The Psychoanalytic Study of de Child V60 Robert A. King, Peter B. Neubauer, Samuel Abrams

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

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Robert A. King, M.D.
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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.
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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
47
74
101
128
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
157
178
vi
Contents
CLINICAL STUDIES
Karen Gilmore
Play in the Psychoanalytic Setting: Ego Capacity,
Ego State, and Vehicle for Intersubjective Exchange
Lissa Weinstein and Laurence Saul
Psychoanalysis As Cognitive Remediation: Dynamic
and Vygotskian Perspectives in the Analysis of
an Early Adolescent Dyslexic Girl
Silvia M. Bell
A Girls Experience of Congenital Trauma: The
Healing Function of Psychoanalysis in the Adolescent Years
213
239
263
PSYCHOANALYTIC PERSPECTIVES ON
THE FUTURE AND THE PAST
Harold P. Blum
Psychoanalytic Reconstruction and Reintegration
Cornelis Heijn
On Foresight
312
Index
335
295
INFANT-PARENT RESEARCH
AND INTERVENTION
Introduction
Who can tell the dancer from the dance?

William Butler Yeats
the following five papers are presented as a group to emphasize the unity of purpose of their authors in furthering parent
young child research and clinical practice and to highlight the variety
of routes they have devised to provide creative and effective interventions.
When Peter Wolff (1959) described infant states, the stage was set
for the burgeoning field of infancy research. At about the same time,
the important work of Chess and Thomas (1986) on temperament
spelled out more explicitly the notions of Anna Freud and others
that infants differed constitutionally in their regulatory and reactive
stylesand that these differences had important, fateful consequences for the reactions they elicited in their caretakers. The findings of this research gradually made it possible to move beyond wellmeant but fundamentally authoritarian recommendations for infant
care. This work thus set the stage for research that supports suggestions for care based on deepened developmental insight and on an
appreciation of individual parent-infant differences.
There seems to be no end to the fruitfulness of infant research as it
provides descriptions of ever more complex competencies and innate capacities of infants and details the moment-to-moment interactions of infants with others with ever greater precision. There is universal agreement that such studies yield a goldmine of data; there is
less agreement about the interpretation of the data and their significance for development and functioning in later childhood and adulthood. One area in which these data might be applied is that of parent-infant intervention.
Many of the pioneers in advocating such intervention, including
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
Introduction
Sally Provence, Albert Solnit, Peter Neubauer, and Selma Fraiberg,

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

provocative questions about the fashion in which the second-to-second interactions of parents and their young children, often on a
non-verbal level outside of conscious awareness, shape each dyads
enduring patterns of mutual influence and relating, and structure
the childs internal object representations, affective and cognitive
self-regulation, and characteristic modes of coping with various
forms of instinctual arousal. By opening to scrutiny the fine-grained
structure and texture of ongoing parent-infant interaction that make
up the quotidian stuff of early childhood life, these studies reveal the
subtle, multifaceted nature of empathic attunement (and the potential derailments thereof ). This work continues the long-standing psychoanalytic agenda of understanding how the childs mind becomes
structured in the context of mother-infant interactions (Loewald,
1978; Ritvo & Solnit, 1958). How the consequences of these very
early procedural (rather than verbal) modes of relating (and misrelating) come to be represented in later childhood or adulthood;
how they interact with temperament to shape drive, defense, and
character; and how they might be re-experienced and accessed in the
transference or counter-transference are all important unanswered
questions. The ongoing empirical study of these processes promises
to deepen our understanding of the links between psychoanalysis
and developmental psychopathology.
For a number of years, researchers interested in infant development and in parent-infant interaction have made extensive use of
video recordings, sometimes reviewed in frame-by-frame detail.
Three papers describe the use of such video recordings in research
but then go on to demonstrate how the same video microanalytic
techniques can be used clinically with parents as an aid to insight and
as a guide to more effective methods of care. The paper by Harrison
extends these video analytic techniques, developed in infant research, to the study of parents in interaction with their young children.
These five papers are the beginning of a continuing dialogue in
these pages concerning interventions with parents and their young
children. It is our personal conviction that these studies are valuable
not only for the assistance they provide to practitioners in this field
but also for their contribution to a more adequate empirical study
and integration of physiological (biological), drive/defense (structural), and interpersonal (object relations) perspectives in our understanding of human psychology.
Introduction
BIBLIOGRAPHY
Chess, S. & Thomas, A. (1986) Temperament in Clinical Practice. New York:

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

Mother-Infant Treatment*
BEATRICE BEEBE, Ph.D.
*Winner of the Albert J. Solnit Award, 2005
A brief mother-infant treatment approach using video feedback is described. This approach is informed both by psychoanalysis and by research on mother-infant face-to-face interaction using video microanalysis. Two cases are presented. In the first, descriptions of the
Clinical Professor of Psychology in Psychiatry, Columbia University; Faculty, N.Y.U.

Postdoctoral Program in Psychotherapy and Psychoanalysis; Faculty, Institute for the
Psychoanalytic Study of Subjectivity, N.Y.C.; Faculty, Columbia University Psychoanalytic Center; Faculty, Columbia Psychoanalytic Center Parent-Infant Program.
This work was partially supported by NIMH grant R01-MH41675, the Fund for Psychoanalytic Research of the American Psychoanalytic Association, the Kohler
Stiftung, the Edward Aldwell Fund, and the Laura Benedek Infant Research Fund. I
am grateful for the help of my research team: Caroline Flaster, Donna Demetri-Friedman, Nancy Freeman, Patricia Goodman, Michaela Hager-Budny, Sara Hahn-Burke,
Elizabeth Helbraun, Allyson Hentel, Tammy Kaminer, Sandra Triggs Kano, Limor
Kaufman-Balamuth, Marina Koulomzin, Sara Markese, Lisa Marquette, Irena Milentejevic, Danielle Phalen, Alan Phalen, Jill Putterman, Jane Roth, Shanee Stepakoff,
Sandra Triggs Kano, Rhonda Davis, Helen Demetriades, Greg Kushnick, Paulette
Landesman, Tina Lupi, Jillian Miller, Michael Ritter, Stephen Ruffins, Claudia Andrei, Emily Brodie, Lauren Cooper, Lauren Ellman, Nina Finkel, Matthew Kirkpatrick, Adrienne Lapidous, Michelle Lee, Sandy Seal, Nicholas Seivert, Hwee Sze
Lim, and Marina Tasopoulos. I thank Frank Lachmann, Phyllis Ackman, Phyllis Cohen, George Downing, Juliet Hopkins, Barbara Kane, Lotte Kohler, Ilene Lefcourt,
Mary Sue Moore, Wendy Olesker, Lin Reicher, and Johanna Tabin for their clinical
consultations. I thank my statistical team, Howard Andrews, Karen Buck, Patricia Cohen, Henian Chen, Stanley Feldstein and Donald Ross. Joseph Jaffe has been an invaluable consultant and advisor.
Beatrice Beebe
videotaped interactions which informed the interventions are presented. In the second, knowledge of mother-infant microanalysis research informed the treatment, even though videotaping was not an
option. The respective stories of the presenting complaints, the video
interaction, and the parents own upbringing are linked. Specific representations of the baby that may interfere with the parents ability to
observe and process her nonverbal interaction with her infant are
identified. The mother has a powerful experience during the video feedback of watching herself and her baby interact. Our attempts together
to translate the action-sequences into words facilitates the mothers
ability to see and to remember, fostering a rapid integration of implicit and explicit modes of processing.
Introduction
more than two decades of research on maternal distress,

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

usually out of awareness, the explicit, declarative mode refers to our
symbolic, verbalized narrative. In the discussion, I suggest that the
mothers experience during the video feedback of watching herself
and her baby interact, and our joint attempts to translate the action-sequences into words, facilitates the mothers ability to see and to remember, stimulating a rapid integration of procedural and declarative modes of processing (see Beebe, 2003). Some mothers, however,
require more extensive treatment (see Cohen & Beebe, 2002).
Psychoanalytic pioneers such as Anna Freud, Melanie Klein, Margaret Mahler, Fred Pine, Anni Bergman, and Paulina Kernberg understood the importance of intervention in the first years of life. Parent-infant therapy specifically has been known for several decades,
spearheaded by Adelson and Shapiro (1975); Call (1963); Ferholt
and Provence (1976); Fraiberg (1971, 1980); Greenacre (1971);
Greenspan (1981); Lebovici (1983); Spitz (1965), Lieberman & Pawl
(1993); and Weil (1970), among others. Although therapeutic interventions are widely available for young children, mother-infant treatment remains less available.
The last decade has shown great progress in conceptualizing methods of intervention with parents and infants. Both psychodynamic
approaches aimed at the mothers representations and interactional
approaches attempting to intervene into specific behavioral transactions are effective (see for example Brazelton, 1994; Fraiberg, 1980;
Field et al., 1996; Hofacker & Papousek, 1998; Hopkins, 1992; McDonough, 1993; Marvin, Cooper, Hoffman, & Powell, 2002; Malphurs et
al., 1996; Murray & Cooper, 1997; Seligman, 1994; Stern, 1995; van
den Boom, 1995). Many different kinds of mother-infant therapies
have been shown to predict positive outcomes (Cramer et al., 1990).
Nevertheless, even in current approaches to mother-infant treatment, the infant is in danger of being the forgotten patient (see Lojkasek, Cohen & Muir, 1994; Weinberg & Tronick, 1998). Weinberg
and Tronick (1998) documented by video microanalysis that the infants of mothers with panic disorder, obsessive-compulsive disorder,
and major depression were still in distress, even though the mothers
reported improvement of their own symptoms with medication and
individual psychotherapy.
Our approach to mother-infant treatment integrates psychodynamic and interactional approaches within the context of feedback
on videotaped interactions. We address the mothers representations
of and transferences to the infant as well as mother-infant interaction
patterns visible on videotape.
10
Beatrice Beebe
Microanalytic research describing face-to-face patterns has been

extensively reviewed (see Beebe 2003, 2000; Beebe & Lachmann,
2002; Stern, 1985, 1995). Two treatment cases informed by mircroanalytic research have previously been presented in Beebe (2003) and
Cohen and Beebe (2002); see also Freeman (2001).
Face-to-Face Interaction Research
The video feedback treatment method attends to specific patterns of
mother and infant self- and interactive regulation which have been
documented by three decades of video microanalysis research. This
work focuses on face-to-face interaction rather than the regulation of
feeding and sleep (but see as an exception Sander, 1977) and is most
relevant for infants 3 to 12 months. The importance of mother-infant
face-to-face interaction for social and cognitive development is extensively documented (see Belsky, Rovine, & Taylor, 1984; Cohn &
Tronick, 1988; Cohn, Campbell, Matias, & Hopkins, 1990; Field,
1995; Lewis & Feiring, 1989; Leyendecker, Lamb, Fracasso, Scholmerich, & Larson, 1997; Martin, 1981; Malatesta et al., 1989; Lester, Hoffman, & Brazelton, 1985; Stern, 1985; Tronick, 1989). This research
provides a rich resource for the parent-infant clinician, but has nevertheless remained strikingly under-utilized.
A dyadic systems view of face-to-face communication informs our
approach to this research (Beebe, Jaffe, & Lachmann, 1992; Beebe &
Lachmann, 2002). Because each person must both monitor the partner and regulate inner state, in this view all interactions are a simultaneous product of self- and interactive regulation, and each form of regulation
affects the other (Gianino & Tronick, 1988; Sander, 1977; Thomas &
Malone, 1979). Both the individual and the dyad contribute to the
organization of behavior and experience.
Interactive regulation is defined as bi-directional contingencies in
which each partners behavioral stream can be predicted from that of
the other. It is a co-constructed process in which each partner
makes moment-by-moment adjustments to the others shifts in behaviors, such as gaze, facial expression, orientation, touch, vocal
quality, and body and vocal rhythms. Although the mother has the
greater capacity and range of resources, the infant is a very active participant in this exchange, bringing remarkable capacities to seek and
avoid engagement (Beebe & Lachmann, 2002; Beebe & Stern, 1977;
Stern, 1971, 1985; Tronick, 1989). This emphasis on the contribution of both partners to the organization of the exchange avoids the
temptation to locate the source of difficulty in only one partner or
11
the other, for example, in maternal intrusiveness or in infant temperament difficulty.

From birth and even in utero, infants perceive durations of events
and temporal sequences (DeCasper & Carstens, 1980). By the time
infants are 3 to 4 months, when most of this research is conducted,
infants perceive the existence and magnitude of contingencies and
can anticipate when events will occur (Haith, Hazan, & Goodman,
1988; Jaffe et al., 2001; Watson, 1985). These capacities enable the infant to anticipate how each partner changes predictably in relation
to the others changes, organizing expectancies of how I affect
you, and how you affect me. These infant capacities for the perception of sequence, contingency detection, and the anticipation of
events underlie the generation of procedural, presymbolic representations of interactive sequences (Beebe & Stern, 1977; Beebe, Lachmann, & Jaffe, 1997; Gergeley & Watson, 1997; Stern, 1985; Tronick,
1989).
Although the terms mutual influence or mutual regulation are
often used to describe the co-construction of interactive regulation,
we no longer use these terms because neither mutuality nor influence in their usual meanings is accurate. Mutuality usually connotes
a positive interchange, but aversive interactions such as chase and
dodge are also co-constructed, in the sense that each partners behavioral stream can be predicted from that of the other (Beebe &
Stern, 1977). The term influence can also be misleading because
no conscious intention to influence the behavior of the partner is implied in these contingency analyses (although obviously the parent
has many conscious intentions to influence the infant). It is not a
causal process but rather a probabilistic one. The interactions we
study are extremely rapid, with individual behaviors lasting on the average 1/4 to 1/3 of a second; lag times between the onset of one individuals behavior and the onset of the partners behavior are generally within 1/2 second (Beebe, 1982; Cohn & Beebe, 1990; Stern,
1971). Thus many aspects of these interactions occur out of awareness, often subliminally; they are nonconscious, rather than dynamically unconscious (see Lyons-Ruth, 1998), although again, the
parent has many dynamically unconscious motivations as well. Thus
we prefer the more neutral terms bi-directional regulation or coordination to describe these contingency analyses.
Self-regulation is just as important as interactive regulation. While
participating in the interactive exchange, each partner must simultaneously regulate his or her inner state. Both infant and parent bring
constitutional proclivities such as temperamental dispositions and
12
Beatrice Beebe
arousal regulation styles which affect self-regulation. Each partners

self-regulation capacity and style affects the nature of the interactive
regulation, and vice-versa. Whereas one meaning of co-construction is that each partner contributes to the interactive regulation, a
second meaning is that inner and relational processes are co-constructed (see Beebe & Lachmann, 1998). Thus both partners come
to expect particular interactive patterns, associated with particular
self-regulation processes. Infant expectancies of different patterns of
self- and interactive regulation provide one process by which parental distress can be transmitted to the infant and alter the trajectory of
development.
In applying this research to treatment, it is important to recognize
that ranges of normal interactions are more ambiguous than extremes of difficulty, and there is no one optimal mode of interaction.
Despite extensive research predicting developmental outcomes from
face-to-face interaction patterns, there are no official norms, and
this research is still in progress. All dyads use problematic patterns at
some moments, as adaptive modes of coping and defense in the context of specific interactive dilemmas.
The Infants Nonverbal Language
The use of video feedback as part of parent-infant psychotherapy
still constitutes a new approach to mother-infant treatment, despite
the fact that Stern (1995; Cramer & Stern, 1988), McDonough
(1993), Tutors (1991), and Downing (2004), among others, have
been using variations of this technique for over a decade (for current
work see for example Bakermans-Kranenberg, Juffer, & van Ijzendoorn, 1998; Hofacker & Papousek, 1998; Malphurs et al., 1996; Marvin, Cooper, Hoffman, & Powell, 2002; van den Boom, 1995).
Video feedback is introduced to the parent as a way of learning
about the infants nonverbal language, and of becoming aware of
the ways the parent may respond. Video feedback is a remarkable
clinical tool in the hands of an experienced baby watcher who is
also a sensitive clinician. Videotape played in slowed time, or frameby-frame, acts like a social microscope, revealing subtleties and subliminal details of interactions which are too rapid and complex to
grasp with the naked eye in ongoing time. It is difficult for anyone to
be aware of his or her nonverbal behavior. If the video feedback is
handled with great care to protect the parents self-esteem, it helps
the parent to see how both infant and parent affect each other, mo-
13
ment-by-moment. Video feedback provides an opportunity for the

