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Psychoanalytic Psychology
2013, Vol. 30, No. 3, 438 455

2013 American Psychological Association


0736-9735/13/$12.00 DOI: 10.1037/a0030894

ENCOPRESIS HAPPENS:
Theoretical and Treatment Considerations From
an Attachment Perspective
Geoff Goodman, PhD
Long Island University

The psychoanalytic literature has discussed many dynamic aspects of encopresis, but no one has explored the meaning of the underlying insecure attachment
patterns that predispose the child to encopresis. This article offers an attachment
perspective to understand the etiology of primary encopresis and suggests
relationship-focused intervention strategies to break through the childs fortress
of denial, omnipotent control, and sadomasochism designed to create emotional
distance from the therapist. Two clinical cases of primary encopresis are
presented to illustrate the severe relationship difficulties that inevitably develop
between therapist and patient and the countertransference reactions likely to
emerge. In both cases, traditional interpretive strategies were ineffective in
establishing an emotional connection. Instead, engagement through imaginative
play and humor were used to draw these children out of their defensive hiding
place and bring them into a genuine, reciprocal relationship with a person who
could help them to regulate underlying painful affects such as separation,
rejection, and loss. Traditional interpretive strategies can be attempted only after
the patients capacity to mentalize these affects has been revived.
Keywords: attachment theory, encopresis, affect regulation, mentalization, child
therapy
The psychoanalytic literature has paid only sporadic attention to the symptom of encopresis. Authors have expressed various points of view regarding its etiology and treatment.
One view suggests that encopresis is a side effect of anal masturbation with the childs

I gratefully acknowledge the assistance of Marcia Miller, Chief Librarian at Weill Medical College
of Cornell UniversityWestchester Division, in locating and obtaining reference materials, and
Tina Lo in checking references. I also gratefully acknowledge the poignant comments of John
Rosegrant, PhD, on a previous draft and the clinical supervision of Thomas Lopez, PhD, on the two
clinical cases presented here. This work was supported by two generous grants from the Association
for Child Psychoanalysis and the Jennie Dugan Fund of the Contemporary Freudian Society.
Correspondence concerning this article should be addressed to Geoff Goodman, PhD, Clinical
Psychology Doctoral Program, Long Island University, 720 Northern Boulevard, Brookville, NY
11548. E-mail: ggoodman@liu.edu

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ENCOPRESIS HAPPENS

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feces as the stimulating object (Aruffo, Ibarra, & Strupp, 2000). The motivational force is
the libidinal gratification that the child receives from engaging in this behavior. The
recommended treatment consists of developing a therapeutic atmosphere in which the
child feels comfortable talking about his or her bowel movements so that the therapists
interpretation can move the child along to the oedipal stage of psychosexual development.
A second view suggests that encopresis is an expression of the childs anger toward his
or her parents, who do not tolerate verbal expressions of anger (Edgcumbe, 1978). Again,
the therapists interpretation is the vehicle through which conflicts among the anal
aggressive pleasures, superego pressures, and the demands of the parents in reality can be
resolved in favor of renouncing anal gratification for genital gratification. A third view
suggests that encopresis reflects either a developmental arrest or a regression from the
Oedipus complex, specifically, castration anxiety (Barrows, 1996; Shane, 1967). The
therapists interpretation of this anxiety brings about the working-through process in
which both soiling and wetting gradually . . . disappear (p. 307). A fourth view suggests
that encopresis is related to separation from the maternal figure (Bemporad, Pfeifer,
Gibbs, Cortner, & Bloom, 1971, p. 282). The child retreats into a fantasy world to
compensate for loneliness while using encopresis to protest the mothers separation.
All these views hold merit in developing our understanding of the etiology and
treatment of encopresis. My aim is to examine this symptom from the perspective of
attachment theory, developed by the British psychoanalyst, John Bowlby. Attachment
theory conceptually overlaps with contemporary relational theory in the sense that both
theories recognize the supreme importance of early relationships in developing mental
representations, which in turn play important roles in the individuals ability to regulate
negatively valenced emotions such as fear and stress using available relationships (Goodman, 2002, 2005). This transactional model of the interplay between relationships and
mental representations subsumes both theories and can be used to illuminate the etiology
and treatment of various psychological disorders such as borderline personality disorder
(e.g., Bateman & Fonagy, 2004b). The application of attachment theory to an understanding
of encopresis would make a novel contribution because in contrast to the prevailing drivebased explanations, attachment theory would provide a relationship-based explanation.
A relationship-based explanation for understanding the etiology and treatment of
encopresis is largely absent from the literature. The keywords encopresis or fecal
incontinence and attachment identified no articles in the PsycINFO database and only
one article in the PEP database (Y. Cohen, 1997). That article used an idiosyncratic
definition of attachment as social fittedness (p. 255) and focused on the merits of
residential treatment, not on encopresis.
This article focuses on only one type of encopresisprimary encopresis. According to
the Diagnostic and Statistical Manual of Mental Disorders (DSMIVTR; American
Psychiatric Association [APA], 2000), primary encopresis describes those children who
never achieved bowel control. Children diagnosed with primary encopresis are considered
to be more poorly functioning than children diagnosed with secondary encopresis (the loss
of previously attained bowel control). Previous authors (Anthony, 1957; Lustman, 1966;
Shane, 1967; Sugarman, 1999) described primary encopretic children as having poorly
functioning egos and disorganized and uncontrolled behavior. The consensus is that
children with primary encopresis have a more primitive personality organization than
children with secondary encopresis.
I will argue that primary encopresis originates in the childs early attachment relationships with his or her parents. A disturbance in these early relationships creates
vulnerability to the development of various symptoms at later points in development. The

