have been utterly impossible. She needed help with travel to and from school. Noni is now 20 months old. All reflective work took place against this backdrop of concrete support and education: help in stress reduction. Jay is still firmly in the picture. . as well as the mutual feelings of love and attachment that he and Noni obviously have for each other. that she may have been hungry or sleepy . Blehar. She’s trying to tell me she’s scared. . I see now that her crying was to tell me she’d had enough . I couldn’t read her . Mia was obviously troubled in watching the tape. This meant she first had to recognize that the baby required safety and that she could participate in providing that. here I can see her face sad telling me what I didn’t know. Noni is clearly a loved child. which required our help in sorting out.

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M. LICSW This paper offers fragments from the first year of a home-based motherbaby psychotherapy. and member of the Boston Psychoanalytic Society and Institute and the Massachusetts Institute for Psychoanalysis. and to relate to the partner’s mind as a separate. Neubauer. I gratefully acknowledge Karlen Lyons-Ruth. Samuel Abrams. Scott Dowling). In addition. Peter B. for his untiring support. ed. Massachusetts. and Mary and John for showing me the way. M.D. Peter B. The treatment was organized in part around certain developmental objectives common to both attachment and psychoanalytic theory. M. with its emphasis on the critical psychobiological role of containing fear and distress in infancy. Sarah Birss. for teaching me so well. Samuel Abrams. and a lecturer at Simmons Graduate School of Social Work. The Psychoanalytic Study of the Child 60. attachment theory. for her invaluable clinical and editorial input. King.. understandable center of initiative and intention. King. The paper reviews research findings on motherSenior faculty member of the Infant-Parent Training Institute at Jewish Family and Children’s Service of Waltham.D. Neubauer. in which I attempted to help a traumatized and dissociated mother to emotionally engage with her infant son. the Center for Early Relationship Support at the Jewish Family and Children’s Service of Waltham Massachusetts.D.. Scott Dowling (Yale University Press.. Robert A. was a useful guide in formulating the treatment. George Ganick Fishman. to evoke a soothing maternal introject. and A.D. for making it possible. copyright © 2005 by Robert A..“In a Black Hole”: The (Negative) Space Between Longing and Dread Home-Based Psychotherapy with a Traumatized Mother and Her Infant Son JUDITH ARONS. Ph. 101 . These include: The ability to name and metabolize feelings. and Ann Epstein. and A.

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. 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. mother and therapist.102 Judith Arons infant pairs described as frightened-disorganized. was a useful guide in formulating the treatment with this terrified mother and her emotionally disorganized son. to name. I will briefly describe some of the challenges of home-based mother-infant psychotherapy and then move on to the case and discussion. and we have little clinical data documenting the therapeutic outcomes of such interventions. There are relatively few case studies describing the psychoanalytically informed treatment of frightened/disorganized mother-infant couples. 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. with its emphasis on the critical psychobiological role of modulating and containing fear and distress in infancy. It is my belief that within fright- . 2004). The case illustrates how mother-infant psychotherapy may interrupt the intergenerational transmission of disorganized attachment by working within the couple to name. mother. These include: the ability to recognize. Whenever possible we attended in the moment to the relationship between mother and baby. and therapist together. 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. understandable center of initiative and intention. the ability to evoke a soothing maternal introject to aid in containment and integration of self states. and baby. and the ability to be aware of and to relate to the partner’s mind as a separate. My work with Mary and John was organized in part around certain developmental objectives common to both attachment and psychoanalytic theory. Attachment theory. baby and therapist. metabolize and flexibly respond to painful. 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. dissociated or frightening experiences. discusses some of the challenges encountered in home-based mother-infant psychotherapy and then discusses the case of Mary and John. and to metabolize feelings.

Bronfman and Atwood. and flexibly respond to painful. 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. 1990a.“In a Black Hole” 103 ened/disorganized dyads. stressful separationreunion experiences of the Strange Situation highlight the contradictory behaviors indicative of disorganized attachment. mother-infant psychotherapy may interrupt the intergenerational transmission of disorganized attachment by working within the couple to name. Main and Solomon. The baby’s relational strategy breaks down or cannot form. or helpless. the infant. 1990a). Lyons-Ruth. Sometimes the infant exhibits an unusual combination of attempts at approach coupled with odd or inexplicable gestures (Lyons-Ruth and Jacobvitz. Bronfman. The resulting increase in mother and baby’s affective competence (Russell. 1990a). Main and Hesse. 1999a. dissociated or frightening affective experiences. upon reunion with mother. 1990b). making slowmotion underwater movements. Researchers have categorized these mothers as hostile/helpless or frightened/frightening. and Atwood 1999b). 1998) paves the way for further growth of intersubjective relating between them. Despite upset during her absence. Lyons-Ruth and Jacobvitz. and he exhibits conflicted behaviors that include wandering in a disoriented state. metabolize. and approach-avoidance or stilling/ freezing in a dissociative-like response (Lyons-Ruth. While researchers agree that there is a correlation between mother’s unresolved state and her ability to . 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. 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. 1999a). appears to be dysphoric. 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. apprehensive. In the research lab. 1999b. 1990a.

Her emotional cues are incongruent or non-responsive sometimes with sudden loss of affect (Lyons-Ruth and Jacobvitz.. Schuengel and Bakermans-Kranenberg et al. LyonsRuth. On the representational level. Bronfman and Atwood... Taking a slightly different tack. Liotti’s work has noted the similarity of these responses to dissociative processes in adults (1999.. 1999).104 Judith Arons provide responsive and consistent infant care. and BakermansKranenberg et al. frightened mothers appear dissociated. Unlike mothers who display overt hostile or intrusive behaviors toward their babies.. For example. Bronfman and Atwood. Schuengel and Bakermans-Kranenberg et al. 163). 2002). 1992). 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. 1999). Schuengel and Bakermans-Kranenberg et al. or react to baby in a helpless. 1999b. there is disagreement on the mode of transmission of disorganized attachment. intrusion into consciousness of dissociated material. Main and Hesse. deferential. mother’s unresolved state of mind impairs her ability to respond to baby’s cues in a sensitive and non-conflicted way (Schuengel. or sexualized manner (Main and Hesse. 1999a. My discussion will focus on the frightened/disorganized subgroup of mothers and their infants. They speculate that when mother is frightened or helpless her emotional withdrawal leads to dysregulation in her infant. 1999a. Mother de- . 1990a). like stepping away while speaking in a soothing tone (Lyons-Ruth. preoccupied. and multiple and discontinuous inner representations (Lyons-Ruth and Jacobvitz. 1990a. On the behavioral level mother’s responses to the Strange Situation demonstrate subtle. From a clinical perspective. 1999). 1999. mother’s performance on the Adult Attachment Interview reveals unmonitored lapses of reason and coherence in discourse. She may appear disoriented or confused by the child’s behavior. p. 1999). 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. frightened. and tentative. mother’s caretaking appears parent centered and organized around her defensive exclusion of painful feelings (Schuengel and Bakermans-Kranenberg et al.. affective incongruence. contradictory reactions to the child’s bid for comfort and care. 1999) and impedes her capacity to repair affective disruptions within the dyad (Lyons-Ruth et al. 1999b). Along with unintegrated internal representations and difficulty regulating her own affect.

Solomon. Fonagy and Steele. inner fragmentation and compromised cognitive functioning. and living with sickening dread or unremitting sorrow (Terr. 1999b. Bleiberg. 1999a. and problem-solving (Bretherton and Waters. George. Lyons-Ruth. 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. and Jacobvitz et al. et al. poor self-reflective functioning (Fonagy and Target. Laurent. 2002. autonomous exploration. et al. 2002). Bronfman and Atwood. Lyons-Ruth. 1999a). Fonagy and Target.. chaotic internal representations (Fonagy and Gergely. dissociation. the onset of dissociation in adolescence and adulthood (Lyons-Ruth and Jacobvitz. et al. 1991). Liotti. 2001. or frankly aggressive behaviors (Lyons-Ruth and Jacobvitz. The impact of chronic fear on brain development and functioning.. Chronic and unresolved fear leaves its indelible imprint upon neurological and psychological functioning. Fonagy and Target.. et al. 1993. 1997. 1999b. Fonagy and Steele. Alpern and Rapacholi. Jacobvitz and Hazen. and physical and mental health has been well documented. Schore. 1995). 1985).. Negative sequelae of Type Two (chronic) trauma in childhood include relational disturbances.. impairment of mastery motivation. 1991). 1991) and compromised cognitive functioning (Moss and St. Bronfman and Atwood et al. Some Challenges Encountered in Mother-Infant Psychotherapy Before discussing the specifics of therapeutic work with frightened/ disorganized dyads. Disorganized attachment places infants at serious risk for impaired affect regulation and right brain development (Siegel. Lyons-Ruth. 1999 & 1992.. excessively caretaking. Self-reflective capacities are thought to be among the key mediators in the transmission of secure attachment (Fonagy. 1999.“In a Black Hole” 105 fends herself against the threat of her baby’s fearful expressions and his need for comfort by restricting her awareness of his state (LyonsRuth. 1991). 1997. 1997. and DeJong. 1999 & 1992. I will broadly describe some of the challenges en- . 2001a&b). 1999a. 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. controling. Liotti. Main. profound affect dysregulation. 1999). 1999. She is hindered in providing the adequately attuned affective envelope that would instill an experience of “felt security” in her baby. stress arousal systems.

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. neurological. For the therapist. name it and hold it in mind. She longs to give her child a better life. mother-infant intervention takes place in the freewheeling realm of the home. while also stimulating exploration within the reflective. Unlike the relatively controlled conditions of the infant lab. the responsibility of intervening in the life of a very small child is great. There is mother’s need to be recognized as the individual she is. but this is a more familiar aspect of psychoanalytic work with adults. proscribing behaviors versus enabling them to emerge. and to emerge as an individual within the mother’s more fixed psychic system. but is mired in chronic difficulties that take time to recognize and to rework. She struggles with this need in the midst of her own negative representations and in face of her baby’s real and constant demands. moving into the future while honoring the past. as we also try to name it. even as she struggles to break these ties and move into the future with her child. and biological systems theories. symbolized domains. The therapist’s experience is one of joining a constantly shifting relational system that moves between poles of repetition and transformation (Lachmann. His presence in the session coupled with his developmental dynamism and very real dependency exert tremendous pressure upon both . 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. The work requires a holistic. Of course we also attempt to feel what the baby stimulates in his mother. implicit domains of experience. developmental. Baby’s nonverbal communication drives the therapeutic triad deeply into the affective. It makes therapeutic use of improvisation and surprise. versatile. Mother’s childhood experiences tie her to the past. and dialectical approach buttressed by all that we have learned from relational. This system and the treatment are filled with paradox. She must live within the paradoxes of acting versus waiting. 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. 2001). give it meaning. There is the infant’s press to develop.106 Judith Arons countered in mother-infant work. to accommodate. Baby’s needs are such that he cannot wait for his mother to change. and hold it in mind. This is couples treatment in which one member is wordless and communicates through the language of body and affect.

which take time to observe and to assess. 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. Mother and baby interact differently in the various domains of care. This pressure stimulates intense transferencecountertransference responses. or respond in a contradictory. Negative or dysphoric exchanges may stress mother’s capacity to remain sensitively engaged more than interactions that are positive or neutral.“In a Black Hole” 107 mother and therapist. These pockets of emptiness can be hard to observe in a rapidly moving relational scenario that also contains positive mother-baby relating. 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. 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. One observes a number of positive mother-baby interactions and few overt fear-inducing behaviors. or helpless manner. and unable to scaffold her baby’s experiences. The pathogenic interactions that occur are more difficult to see than the easily observed hostile-coercive behaviors found in other disorganized couples. When mother struggles with dissociative states or impaired relatedness. frightened mothers may miss the distressed baby’s cues altogether. or sudden loss of affect and attention. . It is often the infant who is responsible for approaching her. Emotional blank spaces or “black holes” may exist within the dyad. When difficult emotions or painful memories are aroused. mother may appear passive. Careful observation reveals a mixed picture of maternal gentleness and sensitivity combined with affective miscommunications. The Frightened/Disorganized Dyad: A Clinical Perspective Frightened/disorganized mother-infant pairs can present a confusing clinical picture and each dyad is unique. In many cases one initially senses a subtle climate of misattunement. preoccupied. Unlike hostile mothers who may overwhelm baby with their intrusive and undifferentiated responses to his distress. she will be unable to consistently keep her baby in mind. In the home one begins to notice mother-baby interactions that are shaped according to which emotions mother can tolerate. deferential. and lends transformative power to mother-infant work.

leading one to speculate that diagnosis and treatment may involve a sophisticated and subtle assessment of motherbaby interactions. The mothers of disorganized infants may present within a wide spectrum of psychological functioning (Lyons-Ruth. Sometimes she responds positively to her infant’s desire to connect and interacts warmly and spontaneously. At our first meeting she said. to give my son more than I got. 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. including home-based parent-infant psychotherapy.108 Judith Arons On the other hand. the child continues to request comfort and care. At other times she is able to react positively to baby’s attempts to structure their interactions. no role models. The Center for Early Relationship Support is part of the Jewish Family and Children’s Service of Waltham. In situations where mother and child do engage in some attuned interactions. her dual diagnosis of alcoholism and bi-polar disorder. I don’t even feel that much for my . some of mother’s responses are relaxed and flowing. her cognitively and affectively disjointed manner of relating this history. 2002). and bi-polar disorder. Massachusetts. post-partum psychosis. but I don’t know how. taking his lead and responding with appropriate feeling. I am a drunk and a loser. was referred to The Center for Early Relationship Support by her psychopharmacologist. and offers a variety of therapeutic services to parents and infants. Mary had been diagnosed with PTSD. 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. I had horrible mothering. Mary and John: Initial Impressions Mary. and her alienation from herself and her son are all consistent with the more severe spectrum of the disorganized dyads described in infant research. “I want to be a good mother. personal communication. At the time of referral Mary and John were also being followed by Child Protective Services. a thirty-two-year-old married mother of a twelve-month-old son. Disorganized attachment research indicates that the infants of frightened mothers may show a superficially secure attachment strategy when stressed. The infants of frightened/disorganized mothers may show relatively subtle signs of disorganization themselves. In the following case vignette mother’s severe trauma history. alcoholism. On the other hand. after her recent discharge from an alcohol detox program.

ignored.k.” Mary had been sober for only twenty-eight days. and they would laugh or be silly together at his prompting. and her urge to drink. joy. whose life is this?” Throughout our initial meetings Mary revealed her painful story. Mary responded well to the structure afforded by particular aspects of John’s daily care. whose house is this. He was cheerful. but could spend an hour amusing himself alone in his crib. As John interjected himself into the adults’ conversation Mary would encourage him proudly and speak of what a good and beautiful boy he was. John was a beautiful twelve-month-old with a shock of curly blond hair and ice-blue eyes. her guilt. “Is it o. lapses in reasoning. In our first interview she revealed the depth of her alienation. He approached his mother for help and to share his toys.“In a Black Hole” 109 son. Mary’s intense self-absorption and dissociated states initially placed . Her narrative was filled with contradictions. She showed sensitivity to his cues around eating and being diapered. and he regularly looked at her and reached for her to help him. Mary asked. These interactions included much mutual gazing. dangerously unsupervised. turn-taking. In these early home visits John would sometimes cry from the other room in the middle of some mishap.” Mary’s eyes spoke volumes of her fearful inner world. John often crawled around the house with the pet dog. I don’t deserve him. curious. and playful physical contact. Mary would wait patiently for John to signal the next spoonful or when it was time to continue diapering or dressing him. Mary could also be attentive and natural in her responses to John’s ebullient expressions. spoke to me of her terrible childhood experiences. He had difficulty focusing in on toys or play. 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. as Mary. and engaging. But coupled with these positive behaviors were more ominous interactions. and affective incongruence. In these domains John was never made to feel passive. 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. “I wake up in the morning and I wonder. but her narrative tone was one of disorienting cheer. “I can’t call myself his mother. I don’t know who I am or what I’m doing here. Sometimes I think he hates me and would be better off with someone else. in a world of her own. and hilarity. Sequencing of events was so confused that I was unclear exactly what had happened to her and when. I observed Mary and John sharing moments of pleasure.” Mary was unable to claim her son or to acknowledge her motherhood. or intruded upon by his mother’s agenda. whose baby is this.

and enabled Mary to attend . “covering my head so that I couldn’t hear his cries. Peter demanded that Mary enter a detox program. Some months into the treatment I learned that for the first eight months of his life. it was he who initiated this type of contact. Mary often allowed John to get into highly charged emotional states that were on the verge of decompensation. all of whom were at work during the day. She was unable to play with him. 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. and lived in terror that she had physically injured him. but desperate to keep his job and needed to deny a drinking problem of his own. Then when John was about three months. Mary plunged into a post-partum psychosis. John was neglected and left alone for long periods of time in his crib without food or diaper change. He was aware of Mary’s drinking. During his first eight months. started to hear voices. He was continuing to do all the reaching out for contact. History After John’s traumatic birth (a mishandled forceps delivery resulting in a subdural hematoma and seizures). Mary would drink and go to bed. Peter was unable to offer adequate protection or containment for his wife and son. There were two unsuccessful hospitalizations during this time. and she often asked if he would like to go up to bed.” For these first eight months Mary was living with her husband Peter and his parents. A year into our treatment Mary shared that she often cared for John in drunken blackout states. there were few spontaneous gestures of affection. Mary could not consistently help John transform his negative states to positive or neutral ones. 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. The move allowed Mary to be closer to her father (a twenty years sober alcoholic). I was uncomfortable with how little we included John in our initial sessions. John responded well to the evening return of his father and grandparents. Toys were often offered as comfort instead of her body or voice. When he was distressed she would pick him up. I observed that she did not seek John out as an emotional companion. but then put him down before he was sufficiently calmed. which she did. From time to time he could successfully engage her but I wondered how much work he had to do to make this possible.110 Judith Arons John on the periphery of our conjoint work. and began to drink heavily.

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I offered her additional weekly individual meetings in my office and telephone sessions as needed. The strange eye movement was determined to be non-organic in nature. She successfully completed high school and college and went on to have several interesting and responsible jobs. and she was struggling to stay sober. who locked her in her room each day. She lost her fear of her “evil stepmother” and became provocative and oppositional. One month into Mary’s sobriety John began to reach out to her for comfort and to track her visually. during adolescence Mary felt she had the love of her paternal grandparents and recently sober father. would not gaze into her eyes. He screamed when she held him. John rejected his mother’s attempts to connect. But two months into our work Mary began to reveal the depth of John’s neglect and the severity of her childhood trauma. Mary began to drink at age fourteen. Our mother-baby work was heightening Mary’s affective numbing and flooding. and would not smile at or reach for her. Mother then abandoned the family and was in and out of young Mary’s life. Until he was eleven months. but at thirteen months he developed a strange rolling eye movement in her presence. She was often locked outside of the house while her stepsiblings had after-school snack. When she was a one year old her schizophrenic mother attempted to drown her in the bath and she required resuscitation. Mary and John each needed to feel held. When father remarried three years later (Mary was four) she lived through cruel and degrading neglect at the hands of her stepmother. known. and remem- . It became clear that weekly conjoint sessions would not provide adequate containment to safely explore Mary’s issues. She fell in love with a gentle if troubled young man. Mary’s own childhood had been devastating. and married into a large family. For a time Mary was passed among relatives so that her father could work. Formulating the Treatment The initial treatment plan was to offer weekly mother-infant sessions in the home in conjunction with twice daily AA meetings. John had been followed neurologically since birth and there had been no sequelae from his early seizures or hematoma. But despite the depth of her difficulties. refusing to feed her or allow her to use the toilet. At that time Mary was frantic and depressed about John’s behavior toward her. In winter the kindness of an elderly neighbor sheltered Mary from the cold. With some concern about the complexity of combining therapeutic modalities.“In a Black Hole” 111 twice daily AA meetings.

My objective was to develop a therapeutic relationship that would provide mother and son with the experience of containment and safety. In his book The Motherhood Constellation (1995).112 Judith Arons bered. Initially we did not know that the journey would require our living through repeated painful and overwhelming states of desperation and danger. 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. In addition. I envisioned the individual work and mother-infant sessions as existing in a figure-ground relationship. affect regulation. even as we “practiced” new forms of relating. Combining immediacy with enactment would afford us the opportunity to hold painful experiences in the moment. 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. It integrates traditional psychoanalytic approaches with interventions designed to have immediate impact upon mother and child’s relating. Her subsequent difficulties establishing evocative constancy. or affect tolerance necessary to fully engage in a conventional interpretive psychotherapy. . Mary’s developmental strides within our dyadic relationship could be transferred to the immediate interactive realm of mother and son. Home-based mother-infant work offers a rich tableau of implicit interaction and a profound sense of intimacy. Within individual and conjoint sessions we could unpack those interactions in which older and more troubled patterns held sway. 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. 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. But the developmental pathway we traveled was rocky and uncharted. verbal self-awareness. and reflective capacity meant that she would not have attained the level of symbolic thought. Stern describes the dynamic interplay between representation and behavior: change in one area affects change in the other. 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.

As she spoke I could hear John playing near her. help me . In contradiction to the malevolent power that I unwittingly possessed. . my helplessness made me feel that I did not really exist. I took my first vacation. No I don’t. Usually an active child. Leading up to the interruption she was dismissive of suggestions that we explore the possible impact upon her of our separation. that . I am holding a knife and I don’t think I can control myself. I am hopeless. No. I wondered how often John might feel similar chaotic states of victim-victimizer. please. please. . of absolute destructive power and utter non-existence. can you help me? I am so scared . I called 911 on my cell phone and did not hang up until I heard the EMTs arrive. fourteen-month-old John had apparently understood that something dangerous was happening and that he should stay by his mother. Mary could not remember either John or myself and was sure that we would soon forget her. A few days before our break. it appeared that all our work was lost. Mary had passed out on the couch with John playing quietly at her feet. Mary felt compelled to enact this role with her son. Mary placed the phone down as I listened in utter helplessness.“In a Black Hole” Attachment Crisis in the Treatment 113 One month after adding individual sessions. I want to die. I want to cut myself. Waiting in silence on the phone. . trying to discern if John was all right and what had happened to his mother. “I’m sorry.” Mary felt that John was better off without her and that he would soon “forget her. During those moments I understood the terror and isolation that Mary must have felt so often in childhood. This precipitated a profound crisis for Mary. I can’t go on. Caught in a transferencecountertransference storm. . Mary had delivered into our threesome the nameless dread of her infancy.” as no doubt she thought I had also done. it’s too late for me. Mary called me in an inebriated and near blackout state. I’m such a loser. Her voice was that of a desperate and confused little girl. Everyone is better off without me. I struggled through my own fear to keep all of us alive within my mind. she was unable to use me as a soothing presence. Despite my efforts during that phone call. They’ll be angry at me for a while and then they will forget. 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. it’s all hopeless. I had become the abandoning mother who filled her with uncontainable and terrifying feelings.

let’s go in the living room. frightened. and throws himself on the floor sobbing. The following vignette.” (I sit by John. He reaches up for his mother. stumbling over his toys. lets try to figure out what’s going on and what each one of you is feeling right now. I came to accept that if we were to work deeply enough to stimulate growth. more forcefully.114 Judith Arons she would be the victim/perpetrator of abandonment or murder. the shadow of deadliness would have to fall across our relationship. his face red and puffy with exertion.. it’s all I can do not to pick him up. She appears tuned out.” (angrily) “You have to learn not to get so upset. She picks him up but puts him down before he can settle. I’m getting frustrated. She puts him down again. I don’t know how to handle this stuff. He confuses me. Living through this crisis marked a turning point. I try one thing and another but nothing helps. John staggers away while pitifully crying for his mother. taken from a mother-infant session three weeks after my return and Mary’s discharge from hospital. Process Vignette I arrive for a session in the home. John has just returned from daycare and seems tired and cranky. mama. Therapist: “O. more cheese!” (His eyes are glassy. He is standing in front of the refrigerator yelling “more cheese!” over and over.) Mother: (with false sympathy) “No more cheese. soon its dinnertime. It also demonstrates my attempts to enhance their communication by combining traditional psychodynamic approaches with interventions on an immediate interactive level. sorry. We three had survived the specter of Mary’s past trauma and its fearful visitation upon the next generation. illustrates how mother and son allowed me into their anxious and disorganized relating. unable to hear or notice him. “Cheese.” John is up off the floor and asking to be held by mother. He is spinning out of control.” (She turns to walk into the living room.” . He suddenly lies down on the rug and becomes very quiet. Mother: (stepping away from him and speaking sweetly. We had glimpsed the gaping black hole of Mary’s longing and terror and could now begin to build bridges across it. I’m not a good mother. Mother looks at me. He begins to wander aimlessly around the house. She spent our first interruption in a psychiatric hospital.K.) John starts to scream. Mary’s near death as a wordless one year old had returned as her possible suicide in front of John and myself. as he lies exhausted on the rug.) “You’ve had enough cheese. He asks again to be held and then strikes her in the face as she reaches for him.) Mother: “I feel frustrated and helpless to make him feel better.

. I could never please the “evil stepmother” anyway. somewhere else. . now feeling you can’t make John happy either . Both mother and son sit quietly together as the affect storm passes. . Look at how he relaxes when you gather him in like this. . or come into the kitchen to be alone. As mother sits down. . . and then he hits me .” John relaxes in mother’s lap and asks for his favorite stuffed animal. how do you feel now?” . I can see that he feels safe and calm. No one really cared how I felt. but I could check out .” Therapist: “Tell me about tuning out .” 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.“In a Black Hole” 115 Therapist: “Hard to handle this confusion and helplessness .) “I know you are angry about no more cheese. . . . I go upstairs and lock the stair gate. When you can’t help him it must make you feel bad about yourself.” Mother: “He makes me so frustrated. . a few minutes ago . . I thought you looked scared too. but could we try to stay in this upset place for a moment more.” Therapist: “This must be so hard for you. which I retrieve. She makes a move to put him down again. You probably want to get away from it all . try to stay away from him. his thumb and his transitional object. He cries and cries. . he stiffens and arches away from her. always hated it when there was arguing in my house. just to see what might happen next?” (Mother continues to hold him and John squirms but remains with her. You let him know that you could feel his anger. . and that there might be a way back from that with your help. . Therapist: “You’re both upset and confused. 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. . . As a child never pleasing anyone. Sometimes I try to help him but it doesn’t make any difference. . almost touching Mary. am I raising him to be spoiled? I just tune out. . As she again begins to hold him. I’m sorry you’re angry. . . To a place where I don’t feel much . No one helped you to manage your feelings when you were a child. .” Mother: “He doesn’t know how to let me help him. where do you go?” Mother: “I don’t know. . . .” Therapist: “Maybe John doesn’t know how to get the help he needs when he’s angry or frustrated .” John has soothed himself a bit with a toy. like I can’t do anything right. I come and sit on the couch very close them. . hated all the upset. Now John has his mother’s lap. . . scared and alone. Kids have pretty strong feelings . maybe he gets scared . he asks for her lap. I don’t know how to do it . You must have handled it by tuning out . Now you are starting to feel a bit better. and upset with him.) Mother: (tentatively) “I don’t know if I should say something to him . but soon I will make your dinner. . what’s that like.

At moments like this he is in emotional free fall. With no reliable way to re-connect. In more attuned circumstances. and depth of feeling could become a source of fear rather than of self-confidence. because he can find no context for her inexplicable (endogenous) and non-contingent responses. or to join his mother in an alien one. John’s disorganized attempts to engage his mother are also inexplicable and frightening to her. self-assertion. 1990a). resulting in multiple and discontinuous inner representations (Liotti. His mother’s inability to consistently respond to his basic needs for com- . In these intense emotional exchanges around John’s need for comfort and protection. Mary must get away from him.116 Judith Arons Mother: “Maybe I can help him . In the current relational context his alternatives are either to exist alone within an unmirrored and inchoate psychic state. the “ghost” of her own past (Fraiberg. Repeated exposure to traumatic affect levels would likely impede his capacity to attain “personal synthesis” and to make meaning of experience.” 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. . . John has become the message and not the messenger. out of control and alone. 1975). Main and Hesse. Anxiously preoccupied and coping with the powerful affects that John arouses. His behavior renders her helpless to comfort him. John has no means of resolving his frightening lack of containment. While it is difficult to predict developmental pathways. She escapes into a dissociated and withdrawn state. John’s vitality. Over time John will internalize both sides of these repeated and confused interactive sequences. she must abandon John in her mind. 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.. Liotti. just as Mary must have been. he would learn to know himself through sensitive connection to the one who knew him. She inadvertently renders him helpless to find the way back from distress. 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. 1999). 1999. it is likely that John would come to experience himself as one who is both a persecutor and a victim. 1999. just as she remains. just as his mother did (Lyons-Ruth et al. Mary feels persecuted by John’s inconsolable demands and the specter of her abusive stepmother. Mary’s initial unpredictable loss of affect makes John feel scared that he cannot find his mother.

We clarified Mary’s defensive need to escape. Her increasing sensitivity and consistency toward John’s need for comfort also allowed him to feel more competent and less frightened. while simultaneously articulating how difficult this was for her to bear. and gently clarified her projections onto her son. .”) When asked. anxiety.“In a Black Hole” 117 fort and protection leave John vulnerable to feelings of shame. he is perpetually without agency. His options include excessively controlling behavior and/or living in a state of chronic mourning (Socarides and Stolorow. In his vulnerability and need John had become Mary’s enraging and menacing parent and her frightened/frightening and uncontainable self. With no way to make restitution. . the attacking other who persecuted her with his relentless demands. We worked to promote an atmosphere in which our threesome could experiment with improvising behaviors and then watch what might emerge between us. John was the source of Mary’s guilt. Articulation of mother’s constructive engagement offers her support as well as an increasing capacity to observe the interaction. observing and naming repetitive interactive patterns as they occurred helped to enhance Mary’s feelings of mastery. (“You let him know that you could feel he was angry . Over time. . explored her dissociated response to John. 1984). The initial interaction was driven by Mary’s defensive exclusion of John’s escalating bids for comfort. It also offers the possibility that some new way of relating may be possible. 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. a therapist may make suggestions around behaviors but the focus is not educational or directive. I empathized with Mary. Mary was eventually able to see for herself that when she avoided John or dissociated in his presence. While both positive and negative interactive patterns were reflected upon. his behavior grew more disorganized. the emphasis was on finding what worked and supporting mother’s positive role. With time we were able to introduce John as a continuous presence in his mother’s mind. rage. related these responses to her childhood experiences. and emotional confusion. you had some good ideas about how to calm him . and to reject or minimize John’s needs. . It was difficult not . Predicting that which triggers interactive patterns renders them knowable and containable. We attempted to make manifest the separate emotional experiences of mother and baby as the interaction unfolded.

It is enhanced by the baby’s natural dynamism. but I believe that this would have shamed his mother. Improvisation addresses experience and change within the procedural domain. Mary’s softening of tone and defensive stance (He doesn’t know how to let me comfort him. . “I don’t know if I should say something to him. I believed that we were going to have to feel our way through the therapy and live through the unnamed terrors. et al.” At this point in the interaction a new developmental level of relating was about to emerge. In the mother-baby sessions at home I had began to gently draw her into my .118 Judith Arons to comfort John in his distress. 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. “stories are lived before they are told” (quoted in Holmes. 1996. In the words of Phillips.” As I sat close to Mary and John on the couch.. p. 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. Mary continued to relax her defended stance. 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. 167). I don’t know how to do it . It makes use of mother’s open sharing of feelings and fantasies. Mary’s suicidal gesture had delivered into our relationship all the uncontained emotions of her childhood. . sometimes. as they are experienced in the moment.) signaled her readiness to let me into her confusion around how to interact with John. giving voice Mary struggled to put words to feelings and experiences. I began to wonder if something new could happen between us. along with the baby’s emotional expressions. and it provides an interactive format in which to modify compulsive role assignments and to model containment. giving narrative voice to the process when we could. 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. Tentatively she mused. 1998).

We found it particularly helpful at such times to use expressions that conveyed active containment. In individual sessions I expressed a similar curiosity about Mary. Fear had interrupted her ability to attend or even to maintain a consistent state of consciousness. I believe that the act of creating a lexicon. Frequently slipping into dissociated or empty states. “gathering in” a disorganized baby. or minimization of cruelty and neglect indicate an insecure and emotionally constricted attachment relationship (Main and Hesse. With each frightening memory or state delivered into the treatment we entered a new interpersonal negotiation. or “finding the way back” to a quiet and connected state. During intense emotional exchanges between mother and son our familiar phrases were a source of comfort and orientation for Mary. Factual and affective incongruencies. It enabled her to speculate about and to feel for the inner life of her child. paucity of affectively charged descriptions and defensive idealizations. such as “getting your arms around” a feeling. Abuse and neglect had taught Mary to expect that her feelings would be forgotten or obliterated. coupled with capturing the specific experiences of mother and baby. 2001). Holmes. It has been hypothesized that within the adult narrative lies the blueprint of early attachment experiences (Slade. We asked. Slade. and the overwhelming feelings and contradictory inner representations it had spawned. We set out to explore the “black hole” left by Mary’s trauma. Our widening conversation implied an increasing ability to express and to hold deep feelings. unmonitored lapses in reason and logic. 1996). how could Mary contain her upset around John? What feel- . Her terrors had derailed her efforts after mastery and psychic wholeness. 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. Mary often did not know what she felt. Together we created a lexicon that captured the unique experiences of mother and baby. Over time our shared language offered Mary a way to name her own complex internal states and to feel more in control.“In a Black Hole” 119 curiosity about John’s behavior and motivations. helped to expand Mary’s emotional communication and her reflective functioning. metabolizing fear Mary was afraid of everything. 1990a. Toxic levels of fear occluded her ability to create and to synthesize (inter)personal meaning. 2001.

I believe that within the transference Mary’s increasingly secure attachment to me offered her similar gains. 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. while valiantly attempting to make loving contact with her son. Within the first year of our work. (1988) link the ability to repair affective mismatches in infancy to the establishment of the attachment figure as reliable and trustworthy. and emptiness with me. She struggled to share her private terror. her husband. Mary minimized or dismissed transference interpretations. 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. As her affect tolerance and self-reflective abilities increased. Gianino and Tronick. and her AA sponsors) for soothing and containment? Mary and I paid careful attention to how we made contact. and his disorganization in response. anger. Mary and I were able to name her intense feeling states (or absence of feeling). We observed the ways in which she dissociated during powerful emotional eruptions around John.120 Judith Arons ings did he arouse in her? How could she use her relationships (with me. and related this to patterns of emotional communication between mother and son. Mary had covered her childhood devastation with an avoidant style and disorienting cheer. genetic material was used to promote compassionate understanding and personal perspective. her confusing responses to his need for comfort. As demonstrated in the vignette. Consistent inquiry into Mary’s inner states introduced the notion that I could know and remember her. Her initial requests to connect were subtle. 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. 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. often overridden by an expectation that she did not matter and could not be known or contained by another. punctuated by states of panic and emptiness. Her diminishing fear led to an increased sense of agency and inner cohesion and to a budding capacity to make reparation to her son. Her affective cues were as confusing to me as they must have been to John. and give voice and shape to her chaotic inner representations. Mary and I could more deeply explore the relational context in which powerful feelings or defenses against them emerged. and they .

Mary’s inner representations (terrifying mother and terrified/enraged child. no matter how disturbing. 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. During the first year of our work. We called this frightening figure out of the shadows. In mother-baby sessions we worked to enhance responsive relating by containing the fear and anger aroused by John’s need for comfort. a baby to be loved and understood. as we co-constructed the scope and pace of what emerged between us. and suicidality. Over time. She is feeling more at home in the fluid psy- . stared her down. Mary was the mother of a child she could not comfort and a child herself in need of comfort.“In a Black Hole” 121 did little to enhance our relating. stimulated each time by my taking a vacation. These messages I saved for her until she felt safe enough to address them in person. During our first year of treatment there were several bouts of drinking. and told her that her days as a saboteur were numbered. The process has been slow and painful however. In individual sessions we explored how Mary’s attachment needs within the transference paralleled those of her son. was offered a place in our conversation. We then began to anticipate the emergence of the “evil stepmother’s” cruel and degrading voice within Mary. he emerged as a positive force of nature. Less constricted by her own defensive exclusion of painful affects. She began to send me e-mail messages about fantasies that scared her. Conclusion In cases of frightened/disorganized mother-infant couples. But each new aspect of Mary’s experience. 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. 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. with fewer overwhelming states of abandonment or deadly nothingness. psychosis. idealized rescuer and cruel saboteur) existed side by side with a budding new way of our being together: We became a collaborative therapeutic team. Mary was able to transfer her growing security of attachment to me onto her relationship with John. But Mary has been increasingly able to remain connected to me during our interruptions.

We continue to explore the emotional impact of mother and son upon one another and their patterns of communication. I continue to worry and wonder about the impact of John’s early life upon his future development. Mary has very much needed to keep me as a “good enough mother. Several authors have written about the fluid and unintegrated inner representations and discontinuous transferences of victim. His requests for care and protection are not conflicted. 1991. they are the expressions of a child who anticipates that comfort and aid will be forthcoming. 1999). Sometimes I am rocked by Mary’s vacillating experiences of flooding and deadness. rage in the transference represents too great a threat to the therapeutic relationship and requires metabolizing and repair in displacement. The frightening inner representations and emotions that inhabit her psychic landscape have emerged in full force. While an in-depth analysis of the multiple transferences of trauma survivors is extremely relevant to this case. She takes great pride in how John is developing as an individual. and rescuer in trauma survivors (Davies and Frawley. It remains unclear whether Mary will be able to analyze her murderous maternal transference toward me. but John now looks consistently to his mother for soothing and protection. Mary feels more connected to herself and to her son. With the help of psychotherapy. have abated. John has responded beautifully to her increasing sensitivity and reliability. She has addressed violent fantasies of throwing her son out the window or slashing his face with a knife. dissociation. and the important role she has played in this. Liotti. Mary continues to use our relationship to hold her fear and her rage. Although prone to regression around his mother’s psychic upsets. Much work remains to be done. or if this is even advisable. and affective misattunements. it exceeds the scope of my discussion.” The difficulties in depicting mother-infant psychotherapy are similar to those one faces in describing human relating and development . But the projections. pharmacotherapy. and AA. she has not had a drink in fourteen months. To date. It may be that in cases of severe early loss and trauma. so prevalent in Mary’s early relationship with John. She has been able to use me as a secure base around disorienting and psychotic flashbacks. we continue to address the need to name and to metabolize such feelings in all areas of Mary’s life.122 Judith Arons chic space that encircles attachment and separation. victimizer. Having partly freed the mother-child relationship from the toxic intrusion of intolerable affects.

Some concepts came to me before or during the time they emerged within the treatment. and deterministic. The case discussion must illuminate both intrapsychic and interpersonal phenomenon. and meaningmaking as developmental constructs and as mutative factors within the psychotherapy itself (Lachmann. most did not come to life conceptually until I had already acted intuitively and improvisationally. 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. and provided a logic to the interplay between my individual work with mother and my work with mother and baby together. but is not intended to impose a privileged position over other useful and creative approaches to mother-infant work. It should discuss both implicit and explicit modes of relating. and affectively nuanced communications that would provide the reader with critical information. I understood the process of my work with Mary and John both prospectively and retrospectively. Stern and Sander. Mary and John’s relationship. 1998).. the case is rendered too neat and organized. case studies can bring to life the depth and complexity of our work. To further complicate matters. remain out of the participants’ awareness and cannot be recorded. 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 . 2001. the thousands of non-verbal gestures. et al. colored by chronic states of fear and emptiness. It must describe recursive and potentially emergent relational processes within a format that is predominantly linear. was the legacy of Mary’s childhood attachment trauma. attachment theory enhanced my understanding of mother’s developmental deficits and baby’s incipient developmental stressors. remembering. My application of concepts from attachment theory and psychoanalysis helped shape the treatment. they would have had little opportunity to explore sensitive emotional relating or creative and meaningful engagement. Without interventions designed to respond to the attachment needs of both mother and son. In addition. Finally. narrative. another difficulty in writing case material is that in an effort to create a narrative out of what is essentially a kaleidoscopic interpersonal experience.“In a Black Hole” 123 in general. 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. But despite all these imperfections.

N. “Mama. to keep him continuously in mind. Post Script Recently.). While these concepts are not new to psychoanalysis. her own capacity to evoke a compassionate and soothing maternal introject. each time he came in and comforted me. Infant . whispering. Attachment. and left the room. Without thinking about it I began to cry. which operationalizes them and grounds them in empirical research. and kissed me softy. Hillsdale. BIBLIOGRAPHY Beebe. (2002). trauma and self-reflection: Implications for later psychopathology. I experienced a moment of grace. Mary and I were reviewing the progress that she and John have made (John is now two and a half). as I sat there on the edge of his bed. and she wasn’t there. covered me with his favorite blanket. closing the door. snuggled me with the blanket. And then. He began a new game: he put me in his big boy bed. Mama!” He rushed into the room. and cozied him up with the blankets. He pretended to cry. “o.124 Judith Arons regulating her baby’s affect. Martin Maldonado-Duran (Ed. Mama!” I rushed in as he had done. don’t cry baby. M. come. F.J. Infant research and adult treatment. Then it was his turn. kissed me goodnight and went out of the room. “Mama! Mama. He wanted to be in his bed with the covers. B. 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. He looked so peaceful lying snugly in his blankets.k. She remembered with great sorrow and remorse leaving him for long spells alone in his crib. don’t cry.: Analytic Press. telling him that everything was all right. kissed him. how he had needed her. and her ability to reflect upon baby’s experience. said goodnight. After doing this several times he became quite relaxed and quiet. 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. I kissed him. Bleiberg. like I am trying to do more with him these days. they nest nicely within attachment theory. Then she related this story: After school yesterday John and I were playing together in his room. I am scared. In J. (2002). baby. E.” and went out. & Lachmann. We repeated this game several times.

11 (2). M. Washington D. A. Fonagy. Stress and coping across development (pp. Moran. George (Eds. (1991). On feeling and being felt with. George (Eds. M. (2001). & Frawley. V. Field. (1999). 5. F. Jurist. New York: Guilford Press. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. In J. G.. & Shapiro. Lyons-Ruth.: Erlbaum.. E. Furman. E. P. K. 679 –700. S. P. Fonagy P. Target (Eds. Development and Psychopathology. P. mentalization and the development of the self (pp. 5–36. J. J. In J. E. 167–186. Dissociative processes and transference-countertransference paradigms in the psychoanalytically oriented treatment of adult survivors of childhood sexual abuse. 33 –56). Disorganization of attachment as a model for understanding dissociative pathology. Jurist. (2002). Bretherton. 67–84. In T. New York: Guilford Press.. 343 –372). Journal of the American Academy of Child Psychiatry. Division 39 Newsletter. Gergely.). Northvale. J.J. N. Davies.C. G. G. A.). & M. (1988). (1991). New York: Simon and Schuster. 47– 68). E. intimacy and autonomy: Using attachment theory in adult psychotherapy. Jacobvitz. McCabe & N. 387– 421. N. & Hazen. Liotti. M. M. Liotti. Fraiberg. Attachment and psychoanalysis. G. Infant Mental Health Journal.: American Psychiatric Publishing. Steele. G. 50(1–2). Affect regulation. D. (1975). Hostile-helpless relationships and disorganized attachment.)... Fonagy. . M. New York: Other Press.. (1997). Fonagy. & Waters. Attachment disorganization (pp. 13. Attachment disorganization (pp. 127–159). L. Attachment and reflective function: Their role in self-organization. (1996). Solomon & C. E.. E. (1992). Ghosts in the nursery. 2 (1). 9. Dissociation. Developmental pathways from infant disorganization to childhood peer relationships. (1996). and Tronick. P. Schneiderman (Eds. Gianino. In P. 47. F. The mutual regulation model: The infant’s self and interactive regulation. Lachmann. Growing points of attachment theory and research. Some contributions of empirical infant research to adult psychoanalysis: What have we learned? Psychoanalytic Dialogues. 200 –217. & Higgitt. Gergely. I. & Target. & Target. 291–317). Ledoux. L. Psychoanalytic Study of the Child. The roots of borderline personality disorder in disorganized attachment.. Psychoanalytic Dialogues. Steele. N. New York: Other Press. Monographs for the Society for Research in Child Development. (1999). 14. G..J. (2001). Hillsdale. (1985). Disorganized/disoriented attachment in the etiology of dissociative disorders.). The emotional brain: The mysterious underpinning of emotional life. Solomon & C. 196 –204.: Jason Aronson. H. (2001).“In a Black Hole” 125 and toddler mental health (pp. (1992). Attachment. Holmes. Fonagy.