parent to process and reflect on the difficult moments in the interaction, as well as the successful ones (Fonagy, Gergely, Jurist, & Target,
2002).
Microanalysis Teaches Us to Observe
Video microanalysis can teach us to observe the subtle, fleeting details of the mother-infant action language. The infants repertoire
during a face-to-face exchange is complex. There is a remarkable
range of behaviors at the infants disposal to initiate, maintain, disrupt, or avoid a face-to-face encounter (Stern, 1971, 1985). The
mother is instructed to play with the infant as she would at home.
Until 9 to 12 months, we do not provide toys. The infant is placed in
an infant seat opposite the mother, who is seated in the same plane.
Two cameras, one on each partners face and upper torso, generate a
split-screen view of the pair interacting.
gaze
We begin by observing gaze. Mothers tend to look at the infants face
most of the time, and it is the infant who typically engages in a looklook away cycle, looking at mothers face for a period of time, looking away, and then looking back (Stern, 1971, 1974). As the ethologists note, looking into the face of a partner can be very stimulating;
most animals do not sustain long periods of such looking unless they
are about to fight or make love (Chance & Larsen, 1996; EiblEibesfeldt, 1970). Field (1981) verified that infants organize their
look-look away cycle to regulate degree of arousal. She monitored infant heart rate during face-to-face play and showed that the moment
that the infant looks away is preceded by a burst of arousal in the previous 5 seconds; following the infants gaze aversion, heart rate decreases back down to baseline within the next 5 seconds, and then
the infant returns to gazing at mothers face. Thus infant gaze aversion is an important aspect of infant self-regulation. Brazelton, Kozlowski, and Main (1974) first showed that mothers typically pace the
amount of stimulation according to this gaze cycle, stimulating more
as the infant looks, and decreasing stimulation as the infant looks
away. Although these are typical patterns, we have also noted a pattern of mutual eye love (Beebe, 1973; Beebe & Stern, 1977) in
which mothers and infants can sustain prolonged mutual gaze for up
14
Beatrice Beebe
to 100 seconds during periods of positive affect. These are the moments, of course, that every parent loves.
Maternal difficulty in tolerating momentary infant gaze aversion is
one of the most common pictures observed in mothers and infants
who present for treatment. If the mother feels that her infant does
not like her or is not interested in her, she may pursue the infant, increasing rather than decreasing the amount of stimulation. In her
pursuit or chase, mother may call the infants name, pull the infants hand, or in rare instances actually attempt to force the infants
head to get the infant to look. Maternal chase behavior is counterproductive; the infant then requires more time to regulate arousal
down sufficiently to return to gazing at mother. Instead, if the
mother can be helped to give the baby a time-out to re-regulate,
cooling it when the infant looks away, trusting her infant to return
to her, the infant will rapidly re-engage.
head orientation
We next observe infant head orientation to the mother: is the head
oriented vis--vis, or displaced in the horizontal plane approximately
30, 60, or 90 degrees away? In the 90-degree aversion, first described
by Stern (1971), the infants head is tucked into the chin, which takes
considerable energy. Are head aversion movements in the horizontal
plane complicated by oblique angles of the head down (or up) as
well? These increasing degrees of head aversion are described by
ethologists as degrees of severity of cut-off acts (Chance, 1962; McGrew, 1972). They are read by the partner as active initiations of
disengagement. As the infant turns away up to about 60 degrees, he
can still monitor the mother with his peripheral vision (tracking
presence, direction, and intensity of movement); by 90 degrees away,
or arching, however, he may lose peripheral visual monitoring of her
movements. More usual gaze aversions retain head orientation
within an approximately 30-degree angle from the vis--vis, retaining
access to rapid visual re-engagement with minimal effort.
In relation to the maternal chase behaviors above, the infant may
dodge with increasing degrees of head aversion, as well as arching
back, freezing (described by Fraiberg, 1982), or going limp and giving up tonus. Beebe and Stern (1977) described split-second sequences of chase and dodge in which maternal chase movements
predicted infant dodges, as the infant monitored her every movement through peripheral vision; but infant dodges also predicted
maternal chase behaviors, a reciprocal, bi-lateral interactive regula-
15
tion. Through increasing head aversions, arching, or going limp, this

infant had a remarkable veto power over the possibility of a sustained, mutual gaze encounter.
face
If mother and infant together manage the infants look-look away cycle so that the infant can comfortably regulate arousal, periods of sustained mutual gaze with infant vis--vis orientation can be enjoyed.
During these periods, facial and vocal communication take center
stage. By 3 to 4 months there is a flowering of the infants social capacity. Although the innervation of the facial musculature is myelinated before the infant is born, the full display of facial expression
emerges only gradually from 2 to 4 months.
The infants opening and closing of the mouth is a powerful and
continuous form of communication. Even without any hint of widening or smiling, a fully opened mouth (neutral gape) is highly evocative (Beebe, 1973; Bennett, 1971). A fully widened smile by itself,
with closed lips, is only moderately positive. As increasing degrees of
mouth opening are added to a smile, positive affect increases up and
up into the fully opened gape smile, hugely exciting for both partners. Mothers intuitively roughly match the infants increments, so
that both build to a peak of positive facial excitement. Often both
partners excitedly vocalize at such moments, further increasing the
intensity (see Beebe, 1973; Beebe & Lachmann, 2002; Stern, 1985;
Tronick, 1989). In general, mothers and infants tend to match the direction of the others positive-to-negative affective change, increasing and decreasing together (Beebe et al., 2004). Rarely is there an
exact match of expression. Elaboration (Fogel, 1993), echo, or complementing (Trevarthen, 1977) are better metaphors than matching
or imitation (Stern, 1985). Instead of the more romanticized notion
that mothers and infants exactly match, or are in exact synch, Tronick and Cohn (1989) have shown that a more flexible process of
match, mismatch, and re-match (disruption and repair) characterizes the exchange. Furthermore, a greater likelihood of rapid rematch (within 2 seconds) predicts secure attachment at one year. It is
unusual for mothers to display no facial matching at all, particularly
when infants are distressed. Malatesta et al. (1989) showed that unusual responses such as maternal joy or surprise to infant anger or
sadness predict toddler preoccupation with attempts to dampen negative affect (compressed lips, frowning, sadness). We construe these
patterns as failures of facial empathy.
16
Beatrice Beebe
vocalization
A key feature of the vocal exchange is a turn-taking structure. Both

partners contribute to turn-taking by matching the brief switching
pause as turns are exchanged. Mothers contribute by slowing their
speech rhythms, providing a great deal of repetition, and matching
the intonation of the infants sounds. Vocal contours refer to the
shape of the sound. Across cultures, a sinusoidal shape indicates
approval and a rightward falling shape disapproval (Fernald, 1993).
Mothers also optimally pause sufficiently to give the infant a turn. On
the one hand, mothers who prattle continuously do not permit this;
on the other hand, mothers who are silent partners can disturb the
development of vocal turn-taking, an essential building block of language. When infants present for treatment with difficulty in sustaining mutual gaze and the face-to-face encounter, matching the infants vocal contours and rhythms can be an effective way to make
contact with the infant. Because the infant does not have to orient or
to look, approximately matching the infants rhythms (vocal or motoric) is a non-intrusive way of helping the infant feel sensed: someone is on his wavelength.
vocal rhythm and the prediction of attachment:
the midrange model
Security of attachment as assessed at 12 to 18 months is a key milestone in the infants development. In the Ainsworth Strange Situation attachment test, mother and infant go through periods of free
play, separations, and reunions (Ainsworth, Blehar, Waters, & Wall,
1978). Based on the infants reactions, individual infants can be classified as having a secure, insecure-avoidant, insecure-anxious-resistant, or disorganized attachment style.
The secure infant can easily be comforted by mother and return to
play, using mother as a secure base while being able to explore the
environment. The insecure-avoidant infant shows little distress at
separation, avoids mother at reunion, and continues to play on his
own. The insecure-anxious-resistant infant is very distressed at separation, but cannot be comforted by mothers return and does not
easily return to play (Ainsworth et al., 1978). The insecure-disorganized infant simultaneously approaches and avoids the mother, such
as opening the door for her but then sharply ignoring her. The
mother herself acts frightened or frightening, and typically has a history of unresolved loss, mourning, or abuse (Lyons-Ruth et al., 1999;
17
Main & Hesse, 1990). In contrast, secure attachment at 1 year is associated with better peer relations, school performance, and capacity
to regulate emotions, as well as less psychopathology in childhood
and adolescence (Sroufe, 1983).
Disorganized attachment at 1 to 2 years is associated with oppositional, hostile-aggressive, fearful and disorganized behavior, low selfesteem, and cognitive difficulties in childhood (Lyons-Ruth, Bronfman & Parsons, 1999; Jacobson, Edelstein, & Hofmann, 1994).
Over 50 studies have shown that the security of the childs attachment to the parent is dependent on the emotional availability of the
parent, using global assessments and clinical ratings (see van Ijzendorn, 1997 for a review). Nevertheless, we still lack a full understanding of the origins of attachment, its modes of transmission, and the
role of the infant (and infant temperament) in this process. Fewer
than a dozen studies have used microanalysis of videotape to predict
attachment outcomes.
Although infants typically vocalize only about 10% of the time at 4
months, vocalization is such a central means of communication that
the way mothers and infants coordinate their vocal rhythms predicts
infant attachment. Jaffe, Beebe, Feldstein, Crown, and Jasnow (2001;
Beebe et al., 2000) predicted 12-month attachment outcomes from 4month vocal rhythm coordination, assessed with a technique that
samples behavior every quarter of a second. As each individual shortens or elongates the durations of sounds and silences, how tightly or
loosely does the partner coordinate with adjustments in his or her
own sound and silence durations? Midrange degrees of mother-infant and stranger-infant coordination at 4 months predicted secure
attachment; very high and very low degrees of coordination predicted insecure attachment classifications.
This work led us to conceptualize interactive regulation on a continuum, with an optimal midrange, and two poles defined by very
high (excessive) or very low (withdrawn) monitoring of the partner.
High coordination increases the predictability of the interaction,
construed as a coping strategy elicited by the uncertainty or threat
experienced by both mother and infant. At the very low pole of coordination, both partners are behaving relatively independently of the
other, interpreted as a withdrawal or inhibition of interpersonal
monitoring. Although much research literature concentrates on the
concept that lowered interactive coordination is a risk condition for
infant development, a substantial body of work examining both high
and low poles is now converging on an optimum midrange model
18
Beatrice Beebe
as well (see Belsky et al., 1984; Cohn & Elmore, 1988; Lewis & Feiring, 1989; Malatesta et al., 1989; Sander, 1995; Roe, Roe, Drivas, &
Bronstein, 1990; Leyendecker et al., 1997).
In our vocal rhythm study, very high mother-infant bi-directional
coordination predicted insecure-disorganized attachment, the most
problematic of attachment classifications. We interpreted the high
coordination on the part of both partners as vigilance, arousal, or hyper reactivity. Our research film of Clara at 4 months dramatically illustrates a very disturbing mother-infant pair with very high vocal
rhythm coordination; subsequently, at one year, Clara was classified
as showing disorganized attachment. In the research film, Clara is
crying and flailing as the interaction begins. Mother excitedly repeats her name. Claras crying rhythm and mothers rhythmic repetition of her name synchronize. Mother flashes big smiles at Clara as
she synchronizes with the cry rhythm, as if attempting to ride high
negative arousal into a more positive state. Both escalate, Clara
screaming more loudly, mother now frantically vocalizing and moving Claras arms. Although most mothers would back off, this mother
just keeps going, and each partner continues to top the other. By
the end Clara has thrown up, sobbing and writhing. In addition to
vigilant vocal rhythm coordination, this interaction illustrates mutually escalating over-arousal, a disturbance of the ability of the dyad
to manage the infants distress.
The optimum midrange model has direct clinical relevance. Vocal
rhythm coordination is an important means of attachment formation and transmission. Whereas the midrange dyad retains more variability and flexibility, the tightly coordinated dyad is less flexible and
variable. Too much predictability in the system may compromise flexibility and openness to change; too little may index a loss of coherence (Beebe et al., 2000). These concepts can be used in mother-infant treatments as a framework with which to evaluate interactive
difficulties and the process of change, in any modality (not just vocal
rhythm), as we do in the first case described below.
The Key Role of the Face-to-Face Interaction
An ongoing NIMH-funded study in our lab has examined maternal
self-report depression and anxiety at 6 weeks and 4 months, motherinfant face-to-face interaction at 4 months, and infant attachment at
12 months, in a community sample of 132 families (Beebe, Jaffe,
Chen, Cohen, Buck, Feldstein, et al., 2003). Maternal depression and
anxiety at infant age 6 weeks or 4 months did robustly affect patterns
19
of self- and interactive regulation at 4 months, but did not predict infant attachment outcomes at 1 year. Instead, it was the quality of the
4-month mother-infant face-to-face interaction itself that predicted
infant attachment outcomes. The implication is that, in a community
sample, distressed maternal states of mind at 6 weeks or 4 months do
not necessarily lead to insecure infant attachment outcomes unless
there is also difficulty in the face-to-face interaction. This study provides a further rationale for therapeutically supporting the quality of
the mother-infant face-to-face interaction when mothers are distressed, which may then prevent later insecure infant attachment
outcomes. Such an effort is currently underway with the 9/11 widowed mothers and their infants, using brief videotape-assisted clinical interventions (Beebe et al., 2002).
self-regulation
From birth onward, self-regulation refers to the management of
arousal, the maintenance of alertness, the ability to dampen positive
or negative arousal in the face of over-stimulation, and the capacity
to inhibit behavior (Beebe & Lachmann, 2002). Neonates differ in
their ability to regulate state (see for example Korner and Grobstein,
1977; Brazelton, 1994). Infant temperament patterns, including
sleep, feeding, arousal difficulties, or special sensitivities to sound,
smell, or touch, are an important area of inquiry in the treatment
(see DeGangi, Di Pietro, Greenspan, & Porges, 1991; Greenspan,
1981; Korner & Grobstein, 1977; van den Boom, 1995). Disturbances
of infant self-regulation can be noted in patterns of autonomic distress (hiccupping; vomiting) and disorganized visual scanning, as
well as pulling the hair or ear, or a history of head-banging (Tronick,
1989). Although maternal touch is a primary means of soothing a
distressed infant, and extra handling is associated with diminished irritability (Korner & Thoman, 1972), some infants with difficult temperaments do not tolerate a great deal of touch (see DiGangi et al.,
1991).
By the time infants are assessed in the face-to-face situation, typically at 3 to 6 months of age, state regulation has stabilized and fluctuations in the management of an alert state have receded with maturation of the nervous system. At this point it is difficult to distinguish
between infant constitutional processing difficulties that may have
existed at birth from problematic interactive patterns. Infant temperament and self-regulation are already intertwined with interactive
regulation difficulties (see also Hofacker & Papousek, 1998). For this
20
Beatrice Beebe
reason, infant self-regulation is both a property of the individual and

of the dyad.
A study from our lab using second-by-second microanalysis of
videotaped face-to-face interactions showed that 4-month infants
who would be classified as insecure-avoidant at 12 months were already distinctly different from infants who would be classified secure
(Koulomzin, Beebe, Anderson, & Jaffe, 2002). These future avoidant 4-month infants showed: (1) more self touch; (2) the necessity
to self-touch while looking at mother in order to look for durations
comparable to those of secure infants; (3) decreased range of facial
expression, with constriction toward a predominance of neutral; (4)
a disruption of the capacity to coordinate gaze and head orientation
into a stable posture while smiling, so that infant gaze at mother occurred while head was cocked for escape; and (5) more labile behaviors (lasting one second), in contrast to stable (lasting 2 seconds or more). This study describes infant self-regulation patterns
that are directly useful for identifying infants who are at risk for
avoidant attachment. An examination of the mothers contribution
to the interactive process is planned.
distress regulation
Dyads show important differences in infant ability to manage moments of heightened distress, and maternal management of infant
distress. Both partners bring capacities to soothe and dampen as opposed to escalate distress. Obviously the mother has greater range
and resources in this process. The pattern of mutually escalating
over-arousal, where each ups the ante, was illustrated above. In contrast, an effective form of distress regulation is a partial or loosely coordinated joining or matching of the infants fuss or cry rhythm, with
woe face and associated vocal woe contours (vocal empathy). In
this process, the rhythm (but not the volume or intensity) of the crying is matched, and then gradually slowed down (Beebe, 2000;
Gergeley & Watson, 1997; Stern, 1985).
the stranger as partner
Identical to our research lab assessment, in our treatment cases
mother and infant first play face-to-face, followed by infant and
stranger. The stranger-infant interaction has been shown to be a sensitive predictor of infant attachment outcomes (Jaffe et al., 2001)
and to discriminate treatment and control dyads (Weinberg & Tronick, 1998). Before the end of the first year, when some infants de-
21
velop stranger anxiety, the stranger is both a novel challenge and at