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440

GOODMAN

shift in etiological focus from castration anxiety (Barrows, 1996; Shane, 1967) to anxiety
about the attachment relationship necessitates an associated shift in treatment focus from
the interpretation of intrapsychic conflict to the affective containment and regulation of
conflicts expressed in the therapeutic relationship. How would a treatment model that
emphasized the therapeutic relationship over transference interpretation work for a child
diagnosed with primary encopresis?
The features of encopresis seem tailor-made for attachment theory. Key attachment
concepts such as contact-maintenance, separation, and loss (the obverse of attachment) are
all present in the symptom. Retention reflects a childs maintaining contact with a valuable
objectfeces. Separation naturally occurs whenever the child has a bowel movement.
Loss occurs whenever the parents or child dispose of the childs feces. Every experience
of defecation represents the practicing of separation and loss for the child.
According to attachment theory, the parent provides what Bowlby called a secure
base for the child when his or her attachment system is activated, typically during
moments of perceived danger (e.g., loss, separation, fear, stress, injury, fatigue, illness, or
punishment; Bowlby, 1973; Main, Kaplan, & Cassidy, 1985). The child achieves a feeling
of security by seeking proximity and maintaining contact with the primary caregiver.
Fonagy and Target (2003) underscored a subtle but important difference between Bowlbys theory of the secure base and Fairbairns (1952) theory of object-seeking. In
attachment theory, the goal of the child is not the parent, as in Fairbairns object relations
theory, but rather a feeling of security or closeness to the parent facilitated by the parents
proximity (see also Sroufe & Waters, 1977). This subtle shift in understanding about the
childs primary motivation positions attachment theory as a theory of affect regulation
rather than a theory of object-seeking. By seeking proximity to a secure base, the child is
engaging in affect regulation. When the attachment system is activated experienced as
a feeling of extreme anxietythe child uses his or her secure base to deactivate this
system and return to homeostasis experienced as a feeling of security.
The parent can demonstrate three different patterns of behavior that relate to her secure
base function. According to Fonagy and his colleagues (Fonagy, Gergely, Jurist, & Target,
2002; Gergely, 2000), the parent can contain their childs anxiety by making facial
expressions and vocalizations that reflect the painful affect, yet indicate through these
behaviors that the parent is not actually feeling the painful affect herself (reflective mode).
In the second pattern, the parent can have difficulty containing this anxiety so that it leaks
into her facial expressions and vocalizations without any indication that the parent is not
actually feeling the painful affect (psychic equivalence mode). In the third pattern, the
parent can also have difficulty containing this anxiety, but rather than reflecting it back
without any marking, she instead reflects a completely different feeling usually positive
affectwhich produces a disconnect between what the child is feeling and what the
external world is reflecting back (pretend mode).
Goodman (2010) argued that these three different patterns of parenting behavior are
directly related to three different patterns of childrens affect regulation discussed in the
attachment literature. Marking is associated with a secure (B) attachment pattern, a balanced
pattern of affect regulation. On the other hand, the anxious-resistant (C) attachment pattern
corresponds to a hyperactivating pattern of affect regulation, whereas the anxious-avoidant (A)
attachment pattern corresponds to a deactivating pattern of affect regulation (Kobak, Cole,
Ferenz-Gillies, Fleming, & Gamble, 1993; Kobak & Sceery, 1988; Main, 1990).
I am suggesting that children with primary encopresis use a deactivating pattern of
affect regulation and ignore painful signal affects (distress cues) such as anxiety by
focusing on the pleasure associated with the retention and release of feces. Focusing on

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ENCOPRESIS HAPPENS

441

the pleasure derived from ones own bodily products simultaneously distracts the child
from painful affects and obviates the need to rely on the parents to deactivate the
attachment system. The child can also develop a sense of mastery over separation and loss
with his or her feces while ignoring the experience of vulnerability and shame associated
with parental rejection and loss.
Overdependence on these affect regulatory processes is common. Addictions, whether
based on external substances or bodily functions, all serve the purpose of denying painful
affects such as anxiety caused by early parental rejection (Flores, 2004). In the psychoanalytic encopresis literature, anal masturbation associated with encopresis has also been
referred to as an addiction (Meltzer, 1966). Aruffo and his colleagues (Aruffo et al., 2000)
concluded, An encopretic child is like an alcoholic who demands the right to drink and
will do so no matter who tries to stop him (p. 1347). Encopretic children demonstrate
remarkable constriction of affect (Sugarman, 1999, p. 500), turn to feces as a substitute
for people (Edgcumbe, 1978), as a comfort in the face of disappointing caregivers
(Rosenfeld, 1968), and as an attempt to regain a state of well-being (Rosenfeld, 1968,
p. 48). In summary, encopresis coopts affect-regulatory functions normally served by the
parents, offers a pleasure pathway that dulls distress cues and keeps the attachment system
deactivated, and thus becomes increasingly resistant to change.
Of course, not every child with a deactivating pattern of affect regulation develops
primary encopresis. Other factors must also make a contribution to the development of this
symptom. The deactivating pattern of affect regulation creates a general vulnerability
(Rutter, 1985, 1987) that combines with other risk factors in the development of primary
encopresis. For example, encopresis is four to six times more prevalent in boys than in
girls (Anthony, 1957; Schaefer, 1993). Theories that characterize mothers as encouraging
sons separation from them earlier than daughters (Chodorow, 1978) and fathers as
socializing sons but not daughters to repudiate the mother (Benjamin, 1987) might account
for a greater tendency among male toddlers to demonstrate a deactivating pattern of affect
regulation (see Aber & Baker, 1990). Greater neurological vulnerability in boys (Bemporad et al., 1971), as well as genetic differences in reactivity to anal stimulation
(Lustman, 1956), might also play moderating roles.
The parents response to encopretic behavior might also contribute to its selection as
the childs primary method of self-regulation of painful affect. Parents who perceive this
behavior as a provocation and respond in kind provide the child with negative attention
that can also serve affect-regulatory functions. Knowing from experience that the parents
cannot provide the emotionally responsive caregiving necessary to deactivate the attachment system, the child comes to rely on the parents enraged responses as an ersatz
substitute for emotionally responsive caregiving to facilitate affect regulation. Bowlbys
(1982) goal-corrected partnership between toddler and parent, which consists of a
negotiation between security and exploration needs, becomes mutually antagonistic. Many
psychoanalytic authors have noted sadomasochistic interactions during this developmental
phase as a core feature of encopretic children (Aruffo et al., 2000; Forth, 1992; Meltzer,
1966; Schoenewolf, 1997; Shane, 1967; Sugarman, 1999). Retention and release therefore
acquire additional meanings, including punishment of parents, omnipotent control of
parents, and self-punishment. These additional meanings, however, obscure the original
function of encopresis: affect regulation without outside assistance.
To treat encopresis, an attachment-based treatment model would address the underlying vulnerability created by the deactivating pattern of affect regulation. The therapist
accomplishes this treatment goal by (1) using his or her relationship with the child to
modify the deactivating pattern and (2) mentalizing the childs affects through the process