. Infant Mental Health Journal. Main. Stevenson-Hinde & P. Trauma and the cognitive function of affects.. E. M. K.). George (Eds. and the emergence of new forms of relational organization. In M. L. Greenberg. (1999a). Cummings (Eds. Alpern. Chicago: University of Chicago Press. Chicago: University of Chicago Press. & Hesse. 282–289. In J. 160 –186). 64. 577– 617. metacognitive monitoring and singular (coherent) vs. A relational diathesis model of hostile-helpless states of mind: Expressions in mother-infant interaction.). M. (1998). 121–160). 22 (1). George (Eds. E. Lyons-Ruth. Laurent. 7–66. Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the pre-school classroom. enactive relational representation. affect regulation. and lapses in behavioral and attentional strategies. Solomon & C. (1990a). (1991). The two-person unconscious: Intersubjective dialogue.). Attachment disorganization (pp. Child Development. D. In J. Disorganized attachment and developmental risk at school age. (2001b). & Jacobvitz. 520 –554). B. Main. and infant mental health. Attachment disorganization: Unresolved loss. (1999). & Atwood. D. K. Kriegman (Eds. London: Fontana. repetition and affect regulation: The work of Paul Russell (pp. Cicchetti & E. Schore. (1998). Implicit relational knowing: Its role in development and in psychoanalytic process. K. (1987). K. (1999). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. G. 33 –70). & Rapacholi. Phillips. The effects of early relational trauma on right brain de- . E. D. Bronfman.). Solomon & C. Attachment in the preschool years: Theory. 19 (3). Trauma. M. research and intervention (pp. Lyons-Ruth. Moss. London: Routledge. In J. Attachment in the preschool years: Theory. Cummings (Eds. Attachment disorganization (pp. S. Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In M. 127–157). New York: Guilford Press.). Russell. 19 (4). Handbook of attachment (pp. Teicholz & D. relational violence. New York: Guilford Press. Cassidy & P. Attachment across the life cycle (pp. J. In J. & Parent. Greenberg. 23 –47). D. (1999b). L. K. research and intervention (pp. & Solomon. New York: Guilford Press. G. Lyons-Ruth. M.. Infant Mental Health Journal. Metacognitive knowledge.. Winnicott. A. A. (1990b). Main. 572–585. P. In J. (2001a). Shaver (Eds.). Lyons-Ruth. St.126 Judith Arons Lyons-Ruth. (1993). M. Effects of a secure attachment relationship on right brain development. multiple (incoherent) models of attachment: Findings and directions for future research. Schore. 161–184).). New York: Other Press. Psychoanalytic Inquiry. Marris (Eds. A. Cicchetti & E.

New York: Guilford Press. Z. In J. A. (1996). Dynamic. New York: Guilford Press. (1994). Emotions and emotional communication in infants. R. D. 112–119. New York: Basic Books. (1984). Stern. & Stolorow. D. van Ijzendoorn. M. A.. George (Eds. Z. Stolorow. Development and Psychopathology. D.. Tronick. American Psychologist. (1971). W. R. 31–46.. Winnicott. W. N. Infant Mental Health Journal. (1997). International Journal of Psycho-Analysis. Babies and their mothers. The interpersonal world of the infant. Affect regulation and the origin of the self. Socarides. 2. A. Journal of the American Psychoanalytic Association. L.. Norton and Company. 148 (1) 10 –20.“In a Black Hole” 127 velopment. C. J. The Annual of Psychoanalysis. Attachment disorganization (pp.. E. The motherhood constellation.. D. American Journal of Psychiatry. K. 1147–1160. (1995). (1991). (1989). 12/13. (1999). (1985). C. Stern. (2004). 337– 346. intersubjective systems: An evolving paradigm for psychoanalysis.. D.. London: Routledge. Nahum. Morgan. Affects and self-objects. Psychoanalytic Psychology. A. Stern. 48 (4). The development and organization of attachment: Implications for psychoanalysis.. A. M. Lyons-Ruth. & Tronick. D. Childhood traumas: An outline and overview.: Erlbaum. Playing and reality. Hillsdale. 105 –120. P. Through pediatrics to psychoanalysis. W. 71–94). W. M. Terr. J. Children classified as controlling at age six: Evidence of disorganized representational strategies and aggression at home and at school. dyadic.. J. affect regulation and infant mental health. New York: Basic Books. C. 201–269. (1995). (2001). (1998). Siegel. George. Solomon. Bakermans-Kranenberg. 79. Non-interpretive mechanisms in psychoanalytic therapy: The “something more” than interpretation. The developing mind: Toward a neurobiology of interpersonal experience. D.). (1999). Solomon & C. E. N. New York: Basic Books. L. W. . Feb. Slade. D. Harrison. Winnicott. H. 22 (1). & Blom. L. Winnicott. Unresolved loss and infant disorganization: Links to frightening maternal behavior. New York: W. Bruschweiler. London: Free Association Press. & Dejong. J. D. Stern. J. 903 – 921.. Sander. C. 14 (3). M. Schuengel. Schore. The present moment in psychotherapy and in everyday life. D. (1975).

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

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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.

Mattie. The next day. Usually I would not discuss Sean’s problems directly. After five to ten minutes. At the beginning of the session. After another ten minutes of playing together. The entire family play session takes about 45 minutes. After this. I will explain that we are going to “play in partners. and his brother as Mom’s partner. Mrs.134 Alexandra Murray Harrison hard for him (Sean) to have his problems discussed in front of his brother. without some framework. R calls and says that she and her husband have decided they would like the consultation. Mrs. We schedule the first meeting. I am putting the emphasis of the decisionmaking back on the parental couple. He is easily shamed. R says that she thinks this approach is just what she and her husband are looking for. I am also giving them a chance to reflect on the approach. the material tends to be overwhelming. Indeed. She then notes that she and her husband are also concerned about the toll the family situation is taking on Sean’s little brother.” I tell her that the play session is intended to be a pleasant experience. I will tell everybody to switch partners. R talk about the consultation together. R’s questions will show up in the play. 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. If they choose to carry on. and considering the whole family will give them an opportunity to take Mattie’s needs into account. I will tell everybody to play altogether. This section is the last part of the play session. 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. and we all pick up the toys and say goodbye. The information I need to answer Mr. and Mr. Then after a similar time period. I announce the end of the playtime. we will schedule the meetings. In suggesting that Mrs.” that Sean will begin as Dad’s partner. and Mrs. I say that I will direct the session and take care not to let anyone be put on the spot. Although these conceptual . 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. 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.

and finally the establishment of affective contact through the communication of emotions in facial expression and tone of voice. or is affective expression constrained or inhibited? Is affect well modulated. These observations lead to the description of various crucial functions in the family interaction—those of participation. or is it explosive or tightly contained? The observer also notes examples of self and mutual regulating behaviors.Herding the Animals into the Barn 135 frameworks work for me. The triangular framework of the LTP includes observations of the famly at multiple levels of interaction—participation.. 11–14). Fivaz and colleagues also describe how to go about making observations. and finally the orientation of the gaze (1999. 1999). which in turn leads to the capacity for joint shared attention through movement of the head and gaze. the orientation of the face and the facial expression is noted. role. Next. such that the orientation of the lower body is a basic requirement for participation. and affective expression. joint attention. 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. The first specific focus of observation is the body position of the family members. and affective contact. 1996. 1994. sad.. and other body movements. Fivaz et al. joint attention. such as gaze aversion. or angry? Do family members exhibit a full range of affect. pp. The triangular framework of the LTP includes observations of the family at multiple levels of interaction—the level of interaction involving the lower body. role. How do the parents comfort their infant? How do they comfort each other and themselves. 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. Fivaz and colleagues explain various functions of family interaction as “embedded” in one another. Stern et al. the orientation of face and gaze. making possible the orientation of the upper body as a definition of role. In addition to providing a framework for the observation of family interactions in a four-step family play session. and affective contact. 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. the upper body. Is the affect communicated by each family member happy. and how does the . self-touching.. The observer also notes the affect expressed by family members.

(Downing. He will consider the interactional function of the orientation. clinically relevant observations about the relationships in these subsystems can be made. observations about body position in the PCM cannot be reliably coded. and their voices. orientation of body in relation to one another. (4) language. face.” However. result in different ways of analyzing the observational data. Do the parents respect the child’s personal boundaries. and (5) boundaries. their faces. or do they spend so much time negotiating the setting up that they have little time to play? (4) In terms of boundaries. father-child play. 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. these observations may still be clinically useful. using their bodies. sibling play. which involves a free-play situation. or on the other hand. and how they manage the time constraints of the interview. for example. whether the parent is inattentive to the child’s expression of initiative or tries to control it. and whether the parent supports that initiative. (2) In relation to autonomy. He notes body positions and their function in the interaction. he notes the various ways the family members make a connection with one another. such as whether the partners make a play space between them with their bodies. in which a structured seating arrangement of the family members is part of the experimental design. he asks whether the child takes initiative in the play. Downing focuses his observations on multiple ways of interacting—using body. Does the family use the large space designated as the play area. . 2005b). and voice. (3) organization of time and space. or do they limit themselves to a corner of the room? Do they settle down to play right away. The differences between the LTP. and the PCM. and how they manage the boundaries of the play interview. For example. 2000. (3) From the point of view of organization of space and time. or do they intrude into them by touch2. The observations of mother-child. he notes how the family members respect one another’s boundaries. (1) In terms of connection. For example.136 Alexandra Murray Harrison infant comfort herself? Finally. 2005a. as they can in the LTP. Downing provides means of organizing information from videotapes from the point of view of five domains of clinical observation: (1) connection. and parent conversation in the PCM are actually observations made of sub-systems of the family rather than as observations of “dyadic relationships. he notes how the families utilize the space of the room. he notes the parent’s style of encouraging the child’s development of autonomy. Yet. (2) autonomy.

and the marital relationship. and fea- . Other Theoretical Influences The PCM as I have developed it derives from other aspects of developmental research. The PCM also offers an assessment of the way the family functions as a unit. including the mini-reunion experience created by the order of the partner play. how is language used in the play session—to promote the play. 1991). Psychoanalytic theory and developmental theory are thus both instrumental in informing the observations obtained from the PCM. you are putting that there” or prescriptive language such as. 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.Herding the Animals into the Barn 137 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. 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. Finally.” Downing’s model is based on developmental theory but is designed primarily as a clinical theory. it has been an important influence on my work on the PCM. because it is a play session designed for preschool and early school age children. the way the family makes transitions. the sibling relationship. In that sense. In sum. It offers a quick clinical assessment of the father-child relationship. in which the identified problem child plays with the father first. or to control? What kind of language does the parent use—primarily descriptive language such as. The PCM does not. of course. replicate the experimental conditions related to the “strange situation” of Attachment Theory. to criticize. Nonetheless. This order offers the opportunity to observe a “mini reunion” of the child with the mother. “Put that there. 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. the impact of the children on the marital relationship. 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. particularly. 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. the mother-child relationship. to comfort. “Oh.

Both parents agree that they are noticing Sean’s immature behavior more now than they had even a year ago. Family neuro-psychiatric and developmental history is positive for mild to moderate learning disabilities on the paternal side. R. I insist that . becomes more apparent. They could tell that he was very bright.138 Alexandra Murray Harrison tures of the child’s play. acting out in adolescence and depression in one of Mrs. contributing to the larger level behaviors that constitute an adaptation. Mattie. and anxiety both in maternal grandmother and in Mrs. Mrs. R’s siblings. He envied Mattie’s possessions and competed fiercely with him for his parents’ attention. and Mrs. The generation of consultation questions is the crucial part of the first meeting. Although Mr. As Sean gets older. R had a comparable job before Sean’s two-year younger brother. Mr. tags on the back of his shirts. the discrepancy between his behavior and that of his peers. R’s job. Mrs. which often keeps him at the office until the children are in bed. At home. but said that he was sweet. R come in for the first parent meeting. R. Play usually ended with Sean’s teasing Mattie. They are an attractive couple in their late 30s. 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. R in particular looks tired and stressed. clinical case illustration of pcm: first step—first parent meeting Mr. I ask about family stressors. but videotape transcription makes possible the recognition of repeated patterns on a micro level. enthusiastic. R works in a demanding professional job. and loved to learn. and loud noises. They explain that Sean was “high maintenance” from the beginning. He insisted on following her from one floor of the house to another. Sean also complained about lumpy food. R tends to defer to Mrs. but that they didn’t recognize it as a problem because they “didn’t know what to expect” from their first baby. he was very dependent on his mother and anxious about being separated from her. or with his aggressive physical attacks on him. and even that of his little brother. The time spent in the family session is short. strong smells. was born but left her job at that point to become a full-time mother. The teachers in his preschool confirmed that he had trouble paying attention and was disruptive during circle time. and the Rs respond that the main stresses are Sean’s behavior and the pressure of Mr. but he also played happily with him for long periods.

Sean leads the way into the office. “How do we help him with his confidence. concluding with a discussion of what to tell the children about the meeting. R. building blocks. the monitor can be viewed in a brief downward glance. “How do I get this kid motivated to do the things he needs to do.” Mr. self-esteem?” Although sometimes I find I am able to answer some of the parents’ questions immediately.” Then I suggest adding. constant picking on his little brother. R’s ideas about how to best present the idea to their children. like get himself dressed in the morning or go to the bathroom by himself?” Mr. Mrs. R asks. and Mrs. She also uses a camera to take a film so that she can remember what happened after the meeting. Openness about the filming of the meeting is particularly important from the point of view of modeling trustworthy behavior in the family consultation. I . “How to relieve his anxiety—he is fearful and anxious. 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. I point out the camera to the family. I arrange the room with toys appropriate for children of Sean’s and Mattie’s ages—a barn with farm animals. Mattie holds his mother’s hand. and then go home again. After hearing Mr. I repeat the description of the family meeting to Mr. and how to develop strategies to deal with his behavior problems. and they do.Herding the Animals into the Barn 139 both give me at least two questions.” so as not to unnecessarily alarm the children. I repeat the different parts of the meeting including the parents’ conversation and the camera. In the office I remind the family of the plan for the meeting. and puzzles. R coaches the children to greet me politely. a garage with cars and people.” Mrs. We discuss the family meeting. and I tell the Rs that a family meeting will help me answer their questions. I meet the family in the waiting room and show them into the office. I suggest that they refer to me by my first name rather than as “doctor. The camera is a small video camera that I place on my lap.g. “How to deal with his negative effect on the family—he wears his mother down. e. in this case I think that a family meeting is essential. I write the questions down verbatim and put the paper where I can retrieve it for the final meeting. and Mrs. “And the way she does that is to have families come and play at her house. He is excited and eager to see my toys. R adds. The boys are very attractive children. second step—family meeting At the time of the family meeting. Mr. R concludes.” We schedule a meeting time. R asks.

R establish themselves in front of the barn. Then Mattie says. Sean calls out to Mrs. and Sean continues playing with the cars and trailers.” Mrs. R also play together well. When I call for the family to play together. and the boys continue their play. The next transition goes smoothly. and Mrs. Sean plays on the periphery. R says. Finally. R move to the chairs. Mrs. R. Mr. R. “Let’s herd them into the barn. R does not look as if she is enjoying herself and is sitting back with her hands folded most of the time. the animals do not get herded into the barn by the time of my call to “change partners. “We’re going to herd the animals into the barn. R asks. though they both look somewhat uncomfortable and constrained.140 Alexandra Murray Harrison tell them that in the beginning. and Mrs. while she helps Mattie and Mr. Mattie goes to play with the barn. Sean says to Mr.” about five minutes later. “O. I ask for the family to make the transition of Mr. Again. “Which ones? Which ones?” and starts to pick up the animals. and listens to Sean explain again about herding the animals. R to the two chairs. They begin to play with the garage and some of the farm animals. The parents are able to have a conversation with each other. Sean and Mrs. “We have to herd the animals into the barn. Mr. R. the animals do not get herded into the barn. but he is . connecting vehicles with their trailers. Sean will be Dad’s partner and Mattie will be Mom’s partner. “Change buddies! You’re my buddy. Mattie. R find the toy garage. and Mrs. and he and Mr. in this seven-minute play sequence. so that they might have a conversation with each other. despite much talking about it. periodically joining the others and then removing himself again from the central family play. They seem to anticipate a problem that they must be ready to manage. R calling out to Sean. because there is a big storm coming!” Mr.” He begins to put the animals into the barn. Sean!” and walking over to him.K. Interestingly. There’s a big storm coming. They are picking up the animals and talking about them. R cluster around the garage and play with it for the entire period. R making suggestions about how they might combine the two types of play. with Mrs. the family makes another smooth transition. though now and then they are distracted and turn their attention to the boys. The two of them are smiling and obviously happy to be together.” sits down beside the barn. Sean comes over to the barn and starts to help him.. with Mrs. Child and Father Play Sean chooses the barn with farm animals.

Mattie declares. yet this is accomplished in an unexpected way. I view the tape alone. “The storm is over now. which I take to signify Sean’s dysregulated behavior and its effect on the family. 1995. Both in his writings and in our discussions.Herding the Animals into the Barn 141 more erratic in his attention and his movements than his little brother. Finally. I capture clips from the digital videotape on my computer. a full answer to the question must wait until later. the computer program allows for frame (about one thirtieth of a second) by frame viewing easily. using the program of final cut express. As I observe the tape.” but Mattie responds. sometimes Mattie objects. Initially I transcribed small tapes from my digital video camera onto a VHS tape and viewed them on my television monitor. it’s not. It is only when the constraining behavior patterns Sean and his parents have created together are relegated to the background. I look for patterns of behavior in 3.” and continues his work of herding. Sean moves back and forth from the barn. Sean declares. “No.3 Yet. Also. At one point. Sander’s work has been extremely influential to my thinking and clinical work. it makes the showing of the film to the parents more efficient. The conclusion of the family play is to find a safe place for all the animals inside the barn. The whole family seems to resonate with this symbolic theme. third step—interviewer viewing the tape In this step. I am thinking of the powerful metaphor of herding the animals into the barn to find protection from the impending storm. I used my remote control to look at certain sequences in slow motion. 1985. How can we understand this interesting eventuality? As I consider this question. and the parents allow the children to exercise their own agency.” In a dramatic conclusion to the course of events. since we must first return to the model as a practical way of answering the parents’ questions. to the activity of hooking up the cars and trailers. Sean’s little brother is able to implement Sean’s stated agenda more effectively than either parent is able to do alone with Sean. 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. “Now they’re all inside—safe and sound. since it isolates small sequences of the tape that are immediately available for viewing. Now. 2004). sometimes he does not. personal communication. While time consuming on my part. Numerous times he grabs a toy away from Mattie. . that Sean’s agenda can be constructively engaged.

Sean’s capacity for enthusiastic engagement with a new situation is also clear. The initial transition into the play room is accomplished smoothly. their tone of voice. and their affectionate physical contact. he could be expressing his own timidity. Here I make use of Downing’s technique of video micro-analysis to evaluate the play sequences of father-Sean. R is showing Sean two animals. He primarily communicates his ideas as they come up in the play. This unusual arrangement of bodies is more evident in split second viewing and again seems to illustrate some avoidance of direct connection. and Sean is seated next to the barn. Sean refers to the agenda of herding the animals into the barn six times in a one-minute film clip. mother-Sean. and parental couple with siblings. and at another point. Connection—Mr. the family values are demonstrated in Mr. However. and they begin and end at the time I direct them to play and then to change. . using the play space in a comfortable manner. At one point. There is little visual monitoring of each other. R’s reminding the children of the rules of courtesy in greeting and the boys’ willingness to comply. R and Sean express their enjoyment at being with each other in their facial expressions. This seems to be because Mr. before his father begins to put the animals into the barn. Autonomy—In spite of their mutual pleasure in the play. perhaps showing a tendency toward reticence. 4. Sean leans comfortably against his father’s leg. Language—When Mr. but Sean’s body is at a ninety-degree angle to his father. 2. Mr. Sean’s expressed agenda of getting the animals into the barn is not implemented. an interesting pattern is created when Mr. Father-Child Play Sequence 1. In this transition. Boundaries—Neither seems to intrude on the other’s space. R puts his hand on Sean’s shoulder. glancing at the animals over his own arm. R takes up the rear. R speaks to Sean. Mattie stays back with her. Father is oriented to Sean. 5. When I count. 3. or “taking care of” his mother. for example reminding Sean of an animal they saw together on a family trip. he does not give him orders. and Sean reaches over his father’s extended arm to reach into the barn. R does not attend to Sean’s repeated requests that they do this.142 Alexandra Murray Harrison the different sections of the interview. now I can complete the process in about 30 minutes. he does not use prescriptive language. This seems to indicate some difficulty making contact. Although at first I would spend more time capturing the clips and viewing the tapes than the duration of the family meeting. in other words. nor to take control from the other. They use the play space available. Organization of time and space—Father is lying on the floor next to Sean. Mrs. family together.

bending over farther toward the barn. No gaze is exchanged during this event. R’s careful attention to Sean when she looks directly at him as he explains his agenda. and Sean frequently pulls his hands back out of the play space. R quickly initiates an organizing activity. they express anxiety about physical closeness. For much of the play sequence Mrs. further assisting him in organizing his intention. but Mrs. They do not touch each other. instead. However. Micro-analysis of the videotape demonstrates a moment lasting a fraction of a second in which Sean extends his arm suddenly. Organization of time and space—Mrs. Mother-Child Play Sequence 1. R and Sean seem to be particularly attentive about maintaining adequate distance between them. it is very quick. Sean turns away from the activity. Boundaries—Mrs. “We’re herding the animals into the barn!” and then turns away again. . This movement is not apparent during normal time. Mr. and Sean’s hand remains empty. and there is a sense of anxious constraint in their behavior. R sits with her hands clasped. R and Mattie. pointing out an interesting toy to them as she moves toward Sean and sits down before him. Sean expresses enthusiasm about the play in his face and voice. at one time sitting on his hands. as he repeats his wish to herd the animals into the barn. She inquires what kind of animal Sean wants to herd into the barn. and each family member responds in a characteristic way. it is after this movement that Sean pulls his hands way back and Mrs. bending over the toy. After Mrs. R supports my directive and helps manage the transition. 3. She turns toward Mr. Mrs. R are seated at a greater distance from each other than Sean and his father had been. making a grabbing motion toward his mother and the animal she is holding. though subtler. taking the animals and in orderly fashion placing them according species in front of the barn. R puts down the animal and clasps her hands. Connection—Sean and Mrs. I announce the transition. presenting a look of earnest concern. It is not until after she completes this communication that she turns to Sean and focuses on him intently. R turns smoothly away from Sean and toward Mattie.Herding the Animals into the Barn 143 The transition to the mother-child play sequence is also smooth. as if to manage the confusing and stimulating experience of the transition. R and Sean make a good play space between them. R displays a pattern similar to Sean’s. 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. Mrs. saying—“Change buddies! You’re my buddy. In fact. 2. R expresses little positive affect. there is little eye contact between them. Sean!” Sean calls out to her as she crosses the room. As she approaches him.

K. they in unison move away from him. “Let’s use the garage for another barn. R both simultaneously turn their faces away from Sean and begin to orient their bodies toward the garage. Mrs. leaving him alone. This communication is in response to Sean asking. Yet. She also demonstrates a unusual vocal turn-taking pattern that involves beginning her vocal turn immediately after Sean finishes his. Language—Mrs.” Mrs. R seems to have anticipated failure in the enterprise. Mattie turns away from the barn and also moves toward the garage. Family Play Sequence 1. framing it in terms of fitting all the animals into the barn. At the same time. It seems clear that the family is attempting to avoid conflict by complying with Sean’s demands. Autonomy—Mrs.” and begins to assist in the transition.” something they can “all do together. R repeats that they are going to look for “a group activity. 1999). In response to Sean’s remonstrance. Mr.” saying. Now and then. He has found several vehicle-trailer pairs. R immediately says. Mrs. 5. Mrs. as they comply. and her negative expectation has been fulfilled. Just after Sean’s aggressive moves toward Mattie. Sean initially rejects this idea. Sean grabs it away from Mattie and declares it “locked. Yet. but when Mattie moves over to the barn. “O.” and Mr. R expresses her skepticism about the potential success of the agenda. R. and Mattie look up at me. R and Mattie begin arranging the animals on the different floors of the garage.144 Alexandra Murray Harrison 4. and by the end of the ten-minute play sequence. R is moving an animal toward the barn. Sean plays on the outskirts of the group. She helps him with the set-up of the plan and encourages him to implement it. R does not use prescriptive language to Sean. “Is that a deer?” when Mrs. “You have to help me!” she begins to put the animals into the barn. Connection—Mr. When I announce the transition to the whole family playing together. but once she talks in an educative way to Sean about the difference in appearance between dairy cattle and beef cattle. Mrs. They communicate positive affect with their facial expressions and tone of voice. just a few of the animals have been put into the barn.. and Mrs. “Yeah! Daddy can play with the farm!.” He again grabs the barn from Mattie’s grasp and pushes Mattie’s arm away from the barn. he joins the family group for a brief period. Sean says. Sean. a pattern associated with anxious overcontrol (Beebe. R demonstrates a clear intention to support Sean’s autonomy. She listens intently when he explains his plan to her. R suggests that Sean can bring some of his animals to the garage if they can’t all fit in the barn. but then he returns . and he occupies himself with trying to connect them. and Mrs. at several points.

because . Autonomy—In the family play. The family is able to begin. his family members do not actively try to engage him in what they are doing. As a result. While this was also true during the “partner play sequences. and complete a play sequence within the time offered. R invites Sean to bring his animal into the family play.Herding the Animals into the Barn 145 to the cars. R takes the cow that Mattie has been playing with. and replaces it where Mattie can reach it. R seems to be maintaining constant vigilance over Sean’s controlling behavior. Mr.” it is more obvious with the whole family playing together. Mrs. 2. he remains relatively disconnected from the family group. It seems that the family has difficulty supporting the agency of both boys—Mattie. Organization of time and space—The family organizes itself in a small space. The other family members allow him to do so without explicit recognition. for example when he tells the others what the cow is “supposed to” do. periodic distancing from the family group. Mr. sometimes Sean uses language to control his family members. 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. or they move to minimize the amount of control Sean can exercise. Mrs. and Mrs. and when he enters the family group play. in particular. R. They allow Mattie to comply with Sean’s commands. and that Sean has just grabbed from him. An example of the latter is when Mrs. however. Language—The family uses language appropriately in a descriptive or suggestive manner.” 5. 3. R.” After a few initial attempts. The boundary between Sean and the family group is strikingly different. elaborate. “Put it here!” In response to his commands. This activity also has the symbolic meaning of “connecting. R. Frequently. Sean moves his cow to the garage with one hand while pushing his father’s hand out of the way with the other. Sean seems to intrude on Mattie’s agency. However. and the family makes efforts to respond to his ideas. R have two ways of responding to this behavior. It seems clear that Sean attempts to regulate himself by frequent. he interrupts his participation in the group play and turn to connecting the vehicle and trailer. he takes toys away from Mattie or gives him orders about what to do. R. without much freedom to move about the floor. He uses the repetitive motor activity of hooking up the truck and trailer as another regulating activity.K. He intrudes into Mattie’s attempted play with the barn. though it is not apparent that his father’s hand was in the way. There is affectionate physical contact but not intrusiveness and control. Mrs. Sean takes the initiative at several points in the play. 4. he bursts into it. and Mattie say. When Mr. Boundaries—The boundaries between interacting members of the threesome including Mr. Frequently. “O. and when he tells them. and Mattie seem comfortable.

4. Sean. whether they are playing in “dyads” or all together. Sean continues his regulating play with the vehicles and trailers. it is as if he recognizes that Sean could introduce a significant disruption in his plan. Neither boy objects.” and continues putting animals into the barn. and he speaks apparently to himself. and the siblings’ ability to play together creatively. This part of the session in particular demonstrates important strengths of the family—the parents’ capacity to constitute a wellfunctioning relationship of their own. the second parents’ meeting: the third of the three meetings In this meeting. it’s not. “Now they are all in the barn. leaves the cars and joins him.” Without looking up or changing his position. “We have to herd the animals into the barn. after a hesitation. and Mrs. the animals are in the barn. Sean pronounces. and Mrs. Mattie moves to the barn. His attention is more focused and his actions smoother and better coordinated than Sean’s. and Mrs. “The storm is over now. and Sean. “No. because a big storm is coming!”4 He is oriented away from Sean. as it was when I was observing the meeting itself. Mr. Leaning back. In ignoring Sean. by allowing the boys to play uninterrupted—cooperate in its accomplishment. This observation gives evidence for the influence all family members have on one another while playing in the same room at the same time. . R also. Mrs. approaches him and attempts to join his play. Mattie surveys the barn and says. which is on the other side of the room and which he has not played with before. despite Sean’s regulatory difficulties.146 Alexandra Murray Harrison of Sean’s intrusive behavior toward him. safe and sound. The transition to the parents sitting together to have a conversation also goes smoothly. Sean. He says. 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. using Sean’s exact words and tone of voice. it is a family agenda and all the family members—Mr. When about half the animals have been put back in the barn. I intend to answer them in simple.” It is remarkable to me observing the tape. it is now clear that although initially articulated by Sean. how Mattie is able to accomplish Sean’s agenda by the end of the meeting. Mattie continues to put animals into the barn. In fact. however. Finally. R sit in the chairs and begin to talk. Mattie responds. Without looking at Sean. R’s questions about Sean. I take out the paper on which I have written Mr. R notifies the boys of what they are going to do.

she is not at all surprised by my observation and agrees that with Sean she often expects to fail. 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. and affect. R the transition into the playroom. R is also very moved. Again.Herding the Animals into the Barn 147 practical answers that lend themselves to recommendations for action. Mrs. R a little about self-regulation. R and Sean. This is a powerful moment in the meeting. including her helpful preparation of Sean and Mattie for the transition and her attentiveness as Sean is explaining his agenda to her. R’s inattentiveness to them. Then. 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 show Mr. The next clip I show them is that of Mother and Sean. Toward the goal of elaborating these ideas about how to help. 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 is deeply moved. I tell them that it is clear that Sean is a child challenged by problems regulating himself. we turn to their original consultation questions. however. and Mrs. I am going to give them my impressions of the family meeting. R toward Sean. and his tendency to get distracted. irregular textures in his food. 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. I get out the tape. I note the multiple statements of Sean indicating his agenda to herd the animals into the barn and Mr. including the way he drops the animals. Then I show the clip of Mr. however. I first point out the evidence of Mrs. I also point out Sean’s difficulties in coordination. Mr. R’s devotion and sensitivity to her children. discouraged reaction of hers may not be an uncommon one. Next. . I suggest that this sad. I explain to Mr. He is astonished to appreciate this observation and wonders how he could have failed to attend to Sean in this way. I remind them of what they have told me about Sean’s sensitivity to loud noises. I point out the friendliness of Sean and his interest and eagerness to engage in this new situation. In contrast to her husband. I note her obvious anticipation of failure in this activity with Sean. I acknowledge the attractiveness of the family and the expression of their family values in the polite greeting. attention. 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. First. especially in the domains of motor activity. and Mrs.

(3) The third question is Dad’s: “How to deal with his negative effect on the family. I am also addressing Mrs. R explains that Sean is unable to dress himself or take on other age-appropriate skills of autonomy. nor does it lead directly to a discrete intervention. Neuro-developmental disabilities have interfered with his achieving certain compe- . R’s exhaustion in her efforts to manage the boys’ aggression. and it indicates a direction toward constructive action—teaching him ways of being more flexible. more flexible ways of working on his agenda so that he could feel confidence in their successful accomplishment. is neither a complete answer. In this answer.g.148 Alexandra Murray Harrison (1) The first question is Mom’s: “How to relieve his anxiety—he is fearful and anxious.” I point out that Mrs. This answer is also neither comprehensive nor specific. I also point out that Mr.” I answer.” I answer.” but that this problem is not the kind that can be “solved” by one person. as well as Mr. I agree with the Rs about how Sean needs experiences of mastery. 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. And we would like to find ways of helping his parents support him in his agenda. e. However. (4) The fourth question is Mom’s: “How do I get this kid motivated to do the things he needs to do?” Mrs. We have seen the positive feature of his persistence in the agenda of herding the animals into the barn. However. It also stresses the need to change the controlling effect Sean has on the rest of the family. “We need to come up with new limit setting strategies. and she has been unsuccessful in helping him learn. R identifies herself as a “problem solver. of course. it communicates a new perspective on Sean’s anxiety and his demanding behavior. constant picking on his little brother.” This. R might be able to give up her role as the family manager if both she and Mr. We would like to teach him new. 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. We would now like to help him find other. more flexible ways of making sense of his world. “Right now Sean tends to be an all or nothing kind of guy. I suggest that we find new ways of the parents working together to make things better. He wears his mother down. Mrs. For her to take this on her own shoulders is too great a burden. R seems to withdraw into his work and feel helpless.” This answer focuses on managing Sean’s aggression and impulsivity through regulating his high arousal states and his negative affect. (2) The second question is also Mom’s: “How to develop strategies to deal with his behavior problems. R could find more effective ways of helping Sean regulate his behavior.

and that I would be glad to help them. but so is everybody else. and Mrs. in an effort to avoid the storm of his temper outbursts. I recommend a therapeutic intervention that includes working with Sean directly—either continued parent consultation with family meetings or individual therapy. key differences in the consultation You will notice that my comments to Mr. that his difficulty managing strong feelings makes it hard for him to take risks that threaten him with disappointment and frustration. my initial formulation of Sean as a child with neurodevelopmental disorders complicated by family patterns of difficulty regulating him and supporting his agenda. I tell them that I think they need help working on these changes. R include neither a diagnosis nor an explicit formulation of Sean’s difficulties. We need to find special ways of supporting him in achieving mastery of skills of independence. all-or-nothing meanings that underlie his separation anxiety and his other fears. That is because those issues are not included in their consultation questions to me. The storm is the focal point of the meeting. I agree. and I know that Sean and his whole family fear that they might not find the means to keep the “animals” safe. to which the family members return again and again. father. Sean is afraid of the storm.Herding the Animals into the Barn 149 tencies necessary for age-appropriate autonomy. and brother either keep a distance from Sean or comply with his demands. and that they would prefer to continue to work with me in family consultation. Since the problems are interfering with Sean’s development in a significant way. informs my answers to the questions they do ask me. and Mrs. I explain. R’s choice of more immediate subjects of joint attention rather than Sean’s main agenda. including their parenting behaviors. Fear of the storm helps explain Mr. In this case. It has important symbolic meaning. also. His mother. At this point. They ask for recommendations about how to implement some of my ideas. It helps understand Mrs. and we set a first meeting. The Rs are thoughtful and interested in my answers to their questions. demonstrated in each family member’s reaction to the threat of the storm. Mr. R’s withdrawal and anxious efforts to manage . R say that they are interested in trying to change the way the family members behave in relation to one another. I know that Sean has made sense of his life experience and that the sense he has made includes rigid. I know that these meanings include that of a destructive “storm” that threatens the living creatures of the farm.

when they felt helpless to deal with the storm. Yet. The PCM includes valuable tools derived from infant observation research to use in my clinical work. It informs the observations of Sean’s sitting on his hands to avoid potential grabbing movements. transference issues usually make family meetings . I would not have seen the significant strengths of the family. and his affects contributed to the creation of the “storm. It explains Mattie’s accommodation to Sean’s refusal to share the toys with him. his motor activity. I would not have appreciated the degree to which and the ways in which Sean’s problems regulating his attention. strengths that will be essential in their attempts to achieve their goals. in an individual session. With videotape I can observe the exchange between the child and the world of his family. I cannot observe the child’s inner world with videotape. The family meeting illustrated—in the micro-process with each parent. Once the child is in individual therapy or psychoanalysis. my fuller understanding of Sean’s problems depends on the micro-analysis of the family meeting.150 Alexandra Murray Harrison the family. However. The opportunity to put together these two complementary views of the child—the inside and outside views—is an exciting opportunity. I would not have understood in what ways the family system has created adaptations to the challenge of Sean’s behavior that backfire. I would not. The family meeting illustrated the way his parents and brother contributed to Sean’s dilemma by symbolically leaving him outside the barn. and in the sibling play—the extreme struggle Sean exerts to regulate his behavior. and sometimes—as in the case of Sean—psychoanalyses. Finally. 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. Had Sean. 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. Often. though. The storminess of his affective state and his attentional state underscores his impulsive grabbing. the PCM evaluations go on to become psychotherapies.” These observations are harder to make when the clinician is playing with the child one on one. 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. and make it even harder for them to help him grow. perhaps. His private world is the territory of psychoanalysis. have seen evidence of crucial features of this behavior. represented his experience in the metaphor of the storm—less likely.

and to how that storm sometimes provokes him to behave. In a similar way. They are trying to support each family member’s agency in their efforts at creative elaboration of their private meanings. analysts and other clinicians would be well advised to be flexible. 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. without fearing the loss of familiar concepts.” Concluding Remarks I would like to conclude by considering analogies between the quest for useful means of helping troubled children and their families. 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. yet at the same time striving to find ways of regulating themselves and also the family system. No linear theory of causality is sufficient. Dynamic systems theory—a theory that provides a broad umbrella theory for therapeutic and developmental change—includes in its general principles coherence. The .Herding the Animals into the Barn 151 impossible. so that it does not come apart. Beginning the evaluation with the PCM often gives me the only chance I will have to capture this “outside view. 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. 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. But as I have pondered Sean’s stormy world. 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. as well as complexity. Through his attempts to get the animals into the barn. These considerations suggest that psychoanalysts and other clinicians should attempt to provide coherence by developing useful integrations. Sean is drawing his family’s attention and my attention to the storminess of his internal world. open to alternative perspectives. Indeed. Sean and his family are searching for greater flexibility in the meanings they make of their experience together and apart. Moreover. and Sean’s desire to herd the animals into the barn.

Two principles of communication: Co-regulation and framing. and Camaioni. (1995).. M. we search for means of “herding the animals into the barn”—bringing the complexity of developmental processes into a coherent framework of psychoanalytic theory. The search is for ways of embracing complexity. Beebe. The Primary Triangle.. Study of the Child. 6. (2002). New York: Basic Books. & Jaffe. Cambridge. J. G. eds. N.. Autism and Personality: Findings from the Tavistock Autism Workshop. (1997). J. E. 31– 37. Downing. Amer. 71–78.. BIBLIOGRAPHY Alvarez. D... A Developmental Systems View of Mothers. including those we engage in our work with patients. Mass.. (2000). and baby. A. Fivaz-Depeursinge. [in press]). J.. F. & Reid.and object representations. and Muir. . D. Heidegger.. F. & Lachmann. Psychoanalytic Dialogues 7(2). body. F. Lamour. eds. A. Emotion. pp. J. eds... (2005a. L. Beebe. Al. 127–265. A different way to help: Position paper for the council on human development. In Sean’s metaphor. (1999). I. and parent-infant interaction. eds. Co-constructing inner and relational processes: Self and mutual regulation in infant research and adult treatment. Bernstein. B.. S. (1994). & Lachmann. (1994). Oxford: Oxford University Press. Downing. Psychoanalytic Psychology 11(2). Mother-infant interaction structures and presymbolic self. 69 – 89. while developing and maintaining the coherence of our theories. D. S. Psychoanal. Present trends in handling the mother-child relationship during the therapeutic process. Stern. Fogel. (2005b). In Wrathall. 245 –270. Emotional Development: Recent Research Advances.. London: Routledge. Fivaz-Depeursinge. Fathers. New Perspectives in Early Communicative Development. G. Corboz-Warnery. Infant Research and Adult Treatment: CoConstructing Interactions. Burlingham. & Lebovici. In Nadel. Downing.. M. The importance of characteristics of the parents in deciding on child analysis..152 Alexandra Murray Harrison self-organizing properties of dynamic systems suggest that there are many ways of understanding the challenges of developmental processes. Beebe. (1999). Emotion theory reconsidered. J. London: Routledge Press.. and Malpas. 6. 133–182. (1951). Coping and Cognitive Science..: MIT Press. In Nadel. Infant Mental Health Journal 15(1).J.. The dynamics of interfaces: Seven authors in search of encounters across levels of description of an event involving a mother. & Corboz-Warnery. A. B. (1993). B. Psychoanal. Lachmann.: Analytic Press. E. G. Hillsdale. and Infants. father.

J. D. . and Tyson.. (1995). 112–119. Change in psychoanalysis: Getting from A to B.. & Tronick. Rapprochment of approachment: Mahler’s theory reconsidered from the vantage point of recent research on early attachment relationships. (1985). A. 903 – 921. (submitted for publication). C. B. K. Psychoanal. Sander. (2. Infant Mental Health Journal. Helsinki.. E. 6. and Siever. N. & Schwartz. pp. Fivaz-Depeursinge.. D. Lyons-Ruth. & Jasnow..: Monograph Series. de Roten. Nichols. New York: Basic Books. (1978). Now we have a playground: Emerging new ideas of therapeutic action. International Journal of Psycho-Analysis.. 66. 315–327. 290 –299. 221–257. Washington D. Dyadically expanded states of conscious and the process of therapeutic change. S. paradox.. Journal of the Amer.C. 51(1)... Tuckett.. Sander. Treatment of under-fives by way of parents. L. 360 – 376. (2003). Bruschweiler-Stern. American Psychologist 44(2). (1957). Monograph Series of the Society for Research in Child Development. Psychoanalytic Dialogues 5. (1991). Jaffe. 19. J. Sander. Rhythms of Dialogue in Infancy. 1–23. K. E..Herding the Animals into the Barn 153 Furman. M. (1996). A. J. Biological Response Styles: Clinical Implications. Study of the Child. (2001). Y. Concepts and Methods.. E. Opening Plenary Address. Adolescent Psychiatry. Psychoanalytic Psychology. Harrison. A. Sander.. K. D.. Serial No. Feldstein. Stern. J. (1995). Galenson. Shapiro. and the organizing process in development. A. New Haven: Yale University Press. E. Boston: Allyn and Bacon. Psychoanal. S. Polarity. EPF Conference. Assoc. New York: Basic Books. American Psychiatric Press. E. In Call. Emotion and emotional communication in infants... M. 12. A. D. (1985). Swiss Journal of Psychology 55(4). 79. E. Lyons-Ruth. 8. Identity and the experience of specificity in a process of recognition. (1983). & Carr.. (1998). Morgan. Frontiers of Infant Psychiatry. Family Therapy.. L. L. J.. Non-interpretive mechanisms in psychoanalytic therapy.. Tronick. E. (1989). E. L. Transitions and the sharing of interactional affective events. eds. A.. Harrison. Towards a logic of organization in psycho-biological development. Crown. In Klar. 204–212.. (1991). Stern. Research on family dynamics: Clinical implications for the family of the borderline adolescent. Harrison. 20 –36. & Darwish. 265). The Interpersonal World of the Infant. Lost in Familiar Places.. (1998). Shapiro. (2004). 250 –62. eds. R. Tronick. 579 – 593. R. Nahum. Beebe.. 1–132. W. Stern. Corboz-Warnery.

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PSYCHOANALY TIC RESEARCH .

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He told Nick Midgley.” This report presents the findings of the study in narrative form. and argues that the recollections of former child analytic patients are an important. In 1922. King. ed. as children. copyright © 2005 by Robert A. King. and A. this study uses a qualitative methodology to explore two central themes: “attitudes toward being in therapy” and “memories of therapy and the therapist. Anna Freud Centre and University College London. Anna Freud Centre. the case study of “Little Hans. but under-used.” Freud added a short postscript. Scott Dowling). PsychD. and A. Samuel Abrams. 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. London. Neubauer. Scott Dowling (Yale University Press. between 1952 and 1980. Neubauer. Peter B. Robert A. 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. source of knowledge for an understanding of the psychoanalytic process. Samuel Abrams. Based on semi-structured interviews with twenty-seven people who. and MARY TARGET. The Psychoanalytic Study of the Child 60.Recollections of Being in Child Psychoanalysis A Qualitative Study of a Long-Term Follow-Up Project NICK MIDGLEY. 157 . and Mary Target. London. had been in intensive psychoanalysis at the Anna Freud Centre. thirteen years after he published his first account of the psychoanalytic treatment of a child. Peter B.