the same time an intensely interesting new partner. On the one
hand, most 4-month infants are very sociable with the stranger, to the
point where often the stranger has an initial advantage over the
mother. On the other hand, some infants are wary with the stranger,
for example the infants of the treatment dyads in Weinberg and
Tronicks (1998) study. We assess the infants capacity to engage the
stranger and, if the interaction is stressful with the mother, the infants ability to repair with the stranger. The degree to which the
stranger feels at ease with the infant vs. feels wary or needs to be
careful not to over-arouse the infant is also noted.
Psychoanalytically Informed Video Feedback
Mother-infant treatment occurs at a unique intersection of implicit
procedural (repetitive action-sequences) and explicit declarative
(symbolic) modes of processing, and it fosters a greater integration
between the two modes (Beebe, 2003, p. 34). Three orienting questions organize our approach: (1) In the procedural bi-directional
action-dialogue, how does each individuals patterns of behavior affect those of the partner? (2) In the declarative mode, can the parent
verbally describe any of the ways in which he or she affects the infant,
and the ways in which the infant affects the parent? (3) Are there
ways in which the parents representation of the infant, and the parents own childhood history, may interfere with the ability to perceive the action-dialogue and to put it into words?
In the initial contact I usually have a long telephone conversation
with the parent. I explain my videotape approach and my preference
that the first meeting be a lab visit, because I can see more with the
aid of the videotaped interaction. However if the parent prefers, I
start with an office visit. In the lab, infant with mother, father,
stranger, and possibly nanny are videotaped in face-to-face interaction.
The format of the lab visit for a treatment pair is identical to that
for a research pair. The parent is instructed to play with the infant as
she or he would at home. Each lab visit is followed within a few weeks
by a two-hour feedback session in my psychotherapy office. This
treatment format is extremely flexible. If a brief treatment is indicated, two to four lab visits and accompanying feedback sessions may
be adequate, as in the first case presented below (see also Beebe,
2003). If a longer treatment is indicated, the same basic method is
applicable. Or, in the case of a more serious situation, two therapists
22
Beatrice Beebe
may easily collaborate, one proceeding with a standard individual

treatment, and one functioning in the role of the consultant for the
video feedback consultations (see Cohen & Beebe, 2002). An
Ainsworth attachment test, coded by someone blind to the infants
status, is usually included in each treatment, somewhere between 12
and 18 months.
A long session, usually two hours, greatly facilitates the work of the
feedback session. I have reviewed the videotape in detail prior to the
session, informed by the patterns of regulation documented by research microanalyses, described above. In the session I follow the
parents lead, attempting to construct with the parent the stories of
the presenting complaints and the parents own history. This initial
psychoanalytically informed conversation is a critical background to
our ability to understand the story that unfolds in the videotape.
Other important aspects of the parents history usually emerge during or after watching the videotape together. (It is extremely rare for
a parent to refuse to view the videotape. In only two of approximately
50 cases that I have seen have a parent refused. In those cases I understood the refusal as an index of the level of trauma, and I simply
used my own microanalysis to inform the interventions.)
In viewing the videotape I attempt to translate specific details of interaction patterns revealed by microanalytic research into terms that
the parent can use, based on a psychoanalytically informed view of
the meaning of the parents complaints in relation to his or her own
functioning and history, and based on my understanding of any temperament or arousal-regulation difficulties the infant may have.
Viewing a small portion of videotape, often at the beginning of the
interaction, usually is sufficient. Nonverbal interactions are highly
repetitive, and similar patterns can be discerned over and over.
I consider that one of my most important functions is to admire
the parent-infant pair wherever possible. Bringing into awareness the
ways in which this dyad already finds each other, enjoys each other,
copes with disruptions, and negotiates repairs, is itself a powerful
therapeutic intervention. My first goal is to point out a successful moment, using this example as an entry into learning to observe the
small micro-moments of the interaction. Together we view the videotape slowly, trying to see exactly when and how and in what sequence
each partner oriented, looked, cooed, smiled, or increased a smile by
opening the mouth or reaching the head forward. I try to help the
parent identify the exact moments where the parent responds to
the infant and the infant responds to the parent. My goal is to give
23
the parent new eyes to see the infants remarkable nonverbal language, and the infants ability to respond to minute, but nevertheless
identifiable, behaviors. Together we try to describe what we see, finding a new language for their exchange as well. I encourage the parent to put into words what he or she is feeling, and what the infant
may be feeling. Very likely I will play this positive portion several
times, at least once in slow-motion.
As we proceed I illustrate how evocative minute infant facial expressions can be, moments when the parent matches the infants vocal contours, how the parent paces and pauses, facilitating the infant
taking a turn. I note infant self-regulation and self-soothing behaviors, and ways the pair manage moments of infant distress, as they occur in the interaction. Having studied the videotape in detail in advance, I will also have selected one or two central difficult interaction
patterns that I would like the parent to be able to see. Together we
try to observe the effects of each partners behaviors on the other in
these difficult moments. I again inquire into what the parent felt,
what the parent thinks the infant felt, and the meaning these moments have for the parent. It is here that the parent is likely to have a
spontaneous insight into the problem. Being confronted with the implicit action-dialogue in the videotape often triggers the parents
associations to aspects of his or her history that the parent always
knew but could not productively use in the current context with
the infant.
Wherever possible I like to use research findings, illustrating with a
drawing, to help parents understand the infants behavior, shifting
attention away from the right way to do it to infants remarkable capacities. I emphasize what this particular infant needs to stay optimally engaged. My role is often to give permission to do less, to slow
down, to wait. For example, with an infant who easily becomes overaroused and irritable, I suggest slower rhythms, more repetition,
longer pauses, and more waiting when the infant looks away.
I attempt to link the stories of the presenting complaint, the
video drama, and the parents childhood history, in an effort to understand what may interfere with the parents ability to see the infant and the interaction. When specific representations of the infant
(or transferences) seem to interfere with the parents ability to
see the infant and how each partner affects the other, they are
identified. At the end of the session the parent is encouraged to trust
what has been learned, and to try not to be too self-conscious. Another videotaped assessment is scheduled in another month or two.
24
Beatrice Beebe
The Case of Cecil
may: first contact
In my first contact with Mrs. C. over the phone she told me that she
had an eight-year-old son and a 9-month-old baby boy, Cecil. The
older son had always been easier and had seemed to match the
mothers temperament. This second baby had been different from
the beginning. He is a friendly baby, but he is not focused on me
when I play with him. Cecil looks past me, unless I energetically try to
engage him. He seems happier by himself. He seems more connected to the babysitter than to me. Mrs. C. thought that perhaps
Cecil needed a higher level of stimulation. Or perhaps she herself
had disturbed the relationship initially, she wondered, by talking to
her older son while nursing Cecil. Or maybe she had never given Cecil sufficient eye-contact and intimate engagement during nursing.
The first consultation occurred in my office. Mrs. C. was warm,
friendly, and seemed quite relaxed. Cecil made very good eye contact
with me, with excited positive affect, and even had moments of a
gape smile. The mother then took Cecil, tried to play with him
face-to-face, and could not get Cecil to engage. Cecil never even
looked at her. Mrs. C. said this was typical. Mrs. C. then tried a peek-aboo game, putting the blanket over Cecils head. As the blanket came
off, there was a moment of brief eye contact, but Cecil emerged from
the blanket momentarily dazed, with a sober look. He then smiled at
his mother briefly, and looked away.
My suggestion in this initial meeting was that although the peek-aboo game did have a moment of built-in eye contact, it did not
seem to engage Cecil. Instead of trying to force more contact
through high arousal games, I suspected she would have more success if she followed Cecils lead for eye-contact, letting him go when
he looked away, and waiting until he initiated gaze before trying to
engage him. I explained that looking away is the babys natural
method of re-regulating his arousal when it has become a little too
high. We agreed to do a split-screen lab videotaping, so that I could
try to see more of the details of the interaction. From what I could
observe in the office, I had difficulty understanding in more detail
why the infant was so avoidant with his mother.
june: first lab videotaping, cecil 10 months
In the lab mother and infant were asked to sit face-to-face, with the
infant in a high chair. The standard instructions to the mother are to
25
play with the infant as she would at home. One camera is focused on
the mothers face, and one on the infants face, producing a splitscreen view, in which both partners can be simultaneously observed.
In my microanalysis of the face-to-face play interaction, I observed
that the mother continuously gave Cecil toy after toy.
Microanalysis of First Two Minutes of Mother-Infant Interaction
In the opening moments of the interaction, mother shook the toy toward Cecil, with abrupt, rapid movements, each accompanied by a
strong sound, gheh! At each maternal movement, Cecil blinked,
with mild startles. Mother then moved into, Whats that! showing
the toy, making a series of ooooh sounds, and Cecils face showed a
hint of a smile. As mother continued with, Say hello, dolly, hello, Cecil, hi, baby, Cecils face showed a hint of a slight mouth opening,
and then receded into his more characteristic neutral expression, as
if the stimulation was just a bit too much for him.
After a brief interruption to get the seating and the camera angles
right, Cecil briefly glanced at his mother with a neutral face, and
then looked down. While he was still looking down, mother asked
Cecil to look at the toy, but Cecil stayed with his head down. Then
mother made an interesting noise, gurooom! and got Cecils attention. Cecil responded with his own ghum!
There was then a repetition of the earlier series of mothers rapid
movements shaking the toy toward Cecil, each accompanied by a
strong sound. At each Cecil blinked. Cecil then looked down and
away, then shifted his body and hung over the side of the chair, limp.
We have come to view such loss of postural tonus as a coping strategy
in the face of overstimulation.
While Cecil was still hanging over the side of the chair, not looking,
mother found a new toy, and offered it with a sinusoidal shaped vocal
contour (the contour of approval and flirtation): Hello, Cecil; and do
you know what else? This vocal contour is usually reserved for greeting, once eye contact has already been made. It was successful in getting
Cecil to look at mother, and to pay attention to the new toy, as mother
continued, Look whats here, the dolly, look at her, look at her.
However, just at this moment, Cecils face took on a negative frown
expression, and he looked down, moved his head down, then
averted, moved his head farther down, and then uttered a fussy
sound. Finally he gave up body tonus and collapsed his head into his
stomach. Simultaneously with the collapsing tonus mother said,
Hello, Cecil and gently tapped Cecil on the head with the toy. Cecils head collapsed further into his stomach.
26
Beatrice Beebe
This is a detailed description of approximately the first two minutes of the interaction. At a more global level of description, in the
rest of the ten-minute session there were nice moments of mutual
gaze, and some interest on Cecils part in the toys mother offered.
However, often without pausing in her movements, or sounds,
mother offered Cecil another toy, and yet another. Periodically Cecil
continued to collapse, into his stomach, or over the side of the chair,
and mother gently tapped him on the head with the toy. When the
play was more successful, there were nice long strings of vocal exchanges, and the mother beautifully matched the contours of Cecils
sounds. Several times Cecil showed intense interest and vocal excitement in a toy, and mother joined the excited sounds. However, Cecil
did not smile. When Cecil became fussy, started to cry and shake his
body, mother offered more toys.
Overall, Cecil was low-key, with his face mostly neutral. Occasionally there were some moments of eye contact, and some nice low positive moments. Mother showed excellent capacity for vocal rhythm
matching, facial mirroring, and following the infants line of regard
to an object of interest. But she did not give the baby a chance to respond, or to organize an interest in the toys on his own, and thus she
disrupted the babys initiative. She also disrupted the babys arousal
regulation, over-arousing the baby by never pausing, offering one toy
after another, and then chasing the baby when he averted gaze. I
understood Cecils difficulty with eye contact and the restriction of
his facial expressiveness toward neutral as the babys attempt to reduce his arousal toward a more comfortable range, but at the expense of the social engagement.
Toward the end of the ten-minute interaction, Cecil began to get
fussy. Mother took a rattle and began to shake it, further increasing
the intensity of the stimulation. Cecil got even fussier, orienting away,
averting gaze. Mother then called to Cecil in the sinusoidal vocal
contour usually reserved for greeting. Cecil did not respond. By the
end Cecil was openly protesting the level of stimulation, very fussy,
throwing to the floor all the toys that mother handed him, while
mother never paused.
stranger-infant interaction
Following the interaction with mother, I played with Cecil for three
minutes, while the mother watched the interaction over a TV monitor from another room. The infants ability to engage with a trained
novel partner is a critical aspect of the assessment. Those babies who
27
can repair the engagement with a novel partner are generally more
resilient, whereas those who generalize the difficulty to a novel partner are in more difficulty (see Field et al., 1988). In evaluating this interaction, I noted that my tempo was noticeably slower than that of
the mother. I waited for Cecil to look at me before I attempted to engage him. When he did look, he quickly smiled broadly. But then Cecil became fussy. When I handed Cecil a toy, he quickly threw it on
the floor, and this was repeated over and over. In the process, Cecil
was very physically active, turning around in his chair a lot.
Eventually Cecil began to bang his own body gently against the
seat, as if to both self-stimulate and self-soothe. There were then a few
moments of eye contact with me, with midrange positive affect, but
these were very brief. Each brief gaze encounter was followed by a sequence of immediate averting, mild negative facial expression, looking down on the floor at an object, and then hanging limp, sideways
over the chair, body tonus collapsed. Each time I waited, and he
came back into the engagement on his own. Once he looked, he became slightly excited, with a positive expression, and then immediately became negative and averted, looking down. My overall impression was that he easily over-aroused. On the other hand, he had the
capacity to re-engage on his own when I waited.
july: video-assisted intervention
A two-and-a-half-hour period was set aside to meet with the mother to
discuss how things were going and to review the videotape. The
mother had already watched the tape and she felt bad. She realized
that she was trying too hard and it was not working. She saw me as
smoother, quieter. I suggested that as we watched the tape, we could
try to make quite specific just what she was doing when she felt she
was trying too hard. My own goal was to help the mother notice exactly what she did, and exactly what the infant did, as each responded
to the other. In essence, I wanted to give her new eyes, a new ability
to observe the details of interaction.
In this process my goal was to help her confirm what she did quite
beautifully, which elicited the response from the baby that she
wanted, as well as to notice what did not work for her baby. I admired
her facial empathy, her vocal responsiveness, and her well-modulated
vocal contouring (see McDonough, 1993). She was quite surprised
when I pointed out the infants blinks and startles at the beginning of
the interaction, in response to her abrupt movements with the toys.
She was also surprised to see me point out very subtle facial expres-
28
Beatrice Beebe
sions of slight mouth openings, hints of shifts in cheek tonus, which

can be expressions of interest and involvement, even when the infant
is not smiling.
We succeeded in defining the mothers trying too hard as lack of
pausing in movement or voice, trying to get the infants attention
when he was turned away, and calling the infant in a greeting contour at moments when the infant was clearly not receptive. I told Mrs.
C. my hypothesis that Cecil dampened his face, lowered his arousal,
averted gaze, and turned away, as self-regulation strategies in the face
of feeling over-stimulated.
Mrs. C. then told me that her own mother was rigid, controlling,
distant, and quite depressed, although she had managed to work.
Her mother was never attuned, had never been able to sense Mrs.
C.s feeling state as a child, and never knew where she was at. Mrs.
C.s mother had set the pace, irrespective of where she was emotionally or what she needed. And now Mrs. C. could see that she was
doing the same thing with Cecilsetting the pace, and setting it too
fast for him.
We then discussed my description of Cecils face as too neutral,
and I showed her again a section of the videotape illustrating it. I reenacted for her the face I saw in the baby. Mrs. C. said that all of a
sudden she saw Cecils face as like that of her own mother, who had
always appeared impassive, hard to read, hard to reach. She saw that
she now felt the same way about Cecilthat Cecil was hard to read,
hard to reach, like her mother. And she saw that she would become
anxious, and try harder with Cecil, as she had when her own mother
had been so difficult to read. In this interaction, the mothers ability
to see Cecils too-neutral face seemed to be facilitated by watching the videotape as well as watching my own entry into the babys
neutral face. Now seeing Cecils neutral face seemed to trigger her
procedural motor memory of her own mothers face.
Together we saw how understandable it was that she could be treating Cecil the way her own mother had treated her by setting the
pace, and that she could be seeing Cecil as like her own difficult and
removed mother. We both empathized with how hard it must have
been for Mrs. C., as Cecil seemed to become more and more un-readable. How natural it was to keep trying harder, as a way of reaching
him. And how counterintuitive it was to lower the stimulation, to try
less hard, to be slower and calmer, to wait, just when she was feeling
more and more desperate to reach Cecil.
We both felt sad over Mrs. C.s own difficult childhood, and the aspects of it that entered into her interactions with Cecil. But as we
29
parted we both felt encouraged by understanding what the difficulty