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442

GOODMAN

of marking to establish mental closeness. The child would begin to use the therapist to
facilitate affect regulation and consequently diminish the use of encopresis for this
purpose. Because of deficits in symbolic function associated with nonoptimal patterns of
affect regulation, an attachment-based treatment model would diminish the role of
interpretation (P. M. Cohen & Solnit, 1993; Lewis, Amini, & Lannon, 2000; Rosegrant,
2001) and accentuate the role of the therapeutic relationship in healing these affectregulatory processes.
In the following two clinical illustrations, I began making headway with these
encopretic children only after I prioritized my relationship with them and made myself
available as an affective container and regulator rather than an interpreter of intrapsychic
conflict. I constantly sought ways of making an emotional connection with themto give
them a taste of a genuine, reciprocal relationship. Like a baseball player waiting for the
perfect moment to steal second base when the pitcher is not paying attention, I tolerated
seemingly endless sadomasochistic interactions, waiting out my opportunity to make
authentic contact while going unnoticed. This process consisted of pursuing emotional
contact in the face of devaluation, rejection, and withdrawal, often using humor to mark
these affective expressions. Humor permitted me to show my patients that (1) I understand
what you are feeling (connection), and (2) I can symbolize your feeling in a playful
manner even though I am not personally experiencing the same feeling (separation).
Affects then become mentalizedrepresented verbally in the minds of both therapist and
patient.
I hope to demonstrate that keeping the child firmly in mind through retaining mental
closeness (Bateman & Fonagy, 2004a, p. 44) facilitated these patients shift away from
relying on encopresis for affect regulation toward relying on me, and later, their parents
and peers, for this purpose. These patients no longer felt compelled to control the anxiety
associated with separation and loss so rigidly, manifested somatically in their encopretic
symptoms of retention and release. The play process took place in a potential space where
our play overlapped (Winnicott, 1968), offering a pathway to explore relationships one
step removed from reality (Mayes & Cohen, 1993) by testing out new ways of relating to
me and regulating affect through me and by forming new expectations of affective
responses from me. According to Bateman and Fonagy (2004b), the play process enables
feelings and thoughts, wishes and beliefs [to] be experienced by the child as significant
and respected on the one hand, but on the other as not being of the same order as physical
reality (p. 84). This process naturally facilitates symbolic functioning, where words can
encode unnamed affects and thus provide affective containment.

First Clinical Illustration


Maverick (a pseudonym) was a 4[1/2]-year-old boy who was experiencing toilet-training
difficulties. He had bowel movements during the day and night in his underwear. These
accidents occurred at school, on the school bus to and from school, and at home. Maverick
could sit in his own products for hours and not seem uncomfortable. When a classmate
asked him what that smell was, Maverick told him, Just ignore it. He also experienced
interpersonal difficulties. Maverick needed to control all his interactions with his peers as
well as with adults. Other children did not want to socialize with Maverick because the
play had to take place on his terms, with his choice of activity and his rules. The parents
and teacher reported that Maverick often refused to follow directions, particularly when
someone asked him to transition from one activity to another (e.g., watching TV to going

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ENCOPRESIS HAPPENS

443

to bed, eating breakfast to leaving for school, playing with peers to sitting at circle time).
After two years of once-per-week individual psychotherapy with me in which Maverick made only modest gains, I began four-times-per-week psychoanalysis, recognizing Mavericks strong intellectual skills and stable family system. Maverick was
now 6[1/2] years old.
Most disturbing to his parents was Mavericks aggression directed toward his brother,
who is 2[1/2] years younger. When his brother wanted to inspect one of Mavericks toys,
Maverick would hit him hard enough to make him cry. When Mavericks mother changed
his brothers diaper, Maverick would sometimes hit his mother. Mavericks use of
aggression was not limited to his brother or mother; he also sometimes hit his school peers
when they refused to play his games by his rules.
This aggression was not always reactive. In school, Maverick once threw a live bunny
against a wall for no apparent reason. When I asked about the incident in the following
session, Maverick expressed anger that the teacher later refused to allow him to hold a
baby chick. Maverick then demonstrated this sadistic impulse in vivo by gleefully
knocking onto the floor a Russian matryoshka of cats, which he referred to as a mommy
cat with her baby cats. He described that a bad guy savagely attacked the mommy cat, who
died along with her babies. At the end of the session, Maverick instructed me to pick up
all the cats because I like to order you around.
To myself, I interpreted this play to mean that Maverick was feeling completely
unprotected by his secure base his motherand had mobilized anger to counteract this
feeling. Mavericks play suggests that he had no secure base his mother could not
protect him from danger. The frightening quality of this play also suggests that Maverick
had formed a disorganized (D) attachment relationship that over the years had become
controlling-punitive (Main & Cassidy, 1988). In a controlling-punitive attachment relationship, the child has no confidence in his or her parent, feels utter helplessness in the
face of threat (Lyons-Ruth & Jacobvitz, 1999), and often reverses roles with the parent to
feel in control (Main & Cassidy, 1988). This strategy reflects a deactivating pattern of
affect regulation in which the child ignores signals of danger by taking charge of the
environment and refusing to rely on others for help.
During other sessions, Maverick demonstrated possible indications of trauma. While
playing Uno or board games, Maverick would often upset the game board and fling all the
pieces and the board itself all over the office without warning. He called this event
Hurricane Floyda metaphor for his chaotic mental state as well as his accidents. I later
learned from his parents that at age 2[1/2], Mavericks family had fled their home during
Hurricane Floyd, which terrified him. When asked about this incident, Maverick reported
that he remembered Hurricane Floyd and how loud the thunder and wind were. He
disclosed that he remembered his parents looking scared. He then made a statement that
he immediately retracted: God was trying to get me and my mommy. Mavericks baby
brother was born only 4 months earlier, which I surmise placed stress on Mavericks
mother. Maverick was probably experiencing this new brother as the loss of emotional
closeness with his mother: the new baby required enormous amounts of attention that
Maverick was no longer receiving. From an attachment theory perspective, Maverick
might have perceived this new baby as a threat to his secure base. With the secure base
less emotionally and physically available, Maverick was already probably feeling worry
about his safety as well as anger toward this new intruder. The hurricane only exacerbated
these feelings, making them more palpable. I believe that eventually, these feelings
necessitated Mavericks retreat from a normal developmental line (toilet-training) to his
encopretic symptoms, which allowed Maverick to self-regulate his affects of unmen-