In a similar review.” despite the severest of ordeals. 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. in Koch’s (1973) review of twenty cases of follow-up contact with former child patients. he told Freud that. in some cases up to forty years after termination. Beiser (1995) writes that of the thirteen intensive child analyses she carried out during her analytic career. he reports that former child patients made some reference to their experiences of analysis. vividly recalling his anger at the therapist for not understanding what he was trying to communicate when enraged” (238). there are hints that the child analysis—and the figure of the analyst in particular—retain some place in the memories of these adults. while naming each animal with an affect—depression. anger. at follow-up. and happiness. The . “dwelt at some length on his experience. 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). we discover that in many treatments some form of spontaneous followup—like that of Freud and little Hans—does take place. The only exception is one child who. in ten cases follow-up data was available. Some spoke of it as being “helpful. and suffered from no troubles or inhibitions.” 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). 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. Most remarkable of all.158 Nick Midgley and Mary Target Freud that he “was perfectly well. For example. 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. envy. and that in a few instances some indications of how the child analysis has been remembered is recorded. more specifically. Far from suggesting that all memories are over-taken by the repression barrier. Yet when we turn to the general child analytic literature. including the divorce of his parents.” He had apparently “come through his puberty without any damage. but with little specificity and some distortion of memory. 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. of the analytic work undertaken by Hans’ father under the “supervision” of Freud.

Ritvo 1966. Although she gives no other examples. Nevertheless. Ritvo and Rosenbaum 1983. In a review of several cases. Babatzanis 1997. and “Evelyne. Ostow 1993. Beiser observes that many of the memories of therapy that these former patients retain were related to experiences of limit-setting by the analyst. as an adolescent in analysis. who “recalled many aspects of her first analysis. she had been able to “get better because [the analyst] was kind like her father. 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). the few glimpses we are given of the former patients’ memories of their analyses are tantalizing: Ms B. She also notes that several of her former patients had entered professions involving the care of children. the young woman who felt that. Parsons 2000. Adatto 1966. “Richard.” “short. who almost forty years later remembers her as “dear old Melanie. in a follow-up interview at the age of thirty-four. 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).” who.” and with “a strong interest in genitalia” (Grosskurth 1987:272–73). inherent to the analytic experience itself. dumpy. encourages the process of internalization. as well as an awareness that “understanding the workings of the mind was the way to resolve their difficulties.g. Colarusso 2000. While the focus of much of this follow-up literature is elsewhere. with big floppy feet. re- . and that the analyst was someone who knows how to help them” (2000:344). and that they often retained an “attitude of inquiry as to the meaning of behavior and feelings” which the analyst had herself promoted (119). and she wonders whether the experience of gratification and frustration. The psychoanalytic literature also contains several case studies of former child patients who have returned to analysis as adults (e.Recollections of Being in Child Psychoanalysis 159 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).” and who recalled particularly a painting on the wall of the analyst’s office (Adatto 1966:500). McDevitt 1995. especially in connection with her analyst’s interpretation of wishes to have a baby” (Ritvo and Rosenbaum 1983:686). Rosenbaum 2000).” in analysis with Melanie Klein as a young child. a number of these case reports do remark on the place the child analyst appears to have retained in the former patient’s mind. so they have not focused primarily on the former child patients’ memories of therapy.

More particularly. Heller chose to publish these. and he describes how as a child he “loved and revered [Anna Freud] above all other humans” (xxvii). they could provide us with the opportunity to discover how former analysands felt about being in therapy as children. . 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.160 Nick Midgley and Mary Target ported “that she learned the art of good listening and communicating from her former analyst” (Ritvo 1996:374). where Heller writes of his family and his childhood. which was carried out in quite unusual circumstances. The book includes a reproduction of the very sketchy process notes made by Anna Freud on Heller’s childhood analysis in Vienna. In his introductory chapter. He remembers that his analysis focused on the loss of his mother and his “problematic” relationship to his father (xlvi). and suggests that former child analytic patients can provide us with another point of view on the psychoanalytic process. 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). 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). 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). together with an account of his own memories of his childhood in Vienna and his “free associations” to reading Anna Freud’s notes. (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). which attempted to follow up all adults who were referred as chil- . To our knowledge. which she sent to him a few years before her own death. one which would complement the many accounts of child treatments from the analyst’s point of view. Heller expresses with great force his deep but ambivalent feelings toward Anna Freud and his analysis with her. knitting or crocheting. . Yet Heller is deeply ambivalent about the experience: he explains how. I did not think I was loved enough” (xxvii). “in analysis I wanted to be loved . Heller’s account of his child analysis hints at the depth of feeling he still retains about this period in his early life. what they understood about why they were taken to see someone. and like so many patients.

but quite major gaps in their memory. this study makes use of only one small part—the interviews which focused specifically on memories of being in child analysis (Barth 1999). Results In the course of the analysis of the data. exploring all aspects of adult life and functioning as well as memories of childhood generally and the child analysis more specifically. a wide range of analytic themes were generated (see Midgley 2003. Some of those interviewed had been as young as three and a half when they had been referred to the Centre. Target and Smith. in press). Perhaps unsurprisingly. one person who had been in therapy at the age of three and a half for about two years. Out of this huge amount of data. the nature of the data (verbatim transcripts of semi-structured interviews focusing on the subjective accounts of personal experience). These interviews were extremely wide-ranging and in-depth. 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. The approach chosen to analyze these interviews was broadly-speaking “qualitative. with the average length of time being twenty-seven years. and this paper will present only part of the findings—those which were related to the participants’ attitudes to- . or whether they saw one or two different therapists.” The relatively small sample (twenty-seven participants). twenty-seven adults who had been in intensive psychoanalysis as children were interviewed as part of this project (see Appendix One). Likewise the period of time since the analysis had ended varied a great deal— from eighteen years to forty-two years. In total. Midgley. Some people refer to specific. 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). or how often or for how long a period they came. had quite clear memories of his therapy and his therapist.Recollections of Being in Child Psychoanalysis 161 dren to the Anna Freud Centre between 1952 and 1980. others were in late adolescence. 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. Inevitably the detail and depth of memory retained by the participants of their child analyses varies enormously. like being unable to remember anything about starting or ending therapy. For example.

“I was never really told why I was going there” (Susannah. although few were specific about the nature of the difficulties. maybe this will make things better. 10.162 Nick Midgley and Mary Target ward being in child analysis. at least) about what they felt their difficulty was at the time. and their feelings about the figure of the analyst him or herself. age ten years and ten months at the time of being referred for analysis. so really I was pretty determined to do it because I thought I needed to. The excerpts will be referenced in the following way: (Anthony. but this does not seem to have been a difficulty for them. 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. or whether certain themes were especially common among men rather than women. In the presentation of the material. their memories of what actually took place. however. Although not given in exact quantifiable terms.3) is a comment that recurs several times in different interviews. although the way different interviewees feel about this varies. 12. or the relief they felt that something was being done to make things better. Anna.g.11).10). 10. verbatim excerpts from the transcripts are included in order to convey the tone and complexity of the individual narratives. and they described feeling that nobody had really explained this to them. some sense will also be given of whether the themes that emerged were common across many interviews. As one puts it: You know I’d obviously—something had gone wrong and I was unhappy and everything.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. especially . or were quite particular to the experience of one or two interviewees. 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 those who had been in analysis at a certain age. 8. meaning that the quotation is from the interview with “Anthony” (all names are changed). although most of them are not specific (in this interview. and to give a more vivid sense of what the interviewees’ experiences involved. In several other cases. as they were able to make sense of it for themselves (e. and I thought maybe. (Richard. In some cases the interviewees indicate that nobody had explained to them why they were going.

. a number expressed a wish that they had been consulted more. 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. you know. (Tamsin. about what’s going to happen” (Daniella.6). as I say at eleven I didn’t have any choice about going. and made it harder for them to make use of the therapy itself. 17. the whole treatment was explained to me . . 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. Without such a process.3). I really didn’t understand why I was there. . or that they had been given more information. let’s see perhaps let’s talk to your parents together’” (Tamsin. being in therapy could feel as if it were actually a “punishment” for doing something wrong: It felt.Recollections of Being in Child Psychoanalysis 163 among those who had been in therapy as adolescents. my adolescence wasn’t brilliant. “I think at thirteen a bit more information would be useful. I wasn’t getting on well with my parents. let’s see what value has been in it. that there was “a negotiating kind of process. 12. the necessity of her to react to me in the way she did . 12.6) Commentary From her earliest writings Anna Freud recognized that one of the greatest differences between child and adult psychoanalysis was the . while another woman remembers feeling that “we never sort of assessed as we went along how it might have be helping [. (Tamsin. thinking back to her experience (Susannah. 12. .” says one woman. 12. the fact that they did not feel they understood why they were coming to the Anna Freud Centre was a more serious obstacle.5) Of those who described this sense of not understanding why they had come to therapy.] and it might have been helpful for her to say ‘Let’s see how you progress. I didn’t choose to go and it was never explained—or as far as I remember it was never explained. at the time. who came into therapy as an adolescent.9). why I was there. . and that theme went on throughout the year. it was the constant. 13. . In one woman’s case. I was like being punished every day and I didn’t understand what good it was doing. and I can only think—but nobody got on well with their parents.6) For another interviewee. major theme of “why am I here?” (Heather.

All of these issues raise very specific questions—perhaps even concerns—about what the child’s attitude toward being in therapy will be. and spoke of the “relief” they felt when their difficulties were finally being addressed. To a considerable degree. Children may not be as troubled by their “symptom” as the adults around them are. this finding seems to confirm some research suggesting that lack of preparation can be an obstacle to children engaging in psychotherapy (Holmes . What comes across very powerfully from this data. It is interesting that of those who expressed this feeling. or a parent. Freud 1965). and they are more likely to seek an external solution to their difficulties (A. they may lack the same motivation to engage with the analytic process. Adults who have an emotional difficulty may sometimes decide to see a therapist. and in general outpatient psychotherapy. Although we have no “objective” data about what information these young people had actually received at the time. While there were a small number of participants in this study who described a sense that they “needed” to be in therapy. is a sense that these participants did not feel as if they had been given enough information about why they were in therapy. and how the process worked—a finding that replicates recent studies into adolescents’ experiences of therapeutic inpatient units (Street and Svanberg 2003). these concerns are confirmed by the findings of this study. Wierzbicki and Pekarik 1993). whereas for those who were in adolescence the meaning of these statements was different.164 Nick Midgley and Mary Target child’s attitude toward being in therapy. If they do see a therapist. 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. a doctor. a large number of participants (about half) in retrospect described some feeling of not knowing why they were taken to therapy as children. 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. what was expected of them. it is probably because they have been asked (or told) to go by a teacher. Of course the problem of engaging adolescents in psychotherapy is a notorious one (Meeks 1971). it is generally accepted that there is a 40 to 60 percent drop-out rate for this age group (Kazdin 1995. very few referred to specific difficulties or worries that led them to be in analysis. however. children rarely do.

the largest number tended to come from the adults who had been in therapy as very young or latency-age children. When describing the experience of being in therapy itself. and how therapy is supposed to help them.3).Recollections of Being in Child Psychoanalysis 165 and Urie 1975) and that helping adolescents to understand why they are coming. This group spoke about how “it was fun. that it was “a good feeling” to go (Phil. whereas those who spoke in terms of “playing” were younger when they had been referred for therapy. those who describe the therapy in terms of “talking” tended to be those who were referred at an older age.” the memories tend to be rather vague and generalized: painting. and this opportunity is described several times with a sense of surprise and pleasure: . given the degree to which these former child analytic patients report a lack of understanding in this respect. 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. most people described it in terms of two main activities: playing and talking. 3. Of those who remember coming to therapy in terms of “playing. 7.10). 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. is of great importance (Griffiths 2003). it was brilliant” (Angela. Interestingly. and that was hugely enjoyable. of those who spoke about coming for therapy at the Anna Freud Centre in the most positive terms. but as an on-going process—is perhaps one of the most important findings of this study. Several people describe some uncertainty about what the purpose of the play was. For these people the emphasis is often on the enjoyment they got from having this quite unique experience. The need to attend to the child’s understanding of why they are in therapy—not just at the beginning. 9. bits of plasticine or a book kept in a special cupboard. (Rupert. Not surprisingly.9) For several of the participants. memories of therapy and the therapist Among the twenty-seven people who took part in this study. rather than as adolescents. and those who felt largely negative.9). 3. the feeling that they could talk about—or do—whatever they wanted was what characterized being in therapy. there was a fairly even spread between those who remember feeling predominantly positive about going to therapy. those who felt mixed. playing with dolls or bricks. or that they “enjoyed spending time with [the therapist]” (Rupert.

it was brilliant. So it was like fun. which I couldn’t go through with other people. several interviewees refer to something their therapist did which we might understand as “making an interpretation.3) While the quotation above describes the therapist’s attentive listening as helpful in its own right. it was something very special.166 Nick Midgley and Mary Target I think. or that they would not be listened to in the same way: Yeah. As one interviewee makes very clear. (Mark.3). you know. (Phil. Although they do not use the word itself. . 12. 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. he would just say “well. to be able to do that was a privilege.g. 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. (Angela. whatever I wanted to do. “I just remember talking and things” (Lillian. this “talking” was not the same as the “talking” that might go on elsewhere. 9. and then I’d start talking about anything that came to my mind. how it affected me” (Phil. Eva.3).” In some cases. it was so. it’s very. 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. because nobody had the patience or the time [laughs] to sit down and to listen to what was on my mind so.” you know. 16) While recognizing the difficulty of this process. 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. 9.10). others talk about things that the therapist did more actively.8) or would “offer solutions to possible problems” (Anthony. initially. 9. that was what I could do. but for others (again. not only was the content sometimes different. A number of people refer specifically to the fact that they were able to talk about “secret” thoughts and feelings. it was like a chance to go through things which. “talking about things. I wanted to talk about. very difficult.10) For this particular woman the emphasis is on both being able to do and to say whatever she wanted. and emphasize that they would not be able to speak like this elsewhere. 7. this interviewee and others acknowledged that it enabled them to talk in a way that was quite different to other situations with other people. 5. and that seemingly you could do anything you wanted. it’s really difficult. you know.

10). you know. like. 10. “20. 17. (Mark. 6. A large number said simply that they “liked” their therapist. a few people expressed a more specific sense that they felt accepted. 16) Another woman refers to the “comments” that her therapist used to make. One man . looked after. and leads directly into his comment about his “fond” feelings for the therapist. you know. When asked explicitly. about two thirds of those interviewed described some kind of positive feelings toward their therapist. and listened to by their therapist. Others spoke about their therapist being “warm and friendly” (Elaine.4) This man indicates that his own behavior was a kind of testing of boundaries. why not?. . the therapist’s “interpretation” seems less about what the therapist said. Among those who spoke about their therapist in these positive terms. I’m pretty sure he would come out with some very interesting sort of links. boundary again.1) and of themselves having “real feelings of warmth” toward the therapist (Neil. and that his experience of the therapist setting limits was an important one. So my memory is quite fond of her. 7.Recollections of Being in Child Psychoanalysis 167 10. One man remembers how he used to make things in his sessions. (Neil. and this was especially true of those who came into therapy as young children. sometimes he came out with. just kind of see how far I could push her and you know. and more related to what the therapist did. and remarks on how. a particular action or response which had significance.4).” that’s absolutely right. In some cases.5).” and she said something like “because I don’t want to. or being “a sympathetic person” (Jason. without elaborating greatly on this. . OK . 16) and goes on to describe what this felt like: Sometimes.4). 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. you know. 10. 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]. One man talks about the way his therapist would “mould” things and “talks about things I’d been talking about. you know with what I was saying. 30 years later I can remember little comments [the therapist] made to something I said that she may not have even thought was important.” Uh. and I’d say “hey hang on a minute. I’m sure I used to deliberately kind of just see. like dreams or whatever” (Mark.” describing this as a “powerful” experience (Heather.

so I was safe from judgement. (Peter. comfortable with her. One man describes particularly well the way in which his feelings about the therapist could change depending on what was happening in the therapy.8) In a similar way. quite different from those with their parents.3) In contrast.168 Nick Midgley and Mary Target spoke about how he “appreciated the attention” that his therapist gave him (Bobby. an initial dislike gave way to more positive feelings: . . He says: I remember liking her. for a period of time. and. In some cases. and then feeling annoyed about that. (Phil.] Sometimes. One says: I didn’t really have any relationship with anyone else. . where I was not able to be relaxed with people in general. if you know what I mean. I felt I could tell her anything and she wouldn’t be cross. (Marigold.10). 9. I mean open. like.11). like at ease with [my therapist] yes. I felt accepted. while a couple of the participants also describe. while also recognizing that the hostile feelings were ultimately related to the difficulties of the therapy. another man describes his relationship to his therapist with the following words: I felt I could be more relaxed. So that was quite nice. but my therapist I was very close to.8) While this man describes different feelings toward his therapist depending on what was happening in the therapy at the time. but I also remember being frustrated about specific conversations and things. especially with teachers . But I seem to recall my overall feelings was that I liked her [. 11. when she would query whether I was feeling in a particular way or whatever. if I reacted adversely to a particular type of conversation. Others speak of the way that they liked their therapist. sometimes my feelings about that spilled over onto her personally. others describe the way their feelings toward the therapist changed over time. or other adult figures. 7. and you know. at the time I felt it was a useless line of conversation. 7. teachers. with obvious warmth. and also she wasn’t in a position—you see in a lot of. they tend to judge the children so. . It was almost like I could feel. but felt hostile toward him or her when they felt under pressure or were going through a difficult period in the therapy. several participants in the research describe feelings about being in therapy which were often quite mixed and even contradictory. 14. the sense of their having a unique relationship to their therapist. not the person of the therapist herself. And everything I told my parents made them cross. . One woman describes her feelings about her therapist as a “typical sort of love-hate relationship” (Angela.

and to me it was “why on earth is he interested in that?” You know. Most commonly among this group. 13. “I didn’t talk about anything—sometimes things were really hard at home” (Dominique. all of these people had been in therapy when they were either latency-age or adolescent. I was very closed” (Joanne. you know. Richard.10) For two others. Because I suppose on some level I was talking about whether I was completely bats and maybe she didn’t realise that. about one third of those who took part in the research expressed some negative feelings about their therapist as a person.9). (Daniella. Whereas some spoke about feeling not understood in a global sense. I think I felt that maybe his priorities were not my priorities like.10). 7. I felt he understood certain things but I think that. (Neil. 10.g. Interestingly. As one woman puts it: I think. I’d tell whopping great lies because I didn’t want her to know what I was really thinking or feeling” (Susannah. I think I might want do what you do for a living.3). yeah. “I’d never open up. one of whom will be described further in the next section. mostly latency-age or adolescent at the time of therapy. “I didn’t really talk to her—I used to sit counting squirrels out of the window” (Eva. 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.” some real feeling of warmth toward him toward the end. . others suggested that there were only particular times when they did not feel understood (e. well I think she said something like—“you’re coming here. Overall. Memories about non-engagement in therapy tended to be linked with negative feelings about the therapist him or herself.4) In contrast.6). 12. I remember later saying to him “I think I might. interviewees spoke about a sense that their therapist did not understand them. . and none of those in therapy as young children spoke about their therapists in negative terms. 7. [the therapist] was strict and wouldn’t do what I asked [. (Angela. or I was scared of a man.8). isn’t there something wrong?” or something. to him it seemed really important about my particular bodily function.] And later I was very fond of him. I think she said something like. and almost all women) their description of the therapy is characterized by their non-engagement with the therapy. in that respect he wouldn’t understand.Recollections of Being in Child Psychoanalysis 169 I didn’t like him at first.9) . for a significant minority of interviewees (just under a quarter of the total. 10. I think that maybe we were at cross-purposes or something. 7. “I wasn’t really sharing anything with him. 9.

” 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. 12. One woman describes her memory of “being asked loads of questions and not knowing the reason. says one. “I thought she was interrogating me half the time” (Susannah. led them to experience the setting and the therapist in more explicitly negative terms. and I loathed it. (Angela. others describe the experience as more negative. 10. . 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” [. the therapist’s questions. . . but in my mind I think he was a bit obsessed by my bowel movements but [laughs] I don’t know . while several refer to their uncertainty about what all the questions were for.10) While these people describe feeling that these questions forced them to think about things that may have been uncomfortable. 6.4). 14. or as giving them a sense that they did not know why they were being asked all these questions.” and she remembers that some of the questions seemed to have “sexual overtones” which she felt confused about (Elaine.4). 7. while another remembers how the therapist “tried to pressure me to look at things I didn’t want to look at” (Bobby. together with their sense that the therapist refused to respond to their own questions. . . 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 [. I totally resented the process which was basically—presumably it’s still the same.11). 12. I don’t know—but she used to just sit and wait for me to say something and I just resented that so much.10).] 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. For a small number of those interviewed. . (Susannah.3). One participant put this especially clearly: You see. another remembers how she used to wonder “why they were asking me all these questions. says one interviewee. 5. 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.] 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.3) . it’s probably a complete distortion.170 Nick Midgley and Mary Target For a number of interviewees.

while another speaks about simply disliking “everything” about her therapist. . 9. Interestingly. not understanding that what I was doing was being interpreted because I didn’t have any concept that behaviour could be interpreted. One of them simply says it was “because he was a man” (Joanne. 8. . while another states that she simply “hated” her therapist (Anna 14. Or I just thought that it was just meaningless. “she drove me demented. and I would sort of think I knew what she was trying to—I thought she was interrogating me half the time [. 7. 7.3). who describe much more explicit. none of them elaborate that much on what it was they hated about their therapists.1).9). 9. . Those in this same group also describe feeling that they were not understood by their therapists. 12. I just thought it was—I didn’t feel any better after going. and that they did not wish to be there. “I thought he was revolting. 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. I didn’t want her to know—when she did ask the questions [laughs]. however. 7.Recollections of Being in Child Psychoanalysis 171 A little later in the interview. that they were not able (or did not want) to share anything with their therapists. the woman above is one of a group of about six interviewees.9). They all describe how they felt using quite similar language: “I just didn’t want to go” (Joanne.11).3) While several participants describe some negative feelings about their therapy and their therapist as a person. . as for some others.” says another (Eva. (Tamsin. . One woman gives a fuller description of how she felt and why: I can’t remember sharing my feelings with her. I thought it was invading my own privacy” (Sarah.6) For this woman. . “I was resentful about having to go.] I’d tell whopping great lies because I didn’t want her to know what I was really thinking or feeling [. 7. (Susannah. her negative feelings about the therapy eventually led her to end her treatment prematurely. having to be there every day” (Dominique.” says one (Joanne. 12.8). 12. almost all women who came into therapy as latency-age children or in early adolescence. . the same woman described how her therapist did ask questions. active feelings of dislike toward their therapists. “I hated it” (Susannah. it was always resisting sharing my feelings with her. “I didn’t like it .] And I felt she was prying.6).9). but that this was equally unsatisfactory: She would ask me questions.

The child’s experience in treatment gradually enables him to sort out the meaningful differences [. there is a powerful sense that the experience of being able to talk about whatever they wanted to. 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. listened to. Sandler et al. . some of the particular “comments” or “links” that their analyst had said. was the essence of the therapeutic experience. 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. In The Technique of Child Psychoanalysis. The emphasis on the experience of being accepted.172 Nick Midgley and Mary Target Commentary 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. 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. . in the presence of a sympathetic. and valued.” (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. although they may have had only a vague idea of what the analysis was about. indicating that a “significant interpretation” (Sandler et .] even if he speaks of treatment as “play. This has the result that the therapist raises the self-esteem of the child by saying. 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. and I am not going to dismiss you out of hand. I will listen to what you have to say. seems to be confirmed by the findings of this study: To a child. The view of Sandler et al. However the current study also suggests that former child analytic patients remembered. “I regard you as someone to be considered important. Llewelyn and Hume 1979).” (1980:112/13) This emphasis on being listened to and understood echoes much of the research into patients’ views of adult psychotherapy. and looked after by a therapist who is “warm” and “non-judgmental” appears to confirm once again what Sandler et al.g. in effect. non-judgmental listener. acknowledge that “for the young child the positive tie to the therapist probably forms the main basis for the therapeutic work” (1980:47). For some participants in this research.

in other cases the feelings are more intense and on-going. or even interrogated. 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”). 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.Recollections of Being in Child Psychoanalysis 173 al. 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.” because the analyst was distant and unresponsive and the child was left feeling misunderstood and dis-empowered. and in a smaller number of cases. Moses Laufer has written extensively about the particular difficulty when the adolescent patient re-experiences the developmental breakdown within the transference itself (Laufer 1989). In a few cases. a general resentment of the analytic process itself. the feelings appear to have continued right through to the end of the analysis. and they often led to premature termination and unsatisfactory outcome. This non-engagement is associated with two factors in particular: a sense of being questioned. While in some cases the negative feelings appear to have been transitory and part and parcel of the therapeutic work. However. experienced as “insulting. in some cases. associated with a general non-engagement with therapy. especially among those who had been adolescents at the time of their analysis. But since. whose questions did not seem to make sense or did not give the child a sense of being “understood”. it appears as if such negative feelings could not always be understood and used as part of the analytic process. 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 were on-going and unresolved. by the analyst. and especially likely to end in premature termination of treatment (Meeks 1971:133). This finding is an important reminder to child psychoanalysts that technique .. it is not possible to be sure. this led to intensely negative feelings both about being in therapy and about the therapist as a person. a feeling of frustration about the analytic process. even at the end of therapy. Chapter 18) made in childhood can be remembered and valued more than twenty years later in life. Analysts in the Anna Freudian tradition have also recognized that the development of the negative transference in psychotherapy with adolescents is particularly common.

they are worth attending to for what they can teach us about the process and outcome of child psychoanalysis. 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. that we believe it is important to simply register this voice first.174 Nick Midgley and Mary Target needs to be geared carefully to the developmental level of the child. and the difference between these contemporary notes and the retrospective accounts would be fascinating to compare and contrast. 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. or how the treatment ended—would be described quite differently in the child case notes. Since these accounts are in some important ways different from those of child psychoanalysts themselves. Concluding Comments By the very nature of being a long-term follow-up of child psychoanalysis. or whether more than one analyst was seen. Most importantly. 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). and to what degree these memories accurately “reflect” what happened in their child analyses is open to question. . But although future studies may well complicate and enrich our understanding. Memory itself. The voice of former child analytic patients has been so strikingly absent in the clinical and research literature. and general adult functioning and mental health. There is a great likelihood that quite significant aspects of the child analysis—such as its duration. current representations of attachment relationships. 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. outcome. the participants in this study were describing experiences that had happened to them at quite a young age and many years previously. especially how the treatment is introduced and the way that its aims are presented. the current study appears to indicate that former child analytic patients. for the great part. is a complex and over-determined process. 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. as psychoanalysis knows only too well.

10 3. Psychoanal. C. Psychoanal.9 Missing data 3.10 2.2 10.1 3. .6 2.4 5. Psychoanal. Child 50:106 – 121.8 4. 14:485 – 509. Beiser.6 175 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 LENGTH OF ANALYSIS (Years.4 17.6 12.9 12.9 1. (1997).8 6.5 3. St.5 9. (1995).1 7.9 2 .0 0.4 7. months) 3.10 6.0 3. On the metamorphosis from adolescence into adulthood.8 8.10 2. G.3 16 5. 9 5.Recollections of Being in Child Psychoanalysis Appendix.8 4. Amer.10 4.2 4.11 7. (1966). Babatzanis.9 11.6 1. The analysis of a pre-homosexual child with a twelve-year developmental follow-up.8 AGE AT FOLLOW-UP 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.9 4 .10 3.8 9. months) 14.6 1.1 10.2 2.11 10.3 1. St.2 1. H.3 3.1 1.11 13.6 1.9 3. J.3 9.0 7.10 11.11 7. Assoc. Participants in the Follow-up Study AGE AT REFERRAL (Years. A follow-up of child analysis.10 2 . Child 52:159 –189.

Child 50:79 –105. dream. of Med. J. McLeod. & Hume. E. and Laufer. (1999). Memories of Therapy: A Qualitative Study of the Retrospective Accounts of Child Psychoanalysis. 52/1. ‘The outcome of child psychoanalysis from the patient’s point of view: A qualitative analysis of a long-term follow-up study’.). & Urie. 62:23 –26. J. (Baltimore: Williams and Wilkins). Psychotherapy Research. 10. (in press). E. Normality and Pathology in Childhood. Griffiths. The patient’s view of therapy. and Clin. Terms of engagement. In Cohen.Psych dissertation. Psychology. Heller. M. Effects of preparing children for psychotherapy. Llewelyn. Midgley. S. Psychoanal. Neubauer. (eds. Laufer. and Cohler. Press). (2000). A Child Analysis with Anna Freud. Freud. Analysis of a phobia in a five year old boy.. fantasy and enactment in Bornstein’s “obsessional child. D. (New York: Int. (1909). Press). & Smith. Strachey (ed. (eds. A. Univ. St. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Reaching hard to reach adolescents. (1986). (2000). (London: Sage). C. J. S. Koch. Bridging child. Practicioner Research in Counselling. Practice. (1989). Young Minds. adolescent and adult psychotherapy: Directions for research. (2000). Ostow. P. J.” then and now. (1990). J. 43:311– 318. and Solnit. (London: Hogarth Press). J. B. Observations on follow-up contacts with former child analytic patients. (1995). Colarusso. A. (New Haven: Yale University Press). J. W. Br. & Cohler. The search for a good-enough self: From fragmenta- . J. Her World and Her Work. Target. (eds. Univ. (1993). and therapy in adolescence. Kazdin. Holmes. Meeks.). M. Research.. N. M. 12:223 –246. In Cohen. Freud.). A childhood gender identity disorder: Analysis. 5:258 –277. R. Cons. (2003). The Fragile Alliance: An Orientation to the Outpatient Psychotherapy of the Adolescent. M.). (1995). (New Haven: Yale University Press). Amer. In J. McDevitt. D. M. Psychology. Vol. Grosskurth. preoedipal determinants. Parsons. University College London. (eds. (1979).176 Nick Midgley and Mary Target Cohen. M. Melanie Klein. (2003). (1971). The Many Meanings of Play: A Psychoanalytic Perspective. Play. N. A. Acad. (1973). The Psychoanalytic Treatment of Lives over Time (San Diego: Academic Press). P. B. Psychology and Psychotherapy: Theory. Unpublished D. The Psychoanalytic Treatment of Lives over Time. (1975). A child-analytic case report: A 17-year follow up. (New York: Knopf ). Child Psychiatry. Developmental Breakdown and Psychoanalytic Treatment in Adolescence: Clinical Studies. Why psychoanalytic treatment for these adolescents? In Laufer. P. J. (1965). Midgley. (Madison: Int. (San Diego: Academic Press).).

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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-

” Ledwith (1960) and Ames et al. Both the Rorschach and TAT were also evaluated using Schafer’s sequence analysis (1954). the level of object relatedness was based on the subject’s ability to differentiate boundaries between objects. 2. Siamese monkeys.” or yearns for an undifferentiated closeness. Rating is based on the degree to which an object’s boundaries are described as distinct or separate from one another. (1974) have published many similar TABLE I Psychoanalytic Rorschach Profile SCALE Object Relations Differentiation LEVELS 1. Projective testing has traditionally been used in psychoanalytic research and has been proven to be a very effective clinical measure (Holt & Luborsky. Separate Two people dancing together. Separated responses indicate that the subject experiences herself as separate and distinct from “the other. One aspect of the Rorschach testing presented in this paper evaluated the children’s level and quality of object relationships. Two rabbits playing. ranging from merged to separate (Table I). 3.Attachment and Autonomy in Latency 183 lytic researchers who have documented reliability and validity for the systematic investigation of these Rorschach measures. Merged SAMPLE RESPONSE Monsters attached with two heads. Separate but Connected Connecting chairs. Two crabs stuck together. Merged to Separating A wall that is split open but still attached to the ground. 1955). Separating/ Touching But Distinct Two animals back to back about to go away from each other 5. 4. . Merged responses indicate that the subject does not feel himself as separate from “the other. On the Rorschach.

Chinese dog dancers. Rorschach responses in their normal children’s protocols for this age group. A fragmentation response on the Rorschach implies that the subject is in an unconscious feeling state of dis-integration. two chins Age 7—Two ladies smashing pumpkins Age 8—People 3. or alive (Table II). Anthropomorphism Rabbits wearing their Easter hats having a tea party. A second aspect of the Rorschach testing appraised the integrity of the child’s self structure. We usually think of frag- . A dead flower 2.184 Rona Knight TABLE II Psychoanalytic Rorschach Profile SCALE EGO STABILITY LEVELS 1. which was evaluated by the degree to which the object remained whole. Fragmentation Crumbled rocks A cup broken in pieces Example of One Boy’s Sequence: Age 5—People Age 6—Two shoes. two knees. A cooking pot Contamination Chinese dancers. A frog in a bow tie going to a ball. Enduring and Solid THOUGHT PROCESSES Person. intact. Bear. Incipient Fragmentation Decaying leaf Humpty-Dumpty falling 4. Dogs playing patty-cake. Death SAMPLE RESPONSE A dead cat.

2) ego ideal.1 Clinical Interview: Each child was administered a semi-structured clinical interview. 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). parents’ feelings and behavior toward the child. Bibring (1959) also found a dramatic difference between the disturbed Rorschach responses of pregnant women and their everyday good functioning in the real world. The principal investigator administered the clinical interview. The child’s mother was asked to fill out the entire questionnaire. the children’s responses were used to confirm and deepen the understanding of the test data. . The child’s father was encouraged to contribute information for this questionnaire. The questionnaire elicited information about the child’s ongoing feelings and attitudes about him/herself. 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. Teacher Questionnaire: Two thirds of the way through the school year. 3) body image. developed for this research to gather information about the following: 1) self-esteem. fantasy and dream material. 6) conscious and unconscious feelings and their discharge. and 7) coping mechanisms and their functioning. Each interview was tape recorded and transcribed. The clinical interviews were not scored for this research paper. general mood. 5) narcissism. temporary break-down in the antecedent mode of object-connection and the concomitant establishment of self-coherence. and he was required to fill out the part of the questionnaire that concerned his feelings and attitudes about the child and himself. behavior and performance in school. 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. 4) quality of interpersonal relatedness. Its presence in these normal children during certain phases of development suggests a normal. This information was not used in the present study. relationships with family and friends. and information about the parents’ feelings about themselves.Attachment and Autonomy in Latency 185 mentation as indicative of a severe problem with self and object integrity. each child’s teacher was asked to complete a questionnaire about the 1. Responses from the questionnaire have not been scored as yet but were used anecdotally to further our understanding of the test data.

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. This sense of separation was related to the denouement of the oedipal period and their feeling pushed out into the world outside their home. school performance and behavior. 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. abandoned. sadness. and anger. All four boys had fragmentation responses on the Rorschach at age six. at age six he saw two heads. TAT stories about feeling lost and without parents were typical. between ages six to eight all the boys were judged to be feeling separated from their objects. which was primarily used in this paper to see how well the children were functioning in school. and at age seven years in the girls. using a five-point rating scale. the children began to develop an unconscious sense of being separate from their parents in a way that they had not experienced previously. Feeling little and damaged. At age six years in the boys. and shoes.to eight-year-old boys and girls. The teacher questionnaire elicited the teacher’s evaluation of the child’s general mood. which were less intense at age seven and were completely gone by age eight. 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. and not nurtured in the big world. Boys: At age six. and at age eight he saw two people. However. and relatedness to peers. At age six the boys had feelings of being alone. Table III shows the process of fragmentation and separation responses in the six. Three of the boys had Rorschach testing at age five and were judged as not yet feeling separated and had no fragmentation responses.186 Rona Knight child. two chins. they had concerns about whether they could make it on their own. Although both sexes experienced this development. Along with this new sense of separateness came feelings of disconnection. legs or knees. a sense of separateness and lack of cohesion first appeared in the boys’ responses. feeling in- . at age seven he saw two ladies smashing pumpkins together. they had different timetables—the boys entered this phase one year earlier than the girls.

wound up with a bad family. like 100 years old. and so she’s gonna get adopted. and another dreamt about a dog that broke loose from his leash. and needed rescuing. Then the father died and everyone else in the family died. which . 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. These responses were present on the TAT and were also expressed in the conscious fears and dreams these boys reported in the clinical interview. They just all died cause they were real old. One boy worried about getting hit by a car while walking to school without a parent.Attachment and Autonomy in Latency TABLE III Rorschach Fragmentation and Separation Responses For Five. One boy’s story to a TAT picture of a girl leaving for school expresses these feelings: “Somebody got killed in her family.” These boys also experienced guilt about their underlying fantasy that separation will lead to the death of their parents. The grandfather. In the clinical interview they expressed fears about people in their families getting hurt and killed and reported dreams about their parents dying.to Eight-Year-Old Children BOYS AGE FIVE Solid Not Separated AGE SIX All Fragmented Separated AGE SEVEN Some Fragmentation Separated 187 AGE EIGHT Solid Separated GIRLS AGE SIX Solid AGE SEVEN Fragmented AGE EIGHT early 8: some fragmentation late 8: Solid Separated Not Separated Separated sufficiently supported by their parents. (How old is the girl?) She’s 19.

Mothers were often pictured as dead or hurt. The boys experienced a conflict over feeling more independent because they still had the same worries and needs they felt the year before. the boys sense of oedipal defeat and their concommitant oedipal feelings continued.” 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. The boys felt a push to be independent but were scared about being lost or in danger on their own. judging from their teacher’s high ratings of their concentration and behavior. more dangerous world. but also able to help and/or protect their sons from danger. The boy felt scared when he was lost and good when his father found him. He goes bird watching and gets lost. was good enough to hold these feelings at bay during school hours. however. . Their ego control. The boys started to see their fathers as very human. parents reported that the boys’ behavior at home was often aggressive and difficult to manage. One boy’s dream at age six illustrates this conflict: “There is a monster coming to the house and I run out. capable of making mistakes. They found two ways to cope with their anxiety about still feeling little and being able to manage on their own in the world. I worry about what will happen to the family when I run away from the house. . At age seven. larger. 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. Then his father was coming home and he found him and brang him home. He feels relieved that the forest animals know where his home is.” Oedipal defeat and the resulting narcissistic injury added to the six-year-old boys’ feeling rejected by their mother and not nurtured by her.188 Rona Knight often increased their worries.” The boys’ developmental push for independence at age seven led to their feeling much more independent at age eight. Separation was still experienced as getting lost in a big world and still included the total loss of parental objects. . . They also began to use the defense of magic to help them cope with their fears of getting lost in this new. Most of the boys still made the connection between separation and the death of their parents. One boy’s TAT story at age seven describes his faith in his father: “A boy is sitting there with nothing to do. The main defenses they used to cope with all these affects were intellectual and obsessive-compulsive defenses. The boys were sad and angry about their loss and unconsciously expressed their depression in explosive discharge. The mother and father thank the forest animals.

and a need for nurturance. By age seven. 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.” None of the girls had any fragmentation responses on a Rorschach at age six. Separating was associated with parents’ dying. Oedipal defeat added to the girls’ sense of loss. they were not yet as separated as the boys were at this age. The following TAT story told at age seven illustrates the girls’ feelings of loss. and a wall that split open but is still attached at the ground. They had fantasies about going out into the world alone and having their own houses. She feels sad. The absence of unconscious feelings of a lack of integration and separation was paradoxical. And she came back to the house and she dropped the keys on the floor and she started crying.Attachment and Autonomy in Latency 189 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. Their Rorschach protocols included responses like animals and monsters with two heads. 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.” One girl had not achieved a sense of separation and also had no fragmentation responses on the Rorschach. At the end she finds out that this is a time that people have to die. So she’s going to run back to her family and tell her family to run. sadness. for this girl separation meant total abandonment that led to her own death. Five of the seven-year-old girls showed evidence of having made a separation based on their Rorschach responses and their TAT stories. They were all still in the throes of the Oedipus complex. The seven-year-old girls were frequently preoccupied with pervasive loss. and conflict around separating: “This is a person crying ’cause her parents just died. Her parents are going to run but they get killed and she survives. monsters. with the attendant concerns about body damage and death related to the oedipal struggle. or deni- . and she’s thinking she wished she never moved away from her parents’ home. Like the boys. hurt. deprivation. making her too anxious to tolerate a complete separation. and separation often was associated with parental death. Their dreams and their conscious worries were about being forcibly taken away from their homes by ghosts. Stories in which men were perceived as dead. and kidnappers. with many fragmentation responses in their Rorschach protocols. they felt little in a big world. She’s worried about the Indians killing her. five girls were feeling a lack of cohesion.

Nurturance needs continued to increase at age eight.’ she thought. And she went to her room and fell asleep on the bed. 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. They felt both an external push to grow up from their parents and an internal push to grow up. One girl’s TAT story nicely describes the need and the conflict: “This is a little boy. the latency separation process converges for both the boys and the girls. the girls who had separated felt psychically impoverished and felt they had to work hard to perform. middle latency—age nine years By age nine. He wants to stay little ’cause his mother just read him Peter Pan. Her mother sent her to her room because she had been bad. She hit him. The high degree of anxiety and emotional disturbance seen on the . The girls defended against these feelings by denying and avoiding strong aggressive and libidinal feelings. And he’s thinking that he doesn’t want to grow up. Projective tests at this age showed a breakdown of defenses. .” Despite strong aggressive feelings.190 Rona Knight grated were frequent. and he’s sitting on the step of a barn door sucking his fingers watching his father feed the animals. leaving all of them feeling tired but hopeful of becoming more competent as they got older. (What had she done?) She hurt her little brother.” Table IV outlines the findings for the six. . Some girls used repression and/or intellectual and obsessive-compulsive defenses to close off or constrict their feelings and impulses. . one girl saw “talking and hearing vibrations” on the Rorschach. exemplified by the following TAT story told at this age: “The girl is sad. they do not have the sense of these impulses getting as out of control that the eight-year-old boys experience.to eight-year-old girls and boys. which added to their conflict between wanting to stay little and wanting to grow up. By age eight. Their increased anxiety around aggressive impulses led them to a conflict over good and bad behavior. For example. ‘I have been a nasty little girl. Both the boys and the girls were made extremely anxious by their newfound separateness. The anger that the girls felt about their loss took the forms of oppositional behavior and aggression turned against the self and siblings. 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.

Feeling separate and fragmented 2. aggression turned on the self and siblings continued . Separation equated with the death of both parents 4. Feeling little and damaged 10. Oppositional behavior at home. Oedipal defeat. Oedipal defeat. mother experienced as dead 6. Nurturance needs 191 GIRLS 1. Feeling rejected and pushed out into the world 3. Fear of explosive discharge. Feeling pushed out into the world 3. mothers seen as dead or hurt 11. Feeling alone and abandoned 5. Sad about the loss. Strong Oedipus Complex 1. sense of deprivation 5. Depressed with explosive discharge. Separation equated with the death of both parents 4. Sense of damage 5. Sad about being alone and mad about being kicked out 6. Oedipal defeat. Feeling not nurtured AGE 7 1. Concern about danger or getting lost in the big world 3. Concern about body damage and death 5. Separation equated with the death of both parents 4. Sad and mad about loss of mother 7. Feeling pushed out into the world 3. Concern about being able to make it on their own 9. Feeling little and damaged 7. Push to be independent 2.Attachment and Autonomy in Latency TABLE IV Summary of Findings for Ages Six to Eight Years BOYS AGE 6 1. defended against with intellectual and obsessive-compulsive defenses 7. Nurturance needs 8. Separation equated with the death of both parents 4. Feeling separate and fragmented 2. Men seen as hurt. Aggressive and difficult to manage at home 8. denigrated or dead 6. Not separated 2. oppositional behavior at home 8.