was. Mrs. C. felt very positive about the experience, and stated that
she thought she could shift what she was doing with Cecil now. I suggested that she try to trust herself with what she had learned, without
becoming overly self-conscious or self-critical. We agreed to do a follow-up split-screen videotaping and an Ainsworth separation test in
a couple of months.
august: second filming, 12 months
There had been a long wait in the lab, and technical difficulty delayed the beginning of the filming. Even without such delays, sitting
in a high chair for ten minutes is hard for any active 12-month toddler. Once we got started, there was no sound track for a couple of
minutes. In evaluating the interaction, I observed that the mother
was slower and softer, and she paused in between her movements
and her vocalizations. Cecil made more eye contact, and it was more
sustained. The mother did not push toys at Cecil; instead Cecil himself took a toy and explored it, and mother was able to wait. There
was clearly more room for Cecils own initiative.
Microanalysis of First Two Minutes of Mother-Infant Interaction
As the videotape began, Cecil was tired. He had been there a long
time, waiting for us to get going. Without the sound in this section, we
see Cecil rocking his body back and forth in the chair. Mother then
rocked her own body a bit too, matching the rhythm. Mother then
showed Cecil a doll. Cecil concentrated on it, while mother held it
quietly. After a few minutes, Cecil lost interest, and mother showed
him another toy. Cecil took the toy, held it close to his body, explored
it, again while mother waited quietly. Then there was an interruption
at the door. Mother was told that the sound was now working, and was
asked if she wanted to continue the filming. We agreed to continue.
The interruption disturbed Cecil, and now he very much wanted
to get out of the seat, holding his hand up in an appeal to be picked
up. The mother was gentle, slow, and held him, but without taking
him out of the chair. Mother made a woe face, joining the infants
distress, and was very sorry that Cecil couldnt get out yet. Cecil collapsed into his stomach, fussing, and mother matched the distress
sounds. Mother then tried some puppet play, moving the puppet
very slowly, and Cecil briefly engaged. Then Cecil was distracted by
the sound of the camera moving, and mother joined his line of regard, explaining the noise. Cecil then made another bid to get out,
30
Beatrice Beebe
and mother joined Cecils vocal distress with similar sounds, and
held him close.
Describing the rest of the session, at a more global level, after a few
minutes mother did a peek-a-boo game, covering Cecils face with
her hands and saying, where is Cecil? This time the quality was totally different: slower and very successful. Cecil emerged smiling, and
sustained the positive affect. Then Cecil was briefly quiet, and
mother waited. Cecil then heard the noise of the camera again, and
mother joined his line of regard, and waited. Now Cecil wanted to
get out again, and this time I stopped the filming after seven minutes. There was nothing the mother did in this second filming that
seemed to interfere with the infants capacity to play and to respond.
stranger-infant interaction
We then attempted a stranger-infant filming, but Cecil would have
none of it. He cried loudly, angrily, and threw any toys on the floor.
Three different attempts by me to play with Cecil had to be aborted,
since he was crying hard. Finally we organized a set-up in which Cecil
sat in mothers lap, and mother was instructed to be the chair, not
to help or respond.
For the first five minutes of the interaction, Cecil was disengaged.
He was silent, made no eye contact, and every toy that I tried to engage him with was immediately thrown on the floor. However, at
some point he finally made a vocalization, a spit sound. Immediately I matched this sound. And right away he looked at me and
made another, similar one. All of a sudden the whole tenor of the interaction had changed, and we were engaged in a fascinating vocal
dialogue. As we continued to match and elaborate on each others
sounds, at some point Cecil began to move his tongue as he made the
sounds, and it came out as la-ler, la-ler. He was intensely visually engaged. I tried making the la-ler sound, and we both burst into big
smiles, and giggled. Variations on this rich vocal dialogue continued
for the next four minutes. Cecil had been enormously responsive to
my matching his vocalization. Since this form of engagement does
not require the child to be visually engaged, it can potentially provide a less intrusive or demanding means of making contact. His own
willingness to elaborate on the jointly formed patterns was critical to
the success of the dialogue.
Toward the end of the interaction Cecil began to be tired. Although he had been having a spirited, at times elated, turn taking di-
31
alogue with me (as he sat in his mothers lap), when he began to get
tired, he arched away into his mothers body, and avoided me. But
then he was able to keep coming back to me, and to continue the
rhythm of the vocal exchange. These movements away from me were
his own self-regulatory efforts to manage his arousal within a comfortable range. The success of his self-regulation efforts could be
seen in his continuing ability to re-engage me, in cycles of vocal dialogue, disruption, and then repair (see Tronick, 1989; Beebe & Lachmann, 1994). This aspect of the interaction with me was used as part
of the therapy. It was a demonstration of a way to make contact without forcing, intruding, or chasing. It also vividly showed the power of
vocal rhythm matching in making contact, since the child does not
have to make eye contact.
This laboratory filming ended with a brief discussion with the
mother that her interaction with Cecil was going extremely well now.
We made a decision not to pursue the attachment test since the visit
had already been too long. Cecil was doing well, and all we needed to
do was to watch to be sure he continued to be fine.
follow-up contacts
September
A telephone conversation: Things are just great. We were on vacation for three weeks and we had a lot of time to spend . . . I totally relaxed with Cecil. I got to know him better. I stopped my agendas,
stopped comparing him to his brother. He is a delightful baby; we are
just charmed by him, he is now so social. I had seen this side of him
from time to time, but now it has really come out. He is more bonded
with me too, he wants mommy only. He seems terrific. Im enjoying
how different he is from his brother.
November
A letter: You have played an absolutely pivotal role in my life. . . . To
begin with, Cecil; our connection is deep and easy and full of joy. He
is an absolutely delicious, funny, charming, very loving little person. . . . you helped me relax and see him; I stopped focusing on who
he was not and on how he and I were not. . . . So, having discovered
Cecil, I fell in love with Cecil. No surprise. . . . In retrospect, my feeling of self-reproach was based on some accurately sensed stuff. I intuitively knew that I was not being with him or being emotionally re-
32
Beatrice Beebe
sponsive to him anywhere near as much as I can be. Now I am, and let
me tell you, the difference is not minor.
discussion of the c. case
We return here to the theme that parent-infant treatment occurs at a
unique intersection of implicit and explicit modes of processing and
fosters a greater integration between the two.
Our three orienting questions provide a framework for conceptualizing the treatment: (1) In the implicit mode of action-sequences,
how does each partner affect the other? (2) In the explicit narrative
mode, can the parent verbalize the nature of either partners effect
on the other? (3) And does the parents 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 infants behaviors, and particularly ways in which
the infant affects the parent, such as, my baby does not smile at me,
or my baby does not look at me. But it is harder to observe ones
own behaviors which affect the infant. Often various representations
of the infant disturb this process further.
Addressing the infants impact on the mother, Mrs. C. could observe as well as verbalize that her infant often did not look at her, or
smile at her. When asked how she would respond to this, however,
Mrs. C. was vague: I try harder, or He needs more stimulation.
Addressing the mothers impact on her infant, Mrs. C. had not been
aware of the specific behaviors that we were able to describe together,
for example, rapidly moving into the face, not pausing, continually
offering toys. Identifying these specific behaviors enabled Mrs. C. to
observe the moments in which they influenced the infant to disengage, for example, to startle, look away, collapse into the stomach, or
inhibit initiation with toys.
We were able to identify some of the transferences to the infant
that seemed to disturb Mrs. C.s ability to observe and verbalize both
sides of the bilateral effects of each partner on the other. She acted
like her own mother, who had set the pace, and her infant seemed
to act like Mrs. C. had as a little girl, that is, to withdraw. Her own
setting the pace behaviors (not pausing, continually offering toys)
were out of her awareness. Mrs. C. was aware that her infant was withdrawing from her, but she was not aware of how similar her infants
behavior was to that of her own in childhood. Thus she and her infant had re-enacted an aspect of her own history, the mother who
sets the pace and the child who withdraws.
33
Similarly, the infant seemed to act like Mrs. C.s own mother, since
the infant had an impassive face, neutral, impossible to read, which
reminded Mrs. C. vividly of her own mothers face. Mrs. C.s response
to her own infants impassive face was very similar to her response to
her mothers face when she had been a little girl, that is, to become
anxious and to try harder. Presumably the similarity of this interaction with ones in her childhood interfered with Mrs. C.s ability to see
that her trying harder was just pushing her infant farther away
from her.
These transferences were identified in the process of watching the
videotape. Being presented with the procedural level of action sequences which are out of the mothers awareness, presumably because they are connected to painful childhood experiences, facilitates the mothers ability to see, and to remember. The mother is being
asked to make a unique integration of procedural and declarative information, in an arena that has been out of awareness due to some
kind of unresolved pain. This work allows the mother to shift her representation, for example, from the baby rejecting her, to the baby as
over-stimulated and attempting to dampen his arousal.
The optimum midrange model of regulation described above is
useful as a framework for evaluating the progress of the treatment. At
the outset of the treatment, Cecil could be described as preoccupied
with self-regulation (looking away, showing lowered level of arousal,
constricting the range of the face), with lowered levels of contingent
coordination with mothers behaviors through facial, visual, and vocal behaviors, and with his initiative shut down, body collapsed.
Mother could be described as a high coordinator, very contingently
responsive to the infants every move, with excellent facial-mirroring
and vocal rhythm matching, but interacting with levels of stimulation
that were too high, with patterns that were spatially intrusive, that disturbed the infants initiative.
Following the videotape intervention, the mother was able to move
from high- to more midrange coordination, less vigilantly responsive to every infant move. She was able to pause more, do less, wait,
tolerate the infants disengagement without chasing, tolerate the
infants distress, and give the infant space to initiate play. Moments of
matching were interspersed with waiting for the infants own moves
(of self-regulation, or initiative), so that they did not seem excessive, or imposed. The infant for his part shifted from a low-coordinator and became more midrange in his level of contingent tracking of the mother, more midrange in facial responsivity with both
positive and negative expressions rather than a predominance of
34
Beatrice Beebe
neutral, more visually engaged, and much more active in initiating

play with objects.
The Case of Nicole
The case of Nicole is a useful counterpoint to the Cecil case, which illustrates mild maternal intrusion coupled with some temperament
and arousal regulation difficulty in the infant. Nicole, on the other
hand, illustrates a maternal absence of provision. Because this family was from a distant city, and I happened to be traveling nearby, the
mother-infant pair was not evaluated in my lab, but rather in an office, and they were only seen in person for one extended three-hour
evaluation, together with a number of follow-up telephone consultations. Since the problem turned out to be an absence of intimate engagement, rather than a complex misregulation of engagement between infant and mother, it was a case in which a detailed videotape
evaluation was luckily not essential. In the Cecil case, I was not able to
detect the problem without the videotape microanalysis. In the case
of Nicole, knowledge of the microanalysis research was nevertheless
essential to the treatment.
Mrs. N. was referred by her therapist, who described her as an anxious new mother, strongly involved in her hard-driving career. Mrs.
N. had become worried that her five-month-old baby was not as responsive to her as she was to the Nanny, and she had requested a consultation with an infant expert. The therapist suggested that Mrs.
N. probably had difficulty giving focused attention to her daughter
because she had never gotten much herself.
The first contact was a telephone session. Mrs. N. felt disconnected from her daughter. She described feeling crushed when she
arrived home to see her daughter laughing and giggling with the
Nanny, but Nicole would not even look at her. Ive been going 100
miles per hour all day, and Nicole has been with someone laid back
with nothing to do but to be with her. I take Fridays off, and it takes
her quite a while to warm up. My husband does not think it is anything to worry about. But what will it do to her in the long-term? I
feel like she does not love me, that Im not good as a mother, Im not
as natural as the Nanny. How much I need her love. I envisioned a
different reaction to me. She smiles more to my husband and the
Nanny than to me.
I have never seen myself as a mother. I was little Miss Career. My
mother was domestic, but she resented it. We were toys and dolls to
her. Now I want to pick back up the domestic side, but it does not
35
come naturally. I commented that evidently she did not have a