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444

GOODMAN

talized anger toward his unprotective parents and his unmentalized need for attention.
Over time, Maverick became skillful at deactivating unpleasant feeling states through
these symptoms.
In my early work with Maverick, I tried to contain his chaotic, hurricane-like feelings
of anxiety and rage by empathizing with him. Maverick responded to this containment by
becoming more organized in his play; the hurricane-themed aggressive play eventually
disappeared. Mavericks encopresis, however, continued unabated. Both parents expressed impatience and frustration with the lack of immediate results; they wanted these
behaviors to stop as soon as possible. During a collateral parent session, Mavericks
mother clearly articulated the emotional impact of this symptom on herI want to kill
him!which also reflected her inability to contain and regulate his affects and thus
reinforced the symptom in a vicious cycle.
I was feeling intense pressure from this exasperated mother to solve the problem of the
encopresis quickly; otherwise, she would surely end the treatment as Maverick suspected.
In the session that followed, Maverick was preoccupied with saying bye-bye over and
over again. I responded by stepping up my interpretation of the aggression I felt certain
was unconsciously responsible for this boys refusal to be toilet-trained. Simultaneously,
I moved away from the relationship-building work that proved so effective earlier in the
treatment. Maverick responded by withdrawing from mea kind of iatrogenic negative
therapeutic reaction. I believe that I fell victim to his mothers projective identification of
her own feelings of incompetence, inadequacy, and disillusionment partly because I was
experiencing those very feelings in myself: in spite of progress, the encopretic symptoms
were not remitting. His mothers projection into me of unwanted aspects of her own
parental representation exploited my own vulnerability.
The unconscious purpose of my confrontational interpretations was to coerce Maverick to start behaving properly rather than to help him to try out a new mode of relating and
to mentalize his affects. Fortunately, Mavericks desire to come to sessions never wavered; instead, he protected himself during sessions through withdrawal. He would play
by himself in a corner. How could I empathize with his mothers frustration, impatience,
and devaluation of the treatment, and not act on the pressure she was exerting on me to
change my method of working with Maverick? This sort of tightrope walking became my
primary challenge. Maverick began to interact with me once again and reveal his internal
world to me, and his mother experienced less frustration and impatience. For example, he
could once again allow me to assume the voice of the Lego robot he was building and
interact with me through the Lego robot. This play had completely stopped during my
confrontational phase.

Analysis of First Clinical Illustration


Mavericks severe psychopathology, coupled with high intellectual functioning, warranted
an intensive, relationship-focused therapy that could activate the chaotic and later controlling mode of relating in the therapist-patient relationship. In the early phase of
treatment, this approach served a containing function for Maverick. He played the role of
God, wreaking havoc on a scared, helpless child played by me. Rather than trying to
reestablish control (deactivating pattern), I empathized with Mavericks scared, helpless
feelings (more hyperactivating pattern). This experience of containment facilitated Mavericks use of me as a secure basesomeone who, like an attachment figure, could make
him feel safe to explore his own mental contents as well as mine. I also acted as a
hyperactivating foil to his deactivating pattern of affect regulation, defying his expecta-

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ENCOPRESIS HAPPENS

445

tions stored in implicit memory. With children diagnosed with primary encopresis, the
therapist needs to offer a pattern of affect regulation on the more hyperactivating end
of the continuum to challenge the deactivating pattern that will come to dominate the
treatment (Goodman, 2010).
In the next phase of treatment, Mavericks mother introduced her interpersonal
dynamics into my relationship with Maverick. The frustration and impatience that she was
expressing to me resonated with my own intrapersonal dynamics, producing a shift in my
intervention strategy to essentially a behavioral intervention implemented through a
coercive focus on Mavericks aggression. Through my own use of reflective functioning
(Fonagy et al., 2002), I recognized this enactment and implemented the original intervention strategy. I attempted to contain his mothers feelings of helplessness and embarrassment produced by fragmented mental representations established in the context of her
own childhood familial relationships.
In the final phase of treatment reported here, I resumed my relationship-building work
with Maverick. Maverick responded by orienting toward me again and using me as a
secure base who permitted affective expression and provided affective labeling. Maverick
needed and benefited from intensive, relationship-focused therapy. I quickly learned that
my first shift in approach had adversely affected the treatment. Because of my awareness
of options, I was able to consider moving away from a focus on behavior back onto a focus
on the childs mind. Like the baseball batter who experiments with a different stance at
the plate and figures out it is not working for him and so returns to the old stance, I
returned to the stance that had been working for me.
Although he left treatment before I felt he was ready, Maverick was no longer
defecating in his pants, had begun making friends at school, and was no longer hitting his
brother. Mavericks parents were feeling increasingly uneasy about the potential stigma
associated with their sons participation in psychotherapy as he approached preadolescenceno doubt reflecting their own discomfort with psychotherapy and, in their minds,
its incrimination of their parenting behavior. Five or so years after termination, I heard
from Mavericks mother. He was excelling at school and had a small group of close
friends. Apparently, he had learned to rely on others to help him regulate his emotional
statesperhaps begun in his therapy with me.