Concern that aggression leads to death 7. Magic used as a defense 10. Oedipal concerns very present Rorschach is not manifested in the children’s typical conscious state and functioning as described by teachers and in the clinical interview. and she wants to go to her friend’s birthday party.” 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. Girls: The nine-year-old girls became much more concerned with moving away from their parents and toward their peers. they were very conflicted about it and had an intense wish to be taken care of like a . however. Feeling psychically impoverished. intellectual and obsessivecompulsive defenses 10. exemplified in the following TAT story: “This girl is crying ’cause her family is going away on a trip. denigrating men 6. She’s gonna get to go to the sleepover party. Fathers seen as helping sons in world AGE 8 1. Aggressive feelings defended against with denial. Feeling small and damaged 3. Separation equated with the death of both parents 6. Nurturance needs strong 4. Mothers of the boys. did describe more fighting with their siblings during this age. avoidance. Conflict over growing up 2.192 Rona Knight TABLE IV Summary of Findings for Ages Six to Eight Years BOYS 9. and she will get to sleep at her friend’s house an extra day. Conflict over good and bad behavior 1. Fear of parental loss 7. Nurturance needs continue to increase 4. Concerns about getting lost in the big world 5. Conflict over independence 2. repression. having to work hard to perform 5. Oedipal concerns. Magic used as defense GIRLS 9. and her parents and brother will go away for the weekend. Feeling small and damaged 3.

and he’s really hungry. The person that found him took him to the hospital. He feels really hungry ’cause his mother is taking so long. The next day he came out of his coma and lived happily ever after. although they were both disturbed sufficiently to see and hear things that weren’t there during times when they were experiencing separation. Someone going down a road saw him. and I am terrified me and my friends will fall. alone quality. or maintained a connection at the expense of feeling anxious. They made a point of noting that the people they saw on the Rorschach were separating or separate. Two boys were able to stay connected while feeling separate. (What is going to happen?) His mother is going to come home with a lot of food.Attachment and Autonomy in Latency 193 much younger child. When the next card (TAT Card 3BM) was presented to him. (How did he get to be so alone outside?) He was locked out in the wilderness and he didn’t live near anyone. they were able to maintain very caring relationships with their peers. This TAT story exemplifies the cold. but he couldn’t. And a man got locked out of his house in the blizzard. This could be seen in the flow of associations through several TAT cards. One girl’s dream illustrates the anxiety at this age: “I am on a bridge with my friends. As I am crossing the bridge it begins to unsnap. They’re poor. For example. he told a story about a boy who has amnesia and a case of seeing things that aren’t . By the time someone found him he was in a coma. and they snap the bridge back together again.” 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 me and my friends are going to the other side. and he is going to eat lots.” While they expressed an unconscious sense of separateness and isolation. This more developed sense of separation and autonomy often made them feel a sense of isolation and disconnection from people. 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.” Boys: The nine-year-old boys’ responses tended to have a more separate. Then his father came and tried to wake him up. isolating quality of the boys’ sense of separateness: “One day there was a blizzard. I have just left my mother on one side. 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. My friend’s parents are on the other side. one boy’s response to TAT Card 4 was a story about a wife and husband who separate and divorce. and we can safely get across.

Sense of aloneness and isolation in the separateness 3. Intense feelings of separation 2. 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. TABLE V Summary of Findings for Age Nine Years BOYS 1. Table V shows the findings for the nine-year-old girls and boys. Conflict over growing up .” Concurrent with the boys’ feelings of separation. Parents reported an increase in the boys’ fighting with their siblings at this age. Intense feelings of separation 2. increased fighting with siblings 6. Increased nurturance needs 8. The boy is scared by what is happening to him. Anxiety about being able to function independently 6. 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. They are separate. Aggressive and sexual feelings that can feel out of control. At times these feelings actually got out of control.194 Rona Knight there. Maybe two big dogs playing patty cake with their back feet and their front feet. Caring relationships with friends GIRLS 1. They are slapping so hard the red stuff is the noise. Responses on the Rorschach also show the boys’ disturbance around separating: “It looks like two Chinese dancers or people of some kind. The red and the sharpness look like noise. 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. Anger about being pushed to grow up 5. Weakened defenses 3. Lowered self esteem 7. Weakened defenses 4. Push toward peers 3. Constriction of affect in aloneness—two boys Anxiety in connectedness—two boys 5. Anxiety about separation 4.

Finally she decides she’s going to be a shopkeeper. cognitive. and two animals back to back about to go away from each other. once again did not have any. fragmentation responses on the Rorschach appeared as frequently as they did at age seven. Based on mothers’ reports. attachment and autonomy meant a moving away from home base to create a life and world of their own. and one girl had reached menarche at age ten years. Girls Ages 10 and 11: The early latency phase of attachment and autonomy was revived and incorporated into this next phase of separation. She needs to find a job. The one girl who had no fragmentation responses at age seven. and physiological development of the individual child. five of the six girls were at Stage Two of Tanner’s pubertal staging (1962) by age eleven. hormonal.Attachment and Autonomy in Latency late latency—preadolescence 195 At ages ten and eleven another phase of separation and autonomy begins to develop. 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. 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. (1974) also reported with their population of normal ten-year-olds. with a knowledge that they could still return when they wanted to or were needed at home. and in five of the six girls’ protocols at age eleven. This is a very different scenario from that of the seven-year-old’s picture of separation. two boys as the same person going out on Halloween. the boys and girls diverge significantly. and one that depends on the psychological. In this next phase. 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. At ages ten through eleven. She . ’cause she just moved here. For the ten-and eleven-year-old girls. This is a response that Ames et al. Once again. 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). This sense of a lack of integration appeared in four out of the six girls’ Rorschach protocols at age ten. and she misses them. which entails parental death. with the girls taking the lead in the developmental process this time. Typical responses on the Rorschach were: two horseshoe crabs stuck together. but she doesn’t know what kind of job she is good at.

She was nervous. ‘She’s drowned!’ I started diving underneath the water.” This next phase of separation was not entirely free of fears and conflicts. and friends also filled in for family. One girl had the following dream about the possibility of death following separation: “A week or two after we got our kitten. It was one of the best summers of her life. which may be why she did not experience the more intense disconnection that the other girls showed. My friend appeared with the mother cat. They didn’t defend against these feelings but tolerated the anxiety and sadness that comes with the separation. age eleven. these girls had a sense that they would survive it and even fare well in the world. and happiness. I had this dream that she drowned. oedipal concerns were more present again.196 Rona Knight thought she was old enough to move away so she moved. and that made her feel better ’cause she was missing her mother. They felt a need to be taken care of and nurtured by their mothers. replacing parents. and the girls experienced a surge of aggressive and sexual feelings that at times would break through their defenses and overwhelm them. But then she thought of all her friends from school and cheered up. . The importance of the peer group for the girls is demonstrated by the following story to the blank TAT card: “Gabrielle. Contamination and anthropomorphic responses were present in all of the girls’ Rorschach protocols. and she was at the bottom. 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. bolstering themselves with a hope for a wonderful outcome. Three of the six girls had very real concerns about death. drudgery. was starting to go to a new camp this year. while at the same time they were telling TAT stories about going off to college and being on their own. As she rode in the bus. which they applied to themselves and their loved ones. she almost cried. and neglect. She will start her own store and it will be okay. 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. I brought it up and started squeezing all the water out.” Frequently teachers were seen as helping the girls achieve their goals.” Conflicts fused with anxiety about growing up were exceptionally strong at ages ten and eleven. creativity. As it turned out. My friend dropped Lizzy [in the water] and we cried. it was the best summer of her life—for friends. Along with this newfound sense of autonomy and its concomitant feelings. While change and separation were experienced as scary. and she couldn’t wait ’til next summer.

and she was still mad at him. And she wants to marry him. He never did. Only one ten-year-old boy had entered a new phase of separation. 2) with their very strong and conflictual instinctual feelings. Three of the four boys had concerns about the death of themselves and their loved ones in their Rorschach and TAT responses at .Attachment and Autonomy in Latency 197 whom they often experienced as either weak or unable to help them in the following arenas: 1) out in the world. But this lady—this guy is a slave to her. Boys Ages 10 and 11: Three of the ten-year-old boys showed no evidence of entering another phase of separation and autonomy. an intensification of oedipal wishes. despite their still early Tanner staging. He wrote a letter to her explaining everything. At ten. images of both connection and separation appeared in all the boy’s Rorschach responses. (Who was the lady?) His owner. So the girl is thinking. he did not have the connected responses that were characteristic of the girls who had fragmentation responses at this age. These feelings were mixed with aggression.” Their mounting sexual and aggressive feelings worried all four boys. 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. ‘What can I do to get rid of this lady?’ So then one day she takes a knife and kills her. and he wrote a lot of letters all the time. these boys were predominantly in Tanner’s Stage I. He just left. And after a while he still couldn’t think of anything. 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. Their early latency feelings and fantasies about separation were revived and incorporated into this phase of separation. He was sad because he really wanted to come back to his family. The boys once again felt that the only way to separate was either to kill their parents or never see them again. and they live happily ever after. These boys had no fragmentation responses and there was no common theme concerning separation. this boy was clearly in Tanner’s Stage II of early puberty. and a longing to remain connected. And then he came back and was thinking what to say to his mom so that she would believe it was him. While he had fragmentation responses on the Rorschach. and he wants to marry her. and 3) with their feelings about their changing bodies.” The boys’ resurgence of oedipal feelings is evident in one boy’s TAT story: “There is this girl in high school. Based on their mothers’ reports. And she likes this guy here. and she won’t let them get married.

one during early latency and another in preadolescence. 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. In both waves there is evidence of a change in the antecedent mode of object connection and the concomitant breakdown of self-coherence. The following TAT story expresses this wish: “This lady was the wife of the guy who got in the car accident.” Table VI summarizes the findings for the ten. oedipal concerns this age. 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. . oedipal concerns Strong aggressive and sexual feelings.198 Rona Knight TABLE VI Summary of findings for Ages Ten and Eleven Years GIRLS BOYS 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 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. there is also a quality of a wish to return to lost oedipal objects.and eleven-year-old boys and girls. So she got really depressed and she committed suicide ’cause that’s a gun right there. He died and so did her kid and then she lost her job. While this appears related to their sexual and aggressive feelings. Discussion Analysis of the responses of these ten children outlines a process of attachment and autonomy that occurred in two waves.

Kohut (1971) also theorized a regression to a state of feeling fragmented when the child experiences an absence of the narcissistically invested lost object. 1969). along with attempts to re-establish the union through visual fusion and other archaic forms of identification. karate. and Sander (1980) described at the beginning of the mother-infant regulatory system that gets established in the neonatal period. Bowlby. screamed. during a crying episode.” When working with children and adolescents in analysis. A sense of an unconscious. as well as object removal and deidealization. as they similarly are in early adolescence. internal lack of integration may be a necessary part of the separation process. 1980. Tyson and Tyson. another developmental period of growing autonomy. dance. a desire to be attached and connected that has roots in the earliest phase of infancy (Pine. This yearning . Experiencing a lack of integration is consciously expressed during normal developmental periods of separation. their expression of feeling a lack of selfcoherence may indicate that they are entering a period of transformation in development. after school programs. all of which can feel destabilizing. Feeling a lack of self-cohesion may also be a response to the conflict of independence. etc. Sander. they are also about a yearning to merge..200 Rona Knight their early latency children for after-school activities like scouts. sports. describe their mothers as “the tape that holds me together when I feel in pieces (or unglued). 1990. 1985. 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. The one girl who did not have any fragmentation responses had difficulties managing separation in her adolescence. While these latency separation concerns are clearly tinged with oedipal wishes. One mother reported that her seven-year-old daughter. 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. “I feel all in pieces!” I have heard several thirteen-year-olds. 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. This new sense of separation leads to feeling a lack of integration and disconnection that is experienced unconsciously.

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. 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. When working with latency children in analysis. which often becomes clinically noticeable during adolescence and early adulthood. Both genders exhibited oppositional behavior at home. Superman. 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. Both her findings and mine suggest that through the process of iden- . Peter Pan. This is consistent with Olesker’s (1984) findings of gender differences in the expression of aggression in the first phase of separation-individuation. most notably in the fictional lives of characters such as Pippi Longstocking. starting with the embryo and continuing. although the resulting fantasy of parental death may be the same. transformed. 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. at birth. 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. an actual death of a parent during this period can severely impede the process of separation. separating in early latency had connected to it an idea of both parents being dead. Luke Skywalker. Because of this underlying fantasy and the guilt that it produces. the girls consistently turned their anger against themselves and their siblings while the boys mostly directed it outward toward people and objects. the management of anger in latency The boys and girls experienced their anger in different ways.Attachment and Autonomy in Latency 201 for a merged closeness is well described by Homer (1992. But on the projective testing. and Harry Potter. p.” For both the boys and the girls in this study. 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. as reported by the parents.

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. I feel like I can get it any time. 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. 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. I feel like there is an easier way. suggesting the strong internal ties the girls have with their mothers. boys and girls develop different styles of processing and expressing aggression at a very early age. least knowledgeable children in that larger world. This cognitive maturation allows the child to decenter and measure himself/herself against others and experience the world as bigger and more challenging. 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. a higher level of cognition (Piaget. All the children used fantasy and magic to help them cope with .202 Rona Knight tification and cultural handling. It’s a moment when it seems like all of your problems are removed from you and you don’t have to grow up. where they really are the smallest.” 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. 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. 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. it sometimes had a quality of being a fantasized way to return or reunite with a lost object. These findings may also be an additional reason for the drop in selfesteem that Gilligan (1982) found in her study of preadolescent girls. leading to anxiety about going out into the world of school and peers. however. 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. 1967).

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. his friend Ron’s father and brothers. 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. and several male teachers to help him avoid dangers as he grows up in the magical world of Hogwarts. boys identify with their fathers and their sense of their fathers’ more competent position in the outside world. 1998–2003). The girls’ TAT stories often expressed a sense of tiredness related to independent functioning in the world.” In latency.Attachment and Autonomy in Latency 203 fears of managing on their own as they felt more separated and alone in the larger. 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. Stephen King (1983) nicely expressed this male-female . relying on her wits to help her and Harry along the way (Harry relies on her ). by contrast. The girls in this study may have identified with their mothers’ tiredness from having to maintain two jobs— work and family care. and she has to study magic very hard (sometimes taking two classes at the same time). This supports Anna Freud’s (1936) and Sarnoff’s (1976) finding that fantasy is used as a major defense in the latency period. yet the girls could not imagine their mothers as helping figures in the world outside of the home in their fantasy. and the use of magic within that defense is significant. in her separation from the post-infancy mother. Harry has his god-father. 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. challenging world. Hermione. noting that the boy has his father to support and maintain his personal and gender identity. and/or their mothers’ overriding maternal function of being the main caretaker of the basic needs of the home and children. All of the girls’ mothers worked part-time in professional positions. 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. while the girl. has parents that are of no help to her. The boys in this study also felt they could rely on their fathers to help them manage difficulties in the world outside the family.

. the talismans. requiring them to remain more dependent on their mothers for help with their school work and the structuralization of their environment. the words of power” (p. maintained caring peer relationships. the quality of the connection did seem to be dif- . put that down you don’t know where it’s been . requiring the boy to more fully repress his primary relationship and. The nine.204 Rona Knight 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. the degree of dependency attached to it. Their unconscious feelings of disconnection seemed to be a response to their internal experience of separation.to eleven-year-old boys in this study. In their effort to break their oedipal tie to their fathers. Another explanation for this gender difference may be found in the remains of the late oedipal phase conflict. but did not necessarily lead to a denial of relational needs in their peer relationships. while the girls unconsciously experienced their fathers in this same way. Two of the boys felt an intense sense of disconnection at age nine that the girls didn’t have. while feeling internally disconnected and isolated. which would increase nurturance needs in the face of moving out in the world without the internal reliance on their fathers. However. It is interesting to note that the two boys who retained a sense of connection at age nine both had mild learning difficulties. While this finding supports her theoretical position. the relational picture is more complicated. Their attachment and loyalty to a primary. when combined with their lowered self-esteem. . the girls need to distance themselves internally from their fathers. the early latency boys unconsciously experienced their mothers as dead to them. close male friend was much more constant than the girls’ friendships were during these years. 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. but it’s from your father that you get the magic. 36). may sometimes leave them feeling that they are not competent enough to be completely out in the world. This might make the girls feel they have to bank on their own resources. This component of the girls’ identification with their mothers. 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. Their increased need to rely more on their own resources may add to their feelings of lowered self-esteem by the age of nine. consequently. In this study.

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. however. additional studies on large numbers of children from different cultural. in that girls don’t have to give up their original love object. This forces them into a differentiation pattern earlier than the girls and may promote earlier development of separation and independence. 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. cognitive. Although both sexes experienced this development. She suggested that this might lead the girls to enter the oedipal period less well separated from their mothers than the boys. more comfortable period. allowing them to remain in the oedipal phase for a longer. reported that mothers were more likely to push boys toward independent behavior and keep girls closer longer. this study can only generate hypotheses about the developmental process for all children in this age group.Attachment and Autonomy in Latency 199 Because of the small number of homogeneous subjects who were studied in depth. they had different timetables—the boys entering this phase one year earlier than the girls. 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.” The biological clock (Shapiro and Perry. these findings can only be applied cautiously to a more varied cultural. 1993). This may explain why the girls may have a different timetable. Olesker (1990). Although both parents and children were ambivalent about this new phase of separation and autonomy. 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. all of these parents registered . Therefore. studying separating toddlers. the convergence of data from a variety of sources makes the results compelling and ring true with our analytic observations. 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. Several possibilities could account for the gender difference in the latency process of the development of attachment and autonomy. While there is value in small N studies (Jones. At the beginning of latency. or socioeconomic group. In addition. racial. 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. and socioeconomic groups are necessary to validate the ideas proposed in this paper.

By age nine all of the children had consolidated the latency phase of separation and autonomy. 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. (1974) noted that the nineyear-olds on the Rorschach protocol look “neurotic or disturbed. Ames et al. This return to the seven-year-old subjects’ feelings was . which were in greater power than their defenses at this point. all the girls’ Rorschach protocols once again had fragmentation responses along with concerns about merging and breaking apart. Between the ages of ten and eleven. Piaget. physical abilities. 1966. 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. late latency/preadolescent attachment and autonomy At age ten there starts to be another clear distinction between the boys’ and girls’ development. socialization. 1967). very similar to their seven-year-old protocols. Freud.Attachment and Autonomy in Latency 205 ferent—the girls talked to each other more and shared fantasies in play. and the autonomous use of defense functioning. (1974) also reported a similarity between the ten. 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. the boys did a lot of physical activity together but talked less. Ames et al. resulting in the breakdown of defense functioning and the considerable distress that can be seen on their Rorschach protocols.” 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.and seven-year-old Rorschach protocols. It is also compatible with Blos’s (1967) description of adolescent separation in which ego impoverishment follows the sense of internal object loss. similar to the talking and hearing vibrations one girl in this study reported. 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.

just as the girls were. as the girls’ newly established ego functions were further bombarded by their drives and the additional stress of a new phase of separation. 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). while the others still looked like latency boys at age eleven. Mahler (1972) has reported the defensive use of rageful. which starts earlier for girls than for boys. This preadolescent phase of separation is certainly related to a biological clock driven by a major change in hormonal functioning. all of the boys were internally preoccupied with connection and separation.206 Rona Knight nicely expressed by one ten-year-old girl’s response to the blank TAT card. as discussed in the introduction to this paper. Because data collection in the present study stopped after age eleven. The girls did manage to maintain their high functioning in school. The biological time-table that contributes to these two waves suggests a discontinuous process of attachment and autonomy separate from underlying dynamic conflicts. 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. when the latency child begins a new phase of separation and autonomy from his/her primary objects. While only one boy was clearly in early puberty and showed fragmentation responses at ages ten and eleven. This finding suggests that boys tend to remain in a late latency/prepubertal stage of development longer than girls do. Middle latency would occur at . The disturbance in defense functioning seen at age nine continued. distancing behaviors in girls toward their mother during separation. This time parents reported that their girls “had become very difficult. albeit not unaffected by them. since the one boy who did feel fragmented was in early puberty.” were easily angered. 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. the early latency phase would be between six and eight years in boys and seven to eight years in girls. One may assume that this next phase of separation is biologically driven. had frequent mood swings. as teachers continued to praise their abilities and behavior. and mothers reported a significant increase in mother-daughter confrontations. stages and phases of latency The stages and phases of latency have been described in the literature in many different ways. easily had hurt feelings and became upset.

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CLINICAL STUDIES .

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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. Samuel Abrams. and the capacity for make-believe to the early intersubjective exchange between mother and infant. Presented as the Robert Kabcenell Memorial Lecture. Neubauer. M. ed. Peter B.D. Robert A. narcissistic balance. Ego State. So—here I am in the dark alone. I play to myself. Neubauer.Play in the Psychoanalytic Setting Ego Capacity. copyright © 2005 by Robert A. Columbia University Center for Psychoanalytic Training and Research. and A. I can play whatever I like to play. King. 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. The Psychoanalytic Study of the Child 60. New York Psychoanalytic Institute. Developmental research links affect regulation. King. There’s nobody here to see: I think to myself. 213 . Scott Dowling). Samuel Abrams. Scott Dowling (Yale University Press. Here I am in the dark alone. and A. and Vehicle for Intersubjective Exchange KAREN GILMORE. And nobody knows what I say to myself. March 9 2004. What is it going to be? I can think whatever I like to think. Training and supervising analyst and Head of Child Division. Peter B.

the child patient will usually produce some form of play that can serve as a shared “intermediate region. and yet distinguished from the enactments that directly draw the analyst into a dramatization of unconscious fantasy.214 Karen Gilmore I can laugh whatever I like to laugh. 1993. despite possible inhibitions and constrictions. Through discussion of one boy’s particular difficulties. Solnit 1987). No longer reduced to merely a discharge or wish-gratifying phenomenon. The child clinician expects that. There’s nobody here but me. are also prevalent in child analysis (Chused 1991).” by A. 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). 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. 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. it has been increasingly privileged as serving a central role in child development. i describe my efforts to understand a latency age boy. . dynamics. pseudomaturity or chaotic impulsivity which may deform the playing function. —From “In the Dark. The absence of play creates formidable obstacles to therapeutic progress and indicates serious ego-impairment in the child. Play has been addressed extensively in the analytic literature even before Freud’s immortal description of the “Fort-da” game (1920). Play in Psychoanalysis In child work. it is conceptualized as a complex normative growthpromoting capacity that evolves with cognitive and psychological development (Marans et al. 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). with the advent of ego psychology and observational studies of infants and children. Milne in this communication. A. of course.” (a term borrowed from Freud’s 1914 metaphor of the “transference as playground”) where the action of the analysis can safely unfold. and mental representation of intolerable psychic experience becomes bearable and achieves therapeutic effect. diagnosis. which. and interpersonal relatedness.

play differs from enactments in that it is. In child analysis. 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. dynamic. Like enactments.” 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. “make-believe. Because the playing analyst. and transference meanings within the play.Play in the Psychoanalytic Setting 215 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. In child work where playing is prominent. and serving as author of. to be truly effective. there are layers of diagnostic. i. Yanof 1996. “symbolic interactions between analyst and patient which have unconscious meaning to both” (Chused 1991). reciprocal engagement. either implicitly or explicitly. Cohen and Cohen 1993). both explicit and unconscious (Abrams 1988).e. 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. 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. Beyond mastering the typical countertransference anxieties around regression and instinctual discharge. However. this state is concretely anchored to favored play objects endowed with layers of meaning. although the patient’s contribution is privileged by the nature of the endeavor. While both action and verbalization are involved. must fully engage in playing (Birch 1997. the play is inevitably co-created and contains elements from the unconscious of both patient and analyst. as well as . play typically reveals that the analyst is both “playing a role in. someone else’s unconscious fantasy” (Ogden 2004) that inevitably reverberates with her own. 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. and interpretive work.

Of course. even young children know.” a world whose rhythms. but bridging it is a crucial moment in the treatment. by no means without its own resistances and defensive organizations. the next level. 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. more than any other professional who works with children. the analyst readily launches herself into the singular world of her patient’s “state of playing. Insights from Developmental Studies Before describing the work with Andy. children differ a great deal in their guardedness around this threshold. This is the moment where the child admits the analyst into his private world. among these are the pathological adaptations that can be addressed best by being in that world with the child. allowing a more informed speculation about how Andy’s par- . 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).216 Karen Gilmore 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. Over time. As for the child patient. 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. Both child patient and analyst must be willing to engage wholeheartedly (Birch 1999. within a short time. 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. that playing with an analyst is a very different business from playing alone or even with another child or adult. rules. to borrow a favorite video game metaphor. Yanof 1996) in the “conceptual world” (Cohen and Cohen 1993) that the childwith-the-analyst creates. Playing with the analyst is all at once revealing the self. but the juncture marks a point where the treatment relationship reaches. I believe that the child analyst. and rituals as well as opportunities for therapeutic work are unique and to some extent idiosyncratic to the particular individual and the dyad.

self-experience. 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). 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. “the infant and the maternal care together form a unit” (1960). A number of seminal papers written by psychoanalysts and psychoanalytically informed baby watchers from previous decades. such as Anna Freud. This idea and its variants rephrase in concrete ego psychological terms Winnicott’s principle: “there is no such thing as an infant. which. Infant observers and cognitivedevelopmental scientists have been able to illuminate the steps in the emergence of affect recognition. Winnicott’s work elaborates the notion that the “inherited . Weil termed this the “basic core” which establishes the earliest “regulatory stability.” “regulatory” and the like. Given the nature of our contemporary child patient population. like Andy. 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. is distinguished by a variety of disorders alternately called “developmental. Emde. and Shapiro. Pine. mutual regulation. Findings from allied disciplines underscore the importance of the earliest relationship for many facets of future development. symbolic capacity. my italics). Weil. and implicit procedures that characterize object-relatedness. Winnicott. adumbrate these contemporary conceptualizations and facilitate their contextualization within our psychoanalytic metapsychology. such as affect regulation.” that is.Play in the Psychoanalytic Setting 217 ticular history and endowment disadvantaged him. Sander. 242– 43. demonstrating the significant contribution of the environmental surround (Stern 1985). Mahler. self-reflective and symbolic capacity in the context of the earliest interaction with the caretaker. While much of Andy’s relevant personal early history was indistinct due to his parents’ relative lack of awareness.” this regulatory stability—or relative lack of stability—contains directional trends for all later functioning” (p. 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. the absence of imaginary play and even typical infantile play (such as peek-a-boo) with either parent was noteworthy.

For example. Pine 1982). Indeed. . of having intentions in mind . of physical cohesion. and theory of mind studies. the senses of creating organization and the sense of transmitting meaning” (pp. Emde 1983. 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 human infant discovers that the other has a mind of her own and that that mind can be engaged in sharing subjective experience. As the study of the self began to eclipse the ego in the literature. 6–7). social referencing referred to above. infancy research offers a series of elegantly simple paradigms. the sense of a subjective self that can achieve intersubjectivity with another. The very young infant “neither distinguishes self from object nor is able to manipulate symbols and . . reflective function. . or rather a number of “senses of self. of continuity in time. the emergence of each process is importantly interrelated with that of the other” (Drucker 1979). 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. the emergence of the self as a developmental accomplishment increasingly occupied infant observers and researchers (Mahler and McDevitt 1982. 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). 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. the “dawn of intelligence and the beginning of the mind” (p.” This maternal matrix facilitates the tolerance of anxiety. Stern and Sander 1980. 45). 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. In 1985.218 Karen Gilmore potential of the infant cannot become an infant” without the maternal care. . the visual cliff. the product of a complex transaction that begins within the first days of life. structured integration of the personality. such as Tronick’s still face. Between seven and nine months. Stern drew upon his infant observational studies to posit that a very early existential sense 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. which in infancy is guided predominantly by “maternal empathy.

it shows that the infant is available to receive the attribution of meanings to objects and circumstances from the mother. this configuration of experience affords an infant the opportunity to learn that given objects and events can have multiple. Gergely (1996) calls upon the infant’s sen- . infantile defenses against traumatic helplessness and impotence. Interestingly. when internalized. “The infant relates not only to the world as perceptually specified. Broucek. provides a key component of future self-regulation of affect. interpersonal. the child achieves the developmental level required for symbolic play. and the process through which meanings of things are conferred by minds. In more recent studies. 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. 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). Another tradition within infant observational studies underscores the crucial role of contingency detection. The meaning-for-me is not necessarily the meaning-for-her” (Hobson 1993).Play in the Psychoanalytic Setting 219 i.e. violations of contingency expectation early in life can instigate withdrawal and avoidance. reviewing the relevant research prior to 1979. . an infant capacity that is demonstrable within the first months of life. this same moment illuminates the infant’s recognition of separateness. this capacity has also been shown to figure as a key component in the development of narcissistic integrity and the capacity for make-believe. or cultural level. Moreover. 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. looking at the mother’s face for affective guidance. a process which. but also to someone else’s psychological relation to that same world . [More important than mere information about the world]. an essential step in the development of symbolic capacity and imagination. is a developmental milestone that highlights the presence of self-other differentiation. Thus. With these developments comes the possibility that objects and their meaning can be assigned and transformed by creative invention on a personal. the intersubjectivity of his mental state as he obtains the required affective guidance from his mother’s expression. In addition. . person-related meanings.

mock displays of emotion. constitutes a vital step toward symbolization and the world of make-believe. as well as on dynamic and educational factors. 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. the infant engages in the excited interplay of emotional expression with the parent. delight. he achieves the associated developmental milestone of distinguishing. psychopathology and color the interchange with the environment throughout life. fear. by their markedness. there is no doubt that these variations feed into. as well as reflect. 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. I believe that the impact of these features are far more powerful in presentations in childhood than in adulthood for a number of reasons. anger. While the stability of findings from neuropsychiatric testing is variable depending on the age of the child. recognizes the nature of his mother’s affects. Many of the children we see today have been examined systematically in terms of their ego equipment and their genetic pedigrees. and sadness and ultimate re-creating these “play” affects. and comes to distinguish real affect from pretend (i. from real ones. and so on. to appreciate and distinguish the mind of his caretaker from his own. including the obvious one that adults have developed more stable . correctly interpreting mock surprise. of course. 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. to identify his unique intentionality and agency (Fonagy and Target 1998). With these miraculous achievements. 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). those playful exaggerated expressions of surprise. This. “marked”) affect.220 Karen Gilmore 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. 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.e. learns to selfregulate his emotional state based on parental mirroring.

I and others (Gilmore 2000. 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. he fell within the spectrum of neurotic/developmentally uneven/ dysregulated patients who are the staple of contemporary child analytic practice. and a markedly constricted inner life.e. despite early indications to the contrary. both considerable and commonplace. fell within what I consider to be the usual contemporary range of analyzable childhood psychopathology. Elsewhere. . plus the report of maternal depression in the first year of life and his parents’ orientation toward emotionality in general. with marked delays in coordination. His vulnerabilities diminished his opportunities for the early repeated experience of joy. diagnostic. In the following. nurture. allows us to take into account the impact of developmental idiosyncrasy on the evolving structure of the mind. 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. support hypotheses about the complex bio-psycho-social underpinnings of this boy’s particular difficulties when he presented in early latency. and sustained alert attentiveness. The working hypotheses which thus guided Andy’s treatment accumulated over the course of my work with him. The degree to which his psychology was influenced by a documented developmental strain due to markedly uneven cognitive and physical maturation is. history. and parental admiration in the routine fine and gross motor accomplishments of early childhood. that is. enhanced by our greatly improved assessment techniques. and environmental expectations and demands are all intermingled and clearly contribute to the child’s suffering. Greenspan 1989. impulsivity. Cohen 1991) have suggested that our current thinking. I believe. self-satisfaction. These considerations. intolerance of affect. i. visuo-spatial integration. and his low thresholds for frustration and stimulation tolerance impacted his sense of efficacy and his availability for easy interpersonal exchange from the outset. I would speculate that Andy’s extraordinary degree of uneven ego endowment.Play in the Psychoanalytic Setting 221 ego organization and adaptations and are rarely called upon to perform in as many diverse arenas as the average school child. on-going development. The child analyst thus faces a diagnostic and clinical challenge where the multiple transactions among nature. I will tell you more about Andy who. which included the absence of unstructured play. I offer them here in advance to show the interweaving of the developmental.

behind which lay anguished loneliness. especially his limited capacity to sustain quiet alertness and focus (ADHD) and his reduced proclivity toward object relatedness (non-verbal learning disability). 3. I came to conceptualize the core of Andy’s pathology as a complex disturbance in his ego organization. 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. His clinical presentation. a state that we rely on as child analysts and that we usually get to experience directly or sometimes only indirectly. Andy did not play because innate constitutional factors. interference in maternal attunement. 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. 2. where affect regulation and imaginary play find their origins. coupled with his perfectionism and his fear of his own affects. Furthermore. corroborated by his history. and. possibly. Andy used his constitutionally based tendency to “tune out” as a powerfully opaque . Andy did not play because ego weaknesses. 5. Andy did not play because affective expression was devalued in his family and precocious intellectuality was strongly prized. 4. diminished his availability for early engagement with his mother. triggered. these defenses further squelched his freedom to play creatively. and mistrust of adults—all attributable to the factors outlined above. exacerbated. To my way of thinking. emotional exploration. Obsessional defenses against his constitutionally determined impulsivity were reinforced by his intellectual. showed that he had on-going difficulty establishing and maintaining an intersubjective state where self-discovery. Over the course of the two years of treatment to date. “workaholic” parents. and were recruited by each other: 1. one that remained as an on-going (although also evolving and transforming) limitation in his development. and creativity are engendered.222 Karen Gilmore and dynamic issues as they served to light the way in what sometimes seemed a discouraging darkness. His analysis has indeed been marked by fierce resistance. 6. where his inner world can be made manifest without crippling self-consciousness. constitutional factors. narcissistic fragility. they represent a complex series of interacting influences which determined. Andy did not play because his narcissistic fragility and sense of internal impoverishment inhibited the development of fantasy and the expression of creativity. as with highly oppositional children. heightened his fear of his affects and his difficulty developing signal function.

his frustration with homework. At home his “oversensitivity” to slights and misunderstandings. New and peculiar behaviors included his refusal to swallow his saliva. most significantly depressed were the scores on tasks that required visuo-motor integration and visual memory. Andy’s distractibility and hypermotility were viewed as serious impediments to his learning and medication was recommended and begun. Attention deficit disorder. However. and twirled about. he had had no prior contact with a child psychiatrist. despite his teacher’s report of significant improvements in his learning. he removed himself from contact with other children. which he retained in his mouth and spat out at intervals. and fine and gross motor delays. His behavior at recess was increasingly reclusive. he was just short of 8 years old and had been on stimulant medication for about 6 months. resistance. the consultation with me was arranged after Andy bolted from home . His nighttime enuresis. Neuropsychiatric test results corroborated an extraordinary degree of developmental unevenness with a 41 point difference in his superior verbal and low average performance IQ. On stimulants. and his insomnia were all worsening. Andy’s overall state worsened over the year to the point that there was now an urgent need for psychiatric input. Andy was more impulsive. rather than less. His meltdowns and impulsivity spilled over to the classroom. seemingly lost in fantasy. paced.Play in the Psychoanalytic Setting 223 ego-state of pseudo-autonomy. these factors conspired against Andy’s experiencing an open exchange with me. Talk of suicide and reckless behaviors finally frightened his parents. Andy When Andy’s parents first sought consultation. and disengagement. to the point where his teachers felt that they needed extra help dealing with him in class. his parents consulted a pediatric neurologist. but with most damaging effect on his weak performance scores. grapho-motor delays. and visuomotor learning disability were diagnosed. distractibility. His attentional lapses and difficulties with organization were felt to impair his capacities across the board. when his school had urged his parents to seek an evaluation for his hyperactivity. Consistent with his parents’ orientation toward cognitive approaches. had increased and he also began wetting and soiling at school. typically occurring once or twice per week. his affect dysregulation and low frustration tolerance were attributed primarily to the combined impact of these disorders. and his emotional instability was becoming unmanageable.

who was herself in an on-going treatment. reacting with dismay tinged with a kind of abashed perplexity and frustration. They complied with the school’s insistence on a “shadow teacher” but viewed it as alarmist. the “ease and continuity” of on-going experience (Pine 1982)? Parents’ transparency in terms of their representation of themselves. but at the same time suggesting that everyone was exaggerating the seriousness of his disturbance. the shared assumptions.” 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.224 Karen Gilmore one night and ran several blocks. they conveyed bewildered sympathy for their son’s situation. Andy’s mother. she felt peripheralized as an excessive worrier. acknowledged her own significant depression during Andy’s first year of life precipitated by her father’s death. The idiosyncrasies of their own dynamics and the dynamics of their relationship as it emerges willy-nilly in the consulting room. their relationship. She also articulated a tension between herself and her husband and indeed his entire extended family. 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. well intentioned. their complaints about each other or their child. the unspoken expectations about engagement. kindnesses. their blind spots. before being apprehended by a policeman. a “mother hen. and exceedingly busy professionals. Well educated. What was most striking in my conversation with his concerned parents was their lack of awareness of Andy’s mental life or.” 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. This posture previewed their reaction to the recommendation for analysis. In meeting with parents. as if. Later in the first year of treatment. lapsing into a kind of hapless posture. I am often aware of a process of identification with my child patient. to some extent this corre- . The mother seemed unable to sustain her position in the face of this attitude. of subjective or interpersonal experience in general. She had come to recognize that as she increasingly gave voice to her feelings. across busy intersections. for that matter. Woody Allen-like. their reflections on their own psychologies and their personal histories. and cruelties accrue in our experience of the parents and facilitate our capacity to understand our patient’s experience. 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. she was just being “neurotic.

he insisted that he couldn’t explain what he was thinking and besides. which he is not. I recognized the . even about the mundane facts of his life.” He spat surreptitiously into the garbage can.” Andy’s parents’ opacity adumbrated the powerful interference within the analysis. the absence of the medium of play. Andy announced: “I’m an oxymoron. but in such microscopic dimensions that he became agitated and inconsolable as his attempts proved unsatisfactory. 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. he would silence me by saying. For example.” and then. He attempted some drawing and coloring. Early in our relationship. I’m trying to think . a posture I have suggested is his “opposite” way of declaring that I’m the “butt-face. He did not play and he seemed most emphatically unwilling to talk. that is. for example. . presumably because we drew together. he insisted that any activity he agreed to participate in must be done lefthanded and claimed to be left-handed. He then proceeded to demonstrate his global determination to “do the opposite”.” While this behavior ultimately yielded to interpretation. On other occasions he would simply stand stock-still and stare at the clock. 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. “Stop talking. 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. after multiple false starts that seemed to lack specific content. while everyone wanted just the opposite” for him.” proof of which.Play in the Psychoanalytic Setting 225 sponds to their own self-reflective capacity. When I tried to explore any topic. among which I include myself. as well as to the particularities of their individual dynamics and psychopathology. he consistently began our sessions by flopping himself upside down on a chair or floor cushion with his buttocks in the air facing me. But as his oppositionality alternated with a worrisome potential for compliance. he suggested. As suggested above. also expressed in presenting his butt submissively to me. “you wouldn’t understand. 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. at one point. . Even after Andy settled into the routine of treatment. was his “wish to die. especially one that bore on him and his mind.

since his agitation seemed driven by anxiety and despondency. to mold to. he was desperate to refuse and resist. but without a better sense of his . It also illuminated how his oppositionality had hardened within the breach into a monument of stony isolation.” he finally replied. 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. In the following 3 months. the sine qua non of child analysis. of course. His nonstop screaming brought the neighbors to my door in alarm! When his mother repeated.” 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.226 Karen Gilmore polar manifestations of his oppositional defense against exposure of a poorly developed sense of self. “Something in me wants to do that. my goal was to “listen” to Andy’s action and find a better solution to his medication problem. While not perfect. an activity that is. “Andy. I’m here waiting for you. it seemed to me as if he had come to experience everything coming from a supposedly helpful person as a poisonous. He repeatedly retreated from the establishment of mutual engagement and. refusing to go farther and bellowing for his mother who was sitting in the waiting room 10 feet away. just come in here. but another part says I can’t after all this. with a very gradual diminution of his symptoms. but he could not seem to use the other for mutuality and progressive development. a threatened sense of agency and a personal agenda that is organized primarily around maintaining his fragile narcissistic balance. murderous. although it remained unclear whether I was medicating an iatrogenic or endogenous disorder. 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. 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. or disintegrating intrusion. understandably. I won’t let me. The assessment period did not auger well for analytic work: indeed. In this initial phase of the treatment then. Andy relied on the other as a form to submit to. a marked improvement was achieved by changing his stimulant and adding an SSRI. I saw Andy twice per week. despite his considerable intelligence and verbal agility. or to repulse.

explore conflict. and resistance. he seemed eager to spare my feelings and to attribute his reluctance to his absorption in reading. unable to sustain the pretend mode in any form. even in the remote form of “I see you are still letting me know you aren’t so happy to be here” worried him. Andy seemed to acquiesce to our sessions and his self-described “oxymoronic” behavior. It was not that his play was primitive. seemed shapeless and aimless. the Andy of the present. quickly undoing the rare and minimal expressions of anger or hostility by his characteristic phrase. and remote but remained unable to generate any play. board games or cards. What was there. refusal. 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. Andy just seemed stymied. deep within Andy? This remained puzzling to me. and analyze. 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.” Whereas the Andy of the past seemed to define himself by anger. treasured opportunities to view his management of competitive feelings. my experience of Andy continued to be curiously blank. that he couldn’t talk about certain things with me “yet” because he didn’t know me well. But he remained aimless and profoundly impaired in his capacity to play. despite his earlier presentation. apparently divested of oppositionality. “I’m only kidding.Play in the Psychoanalytic Setting 227 inner life. But they were few and far between. perseverative. chaotic. When he told me in response to a question. The Andy that gradually emerged was manifestly far less disturbed. I later understood that any allusion to feeling on my part. with Andy. those moments were. In general. with its reflexive oppositional stance. upon which the dynamic child clinician typically depends in order to diagnose. dysphoric. 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. In most sessions. stereotypic. or lacked key features. Andy seemed exceedingly careful and polite. abated. When I addressed this whisper of resentment. . 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. courteous spinning top. After the medications were removed and with an increased frequency of sessions that I proposed as a trial. I felt more optimistic. It was as if both of us had to be affect-neutral to maintain Andy’s equilibrium. and mostly at my instigation. such as characterizations and narratives. as if I were in the company of a highly mobile.

he would rock on the rocking chair. I began to feel that I complained about his not playing with me the way he did.” I was of no value as a playmate. These petered out quickly and never got carried over to the next . I had no insights or hunches. My presence did not even promise the simple advantage of a compliant other “at his service. Once in the playroom. wheel about on the wheeled chair.228 Karen Gilmore with little or no affective expression. For example. I began to sense that the paucity of “ideas” that Andy manifested had colonized my mind. less depressed than he had been on antidepressant medication. and in this way. 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. formerly distinguished by passionate refusal. and despondency. Moreover. developing a relationship with him. gaining understanding for both of us. and he was able to play with peers when they provided direction. Indeed by not providing a play agenda.e. he reported great enjoyment of role-playinggames (RPG’s) but said he was a poor “dungeon master” (i. I had the demoralizing impression that I had no ideas about him dynamically. 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). At home. While I did not minimize the potentially inhibiting impact of my “other” agenda. that of knowing him. the atmosphere in the sessions. was now curiously flat. about my office. he could not direct the play) and was therefore unable to import such play into our sessions. or jump free-form about the room. in order to attempt an RPG with me.e. although much less often. He said with some resentment that since I did not “give him ideas. with no play agenda but Andy’s own. often colliding into various projects of other children but without a discernable intent to destroy. I came to feel that the apparent paucity of internal resources was pervasive in Andy’s experience. frustration. To reiterate the absence of the usual culprits: Andy seemed. he did not appear grossly inhibited in any obvious way. at least superficially. there was conversation but the evolution of themes that could knit our work together was curiously absent. Even worse.” i. usually quite apparent in the palpable rivalries of our child patients. he was no longer adamantly oppositional and resistant. his “play” consisted almost exclusively of video and computer games whose complex story lines he would “borrow” on rare occasions. he did not appear chaotic. I denied him the necessary borrowed scaffolding (or content) for what Andy called “playing” to take place. The content of the hours was almost impossible to recount.

he was unable to generate any activity where we engaged in mutual discovery and elaboration of meaning. by definition an avoidance of a shared mental state. Andy’s insomnia. Nonetheless he told me some time later that while he appreciated the improved sleep. I would realize that he had gradually turned his back to me. Andy most readily lapsed into his default position. 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). 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. were attempts to trick me. his parents and I agreed to try it. marked hyperkinesis. 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. Other activities he proposed. his “tuning out” state of mind. was finally introduced. there was none of the often preemptory drivenness of the child patient who is playing out important thematic conflicts in displacement. often in response to my observation of his disengagement. Andy’s progress in the past two years of treatment has been considerable. who comes in knowing just where the play left off and easily reestablishes continuity. he frequently responded to my interest in what was on his mind as if I were. and therefore did not generate the same resistant response that he was able to mount to the stimulants. In the assessment period. Without my intervention. Often. when he engaged in some motor task like tracing a picture. I began to think about Andy’s quality of relatedness. and restlessness improved. his transference in the broad sense. Overall. moreover. with a dramatic cessation of disruptive meltdowns. the Strattera seemed to have little effect on Andy’s conscious experience. a state as closed to introspection . whether he actually noticed it or not. While this seemed to improve to the extent that he did not forcibly attempt to silence me. Strattera. 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. a new non-stimulant ADHD medication. Andy returned to school without any medication and when 4 months later.Play in the Psychoanalytic Setting 229 day. he didn’t like the idea of medicine. improvement in frustration tolerance and in overall functioning. like the intrusive medication. on a relatively low dose of Strattera. In fact it was the rare exception that a motif generated one day was taken up the next. trying to disrupt his control of his thoughts.

he interpreted any sign of intensity in me with alarm and did his best to neutralize his own emotions. I could also sample the frustration and anger that this neglect engendered. Andy certainly was not eager to engage in an open communication with me. “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 was struck over and over again by Andy’s effort to be objective and to eschew the range of emotion that most people experience. at times this appeared as a visible shift in his attention which in some children marks the intrusion of inner fantasy or preoccupation. I regularly observed Andy’s use of this “tuning out” to slip into an ego-state unavailable for communication and intersubjectivity. emotional expression was fraught with potentially catastrophic narcissistic consequences. Only unmodulated disruptive affects (Lecours and Bouchard 1997) could force themselves into full expression. in the treatment relationship. Affects that were better contained and potentially verbalizable were apparently experienced as intolerably demeaning. “maybe other people have more.” Andy’s stance was clearly an identification with and an attempt to please his father. It was clear that for Andy. when the dust settled. but this identification had a far-reaching impact on .230 Karen Gilmore as it was to my inspection. once again denying his loneliness and distress. As mentioned earlier. but I just have two ‘big emotions’: frustration and embarrassment. he admitted to almost no emotions at all. In fact. but which protected him from any experience of interpersonal desire or vulnerability. his mirroring my neutrality was far more successful than my capacity to maintain it! In one session. “My parents never play with me. I came to realize that Andy’s access to his inner life was also compromised.” those inarticulate chaotic tantrums. as in his so-called “melt-downs. In order to even establish contact I had to break through his self-absorbed inwardness with my increasingly plaintive refrain. he described a frustrated. While Andy concurred with the “fact” of this connection by saying. and were vigorously disavowed. which at this point were rare events and hardly ever occurred in my view. While I initially approached these “disappearances” with the confidence that he was internally occupied.” he demurred about the associated affect. a sense of pressure. and an absence of specific content. but this was at least in part because he simply did not have the tools to do so. but. To this he replied. I recalled his apparent willingness to be wildly out of control in the opening months of our acquaintance. stymied feeling. that’s why I don’t know how to play with you.