model of what it would be like to really enjoy ones child: her mother
resented children and domesticity. It was very understandable that it
would be hard for her to learn. I dont measure up to the Nanny;
she knows exactly what to do. I dont mind if she loves the Nanny, but
I want her to love me more. Its my nature to be doing three things at
once. Instead of being able to relax, and take the time to be with her,
Im on the phone. I tell myself, this is her time, dont pick up the
phone. As she told me this, I sensed the rapid clip of her speech. I
commented on how aware she was that she needed to try to relax and
slow down to be with Nicole. I dont like myself when I am with her. I
feel like my mother when shes running around like crazy and cant
get organized. I said that evidently she had learned to be like her
mother in this, and perhaps it had been a way of being close to her
own mother. But now shes not so happy about it, and shes trying to
help herself change it. We then discussed exactly what happens when
she comes home from work. She nurses Nicole when she comes in,
but the infant will not look at her. Maybe its because I always had
the phone in my ear when she was nursing. Have I hurt her now? Can
it be fixed? Would I have had a better relationship with her if I had
been different? She did not deserve a mother like me. And then she
cried.
I empathized with her agony over feeling that she had disturbed
her relationship with Nicole. I told her how important it was that she
had taken the step of calling me, and that she was struggling to find a
way to slow down to be with Nicole. She lamented that she did not do
it right, and that she had been stupid. I said that we needed to find a
way of re-righting this without blaming. She responded that I had a
beautiful voice, and that she felt smart for trying to get help.
The second contact was a three-hour consultation with the mother
and baby. Although the father came as well, he declined to be involved. This was the only contact in which I actually saw them in person because of the extremely long distance involved. Nicole at 5 1/2
months was a big girl, and heavy. Mrs. N. propped her up at one end
of the couch with a toy. As she was settling Nicole in, the infants body
arched away from her. Mrs. N. then sat at the other end of the couch.
I pulled up a footstool and sat halfway between the two of them. The
baby played with the toy, putting each different part of it in her
mouth, quite placid and self-sufficient. She never looked at her
mother or at me, nor did she look around the room, while her mother
talked to me about her work schedule and her dilemma of work vs.
home life.
36
Beatrice Beebe
Nicole then needed her diaper changed. She had a large bowel
movement. Mrs. N. was gentle, solicitous, and managed it well. Now
Mother and Nicole were together on the couch, and Mrs. N. showed
me a pull-to-sit game that she plays with Nicole, a game that her
friend had taught her. The baby clearly knew the game, anticipating
the moves with her body, but she did not look at her mother, her face
showed no animation, and at the last moment before attaining the
sitting position, her head oriented up and 30 degrees away from the
vis--vis. Mrs. N. then held Nicole lying across her lap on the infants
back. This was the nicest connection they made, slow, both bodies relaxed, both looking at the other, but without smiling. Mrs. N. then
began to talk about how terrible she felt: Have I hurt her, what will
be the effect, will she know her own mother, should I stop working?
She cried during most of this discussion.
After about an hour, I suggested that we start to see how we could
help her engage Nicole more. I said that I did not think the issue was
the amount of time that she worked, as much as finding a way to
make a connection with Nicole. I explained that first I needed to play
with her to try to see her range of responsiveness. Nicole chortled,
with high positive affect, sustaining long gazes with me. She was marvelously socially engaged. From this interaction it was clear that the
difficulty was not an incapacity on the part of the infant. Evidently,
the social engagements with her Nanny and her father were going
well.
I then set about trying to teach Mrs. N. how to engage Nicole. The
first thing I taught her was vocal rhythm matching, making sounds
contingent on the babys sounds, both matching and elaborating on
the intonation, pitch, and rhythm. I chose this first because the child
does not have to make eye contact in this mode of relating. Mrs. N.s
sounds were thin and squeaky. She did not give the sounds a robust
prosody, she could not elaborate on them, and she did not put any
words to the sounds. She did not seem to know how to play. I
coached the sounds from the sidelines. Eventually the sounds she
made were adequate to make some contact with the baby. Nicole oriented to her a bit more, and returned some of Mrs. N.s sounds with
her own, beginning a rudimentary vocal dialogue. But Nicole did not
look at her mother.
Noting how flat her face was as she interacted with Nicole, I then
tried to teach Mrs. N. facial mirroring, by having her roughly match
some of my faces (gape smile, mock surprise). I tried to get her to
move her face in ways similar to the ways I moved mine (small increments of open mouth, open a little more, then a little more; moving
37
the upper lip in and out of a purse etc.). She was unable to play with
her face; her face was tight, flat, and unvarying. I then had the idea of
showing her how to unlock her jaw, and how to massage her face. I
asked her if she would be interested in trying this. She agreed. In this
process she had an association to her mothers angry, tight face, and
she became a little teary. I suggested that her reaction to her
mothers angry face was expressed in her own facial tightness and
constriction. She was receptive and felt sobered by this idea. The attention to the behavioral details of the procedural level, particularly
the constriction, seemed to trigger her representation, which we
could then address and elaborate at the symbolic level.
We then moved to an attempt at face-to-face interaction between
mother and baby. At first Nicole was very gaze avoidant and her
whole body arched away from her mother. The infant made absolutely no eye contact. Gradually I taught Mrs. N. to slow down and
to make some slow rhythmic sounds, and to do vocal rhythm matching if Nicole made any sound. When the infant would give her a
darting glance, I taught her to give an exaggerated mock surprise
greeting. The instant the infant looked away, I taught her to cool it.
Nicole began looking a bit more. We spent quite a while at this.
By the end of the three-hour session Nicole showed some brief partial smiles to her mother. The gazes were not sustained. But Mrs. N.
had a direct, powerful experience of getting some more response
from her baby. She could see that she was getting somewhere. She expressed relief and gratitude that I had validated that something was
wrong. I reminded her of the many things that were right as well: she
had a very gentle and affectionate capacity to hold Nicole and to
feed her, she did have some games she played with the infant, and
most of all, she wanted more contact with her.
Ten days later we had a telephone session. Now I make it totally
Nicoles time when I get home. If I can slow down, we can connect
better. By the end of the week I feel totally disconnected from her.
When the Nanny leaves, she is used to her. I have to be careful: I expect her to demonstrate affection and attachment. When I dont get
it, I get worried. Sometimes she does not make any sounds, so I cant
mimic her. I asked her if she could start it with occasional sounds of
her own. My husband can walk in the room and connect with her
right away. He is like the Pied Piper. It is hard for me. I feel bad that I
dont connect the way he does. If I dont get a lot of feedback, I feel
unliked. I asked if there was then a danger that she would feel rejected and withdraw. She agreed, yes, very much. She then reported
that Nicole is not as avoidant as she was: She looks at me, she
38
Beatrice Beebe
watches, though she does not smile. She can concentrate on my face
though, thats new. She told me that Nicole was right there with her,
looking at her face right now. I suggested she try a mock surprise expression right now, and she did. I waited a moment while Mrs. N.
played with her. She reported that Nicole looks but she does not
smile. She will watch me now if I do interesting things with my face.
But I noticed that if Im tense I close my face up. I said that it was
wonderful that she was trying to engage her child with her face, and
that Nicole was clearly beginning to respond. I congratulated her on
becoming so aware of her own face, and able to notice when she
closes it up.
When Nicole looks at my husband, she gets this glow; will it always
be this way? In the morning I am terrible with her. Im trying to get
ready, Im in a hurry, and I do a dancing conversation in front of her
face, all speeded up. I commented on Mrs. N.s increasing ability to
notice what she does and to see if it is disturbing Nicoles ability to
connect with her. She then asked, Have I lost my chance? When I
left you, I felt so bad, and angry; I missed my chance. I should have
stayed home and not worked. Without waiting for me to respond,
she immediately told me that Nicole was looking at her right now,
and Mrs. N. began to make sounds. We practiced the sinusoidalshaped hello, she and I saying it to each other, and she reported
that Nicole was looking constantly at her while she made the sinusoidal sounds.
Then I asked her about feeling angry. She said that she was angry
her husband wasnt encouraging her to quit work, and she was angry
that no one had been agreeing with her that something was wrong.
She felt that finally I had validated her. I would be devastated if I do
not have a good relationship with Nicole. She lights up for my husband. She is so responsive to the Nanny. But what you are saying to
me is, its not too late for me to connect. Ive never felt so insecure in
my life. I empathized with her fear and distress. Then I told her how
terrific it was that she was holding on to her hope to connect with
Nicole, and that she and I could both see progress.
A telephone message two weeks after the initial three-hour session
in person: Mrs. N. was canceling our tentative appointment to see
each other in person because she and Nicole were doing so well: I
am getting so much feedback from her, I am relaxing a little. She
smiles more, looks more. I dont feel crazy anymore. All of a sudden
she has started really vocalizing. The biggest thing you said was, focus
on her. When Im with her, Im just giving her all my attention.
A telephone session one month after the initial three hour session
39
in person: Shes wonderful, shes happy, shes more vocal, more expressive, shes really relating to me. Occasionally we have a bad
evening. But Im more comfortable around her. I may be doing more
of her language. I try to slow it down for her. If Im rushing, I notice
it. Then I just hand her to the Nanny, because I dont want her to
sense it. I imitate her sounds, but not all the time. If she initiates, and
I respond, and make it even bigger, then she laughs. I tell her how
wonderful all this is, how thrilled I am that things are so much better.
I think were doing a lot better. When I come home, I get a greeting.
She looks, she smiles, she kicks. Then she asked me if it was a mistake not to come for a second consultation in person, and I said no, I
didnt think so, because things were going so much better. We agreed
that she would call me if she had any more concerns. She thanked
me profusely. I told her that it was so remarkable how quickly she and
Nicole were able to turn things around.
discussion of the n. case
This pair illustrates an absence of maternal provision of the usual infantized facial and vocal behaviors that engage infants in face-to-face
play. Presumably the more adequate provision of the Nanny and
the father had to this point safeguarded the overall social development of Nicole. The mothers frozen face and inhibition of maternal
play behavior required me to figure out how to get the actionsequences going, how to prime the pump.
Mrs. N.s immediate transference to me in the first telephone contact as having a beautiful voice set the stage for me to provide something that seemed to have been absent for her. By teaching her specific ways of engaging the infant, that is, vocal rhythm matching,
vocal contouring, facial mirroring, and cooling it when the baby
looked away, it is possible that she experienced a provision from
me. I was also admiring of her willingness to try these new behaviors,
and of her increasing ability to engage Nicole, as she tried it, over the
phone.
The key to unlocking Mrs. N.s capacity to mother Nicole was the
discovery of her traumatic reaction to her own mothers face, which
was then carried in a procedural form through her inhibition of
her own face with Nicole. In retrospect, the vocal modality proved to
be easier for Mrs. N. to develop with Nicole. Since the vocal modality
did not require Nicole to look, it was initially easier to reach Nicole
this way. But Mrs. N. had also been so responsive to my voice, from
the very first contact, and she carried on most of her relationship
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Beatrice Beebe
with me over the telephone. It may be that the voice was a non-traumatized mode for Mrs. N., compared to the face (M.S. Moore, personal communication, August 18, 1999).
Discussion
Many different approaches to mother-infant treatment yield dramatic progress (see for example Cramer et al., 1990; Fraiberg, 1980;
Seligman, 1994; Stern, 1995) (but note that controlled clinical trials
are rare). Although the use of video feedback is growing, three
decades of microanalysis research on the mother-infant face-to-face
exchange is surprisingly under-utilized in current treatment approaches. Microanalysis of behavior allows us to perceive the details
of interactions which are usually too rapid to grasp with the naked
eye. These details provide the clinician with the ability to translate
the parents presenting complaints into specific behaviors which can
then be understood as an unfolding story of the relationship. With
the additional perspective of the dyadic systems view of communication (despite the mothers obviously greater ability and range of resources) the clinician can continually attempt to understand how
each partner contributes to the exchange, how each affects the
other. And the clinician can notice how the self-regulation strategies
and styles of both partners affect and are affected by the nature of
the interactive exchange. With this perspective, for example, negative interactions such as chase and dodge or mutually escalating
over-arousal can be seen as reciprocally responsive co-constructed
forms of engagement. This systems view helps us remain empathic to
how each partner is affected by the other.
However, video microanalysis of the interaction from a systems
view can only richly set the stage for the treatment. A clinicians sensitive ability to construct jointly with the parent a description of the exchange, to help the parent use the behavioral details of the video
drama as a springboard for memories and associations, and to link
the stories of the presenting complaints and the parents own history
to the video drama, form the core of the treatment. The clinicians
careful attention to the parents self-esteem, particularly feelings of
shame and humiliation, is essential.
The video feedback method does not disturb the dyad while they interact. Later, when the parent and I view the videotape, it is simultaneously immediate and visually concrete, as well as somewhat distant and safer, in that it is not happening right now (Lefcourt,
personal communication, July 7, 1998). In the video replay we can
41
concentrate on a particular modality, and slow it down, whereas in

the live interaction all modalities, as well as words, flood the senses.
Since the visual information speaks on its own, the therapist is free to
emphasize different aspects, to underscore the positive elements as
well as identify derailments (Tabin, personal communication, September 10, 1998). Because the mother is usually so motivated to engage her infant, she can make an effort to overcome any natural awkwardness at seeing herself. We rarely know what we really look like as
we interact. Seeing oneself on videotape may operate like a shock
to the unconscious, perturbing the system (Milyentijevic, personal
communication, June 26, 1998; Kohler, personal communication,
October 23, 1998). This shock may be part of the emotional power
of the video feedback method. The therapeutic viewing promotes a
capacity to observe oneself in interaction, to think about the emotions seen in the video, and to reorganize representations (Beebe,
2003, p. 45).
Both parents in the two cases presented felt that the treatment validated their sense that something was wrong. Mrs. N. was able to
persist in trusting her discomfort even though her husband did not
think there was a problem. This vague discomfort is the parents ability to sense the impact of the implicit procedural mode and enables
the parent to seek treatment. But the meaning of this discomfort is
not usually recognizable without help (Tabin, personal communication, September 10, 1998). Procedurally organized interactive memories that are unrecognized and unsymbolized often come to play a
role in shaping the action-language of our intimate interactions as
well as the representations of our intimate partners. The psychoanalytically oriented video feedback method goes directly to the core interactional dynamic that is out of awareness and provides a safe format in which this dynamic can be verbalized and reflected on. The
parent can become more aware of the infants mind as well as her
own (Fonagy et al., 2002). In this process implicit, procedural aspects
of the parents mode of relating to the infant which have remained
out of awareness can be translated into explicit, narrative forms of
understanding.
BIBLIOGRAPHY
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What Is Genuine
Maternal Love?
Clinical Considerations and Technique
in Psychoanalytic
Parent-Infant Psychotherapy
TESSA BARADON
The question of what is genuine maternal love was posed by a mother

struggling to understand and value the nature of her bond with her
small baby. The question surfaced time and again in the context of this
dyads long-term parent-infant psychotherapy and has challenged me
to examine my thinking and, indeed, has produced impassioned discussions within the Parent Infant Project team at The Anna Freud
Centre. In this paper I will address this question through sessional material of this mother and baby and discuss issues of technique in response to it, including my countertransference and conceptualization.
Trained in child analysis and psychotherapy at The Anna Freud Centre, London.
Developed and manages the Parent Infant Project (clinical services, training, and research) at the Centre; practicing therapist and supervisor, and writes and lectures on
applied psychoanalysis and parent-infant psychotherapy. Member of the Association
of Child Psychotherapists and the Association of Child Psychoanalysis, Inc.
The Parent Infant Project teamCarol Broughton, Jessica James, Angela Joyce,
and Judith Woodheadhave provided valued collegial consultation during the
course of this work and on the paper. I also want to thank Dilys Daws for her interesting comments.
47
48
Tessa Baradon
asked about her position on the different heuristic models of

the mind, Anna Freud replied: I definitely belong to the people who
feel free to fall back on the topographical aspects whenever convenient and to leave them aside and speak purely structurally when that
is convenient (Sandler with Anna Freud, 1981). Parent-infant psychotherapy is a meeting point for the different disciplines addressing
infant development: psychoanalysis, attachment, and neurobiological research. In facilitating our understanding of the ebb and flow of
the therapeutic construction, Anna Freuds advocacy of conceptual
flexibility in the aid of clinical expediency is often helpful.
The therapist working with young babies growing up in an environment of intergenerational deficits needs to understand the quality of mothering and the babys predicament. Psychoanalytic concepts of good enough parenting and maternal failure, attachment
paradigms of security and disorganization, and neuropsychological discussion of relational trauma are useful frames of reference. Yet
there is an additional ingredient to do with love, captured by the patient in her question: How can we integrate love into scientific and
clinical discussion?
Genuine maternal love for the mother who asked the question
was defined by selflessness. My clinical work has convinced me that
the love of a mother for her infant and of a baby for his mother
needs both measure and passion. It contains the temperatethat is,
regulated kernels of love and responsivity, and passionate appetite,
ownership of the other and capacity to be consumed by the other.
These latter rest upon the mothers narcissistic love of herself in the
baby, her adoration of His Majesty the Baby (Freud 1914), and her
capacity to tolerate her hatred of her bondage to him (Winnicott
1949). Thus, her identification with her baby and yet her ability to
differentiate between herself and her baby and allow individuation
(Mahler et al. 1975) are required. Only then is the baby able to safely
love his mother, in the sense of moving from relating to object-use
(Winnicott 1969) and development of a sense of self as real. At the
same time, love is not a static concept. In this paper I attempt to describe the development of this mothers love, matched by changes in
her babys expressed love for her, and the interventions that may
have contributed to this process.
Maternal failure in psychoanalysis refers to intrapsychic processes in the mother which violate their infants state of going-onbeing, such as projection and attribution resulting in distortion of
self (Silverman and Lieberman 1999), failure to protect the infant
from impingements (Winnicott 1962), inability to contain the infant
What Is Genuine Maternal Love?
49
through maternal reverie (Bion 1962). Disorganized attachment