Second Clinical Illustration


Dennis (a pseudonym) was a 5-year-old boy referred to me for outpatient psychotherapy by his parents. In the initial consultation, Denniss parents expressed exasperation at their only childs stubbornness, expressed in his use of pull-ups for
defecation instead of a toilet. They feared that Denniss toilet-training refusal was
going to interfere with his self-esteem as he was beginning kindergarten in the fall. At
the time of referral, Dennis was attending preschool for a full day, five days per week.
Before this placement, Dennis had attended a different preschool for a full day, five
days per week since age 2. His mother shared this information with me nondefensively, never having considered the possibility that a very young child might need
more physical and emotional proximity to his secure base. I said nothing about this
arrangement because both parents had already shared with me their need to work
full-time. In the course of treatment, I also learned that the parents did not have
relatives nearby such as grandparents (i.e., secondary attachment figures) with whom
they could leave Dennis while at work.

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GOODMAN

Denniss parents reported that he had never been toilet-trained. At the time of the
initial consultation, Dennis had used a toilet a handful of times, according to his mother.
His parents reported that they had attempted toilet training since Dennis was 3 by
rewarding Dennis for using a toilet with M&Ms or toys, which had only a temporary
impact on his behavior. Out of exasperation, Denniss father sometimes used threats to get
him to conform to their expectations of using a toilet, for example, Im going to put you
down the drain. He also admitted to kicking Dennis in the buttocks after some accidents.
On the other hand, Denniss mother sometimes behaved in ways that allowed him to
receive gratification from the encopresis. At the time of the initial consultation, Denniss
mother was still cleaning up his accidents, wiping him and putting new pull-ups on him.
His parents description of this routine strongly suggested that Dennis enjoyed playing the
role of the baby with his mother, who readily shared her exasperation with me even with
Dennis in the office. His parents also reported other symptoms suggestive of oppositional
behavior and a need for control, such as refusal of food presented to him at the dinner
table, resistance to getting dressed in the morning, and resistance to getting ready for bed.
Dennis also had an obsession with toy monster trucks, monster truck rallies (which he
attended with his father), and monster truck video games. What was originally a father
son activity evolved into a devotion that far exceeded the fathers interest. Dennis stated
that he wanted to be a monster truck driver when he grew up.
I treated Dennis for five years in once-per-week individual psychotherapy. This
therapy included working collaterally with his parents to agree on a uniform behavioral
approach to Denniss difficulties and working with Dennis individually to allow him to
express any feelings that might be motivating his reluctance to use a toilet. Since the initial
referral, both parents had made amazing progress in adjusting their behavioral approach
to Denniss toileting difficulties. His father stopped making threats, while his mother
stopped cleaning Dennis after accidents, instead getting him to clean up after himself.
Dennis began to express angry feelings in therapy sessions, which coincided with his
increased use of the toilet. During our psychotherapy, Dennis experienced some successes
while sitting on the toilet and showed pride in these successes. Nevertheless, Dennis still
experienced accidents, which prompted his parents to welcome the prospect of a more
intensive, relationship-focused treatment. Thus, I began four-times-per-week psychoanalysis with Dennis at age 10. The parents were enthusiastic about Denniss beginning
psychoanalysis. I initiated psychoanalysis because of Denniss high intellectual functioning: I believed that he could eventually tolerate my attempts at symbolizing his mental
contents such as monster trucks, which I could use to represent internal feeling states. I
hoped that this work would eventually cultivate Denniss own capacity to symbolize (i.e.,
verbalize) his feelings and reduce his need to act out his feelings by having accidents.
At the onset of psychoanalysis, Dennis used the defensive processes of isolation
of affect and omnipotent control to exert the maximum degree of control over his internal
and external world. Consistent with a deactivating pattern of affect regulation, Dennis was able
to put his feelings into a compartment and leave them there for long periods of time, which
gave him an illusory feeling of control. He also behaved as though he were more powerful than
I and could therefore order me around. For example, I had to hold Denniss toy monster trucks
in a particular way; disobedience resulted in withdrawal and complete emotional unavailability. He seemed to use encopresis as a mode of distancing himself from others and forcing
others to distance themselves from him when he or they were getting too emotionally close and
therefore making him feel too emotionally vulnerable.
Paradoxically, these distancing strategies also maintained emotional involvement,
even though the involvement was antagonistic. Dennis learned that fecal smells are an