While he demanded his parent’s presence in these struggles. Andy would fall into an anxious and paralyzed state that extended the activity for hours. The same narcissistic pressure impeded verbalization and thought in other arenas. as if they diminished him.” since any input from others immediately threatened his originality. because he was unable to rest until he was sure of producing work that was extraordinary. as he could tolerate my musings about his extraordinary absence of feelings and what I. a mere mor- . and loneliness. but he vigorously and elaborately denied these feelings. 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. Despite my first-hand knowledge of his rages. also contributed to this disavowal of feelings. some of them quite obvious to me. 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. Its impact in regard to his academic performance was onerous. even something as banal as an “interesting sentence” using a new spelling word. Over the course of the work. It became apparent that Andy’s urgent need to be “an oxymoron. and denied his anger in moments when he was clearly angry. he far preferred a victimized posture which he seemed to willingly embrace. tried to subdue his joy upon winning. For example. his ideal was a caricature of his father who was so remarkably unflappable. hurt. Andy’s capacity for sophisticated humor was a great asset here. an original. such as anxiety. He even denied curiosity about sex. 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. he struggled to disguise his visible deflation upon losing a game and with somewhat less determination. His parents reported that any time something “special” was called for at school.” that is. but increasingly noteworthy as his peers showed more excited interest from which he anxiously retreated. he could not use them to “brainstorm. Certainly Andy experienced many other feelings. certainly not atypical of his age group. to name a few.Play in the Psychoanalytic Setting 231 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. jealousy. and further impeded his capacity to name them and understand them. he undid even the mildest hostility by the “I’m only kidding” mantra. pride.

that in fact.” he was able to identify and admit to more feelings and more nuance of feelings. If you don’t tell me anything about you and if you don’t start anything. if you don’t show your feelings. might feel in his shoes. In one fascinating hour when Andy (I fear accurately) read my attempts to connect as a critical complaint. when he was bereft at the painful yearly change of au pair. would lure me away from seeing the hot spot where he was acutely suffering at that moment. taking the form of an imitative pseudo-analytic stance. why should I?” Here again his oppositionality seemed pronounced. and we were gradually able to recognize it in relation to a range of narcissistic and oedipal conflicts. 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- . he would transpose his feelings of loss and/or anxiety into a diatribe about treatment. He adamantly denied my observation and attributed his tears to his frustration at having to see me so often. For example. he shifted way from acknowledging his loss and resumed his litany of reproaches to me. Despite this work. was clearly present in this struggle with me over affect expression. so I won’t give mine. he said with considerable bitterness. the competitive struggle with me made him veer away from openly depending on me to sort out painful feelings. 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. It was clear to me that Andy was enduring even greater loneliness than usual. You see as much of me as I see of you. On another occasion. a pattern demonstrated outside of the treatment in his relationships with his mother and brother. It was almost as if Andy intuited that a transference complaint. instead. he thus substituted friction with me to indirectly achieve his shameful wish for closeness. As I examined the responses he tried to elicit in me by his remarkable “absence in my presence.232 Karen Gilmore tal. no matter how stereotypic. and the implicit accusation of “abnormality” that the treatment comprised. This was all the more striking because our schedule had been disrupted by his day camp and we had met only once that week. The intensity of his competitive dynamic. on one occasion. my lack of forthrightness about myself. 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. I addressed his palpable suffering while his brother was at camp and his parents were traveling for work. he was with me just like I was with him: “You don’t give your ideas.

which of course were at once displacements of painful states experienced in relation to others. narcissistic injury. to overcome helplessness. since play provides the opportunity to try on identifications. Not unexpectedly. 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. 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. Solnit 1987. (From “One. were typically followed by a rapprochement which was certainly motivated in part by guilt and anxiety. he is suffering from an on-going developmental handicap that has widespread reverberations. and shameful sense of inadequacy. to modulate drive derivatives. and a way to engage with me and keep me at a distance all at once. was less available than its defensive function in the here and now. One is the loneliest number that you’ll ever do (But) Two can be as bad as one. Neubauer 1994. its history in his relationship to his father. that his attempts at creativity were strained and empty. he said with great poignancy. expressions of on-going transference themes. Friedman and Downey 2000) on its crucial role in development. these rare moments of openly expressed resentment toward me. Mayes and Cohen 1993. to practice gender roles. 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.e. i.” by Three Dog Night) Without the precious medium of the playing state. It’s the loneliest number since the number one. there is at least an equal emphasis (A. The transference meanings of his complaint. I had ample opportunity to see that this posture protected him against the frightening feeling that he couldn’t think of anything. Abrams 1993. 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. Freud 1965. and so on.Play in the Psychoanalytic Setting 233 sue him. to master developmental challenges and personal trauma. and that he was just an ordinary sad and lonely kid. and therefore unlovable. A child who does not play is not only manifesting a symptom. The ability to play is a developmentally . that his thoughts and intentions seemed to drift out of his mind.

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. mammals. the array of cognitive and motor capacities required to enact the roles or manipulate the props of the play. of course. profound narcissistic vulnerability. the play with a parent. or superego severity. and the play of the child alone all share many features but differ from playing with the analyst. These variations reflect the child’s posture toward the threshold of engagement 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. and birds (Friedman and Downey 2000). These features differ in prominence and amplitude depending on the developmental phase and the psychology of the individual child. for brief or sustained periods. the play with a peer. so there are differences in play from one setting to another. critical self-consciousness and censorship.234 Karen Gilmore determined capacity with strong biological foundations serving a range of social. and intrapsychic functions. Just as Lewin (1955) observed that there are several types of free association depending on the context and intention. to play in our playrooms. interpersonal. I believe that the many excellent psychoanalytic contributions on the subject have underemphasized the unique nature of play in the psychoanalytic setting. But the child’s capacity to play with the analyst also reflects his freedom to achieve. the displacement in the service of the ego. the associated tolerance of otherwise unacceptable impulses and affects. oppositionality and overt resistance. and. As child clinicians well know. While this circumstance may bear complex relationships to transference and resistance. in the presence of his particular analyst. there are some children who play in life but refuse. Although my intention here is not to iterate the mental building blocks of this complex function. more like the secondary elabo- . and some children who play nowhere but with the analyst. the willing suspension of a number of ego and superego functions such as reality testing. shame. it exists as fundamental premise in any session in which the child is playing. and observable in the young of all human cultures. In emphasizing the crucial and ubiquitous development-promoting features of the capacity to play. variously understood to be affected by disturbances in attachment history. 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.

recognizable self-states. I believe that despite the considerable controversy about the therapeutic value of playing in and of itself (Mayes and Cohen 1993. whose historical meanings are gradually transformed as they become incorporated into the history of this new relationship. nameless and disorganizing anxieties are named and organized. just as transference paradigms and historical memories show plasticity and evolution in the course of adult analysis (Rizzuto 2003). transforming element. narratives about the self are made coherent. describing and interpreting them with his or her own speech. In regard to this evolution. this state is more or less porous to the analyst’s playing participation. Mayes and Cohen 1993. 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. as the child dictates how much input the analyst is permitted. Moreover. because once the state of playing is produced in the treatment it becomes an intersubjective medium with its own conventions and its objects. in a comparable way. even in latency-age children fully capable of concrete operational thought. the analyst’s verbalizations are a central. Inevitably. and dissociated self-states are open to contact both . “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. in all such instances. Nonetheless. As Rizzuto (2003) declared in a recent paper on the transformation of self-experience in adult treatment.Play in the Psychoanalytic Setting 235 ration of a dream with a less exacting requirement for logic and reality. is achieved primarily through verbalization while in the state of playing. disavowed self-representations are clarified and modified to permit reintegration. Scott 1998. much like the mother’s transformation of the infant’s chaotic experience into discrete affects. Slade 1994). 293) I believe that the same process occurs in the play dialogue of child analysis. the transformation that child analysis facilitates and which the child patient anticipates. the analyst’s play state is also informed by her own unconscious mentation and her countertransference toward the particular patient. and familiar interpersonal exchange by her naming and dialogical prosody.” (p. The resilience and stability of the playing state are unique to the individual child and his relationship to the specific analyst. Cohen and Solnit 1993). 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.

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He is a faculty member of the Columbia Center for Psychoanalytic Research and Training. Peter B. An earlier version of this paper was given on June 16. within the analytic context. The interface of neurocognitive problems and dynamic concerns are examined in the treatment of an early adolescent dyslexic girl. and A. Saul is a Clinical Instructor in Psychiatry at the Weill Medical College of Cornell University and an Attending Psychiatrist at New York Presbyterian Hospital. Samuel Abrams. Through the process of reexteriorization in the transference. lecturer on the faculty of the Columbia Center for Psychoanalytic Research and Training. is mutative for learning disabled children.D. Robert A.” sponsored by the Association for Psychoanalytic Medicine. King. M. Weinstein is an Assistant Professor in the Clinical Psychology doctoral program of the City University of New York. ed. she had been unable to master reading and spelling.D. 2001. Despite previous intensive remediation. Psychoanalytic and Vygotskian perspectives are integrated to provide a model of how play. Scott Dowling (Yale University Press. and A. Scott Dowling).. King. play allows for the interpretation and resolution of traumatic situations which have become associated Dr. and LAURENCE SAUL. Ph. The Psychoanalytic Study of the Child 60. Samuel Abrams. Neubauer. New York conference: “Brainstorms: Psychoanalysis Meets Neurobiology in Development. copyright © 2005 by Robert A. Peter B. Neubauer.Psychoanalysis As Cognitive Remediation Dynamic and Vygotskian Perspectives in the Analysis of an Early Adolescent Dyslexic Girl LISSA WEINSTEIN. 239 . at the New Paltz. and a graduate of the New York Psychoanalytic Institute. Dr. but made remarkable progress after a relatively brief period of psychoanalysis.

As the act of learning becomes separate from the personal and affective context in which it took place. Lacking a clear rationale for why analysis might be helpful.” often trying on the new role of “student. papers focus on the affective difficulties rather than the manner in which analysis alters or enhances ego functions which support learning. 2000. more normative. will support reflective awareness and help modulate affective states. For a dyslexic child. Cohen & Solnit. albeit more slowly than normally developing readers. 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. the child gains access to other. The pleasure in play and the repetition it generates aids the internalization of the task and the development of automaticity.g. The existing clinical papers often fail to precisely delineate the nature of the neurocogntive problems. for whom reading may never become completely a part of procedural memory. 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 . 1998. 1998). eventuating in a hodgepodge of diagnoses lumped under the rubric of learning disabilities. These two capacities.” As Vygotsky notes. Garber. 1988. Rothstein & Glenn. Finally. Introduction the emotional problems of learning disabled children often bring them to psychoanalytic treatment. becoming conscious of what he knows may also enhance mastery of the skills of phonological processing. 1985).240 Lissa Weinstein and Laurence Saul with learning. Migden. The abilities furthered in play also act to remediate one component of dyslexia—the difficulty separating context from more abstract bits of knowledge. 1993). and in recent years the view that analysis is not the treatment of choice for children with neurocognitive difficulties (Giffin. play is essential in allowing the child to become aware of what she knows. it becomes impossible to evaluate the necessity for any changes in technique. With few exceptions (e. the child learns to “play at reality. 1968) has gradually shifted (Arkowitz. functions of play. 1989. 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. fundamental to the development of abstract thought.

analytic perspectives on play will be briefly reviewed. 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. defining trauma operationally as “an onslaught of more events in a . Waelder (1933). the focus of examination will be one curious fact—despite intensive cognitive remediation prior to beginning analysis. nor is it our intention to present an “ideal” analytic treatment. a Russian constructivist thinker and early member of the Russian Psychoanalytic society. 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. and school performance. 2003. The necessity for the interpretation of unconscious conflict is integrated with the work of Lev Vygotsky. Relying on Freud’s (1918) notion of the repetition compulsion as a way to bind traumatic overstimulation. Developmental dyslexia.Psychoanalysis As Cognitive Remediation 241 which were mutative. Natalie continued to have difficulties with spelling. 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. she was increasingly able to access reading and spelling skills that everyone had assumed she did not possess. After a relatively brief period of analytic treatment. reading. 2003). can enhance the capacity to learn even in cases of clearly documented neurologically based deficits. In the discussion. a multifactor model is proposed to explain how psychoanalysis. a treatment not directed at cognitive change. the most common neurobehavioral disorder affecting children. No effort will be made to examine the entire complex of dynamic factors in her analysis. 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. Shaywitz. Natalie made this remarkable progress despite the fact that she was not currently being tutored in reading. 1998). Instead. dynamics and development. who noted play’s dual role in helping the child to restructure cognition and embrace the constraints of reality. seems an ideal starting point for a discussion of the interactions of neurocognition. as a rocky course may be inevitable in the treatment of learning disabled children (Rothstein & Glenn. Before embarking on the case material.

Solnit. must suffer experiences that they cannot absorb and which they attempt to master through repetition. 1978) Case Presentation presenting problem Natalie’s mother sought psychological testing at age 12 years and two months because of Natalie’s worsening irritable. suggesting that play in itself acts as a force in getting development back on track (Mayes & Cohen. the child can instead be a world creator. 1993). 1987) analytic writers have recognized the role of reality in shaping play. Although popular notions oppose play and reality. 1997. being passive. By offering the most satisfying solution between the desire for pleasure. play strives to make up for anxieties and deficiencies at a minimum risk of danger. Play aids mastery by turning passive to active. Rather than a suffering victim or an anxious onlooker. and aggressive behavior both at home and at school. Slade. Oremland. who was 3 years her junior. 1998. from Freud (1918) onward (e. Santstefano. 1979. In addition to the disappointments of reality. Natalie frequently screamed. the reenactment of an experience in itself constitutes a switch from passive to active. 1994). 1998. and the conscience. In addition. It allows the child to alter the outcome of the experience or to change his role.” suggested that children. hit. The actual play is a compromise formation.g. 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. Scott. She directed these outbursts mainly at her sister.242 Lissa Weinstein and Laurence Saul relatively brief period of time than the immature ego can handle. cognition and its relationship to play has been largely ignored in the psychoanalytic literature with only a few exceptions (e. Ostow.g. 1998. withdrawn. Plaut. 1993. cried. Although this structuring role of play has been noted particularly in children with ego deficits (Cohen & Solnit. Neubauer. 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. and kicked. but also at her parents and . 1993. theorists have noted the contribution of play in the creation of new representations. the demands of reality. 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.

From early in childhood. Although highly intelligent. Natalie frequently witnessed her father vomiting and passing out in a drunken stupor. as her mother often did not arrive home until 10:00 p. Natalie’s sister attempted to break up the battles by getting physically between her parents while Natalie. Natalie did not speak her first words until 18 months or speak in full sentences until 4 years of age. but there was a notable delay in language. Natalie saw her mother sustain a fractured arm and. Menarche was at age 11 years and 10 months. led to transfer to a specialized school for learning disabled youngsters. her father read her Greek mythology and studied American Civil War tactics and strategy with her. This non-English speaking woman was stern and cold but reliable. 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. Speech therapy was begun at 4 years and continued until she was 11.Psychoanalysis As Cognitive Remediation 243 peers. Natalie’s father was also a constant presence. Two weeks after Natalie’s birth. he was an alcoholic who was unable to keep a job. Natalie’s paternal grandmother moved from Eastern Europe to become Natalie’s primary caretaker.m. her father lay down in front of his family. in sharp contrast. and threatened to kill himself. Particularly close with Natalie. Natalie’s interactions with her peers at school. would run to her room and remain under her bed covers. Natalie’s mother returned to her career full time. initiated because of her distress over not reading. Shortly prior to the start of treatment. She also regularly witnessed verbally and physically violent altercations between her parents. Testing resulted in a recommendation for psychoanalysis. uncomplicated pregnancy with an induced delivery at 41 weeks that required forceps. at another point. Psychological testing at age 8 years. . Fine and gross motor milestones were within normal limits. missing her. Natalie was highly opposed to psychopharmacological intervention. held a steak knife to his throat. when Natalie was 7 years old. Father also frequently exhibited bruises his wife had inflicted on him. Natalie threw a butcher knife toward her sister. developmental history Natalie was the product of a planned. provoked them into antagonizing and ostracizing her. although far less dramatic. a subdural hemorrhage from father’s beatings. Once. Medical history was significant only for seasonal environmental allergies.

While she needed the scaffolding provided by a listener in order to organize her thoughts. and turn taking) were intact. completed at age 12 years. supported the earlier impression of a dyslexic child of average to high average intelligence. 2003). A second evaluation. A few months after Natalie’s father was removed from the home. The WISC III yielded a Full Scale IQ of 103. Natalie never asked to see him. Natalie’s paternal grandmother died. with a fairly focalized language disorder. Shaywitz. and a Performance IQ of 99. her mother had the police remove Natalie’s intoxicated father and placed an order of protection against him because of verbal threats. and had poor memory for phonemes. the more object related and para-verbal aspects of communicative language (prosody. eye contact. are very difficult to remediate. and who. 2 months when Natalie was in 7th grade. could not identify medial vowel sounds. Therefore.244 Lissa Weinstein and Laurence Saul When Natalie was 11 years old. psychological testing Several evaluations provided ample evidence for the diagnosis of developmental dyslexia. a term used to identify children who show problems in both rapid automatized naming and phonological processing. and hypersensitive behavior which led to her mother seeking help. Natalie failed to initiate a lot of language. 1998. had trouble sequencing her thoughts. Natalie met the criteria for double deficit dyslexia (Wolfe. typically. and had difficulty with word retrieval and naming. and visitations continued sporadically.. Natalie had poor auditory discrimination. Phonological processing was impaired. Visitations were started 6 months later because Natalie’s sister requested to see him. intermittently violent. 1999). she suffered two major losses simultaneously. with a Verbal IQ of 106. 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 . An educational evaluation completed at age 8 demonstrated receptive and expressive linguistic difficulties rather than oromotor problems. These apparent precipitants closely preceded Natalie’s increasingly withdrawn. This skill (the ability to hear and sequence the sounds within words) is the central deficit found in reading disorders (Morris et al. In sum.

as measured by her ability to form word classes. spelling. and written expression. the testing provided strong evidence of classic dyslexia with problems in decoding. poor punctuation. her tendency to misread or skip small function words (such as the. as was mathematical computation. was average. Reading comprehension was above grade level. volume. A writing sample showed a difficulty using vowel sounds. Informal assessments of oral expression were deemed normal for her age. She had no trouble processing semantic relationships and was able to answer questions about paragraphs that had been read to her. None of her responses involved a sophisticated integration of the components. ten response Rorschach showed her difficulty in mobilizing her cognitive equipment in new situations. and fluency were within normal limits. Natalie’s Rorschach resembled that of a much younger child with few content categories. Natalie’s ability to understand the motivational states of others. Tests of reasoning and problem solving were in the superior range. In short.Psychoanalysis As Cognitive Remediation 245 Despite the apparent evenness of the major subscale scores. Thus. The qualitative nature of Natalie’s performance. 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. as well as to process complex perceptual material was intact. Natalie’s functioning was more compromised in ambiguous situations than in structured ones and her sparse. Instead. or but) which are not directly representational. a finding compatible with a diagnosis of dyslexia as computations (unlike mathematical concepts) often tap semantic/linguistic abilities rather than the visual-spatial skills. there was considerable variability amongst her abilities. Natalie’s oral language was not impaired. Voice quality. suggesting that the act of decoding was what barred the way to comprehension in timed settings. also spoke to the presence of a developmental reading disorder. Natalie’s ability to follow complex multipart directions were within the average range and her lexicon. 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. Reading/decoding skills were several grade levels below average. While verbal skills ranged from the average to high average. poor sequencing of sounds within words (“breath day” for birth day). . In structured settings. was. pitch rate. and omission of sounds (“presten” for present).

” Christmas “where there’s so much pressure to get the right gift. marriage. and a tendency to become emotionally overwhelmed and cognitively impaired in situations of stress. .246 Lissa Weinstein and Laurence Saul little ability to integrate her emotional responses to a situation with a more cognitive viewpoint. claiming she didn’t want to see a psychoanalyst because she had “other things [she] wanted to do .” or the absolute worst holiday. The early manifestation of this theme took place primarily in the behavioral realm: Natalie kept her coat on during the first session. rather than a victim. with its associated themes of love and kisses. voicing a desire to be unique and different from the “boring popular crowd. 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.” In a dramatic demonstration of her wish to be the aggressor. The analyst tied these two videos together.” This contrasted to all the family based holidays she hated like Thanksgiving. course of treatment Natalie began treatment at age 12¹⁄₂. those things had not worked out so well for her. but continued to struggle against becoming absorbed in the analytic relationship. noting that “women better maintain control of men or they’ll end up dead. 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. “X Valentine’s Day. she isolated herself with peers.” Continuing her posture of “not getting involved” Natalie kept her coat on for the first weeks of treatment. Natalie then decided that she would write an article for the school newspaper entitled. where “you just get a big stomach ache. and you don’t know what it’s going to look like. Literally within the first few minutes of treatment with her male analyst. In response to an observation that she didn’t like showing off. and having babies as well.” Similarly. For example. .” After the third week. Natalie took off her coat.” She added that she wanted to “X” dating. Shifting identifications between victim and victimizer reverberated in her fantasy life as well.” When speaking of her family. refusing to discuss “personal stuff. Natalie agreed with the offered interpretation that “up close. she . Valentine’s Day. Natalie punched her sister in the mouth on the way home from her second analytic session. she claimed July fourth as a favorite holiday because “the fireworks are like paint in the sky bursting. Natalie expressed both despair and a wish to remain distant. like kick boxing.

she would pull her hat over her head. 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. He felt relieved when Natalie talked and careful not to confront her or her anger. painting vivid scenes of serene. She excitedly reported being “stalked” by two boys in her class. 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. alluding to her fears of being seen in the analytic encounter. Natalie began to express an interest in acting. Usually ill at ease with her desires to be seen. inanimate content. Natalie would also remove herself from the more passionate arena of verbal interaction and seek solace in a calmer visual perceptual world. or even sleep. 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. Natalie’s exhibitionistic desires were not interpreted. even to direct questions. turning passive to active. 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. Often. Gleaming with pleasure. She performed Shakespeare soliloquies for her analyst and simultaneously blushed and smiled with pride at the applause he would give. It is also noteworthy that in moments of high affective intensity. At this point. words did not “hold” her and she quickly moved to highly symbolic and expressive actions to regulate her feelings. remaining silent for entire sessions during which she would refuse to respond. The analyst’s countertransference responses illuminated the nature of the conflicts aroused. Natalie found a spare tie in the analyst’s closet and put it around her own neck. castrating wishes were expressed directly. as well as worried that he had caused her periods of retreat by being too aggressive with his interpretations. Natalie alternated between attempts at contact and a need to lessen the amount of experienced stimulation through physical distance. She alternated between talking engagingly and playing catch or being by herself. In the following session. “silent” sessions followed ones in which she had been particularly talkative. turn away from the analyst. During sessions. the analyst allowed Natalie to ex- . an analogous situation surfaced in Natalie’s school life. In addition to action. Rather.Psychoanalysis As Cognitive Remediation 247 agreed that she preferred to blend into a crowd and did not like to be closely observed. 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.

she imagined the analyst was plotting with Hussein to blow up some countries.” The analyst said. exclaimed. at her beach club. or harmlessly castrated and ineffective crystallized in the transference. “Now. 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. Looking at me under a microscope. Natalie went on to say that she felt “You’re poking at me. The analyst noted how untrustworthy and dangerous he seemed to her. take over the world kind of guy like me. Natalie complained of being “stuck with ‘Mr. Tingle. Natalie began taking photographs of a 15-year-old boy she had a “crush” on. and drew portrait after portrait of him. Tingle. Mrs. Natalie responded.” In later sessions. a sadistic high school teacher. “You are the stalker. It was at this juncture that Natalie’s conflict around men being either dangerously abusive and exciting.” Natalie replied jokingly. you’re doing the stalking!” She brought in prints of this boy. This stance seemed to support Natalie’s ability to tolerate previously disavowed affects. beer guzzling.248 Lissa Weinstein and Laurence Saul perience that wishes could be expressed and contained in the analytic situation without dire consequences. over a year into the analysis. . Mr. you’re Barney. The analyst pointed out that it appeared as if it didn’t matter what this boy thought of Natalie. Tingle. She then sold the prints for $5 each to girls at the art school where she was taking classes during the week. she remained defended against recognition of any excitement about her analyst.” Natalie retorted. . “So I’m the teacher from hell. “Yeah. He was too adorable and clearly inept: “Do you see purple dinosaurs on Wall Street or at a desk getting a fax?” Natalie quipped. 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.” While Natalie felt freer to express her sexual and voyeuristic interest in a peer. You’re buddies.” referring to the goofy pre-school TV character who teaches the letters of the alphabet. The analyst. In another variation upon this same theme. “I guess you want to keep a safe distance from a dangerous. You are in control. 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 . drooled over them. don’t spoil my fun.” The analyst said. and I don’t want to!” . Forcing you to talk about things you don’t want to. “You’re not Hussein. Several months later. “Hey.’” a male version of a comedy movie character. Upon returning from a vacation.

Natalie got worked up thinking about how her “jackass father can’t even work at Barnes and Noble to help us out. and difficulty being soothed. and a lessening tendency to provoke attacks from peers.” The analyst replied. A year and a half into the analysis. He’s just a moron .” Natalie said. Natalie remarked. turning him back into the ineffectual dinosaur: “Or you could be Barney. Even more curious was her teacher’s report that Natalie was beginning to absorb academic material in a new way. For example.” with decreasing moodiness and impulsivity. “You’re not scary. “In the same way that you call your father names. Natalie’s teacher reported that she was “blossoming. a new aspect of Natalie’s relationship to . 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 began to describe how she had always been scared of her current 8th grade male teacher because of his reputation as strict and demanding. You’re a chubby. given that scholastic performance had not been a focus of treatment to date. The analyst noted that when he thought of a scary man for Natalie. you’ve called me a few. “Yea. Tingle and yea. In school as well. and addressed in the relatively calm context of the therapeutic relationship. Natalie’s mother reported that Natalie was expressing a new desire for physical contact. chubby man. in the context of angrily calling the analyst names. “There seems to be two sides to me for you. As her fear and excitement about being with a man continued to be evoked. Natalie began to articulately reveal how her mother degraded her father. tolerated. “So now you’re having more fun—at my expense. The analyst further mused. this scary teacher or this wimpy dinosaur. while mother and daughters went to a beach spot during summer weekends. . This contrasted sharply with her lifelong pattern of physical avoidance.” He’s a “goodfor-nothing drunk. her father came to mind. withdrawal.” A few months later. Mr. “Perhaps you feel safer around my possible scary side by turning me into a chubby and bumbling dinosaur. and comfort. Barney.” As the historical roots of her bivalent attitudes toward her father were becoming more conscious.” Natalie laughed. just add a tail.” Natalie grinned.” The analyst became acutely aware of feeling emasculated and pointed out.Psychoanalysis As Cognitive Remediation 249 Natalie’s excitement became intolerable to her and she swiftly emasculated the therapist.” Natalie retorted. of course—with me being chubby—the wimpy Barney side of me. . “I hate my father! But he’s not scary. affection. you’re just chubby.” The analyst remarked.

and soothing physical presence who would sit with her quietly observing while she worked. used to regulate the comfortable space between her and the analyst. it was a far more productive compromise formation than merely keeping her coat on. In her outside academic life. rather than the analyst’s words or the function of reflection. Natalie had begun to play “the student. Natalie did not hold back the excitement of her triumph at being chosen and not only practiced the speech before her analyst. Natalie began to shine. She asked to be quizzed on vocabulary words or geographical locations.250 Lissa Weinstein and Laurence Saul her father began to manifest in the transference. Animal Farm. The studying was. In short. but went into a blow by blow account of the audience responses. However. In this example. as it incorporated elements of sublimation and identification rather than just turning passive to active. “who had strong feelings but couldn’t figure out how to put . helping her to defend against awareness of sexual excitement by taking an active stance. She started to use the analyst as a teacher. Natalie had also gradually became quite comfortable in the transference with her desires to do the “looking. In describing George Orwell’s novel. because she was the best speller. She would test her analyst. Natalie began to avidly use the analyst as a model (primarily his hands) for her drafting class assignments. it is interesting that Natalie’s mode of internalizing the analyst still involved a concrete representation. She was chosen to represent her class at 8th grade graduation by giving the senior speech.” Toward the end of treatment. and other children asked to be in her group. It is equally important that the studying served the adaptive purposes of learning. (1¹⁄₂ years into treatment). of course. She acknowledged that this was a way of remembering her analyst. However. taking particular sadistic pleasure if he didn’t know an answer. Natalie focused on Clover the horse.” In behavior typical of the “teacher game” (Ross. Natalie also became increasingly able to symbolize and take a reflective stance about her learning problems. She increasingly viewed the analyst as the nurturing father who read to her and acted as a comforting. making particular strides in the area of written language and speech. 1965). albeit this time one who remained more separate from the frightening aspects of her teacher/father. using the analyst as a homework helper or stayed after sessions to complete her assignments in his presence. over 2 years into the analysis. She brought schoolwork into the sessions. Natalie frequently switched roles and began actively examining being the “teacher” as well as the student. common in early school development. Natalie was moved to the most challenging reading group. At this point. organizing.

Natalie presented as a young adolescent with affective symptomatology. Conceptualized thus. 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. and her entrance into adolescence. At 12¹⁄₂ years of age. with its heightened drive pressure further increased the demands on her stressed ego resources. Natalie was accepted to several mainstream private schools and ultimately attended a competitive public school specialized for the arts. making it harder for her to access words as a mediating force during critical periods (Migden. speech usually helps the child to master the waning symbiotic ties and the loss of the accompanying feelings of omnipotence and safety. she was able to say that problems learning “really suck.” When her analyst made the analogy between herself and Clover. For Natalie. clearly her analysis had been instrumental in making her educational interventions increasingly assessable. Natalie was thriving at school both academically and with peers. before the last session Natalie was an expert. 1998). Although there was certainly more analytic work to be done around her conflicts with her mother and father. Natalie’s language difficulties affected her not only in school.” Particularly determined to learn to shuffle.Psychoanalysis As Cognitive Remediation 251 those feelings into words. This was pleasurable for both analysand and analyst as Natalie had become a “model student. her chronically traumatic home life.” While Natalie was able to voice these feelings after having some academic success. but throughout her development. 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 . language is a central aspect of the separation process. for example via identification with the aggressor. Exposed to a greater than normal degree of aggressive stimulation. Natalie was developmentally back on track. Finally adolescence. Because of financial difficulty. learning problems and a history of traumatic overstimulation.” She anticipated missing “our homework sessions. Natalie’s mother requested that treatment be terminated after 2¹⁄₂ years. In the final weeks of analysis. Offering new gratifications and connections. these traumatic experiences shaped the way she perceived herself and interacted in relationships. and placed considerable strain on defenses already compromised by processing difficulties. an oppositional defiant disorder. Natalie requested that the analyst teach her how to play poker. Natalie was very proud that she was one of the few students with learning disabilities admitted.

whether external ones such as the behavior of caretakers or internal ones such as the perception of bodily or intellectual processes. Luria (1979). potentially offers some answers that predictions based on the severity of neurocognitive deficits alone cannot. would be drawn into conflict. are woven into a web of meaning. 1954).252 Lissa Weinstein and Laurence Saul speaking grandmother. 1977). Like A. All these factors made it more likely that the autonomous functions (Hartmann. Because she could not interpolate words as a form of trial action. Events in the outer world and those in the internal environment meld. Analysis is a science of subjective experience. Given these complicating factors in Natalie’s development. Her learning difficulties prolonged the necessity for an intimate relationship. Natalie’s need for support in order to function cognitively intensified the relationship with her learning partner. in her case language and to a lesser degree perception. 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. In addition. who chose to humanize and make whole the most puzzling of neuropsychological entities. Natalie had a more limited array of impulse control mechanisms. father. how are we to understand the helpfulness of psychoanalytic intervention. her brilliant. particularly as it relates to her school performance? Discussion While developmental dyslexia can be conceptualized as a deficit (Winner. Psychoanalysis. and made the repression of oedipal impulses more difficult. 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. R. with its unique observational vantage point on the question of motivation. and how one interprets neurophysiological events is imperfectly correlated with the events themselves. 2001). but erratic. without language. Finally. which then become: the starting point for further causalities. some children are able to make use of compensatory strategies and others are not. slowed efforts at separation. it was harder for her to distance from the immediacy of a situation (Lewis. As analysts. with neurophysiology and the transactions around the developmental crises of childhood mutually influencing each other . we learn the specific connotations of the disability for the child by accessing the personal landscape and its presuppositions—how events.

spelling difficulties remain one of the indicators of compensated dyslexia. 2002). For example: they are more vulnerable to states of overstimulation which generates trouble with impulse control and difficulties with affect regulation (Arkowitz. . her own excitement. Additionally. the association of learning with conflict and the regulation of affective intensity While defending against sexual excitement with aggression is typical of early adolescence. Natalie was unable to learn because of the disruptive effects of what she experienced as her father’s seductiveness. there was an inhibition of function. suffer poor self esteem and alterations in their object relations (Migden. Along with slow reading speed. and her aggressive responses. It is our argument that the analysis allowed Natalie to access skills that had been acquired during previous remediation efforts. Learning became connected with sadomasochistic fantasies about sexuality. 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. in Natalie’s case. 1998). 2000). As learning became libidinized. it is not usual for spelling skills to improve. was also a way of warding off an affective awareness of the traumatic overstimulation of events with her father. and have a tendency to rely on weaker or more primitive defensive structures (Rothstein & Glenn. or to retrieve what she knew.Psychoanalysis As Cognitive Remediation 253 in a manner that is truly individual and not easily subject to regular laws. 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. For Natalie “knowing” became drawn into conflict when she saw her father (her teacher) act violently toward her mother. but what is more salient is that her inability to learn. The literature offers numerous general statements about the psychological functioning of dyslexic children. 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. but had remained dormant or blocked by conflict. which led to her trouble with looking as well as with its opposite—exhibiting. All of the above general statements are to some degree true about Natalie. Given the mind’s tendency to associate like-valenced affects. 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.

“I don’t love you. in choosing it as a defense. She alternated between excitement. In the analysis. as she kicks her male analyst. talkativeness. Natalie was able to “look” and to learn.” she says. the memories remained in a state of activation that accounted for their continuing effects. She also regressed to action as a mode of expression. to spell and to remember. she also turned passive to active. In Natalie’s case these events. Natalie experienced pleasure both as the terrorized girl and as the emasculating female. affected her motivation to learn. These dynamics were revealed when they were re-externalized in the transference which. previously unconscious memories into cognitive structures. When she could not talk. Tingle were teachers. she withdrew into a world of art work. The analysis allowed Natalie to access language for what had been inchoate and in so doing to connect a variety of associated. It was harder for Natalie to use language as a tool to abstract and distance herself from her experience. a model based on constitution around which the defenses can crystallize. Tingle and Barney explicate Natalie’s repeated experience of intense excited attachment coupled with fears/desires of being attacked/attacking. through the mechanism of the transfer- . Natalie’s neurophysiological weakness left her with a tendency to focus on the non-linguistic aspects of the environment. 2002). The Janus faces of Mr. the other an emasculated and useless wimp. Although unconscious. functions as a powerful anamnestic tool. 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. Natalie’s fusion of sexuality and aggression is determined by her age. but also by her history. Natalie’s dyslexia came to function as an anlage.254 Lissa Weinstein and Laurence Saul about which she wished to remain blind.” she says to her father as she fails to learn to read. 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. and silence. because of its connection to affect. “I don’t love you. Not knowing became a defense. She was helped. Natalie was thrilled and repulsed by sexuality and furious at being reminded of her interest. Of significance is that both Barney and Mr. When her conflicts with the father were repeated in the transference and interpreted. associated with the process of learning. Becoming a “student” and learning was either dangerously exciting or doomed to devastating disappointment. one sadistically drilling facts into her.

In play. To a young child. varied perspectives. a dust mop can be “Black Beauty”. he explains to his shocked nanny. Thus. rather than representing an angry feeling. motor activity.” or “sit in” and “a place for a mouse to live in.Psychoanalysis As Cognitive Remediation 255 ence to work through the exhibitionistic and voyeuristic wishes that were tied into reading and learning. sitting on his ride-on toy. when they tell us “A Hole is to Dig. or motivation. “I’m backing up. Vygotsky’s conception is virtually identical to Rappaport’s (1951) description of the shift from the drive-organization to the conceptual organization of memory. perception cannot be separated from meaning. 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. Krauss and Sendak understood this developmental point as well. a word is part of the object it names: the word “ice cream” causes the child to see. using the . 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. a hole is to dig: play as a tool of cognitive structure Up until this point. or even the context in which it has been used. I say ‘Fucking damn it’” as if the curse were simply part of going in reverse. her improvement can be understood in other terms than as a transfer of energy within the ego system. objects will inevitably have novel uses and the same object will have multiple uses. to taste the food behind the sounds. suggesting that play aids structuralization by allowing a child to become less tied to situational constraints and to act independently of what he sees. and experiences with objects accrue. In play. This connection between an object and its context was more poetically articulated by Ruth Krauss and Maurice Sendak.” a thing “to look through. Very matter of fact. What was implicit memory became explicit. you go down. however.” in their classic children’s book: A First Book of First Definitions. curses as he pedals backward. Initially. an object is what it is used for.” As multiple connections. Over the course of their book a hole changes from something that is “to dig” to “something you could hide things in. they form new grids of meaning separate from any one action and there is a consequent shift from action to semantics. The next day the child. Vygotsky (1933/1978) offers an additional perspective. to a child.” and “when you step in it. While part of the explanation is that she no longer needed to use so much of her available energy for defense. however.

99) In this way. These shifts can be described at any one time as the product of a ratio between object/ meaning and action/ meaning.256 Lissa Weinstein and Laurence Saul 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. Thus. or hits out at others. capable of stepping back. . . (Vygotsky. Later. in the fact that before a child has acquired grammatical and written language. but threatening relationship with her father. translated into action. The fact that the analyst does not respond to her provocations or collude with the underlying unconscious fantasies (i. 1978. she cuts his tie. Vygotsky parallels this shift to the change in the child’s ability to observe his oral language after acquiring grammatical forms and written language.e. In their usual prescient manner. In Natalie’s case. This change is seen too. he carries out these acts consciously. turns away from him. but gradually. the play object must share some similarities with the represented object (i.e. even to the “Black Beauty” mop. that men will frighten and violate) allows the original context of her fears to emerge. semantic qualities come to override perceptual ones and the word “horse. he knows how to do things. can be used to represent horse in the creation of stories about horses.” which bears no similarity at all. 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 mop is “Black Beauty” because you can ride it between your legs). to become amenable to thought and self reflection. . but does not know that he knows. 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. through play the child achieves a functional definition of concepts or objects and words become parts of a thing. the process of learning is associated with the context of her excited. 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. At first. p. She responds to his verbal interpretations in action. She is helped by the relatively calm affective climate that develops as the analyst allows . play allows the meaning of a situation (both conscious and unconscious) to emerge more fully and then. 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). the child becomes able to exist above the field for a moment.

motivation is the bridge between a nascent developmental achievement and its final form. During the act of play. As language gains ascendancy over action. Her defensive strategies consist mostly of instinctual vicissitudes such as turning active to passive and reversal. 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. Because imaginative play evolves into play with rules. A second central point in Vygotsky’s work is that play is intimately tied to reality and the development of self regulation. The child is literally “playing with reality” (Vygotsky. dentist. In analytic terms. Thus. with whom she shares a partial identification as being unable to put his feelings into words. eventuating in her story about Clover. Now . by trying on the actions that define important others. or student. her responses become increasingly sublimated and distanced from her physical body. 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. Early on. rules of behavior which are observed and imitated but not necessarily conscious or available to reflection are made conscious and explicit. she is able to make increasing use of his interpretations. Over time. noting that in all play the child invokes rules—the rules of role based behaviors as the child has observed them. Natalie’s ability to use the analyst develops in tandem with a change in her play.Psychoanalysis As Cognitive Remediation 257 Natalie to titrate the level of stimulation so it remains tolerable to her. They can then be internalized and used for self regulation and delay. Emotion is expressed in action and there is no “as if ” quality to her involvement in the transference. For Vygotsky. While the child would not participate in play if it did not involve pleasure. 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. play is instrumental in the acceptance of the demands of reality. Natalie is unable to symbolize. such as mother. Vygotsky started his investigation searching for the origin of this trajectory. teacher. 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. 1978). However. she becomes able to use the analyst’s words in a new way. he was not focused on motivation in the psychoanalytic sense of hidden desire nor the need to deny reality through imagination. Only actions that fit these roles will be acceptable to the play.