describes a collapse of adaptive strategy when the infant is frightened, seen to develop in the context of mothers unresolved trauma
and lack of reflective functioning thereof (Lyons-Ruth 1999, Fonagy
2001). Relational trauma depicts the neuropsychological disregulation of the infant in a situation in which danger emanates from the
attachment relationship wherein the mother (a) disregulates the infant and (b) withdraws repair functions (Schore 2001, Perry et al.
1995, Tronick and Gianino 1986), leaving the baby in an intensely
disruptive psychobiological state for extended periods of time
(Schore 2001, p. 209). In this paper I consider those aspects of maternal failure and relational trauma that resulted from the mothers inability to meet her baby with passion and reverie. This included the negation of herself in him, dis-identification with his state
of dependency, and projection into him with consequent distortion
of self and object boundaries and impingements on individuation.
What is the experience of an infant within a primary relationship
that fails to respond appropriately to his personal and intersubjective
needs? From the observation of babies in this predicament, this maternal failure appears catastrophic. The infant patient, so dangerously dependent on his mothers/caretakers capacity to identify and
understand, expresses extreme anxiety, fragmentation and, finally,
retreat. Because the anxiety is embedded in their relationshipoften underpinned and driven by intergenerational patterns of relatingit is enduring. Therefore the concept of cumulative trauma
(Khan 1963), the repeated breaching of the adaptive and defensive
structures available to the immature ego, is pertinent.
Extreme maternal depression can constitute a situation of relational trauma. Green (1986) discusses a situation where there is a
mutative transformation of the mother from a live, vital presence to a
dead detachment from her infant, and the trauma this inflicts on the
baby. This is a particular situation where the infant has had an early
period of resonance and lost it in the face of maternal loss and depression. But what of those infants who have been born, so to speak,
into a relationship with a dead mother?
The psychotherapeutic work informs us about the experience and
the developmental endeavors of babies in this predicament. Psychically they display the dead baby complexa decathexis of the maternal object and apparent identification with the dead mother (Bollas 1999). These babies lie slumped and blank. They seem careless of
the maternal presence or non-presence beside them and appear
non-present in their own bodies. Their precocious defenses of avoid-
50
Tessa Baradon
ance of emotional engagement with the mother, freezing and disassociation (Fraiberg 1982, Perry 1997, Schore 1994) put them in a
state of unrailed/derailed development. I suggest that this was the
predicament of the baby in the case to be discussed.
Parent-infant psychotherapy intervenes in the parent-infant system
to achieve the best accommodations that can be made between a parent and baby for the babys development. As an applied technique
within the psychoanalytic framework it has its roots in the groundbreaking work of Selma Fraiberg and her colleagues (Fraiberg 1980,
Lieberman and Pawl 1999). In recent years a model has been developed at the Anna Freud Centre (Baradon 2002, Baradon et al 2005,
James 2003, Woodhead 2004), the defining feature of which is the
use of the analytic mind to scaffold the affective experiences and representations of parent and infant in relation to each other. Intervening at the procedural as well as declarative levels of self organization,
the aim is to create meaning through validating and cohering the
parents experience and responding to the babys requirement for
an attentive, adult mind to meet his developmental and attachment
needs.
In our model, the therapist straddles numerous roles in relation to
her patients, both individually and collectively. She is a clinical observer (Rustin 1989), using observation as a mental stance and a
technique to inform her understanding of the parents and babys
(emergent) mental models of attachment relationships. She is, in
parallel, an analytic therapist, employing psychoanalytic frames of
reference and techniques in the work with what is manifest and conscious in the room and with the hypothesised unconscious fantasies
and defenses underpinning these. Inevitably, she is a transference
figure for the parent, sometimes benign but also at times perceived
as hostile and/or persecutory. The therapist is a new object (Hurry
1998), offering a revitalizing attachment experience to parent and
infant. As a new object for the baby, the therapist is also a developmentalist, supporting the infants development through providing
contingent responses, stimulation, and regulation where the parent,
at least temporarily, is unable to. In cases of severe maternal depression and withdrawal the therapist may also be the only live company (Alvarez 1992) for the child, providing the functions of enlivening, alerting, claiming and reclaiming (p. 197). Having the
therapist to love, until the mother is able to receive and scaffold his
love, may be pivotal for the babys psychic survival. And finally, the
therapist is an external affect regulator of the patients disregulated
51
states, particularly crucial in light of research suggesting that external regulation of the infants immature developing emotional systems during critical periods may influence the experience-dependent structuralization of the brain (Panskepp 2001, Cirulli et al.
2003).
Parent-infant psychotherapy poses countertransference dilemmas
particular to this method of intervention.
Primitive emotions and projections are the fabric of infancy and
parenting and invariably resonate with the therapists past and present attachments. The actual presence of an infant in the room intensifies the sense of immediacy and clinical (and of course legal) responsibility toward the baby. With at least two, and often three,
patients presentinfant, mother, and fatherthe therapists attention and receptivity are often pulled in different directions and her
identifications may shift between the infant and parent, challenging
the analytic stance. As always, the therapists countertransference is
used and must be watchedher own hopes and despair, riven identifications between mother and baby, and her rescue fantasies. Above
all, the therapist needs to maintain sufficient emotional resonance
with the mother, in the face of the acute emotional pain and helplessness of her infant. Without this there is no way for mother to empathically recognize the real infant as opposed to the infant within her
whom she often treats with cruelty.
In the case under discussion, where the babys early attachment
needs were thwarted by his mothers failure to embrace him with
genuine love, considerations of clinical process and technique
were particularly charged. On the one hand, mother sought the ascetic and altruistic (A. Freud 1937) virtue of genuine love, devoid
of all narcissistic investment and reward, and her severe depression
was compounded by a sense of failing her own standards. On the
other hand, her infant son was starved for the maternal appetite of
ownership and adoration, and his experiences of going-on-being
were distorted by her projections and hostility. These experiences of
trauma for both baby and mother required ongoing scaffolding and
regulation from me, the therapist, and I needed to be alert to the
challenge to my capacities for reverie in my various roles and from
within.
Thus the matrix of intersubjectivity, transference, and countertransference was extremely complex. It raised minute-by-minute
questions of technique. Which patient/what material should be privileged at any given time, and in what domain of relational knowing
52
Tessa Baradon
(Stern et al. 1998)procedural (psychological acts) or symbolic

(psychological words)would the communication be most effective?
Clinical Material
Ms G was referred by her obstetrician just before her baby was due,
with concerns about her depressive mood. A psychiatric report attached to the referral mentioned a long-standing history of eating
disorders and self harm, and a number of attempted suicides requiring hospitalizations, the latest one year previously. Consequent upon
the concern about this troubled young mother and her baby, a network of health and social service support was put in place.
Ms G was in a stable relationship with D, the babys father. However, Ms G requested to attend without her partner, explaining that D
reassured her that she is a good mother and that she needed her
fears to be heard and not brushed aside. Although we ask to include
fathers in the therapy where possible, I decided it was important to
enable this mother to indeed be heard in her request and to explore the possibility of including the father after we had established a
therapeutic alliance. In the course of the therapy father did become
involved, but in this paper I will not discuss the work done with the
triad. Mother, baby, and I met once a week for a period of two years.
This paper focuses on the first year of therapy.
tentative beginnings: mother, baby, and therapist
In the event, although I was in telephone contact with Ms G from the
time of referral, we only met 3 weeks after baby Ethan was born. A
vulnerable baby, he had required special care in the early postnatal
weeks and Ms G stayed in hospital with him.
In the first session Ethan, still a fragile newborn, was asleep when
they arrived. His painfully thin and pale mother sat sideways to me
with her face averted. She spoke in a near whisper, her low voice and
withdrawn facial expression camouflaging much of the terribleness
of what she was saying.
Ms G explained that she had never thought she would have children
as she was afraid that she would damage them. I wondered whether
at the same time as being afraid to have a baby she had also perhaps
hoped for one. Ms G thought not. She explained that the likelihood
of conception was low as she has irregular periods because of her eating disorder. I asked how she had felt in her pregnancy and she said
she had not wanted it, and had continued smoking and bingeing.
53
She had felt that the fetus was a parasite. She felt very guilty about
this. I asked whether these kinds of thoughts were continuing. At this
question Ms G became distressed, saying that she feels that she is
forced by him into an artificial position . . . of trying to be a good
mother, who loves her child and takes care of him. Ms G said she
does not feel like that much of the time. She added that she would
not harm him physically.
Somewhere early in this conversation Ethan fretted a bit. Ms G immediately picked him up with extreme care and held him to her, his
little body slumped against the palm of her hand. She checked with
me whether she could feed him. She snuck him under her shirt, careful to keep her breast hidden. The feed was quickly over and Ethan
went on sleeping. Ms G removed him from the breast and covered
herself up.
We spoke about attending parent-infant psychotherapy. I wondered what she was hoping to get. She replied that she wanted a filter so that her feelings dont all come out on Ethan. I noted that I
would not have been able to tell from her facial expressions and tone
of voice when disturbing thoughts toward Ethan intruded during the
session, and that from this I could tell that she was really trying to
keep a tight grip on her feelings. Ms G reiterated her fear of damaging him through her depression as her mother, too, had been depressed and unavailable. I suggested that we would attend to both
the good things that happen between her and Ethan, such as her
gentle stroking of him that I had observed even when she was upset,
and to her bad feelings and thoughts. Ms G hugged Ethan to her.
I felt that the central verbal and affective communication to me in

this session was Ms Gs sense of being damaged herself and, through
her very being with her baby, of damaging him. Her state of primary
maternal preoccupation had a particular quality to it: hypersensitive
to the baby via herself, it seemed that projection did not aid her to
feel herself into her infants place (Winnicott 1956, p. 304) but that
the infant was equated with her, as a disturbed extension of herself
(King 1978). Moreover, his critical early hospitalization, in which her
dread of damaging a child was actualized and exposed, seemed to
have been a trauma which confirmed a psychic equation between
her inner and external worlds (Fonagy and Target 1996; Target and
Fonagy 1996).
In turn, I experienced Ms G and Ethan, separately and as a dyad, as
extremely fragile and needing both to be reached out to and to be
handled with care. On the one hand, I struggled with my own need
to establish some contact with her averted face, as I strained to hear
her whispers. I felt responsible for her very life, as I imagine rescue
workers feel in response to the sounds of life after disaster. In this
54
Tessa Baradon
process of projective identification I assumed the omnipotence attributed to the caregiver in relation to the infantile self. At the
same time I was acutely aware of the danger-in-contact ricocheting
between us during the session, manifested in her whispers and cautious handling of Ethan. My association was to a sea of shards in
which any movement could be calamitous. Only later did I realize
how her history of self-cutting had penetrated my subconscious.
Thus, from the beginning this was a dyad with whom I engaged in an
intense and worried way, responding perhaps to her unconscious invitation to assume this mantle.
In the second session Ethan, now 4 weeks old, was awake, a tiny little thing with big blue eyes and a peaky face.
Initially he slept on his mothers lap, fists tightly clenched. Ms G
stroked his hands but he did not relax his fists. A few times she pried
them open and stroked his palms. Ethans eyes flicked open when he
heard a door slam and he started crying. He seemed to move quickly
into a loud cry, with no fretting or working up toward the upset. He
cried hard. Ms G put him to the breast and he sucked, then fell
asleep. She put him on the mat and he opened his eyes. I spoke to
him about his experience being in a big room and hearing my
stranger voice and not knowing where it came from. Ethan stared
fixedly toward the ceiling lights above him. After a while he turned
his head slightly in his mothers direction, and I confirmed that that
was where his mummy was.
As I observed this tense baby, I wondered whether there was

heightened sensitivity to invasive stimuli (lights, noise), carried over
from the weeks in the special care baby unit. I also wondered
whether he was already reacting to the conflicted and disregulated
quality of maternal emotion, transmitted and received through the
ministrations of care. His ordinary going-on-being seemed to be
punctuated with periods of disassociationas expressed in fixing on
the lights, and falling foreveras expressed in his urgent cries.
Again my own emotional responses were strong. This time the pull
was toward Ethan, so desperately in need of enveloping in maternal
love.
We had 6 more sessions over the following 6 weeks leading to the
first break. The sessions acquired form and pace. Ms G sometimes
looked my way and I found it less of a strain to hear her. Ethan moved
between brief periods of wakefulness and prolonged periods of
sleep. I found myself accommodating to their muted tone, characteristic of depressed mothers and their infants (Bettes 1988), by dampening my spontaneity, speaking slowly, riding the silences. But in-
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, I took care to acknowledge negative affect as conflictual, and positive interactions were noted without
hollow reassurance that she was doing well. With Ethan I was relatively active, representing his mental states and communications, offering contingent responses, linking him up with his mother. I tried
to balance offering myself to him for use as live company with
awareness of Ms Gs envy of what she perceived I had to give Ethan,
and which she had never received. At times indeed I felt rich in resources, but at other times I felt dull and drained.
the meanings of dependency
When I collected Ms G and Ethan, now 12 weeks of age, from the
waiting room after the 2 week break, Ms G gave me a very quick
glance of tenuous pleasure and then turned away with an avoidance
of my gaze and bodily withdrawal. I felt I had become dangerous
again during the break, even more so as I believed from her darting
pleasure that she had missed me. Ethan woke up as she put him on
floor beside her. He looked bewildered. We settled on the carpet and
Ms G placed Ethan against her feet, facing me. I thought she was in
some way offering him as a transitional object for reengagement. I
adjusted my position so that Ethan could see my face directly. In so
doing, I was also placing myself in Ms Gs range of vision should she
chose to raise her eyes.
I spoke to Ethan: Youre not quite sure where you are, are you? . . .
you havent been here for a while . . . have you? He murmured. I
asked him if it all right to wake up in this room now, and Ms G reminded me that the last time he was quite upset. I acknowledged
this. Ms G asked Ethan if he wanted to sit down and placed him on
her lap. I said, that way you are with mummy and can still see me . . .
and still give these gorgeous little smiles. Ms G whispered, yeh.
Ethan relaxed into her lap and looked back to me and made a gurgling noise. He gave a big smile and looked into my eyes for a few seconds, then looked away. Then he looked back, pursing his lips, and
eventually produced a rolling sound. In a lilting voice (motherese)
I to him, Its a little conversation, isnt it? His face opened and he
smiled again, then looked away. I waited. After a few seconds he
turned back to me. I said, Are you ready to chat again? Hey . . .
yes . . . yes . . . and when youve had enough you look away for a
while, dont you? Ethan gurgled again. Ms G looked down at Ethan
and said, He can be quite coquettish, sometimes he turns his head
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Tessa Baradon
and looks from the corners of his eyes. I replied to Ethan, mmm
. . . hmm . . . I guess youre taking a breather then, arent you, we
adults do the same. Yah . . . Take a little break in a conversation, ah,
otherwise it gets too much, doesnt it?
Ms Gs response to me in the waiting room suggested that the

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

attributing her own conflicts to the baby. Ms Gs fear that Ethan already preferred the company of others seemed multilayered, containing the fear of his rejection of her, a projection of her wish to get
away from him, and the rivalry with him over me. At this point I was
unsure whether words alleviated or intensified her conflict and I also
felt that the urgency of Ethans need for her was overriding. I, there-
57
fore, chose not to follow the route of interpretation and simply commented that he had been looking at her. Ms G was able to make use
of my validation of Ethans desire for her to express her conundrumcan she allow personalization: Should he be smiling at me
more? This offered an opportunity to explore what Ethan might be
avoiding. I learned that Ms G habitually scanned the object for their
affective communications/demands and that, since Ethans needs
and wants evoked her hatred, it felt dangerous for him to look into
her face/mind as he may see those emotions in it.
I was aware that she had not related to Ethan for some length of time
and asked whether she was feeling ambivalent about Ethan there and
then in the session? Ms G said she was not sure . . . perhaps her instinct was to touch him but she did not want him to feel smothered
by her. She wondered if she is not perhaps too disengaged with him. I
suggested that, on the contrary, I thought she was very engaged with
him but that she is protecting him from the toxicity that she felt was
passed to her by her mother and which she fears she may pass to
Ethan. Ms G nodded. She said she wanted to make it clear that her
mother did the best she could at the time and added that of course
she feels that it wasnt good enough. I rushed in too quickly at this
point, saying that perhaps in her attempts to protect Ethan she was
keeping a distance between them that prevented them from spontaneous exchanges, such as laughing and playing together. Ms G
replied that Ethan may in years to come experience her as in a state
of severe depression or absent from him. Almost under her breath
she murmured that if she were to leave through dying she would not
come back. Ms G was quite tearful and picked Ethan up, caressing
him. Then she said that she is not sure whether shes holding Ethan
because he is a soft, comforting thing . . . and she put him down on
the floor, on his side facing away from her, and at a distance. He
sucked hard on his hand and just lay there, looking into space.
The whole interaction was extremely painful as baby and mother