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ENCOPRESIS HAPPENS

447

effective means of removing others from ones proximity, while keeping him emotionally
present in their minds as an antagonistic figure. I noticed Denniss needs for emotional
distance and invincibility coexisting with his needs for emotional closeness and camaraderie with me. Getting too close to me emotionally put Dennis at risk of getting rejected
or abandoned by me. These are some of the most painful feelings experienced by human
beings. I surmise that Dennis experienced these feelings every morning before his parents
dropped him off for a full day of childcare at age 2, at around the time of his parents
initial attempts at toilet-training.
My countertransference reactions were consistent with a therapist who was perpetually
assigned a masochistic role to play: I felt helpless, disillusioned, ineffectual, frustrated,
humiliated, dismissed, marginalized, and invisible. Typically, I did not feel all these
feelings in the same session, but invariably, I felt at least one of these feelings in every
session. My countertransference reactions were notable because unlike many of my other
therapeutic relationships, I knew exactly what I was feeling in a session with Dennis.
There was no ambiguity. In spite of my knowledge of the origins of Denniss psychopathology, I still found my responses to these countertransference reactions at times challenging. For example, Dennis once intentionally threw a ball at my face and hit me in the
eye. When I pointed out that he had hurt my eye, he started making clucking noises that
indicated that he thought I had stopped playing because I was chicken, afraid of getting
hurt. I felt not only angry but also too stunned to say anything other than to stop the play.
Perhaps I was afraid of expressing my own angerno matter how justified it might have
been as a self-protective response.
Feelings of helplessness induced in me by Dennis led me at various points in the
treatment to consider reducing treatment frequency to prepsychoanalysis levels. Selfreflection, however, always helped me to analyze these moments of countertransference
and to recognize them for what they were: self-protective attempts by Dennis to push me
away and thus diminish his feelings of vulnerability. Disdain was perfectly suited to
accomplish this self-protective goal. In those moments when Dennis was feeling disdainful of me, sometimes it was good enough to act as simply a container rather than a
retaliator. Retaliation would only gratify his need for engagement through control without
the dreaded experience of any accompanying feelings of vulnerability elicited by the risk
of loss of control and by extension, risk of loss of me. Making me angry and getting me
to punish him (e.g., by yelling at him or withdrawing from play with him) would represent
to him my loss of control, not his. He could control me and not risk having to face what
it feels like to lose someone he loves and depends on for security and comfort.
Denniss controlling stance protected himself from genuine contact with me based on
feelings of mutual love and caring. These feelings require both persons in a relationship
to risk feeling hurt by the other person and even risk losing the other person. Dennis felt
too frightened underneath his faade to risk more genuine engagement with me. It was
easier to provoke me into fighting with hima controlling form of contact minus the
emotional risk.
Early in the psychoanalysis, I attempted an exclusively interpretive approach focused
on Denniss feelings. This strategy repeatedly failed as Dennis emphatically stated that he
did not want to talk about his feelings. He even complained to his mother (who reported
it to me) that I asked the same five boring questions in every sessionall having to do
with feelings. I eventually realized that an exclusively interpretive approach was not going
to facilitate a therapeutic alliance. I gradually shifted from an attitude of looking for
opportunities to make meaningful analytic interpretations to an attitude of looking for

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opportunities to make meaningful emotional contact with Dennis as a feeling, desiring


person.
This new stance also proved difficult. During the first half of the first year of analysis,
Dennis erected roadblocks to the path of my discovery of his personhood. He incessantly
played competitive board and card games in which he compulsively cheated to guarantee
a favorable outcome. One time, in the only game I played with him in which he never
cheated, I beat him in checkers. Afterward, I told him that I knew how he could change
his strategy to beat me the next time (he had moved his back line too early) and that I could
share this information with him. Dennis declined this offer and instead resorted to cheating
in all future checkers contests. In Denniss mind, lack of knowledge was equated with
vulnerability; thus, Dennis knew everything. He therefore categorically denied any acknowledgment that I might know something that he did not know.
I came to understand why an exclusively interpretive approach would not work with
Dennis, at least in this early phase of treatment: interpretation requires a patient who
realizes that he or she is not omniscient and is therefore willing to consider the information
given by the therapist. A standard psychodynamic interpretation such as, You poop your
pants to push people away so that you can be in control of rejecting feelings, implies that
the listener (in this case, Dennis) does not already know this information about himself.
Because Dennis knew everything, he did not need to hear this information from me.
Another therapeutic strategy would be necessary.
The equation, knowledge equals power, and its corollary, lack of knowledge equals
vulnerability, made the therapeutic work especially challenging for me. Not only did
Dennis deny that I possessed knowledge that could be beneficial to him, but also Dennis
refused to share knowledge about himself with me, thus making me feel helpless. At
times, it was almost impossible to learn anything about his life outside sessions his
home life, teacher and peer interactions at school, or friendships. Sometimes Dennis
actively refused questions about his life; at other times, he just ignored me altogether.
One exception to this knowledge blackout was Denniss only discernible passion:
monster trucks. Dennis often spent entire sessions talking about monster truckstheir
designs, the drivers, the tricks they perform, the winners in various categories of monster
truck contests, and their sponsors. He also demonstrated an encyclopedic knowledge of
monster truck trivia. At some point, I quietly entertained the idea that Dennis might have
subthreshold Aspergers disorder because of his markedly restricted repertoire of interests,
but his frequent eye contact and physical affection initiated with both parents directly
refuted this idea. In these sessions, I played the role of the interested, admiring pupil of
the master teachers vast knowledge and expertise. He was delighted and content to
maintain a monotonous pattern of sharing facts about monster trucks. I felt marginalized
in our relationship, unable to reach him.
The extensive mirroring he received from me, conducted in the context of a more
hyperactivating pattern of affect regulation, allowed him to begin to form an image of
himself in my mind as someone worthy of attention and admiration. It also implicitly
challenged his deactivating pattern by eliciting affective engagement. The goal then was
for Dennis gradually to identify with this new self-image and its accompanying expectations of comfort and support from his family, friends, and me and risk affective engagement with us.
Toward this end, I sought to break up this in-session monotony. Dennis was making
a Lego house for a monster truck driver to live in. I started building a Lego monster truck,
but Dennis instructed me to stop because the truck would be unable to fit into his Lego
garage. I countered that I was going to build a truck called the (Denniss last name)