Therefore. 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. semantically dominant. 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. The areas where play is essential. on a fictitious “I” that relates to the rules of external reality and takes them in. thus allowing the child to take an abstract attitude. and more emotionally distant attitudes. Secondly. offering a measure of the difference between the child’s actual developmental level and her potential. Thus. learning is an everyday trauma inflicted by parents and teachers on a daily basis. Several authors have noted this common type of play in learning dis- . 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. this development is seen most clearly in her teacher play. This development.258 Lissa Weinstein and Laurence Saul the child’s desire centers on her role. play in analysis must initially function in the transference to externalize and interpret conflicts associated with learning. are also those which analytic writers have noted to be impaired in dyslexic children. making them her own. provides remediation for one aspect of the dyslexia. This offers the opportunity to separate objects from the actions done upon them and ultimately to distinguish meaning from action. the child acts ahead of her average age. find it more difficult to separate from figures that are associated with learning. If this task of working through in the transference is successful. learning disabled children. In this zone. the difficulty separating context from more abstract bits of knowledge. In this way the process of learning can be separated from fixed roles and internalized. with their increased need for external cognitive support and structure. and learning is more likely to become entwined with conflict. In Natalie’s analysis. First. even in the absence of an aggressive father. As Ross (1965) notes. play exists in the child’s zone of proximal development. Conclusion It is our contention that play in analysis functions in essentially two ways for language based learning disabled children. namely in the development of abstract. Undoubtedly. In play. in itself. rehearsed. and eventually internalized. functions such as abstract thinking and the child’s relation to reality are in the process of maturing.

the analyst also functions in a role as a new object which has some overlap with teaching (Freud. Third. then the child can begin to use the analyst as a partner (new object) in play/learning. a possibility suggested by the Boston Change Process Study Group (2002). 2002). Beyond the mutative aspects of interpretation. 1996. as the child is finally able to make use of play for cognitive structuring and for developing a decontextualized abstract attitude. 1993). using shorter words.Psychoanalysis As Cognitive Remediation 259 abled children. Thus the analyst acted neither exclusively as a developmental new/real object nor as transference object. some differences in the way play and the analytic context may function for learning disabled children should be highlighted. In the context of the analysis. During this phase. learning disabled children may need to play beyond the usual age than that of other children. both inside and outside of the analytic context. although it would be impossible to judge whether the nonverbal aspects of the interaction are more salient than the interpretive ones. it is clear that the regulation of a tolerable state of affective stimulation becomes necessary before the analytic work can take place. The necessity for factoring in the child’s level of cognitive development in the formulation of interpretations as well as the interrelationship be- . conflicts around learning will be re-evoked as the traumatic situations accompanying learning come closer to consciousness. interpretation is probably less required. or even allowing for an enhanced role for action in the treatment. Once these conflicts are interpreted. play that might traditionally be considered resistance (i. as they were with Natalie. Weinstein. doing homework in the sessions) may. These skills are notably essential for learning to read as well as other modes of symbolization. Although it is beyond the scope of this paper to offer technical prescriptions.e. It has been suggested that in addition to functioning as an object in the service of transference repetition. 1974. be a sign of progress in the treatment and essential in the remediation of the learning problems. interpretation is most successful if geared to the child’s cognitive abilities. As the analyst functions as an object in the service of repetition. Finally. by allowing Natalie to titrate the level of stimulation. Both aspects of the analytic role are heightened and intertwined for the dyslexic child. but as both depending on the context of the treatment at any one point. in fact. the analytic context also supported her ability to access knowledge she already possessed. a play very close in nature to reality (Cohen & Solnit. either by adjusting one’s use of syntax. Wilson & Weinstein. This teaching role allows for the internalization of insight. First.

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The author offers evidence to show that conflicts over aggression and oedipal desires. Robert A. BELL. King. Scott Dowling (Yale University Press. I thank also Drs. Peter B. The Psychoanalytic Study of the Child 60. were involved in the defensive function of her paTraining and Supervising Analyst. University of Maryland School of Medicine. Samuel Abrams. the failure of repetition to effect mastery of the trauma. including the impairment of the ego’s capacity to utilize anxiety as a signal function that mobilizes defense. Ph. Zients. 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. This paper addresses the centrality of conflict in psychic trauma. Boyd Burris and Charles Brenner for their thoughtful critique of an earlier version of this manuscript. Alan B. and A. 263 . whose insight and support were instrumental in my treatment of this patient. Scott Dowling).A Girl’s Experience of Congenital Trauma The Healing Function of Psychoanalysis in the Adolescent Years SILVIA M. ed. copyright © 2005 by Robert A. I gratefully acknowledge the invaluable contribution of my discussions with Dr. and Associate Supervisor in Child and Adolescent Analysis. Peter B. Neubauer.D. The focus is twofold: to elucidate certain characteristics of analysis in the adolescent phase that promote the integration of early trauma. characteristic of adolescent girls who have not been subject to trauma. Case material is presented indicative of the psychic consequences of early medical traumata. Samuel Abrams. the predominant use of aggression in the interest of defense. Neubauer. and to shed light on the modes of therapeutic action of psychoanalysis. and distortions in self and object representations. Clinical Assistant Professor of Psychiatry. Baltimore-Washington Institute for Psychoanalysis. and A. King.

in a recent publication. 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. and points to the resulting increase in the capacity to observe and to exercise volitional control over heretofore unconscious. In the first. The classic definition (Freud.” cautions Blum. Psychic trauma.264 Silvia M. taking place at a particular point in time. 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. and posttraumatic sequelae” (p. 2003. When the trauma is imposed by congenital conditions. the nature of therapeutic action in psychoanalysis has been the focus of active controversy. 506). She postulates that the interpretation of conflict and defense is the analyst’s attuned response to the mind of the patient. 500). p. p. In either case. Trauma can be caused by an exceptional event. 512). actingout. or whether change results from the experience of “self with other. and somatic phenomena” (p. interpretation and reconstruction. While the benefit of psychoanalytic treatment for patients with a history of trauma is unquestionable. This speaks to the central role of the child’s internal experience of the trauma. 2003). Memory of the trauma is registered both consciously and unconsciously. “It is important. 2003a. which is represented in unconscious fantasy. Bell tient’s pervasive sense of defectiveness. 416). 2003a. the internal traumatic situation. 1926) emphasizes a psychic state that results when the ego has been flooded and overwhelmed by stimulation emanating from danger. then. “to differentiate the traumatic event. Blum states that it “has both verbal and non-verbal elements. p. or it can be an ongoing life circumstance. refers to the experience of the ego which is helpless to cope with a state of excitation that has annihilating power. automatic mental processes as evidence of the mutative function of dynamic interpretation. motor. though inexact.” where “the crucial component is the provision of a perspective or a frame for interpreting subjectivity” (Fonagy. One aspect of disagreement that surfaced in a recent publication (IJP. 418). it has an organizing effect. it inherently marks the development of the ego and of object relations. be it internal or external. as it marks subsequent development and affects adaptation. or traditional conceptualization. affective. harold blum (2003c) reminds us that psychoanalysis began with the concept of psychic trauma. While not excluding the therapeutic effect of . the latter reflected in sensory.

intrapsychic) conflict is not considered pathognomonic. non-declarative. she faced me and asked. perspectives”(ibid. emphasis mine). “Yes. memory representations from past relationships. p. and made a point to bring her face very close to mine as she went past me to enter the consultation room. 218).. The second view. “Can you tell?” “Tell?” I asked. “Yes. Psychoanalysis works by effecting changes in implicit relational structures that represent “non-conscious” influences of the past on the present..Healing Function of Psychoanalysis 265 the patient’s experience of safety as the trauma is revisited in the presence of the nonjudgmental figure of the analyst. and a lot of work on my skin. She came to our scheduled appointment dressed in Spandex running shorts and a sports bra. It is the analyst’s “attention to the patient’s currently repudiated feelings in the analysis” (Fonagy. 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. can you tell that I’ve had something wrong with my face?” In response. the emphasis is on “the analysis of unconscious retarding and inhibiting forces” that are inherent consequences of trauma (ibid. Before sitting down. and to shed light on the mutative aspects of a psychoanalytic intervention that focuses on the interpretation of conflict/compromise.” she said. 1999. 2003. 506). This paper discusses the psychoanalytic treatment of an adolescent girl born with a life-threatening. 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. Clinical Presentation I first met Beccah when she was 14. that promotes intrapsychic reorganization.). She approached me quickly with a broad smile when I greeted her in the waiting room. 507). . Dynamic (i. I said that that seemed to be very much on her mind. which results in “the active construction of a new way of experiencing self with other” (Fonagy. that is. .” This launched her into a description of her . and reconstruction of past trauma is significant only to the extent that it leads to generating a coherent historical self-narrative. expounded by Fonagy (2003). “I’ve had surgery on my lip and my face many times. The “curative” aspect of psychoanalytic treatment is ascribed to “the process of reworking current experiences in the context of other .e. This view privileges the importance of implicit. rather than the interpretation of their unconscious derivatives. p.

in particular. because it’s so important that they like me. My mother cries about me. Bell history of many surgical interventions aimed at repairing and reconstructing her features as a result of disfiguring birth defects. she gave a coherent autobiographical account that included the consciously stored aspects of her painful childhood. in a defensive maneuver that helped to regulate affect. a salient appearance. She spoke. and I still remember how it feels being looked at funny. the exposure in her manner of dress and her confrontational style evinced a deeper struggle marked by self-conscious- . on her endurance of rejection (“It’s amazing how much I’ve changed.”). as she spoke of her compromised sense of confidence in light of her early experiences of rejection. clearly a reaction to defend against the anxiety that our meeting stirred up in her. and on the difficult relationship with her parents (“My parents don’t know how to work things out. She reflected on her fear of pain and hospitalizations (“I’ve had to weather it for my own good. She behaved as an action-oriented young lady. turned into a description of experiences of early trauma. who was not able to express a sense of pride in her. I might not be able to stop him.”) This rather dramatic first meeting. with embarrassment. rather provocative “take charge” attitude. she turned to chastising thoughts about her mother. However. especially boys. that impressed me for its balance and forthrightness. even seek nurturing from me.”).266 Silvia M. In these respects. Beccah presented as an attractively built. now it was her manner and style that cut a striking figure.” and described her conflict about an intense neediness for attention that rendered her vulnerable (“I know that I need to please. who took charge of the session. for much of her childhood. In this session. revealed key elements of Beccah’s adaptation that remained central considerations for the duration of our work. and all I want is for her to feel proud of me”). about her concern that she “does not know how to handle boys. she was responding like a well-functioning adolescent. Her initial. As feelings of defectiveness and hopelessness surfaced. So maybe if someone were to force himself on me. While there were no obvious physical signs of what had been. 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. of the impact she wanted her appearance to make on me. 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.

Her question revealed her own confusion around internal representations. not as she might be expected to look. there was a deeper meaning to her question about whether I could tell. which rendered her vulnerable in relationships with others: she couldn’t tell. past and present. Her medical status stabilized after age five. she made clear that her longing search for mother’s admiring gaze had now turned to seeking acceptance in the eyes of a boy. Her parents. Indeed. However. the vascular system. and her condition was considered life threatening. almost oppositional posture—she came dressed as she wished. both professionals who had been educated in the United States and counted many friends and relatives here.” Despite the cosmetic success that had changed her external appearance. with facial deformities and serious birth defects. She exposed her new female body. that was revealed in her question. As we would discover together. Beccah required multiple surgical interventions in the first four years of life. like the mother. Beccah was aware that she couldn’t get away from “remembering how it feels being looked at funny. and multiple benign soft tissue tumors which involved the face. recognized that her medical needs would be extensive. These interventions became less . including complete cleft lip and palate. and masking her sadness and anger in a casual. insecurity. and she was essentially healthy thereafter. unconscious aspects of her internal experience prevented her from integrating a healthier image of herself. she underwent staged periodic facial cosmetic surgery between the ages of five and twelve to approximate a normal appearance. Her presentation communicated an almost desperate need to figure out what others thought of her now. There was a readymade transference to me as “judge”—the female who. In a shift expectable in adolescence. 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. Can you tell? In fact. and vulnerability to deep narcissistic hurt. would scrutinize her with a critical eye. as she sought to make sense of the confusing images of herself. and took immediate action to relocate. history Beccah was born in an Eastern European country. yet ready to run away.Healing Function of Psychoanalysis 267 ness. but she spoke of her sense of defectiveness and of her fear of sexuality. and obstructed the airways and bowel. rushing toward me. She reacted by assuming a provocative. yet “tough” demeanor.

Beccah was a charming. who lived in close proximity. four years her junior. cried excessively and had poorly regulated sleep-wake cycles. nevertheless. and experienced her as a refuge when she felt embattled with her parents. active little girl in early childhood—a stoic patient who seemed to find the strength to maintain a sense of relatedness toward others. she had angry outbursts.” who wanted his children to be strong and active. and the resilience to tolerate her hospitalizations. more attuned to her daughter’s emotional distress. His affirmation that there was “nothing the matter with Beccah now. Threatened by Beccah’s history of damage and suffering. in identification with the father. The father was a self-acknowledged “no-nonsense person. Her brother. Bell invasive as she grew older but represented. was the one seeking psychological help for her. the parents reported an otherwise normal accomplishment of developmental milestones. Beccah was the older of two children. he focused on his daughter’s present status and denied the psychological impact of her early appearance and medical vulnerability. Beccah took pride in being “the smart one. academically. Infancy was a highly stressful period for mother and infant. Despite Beccah’s medical history. The children shared an interest in sports. were it not for the enormous achievement it represented for this little girl to function competently. given the mother’s decision to pursue her career. A maternal aunt. She had the competent demeanor of one experienced in the handling of emergencies. the relative respite from anxious concern over her status was periodically broken by emergency hospitalizations for various complications in vital organ systems. The mother. and not easily soothed. however. aggressive. Periodically.” whose academic accomplishments far surpassed his. and socially. Beccah turned to her aunt for comfort.268 Silvia M. an inescapable specter in her childhood experience.” and it was clear that Beccah was at the center of marital conflict. 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. As her rhythms stabilized in her second year. but she could verbalize her awareness of underlying anxiety and conflicted feelings about this child who had “brought so much trauma” . was described as healthy. Beccah’s developmental history would have been considered unremarkable. and irreverent like his father. and there were no obvious conflicts between them. through the grammar school years. was demanding. Beccah had projectile vomiting.” obviated what comfort this conflicted girl might have garnered from his seemingly supportive comment. provided daytime care for her since infancy.

The mother was deeply pained by the undercurrent of anger which surfaced in periodic outbursts between them. The affect would be further moderated through primitive denial. to explore Beccah’s capacity to tolerate anxiety and regression prior to the recommendation for analysis. and resisted doing her school work. able to understand. yet she had been available to support Beccah as she endured the uncertainties. and she expressed a wish to soothe and promote her daughter. After evaluation by the school psychologist. repetitive invasive interventions. and frustrations of her medical condition. She became defiant at home. She was neglectful of her academic work. and “threw herself at boys. As is characteristic of individuals who have suffered early trauma. but also experienced the victimization of being the object of abuse. She felt close to Beccah. the parents felt that she had no awareness of real danger. In fact. she exposed herself to the very situation she dreaded so she would not be surprised by it. and had become sexually provocative— she dressed in tight. However.” With the onset of prepubertal changes at age ten. caused fights with and between her parents.” Nevertheless. It was this recognition that lent urgency to their request for help once more. Beccah’s behavior deteriorated. got into fights with her friends. with noticeable improvement in her mood and conduct. Beccah had once again become unmanageable. . Since menarche at age 12. Beccah experienced anxiety as a sudden and intense onrush of affect. she continued to devote herself to her passion—horseback riding. nurture and comfort her. treatment An extended evaluation was undertaken. She acknowledged that she had returned to work as a respite from trauma. I noted with concern. which felt disorganizing. She was undergoing psychotherapeutic treatment to address “a pervasive sense of guilt” that interfered with her relationship with her daughter. wore a lot of make-up. She defended against this feeling by taking counterphobic measures—that is. a pervasive tendency to repeat trauma by creating sadomasochistic relationships wherein she identified with the aggressor. she underwent once-a-week psychotherapy for one year. but also felt overwhelmed and entrapped by the requirements of her care. whom she experienced as “masking pain with anger. and she seemed constantly to put herself at risk. or isolation—she would purport not to feel anything at all. she had demonstrated substantial equestrian ability and had won many ribbons in competition. revealing clothing.Healing Function of Psychoanalysis 269 into their lives.

In a displacement of the conflict. and triggered a defensive identification with the aggressor. as she talked excitedly to me. about him. She developed a verbally abusive stance towards him. now she created a sadomasochistic entanglement in which she exacted and suffered pain and humiliation. A relationship with a boy she regarded as more defective than she was. 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. He became “a good-for-nothing. . It became clear that the nature of her conflicts required a more intensive intervention that would promote the development of her capacities for introspection. with no culture and no morals. her relationship with this boy expressed in displacement her unconscious fear of what would happen between us—we would hurt and disappoint each other. and against the dread that the wished-for closeness was inevitably linked to abuse.270 Silvia M. She had picked him up at the beach after he made “an obscene remark about her body. demeaning his socioeconomic status and his academic ability.” This relationship was an enactment of her experience of past relationships. 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. She phoned him repeatedly. Beccah had established a therapeutic alliance with me by the time that we started psychoanalytic treatment. and provide her with the opportunity to integrate her chaotic early experience. which she expected would be repeated with me. Bell She seemed to need to relieve a pervasive sense of defectiveness through impulsive action that imperiled her safety.” In her sessions. His tough manner and provocative sexual comebacks fascinated and terrified her. The excitement generated in the interaction defended against her belief that “no nice boy” (or “nice doctor”) could genuinely like her. In fact. whilst she consciously regarded me as a trustworthy confidante. she developed a fascination with a boy. she recounted the details of their interaction. hounding him with demands for attention. ameliorated the sense of being damaged and “bad” that was exacerbated by my recommendation to increase the frequency of our sessions. Beccah responded to the intensification of the treatment by becoming more conversational and less introspective in a defensive maneuver to maintain distance from affect. ten months after our original meeting. and stimulating him with seductive stories about her provocative behavior. Whereas she had often felt victim to surprise and hurt in response to the reaction of others.

” In this early period. Mindful of her observation in our first session that she had had to weather fear and pain for “her own good. I reconstructed that sometimes it was hard for her to distinguish whether the attention she gets is helpful or destructive.” She replied insightfully. “When a boy notices you. 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.” She reflected on not being able to tell me that her boyfriend had made a vulgar comment about her breasts. “I’ve had to put up with so much pain. However. the interventions aimed to help her to consider her sense of confusion. “When I get attention.” 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. I can’t make sense of myself or what is going on.and other-representations. This led her to observe that “something happens inside when a boy is interested. rather than explore directly the nature of her fantasies and self.” Thinking about her experience in the past created a respite from the intense anxiety generated in the moment. We noticed that focusing on what a boy thought of her. because in the past even good attention was tied up with so much bad feeling. I can’t figure it out.” 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. I can’t let it go. Rushing at him with excitement. and you couldn’t figure out what kind of attention you were getting. as she had . something happens inside and you feel that you need to find out what he thinks of you. I never know whether the pain is for my own good or not. I don’t know what I feel. She reflected. Maybe I don’t want to think about it. to stop yourself from worrying.” a statement referring to elective but “necessary” painful cosmetic surgery. kept her from letting herself know more about what she was feeling. 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. non-verbal memory. and thus it facilitated her capacity to observe her internal state. My early interventions aimed to help her to observe her affect in relation to her actions. which she found pleasing and scary. and to begin to consider her use of defense to regulate her internal state (turning passive into active. and identification with the aggressor). Maybe you rush to find out.Healing Function of Psychoanalysis 271 These complex dynamics needed to be addressed gradually.

born with all these birth defects I have to live with the rest of my life. 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. Her salient behavior deflected the onlooker’s . affects kept in abeyance by her aggressive stance. came to the fore. and then isolated the affective content of the interaction. which she experienced as dangerous. but they choose somebody else for a girlfriend. Beccah’s traumatic history predisposed her to repetition. her behavior elicited the rejecting response she had dreaded in response to her appearance. As our work progressed.” her manner was a defensive maneuver that startled and interfered with close scrutiny.” She told me of her recent encounter with her first grade teacher who. I’m the one they abuse. “What happened to you?” In the safety of the analytic work. and her exciting. however. as in meeting someone new. We learned. 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. she added. “I’ve had such bad luck. surfaced. she defended against feelings of vulnerability and helplessness that surfaced with his attention. that feelings of defectiveness also surfaced as a defensive turning against the self in the service of maintaining equilibrium when sexual feelings. Our work gradually elucidated the complex meaning of her feelings of defectiveness. in an attempt at mastery where she had felt the helpless victim. Often. On the one hand. but then doubted that anyone could find her attractive. She commented: “Only dirtballs are interested in me. Sadness and despair. With sadness. I have this need to get attention from guys and then I let them abuse me. She invited hurt through teasing. attractive body. I’m so angry inside. She projected her sense of defectiveness and became provocative and aggressive to defend against the disappointment of not being lovable. she called attention to herself. She recognized that she felt attractive some times. not having seen her in the intervening years. we explored Beccah’s painful experience of looking and being looked at. Bell done with me on our first appointment.” I noted to myself that she had turned to thoughts of pain and damage after she had allowed herself to acknowledge her new. While her provocative actions seemed to cry out “look at me!. seductive behavior.272 Silvia M. thus enacting her sadistic wishes. Beccah verbalized feelings more directly. asked unfelicitously. When confronted with a situation that called up a sense of defectiveness. and caused her pain. and her tendency to enact became less ubiquitous.

which mobilized fantasy and conflict.” and I asked her whether she was curious about it. she brought a porcelain baby doll. so much.” The connection with her wish to have the perfect face with a flawless complexion was unconscious. unexpected opportunity to reconstruct the genetic aspects of her pervasive feelings of vulnerability. that I don’t even know it’s there. Looking and being looked at were highly charged affective moments. Now aware that her behavior had meaning beyond an interest in the hobby. My office was located at the end of a U-shaped corridor in a suite with four other offices. She connected with her anxiety upon meeting people.” At our next appointment. keeping our work in the displacement—I noted the unremitting quality of her concern about not getting the doll’s face “quite right. as she had done on our first meeting. we considered the meaning of her searching in my eyes. After sharing in her interest in porcelain dolls—that is. who had not passed on a normal body to her. Beccah had enrolled in a course to make porcelain dolls. “I like babies. 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. She began to recognize that her own looking was compromised—she looked to others as mirrors of herself. She asked my opinion. she said. 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. even startled at my presence. 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. and then responded by assuming a casual. As I wondered with her whether she experienced a . The transference deepened. I worry about having babies in the future. “I have this constant knot in the pit of my stomach. distracted demeanor that resolved into a broad smile denying deeper feeling. I still often found her roaming the hallway. This work was also a harbinger of conflicted feelings about her mother. and Beccah’s response to the treatment setting gave us an added. After several months of treatment. “can you tell?” We addressed her externalization. a search that repeated her experience with her mother’s eyes. She did not recognize that her newfound interest represented her experience of remaking her own face.” We explored her worry that she could not have a normal baby—a worry which.Healing Function of Psychoanalysis 273 gaze away from her face. her checking what others felt kept her confusing feelings about herself temporarily out of mind. She seemed momentarily surprised. As our work progressed. because she could not see the young woman in the mirror as herself.

or on a sofa. I considered that.274 Silvia M. with a TV on. In keeping with her massive denial and isolation of affect. She responded by disclosing her worry that someone could come through the window and attack us. after acknowledging the humorous quality of her story. which defended against the traumatic impact of that moment. that compelled her to “check out the place. she “remembered” an episode when her incision “opened up” after abdominal surgery when she was a toddler. now impelled her to take charge but still impaired her effective mastery of the situation. as she was alone to handle this emergency. As Beccah understood that fantasies of rejection and abandonment were mobilized in the treatment. it revealed how humor had been used to cope with trauma. as if telling an exciting. I felt the importance of respecting the affective tenor of her communication. she needed to hear that there were people around her who could rescue her if she stopped breathing. that remembering how her aunt had experienced this moment helped her to put aside what it had been like for her. As the transference deepened. in the regressive state promoted by the analytic process. Beccah was enacting an earlier. and she recognized that. which must have felt intolerable then. in turn. she felt increasingly able to take charge and this. when she repeatedly found herself in strange. As we explored this fear. furthered our exploration of her internal experience. Her anxiety. and that a stranger with harmful intent might appear instead. she recognized a mounting feeling of anxiety as she waited for me passively. funny story. She also started setting an alarm to signal the end of our appointments before the time was up. I commented. She realized that . She recalled that. she felt confused and could not make sense of the office space. She was abandoned and helpless. her aunt’s panic and ensuing confusion. she revealed her chronic difficulty sleeping in her bed at night. “I like to know when you’re going to tell me it’s time to go. Bell discomfort in the waiting room that compelled her to move around. 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. She recognized that waiting brought up fears that I would not come for her. She responded to this insight by making a map of the office. Her account had the quality of bringing me into the family lore.” she stated. She slept on the floor. as a child. frightening doctor’s spaces waiting for something to be done to her.” Beccah became aware of an internal state of alarm. She described. this behavior was automatic and she was not aware of the feelings that necessitated her avoiding her bed. despite her frequent checking.

Noting her anxiety prior to a particular equestrian competition. Winning was of paramount importance. Every event was a new challenge. a projection of her enviousness that also reflected her expectation of punishment. in contrast to her athletic. and to recognize that.” In the months that followed. She reported a worry that “people out there” wanted her to lose. indeed her stellar performance. She expressed anger at her mother who. Beccah focused more actively in sports. that she felt a great pressure to maintain an “unblemished” record. We noted that she was worried about whether I would or could protect her from harm. had triggered a fantasy of assault that elaborated on her feelings in the waiting room. the fantasy that I might assault her. as if her previous success did not serve to ameliorate her blemished self-concept. which was emerging in the transference. as recognized in newspaper clippings.Healing Function of Psychoanalysis 275 she lived with a pervasive fear that she might die. became amenable to interpretation. and whose interventions she experienced both as life-saving and as murderous assaults. You could do something that would hurt me. Her awareness of feeling vulnerable with me gave us an entry to explore her aggressive feelings. Beccah explored her confusion about her mother. her old feelings of being faulty and at fault remained unchanged. the powerful doctor-mother who. Gradually. was a compromise that included the projected aspects of her rage at me. Beccah spoke of the comforting feeling of hearing the sound of voices from the TV at night. The exploration of her exaggerated sense that so much was riding on the outcome. The fantasy of the intruder who would attack us. which depicted her mother’s unavailability and her aunt’s helplessness. She reflected thoughtfully: “I tell you so much.” 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. they helped her to feel safe. exacerbated her feelings of being damaged. I said: “Perhaps the sound of voices from the TV may even feel safer than a voice up close. It was also a harbinger of the deepening paternal transference. I had registered that her memories. so fraught with promise and risk. ribbons. although her body had undergone a process of change. We noted. by providing treatment. aggres- . As the treatment progressed. however. led Beccah to recognize that she dreaded failure as evidence “that it was all her fault. and citations. who seemed to be in charge of her well-being and yet so helpless to protect her. I wondered if these events recalled her experience of her cosmetic surgeries.” This insight allowed her to connect with her sadness about needing reconstructive surgery. yet fraught with conflict. and she brought evidence of her success.

She began wearing age-appropriate. She talked about being glad that I was not a male doctor. “I’m afraid that I’m just like him. Her sense of defectiveness seemed to intensify with her fear of her destructive wishes toward her mother. The identification with him did not offer lasting comfort. Sometimes she felt reassured of the much-needed mother’s love and approval. Her bisexual conflict was openly manifest in this period in her analysis. She revealed that she had asked her mother to sleep with her. she painfully uncovered her confusing feelings toward her mother. as she focused on sports in an effort to identify with her father and disavow her dangerous. There was a shift in the transference. porcelain-skin child. “I would worry what he might do to . he was insensitive and didn’t care about her feelings. In the course of our exploration of her regressive response to oedipal pressures.” was felt as the mirror reflecting her defectiveness. 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.” 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. and nobody will be able to set limits on me. helpless to create a haven of safety where she would feel protected. “He is an angry person ready for a fight. The intensification of Beccah’s feelings towards her father led to an increase in her nighttime fears. Bell sive father who “did not see anything wrong with her. We recognized that anger maintained closeness between them. and defended against intimacy and disappointment. Beccah’s appearance and demeanor changed. Often. however. She added. and proceeded to turn against herself as the defective one. As our work progressed. and was a relief from the complex feelings in relation to her mother. She developed a concern about her mother’s health and well-being. which increased her sense of vulnerability. She reported “shouting matches” between them. However. and wishes for me as the oedipal father surfaced. Beccah accessed her conflicted feelings about her father before she could fully address the complexity of her reactions to her mother. it also promoted fantasies of unbridled impulse.” The identification with his intact image seemed to bolster a sense of hope about her own strength. defective femininity. also experienced in her horseback riding. stylish outfits and joined the “preppy” crowd. “How can I be so angry with my mother when I have been the cause of so much pain?” she protested. she experienced mother as abandoning. as when she was a little girl.276 Silvia M.

Beccah developed an idealized view of me that promoted her capacity to relinquish her mother.” She mentioned getting a learner’s permit. while mindful of the defensive aspects of her remark. thus revealing her burgeoning interest in my body and my sexuality as she tried to reconstruct and imitate me in my adolescence. Her fantasy of my sexual feelings toward her. condensed oedipal components and a developmentally expectable erotic interest in me. I spoke to her excitement as a defense against her worry about feeling unloved. identified with me in considering career choices. but I was aware of her unconscious association to a sick bed. Noticing an adult female patient who had left the office. which had been delayed by conflict.Healing Function of Psychoanalysis 277 me. she was determined to use it. I don’t think so. She mused that it was good that it was just the two . my education. I provided the necessary unblemished female substitute. She reacted against the relative restraining quality of it. and to her fears of dying. you’re too conservative.” The couch was “weird” but. as if it were a test of her readiness to face her growing up. In conjunction with the process of object removal.” 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. “Nah.” At a time when development required that she relinquish mother in order to attain a separate and independent sense of herself as female. and asked “to try it. She replied to herself. I commented that she was thinking about things we might do together outside of the office. my salary. and interested in her: “You never forget anything I say. She came to one of her appointments dressed like a hippie and asked whether I had been one. Beccah pondered whether she used the couch.” I commented that thinking about things that happened in the movies kept her from considering her thoughts about me. manifested in sadomasochistic wishes. if I did not reciprocate her interest and longing for me. reliable. She said: “It’s a relief. 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. She became curious about my interests. and jokingly added that we could go driving together. there are movies about this. You go too much by the rules. right here. She imitated me in her manner of dress. she felt that I was smart. that led her mostly to sit in the middle of the couch with her back leaning against the wall. and admired that I had become my own boss. as adolescents are prone to do. 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. thinking that we share in that feeling”).

I felt that. Then she took off her shoes and picked her toenails. “I’m lengthening the healing process. “But she does not fit into my clothes.” She started picking on a scab and said. I know that. in light of her past history. and she was able to explore more directly her fears about being a woman. I felt this provocative behavior as action language that expressed the multiple dangers she experienced around her wish to become a woman. Beccah reported that she had gotten good grades. She needed to remain the little girl who would incur my wrath for her messiness. the fantasies and realistic concerns about her “vulnerable femaleness” were surfacing in the image of the fragility of her stockings. all the while as if she were oblivious to me. Bell of us in the office—then she didn’t need to decide what to call me.278 Silvia M. I might also want what she has. While I was mindful of the defensive aspects of this behavior. I will have to have more plastic surgery. I’m attacking my skin. I replied that she wonders whether I like what she has and whether. At this point in the transference. In a subsequent session. I was experienced as the longed-for. The erotic wishes from the previous session had given way to the lesser risk of the defiant stance. regressive behavior defended against the risks inherent in the wish to be the woman who might incur my retaliation. then she pointed to a run in her brand new stockings. dangerous witch-mother who could become malignant in my envy. a risk fueled by her projected envy. Beccah was now aware of her feelings. so as to avoid my retaliation against her femaleness. first littering and then cleaning up the debris from her body.” I noted to myself that. and pranced around the room. her conflicted feelings about her self-representation were coming to the fore with an increase in depressive affect. She came to our next appointment wearing very high heels. We noted a sense of risk that prevented her from speaking freely about her wishes for a special closeness with me. She had brought greasy food that she spilled/contained/cleaned up. She told me she has many others like it. I said that by not calling me anything she wasn’t letting us know more about what made the choice difficult. like her mother. from one of her procedures. a wish that brought up closeness as well as competition between us. and told me that her mother borrows them. I am so bothered by little things!” She showed me that it looked just like the hyperplastic scar on her abdomen. as she was more in touch with her wishes to be like me and liked by me. “I can’t wear a twopiece bathing suit. She exposed herself as she flipped over on the couch. “I hate runs. eroticized. whether by my title or by my first name. She spoke . Do you like them?” she asked in a challenging tone. sat up. Her messy.

and sometimes you like what you see.” Then she told me that there are pictures of her “back then” all over the house.Healing Function of Psychoanalysis 279 about the worry that her menstrual flow would not stop. something was interfering with letting herself change the old picture in her mind. “I’ve never met her. like her mother. The work in this period gave us further access to the defensive function of the defective view of her self. She told me that she spoke on the phone with her boyfriend’s mother every day. She reported that her mother had commented on her progress—“we don’t fight any more”—but now she was angry with me. “Look at my face there. Her past history of defectiveness accentuated the developmentally expectable concerns about her changing body. I don’t want to do that. 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. Maybe being her new. and stimulated the certainty of future trauma. or in childbirth. no matter what image was reflected back. I don’t care what she thinks. and of her fear of dying in sexual intercourse. as if what she saw in the mirror was not convincing.” clearly taking pleasure and pride in her image.” 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.” As if my words had touched on something that brought up discomfort. and taking charge of her own body—a body that had felt unreliable as a child. and was undergoing a risky process of change. 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. gleefully. She expressed despair about whether she would ever feel “good enough.” I ventured that she seemed aware that. I don’t want to remember. “I don’t have the maturity for this analysis. Beccah’s behavior toward me became more erratic. she dismissed her pleasure . You’re trying to connect things up. grown up self felt scary and she kept herself looking back. her hair was not right on the next one. 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. Beccah was aware of still looking at other people’s reactions to her in order to get a clearer sense of her self. wished to ensnare her in the past in order to keep her from moving forward. I clarified her ambivalent feelings: “Sometimes you can’t stand looking at yourself. I was “weird” and out of touch with kids her age. Then she found a “good one” and said. there she looked deformed.

The impulse to call him repeatedly resurfaced. I was moved by her presence. so prominent in her thoughts about her boyfriend’s history. In that sense. “Can you understand. and commented on the few vestiges that remained. he was more defective than she—her parents had not given her up.” His adopted status fascinated her.” she asked. “You wonder whether I see an old you that’s not right. a gesture no longer masked and distorted by the defensive provocative stance she had displayed in our first meeting. Her boyfriend was “a nice guy. she felt miserable and sought his constant reassurance. “You worry that something about my seeing you back then would change what I feel about you now. She propped them in front of me. but he is adopted. “why it’s hard for me to make sense of how I look now? It’s like. I said. Beccah exposed her vulnerability in the wish that she would feel undamaged as she displayed her defects. She had brought the childhood pictures to the office as if reclaiming ownership of her experience. 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. and resulted in an exacerbation of her anxiety. and how that makes me feel about you. She pointed to the many defects of old. I’m me then and now. she was valuable to them.” Beccah came to her next session carrying the framed pictures of herself as a child that her mother displayed in the home.” I felt the poignancy of this moment. was also a central aspect in her conflict about growing up. to me. This session was powerful for both of us.280 Silvia M. aware of feeling sorrow and pain for the little girl who had been subject to the experiences betrayed in the pic- . albeit in the context of the analytic experience that granted me a vital role. the 16-year-old girl in front of me. Beccah developed a relationship with a boy. One day she broke out in great anger at me: “Despite all this work. Her relationship with this boy stimulated heterosexual feelings that signaled the potential disruption of her childhood tie to her mother. or a changed you that makes you acceptable. I understood intuitively at that moment the importance of my role as trusted observer of her struggle.” 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. I’m the same.” “I still don’t believe anyone could find me attractive. all the while scrutinizing my face.” she said. she saw it as his secret defectiveness. a struggle she was proclaiming and was determined to work through. symbols of past and present. The threat of abandonment and loss. Bell and remarked: “There’s only one good one.

on the one hand. talking was not doing anything. she could not trust that she could be safe. to dangerous developmental wishes to experience herself as a young woman in my presence. Beccah was now “telling herself.” I said that maybe she wanted for me to worry about the danger. A simple cold triggered fears that she would not be able to breathe.” Like the rat on the dissecting table. As those feelings. She assaulted me with my helplessness while exacerbating her own sense of vulnerability. albeit temporarily. If I get sick. Testing my response to her as a child at this time. she was thus enacting with me in the transference the sadomasochistic symbiotic fantasy that kept her locked in a sense of defectiveness. Beccah had been expressing openly her experience of being lovable in the context of the growing relationship with a boy. But.Healing Function of Psychoanalysis 281 tures. A stormy period ensued during which Beccah enacted the sadomasochistic fantasies pertaining to her early relationship with her mother. deepened. While.” was in effect a maneuver that put a halt. Do you think it’s dangerous to walk around barefoot? I can decide what to do. 2000). She reported that she had eaten her lunch during her biology lab. I do not doubt that Beccah was impacted by the affective tenor of that session. She came to the office barefoot. a move which could be regarded to serve in the interest of acquiring a new way of “seeing herself with me. I was also responding to the strength and courage of the young person before me. Her agitation switched to cool withdrawal. she felt that her mother was responsible for her defectiveness. She put down our work. it is necessary to place it in the rich context within which it manifested. in which I served as witness to her increasing appreciation and acceptance of her struggle (Poland. I was helpless and ineffectual. She worried that her immune system “was down. harbingers of her developing femininity. and consider what compelled Beccah to bring the pictures to me at this point in her treatment. without maternal controls. .” and that her body could not fight infection. who hurt her mother with her defectiveness. The teacher said there was a possibility of bacterial contamination. and then she wouldn’t have to worry about her decision. “My mother made a comment. Beccah felt dangerous to herself and to others. she also struggled with the fantasy that she was the one at fault. She wanted me/mother to rescue her from herself because. in order to understand the psychic meaning of her action. Fears about her vulnerability to illness became prominent. I could pass it along.” However. “We were dissecting a rat. the threat of the loss of the childhood experience with mother mobilized intense conflict.

“That’s right! And just as I get worse. Beccah revealed a fantasy that her mother would not be there for her unless she needed her in sickness. like her mother. Maybe she was looking for me to say we needed to continue our work because that would stop her from leaving. She said. “My only requirement. but it engendered hostility in response to what felt like a requirement to succumb to mother. it seemed inevitable that letting go. a signal of her health. and would relieve her of her worry about making the decision to go. she started to face the end of high school and the move to college. she was more aware of other feelings.” We both understood that this was an expression of her wish to feel “main stream. and her anxiety about separation intensified. as she had done with her mother. The regression ensured their closeness. Fighting with me. and she brought books to her sessions to discuss her college search. She began actively to make plans to attend college away from home. was an attempt to regulate the interpersonal distance between us. Her history of risk-taking behavior had come under close scrutiny in the analytic work. Leaving mother and me was a loss associated with death and harm.” and one among many . 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. “is that it be a very big school. 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. scary things. would have destructive consequences. while it heightened her real susceptibility to damage. thus safeguarding her closeness to her mother.282 Silvia M. As Beccah connected with the affectively charged fantasies that pervaded her internal experience and observed her conflicts. being subject to the old dread of meeting people that would inhibit her. she met with her college counselor. with all kinds of people and pretty buildings.” she said when considering schools. I added that maybe her fears had intensified as she was experiencing upset feelings towards me who. Family discord had become greatly exacerbated. seemed helpless to make things right for her. given the dependent longings and aggressive reaction that were stimulated in the transference. being alone to meet life in its many challenges. “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. Bell As these issues were addressed. Her behavior was a compromise that represented her wish to experience herself as invulnerable so she might dare let go of the mother. Beccah gained in self-confidence. she was able to address her present fears about going to college—feeling small and at risk.

and I don’t have to have people prove they like me. she functioned like a highly traumatized youngster. I don’t chase guys any more. and her relationships became battlegrounds that expressed her inner turmoil. I interpreted that thinking about “many people” was a way not to think about the worry about being all alone.” While Beccah could have profited from further analytic work. The adolescent reworks the tie to the parents in the interest of individuation and disengagement from infantile dependency. now that our work would come to an end. Discussion This presentation details the analytic treatment in adolescence of a girl who suffered pervasive trauma. but I didn’t want to know about it. while sadness and rage locked her in a fixed view of herself as defective.” I interpreted that she was leaving me before we terminated. I have more esteem for myself. originating from a congenital condition that persisted for many years and necessitated multiple invasive medical interventions. and chaos on an ego incapable of mobilizing adequate defensive action. I told this guy off who was after me. I feel calmer all around. helplessness. “I’m proud of myself now.” where she acted outrageously to counteract worries about the dangers of adolescence. She tended to enact in order to defend against sudden. She projected her hostile view of herself onto others. At the inception of the analysis. The final weeks of the termination phase were stressful. She had taken a job and “was going to the lounge to talk with her friends. she left for college rooted in a sense of being a young woman with much to offer.Healing Function of Psychoanalysis 283 people who displayed differences that made them uniquely pretty. Beccah’s history involved all of the elements common to trauma—repeated assaults of intolerable magnitude that inflicted pain. I was missing appointments here to try it out on my own.” As we worked through old and new feelings about being on her own. disorganizing anxiety. she reflected thoughtfully on her reaction to ending: “It really did sink in that I’m going away to college. a process that involves the need to solidify the image of one’s own personality . During her last sessions. because of the worry about what feelings might come up on our final good-bye. She started to miss her sessions. She went through a period of “action-filled adolescence. Blos (1962) describes the central role of regression in adolescence. a view of her self that would stand her in good stead to meet the challenges ahead. she reflected on her gains.

Earlier conflicts and fantasies that interfere with successful individuation. 1989) attest to the vicissitudes of this phase. by seeking emotional closeness with the protective mother of early childhood. 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. and it threatened to keep her locked in a pervasive posture of defectiveness that defended against separateness. adolescence is a phase that facilitates the opportunity to undo developmental arrests and promotes restructuralization. and estrangement from the mother take over. she responds to the major shifts in physical. The girl’s entry into adolescence is characterized by a resurgence of the preoedipal object tie to the mother. Experiences involving her new female body. and the possible—Beccah was able to rework the governing childhood adaptations. Rather than . future. When the resurgence of sadism is too powerful.284 Silvia M. because of the centrality of regression. now are uniquely available for observation. aversion. Both Blos (1962) and Winnicott (1971) state that. and reactivate earlier conflicts about merger with/engulfment by her. 1995. which were much exacerbated for Beccah given her past conflicts. and mental. A replay of the struggles of the anal period can ensue. 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. The data from Beccah’s analysis attests to the importance of the adolescent period as one that provides a propitious opportunity for psychoanalytic intervention. Bell as the parental figures are relinquished. Ritvo. the girl may defensively externalize the sadism onto her mother. With the onset of menarche. Given the mental capacities of adolescence—the ability to think beyond the concrete aspects of the present. and effectively utilize the forces that promote development. and can become further structuralized in pathological outcomes. provided a context that promoted our exploration of the crippling conflicts that were interfering with the process of psychic differentiation. Beccah’s experience of life-death dependency on mother’s ministrations and protection was reactivated in this phase of development. 1989). to consider past. Accounts of female adolescent development (Dahl. 1984. and oppositional feelings. and the intensification of drives that safeguard individuation. functioning. as well as to the intensification of drive impulses. These longings stimulate fears of passive submission to the mother.