seemed quite unable to come together. The essential elements of
adoration and appetite for the baby were missing from Ms Gs love. It
seemed that his dependency, need, and desire for her resonated with
the representation of him as parasitic during pregnancydepleting
her of self-hood. The transference to Ethan was thus of a consuming
object like the mother of her childhood. This dilemma is likely to
have been accentuated by her feelings of abandonment by me during the break. In an identification with the aggressor (myself), feelings of dependency and need in herself and in her baby were denied.
At the same time, Ms G cared intensely that her child should not experience the maternal toxicity or disappointment in the object that
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Tessa Baradon
she suffered. In this way, distancing him was an act of love as well as
cruelty. Ethan, to my concern, veered between disintegration and
precocious defense.
I felt caught in the middle and responsible for the devastation, as
though during the break the therapy had replicated the hollow maternal stancethe offer of dependency withdrawn. Thus my maternal best was in fact toxic also for Ethan via the impact it had on his
mother. Certainly my too quick response contained a veiled criticism (also reversing the attack on me): in protecting Ethan from
damage you are in fact killing off a live relationship. Obviously, I may
have responded from the countertransferential reserves of my own
tetchy narcissism. We also know from clinical experience that past relational trauma can be reproduced in the present therapeutic situation, in the transference-countertransference transactions. Yet I
think I was also nudged into the patients unconscious wish-gratifying role (Sandler 1976), as Ms G went on to speak of Ethans (and of
course my) possible future loss of herself. The habitual solution to
overwhelming dependency and inevitable disappointment was destruction of self and object.
With my therapeutic goods thus spoilt, resonating her emptied
state, I was unable to protect Ethan, who was put down and away
from us. As he lay rigidly on his side looking into space, I felt I was
witnessing his emergent identification with the dead mother (Bollas
1999)a kind of dying in situ.
good enough loving and impingements
I am trying to understand, said Ms G two months into treatment,
what is genuine maternal love? She feared that when she did experience maternal feelings it was because of her delight in his need
(for her) and that, therefore, her motives are suspect. She
weighed her gratification about his complete dependency on her
against her wish to walk away. I have to keep asking myself what is
this about? Is it about me? About Ethan? She dismissed my suggestion that it may be about both of them, and I commented on her fantasy that the ideal mother is selfless. Ms G confirmed this ascetic representation of the genuinely loving mother and said that the ideal
mother could understand all the babys needs, thus rearing emotionally, mentally and physically strong children. She said she was
humbled now when she saw others managing to do this.
Ms Gs repudiation of gratification as a constituent of the maternal
bond could be traced to her grievance with her mother, past and pre-
59
sent, in which she felt used by her mother for her own narcissistic
needs. Moreover, she held her parents responsible for her damaged
mental state and, even as an adult, had no real sense of volition to
modify the childhood feelings of helplessness.
Yet, despite the relentless grip of the past, I observed her handling
of Ethan extend to more animated exchanges. Ethan responded to
these tentative protoconversations with widened eyes, excited kicking, and large smiles. He seemed to gain efficacy as a partner; for example when he lost her attention he would call her back by looking
at her and cooing. When I pointed this out, Ms G said that friends visiting had commented that Ethans eyes followed her wherever she
istracking her voice when he could not see her.
As the months progressed the sessions felt safer, more predictable,
encompassing a broader range of feelings, allowing Ms G to offer less
ambivalent parenting and Ethan aspects of good enough relatedness, and thus also development. Indeed, during this period in the
therapy, there were times in the sessions in which Ethan was a contented little baby.
However, these quiet periods of regulated positive affect were also
the backdrop to rapid transition into states of inconsolable crying. I
noted that sometimes Ms G reached out to Ethan, and he, in the process of being attended to, became distressed. His tiny body became
rigid and he clawed at his mothers body. At such times Ms G moved
through a repertoire of feeding, winding, rocking, walkingseeming to act promptly and contingently to effect interactive repair
(Tronick and Weinberg, 1997).
Four months into treatment. Ms G raised the question: Why is it so
hard to soothe Ethan? Was he damaged at birth, would another
mother get it right? I tried to explore with her what happens to her
when he cries. Ms G confirmed that she gets very upset. I suggested
that sometimes Ethans cries feel like her own. Ms G became tearful
and then reprimanded herself for not always acting the adult with
him. I said that when they are both crying she no longer feels the
mother. I also spoke about the rage that she feels when he triggers
her pain. Ms G whispered that she feels so guilty and ashamed.
Thus, it was becoming clearer the extent to which Ethan was the
barometer of her own emotional state. When his needs did not resonate with her own conflicts, Ms G was able to respond. Unpredictably, however, his ordinary infantile needs could trigger or link in
with her own volatility. This is another aspect of relational trauma
where the quality of affective communication with the baby imparts
trauma from the mothers internal world to that of the baby.
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Tessa Baradon
Through the most careful observation of their affective interaction

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

the absence of such exchanges with his mother), and a mother who
61
felt diminished by this, I was in a conundrum: to embrace the one

seemed to be a rejection of the other. It was as though I had to experience the possibility that only one of the dyad could survive. If I was
unconsciously being faced with the choice between them I, equally
unconsciously, resisted it by replacing Ms G as the object of her sons
love. Perhaps I hoped that Ms G would allow herself the experience
of Ethans giving her pleasure and making her proud. Because she
was more able to respond to cues of distress but not those of joy in relation to her, he was missing out on swathes of exchanges around
emotional sharing, crucial for his development (Stern 1985, Trevarthen 2001). Indeed in this sense Ms G was not able to facilitate
Ethans development as an emotionally, mentally, and physically
strong child.
Yet, as the therapy progressed, it seemed that by my modeling
more playful exchanges with Ethan while emphasizing my notmother status, Ms G was sometimes able to respond contingently
and offer herself to be used by him.
separation-individuation
In the course of a longer-term therapy the infant naturally moves
from a state of total dependency on the mother toward the beginning of separation-individuation. This offers opportunity to work
with the mothers conflicts as they impact on her baby at each developmental phase.
In the treatment of Ethan and Ms G there were hints from the beginning that separation, like dependency, was an area of extreme difficulty. Ms Gs history held no personal experience of moderated separation, only that of violent, mutually destructive rupture. The risk
for this dyad was that separation-individuation would plunge mother
into narcissistic despair and rage.
Sleeping and feeding were ubiquitous arenas for expression of
conflicts over separation in Ms Gs history and were, perhaps inevitably, the areas in which the conflicts were played out with Ethan.
In the early weeks Ms G reported that Ethan would fall asleep only
when lying on her chest. This meant that any movement of his woke
her up. She moved Ethan to his Moses basket at her side, but kept
vigil through the night. She recalled childhood fears of the dark and
of sleeping alone and felt unable to tolerate Ethans cries when put
into a cot. At the same she felt driven to madness and despair by lack
of sleep. D, with his own difficulties in this area, was unable to offer
support, and soon Ethan was restored to the parental bed. Ms Gs
chronic insomnia was thereafter channeled into nightime rumina-
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Tessa Baradon
tions as she waited for dawn so as to escape from the bed to a strong
coffee and cigarette.
With Ethan waking hourly, sleep disturbances became woven into
the conflicts around feeding and weaning. Ms G repeatedly expressed her feelings that feeding was the sole good thing she could
give him and admitted her gratification that only she could provide
this. However, these feelings also came into conflict with her experience of his dependency as depleting. In the sessions I observed feeding encompass many regulatory functions, so that Ethan was put to
the breast when he cried, when he was tired, when they were both at
a loss as to play. With feeding used to meet such a variety of situations, it became difficult to tell when he was hungry.
At around 5 months of age, Ethans weight began to drop and professional concerns about failure to thrive emerged. Medical opinion
moved toward supplementary feeds, with a bottle also offering a possibility of respite from the hourly feeds at night. Ms G came under increasing pressure to achieve some measure of weaning. Her internal
split was thus effectively externalized, with the medical network and
her partner now carrying for her the thrust for forced separation,
while she maintained the ubiquitous place of breast-feeding. It
seemed important that at that point I did not know what would be
best, and held neither a wish for Ms G to wean nor for her to continue feeding.
During this period, Ethan 6 9 months, many threads in the therapy seemed to coalesce around the question of closeness versus distance and the losses implied in each.
Week by week Ms G described her dread of the long days with
Ethan while D was at work. She felt mired by his wish for her presence, for example crying when she left the room, and her inability to
let him cry. She said that before Ethan was born she spent much of
the time alone. I wondered if that was her way of keeping her emotions on an even keel and she confirmed this. I suggested that having
Ethan with her all the time meant that she has no means of regaining
her emotional balance (her words). Thus the closeness was experienced as loss of self, provoking rage. Getting away was a relief at that
level, but it also brought with it the fear that she could disappear
from their lives and it would not matter.
As Ethan became more mobile he could initiate movement toward
and away from his mother.
7 months into treatment. I noted how Ethan seemed to want to be
close to her today. Ms G said she did not know if she wanted him
close or not. She said her guilt at not really wanting his relentless
63
closeness makes her try harder. I then witnessed this as Ms G finally

allowed Ethanwho had been struggling for a while to get into her
lapto find a place there. He crowed and cooed and bounced.
From the outside their little reunion seemed pleasurable and yet
Ms G was talking about times when she feels she cannot go on. I
asked whether those were times when she harmed herself. She was
silent. Ethan seemed to get extremely boisterous in her embrace
sucking on her arm and blowing raspberries. He appeared to be
both kissing and biting her and I said this to him. My thought was
that they both moved between intimacy to destructiveness with confusing rapidity and that, despite being with them, I could not tell
what felt good and what bad.
It is interesting that at age 8 months, when biting could be considered as a normal expression of desire (incorporation) and/or exploration, I attributed destructiveness to Ethans biting of his mother.
Was I taking on Ms Gs attributions? In which case Ethan was subject
to my projections as well as his mothers. Was I picking up on an aggressive quality of relating in Ethan that indeed would be a pointer to
derailed development at this age? If so, why did I not follow this
through with an explication of his aggression as reactive to his
mothers unresolved ambivalence? Certainly, addressing his predicament would then need to have been privileged. In retrospect, I think
that my shifting identifications with mother and with baby were enacted here through muddled, partial interpretations.
Just as imaging the babys ordinary movement toward separateness
was not available to Ms G, she was also not able to manage a normal
loss through establishing the triad of mother, father and baby (Daws
1999). I noticed in the sessions that I felt increasingly forced to relate
to Ethan, with Ms G watching and withdrawn, or to Ms Gwith
Ethan either observing or dis-engaged. Thus, the father/therapist
was seen not as a gain but as a threat to the symbiotic tie. In the issue
of weaning, the bottle symbolically represented the competent, third
object, and there was a concrete idea that the bottle would deliver
Ethan to his father. With this came powerful statements from Ms G
that D and Ethan were doing so well together. There was affective undertone of not being needed anymore, and I was left with a concern
that intense pressure on her to wean could precipitate a crisis, primarily in terms of her desire to stay alive. My anxiety about a possible
suicide attempt was high, and I checked that the network was in
place. In retrospect, I believe I was also caught up in powerful projections around loss of myself, as we were approaching another break (9
months into treatment).
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Tessa Baradon
Anticipating this loss Ms G thought she and Ethan would miss their
sessions with me, but she continued to insist that the solution was disengagement and self-sufficiency. Separation, as an intrapsychic process leading to growth, still felt beyond our reach.
enacting rupture
On their return after the holiday, Ms G appeared terribly thin and
wan, while Ethan seemed to have gained bulk and weight. My first
thought was hes feeding off her! He also looked strikingly like his
father, as though fulfilling her fears of losing him to D. They each responded to me with a measure of reserve.
Ethan took his time before he approached me: gazing at me from a
distance and looking worried. After a while he gave me a smile and I
smiled back and asked whether he was beginning to forgive me for
the summer break. Ms G told me that on their holiday everyone had
adored Ethan and that he had gone easily to the men but not to the
women who wanted to pick him up. I wondered whether she was linking Ethans reserve with me to this. She shrugged. I asked her what
she made of her observation. She said, Its like being run over by a
red car and then not liking red cars afterwards. I said it seems to
have reinforced her fear that she was not a good mother and as a result all women were like red cars to Ethan. Again she shrugged, this
time seemingly in agreement. Ethan was crawling aboutinitially
energetically but then looking lost. A number of times he headed toward his mother and then veered away. When he absolutely ran out
of resources he crawled to her and tried to clamber onto her lap. Ms
G held him loosely, pulling away a bit and getting her hair out of his
clasp. She then abruptly stood up muttering that he needs a climbing
frame, carried him over to one of the chairs and stood him there.
Ethan looked tiny and forlorn across the room. I felt shocked. She
came back to her place on the cushion. I said she was equating herself with the chair, as though it was not herhis mother specificallythat he needed. She replied that she does not want him to depend on her for his happiness. Feeling very anxious about what I was
about to say, I asked whether she wanted him to be independent of
her so that she could do away with herself if she felt she needed to.
Ms G looked pale. She whispered that this was very selfish. I said perhaps she thought that in order to continue living she needed to feel
that she could kill herself. Ms G said everybody had their escape
routes.
Ethan had crawled back to our vicinity and was searching Ms Gs
bag. He pulled out a plastic container with food. We watched as he
struggled to get an apple out. I accompanied him with words: is he
wanting the apple, can he get to it? He managed to extract the apple
65
and tried to bite into it. I asked him if he can eat it, is it too big? I said
maybe Ms G thought I was fussing too much. She moved closer to
him and asked him if he needed her to cut it for him, but Ethan had
in the meantime made indentations with his teeth. He chewed on
the apple for a while and then tried to get the bottle of baby food
out. Ms G watched him closely and I found it agonizing that she did
not capitalize on his interest. When she finally, tentatively offered
him some food, he spat it out. She immediately put the bottle of food
away. Shortly after this he began to cry.
Ms G told me that at Ds insistence she had taken Ethan to a nursery that morning. I asked how they had felt about it. She said Ethan
had choked on a brick during his visit. She conveyed immense sadness. I said she seemed torn between loving Ethan and wanting his
love for her, and her fear that this dependency in both of them
would take away her escape route. I suggested that the long break
had probably also brought up these feelings in relation to me. Ethan
was getting more upset and when picked up by Ms G he clung to her
strongly. I said to him that he was showing his mummy how much he
needed her and how frightened he gets when she thinks about leaving him. Ms G carried him over to the windowsill and sat him on it so
he could look out. Ethan calmed, and soon after this it was time to
end. Ms G fled the room clutching Ethan in her arms.
The story of the holiday could have been taken entirely as a transference communication: I had run over her dependence on me
and left her, prematurely, to feed herself. Thus forsaken, she felt driven toward her habitual escape routes of self-denigration and selfharming, both to rid herself of her shaming infantile needs and as a
retaliatory attack on me. Her rage with me was communicated in the
narrative of the red car and enacted in substitution of climbing
frame/chair for self, that is, in her refusal to embrace Ethanagain,
an identification with the aggressor.
A central dilemma in parent-infant psychotherapy is when to take
up the transference to the therapist? Certainly the negative transference was in the forefront and needed addressing. However, my initial
attempt to relate to my perceived dangerousness (via Ethans avoidance of me) was shrugged off. I reckoned that to pursue the transference and/or her defenses could be experienced by Ms G as retaliation on my part (Steiner 1994). In retrospect, it is the displacements
that perhaps could have been taken up for it is there that the experience of cruelty lay. Addressing her rage with me may have relieved
Ethan from the burden of carrying it.
With the rupture (break) with me unsufficiently reflected upon,
what followed was Ethans performing a transference enactment of
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Tessa Baradon
failed self-feeding while the intergenerationally depriving mother