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ENCOPRESIS HAPPENS

449

Express that I would make out of aluminum, an ultralight metal that would get some
really sick air (a colloquial expression I learned from Dennis that indicates that during a
jump, the truck stays in the air for a long time). Dennis immediately refuted this claim
because aluminum monster trucks were outlawed in 2000, and monster trucks also have
to be a certain weight. I then told him that I was going to hide cinder blocks in my trucks
secret compartment that the inspectors would never find, which I would take out after the
precontest weigh-in. Dennis countered that there could be no secret compartments. In spite
of its mildly antagonistic nature, we were engaged in a relationship. I was making
emotional contact with him by using my own imagination and getting him to engage with
my mind.
In the following session, Dennis brought in his toy monster trucks in a customized
suitcase, laid them out on the floor, set up ramps and obstacles, and directed each truck
through the obstacle course with no variation each truck performing identically to the
previous one. I took a truck and began doing unconventional tricks with it counteracting
his deactivating mode of relating. Dennis immediately dismissed my tricks as impossible. I reminded him that my own truck, which was sponsored by the American Psychological Association, had already performed all these tricks in real life. Dennis responded
to this tall story with vigorous denials. Yet as I watched him run each truck through his
obstacle course in monotonous succession, something novel happened he began performing more unconventional tricks with his own trucks. I settled into the role of an arena
announcer, mirroring him by enthusiastically praising his unconventional tricks as unbelievable, incredible, and unprecedented. Dennis allowed himself to smile when I
pretended to be an arena announcer. He even joined me occasionally in the announcing
duties by highlighting a special feature of a particular trick. We were collaborating for
perhaps the first time in treatment. He was surreptitiously getting a taste of a relationship
without having to defend against it with his characteristic deactivating pattern of affect
regulation. My efforts at engaging him getting him to experience mental closeness to
mewent unnoticed by him.
By making up tall stories, I was introducing myself as a person with my own intentions
and feelings. Essentially, I was introducing Dennis to a separate person eager to engage
with him on a series of adventures in fantasy, which he ultimately preferred to the
deactivating monotony of his own ritualized play that characteristically shut me out. I
chose story lines that mirrored his own stories, yet illustrated to him that I had a different
understanding of theman instance of marking. For example, in my story, I too had a
monster truck that competed with the others, yet my monster truck was built differently
(perhaps a model of his disavowed, devalued self-representation) and performed unconventional tricks (perhaps a model of his idealized, exhibitionistic self-representation).
Just as a mentalizing caregiver communicates his or her understanding of the infants
mental states through the process of marking using exaggerated facial and vocal
expressions to indicate that the caregiver is aware of the infants mental state but is not
experiencing what the infant is experiencing (Fonagy et al., 2002), so too did I use
exaggerated storytelling to indicate to Dennis that I was aware of his mental state but was
not experiencing what he was consciously experiencing. Thus, I was both attached to him
as a secure base and separate from him. This stance simultaneously confirmed the
existence of our relationship and challenged his need to dominate and control me, which
deprived me of my subjectivity and thrust him back into his isolated, lonely position.
My work with the parents was limited but effective. I believe that my ability to act as
a container for their own frustration with Denniss provocative behavior helped them to
contain this frustration in their interactions with Dennis and perhaps also allowed him in

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turn to risk relating to his parents in a more prosocial manner. An opportunity to practice
my containment and thus facilitate their capacity for self-reflection came in the form of an
e-mail message from Denniss mother four months after I began psychoanalysis: I
CANT TAKE IT ANYMORE!!!!!!!! Do you know of any good boarding schools or
military schools or scared straight programs? I am serious. If this is him at 10, I cant
deal with this as he gets older. I responded that Denniss expressing his anger more
directly could lessen his need to communicate his anger through his behavior such as
defecating in his pants. Two months later, his mother expressed her frustration on learning
that Denniss school was recommending that she get him a tutor: I am SO ANGRY!!!
[Denniss father] and I finally have a few dollars put away and are saving so I can buy a
new car next year. Now I have canceled my first therapy appointment as I cant afford
that his music lessons are also canceled. Here we go againmore money into fixing
[Dennis]!! Horrible for a mother to say about her son. This doesnt even count the braces
he will need. I just look at my sister who has a child the same age as [Dennis]. No eyesight
issue, no allergy issues, no toenail issues, no pooping issues, no academic issues, no
weight issue, etc., etc., etc., it just goes on and on with him. I am crying as I write
thisanger and guilt fill me. Have to stop and compose myself as Im at work.
Almost six months after this message, Denniss mother wrote: From my point of
view, [Denniss] personality and attitude have changed. We see he has more empathy, is
more appreciative and is more verbal. Overall, he seems much happier. This is great
progress. Thank you. Although Dennis still occasionally had accidents, he was on his
way to becoming a separate yet connected preadolescent who was about to face a series
of new challenges presented by adolescence. Dennis and I continue to work together. I am
excited to discover where this process will take us next.

Analysis of Second Clinical Illustration


In this case, I realized that an exclusively interpretive approach focused on Denniss
feelings was failing to reach Dennis behind his primitive fortress protected by barbed wire
and armed guards. Such interventions were aimed at a symbolic level of thinking not yet
sufficiently consolidated for therapeutic use. He also had the problem of knowing
everything that would have defeated such a strategy. I gradually shifted to looking for
opportunities to make meaningful emotional contact with Dennis as a feeling, desiring
personthe first therapeutic principle I used. In so doing, I held in my own mind the
image of a boy-in-the-making who is worthy of caring, attention, and admiration rather
than yelling, rejection, and abandonment. Dennis could observe my attitudes and behaviors toward him and begin to identify with and perhaps internalize this nascent self-image,
which was both similar to and different from his own image of himself. This principle
emphasized my mentalizing his feelings, desires, and intentions on his behalf, using
imaginative play and humor, rather than articulating mental representations located in the
transference. Through the use of imaginative play and humor, I elicited affective engagement that rendered his deactivating mode of relating unnecessary.
Bateman and Fonagy (2004b) have suggested that treatment approaches that emphasize transference interpretations expect too much agentive thinking from the patient,
which the patient could perceive as blaming. In contrast, a mentalizing approach would
not expect the patient to understand much of the discourse that the therapist might
verbalize in relational terms (Bateman & Fonagy, 2004b, p. 117). Primitively organized
patients such as Dennis experience widespread symbolic failure, particularly associated
with incongruent mirroring (Bateman & Fonagy, 2004b, p. 118). Thus, transference