Competitive feelings may surface defensively to establish a more comfortable distance. she experienced it unconsciously as damaging actions against her body and self that had resulted because of her mother. describing the analysis of an adolescent boy who suf- . In a projection. Beccah understood on a conscious level that the trauma befalling her was not a premeditated act of cruelty. characteristic in individuals who have experienced an insufficiency of safety (Sandler. Fears of “being overwhelmed. However. Now in adolescence. she experiences her mother as a “jealously possessive. 460). 2003. the mother may remain fixed unconsciously as the erotically longedfor object the girl is inadequate to satisfy. 1986). 1995. In the state of total dependency of infancy and early childhood. 1995). ongoing power of annihilation fears and traumatic anxiety. were intrinsic to Beccah’s affective state. she then feels endangered by the mother’s rage (Dahl. merged. 1984). p. albeit marked in specific ways by her history of early trauma. The analytic work with Beccah attests to the pervasive. 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. The girl may ward off the homosexual danger by turning to precocious heterosexuality (Ritvo.Healing Function of Psychoanalysis 285 fearing her own murderous impulses. and because of herself. Beccah’s focus on her body. 1995. penetrated. which interfered with the development of a view of herself as an attractive young woman. her mother was the defective/intact mirror of her damaged self. she experienced sadomasochistic fantasies about surpassing her mother. Laufer. as they influenced her internal experience. Moreover. 1960). Nevertheless. p. 196). 579). state that trauma “creates a strong impulse to repeat destruction” (p. In order to mask and protect her heterosexual longings. a rescuing lifeline unable to provide a haven of safety. but this can lead the girl to experience her development as a destructive surpassing of the mother (Dahl. malignantly destructive witch-mother” who fascinates and imprisons her (Dahl. the regressive pull to the mother who took care of the body is a harbinger of an erotic entanglement with her. referring primarily to the psychic consequence of acts of cruelty. disorganized presentation that safeguards her from a fantasized attack. are in keeping with these expectable characteristics of adolescent development. or to help her with the regulation of suffering. envious. and the nature of the conflicts around developmental progression that emerged in the analytic exploration. fragmented and destroyed” (Hurvich. Laub and Lee (2003). Kennedy (1986). the girl regresses to a messy.

the picture is more complex. 2003. and kept her locked in a regressive posture of being the defective child.” A posture of “nonchalant bravado” is a characterologic defense in traumatized youngsters. Bell fered from phimosis requiring surgery at age two. serving to obscure intense object hunger. Hoffman (2003) comments on the prominent role of aggression in enactment and defense in the traumatized person. The excitement of her sadomasochistic entanglements. Repetition. in particular the predominant use of “identification with the aggressor” and “turning passive into active. has experienced painful maternal ministrations. and derogatory object. and a rejected. restructured and organized a whole range of earlier experiences and conflicts” (p. and impotent self ” (Kernberg. whose longed-for attention and concern could be attained only by suffering and pain and by relinquishing his penis. The child who. provides normally a much-needed opportunity to re-experience a situation. Goldberger (1995) comments that the incessant need to repeat the traumatic experience is a hallmark behavior of the victimized child. as Goldberger (1995) points out in her account of the analysis of a five-year-old-girl who suffered medical trauma. and conflict (rooted in oedipal and pre-oedipal wishes wishes that mandated punishment) interfered with the appropriate restructuring of her internal representations. 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. p. which is a function we observe in play. can be conceptualized as expressions of her internal representation of self and objects—a “systematic repetition of the relationship between a persecutory. Beccah’s “affect storms. detailed how the perception of the mother as “a vicious attacker. 217–218). and complex function. this . but also looked to have repeated” (p. required careful interpretation and working through. as reported in Mazza. that she damaged her mother through her defectiveness). 2003). as well as the unconscious connections between health—loss of mother—abandonment/death. The data from Beccah’s analysis gives evidence of the pervasive nature. that interfered with the development of an adequate view of herself. develops an attachment to being handled in painful ways. and passive libidinal object longings. absorbed.” which she enacted in her relationships with others. depressed. the gratification obtained from such relationships is “something which is feared. However. of repetition. in fact. as well as to ward off expectations of repeated rejection and loss (Steven Marans. 520). out of medical necessity. scolding.286 Silvia M.

In the early phase of our work. facilitated the capacity to distinguish between “reality and fantasy.e. to experience them in miniature” (Yorke. the capacity to utilize anxiety as signal function is impaired. 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.Healing Function of Psychoanalysis 287 time as the active agent rather than helpless victim. 2003a. non-verbal) level.. once again. 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. 2003) stress that it interrupts the development of healthy omnipotence. 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. 1990). but to the recovery of affective experiences which. The affective impact of these experiences. she experienced a resurgence of the traumatizing childhood feelings that accompanied her many overwhelming experiences pertaining to her medical needs..e. however. past and present. p. prevents the establishment of self-soothing and self-regulating capacities. underscoring the importance of genetic reconstruction. overwhelmed and cannot mobilize defense in response to the affect generated in the process of repetition. Blum (2003c). 500). one of the functions of the analytic intervention is the restoration of the ego’s capacity to utilize anxiety for adaptation (Yorke. 2002).. Beccah’s treatment created an opportunity for contained repetition. This experience promotes the gradual assimilation and mastery of anxiety. As the record of Beccah’s treatment elucidates. 1986). many assert that the major goal of treatment is to facilitate the development of the capacity to conceptualize and make sense of situations. Certain authors who write about the impact of early trauma (cf. Referring to Fonagy’s concept of “mentalization” (Fonagy et al. and she ex- . which were recorded at a procedural (i. when understood in light of what was known of “the relevant dimensions” of her childhood (i. nor to a simplistic ascription of causation between early factors and later pathology. cause and effect” (Blum. within a genetic context). and disrupts the capacity to recognize mental states and to find meaning in one’s own and others’ behavior. where she was able to “take an affective sample of these basic danger situations. affect and behavior. The ego is. 1986). Hence. reconstruction did not refer to the accurate recall of past events. Mazza. When trauma is involved. were actualized in the transference as she felt disoriented in my physical space.

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

44). 1988. as Gray emphasizes. when Beccah recognized that her aggressiveness protected her from the worry about being overwhelmed by fear. as differentiated from an aim that merely seeks to reduce the patient’s anxiety” (Gray. her behavior. and understood that thoughts of “defectiveness” kept her safe . and the quality of her thought processes increasingly reflected changes indicative of a modification in the constellation of intrapsychic factors that determines adaptation. In the course of the analysis. and relinquished the defensive use of defectiveness that interfered with adolescent development. We uncovered that she adhered to a devalued view of herself for complex reasons intended to restrict her functioning. the therapeutic aim of a focus on the analysis of resistance. as it became involved in compromise formations that relied on turning aggression against her self in a depressive response intended to relieve anxiety (Brenner. The interpretive work functioned to promote insight. 41). 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. and permitted her to achieve “conscious solutions to those conflicts that. when they were unconscious. threatened to mobilize anxiety” (Gray.Healing Function of Psychoanalysis 289 which represented the affective experience of her early years and her adaptation to it. she was able to achieve a new integration that reworked the heretofore sadomasochistic aspects of her relationship with her mother. 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. 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. p. her affect. is “to reduce the patient’s potential for anxiety. p. While. she gave eloquent testimony about the differences she experienced in herself. In Beccah’s case. 1982). As a result. profound unconscious changes take place as a result of the influence of the experience of the analyst-patient dyad. Specifically. when she realized that she experienced being healthy as a harbinger of loss. For example. 1999). By the time treatment discontinued. to quote Gray. Beccah’s attention was directed to the defensive function of her sense of defectiveness. 1988. depressive affect was also a target. she was better able to evaluate her anxiety and could establish more satisfying relationships with others. Because the meaning of this experience became accessible to interpretation in the context of our work.

New York: Free Press. Brenner. Psychoanal. Univ. because she had gained insight into her inner reality. In Int.290 Silvia M. 171–180. Conn. 50:187–204. The psychoanalytic intervention requires a specific kind of matching between the mind of the analyst at work. 84:497– 503. Analysis is an experience where the patient increasingly exposes these processes. J. Boesky. transference and reconstruction. Conn. and a sense of her capacity for conscious management of internal impulses. ——— (2002) In her mother’s voice: Reflections on “femininity” and the superego. 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. BIBLIOGRAPHY Blos. ——— (2003b) Response to Peter Fonagy. Psychoanal. J.: Int. (1988) A discussion of evidential criteria for therapeutic change. H. E. . C. Madison. Rothstein. Dahl. A. 1988). (1999) Rethinking Clinical Technique. 57:3 –26. promotes the affective reliving of inner experience. Study Child. In Int. 1988. p.. ed. The congruence of these processes creates a context that enhances the patient’s capacity for self observation.66). The psychoanalytic method engages complex verbal and non-verbal processes of the mind. Press. she was free to pursue her goals and wishes. and the mind of the patient at work. D. 84:509 – 513. The Mind in Conflict. Given that fantasy and conflict were pervasive and persistent at the inception of treatment. Northvale: Aronson. Blum. ——— (2003c) Psychic trauma and traumatic object loss. Press. K.: Int. Busch. and stimulates the integration of present in light of past experience that lends meaning to mental functioning. Study Child. engaged in an “effort at self-healing” (Jacobs. F. 51/2: 415 –432. In How Does Treatment Help?.. Univ. In JAPA. pp. P. Madison. as it facilitates the elaboration of the patient’s mental processes and elucidates them. about which he/she remains unaware pending intervention from the analyst. In Psychoanal. (2003a) Psychoanalytic controversies: Repression. Bell from strivings she experienced as dangerous. In Psychoanal. (1995) Daughters and mothers: Aspects of the representational world during adolescence. (1962) On Adolescence: A Psychoanalytic Interpretation. Beccah was able to look forward to leaving home to attend college.

(2003) 84: part 3. In Psychoanal. (1988) On the significance of influence and insight in the spectrum of psychoanalytic psychotherapies. 61– 80. J. In Int. The image and uses of the body in psychic conflict. Sandler. Study Child. P. Study Child. Study Child. Richards. Kramer. pp. New York: Basic Books. ed. Mentalization. XX: 87–174. Poland.. Winnicott. Kennedy. (2003) Dangerous behavior in children and adolescents. (1995) Enactment and play following medical trauma: An analytic case study. Kernberg. Jacobs.. Psychoanal. M. Press. SE. 48/1: 17–35. 51/2:579–616. 51/2:375– 380. 41– 50. Gergely. (1985) The Interpersonal World of the Infant. (2003) The management of affect storms in the psychoanalytic psychotherapy of borderline patients. Rothstein. In JAPA. J. & Richards. S. Myth and Reality: Essays in Honor of Jacob A. 41:259 –276. 41:209 –219. W. T. pp. Blum. (2003) Thanatos and massive psychic trauma: The impact of death instinct on knowing. M. ——— (1989).: Int. Jurist.. E. Yorke. D. . In JAPA.Healing Function of Psychoanalysis 291 Fonagy. In Fantasy. (2003) Vicissitudes of aggression: Theoretical and technical approaches to psychic trauma. In How Does Treatment Help?. P. Madison. Conn. In Psychoanal. Psychoanal. M. Laub. (1971) Playing and Reality. eds. Study Child. Arlow. Laufer. S. (1988) Notes on the therapeutic process: Working with the young adult. M. Stern.. Mazza. pp. Madison. In JAPA. Goldberger. 39:449 –468. & Lee. Madison.. In JAPA. In Psychoanal.: Int. 51/2:517– 545. Press.: Int. D. J. In How Does Treatment Help?. O. 41:352– 365. Univ. Fonagy. 51/2: 433 – 464. In Psychoanal. (1960) The background of safety. 51/2:651– 666. D. Gray. (1984). D. C. In Internal. ed. Univ. 41:221–236. (1986) Reflections on the problem of psychic trauma. & Target. A. (2002) Affect Regulation. 50:252–271. H. (1986) The female oedipus complex and the relationship to the body. A. G. In JAPA. Psychoanal. Univ. Rothstein. 371– 380. New York: Basic Books. Freud. Ritvo. and the Development of the Self. L. J. Hoffman. Hurvich. (2000) The analyst’s witnessing and otherness. remembering. (2003) The place of annihilation anxieties in psychoanalytic theory. Conn. daughters and eating disorders. 84:503 – 509. and forgetting. P. Study Child. symptoms and anxiety. (2003) Rejoinder to Harold Blum. Mothers. Conn. In Psychoanal. In JAPA. (1926) Inhibitions. E. Press. (1986) Trauma in childhood: Signs and sequelae as seen in the analysis of an adolescent. New York: Other Press. S. Int.

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PSYCHOANALY TIC PERSPECTIVES ON THE FUTURE AND THE PAST .

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which integrates genetic interpretations and restores the continuity of the self. Neubauer. published here in English with the permission of Stroemfeld Verlag. The Psychoanalytic Study of the Child 60. and irrational childish fantasies and behavior point to the necessity for reconstruction. 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.D. Neubauer. In this paper transference is viewed as a guide to reconstruction. Reconstruction organizes dissociated. M. Peter B. and to meaningfully connect past and present. Robert A. BLUM. potentiating the further retrieval of repressed memories. Given as the Freud Lecture. Germany. Samuel Abrams. Clinical Professor of Psychiatry.Psychoanalytic Reconstruction and Reintegration HAROLD P. is based upon childhood fantasy. 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. King. 2002. King. copyright © 2005 by Robert A. New York University School of Medicine. fixations. Reconstruction is a complementary agent of change. and is a new edition of unconscious intra-psychic representation and relationships. ed. Scott Dowling (Yale University Press. Samuel Abrams. Recapture of the past is necessary to demonstrate and diminish the persistent influence of the past in the present. Transference. New York University Psychoanalytic Institute. but transference itself is also an object of reconstruction. Peter B. features. A case is presented in which reconstruction had a central. vital role in the analytic process. Training and Supervising Analyst. fragmented memories. Reconstruction is essential to the working through and attenuation of early traumatic experience. 295 . however. November 1. and A. Frankfurt am Main/ Basel. and A. Scott Dowling). The patient’s childish traits.

psychoanalysis has moved in many new directions. This cannot be said among analysts too emphatically or repeated too often . 1980. or trait is derived in some way from childhood. this paper supports reconstruction as inherent to the psychoanalytic point of view and virtually all clinical work. reconstruction is not only reciprocal to transference interpretation in the present. “Up to your nth year you regarded yourself as the sole and unlimited possessor of your mother. permanently influencing the personality. Freud (1937. anyone who neglects childhood analysis is bound to fall into the most disastrous errors. . p. . Experience such as the birth or death of a sibling had an impact on the patient’s life. Reconstruction for Freud was both a technique.” Extending my previous work on the theoretical and therapeutic value of reconstruction (Blum. p. but all persons and peoples. and reconstruction has particularly fallen out of favor as there has been more immediate attention and emphasis on the here and now. It is not only the adopted child who is curious about his/her origins. then came another baby and brought you grave disillusionment. and a goal of psychoanalysis. 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 . and even after her reappearance she was never devoted to you exclusively. . 2000). Actually. . which are constructions compounded of fact and fantasy. behavior. . and so on. Blum in its second century. In my view. Psychoanalytic reconstruction has been treated either with neglect or declining interest as attention has turned to other psychoanalytic issues and agents of change.” A genetic interpretation shows that a current symptom. but it is a complementary agent which guides and integrates interpretations and reorganizes and restores the continuity of the personality. inside and outside psychoanalysis. feeling. Nations have legends about their origins. 26) illustrated such a prototypical reconstruction. Your mother left you for some time. analysts and patients have pondered the question of where the patient was coming from. 1994. It is .296 Harold P. Your feelings toward your mother became ambivalent. often with increasing distance from its origins and core formulations. and how he or she got there. your father gained a new importance for you . Psychoanalysis itself is not regarded as particularly popular in many parts of the world today. thought. . Freud (1919. a means toward the goal. 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.

to childhood conflicts concerning feeding and object loss. organize. and it traces. Reconstruction would encompass broader considerations. the transference. As analysis proceeds. and the patient’s resistance in the analytic process. etc. self analysis. Contrary to the current position in some analytic quarters. for example adult obesity. and the unique quality of individual endowment and experience. identification with the lost object. and moral development. concurrent parental regression. provide a foundation for the process of reconstruction. the wealth of associations. A cari- .g. Genetic interpretations are fostered by the regressive character of free association and transference. Although analytic work requires the reconstruction of childhood (Freud. e.” Analytic theory does not derive entirely from adult regressive states. Like interpretation. education. 1937). confirm. but has long been complemented by infant observational research and child analysis. and experience should contain and limit the analyst’s human subjectivity. or from another point of view. it may provide further insight into the patient’s conflicts. cognitive. of dependent relationships. the patient’s childish traits. this does not mean that any two reconstructions by two different analysts will be identical. Reduction of the transference to its childhood roots and the accumulated analytic data converge in a reconstruction. and interpret the data with some degree of theoretical and personal preference. which in turn furthers the analytic process. The analyst’s analytic attitude. The analyst’s countertransference may make it difficult to analyze the transference. transference reactions. Usually there are a number and variety of reconstructions rather than one grand encompassing reconstruction. The reconstruction of childhood takes into account affective. that such genetic data are co-determined by the analyst’s suggestion or countertransference.Psychoanalytic Reconstruction and Reintegration 297 specific and focal. the childish character of the transference. Because of the theoretical implications of reconstruction. etc. memories. inability to mourn and accept loss. and irrational childish fantasies point to the childhood locus of pathogenesis and the patient’s psychopathology. it has been used from the beginnings of psychoanalysis to propose. or challenge a theoretical or developmental hypothesis. Each analyst will select. fixations. Reconstruction considers the overlap and sequence of developmental phases. features. All too often what is depicted as analysis in popular distortions and misconceptions is a parody of the psychoanalytic process. which do not reproduce earlier states unaltered. retaining “good enough objectivity. reconstruction is neither arbitrary nor capricious nor dogmatic.

usually conscious verbal memory for persons and places and general knowledge. but on evidence. and further confirmation or alteration with new data. The present as well as the childhood past may be viewed through a glass darkly. Our knowledge of memory has significantly advanced in the recent decade. inference. Bridges are under construction between psychoanalysis and neuroscience. If the past and present have not been meaningfully interconnected. Fragmented. preferred to reconstruct her childhood strife with her mother. tentative and always an approximation. 2002). rather than scrutinize her derivative overprotection and over-indulgence of her daughter. implicit memory for skills. then the patient’s defenses have not been sufficiently diminished. Traumatic memory is an exception. it is a product of prior analytic work. riding a bicycle. A patient. and repressed memories emerge and have to be differentiated from screen memories and pseudo-memories. robotic. Self-protection is preferred to self-knowledge. Blum cature of the psychoanalyst as insensitive. Procedural. dogma. though not repressed. Severe trauma alters the structure and the memory function of the hippocampus. and selfserving is deployed to defend against the authentic yet disturbing nature of analytic insights. Screen memories are often similar to the patient’s constructions. At this time the dynamic unconscious has not been definitely delineated within any specific memory system or configuration. explicit. storage. When a reconstruction is offered to the patient. dissociated. e.g. These systems appear to have their respective modes of registration. or conjecture. for example. Any confrontation with her daughter was to be strenuously avoided. insistent. Autobiographical memory is closely connected to declarative. playing the piano. Psychoanalysis and the process of reconstruction are not based on faith. and retrieval with interrelated functions and controls.298 Harold P. Several memory systems are now recognized. is not conscious. Patients sometimes offer reconstructions before the analyst. . These findings illuminate the complexity of memory and the necessity of reconstruction superseding the limitations of discrete memory. which appears to instigate automatic fight-flight reactions to stress. Unconscious traumatic memory is essentially formed in the amygdala (Le Doux. however. Before the reconstruction is verbalized and offered to the patient. In any case. and appears to be processed differently from other memory. reconstruction will be invoked in analysis unless the past continues to be resisted and avoided. and is not modified as a consequence of psychoanalysis. The past will continue to influence the present. but the past may also defend against the present. and both disciplines should benefit.

. except that the analyst works under better conditions and has more material at his command to assist him. particularly concerning the nature of the patient’s psychopathology and its relationship to pathogenesis. Reconstructions have transference and counter-transference meaning. and there may have been developmental transformation of meaning and function.Psychoanalytic Reconstruction and Reintegration 299 the psychoanalyst has been building a mental construction of the patient’s childhood. The adult’s present personality and life situation influences the form and content of childhood revivals. . the persistence of childish features and fixations within the adult personality. the life history described by the patient. construction evolves. which goes on silently in the analyst’s mind. however. and the initial transference reactions of the patient along with the analyst’s countertransference responses. or if it is preferred. . Some of the main features of clinical reconstruction will be illus- . This is not to say that the child in the adult is ever revived as he/she actually existed in childhood. and the revival of childhood in the patient’s regressive responses. “His work of construction. 1994). Reconstruction of the patient’s past is necessary to demonstrate the persistent influence of the childhood past in the present. This will allow a deeper understanding of the significance of the child that lives on within the adult. of reconstruction. 1937. p. Blum. Patient and analyst develop rational conviction about a reconstruction based upon analytic knowledge. . Construction is an initial preliminary formulation. The archeological metaphor which Freud originally used in his description of reconstruction as reclaiming the buried past is still apt in many respects. observations. since what he is dealing with is not something destroyed but something that is still alive . Differentiated here from construction. reconstruction is generally formulated after the opening phase of analysis and is shared and shaped with the patient. 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. Based on the patient’s presenting symptoms and character. Childish reactions in the adult may or may not serve their original defensive and adaptive functions. . re-experienced. inferences and their cohesive integration. but contemporary reconstruction also demonstrates the influence of the present in the way the past is revived. 259). In the material that follows I shall focus primarily on reconstruction.” (Freud. resembles to a great extent an archeologist’s excavation of some dwelling-place that has been destroyed and buried or of some ancient edifice. and understood. so a patient’s reaction to reconstruction becomes part of the analytic process.

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

Separation reactions activated in the transference. Later he began to examine the many stereotypes of his childhood. which reflected in all his current relationships. Disgusted. and he was fearful of the . His masturbation while looking at the parental pornography was unconsciously incestuous. When his girlfriend learned about his “affair” with his former fiancee. When he had asked for the analyst’s card. but excited. and as an adolescent he audited their sexual relations and was sexually aroused. In his view. He had slept in the same room as a sister until puberty. wondering if the analyst were trustworthy or a lascivious hypocrite. The patient was dimly aware of his fear of all women and preferred to think of them as asexual Madonnas. “have a nice weekend. His removal from their bedroom at puberty convinced him of his sinfulness and motivated his urge to confession in church and later in analysis.Psychoanalytic Reconstruction and Reintegration 301 and loyalties. He was reluctant to leave sessions. “I’m Jewish. Although he was afraid of getting caught. He confessed guilt about reading a magazine report about a mass murder in the waiting room. At this point the analyst could reconstruct the patient’s reactivated primal scene fantasy and sibling experience during his childhood and adolescence. His adolescence was burdened by guilt and fears of punishment. were major reasons for his seeking psychoanalysis. she repeatedly told the patient that had hurt her deeply. He had grown up in an antiSemitic milieu with contempt of Jews. undressing together. This led to feelings about morality and specifically religion. Jews could be ruthless and they did the dirty work (like servants). He then recalled that in adolescence he had found his father’s pornographic pictures.” The intrigues in his personal life entered the analytic situation. He was so afraid of being discovered that he replaced them exactly as he found them. he felt feminine and was homophobic.” The patient was stunned and mortified. On the couch he was vulnerable. he had somehow left the magazine open to that page. and on Friday would cheerfully state. he masturbated with these pictures. He thought his parents were shameful hypocrites. and then she broke off all contact with him. though weaklings. In a Catholic college he had told a fellow that he had no use for any Jews and this person declared. He was unconsciously afraid that the possibly Jewish psychoanalyst would encourage immoral thoughts and acts. he was unconsciously referring to his father’s pornography. and his guilt toward these women. As a child he had wondered about sounds coming from the thin partition of his parents’ bedroom. He wondered if the analyst were Jewish.

their not setting limits. After this reconstruction he could understand his fear of intimacy. servant’s quarters. his parents and the estate owners with different styles of lan- . The patient had grown up in New England. The priests and nuns were supposed to be kindly but they were frequently cruel. and his unconscious fantasy of impregnating sister and mother. and their implicit condoning of inappropriate sibling intimacy. but pornographic. Payment led to associations about dirty money. He then described physical abuse. his fragile self-esteem and compensatory striving for social status and affluence. The analyst reconstructed the influence of the servant experience on his fear of being compliant and dependent. the servant’s entrance. which had appeared in the transference. Blum incestuous voyeurism. The idealization of wealth was introduced when the patient had difficulty in paying the analyst. The secret of his affair was tied to the secrecy of the primal scene. They too were unreliable hypocrites. The analysis deepened in its middle phase after a vacation. and sibling sex play. He had despised the Jews in part as a defense against his ambivalence toward the Christian authorities of his childhood and adolescence. not proper. The patient spoke again of the hypocrisy of his parents. The two different styles of language and manners.302 Harold P. A very important childhood theme then affectively emerged in the center of analytic work. carrying golf clubs for affluent adults to earn extra money. exhibitionism. his sibling experience. could now be reconstructed as related to his early experience. He was guilty and anticipated punishment for his incestuous fantasies. The bare check would be nude. He was the son of servants. His attention turned to his irrational fear of the analyst’s cruel and dirty impulses and then to recollections of parochial school. The patient too had to know his place. and penance for minor infractions. nor did he know proper etiquette. His father was a tyrant at home but deferential and subservient toward his rich employers. and the analyst becoming enriched through the patient’s efforts and expense. their own crude behavior. mostly on large estates in which his parents worked as servants. The patient had played with a Jewish employer’s son. The primary house of his childhood was actually a cottage on an estate. greed. but they were not allowed to eat together in the main dining room. endless repetitions of prayers. that of observing two classes. within a socioeconomic class system. ostensibly because he did not have an envelope in which to enclose the check. He recalled with humiliation and rage how his father made him walk to the back door. He realized this accounted for the lack of boundaries and privacy since the few small rooms had flimsy walls. and how he hated being a caddy.

and could know too much. envy. The wealthy estate owners had referred to his parents by their first names or without a name. educated. and resentment of the aristocrats. treating his belittled parents as if they were children. and elegance but he knew that deep inside he had a servant mentality. Apparently some of the estates were owned by descendents of the “Robber Barons. Secrecy had also referred to the social devaluation of servants. The estate owners. haughty superiority toward their servants. He had not been aware of his dual identifications. and his mother probably served as a maid. He transiently thought of quitting analysis rather than lying compliantly on the couch. He displayed the superficial accoutrements of affluence. for manual laborers and for the lower class. but also contempt. partially through projection. He had lived in two worlds which were dissociated. ego integration was possible only after reconstruction of his childhood. He felt compassion and pity. and ambivalent attachments. Yet his identification with the cultivated. which he regarded with shame and humiliation. integrated in the reconstruction of the patient’s childhood as the son of servants. Acting servile and submissive was unconsciously associated with being feminine. His father had done manual labor. He identified not only with the values of the aristocracy but also with their condescending. feared that their servants would engage in theft.Psychoanalytic Reconstruction and Reintegration 303 guage and dress. enraged and frightened the patient. He admired and idealized their prestige and power. not only because of his guilt. The “have-nots” attempted to devalue what they did not have. Moreover. with being Jewish. refined aristocrats proved to be a very important factor in the patient seeking higher education and developing many cultural interests. languages. He wanted to realize grandiose omnipotent fantasies and to never again be subjected to being humble and humiliated. The patient saw this as a lack of respect. Reconstruction elaborated how he and his family were filled with awe. or was suggestive of being submissive or subjugated. but because of the dirty work of his parents. 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. He should have been rich. Anything that reminded him. and what a better life he would have if he were the son or adopted son of the nobility. A flood of painful memories returned.” influential individuals who inherited great wealth from the financial manipulations of their forebears. He needed to be clean and neat. He identified with his parents of the servant class and also with the aristocratic parents. The pa- . servants knew some of their employers’ secrets.

like the landed aristocracy. and revenge the humiliations.304 Harold P. and turn humiliation into pride and glory. The analyst reconstructed the patient’s organizing his life around overcoming any narcissistic injury. but he identified with their silent compliant acceptance of shame and humiliation. On one level he regarded his parents as shameless. The patient had a fleeting coprophagic fantasy. servant and master. two sets of parents. Why their job dismissals and moves? Servants had no job security and . and feelings were organized into a cohesive. The analyst pointed out that the patient’s view of his servant parents was that they had to swallow their pride. prince and pauper. many of his disconnected thoughts. a role formerly assigned to his analyst and Jews. As servants they had been fed and swallowed a steady diet of denigration. and humiliation. He had two languages. he had taken upon himself or had been delegated by his parents to redress their narcissistic mortification. He was of. obtaining narcissistic supplies. He would not be treated with contempt by his analyst or any authority. As a consequence of the reconstruction. guilt. He had fantasized that he was not the child of the servants. his parents. Blum tient had fantasies of acquiring great wealth by defrauding the rich. He could reflect on the family life of servants. In the analysis he wondered about concealing his still rising income so that he would not have to raise the fee. These various associations and interpretations were followed by further enlarged reconstruction to which the patient contributed. reverse. He rebelled against any idea of being subservient toward his analyst. and becoming an aggrandized aristocrat. the secrecy of sibling sex play. memories. two women. In fantasy he was the greedy thief. meaningful constellation. or destined to be. The reconstruction unified what had been a double identity. The analysis then veered further into the arena of shame. His self and object world had been split between idealized and denigrated childish representations. the secrecy of the primal scene were associated with the child’s secrecy and confusion concerning his parents’ denigrated status. he identified with his degraded parents. The secrecy of his ex-wife’s illegitimate child. and two polarized sets of attitudes toward people and society. the nobility. In a parallel reconstruction. to overcome the family shame. The patient could see that some memories defended against much more disturbing memories of his adolescence and childhood. The patient wanted to erase. coherent. but would rise to the superior status to which he was entitled. but the masters. He realized that he. the Robber Baron. but also was hungry for money and its power. and the aristocrats all had a common religion—they worshiped wealth.

He was less confused by his pendulum-like swings between his feeling affluent and indigent. The reconstruction elucidated to the patient’s intrapsychic fantasies and responses to his pre-adult experiences. Freud reconstructed a part of the analysand’s development. and early differentiated between genetic and developmental perspectives. Frosch. forgotten. It allowed greater access to the negative feelings of guilt. So long as we trace the development from its final outcome backwards. The recovery of dissociated. they avoided income tax. We notice at once that there might have been another result. his fear of failure. basking in their reflected glory. 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. Although Freud noted that reconstruction may serve as a convincing surrogate for a memory that could not be retrieved from repression. Were they actually fired because they committed robberies? Frequently paid in cash. But if we proceed the reverse way. 1909. 1959)? The reconstruction gave him insight into his thoughts and feelings about the past and his plans for the future. now manifest in wishes to be adopted by the analyst (Freud. his basic premise was developmental and dealt with a forgotten piece of childhood. which could not have been otherwise determined. master and slave. 258). which is completely satisfactory or even exhaustive. and humiliation. his low self-esteem. and repressed memories reciprocally facilitated reconstruction. The reconstruction did not compete with nor defend against transference interpretation. aristocrat and servant. if we start from the premises inferred from the analysis and try to follow these up to the final result.Psychoanalytic Reconstruction and Reintegration 305 no status. Freud added that the task of the analyst “is to make out what has been forgotten from the traces which it has left behind. then we no longer get the impression of an inevitable sequence of events. and/or secretly enjoying humiliation? What had led to their becoming servants? Did his parents also idealize and identify with the aristocracy. but advanced understanding of both transference and genetic interpretation. and that we might . and his drive for success. Did they deserve punishment? Were they without self-respect. or more correctly. shame. with pathogenic or progressive ramifications. 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. the chain of events appears continuous and we feel we have gained in insight. to construct it.” Freud (1920) anticipated the contemporary developmental issues in reconstruction.

How could this patient understand his master-slave fantasies. the more speculative it inevitably becomes. Some of the ambivalence toward his father may have been transferred and displaced from his mother.306 Harold P. and dangerous. of tracing the over-determined numerous factors of pathogenesis both evokes and challenges reconstruction. and by the discontinuities which have to be bridged. hardly playful. and the reconstruction to which they were attached. callous nun? Mother could be a Madonna-like figure who protected him from his own impulses. The earlier the level of reconstruction. The issues of genetic fallacy and adultomorphic myth are further complicated by the possible confusion of pathological regression. The reconstructive inferences depend upon the totality of analytic data. tempting. She was not described in warm terms and was regarded as rigid and unempathic. So far the classical explanation of the patient’s disorder was in terms of oedipal conflict. but also an exciting and emasculating prostitute.” Women were cracked. by the number of factors and varied strength of forces involved. 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. which were important antecedents of later conflict? Of course the further back into the pre-oedipal period a reconstruction is attempted. He stated. Were there not also primary narcissistic and pre-oedipal issues. 167) The problem of reconstructing developmental steps and sequences. insensitive. normal development. Reconstruction is made possible by the wealth of information provided by the analysis. on the elaboration and remodeling of the reconstruction in the crucible of the analytic process. Was his mother the prototype of the rigid. they were split into degraded pairs of prostitutes and nuns. (p. the greater the level of conjecture. and not just the transference alone. The synthesis is thus not so satisfactory as the analysis. veridical “red thread” of connections. It is likely that his feeding. and deviant development. did not fully explain the patient’s psychopathology. Only after more analysis could he admit that some of the clergy were dedicated and effective . What was his early experience with his mother? She was stoic in her menial work of cleaning and laundering. She was quite possibly depressed during his early childhood. Blum have been just as well able to understand and explain the latter. “I’m uncomfortable with cracks in the edifice I have created. sleeping. The genetic interpretations. and toilet training were rigidly controlled. his feelings of emasculation and inferiority. But it is never a singular.

There were few if any parties in his childhood. as well as filling in memory gaps. . An attempt is made to clarify the details of the traumatic situations. Somatization reactions and non-verbal communication may be at least initially of great importance. In later childhood he was painfully ashamed of his parents and strenuously defended against feelings of shame. and holidays were not celebrated. Reconstruction may contribute to the retrieval and reorganization of fragmented.Psychoanalytic Reconstruction and Reintegration 307 educators. The reconstruction was regarded as mutative. Only then can traumatic reality and its fantasy elaboration be integrated into the relatively intact personality. but also the patient’s apperception of his/her inner and outer world. enacted. or acted-out through the children. reconstruction is required of the trauma. Without the reconstruction of memory what is indescribable and ineffable may be somatized. 1991. 1994). . The atmosphere of home was somber. 150). to uncover the intergenerational transmission of trauma. self-representations as well as object representations from various phases of life are re-evaluated and reintegrated into new and more realistic representations. the past within the present is transformed forging a new vision of reality” (Blum. and of the void of protecting or rescuing objects (Grubrich-Simitis. 1994. and they were little interested in their children’s feelings. but they and the aristocrats encouraged both his later achievement and entitlement. memories. Blum. and panic. If he did not like the food he was offered. “making a decisive difference in clinical analysis . To avoid a collusion of silent avoidance. so that his preferences were largely ignored. p. 1981. though the patient was aware that the aristocrat’s children on the estate had such parties. distorted. The verbal reconstruction coalesces with step-by-step working-through of trauma and terror. He had never had a birthday party. terror. His parents’ relationship was not marked by overt affection and friendship. the next generation. Transference analysis and reconstruction were synergistic rather than competitive or adversarial. and when necessary. there may be ego regression and damage to cognitive and affective processes. recalled and re- . Krystal. In clinical situations where there has been massive psychic trauma. Not only were the defenses modified. In the process of reconstruction. This permits the massive trauma of the past. His father was not sure about his son’s birthday. of the feelings of helplessness. with analytic awareness of inevitable unknowns and ambiguities. His parents conveyed their feelings of denigration to their son. he was expected to eat it without complaint. What the patient cannot remember and articulate has to be laboriously reconstructed.

Further analytic reconstruction may encompass prior and subsequent traumatic experience. which the patient has helped to create. The patient had become the critical parent and the . . and we avoid telling him the whole of what we think we have discovered. Transference and current reality may take precedence. While it is true that reconstruction is not necessarily a part of psychotherapy as it is in psychoanalysis. His feelings of mistreatment derived not from the present. whereas the patient believes that the analyst truly merits criticism. to belong to the past rather than the ever present. but early reconstruction can be very helpful. A borderline patient. Blum constructed. Where the patient has experienced a pathogenic relationship with a parent involving regular overdoses of criticism. reconstruction is often utilized to help the patient become aware of the power and persistence of childhood fantasy and experience into their adult lives. which is not always easy to decide” (p. justifying in his mind his criticism of the analyst. A transference-countertransference stalemate might ensue. “we never fail to make a distinction between our knowledge and his knowledge. The analyst has a negative counter-transference. We avoid telling him at once things we have often discovered at an early stage. The patient has identified with the aggressor and was treating the therapist to the same disparagement to which he was subjected. 178). There are different approaches to such thorny problems. telescoped into the maelstrom of massive trauma. who is bitterly critical and contemptuous of the analyst. the therapist could point out that the patient had experienced withering criticism long before his treatment. . reconstruction may be necessary to illuminate the transference and the current reality situation. and disparagement. The patient has succeeded in eliciting the psychotherapist’s hostility. contempt. This is a departure from the general use of reconstruction after the initial phase of therapy. but at the same time. I shall now turn to the early facilitating value and integrative effects of reconstruction psychoanalysis and in insight oriented psychoanalytic psychotherapy. about which he is inwardly conflicted. to the psychoanalyst as well as to the patient. We reflect carefully over when we shall impart the knowledge of one of our constructions to him . The psychoanalyst regards the patient’s criticism as part of transference fantasy. but predominantly from the past with his parent.308 Harold P. The exception here is not meant to detract from Freud’s (1940) counsel. may not respond to the analyst’s attempts to show the patient that the attacks on the analyst are irrational and unjustified.

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. She gains control over the analyst in fantasy and unconsciously seeks not so much his falling in love with her. The value of reconstruction is exemplified in the clinical material in which the past so prominently influences the present and impinges on the future. correcting personal myths while simultaneously fostering greater and more realistic self-awareness. and the context and shaping of life experience. may still be readily subjected to projection and rationalization that the others deserved his animosity. cause and effect. but with loss of balanced focus on childhood. the reality of a patient being contemptuous and insulting toward others in his life situation. Seduced by an older brother into sibling sex play. In this case the erotic transference recapitulates the sibling relationship. 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. dissociated from the infantile unconscious. 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. and patient’s infantile neurotic fantasies and features.Psychoanalytic Reconstruction and Reintegration 309 analyst is treated as the child whom the parent holds in contempt of court. knowledge. she is now the active seducer. Without this reconstruction of a piece of the patient’s childhood. psychoanalysis tends to become a-historic. and defends against an underlying hostile fantasy of emasculating the analyst and destroying his reputation. weapon and defense. This would be a specific genetic interpretation. The adult woman who is seductive and exhibitionistic in an erotic transference may have similar dynamics. but his downfall. The reconstruction integrates and explains her seductive behavior as repetition and revenge. fantasy and reality. Furthermore. Reconstruction restores the continuity and cohesion of personal history. unrealistic self and object representations. in analysis and in life. The analyst also engages in reciprocal self-examination and counter-transference analysis. as proposed by inter-subjective theorists. Reconstructions are selected from their alternatives on the basis of the convergence of analytic data and of the patient’s response to the . It is difficult to understand how analytic experience without the insights enriched by reconstruction would significantly alter unconscious. Spanning life experience. Without reconstruction. and insight. reconstruction integrates past and present.

logical and lucid. While it may replace gaps in memory. Moreover. which did not exist in childhood. reconstruction has a different contemporary position in the theory of technique. Memory is remodeled. but there are always individual variations. deriving from and applying the genetic and developmental points of view in clinical psychoanalysis. Either analyst. Patients are stimulated to check and correct reconstructions whenever possible through objective evidence. 1968) at childhood is through analytic . developmental transformations may not be retrievable in their pristine form.310 Harold P. with the major exception of shock trauma.g. 216). The past has taken on elaborate new meanings. no source or selection of data is inherently free of distortion. Reconstruction also has an important current research dimension. In contemporary psychoanalysis. Validation and conviction are not necessarily achieved. 1998). Patterns are more important in general than are single memories. Individual fantasy and experience may coalesce with universal fantasies and the universals of life experience. A reconstruction should be internally consistent and cohesive. or researcher may be much more convinced of the validity of a reconstruction than the other persons. analysand. testing and potentially integrating analytic data with the findings of infant developmental studies. The past is not only rediscovered but is recreated in clinical psychoanalysis. This is exemplified in the family romance of the son of servants. External confirmation can be analytically useful and contribute to rational validation and conviction of correct reconstruction (Good. 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. Freud (1926) referred to the sometimes “irrefutable evidence that these occurrences which we inferred really did take place” and he then stated. e. However. of such forgotten experiences of childhood always has a great therapeutic effect. of documents and the reports of relatives and witnesses. you must know. reconstruction has largely supplanted reliance on the recovery of repressed memory. whether they permit of objective confirmation or not” (p. he never relinquished the importance of trauma. The “second look” (Novey. It is remarkable how often psychoanalytic reconstructions are confirmed and expanded with extra-analytic evidence. While Freud at times shifted positions concerning the relative importance of fantasy and real experience. “The correct reconstruction. Blum reconstruction. The legal system has painfully learned that eyewitness reports may not be reliable. and closely linked to the prevailing unconscious conflicts and analytic issues.

The psychogenesis of a case of homosexuality in a woman. Integration and self-healing in post-traumatic states: A ten year retrospective. Though the analytic autobiography is further illuminated and integrated by a particular reconstruction.. Amer. LeDoux. Good. Krystal. (1975). 17. M. Psychoanal.. ——— (1940). (1980). An outline of psychoanalysis. Imago. there are no guarantees in analysis of valid reconstruction or interpretation. J.. Childhood Revisited and Recreated. 47:1125 –1144. (1981). Psychoanal.. ——— (1937). 23. Physics and Philosophy. 1958). Internat. ——— (1994). J. Heisenberg. S. Constructions in analysis. S. (1968). S. Amer. 20.. Synaptic Self: How Our Brains Become Who We Are. The reconstruction of reminiscence. Screen reconstructions: Traumatic memory. I. The Second Look. ——— (2000). J. (2002). 18. New York: Viking. S. Assn. 7:503 –520. Psychoanal. Family romances. the pleasure and reality principles. 48:93 –118. Frosch. Assn. Greenacre. Assn. (1998). ——— (1920). Psychoanal. P. Extreme traumatization as cumulative trauma: Psychoanalytic investigations of the effects of concentration camp experiences on survivors and their children. H. 23:693 – 771. 46:149 –183. J.. The empty circle: Children of survivors and the limits of reconstruction. conviction. S. The problem of lay analysis. The value of reconstruction in adult psychoanalysis. 23. and the problem of verification. J. J. Novey. On reconstruction. Assn.E. Freud. Amer.E.E. Amer. . ——— (1919). (1958). 46:508 – 529. Transference derivatives of the family romance.. W. (1959). Reconstruction in Psychoanalysis. Psychoanalysis requires tolerance and evaluation of alternative considerations.. Study Child. we live and work with the uncertainty principle (Heisenberg. New York: Harper. S. (1909). H... S. Laub. BIBLIOGRAPHY Blum. Psychoanal. S. Amer. In addition to Freud’s (1911) two principles of mental function.Psychoanalytic Reconstruction and Reintegration 311 eyes with the refraction of an adult lens.E. Assn. (1998).E. ——— (1926). 36:415 – 450.. A child is being beaten. Psychoanal. Ambiguity and perplexity are part of psychoanalytic work and the quest for greater insight.. D. Grubrich-Simitis. New York: International Universities Press. 9.E. J. 61:39 –54. Baltimore: Johns Hopkins University Press. Amer. (1991). Psychoanal.

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.” No other living being can hold an imagined future before the mind. In addition. we often discover we’ve been quietly including the future anyway. and recovery of repressed. and has the responsibility of its opportunities and dangers.. than that of past. experience. may also have discouraged serious scientists from attention to the subject. —Ralph Waldo Emerson 313 it seems that only man imagines the “winter of his discontent. but we have neglected the influence of the future. 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. It is about forms of anticipation that do not transcend our senses. which validates our imagined fears over and over again. His well being is always ahead. has been so useful a focus of clinical work. whether in anxiety or hope. about prediction of specifics.On Foresight If a man carefully examines his thoughts he will be surprised to find how much he lives in the future. reconstruction of the past. and although attention to the future is implicit in much analytic writing. psychics. about foreknowledge. The neurotic part of us is in the grip of the past. Even when not pondering in this vein with full deliberation. etc. 1. 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. Emde (1995) notes.1 Although there are studies on related topics such as judgment and anticipation. as the past is repeated over and over again. The psychology of the future is less developed in psychoanalytic thought. A mature imagination has much to contribute when its limitations are recognized. “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. and judgment. In fact.” or the “glorious summer. The fact that foresight has often been the province of astrologers. one way to view neurosis is as a truncation of realistic foresight. I found no papers on the specific concept of foresight in the analytic literature. impassioned thought or quiet reverie. It is not about knowing events in advance. however. seers.

envision a horizon. don’t elbow their way in to focused attention. revealing its manifestations more than its workings. secondary process. on the “edge of awareness”2 that later appears in the patient’s associations. One isolates. whereas to predict along the lines of synthesis is impossible. however. (Freud 1920) However. See Bibliography. but may be of surprising value when noted. on the other hand. in analysis we do often sense a direction. These delicate impressions. makes ideas collide. and we feel we have gained insight which is completely satisfactory and even exhaustive. They are more like a quiet breath. such as the state of the therapeutic alliance or the tactfulness of the analyst’s wonderings. we pay little attention to such impressions. often don’t come in verbal language. Bennett Simon. . the chain of events can always be recognized with certainty if we follow the line of analysis. and focus. if we start from the premises inferred from the analysis and try to follow these up to the final result. We feel that conscious. spill over. analyzing.314 Cornelis Heijn Freud observes the difficulties of prediction during the flow of analytic work: So long as we trace the development from its final outcome backwards. however. and also is not as easily studied since it goes on in a silent realm. then we no longer have the impression of an inevitable sequence of events which could not have been otherwise determined . deliberate thought is the locus of higher mental functions such as insight. come together. in the other we find ourselves involved.D. This often depends on delicate circumstances of the moment. has made such an event the subject of an interesting article in Psychoanalytic Inquiry. Primary process thought blends and synthesizes. is in practice still viewed with more skepticism among us. 3. M. In one we step back and observe.. one narrows. . and influence each other over a wide field in a manner in which we remain immersed. Robert Gardner’s phrase suggests psychic events that one may easily attend to or not. separating. Sometimes we have a fantasy or image. Secondary process. They objectify and detach us from what we study. makes greater use of the lan2. . intermingle. and are easily overlooked. or a passing fantasy or fleeting image. the other broadens. categorizing. Primary process. and feel that some possibilities exist more than others. however. But if we proceed to reverse the way. the other unites.3 Often. all processes that restrict the breadth of gaze while also removing us from full involvement. The characteristics of conscious. the chain of events appears continuous. secondary process thought work toward differentiating.

His family had prospered in Germany for many generations. if one can call it that. and much of the power of religion has come from promises of some kind of eternal life.” and thus make possible realistic foresight. and life that suggest the pervasive importance of our concern for the future. an image on the “edge of awareness. We see a less conscious type of foresight in analysis at times. of insensitive control by an unempathic analyst.On Foresight 315 guage and symbols familiar in the logic and reasoning of conscious life and can be studied. his foresight and ability to act upon it with the sureness of faith in his own judgment. did well. evaluated. The patient is not aware that he or she is reacting to an unconscious assessment of what may happen in analysis. but he had foreseen the coming persecution of the Jews very early in the Nazi era. help “ghosts” become “ancestors. I saw an elderly man who was in the hospital after a stroke. may be experienced as a sense of foreboding. We are often eager to modify this certainty. Much of the work of analysis is to free the future from such influences of the past. 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. However. and was soon on to other ventures. he started a farm. psychoanalysis. Many years ago. His realism when most anguished. Unable to practice his profession here. Although we talked only once. and we can expect some form of long negative. criticized. We learn that the patient has been anticipating. or at least measures of consolation for life reaching its end.” the surface feelings of deeper happenings. but the awful relationship he first complained about is happy now. and moved here with his wife and children soon after Hitler came to power. his story left a lasting impression. as noted earlier. and its products then embraced or cast aside. The patient is in the grip of the past and can hardly believe that today or tomorrow could be different. as consultant to a medical service. and his gentleness. or. Unconscious foresight. modesty and essential happiness all spoke of character evoking spontaneous respect. One of the great organizers of our lives is the certainty of time passing and of our own eventual death. or in Loewald’s words. poetry. perhaps especially in a scientific age in . transference. an analytic experience of lost freedom. or false positive. without consciously knowing it. his resilience and capacity for adaptive renunciation. or as a welling up of courage or hope. These reflections begin with some examples from general medicine. leaving behind a considerable fortune. the problems at work have been resolved.

“To carry experience itself alive into the heart is an extraordinary achievement. Love and death are often the subjects of poetry. [. MacLeish writes.” But at my back I always hear Time’s winged chariot hurrying near: And yonder all before us lie Deserts of vast eternity. let’s get with it babe. 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. shall sound My echoing song: then worms shall try That long preserved virginity. . Here words are used to evoke images. but here it is used in the creation of new meaning rather than for disguise. Poetry .] (The Oxford Book of English Verse. A lesser poet of our day might say something like “hey.” but the arresting images of the poem bring a power and depth of meaning to the argument. Thy beauty shall no more be found. Religion and poetry each aim at trying to make our present and future more meaningful and the inevitable end more tolerable. 67). This seems to be brought about by a process akin to condensation. beauty and perishing. “One image is established by words which make it sensuous and vivid to the eyes or ears or touch—to any of the senses. The grave’s a fine and private place. in this case love and death. Another image is put beside it. and this influences how we view the future. many of us have that event hovering in mind. 65. Now therefore. and the images side by side build a complex new meaning that neither image has alone. in their relation to each other. . and this synthetic act seems typical of mechanisms we think of as primary process. And into ashes all my lust. I think. Nor. in thy marble vault. Poetry brings together what is usually unrelated.” And later. regarding the effect of coupled images. But none. as in these few lines from the famous poem by Andrew Marvell “To His Coy Mistress. do there embrace. while the youthful hue Sits on thy skin like morning dew. pp. And your quaint honor turned to dust. and when talking of love the theme of time and perishing is close by.316 Cornelis Heijn which we doubt ideas of immortality. an achievement neither science nor philosophy has accomplished” (MacLeish 1960. 1902) The message is not a complicated one. and religion has more trouble finding a relevant message.

but this may be only an aspect of their importance. Paul Ricoeur writes: because history is tied to the contingent it misses the essential. S.” by T. Images carry affect in a way that other symbols cannot do. the timelessness of the primary process.On Foresight 317 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. not being the slave of the real event. in The Prince. present. In Keats. Eliot had a profound impact not only as a statement of the present day but of ominous trends leading into the future. whereas poetry. 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. (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. we also do infer from these events some important truths. Pinchas Noy has written about the need to concretize in order to carry affect. ie: to what a certain kind of person would likely or necessarily say or do. can address itself directly to the universal. “The Wasteland. A Brief Diversion into History While the “contingent” events of history in themselves may miss the essential. displacement. and writes: 4. 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. Emily Dickinson. Machiavelli. . As poetry leaps into what is timeless it includes essences of past. The intellectualization of the obsessional bores us because of its distance from the moment of real experience. symbolization. condensation. or draw us away into details.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. Frost. discusses the disadvantages of using auxiliaries and mercenaries in warfare. and future. Shakespeare we repeatedly feel the search for the eternal moment. in the continually perishing beauty of the world.

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. . and the terrible revenge peasants would inflict on any stragglers.000 was destroyed and only 10. and this ability is given to few. The Russian campaign was after Napoleon’s great successes but while he was still a relatively young man. we see many examples of the deterioration of this faculty. . than the reasoned judgment of the Emperor on certain questions. Later. more the victim of his imagination and passion. p. but it does not notice the poison that is underlying it: . in the Russian campaign. easily lost or perhaps disrupted by the . along with intensive study of the various structures of government that attempt to channel such motives. Early in his career Napoleon had shown a high degree of foresight. He describes the disastrous result of failing to provide for such small necessities as horseshoes with spikes. one might say he exuded it from all his pores. when his army of 433. And so whoever does not recognize evils when they arise in a principality is not truly wise. of valuable foresight ignored or rejected. p. Once he had an idea implanted in his head. enabled him more than anyone to see the long-range implications of the various plans put forward at the Convention. Never have a man’s reason and judgment been more misguided. one of Napoleon’s closest aides.000 half-frozen and starving men escaped. [He goes on to describe causes leading to the overthrow of the Roman Empire—a principal one being the employment of Gothic mercenaries. He cherished it. . caressed it. and of foresight used to ultimate victory by the opposing General Kutuzov. His profound knowledge of good and evil in human affairs. This is described in the remarkable journal of General Caulaincourt. the fierce cold of the Russian winter.318 Cornelis Heijn But man’s little foresight will initiate a project which at the start seems good.] (Machiavelli. the Emperor was carried away by his own illusion. We owe much to James Madison in the design of our Constitution. suitable for travel on ice. more led astray. Horses were unable to haul wagons up frozen inclines and many supplies had to be abandoned. and his awareness that greed and power would be avidly sought unless contained. 177) History provides many examples of the success and failure of foresight. became obsessed with it. (Caulaincourt 1935. He knew the vast area into which the Russians could withdraw. . 28) Caulaincourt anticipated the probable course of the campaign.

p. and upon the foresight of wisdom. loss of species.” all took place when those in power would not listen to reasonable foresight. to give the devil his due. the Emperor could not or would not show a trace of foresight. rapid transmission of world diseases. . changes in family structure brought on by economic forces. Barbara Tuchman describes how great events are often determined by people who cling. as science and technology grow in power. (Caulaincourt. controlled by an economic system that feeds on the demand for constant growth and ever increasing private profit. There is no doubt that we should have preserved much more undamaged if we had made the necessary sacrifices in time. enormous inequality of wealth. we lost four or five a few days later. which someone described as “destined only to awaken a sleeping giant. all with little effective consideration of risks until they appear as crises. the Vietnam war. the Japanese attack on Pearl Harbor. Such problems envelop us today. Thus we run great dangers with calmness. as the saying is. Science has been so triumphant that we may have lost perspective about its limitations. 208) Although the focus of this paper is the concept and process of foresight. But to two or three unfortunate horses we allotted guns and waggons that needed six. the intransigence and corruption of the Renaissance Popes that led to the Reformation. . genetic engineering. 5. 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.” to plans seen by others at the time to be unworkable. with little consideration of long range consequences to a finite and fragile world. The March of Folly. and by not abandoning one or two guns and waggons at the proper time.On Foresight 319 hubris that may flower with success. Britain’s loss of the American Colonies. So we see the problems of global warming. Napoleon’s campaigns suggest another subject of importance. through vanity or what she calls “wooden-headedness.5 Toynbee emphasizes the need for a currently felt challenge to evoke creative response. and one senses that she was doing what she could to awaken a world moving mindlessly toward great dangers. We planned for the day only. . environmental destruction. . we paid heavily in the end to the enemy. Its loss was revealed in many ways in the months to come. In one of her last books. Apparently he feels our imagination mostly slumbers when long-range adaptation is concerned. Her meticulous gathering of evidence is compelling. and because we refused. that of the factors that influence its adaptational use. Yet in idealizing science we have also given up much of our reliance upon expert experience. and this contributes to the rise and fall of civilizations.

(Oxford English Dictionary) In warm climates. Anne had sacrificed a deep love when she was young. as the bloom of youth faded. It showed how destruction of the existing tradition and ideals that ground a coherence of life. (Oxford English Dictionary) On a more optimistic note we have in the recent past the example of George Kennan. As the years went by. Jane Austen illustrates the wisdom of humility in this regard with a beautiful passage from her last novel. against the over-anxious caution which seems to insult exertion and distrust Providence!” (Austen. An article in the New York Review of Books. “How eloquent would Anne Eliot have been.320 Cornelis Heijn Lack of foresight makes us more merry. at least. This perspective became the basis of our containment policy. Lady Russell. Kennan was also the primary architect of the Marshall Plan. yet ahead in his vision of . Persuasion. analyzed the deficiencies of the radical Soviet policies then being implemented in Russia. Anne felt she had made the most unfortunate mistake of her life. how eloquent. Latvia. there is no need of foresight. Advised by a well-meaning aunt. She would not give such advice in a similar situation. p. 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. undeveloped potential. Analysts know the hazards of believing that we know what would be best for another person. but confidence in her own judgment grew. The parent ideally is in an empathic relationship of understanding the child’s particular stage in development. 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. 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. and a cheerful confidence in futurity. which reflected an understanding of these inherent deficiencies. then a 28-year-old member of the delegation at Riga. on the one hand. He finds that the possibility of beneficial change springs from the analyst’s appreciation of the unknown. on the analyst’s vision of the patient’s future. 2001. April 26. nature being bountiful. As head of the policy planning group at the State Department when Marshall was Secretary. entitled “A Memorandum for the Minister” describes how in 1932 Kennan. It is an all too common story. were her wishes on the side of early warm attachment.

how we come to see the potentials of character. In addition. . . the major medium of the primary process. and nourish them while respecting their freedom. pp. are all related. the future. if it is to be a process leading to structural changes. always from the viewpoint of potential growth. James Engell. p. the function of the image in thought. . “They and they only can acquire the philosophic imagination. (Loewald 1960. then reason cannot express its comprehension of the imaginative power. . 20) He comments on the many ways such interactions occur and writes: In analysis. that is. 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. . It may be useful to consider more deeply the role of the primary process in addition to that of disguise and defensive regression. interactions of a comparable nature (comparable to parent-child interactions) have to take place . The child. and every higher power includes the lower power. in a beautiful scholarly book The Creative Imagination. 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. (Loewald 1960. 21) What a lovely project it would be to explore how we develop and communicate this vision of the patient’s future. He quotes Coleridge. They know and feel. and how we responsibly imagine a small kernel of talent blossoming with maturity. also internalizes the parent’s image of the child . . 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.6 It would take considerable artistry to provide examples because such interactions are subtle and complex. the analyst relates . by internalizing aspects of the parent. It seems likely that these three issues. p. of intellect and feeling. much remains to be learned about the functional properties of the image. 346 – 47) . 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.On Foresight 321 the child’s future and mediating this vision to the child in his dealings with him . but these are at least 6. and the primary process.” (Engell 1981. .” If the imagination is a higher power than reason (as the Romantics said). even as the actual works on them. who within themselves can interpret and understand the symbol. the sacred power of self-intuition. from the viewpoint of the future. that the potential works in them. .

Some 7. She is sensing tendencies. .” . yet I know no cause Why I should welcome such a guest as grief.” Some unborn sorrow. sorrow to sorrow join’d. Shakespeare provides a rich example. The Queen feels disaster approaching. directions that are probably in their essence if not predictable in their particulars. . a gasping new-delivered mother. He has just banished a powerful Lord. The King’s power is quickly evaporating. all seem noteworthy. 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. . he is a flatterer. and my inward soul With nothing trembles. Her character seems comparable to that of Oedipus or Hamlet in its requirement that she see the world without illusions. the King has neither consolidated his power nor gained the confidence of his subjects. In Richard II. without being able to specify why. What form may this take? As with so many human issues.7 And I. explains that prodigy as used here means “monster. edited by Robert T.” (Shakespeare.” After some time news comes that the exiled Lord Bolingbroke has landed with an army and the other Lords are flocking to him. Madam. A parasite. p. The Yale Shakespeare Edition of The Tragedy of King Richard the Second. Her realism. and be at enmity With cozening hope.322 Cornelis Heijn in part expressions of what we know from the past and what we see today. to have easy access to different contexts. a keeper back of death. His decisions vacillate. Have woe to woe. or what form it might take. Petersson. and then gone to quell a rebellion in Ireland. ripe in fortune’s womb. Lord Bushy urges her to “lay aside life-harming heaviness. Queen: Now hath my soul brought forth her prodigy.’ Queen: “Who shall hinder me? I will despair.” Queen: “I cannot do it. 44) The Queen is feeling disaster ahead without being able to name specific causes or outcome. refusal to accept false hope. To approach a vision of the future is to embrace in thought and feeling many variables that differ in weight and quality. her trust in her own feelings without elaborating them into specific fantasied disasters as a paranoid person would do so exuberantly. in a complex situation. Is coming towards me.’ Lord Bushy: “Despair not. and to weigh facts that are constantly changing. at something it grieves.

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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).

On Foresight
The Study of Mental Imagery

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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

their skill and accuracy? Perhaps some of us dream with the fidelity of Vermeer. in eternity. This immediacy of insight may have contributed to the belief that some people of genius seem to work effortlessly. When our experience is connected to primary process we feel no past or future in the same reflective sense. How often do we inquire about the formal qualities of dreams. and intensities. Perhaps wisdom. would seem a great advantage for some issues. Books by Arthur Koestler and Harold Rugg outline steps in the creative process. . We dwell then outside of time or. while talent is needed. allowing integration of related experience. ambition. disappointment.330 Cornelis Heijn would make a great clatter and wake him up while the hallucination was still vivid. 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. hard work and much preparation are essential preparation for creative work. Eventually there is a turning away from the problem. the absence of time. as Loewald says. Remote aspects from the full granary of related past experience may enter the present. in a fluid medium capable of infinite variation and great preci14. or the limitations of time. 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. one that Rugg calls “trans-liminal. In fact. a feeling that things do not fit. usually during some not fully alert focused state. and people long gone may appear as they were. then follows a continuing sense of puzzlement. and at an unpredictable point what Rugg calls a “flash of insight” and Koestler the “Eureka phenomenon” ensues. others with the skill of a Sunday painter. help from past experience. fresh and vital in the immediate moment. all with deep involvement but without the distraction of troubling feelings of loss. The potentials of having at our aid all the related experience of our lives. to be felt and worked with in a plastic medium capable of an infinite variety of shades.” 14 While there are many descriptions of the phenomenon. drawn together as by a magnet. Our thought when expressed in words is more open to our examination than is our thinking in images. This usually begins with intense study and conscious efforts to solve a problem. forms. such as we feel when awake. depends upon such thinking involving the primary process. beyond intelligence and knowledge. it is very difficult to study the underlying process.

Even so. painter. A man prior to analysis had always dismissed his anxiety dreams as nightmares. Musings and Concluding Remarks Psychoanalysts and their patients know the difficulties of gaining insight. We have no sense of authorship even as we are the director. the relevant facts are at least potentially available to the resourceful and determined inquirer since they all lie within the present or the past. an avoidance that had resulted in a half-hearted and failed effort and lifelong regret. Eventually he thought they were wiser than he was. with our varying per- . the first major instance of avoidance due to anxiety.On Foresight 331 sion. balance. of thought in this mode. The rational part of us. In this arduous quest. and we can’t step back from the dream reflectively and ask if our thinking partakes of our usual standards of logic. but then would show him forgetting to go to class or sleeping through the exams. and on the blends of deep color that seemed to reflect mood as truly as in a Bergman film. At times of potential achievement in later life his dreams might offer him a second chance at courses he had neglected. They seemed repeatedly to be trying to alert him to the possibility that he might continue to fritter away his precious time. honesty. realism. and only audience of our dream. the danger that he might again avoid a challenge. and earnestness. 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. honesty or realism. Awareness of today’s reality is in suspension. They returned at moments of important choice to the theme of the undone thesis. and judgment can guide our thoughts when we think in images. Finally. which never seems complete and is always subject to revision. and is not in itself reason to question the integrity and balance. Why we would be so grasped and take so seriously something that we then may dismiss as “just a dream” is not entirely clear. One man did remark on the exquisite beauty and realism of the women in his dreams. we might renew an inquiry into what standards of honesty. however. tends to dismiss the dream upon awakening. It is true that the logical forms and structures of verbal language are lacking but this is inherent in the formal qualities of images. however. indeed his life. He felt that his dreams kept him in touch with both the opportunities and danger in his current situation. That sort of detached critical thinking seems absent from the dream state.

Historical events are not only difficult to foresee but explanations after the fact often seem simplistic and inadequate. and chance of tragedy cannot be eliminated. dream work as disguise.332 Cornelis Heijn ceptions. surgeon. revision of memory. analysis can also be a joyous adventure. imperfect judgment. sorrow. skill at self-deception. to mutuality in the process of inquiry. honest. 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. or assistant analyst to the patient who is the true analyst. I have gradually come to feel that some of the distinctions between consciousness and the unconscious. where the problem is still developing in a constantly changing world and some relevant facts have yet to be born. to curiosity and wonder. often following the personal predilections of the historian. censor. I think I worked better when I saw us all struggling to find meaning. gardener. Here we sense the need for abilities and qualities of character in a new dimension of realism and imagination. tendency to leap to theory or preconceived explanation. the gaining of insight is full of difficulty and must always be tentative. 15. and integrated in our imagery as in our wordiness. I worked best when I thought of analysis not as a “science of suspicion” but as a science of discovery. leads to notions of acceptance rather than hard earned neutrality. while still with ample difficulty. reality principle. 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. The concept of analyst as assistant-analyst to the patient originated with Robert Gardner. Much understanding of life escapes our best efforts and remains a mystery. To experience it as a science of discovery. etc. and to the analyst as good traveling companion. wilderness guide. and to reveal and conceal from others and ourselves in any of the modes we have available.” While pain. . Imagine then the added difficulty achieving reliable foresight.. and analyst as general. hunter or trapper. 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. We know this well in analytic work but it is equally true of human behavior on the larger scale.15 One of my last patients said that her analysis had been like a “treasure hunt.

Poetry and Experience. (1935). Fortress Press. W. Avon Edition 1963. McGraw Hill. J. Psychoanalytic Inquiry. Ineffability: The Failure of Words in Philosophy and Religion. Clarendon Press.E. Ed. Image and Language in Psychoanalysis. (1902). Harvard University Press. E. Journal Psychoanalysis. The Consciousness of Being Conscious. Knopf. Fantasy and Beyond. Ed. (1978).A. The Prince. Jason Aronson.” Yale University Press. Int. Koestler. Harper and Row. P. N.A. Robert N. On Freud’s “Creative Writers and Day Dreaming. Martin’s Press. (1933). Kosslyn. A Case of Homosexuality in a Woman. Psychoanalysis and the Humanities. The Creative Imagination. (1960). The Oxford Book of English Verse.On Foresight BIBLIOGRAPHY 333 Austen. Basic Theory of Psychoanalysis. (1920). (1995). Denial and Defense in the Therapeutic Situation. The Tragedy of King Richard the Second. Emde. Figuring the Sacred. Waelder.I. Bonanza Books. 15:182. A. 5:71–76. Inc. 70:189 –203. Simon. S. Image and Brain. Smith. S. Shakespeare. R. 1954. Houghton-Mifflin. T. H. Communication or Failed Communication. (1985). J. H.A. James. The Principles of Psychology. L.P. S. The Act of Creation.A. (1964). Imagination. Rev. H. Tuchman. Machiavelli. 35:5 –22. . William Morrow and Co. M. State University of New York Press. Limited. The Collected Poems. Riverside Press. Rugg. Psychoanalysis. ——— (1933). Quiller-Couch. B. P. 1:471– 488. (1994). (1981). (1989). With Napoleon in Russia. J. Third English Revision. From Dream to Discovery: On Being a Scientist. The March of Folly. Psychoanalysis. Vintage Books Edition. Macmillan and Co. (1987). (1960). Joseph. International Universities Press. vol. Inc. chosen and edited by A. The Interpretation of Dreams.T. C. ——— (1995). Caulaincourt. Int. H. Press. (1982). by J. St. MacLeish. (1974). (1978). Engell. XLI: 16 –33. Loewald. On the Therapeutic Action of Psychoanalysis. (1987). Arkana Press. Study of Images I. Knopf.P. W. Int. T. & Pearlman. Confluence of Visual Image between Patient and Analyst. A. (1890). Ideas and Opinions. Rangell. Freud. Yale University Press. Yale University Press.. (1984). R. Action Theory within the Structural View. Basic Books. Selye. J. (1964). Scharfstein. Stevens. translated and edited by Mark Musa. Greenberg. B. If Freud Only Knew: A Reconsideration of Psychoanalytic Dream Theory. (1963). Noy. Ricoeur. B. (1978). Originally published by Alfred A. (1961). Insight and Creativity. Marvell. 26:717–748. Henry Holt and Co. A. J. Dorpat. (1964). Persuasion. Einstein. (1993). W. (1921). George Libaire. A.

41:7–30. Int.A. Testing Hypotheses about Unconscious Mental Functioning. Psa. Prometheus Books. In the Mind’s Eye: Visual Thinkers. J. Science. Charles Scribner’s Sons.A. ——— (1993).P. 69:87–95. 122:1256. Science and People. (1997).334 Cornelis Heijn Weaver. J. . T. Weiss. West. (1988). (1955). J. Empirical Studies of the Psychoanalytic Process. Gifted People with Dyslexia and Other Learning Difficulties. W.

relational trauma. effect of. relational trauma. B. latency development. 135. 50. 142–152. 298 Autonomy: consolidation process. latency development. 8. 320 Autobiographical memory. 286 Abusive behavior. 93–97. 178 –207. 289 –290 Black holes.. 287–290. 102–108. 180 Boston Change Process Study Group. 119 Aggressiveness: as defense mechanism. Mary and John. 107. H. vocalizations. Sean (case study). A. 269. 77 Beebe. 246 –250. 205. 184. 196 –198. J. 275 –276. 144. 91– 97. Nicole. 60 Bateman. 180. 14. A (Heller). 188. 85– 91. 182 Bergman. 215 Broucek.. 205 Analytic third. 173. 269 –270.. 183. cognitive remediation. B. 267–269. 143. 137 Attention deficit hyperactivity disorder (ADHD).. 40 Chess. neurocognitive problems. 221–233.. 138 –139. 201–202. 90– 91. parent-infant interactions. 190. 288 –290. 269 –272. Mia. gaze. 14–15. 227. H. 179. 283 –284 Blum. 266. as defense mechanism. M. 108 –124. 36. 253 – 254 Ainsworth. 242–258. 136 –137.. 265 – 290.. 232. 26. 13–23. psychic trauma. F. 272. Natalie (case study).. 13 Bromberg. Ethan. See also Death anxiety: Andy (case study). 269 –275. 145 –146. latency development.. 119 Blatt. 135 –137. 251 Adult Attachment Interview. W.. Cecil. B. 266 –267. 281– 283. 158 –159 Bender-Gestalt.. separationindividuation. P. 259 Boundaries.. 135 –136 Bornstein. latency development. 282–284 Attachment theory: frightened/disorganized attachment. 274 –276. 201– 202. 182 Buxbaum. 215 Anger management. See also Facial expressions: body orientation.. 16. Strange Situation attachment test. Sean (case study). L. 23. 302 Adolescents. 264. E. W. A. 138 –152 Caulaincourt. 26. 250 –251 Anna Freud Centre. video microanalysis. 142. 13–14. 16–20. 222. P. 169 – 171. Sean. A. 49 – 50. S. 9 Bi-directional regulation. 17 Behavior observations. 280 – 282. 14– 15. 190 –192.. maternal distress. 199 Case studies: Andy. 30–31. 195. 135. 120 –124.Index Abandonment. 194. 160 335 . 263. 52–70. E. 24– 34. See also Latency development: attitudes toward therapy. S.. Little Hans. 188 –194. 286. 205. 278 –279. 148 –149 Aversion movements. 18. Iliana. 40–41. 239 –241. 11 Birth defects. 223 Austen. 263. 318 – 319 Center for Early Relationship Support. 33. 195. Beccah. 179 –180. 34– 40. maternal love. 48–49. 103 –104. 272–273.. 16–18. 145 Brazelton. 278 –280.. 157–158. 108 Chase and dodge behavior.. 267. latency development. 182 Blos. 266 –267. 219 Burke.. 164 –165. 16 Alcoholism. Natalie. 3 Child Analysis with Anna Freud. 231– 232. 135 –136. 14. 161 Anthropomorphism. 239 – 260. 136. 110 –111 Ames. See also Aggressiveness Animal Farm (Orwell). 196. head orientation. 266 –268. 263 –290. 287 Body awareness. 284 Balint. play ses- sions. T. 39 Beiser. 142. 271–272. 195–196 Anxiety. 104 Adult narratives. 284 –285 Body orientation. 178 –207.

The (Engell). 119 –121. 220 –221. 78. 27–28. 162–165. 202–205. 328–332 Dyadic systems. 49– 54. 190. J. 287. 313 Emerson.. 88–89. incestuous fantasies. 239 –241. 216 – 217. S. 34. 282. J. 39. Dahl. Mary and John (case study). 255 –256 Fivaz-Depeursinge. 329 Downing. 206 Cohn. 204 Disorganized attachment. 192–198.. 220 –223. capacities. 129. 216 –217. latency development. regulation patterns. 270 –273. See also Disorganized attachment. 330 Crown. stranger-infant interactions. 242. 221–222. 180 Facial expressions: mirroring. T. Beccah (case study). 246 –247. therapist’s role. 230 –231 Einstein. 307. reconstruction process. 12. 265. 15. See also Fantasy formation Engell. 15 Conceptual frameworks.. 107 Creative Imagination. C. 288. 58.336 Index Edison. 287–288 Foresight. A (Krauss and Sendak). 26–27 Faith.. 288. 62. 187–192. 179 –180. 134 –135. parent-infant interactions. R. 83. 148. 132. 264 –267. 17 Ferenczi. non-engagement. 284. 179. 235. 184. latency development. 169. 17 Culver. 230 –233 Empathic attunement. 214 –215. 258 –259 . 151. 288. 324. state of playing. 215.. 179 –180. 295 –311. 193. maternal distress. T. 288 –289 Conflicts in learning. 225 –226 Countertransference: Ethan (case study). 107. 201–203. E. 285 –286. The (Freud). 37. 214 –215 Fear.. 173. 134. 18–19.. 94. regression. 214. 88. T. 15. 288 Dead baby complex. 20 Dorpat. 26. P. 244 –245. W. reconstruction process. social status. feelings about therapist. conflict interpretations. 187–189.. 263 –290 Conscious insight. 5 Enactments. 52– 54. 317 Emde. See Frightened caregiving Dissolution of the Oedipus Complex. 151 Fonagy. 258 –260 Coherence. 60 – 61. See Malatesta. 201–202 Dependency. 60. 151–152 Dyslexia. 196 Contingency detection.. S. 62– 63 Cognitive development. 326 Field. 113. 204 Closeness versus distance. 271–273. 220 –223. J. Natalie (case study). 328 – 332 Construction. 179 Distress: infant distress. 89– 90 Distress regulation. 329 Eliot. 185 –186. 76. 247. 301– 302. S. 60– 61. 92–93.. memories of therapy. See Parent-infant interactions Dynamic systems theory. 166 –173. G. K. R. A. 113 –117 Dissociation. 258 –260 Congenital trauma. state of playing. 8–9. psychic trauma. 136 –137 Dreams.. 323 Family interaction patterns. Frightened caregiving Feldstein. C. 134 –138 Conflict/compromise interpretations. 68–70. 312– 332 Former child patients: attitudes toward therapy. 200. participants. Natalie (case study)... 18. 222.. 23. 195 –198. ego capacities. T. 218 –220. 284. 137 Disconnection. 135. E. 230 –231. 198 –200.. 303 – 305. 217. 275. uneven functioning. A. 234. and Freud. 175 Childhood analysis. 8. 165 –174. 137 Flexibility. 309 – 310. 89 – 91. state of playing. 299 Contamination. 253. 55– 66 Depression. 300 Developmental theories. 219 –220 Coping mechanisms. 77. 303. 252–254. 36– 37. N. 321 Creativity. 49 – 50 Death anxiety. reconstruction process. parent-infant interactions. 158 –162. 321 Erikson.. 102–108. S. 296 –297.. 116 –123. 145. 296 – 311 Chodorow. 307. 48– 49. 188. 86– 87. 324. 276 – 281.. 214. 263 –264. 313 Emotional issues. 329 – 330 Ego: Andy (case study). 51. E. separation-individuation.. 281–282. 68. 131–152 Fantasy formation: Andy (case study). C. 179. 264. sexuality. separation-individuation. 13 First Book of First Definitions.

. G. and Heller.Index Fragmentation. S. 316 –317. 330 Longitudinal study of latency development: analytical discussion. E.. N. state of playing. G. L.. 4. M. 202 Goldberger.. 144 –145 Intersubjective exchanges. P. M... late latency. 9 King. 242 Friedman. 157–158. 328 Jurist.. S.: attitudes toward therapy... 299. 179 –180 Kohut. 318 Language usage: dyslexia. 3. See also Fonagy. A. 50. prediction difficulties. 180. methodology. D. 308 – 311. T. 296 –297. 78–80 Freedman. latency development. 13–14. 200. A” (Krauss and Sendak). early latency. 185 Lee. 203 Head orientation. 328 Greenspan. A. See Frightened caregiving Hesse.. 178 –207 Laub. 178 –181. E. M. Kernberg. L. 314. 203 –204 Klein. 200 Kozlowski. 14–15 Heller. 145.. results. 179.. 251–254 Latency development.. 173 Lausanne Triadic Play Model... 328 Isolation. L. Kantrowitz. 322– 323 Irma dream.. 285 –286. 204. 214 –215. 234 Lewis. 313. 190 –194. 13 Krauss. 286 “Hole Is to Dig. S. 144. B.. H.. E.. middle latency. 120 Gilligan. S... 320 Kennedy. 286 Gorlitz. 239 – 241. 159. B. 327 Jasnow. 217. W. 181–186.... P. 108 Joseph. infant psychoanalysis. latency development. P. See also Fear Future. 47–71 Gergely. H. 269 Jaffe. P. 186 –198. 158 Koestler. influence of. 17 James. 235 Intuition. 320 – 321. 135 Genuine maternal love. 244 –245. 53– 54 Images. 11. 267. 79–82 House-Tree-Person Drawings. 163– 164. M.. 326 – 331 Imaginary play. 159 Klopfer. 274. 246. 182 Hume. parent-infant interactions. 255 Home-based mother-infant psychotherapy.. 232. 137.. 201–202. 160 Helpless caregiving. gender differences. 312– 332 Gaze. 229 – 230. 143. reconstruction process. 305.... 195 –198. 78. 287. 285. impact of. A. 136. 160. 239 –260 Ledwith. 9. 178 – 179. S.. See Fantasy formation. 193 –194. 327–328. 218 Freud. M. 186 –190. 255 –256 Kutuzov. repetitive activities.. 182 Frightened caregiving. 285 Lewin. 101–124 Homer. 241... 219 –220. C.. 117–118 Interactive regulation. 330 Kohlberg. 186 –207. 191–192. G. anger management. 113 –117. 184 –187. 104 Hoffman. 182 Green. 102–108. timeline. S.. See also Sandler. 285 Laufer. 205 – 206. 9. play sessions. D. 183. learning disabled children. P. J. H. repression barrier. 189. 327 Hypersensitivity. R. 305 – 306. E. 203. imagery symbolism.. 180. A. 260 Little Hans.: ego. 182 Koch. 157–158 Loewald.. 215 –219. 206 –207 . J. 142.. 48. 180 Freud. Make-believe. Play Improvisation. J. 201 Home visits.. 142. 203. 17 Jewish Family and Children’s Service. 195. 182 Kennan. See Fonagy. 56 Internalization. R. W. 198 –201. 226. background information.. P. relational trauma.. 181 “Harry Potter” stories (Rowling). 205 –206 Fraiberg. M. Gianino. 252– 254. fantasy formation. 201. 19. 287– 288 337 Interpersonal connections. 135 –136 Learning disabled children. B. 49 Greenberg.

217 Main. 220 –223. 128 –152.. 267– 269.. 137 Modell. L. 217–218 Non-engagement. 40–41. 169. 192.. 142–152. 201 Motherhood Constellation. 225 –227. Cecil (case study). frightened/disorganized attachment... P. W. 80 Nurturance. mind-body awareness. A. 48–71. 320 Phonological processing. A. 91. C. Natalie (case study). 230 –233. Cecil (case study). 204 –205 Perry. 232. Parent Consultation Model (PCM). The. 11. psychic trauma. M. parent-infant interactions. 173. 102–124. 328 Pearson correlation coefficient. 74– 98 Mini-reunion experience. 284 Orwell. M. 19–20. 87– 90. 216 – 217. 28.. 19. 252 Lyons-Ruth. 106. 190. ego capacities. 25–28. regulation patterns. perception. 186 –192. psychotherapy interventions. 165 –174 Memory. Iliana (case study). Mary and John (case study). J. 316 Magic. 253 –254.. 3 – 5. Toddlers. 34– 40. 79– 98. 179 –180. 222–223. Midrange regulation model. R. R. 267. T. 284 –286. intersubjectivity exchanges. 21– 34. reconstruction process. 222. 217–220. 135. 21–23. 316 Maternal failure. 239–241 Neurotic conflict. 219. 10–12. G. 4 Neurocognitive problems. 129 – 138 Pearlman. use of. C. A. reconstruction process. 216 Metabolizing feelings. 53. Ethan (case study). 76–77. 317– 318 MacLeish. 306. 47–71 Mathematics. 218 . A. 304. The (Stern).. 276 –277. 40 Parent Consultation Model (PCM). 80 Olesker. 218 –219. 18–20. 228 – 230 Nonverbal language. 217–220. 9. 180. Mia (case study). 135 –137. 319 Marshall. 101–124. D. A. 24– 34. 179 –180 Pine. 199. 318 – 319 Narcissistic balance: Andy (case study). N. 91– 97. 226 Napoleon I. 287–288. Mia (case study). The (Tuchman). 112. 203. 32– 35. 218 –220 Malatesta. 295 –311 Mental imagery. 317 Nurse Home Visitation program. face-to-face interactions. 128 – 152 Parent-infant interactions. treatment methodology. and Families. R.. Emperor of the French. 320 Marvell. 79 Neubauer. temperament. 198. 11. 112 Mutuality. 12–13. 19. See Ames. 40. 78– 81. 250 –251 Overstimulation. 7–13. 306 –307. 186 –194.. 5. A. 206. 48– 49 Maternal love. 13. 218. 11–12. 225 –226. 9. 188. Iliana (case study). Mary and John (case study). 263 –264 Oedipus complex. 255 –256.. See also Self-regulation Parental history: Beccah (case study). 202–204 Mahler. 253.. 247 Normality and Pathology in Childhood (Freud). K. reconstruction process. 325 – 326 Memories of therapy. 110 –114. Mia (case study). 201 Oppositionality. 183 – 185.. F. 13– 41. 158 –162. contingency detection. 301–304. 58– 59. 95– 98.. C. video microanalysis. 180 Persuasion (Austen).. state of playing. 24– 34. 33 Milne. 108 –124.. Minding the Baby program. psychic trauma. 204 Object relations theories. 243 –244. 47–71. 104 Machiavelli. H. 215 Olds. 85– 91.. 220. 55– 56. 3. See also Latency development Ogden. 81– 85. G. 104 Make-believe. P.. See also Minding the Baby program: behavior observations. 267. 87. 327– 331 Mentalization theory: fantasy formation. video microanalysis.338 Index Noy.. 251. 182 Peer relationships.. 215. 217 Long-term follow-up project of child analyses. 213 –214 Minding the Baby program. 157–175 Loss. Nicole (case study). maternal love.. 15 March of Folly. Iliana (case study). 306 National Center for Infants. 119 –122 Metraux. 83. 232 Luria. intervention techniques. 196. 244 Piaget.

parent-infant interactions. Rorschach tests. 281. 48 Self-other differentiation. 194. 286 –287 Representational/behavioral domains. 239 –241. parent-infant interactions. 4 Space/time organization. 76–81. 195. L. 182–185. M. 288. D. 206 Rangell. 269. C. 24– 34. 183 Scientific method. 233 –236. 119. 324. 272. 277. R. 142. gender differences. The (Machiavelli). 326 Ritvo. 139 –141 Poetry. 287. 257–258. 112. 218 Stevens. 26–27. 329 –330.. Ethan (case study). 143. 326 Stranger-infant interactions. 270. 218. 186 –207. 269 –270. 51. C. 315. latency development. 200.. 24– 34.. W. 274 –275. Solnit.. See Malatesta. 203 Rugg.. 317. 330 339 Sadomasochism. 66–68.. importance. 284 –285. Mary and John (case study). 322 Ricoeur. 186 –207. frightened/disorganized attachment. See Ames. 277. Iliana (case study). 330. 255 –256 Separation-individuation: adolescence. 197. L. The (Stevens). 112 Repressed memories. H. 194. state of playing. S. 76 –77. 59– 60. state of playing. 217 Sandler. fantasy formation. regulation patterns. 132 Sendak. 205 –206 Primary process thought. learning disabled children. 19–20. 218 –220 Sexuality: Beccah (case study). J. 217–220. 255 Reconstruction process. 332 Self-esteem: dyslexia. T. 215. 179. 316 – 317. 284 – 286. 317– 318 Provence. 205. K. 182–183 Secondary process thought. 218 –220. 95–98. Mia (case study)... 90– 91. See Death anxiety Sullivan. 204. 172–173 Sarnoff. Ethan (case study). parent-infant interactions. 200. 120 Repetitive behavior. 16. 182–190. 196 –198. 221–233. 11– 12. 247– 250.. Natalie (case study). 251. 326 Suicide.. 158 Richard II (Shakespeare). Mary and John (case study). latency development. 180. 195 –198. 269. 285 Sander. aggressiveness. 324 – 325. 322 Shapiro. 181. 269 – 270. psychic trauma. 30 – 31 Strange Situation attachment test. 192–197. See Reconstruction process Repression barrier. 295 – 311 Reflective awareness function: frightened/ disorganized attachment. 267. 136. 258 –260. parents. 203 Schafer. 271. 135 –136. 283 – 286 Rejection. 329 Scoring systems. 145 –147. 266 –267. challenging behaviors. Mia (case study). 179. Natalie (case study).. 242–244.. 180. S. 235 Rodell. 314 –315. 282–284. See also Abandonment Relational trauma: Beccah (case study). L. 253 –254. B. 332 Prince. 180 –183... 300 Selflessness. 245 –246 Rowling. W.. 269 –270. 258 –260 Play sessions. 202. 266. 55– 56. 145 Stern. 314. 255 –256. therapeutic value. J. 253. 263 –290. 213 – 236. 70. Iliana (case study). Minding the Baby program. 103 –104. 274. 89–90. H. 105. state of playing.. 48 – 49. 316 – 317 Preadolescence. A. 217 Shepard. 244 – 246 Puberty. 91–97. 159 Rizzuto. 276 –279. 133 –137. 110 –123. 328 Rappaport. 76 –77. 104 –105 Reparation. 193.. self-other differentiation. traditional evaluation process. 284 –285. 282. 254. 263 – 265. 216. 253 –254 Shakespeare. latency development. 20–21. 61– 64. J. object relationships. reconstruction process. 289 Safety issues. 285 –286. 81– 85. 76–77.Index Play: lack of play. as defense mechanism. 249. D. 40. parent-infant interactions.. 298 – 311 Psychological testing. 202.. 225 Regression. Cecil (case study). 241– 242. 14. 272. 288. psychic trauma. P. 288 Self-regulation: aggressiveness. 4 Psychic trauma. 137 Study of Images. 257–258. A. 180 . 271. 87– 90. 105.

250. M. See Psychic trauma Triangular frameworks. 36. R. E. 218. 273 –275. 246 –250. 7–12. 182– 183. 3 Words. 181. 219 Tronick’s still face experiment. 57– 58. 264 –265. Poetry Index Turn-taking structure. 268. 332 Verbalizations. 9. 64–70. 319 – 320 Traditional evaluation process. 246 –250. 241. 329. Minding the Baby program. 106 –107. 214 –216. 317 Watson. 77 Yale University School of Nursing. See Fonagy. paternal/ maternal transferences. traditional evaluation process. 287–288. 258 Technique of Child Psychoanalysis. 173. 315. 82 Tesman. 60 Unconscious foresight. 242.. P. 315.340 Symbolism. 120 –122. J. B.. 325 –326 World Association of Infant Mental Health. psychological... Teacher game. M. 79– 80. The (Sandler et al. 284 Wolff. microanalysis. 235. 319 . J..). 77 Yeats. impact of. 172–173 Teen parents. 23 Tutors. L. See Images. 82–84. psychic trauma. “Wasteland. E. 40– 41. 79 Tanner. nonverbal language. Ethan (case study). A. 214 –216. 182–185. 329 Williams. treatment methodology. 39. 255 –257 Waelder. 16–18. P. B. M. 78.. state of playing. 13– 34. See Malatesta. 26. 32– 33. Mary and John (case study). A. negative transference. The” (Eliot). relationship issues. 39 Vulnerability. 120. 312 “Three Essays. 192–198.. 5. 23. 12 Tyson. 275 –282. 232– 233 Traumatic memory. 195. erotic interpretations. 327 Wechsler Intelligence Scale for Children (WISC). 235. transference complaints. J. 314.. D. 4. parentinfant interactions. 295 – 311. 135 –137. 9 Weiss. 135 –136 Tronick. 53 – 71. 3 Zero to Three. 258 – 260. 244 – 246 Thematic Apperception Test (TAT). W. L. 272–283 Vygotsky. transferences.. distance theme. 50– 51. H. therapist’s role. The” (Freud). Testing. 79 Yale Child Study Center. W. 217–218. 131–152.. 16. 79. A. J. Unconscious communication. See Ames.. 32– 33. See Foresight Vocal rhythm coordination.. R. See Sandler. 267. 12–13.. 218. 241–242 Walker. 266 –267. R. impact of. 21–23 Vision. 182 Weil. J. 197 Target. Nicole (case study). 30–31. K. 219 Tuchman. 51. Mathematics. 186 –190.. 203. 130 –133 Transferences: Cecil (case study). 258 –260. reconstruction process. 206 Therapist’s role: Ethan (case study). 106 –107 Thomas. 231... 316 Toynbee. 15. 309. 217 Weinberg. family interaction patterns. 242 Video feedback techniques: behavior observations. 234 –236. 142–152. 129 – 138. 179 “To His Coy Mistress” (Marvell). 254 –257. 130 – 133. C. 3 Thoreau. state of playing. 113. 40–41.. 244 Wechsler Intelligence Scale for Children— Revised Edition (WISC-R). 180 Winnicott.

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