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ENCOPRESIS HAPPENS

451

interpretations, particularly with severely disturbed patients, whose symbolic capacity has
clearly failed, would be ineffective. Only after a primitive symbolic capacity has become
activated should a therapist attempt transference interpretations with such patients. Thus,
retaining mental closeness (Bateman & Fonagy, 2004a, p. 44) is the therapeutic
principle used to accomplish the enhancement of mentalizing capacities.
Providing a gentle challenge (Dozier, 2003, p. 254) to a deactivating pattern of
affect regulation is the second therapeutic principle I used to accomplish a secure mode
of relating to others. A more hyperactivating therapeutic response defies the childs
expectations of rejection stored in implicit memory, which is not verbally mediated, yet
governs his or her mode of relating to others. Verbal interventions cannot access this form
of memory (Lyons-Ruth, 1999; Stern et al., 1998).
These two therapeutic principles represent the essential ingredients of an effective
treatment for patients diagnosed with primary encopresis. A relationship-focused intervention approach requires the temporary use of mentalizing interventions early in the
treatment process that serve the treatment goals of relationship-building and stabilization
before more ambitious interventions such as transference interpretations are attempted.
Child patients need to feel secure enough in the therapeutic relationship and skilled
enough in their symbolic capacity to explore the contents of their own minds, particularly
the split-off mental representations contained therein. In Denniss case, I noticed that
underneath the controlling, know-it-all attitude lurked a scared, wounded child that I
needed to reach somehow through imaginative play and humor. I made my differently
built truck show off by doing its own thing: my truck was driving to the hum of a different
engine. In the future, when Dennis becomes more vulnerable in sessions for longer periods
of time, I might be able to sprinkle into my work some interpretations that verbalize the
symbolic meaning of his patterns of relating to others. Transference interpretations would
come still later, when Denniss capacity to symbolize his affective experience has
developed further.

Conclusions
Both Maverick and Dennis shared a tendency to act self-sufficient and precociously
autonomous, which necessitated a dismissal of unpleasant affect states and a consequent
desire to control all relationship outcomes to avoid the emergence of such states. Not
coincidentally, both patients also shared a symptom, encopresis, that reflected a disconnection from unpleasant body-based sensations and a desire to isolate themselves from
others, while enraging their parents in the process. These behaviors thus insured the
patients some level of proximity to their parents, albeit with a hostile, sadomasochistic
tinge.
Both sets of parents, perhaps inadvertently, signaled their lack of comfort with their
childs need for closeness, protection, and comfort; thus, a goal-corrected partnership was
never established. Mavericks parents had a new baby during Mavericks toilet-training
phase while simultaneously struggling with the aftermath of Hurricane Floyd. I suspect
that they were emotionally unavailable to Maverick during this time, which Maverick
undoubtedly experienced as a rejection or abandonment. He responded by turning away
deactivating the experience and communication of his attachment needs that his overwhelmed parents might have ignored or even been irritated by. Denniss parents placed
him into full-time childcare at the age of 2also during Denniss toilet-training phase.
During the first two years of his life, Denniss mother also faced enormous challenges at

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her workplace, which might have distracted her from being emotionally present. Like
Maverick, Dennis also responded by deactivating the experience and communication of
his attachment needs. In contrast to my experience with Mavericks mother, I felt better
able to contain Denniss mothers frustrations with her son. Additional clinical experience
working with my countertransference as well as additional therapeutic work on myself
probably account for this difference in response to these two mothers, who shared a sense
of profound hopelessness and helplessness.
The success of both treatments depended on my recognizing the latent needs for
attachment and closeness and not allowing these patients to deceive me (as they had
deceived their parents) into listening to the manifest content of their presentations, which
could easily be summed up by the command, Get away! Dozier (2003) suggested that
therapeutic interventions are most effective when the therapist provides a gentle challenge (p. 254) to the patient. By relentlessly pursuing emotional contact and intimacy
with Maverick and Dennis (hyperactivating pattern) even though they signaled distance
(deactivating pattern), I was defying their expectation that I would be uncomfortable with
their need for closeness, protection, and comfort. I was letting them know instead that
these needs were acceptable to me, and therefore, that they were acceptable to me. My
patients defensive needs to interact sadomasochistically were no longer necessary.
Because of both patients compromised symbolic capacity (i.e., using nonverbal
channels of communication to act out their feelings rather than expressing them verbally),
I chose to help them to mentalize their affects rather than act them out in a bodily function
(encopresis) from which they were disconnected. In the case of Maverick, I got sidetracked by his mothers anger and disapproval of my work, which temporarily shifted me
into an essentially behavioral approach. After figuring out the nature of this enactment, I
reset the treatment course back to its original relationship-building process. In the case of
Dennis, I initially felt a need to engage in interpretive work but realized that this need was
mine and was in fact getting me nowhere. Mentalizing affects with storytelling can
facilitate the childs perspective-taking and theory of mind (Mar, Tackett, & Moore, 2010)
and eventually pave the way for later exploration of mental representations. A mentalizing
approach (Fonagy & Target, 2000; Midgley & Vrouva, 2012; Verheugt-Pleiter,
Zevalkink, & Schmeets, 2008) can prepare encopretic patients for later interpretive
approaches that include transference interpretations and exploration of fantasy material
related to parental and self-representations.
Another way of putting this idea is that the child needs to make contact with the
therapist in a genuine, reciprocal relationship in which the child becomes aware of having
a mind with mental contents, while the therapist also has a mind with separate but related
mental contents. Only then can the therapist proceed to explore fantasy material and try
out more symbolically advanced intervention strategies. In a later treatment phase, the
therapist can help the child understand the complexity of his or her internal conflicts, for
example, that a symptom like encopresis exists because it protects the child from
emotional vulnerability, specifically, from the risk of rejection and abandonment, by
preemptively alienating others. In all treatment phases, the therapist is striving to make
emotional contact with all parts of the patients self, which eventually permits the patients
exploration of the contents of his or her mind as well as the therapists mind. Through this
empathic connection, the therapist provides a mental secure base from which the patient
can explore unknown territory and to which the patient can return when the terrain
becomes too frightening. Child therapists need to acquire a whole arsenal of artists tools.
In some situations, a therapist might need a chisel, whereas in others, a paintbrush will do.
Our field needs fewer technicians and more artists.

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