stood by. By this point I was able to address the struggle to manage
alone, but although Ms G carefully watched Ethan, her active intervention came too late (like mine) and was rejected. I wondered
whether in fact Ms G experienced me as empathic toward Ethan
when I had been withholding toward her, and this perhaps contributed to her not helping him feed. I also thought she was possibly
punishing me through forcing me to witness her abandonment of
her child (which was painful to watch). In a similar vein, going to
nursery was experienced as forced upon them, with life-threatening
consequences. However, Ms Gs sadness was here undefended and it
gave coherence to the preceding narratives. Acknowledging the
need and the pain allowed some movementby the end of the session Ethan was ensconced in Ms Gs embrace.
The following session Ethan was unusually free and playful, particularly in relation to the apple. He held it, bit into it, he lay on the apple and rolled around. I noted Ethans playfulness and Ms G said she
too had noticed itit was so different from his clinging. I suggested
that he might be picking up that she and I were trying to work something out and it was a relief to him. Ms G said, maybe he is being
trustful.
falling in love as reparation
In one of her earliest sessions Ms G asked, When does one know that
reparation has taken place? Reparation was her choice of word,
denoting making up for her destructiveness.
Toward the end of the first year of treatment we came back to this
theme. It was a period of creativity following the enactment of rupture, described above. In the sessions there was a shift, with Ms G taking a slightly more reflective stance (i.e. less rumination and self reproach) than hitherto. In the core relationship toward Ethan, so
dominated previously by her ambivalence, there seemed to be a flowering of love. Between them there was a more robust link, which enabled Ethan to move to and from his mother and to refuel from a distance through gaze. Ethan also established his own little routine in
the sessions. He would start by checking out the toys and re-establishing himself with melittle smiles, crawling over to me, gradually
climbing up to explore me. Then he would go over to Ms Gs large
bag and get out his food parcelan apple and berries in a plastic
bag. He had to work hard to get his hand into the bag, but Ms G
67
monitored his endeavors and encouraged him. Ethan then ate his
fruit, swallowing some and spitting some out. Gradually eating and
playing/exploring became somewhat more integrated, and he
moved between the activities and us.
He approached his 1st birthday and this preoccupied Ms G.
She said she still had not found the perfect present. She mentioned a
cloth shed had as a comforter which had worn awayshe wished
she still had it to give to Ethan. I said it sounded that she was wanting
to protect and comfort him for the years to come. She replied that
she had a lot to make up. I said this made me think of the perfect
present as representing a wish to make good their very difficult early
beginning. Ms G spoke of reparation and I thought she was also repairing something for herself. Her emphasis was on her wish to protect Ethans trust and expectations that people will respond to him
kindly. I suggested she may have felt unprotected and that cruelty hit
her abruptly as a child. Ms G spoke about her mother doing her best,
but that it was not good enough. She added that her mother does a
lot of charitable work but she wishes she could have given the same
to her children. I said that perhaps she feels that sometimes both her
parents didnt really do their best and that some of the cruelty she experienced came from themand this is what is so hard for her. Ms G
struggled with this, though she did not deny it.
Ethan had finished eating and messing and was exploring under
the table where he discovered the telephone wire and plug. Ms G initially asked him not to play with the cord and then went over and
picked him up. Ethan gleefully crawled back to the table and Ms G
became firmer in her tone of voice. I spoke about what was happening between them, reflecting that he really enjoyed being gathered
up by his mother and had found a hide and seek game which he
could play with her.
This session was characterized by a sense of calmness and reflection between Ms G and myself, the adults, and playful exploration
on Ethans part. It felt that I was allowed to hold a position of the benign third, and this was perceived to be containing to both baby
and mother.
The quest for the perfect present seemed to capture Ms Gs regrets
about the lacks of their beginning together, and her wish to celebrate
their coming together through the love she had discovered within
herself for her child. In wishing to extend the comforter from her
childhood to him, she also had begun to mourn the lonely childhood she had, and to relinquish some of the envy of her child for the
maternal comfort he could still have in his. Ethans play with the tele-
68
Tessa Baradon
phone cord seemed to represent hope for more genuine, encompassing communication between them through which he could be
gathered up and contained.
Discussion
Ethans first birthday also heralded the end of our first year of work
togethera good time to take stock. The wish, and failure as yet, to
find a perfect present seemed symbolic of what had been achieved
and of that which still needed to be addressed.
Ms G had approached parent-infant psychotherapy with the wish
for a filter to protect her baby from the transmission of damage she
felt had been done to her by the parenting she had received. In equal
measure, although more hidden, was the fear of being damaged by
her baby. This mutual threat was created through their very existences in relation to each other. As Ms G said, Can one damage
ones baby just by being available? In the transference I was also often a source of danger, most spectacularly around breaks when my
unavailability confronted Ms G with her the extent of her dependency on me and my maternal failure to hold it. Ethans post-natal
vulnerabilityhis smallness, sensitivity to lights and noise, seemingly
low threshold to unpleasurable experiences and the difficulties in
comforting himintensified the sense of fragility and risk. My countertransference fantasy that we were constructing the therapeutic
space within a sea of shards highlighted the power of the emotions,
projections and enactments.
In the course of the first year of the therapy there were some
changes in the quality of the relationship between Ms G and Ethan.
The most significant was the expanding sense of maternal love for
Ethan. In the early months Ms Gs fear of, and guilty hatred for, her
babys dependency overrode her ability to accept more benign feelings in herself. She defensively adopted an ideal of altruism that
negated not only her passions but also his. Ethan was forced into precocious inhibition of attachment behaviors toward his mother. His
turning from her, and her failure to meet her ascetic standards, compounded her depression. In the course of the first year of therapy
there was a lessening of Ms Gs preoccupation with the question of
genuine maternal love and a move toward more ordinary, at times
good enough, mothering. She seemed more able to acknowledge
and tolerate her wish to be central to Ethan and, albeit less consistently, her importance to him. Her gaze and facial expressions conveyed growing adoration of him. What facilitated these changes?
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. By the
third quarter of the year Ethan, although delayed, was making up the
early impingements and developmental tests confirmed he was on
track. Thus Ms Gs psychic reality of the inevitability of damage
could, sometimes, be challenged by a different, external voice.
Ethan, for his part, seemed to capitalize on the openings in their relationship and became more forward in expressing his desire for her.
This, too, was a positive reinforcement which Ms G could at times
perceive.
In the transference relationship with me I, too, was surviving her
destructiveness and was not retaliating with narcissistic demands of
my own. Thus Ms G was meeting with a different motherhood constellation (Stern 1995) from the persecutory internal one, one in
which the intergenerational mother could be experienced as containing and repairing of the damaged child.
The clinical process, as the sessional material indicates, took place
in the procedural and symbolic domains. Interpretationsusing
words as a means of giving meaningwere important to this mother,
as were verbal (vocal, tonal) representations of his mind to Ethan.
The procedural processes seemed to cohere more slowly. At first, the
misattuned emotional dance between mother and baby was repeated in the interactions between the three of us. In time, I became
better at matching and repair of the spontaneous gestures and affects that constitute authentic person-to-person connection (Stern
et al. 1998, p. 904) and this then framed the developing relationships
between mother and baby and myself.
Because so much in the earliest transactions between Ms G and
Ethan was driven by her negative transference to him, offering myself
as someone who could simply be with mother and baby and could reflect on them in relation to each other without fear of damage, seems
to have been important. For quite some time it seemed that only in
my mind could their survival as a dyad be contemplated. This raised
the question of which patient should be privileged from moment to
momentEthan, mother, father (present or absent), the relationships? At times I left a session feeling that more work should have
been done with Ethan, for example to enhance his efficacy in engaging his mother. At other times I felt that the focus should stay with Ms
G, to address her depression and the defenses and distortions that
constituted her zone of safety but also derailed the relationship with
Ethan. Despite the compelling nature of Ms Gs narrative, it was cru-
70
Tessa Baradon
cial to keep Ethan in my mind at all times, so as not to slip into individual therapy in the presence of the baby. These issues were all the
more urgent given Ethans young age and the chronicity of Ms Gs
difficulties, spanning critical periods in his development.
Alongside the changes that marked the achievements of our first
year together there remained areas of great vulnerability in their relationship. It seemed that the quality of love Ms G was able to offer
Ethan was contingent on her emotional state at any given time and
the extent of preoccupation with herself. Often Ethan had to make
do with the crumbs of emotional availability that penetrated her depression and withdrawal. Not able to love herself in her baby, or to allow his appeallingness to reflect on her, Ms G could not really entertain exuberant passion and appetite in her relationship with Ethan.
Moreover, to be consumed by the other was only too real a threat
and to be avoided at all costs. Thus Ethan was not able to safely experience himself as an object of hatred as well as of love. His own actions directed at separation-individuation were still, at times, subject
to transferential attributions that frightened Ms G and evoked her rejection of him. In turn, Ms Gs fluctuating emotional state, and particularly when she became extremely depressed, could be frightening for Ethan, betrayed initially in disintegrative crying, and later in
occasional veering away in the midst of approach or a momentary
freezing when mother seemed annoyed.
These thoughts about clinical process are relevant to the question
of whether genuine maternal love exists.
It seems to me that what Ms G captured in this term was the affective quality of her love for her baby as described above. In presenting
the question she was disclosing her knowledge that something was
going very wrong for them. At the same time, bringing the question
into the therapy also underlined Ms Gs commitment to do better by
her baby: whatever her state of mind, however conflicted she was
about the therapy, Ms G and Ethan attended their sessions without
fail. In using the therapeutic space to risk intimacy, Ms G and Ethan
were constructing their particular version of genuine lovesomewhat more measured and a little more vibrant at the end of the year
than at the beginning.
For myselfI was intrigued by this question in the context of my
work with attachment disorders. It seems an important concept to
hold in mind in the course of the therapy with mothers and babies.
In the face of conscientious maternal care, it provides a framework
for understanding a particular quality of maternal failure and ensuing relational trauma for the baby. It also suggests an outline of the
71
clinical process that may be needed to free up object hunger and to

encourage the risks of appetite and dependency, identification, and
individuation in a dyad.
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Minding the Baby

A Reflective Parenting Program
ARIETTA SLADE, Ph.D.,
LOIS SADLER, Ph.D., R.N.,
CHERYL DE DIOS-KENN, L.C.S.W.,
DENISE WEBB, M.S.N., P.N.P,
JANICE CURRIER-EZEPCHICK, L.C.S.W.,
and LINDA MAYES, M.D.
Minding the Baby, an interdisciplinary, relationship based home visiting program, was initiated to help young, at-risk new mothers keep
their babies (and themselves) in mind in a variety of ways. The interventiondelivered by a team that includes a nurse practitioner
and clinical social workeruses a mentalization based approach;
Arietta Slade, City University of New York, Yale Child Study Center; Lois Sadler,
Yale University School of Medicine; Cheryl de Dios-Kenn, Yale Child Study Center;
Denise Webb, Yale Child Study Center; Janice Currier-Ezepchick, Connecticut Department of Children and Families; and Linda Mayes, Yale Child Study Center.
This work was supported by a generous grant from the Irving B. Harris Foundation, and grew out of a collaborative effort between the Yale Child Study Center, the
Yale School of Nursing, and the Fair Haven Community Health Center. Other members of the research team who have been essential to our progress are Michelle Patterson, Betsy Houser, Megan Lyons, and Alex Meier-Tomkins. We would also like to
thank Jean Adnopoz, the Director of Family Support Services at the Yale Child Study
Center, as well as Sean Truman, both of whom were instrumental in getting the program off the ground. Finally, we wish to thank the administration and staff at Fair
Haven Community Health Center, particularly Katrina Clark, Kate Mitcheom, Karen
Klein, and Laurel Shader, who along with many other members of the pediatric and
obstetric services gave Minding the Baby a home.
74
Minding the Baby
75
that is, we work with mothers and babies in a variety of ways to develop mothers reflective capacities. This approachwhich is an
adaptation of both nurse home visiting and infant-parent psychotherapy modelsseems particularly well suited to highly traumatized
mothers and their families, as it is aimed at addressing the particular
relationship disruptions that stem from mothers early trauma and derailed attachment history. We discuss the history of psychoanalytically
oriented and attachment based mother-infant intervention, the theoretical assumptions of mentalization theory, and provide an overview
of the Minding the Baby program. The treatments of two teenage mothers and their infants are described.
Sometimes my daughter is just really nice and generous, and she likes giving me hugs and stuff . . . sometimes, just for nothing, shell walk up to me and hug me
so tight in my neck and it feels so good . . . cause I
never had that when I was little . . .
She probably doesnt understand why shes getting
me mad. Cause shes so tiny she probably doesnt understand. But, thats kind of what I think about, you
know, you cant compare your capacity to hers, cause
shes still so small, she doesnt understand what shes
doing wrong.
I usually try to hide my anger. I try not to let anyone
see those feelings. I did that for a long time before
Denise and Cheryl came along. Thats when I started
opening up and talking to them. Because I had so much
built in I couldnt hold it anymore.
Iliana, 19, mother of Lucia, age 13 months
I look at this tape of me and Noni, and shes so little . . .
I cant believe shes so big now . . . Its so hard to watch
this . . . I see now that maybe her crying was to tell me
shed had enough . . . here I can see her face sad trying
to tell me what I didnt know, that she may have been
hungry or sleepy. The whole time she cried, I had no
idea what she wanted.
Mia, age 19, mother of Noni, age 14 months
these young mothers are struggling to find words for the inner lifetheir babys and their own; tentatively, poignantly, they
glimpse the other, and themselves. They look for ways to describe
what is inside, what can be known, what can be held in mind, and
what can be contained. They hold the past next to the present, the
76
Arietta Slade and others
self next to the other. And as they discover their babies, they are discovering themselves for the first time.
Mia and Iliana joined Minding the Babya relationship based
mother-infant intervention programin their third trimester of
pregnancy. Both had been in different ways abandoned and betrayed
by their own mothers when they were but babies themselves. They
had lived their whole lives against the backdrop of trauma, within
their own families and within the culture of their violent, impoverished, and chaotic communities. Knowing others and their minds
had been fraught with terror, disappointment, and rage. And now
they were faced with the enormous challenge of holding their own
children in mind, children who had been born at a time when they
were still children themselves.
The crucial human capacity to understand the mind of the other,
to make meaning of behaviorones own and othersin light of underlying mental states and intentions, is essential to the development of
social relationships, and most particularly intimate relationships
(Fonagy, Gergely, Jurist, & Target, 2002). Fonagy and his colleagues
have referred to this interpersonal and intrapersonal capacity as the
reflective function, and they suggest that it is essential to affect modulation and regulation; experiences that can be known and understood, held in mind without defensive distortion, can be integrated
and contained.
The capacity to mentalize, or envision mental states in the self and
other, emerges out of early interpersonal experience, particularly the
experience of being known and understood by ones caregivers. The
child discovers himself in the eyes and mind of his caregivers, and derives a sense of security and wholeness from that understanding
(Fonagy et al., 2002; Fonagy, Steele, Steele, Leigh, Kennedy, Mattoon, & Target, 1995; Fonagy & Target, 1998). The childs discovery
of himself depends largely upon the caregivers capacity to hold, tolerate, and re-present the range of his diverse and contradictory mental states. Thus, a parents reflective awareness is inherently regulating and containing for the child. Importantly, though, it is also
regulating and containing for his caregiver. Parenting is a fraught
and complex enterprise, and without developed capacities for reflective functioning, parents are vastly more prone to impulsivity, disorganization, and dysregulation in relation to their child (Slade,
2002, in press, 2005).
Trauma interferes in a number of profound ways with the development of reflective capacities (Fonagy et al., 1995, 2002). Parents who
have been traumatized find their childrens needs and fears over-
Minding the Baby
77
whelming and profoundly evocative, and as a result often find it difficult to read the most basic cues without distortion or misattribution
(Fraiberg, 1981; Lieberman, 1997). At a most basic level, the defensive processes enlisted in the face of trauma fragment the development of stable, coherent representations of the self and other. What
we see in the words of the mothers quoted above are tentative efforts
to form such representations, and allow themselves moments of
knowing the self and the other. Mias evaluation of her own failure to
understand what her 4 month old infant was feeling provides a clear
example of how difficult this can be.
Minding the Baby, a relationship based home visiting program developed out of an interdisciplinary collaboration between the Yale
Child Study Center and the Yale University School of Nursing, was
initiated in 2002 to help young, at-risk new mothers keep their babies
(and themselves) in mind in a variety of ways. We began with the assumption thatin addition to being relationship based and interdisciplinaryour program would focus on the development of mothers mentalizing capacities. Based on Fonagy and his colleagues
work of the last decade (see Fonagy et al., 2002, for a review), we
knew thatby virtue of early relationship histories that were universally characterized by attachment disruption and traumathe reflective capacities of these women would be compromised. Furthermore, we believed that addressing the deficits and defenses that had
led to such disrupted functioning would be vital to the development
of healthy mother-child relationships. Obviously, while parenting is
not the only factor contributing to the regularity and evenness of infant development (temperament and biology being but two of the
myriad endogenous and exogenous factors that can affect development), we believed that enhancing parental reflective functioning
would help mothers facilitate their childrens development in crucial
ways.
This approach is in line with what Fonagy and his colleagues have
termed mentalization based therapies (Bateman & Fonagy, 2004);
this term refers to treatments that directly address and target the development of reflective functioning or mentalizing capacities. In
essence, these approacheswhich Fonagy and Bateman have most
extensively developed for work with borderline patientsare designed to very explicitly help patients make sense of mental states. It
is this model that has informed the development of Minding the
Baby.
We also began with the assumption that when working with infants,
containment and regulation take place not just at a mental level, but
78
at a physical level as well. The knowledge of mental states, thought so

crucial to responsive caregiving, is preceded and indeed founded
upon an understanding of physical states. As Freud pointed out,
The ego is first and foremost a bodily ego (1923, p. 6). Winnicott
(1965) made a similar point:
In healthy development at this stage the infant retains the capacity
for re-experiencing unintegrated states, but this depends on the continuation of reliable maternal care or on the build-up in the infant of
memories of maternal care beginning gradually to be perceived as
such . . . The infant becomes a person, an individual in his own right.
Associated with this attainment is the infants psychosomatic existence, which begins to take on a personal pattern; I have referred to
this as the psyche indwelling in the soma . . . the infant comes to have
an inside and an outside, and a body-scheme. In this way meaning
comes to the function of intake and output; moreover, it gradually
becomes meaningful to postulate a personal or inner psychic reality
for the infant. (p. 45)
In other words, the child comes to know his body through the hands of his
mother. As we can see from Mias reflections on her inability to acknowledge her babys most essential needs for sleep or food, even
the recognition of physical states can be compromised in traumatized mothers whose own bodies have in a variety of ways often been a
source of trauma. Thus, we wanted to help our mothers come to feel
safe and confident in knowing their babies bodies as well as their
minds, to feel that they could contain and regulate their babies physical states, and then slowly, with time, come to know their babies
mental states.
In the sections below, we will begin by briefly describing the essential principles and methods of Minding the Baby, as the program has
evolved from its original inception three years ago. We will then present two cases in an effort to exemplify the approach intrinsic to our
reflective parenting program.
Mother-Infant Intervention: A Brief Overview
Thanks to the remarkable and groundbreaking work of Selma
Fraiberg, clinicians have been working in a psychoanalytic way with
mothers and babies for more than 30 years (Heinicke, Fineman,
Ponce, & Guthrie, 1999; Heinicke, Fineman, Ruth, Recchia, Guthrie,
& Rodning, 1999; Lieberman, Silverman, & Pawl, 1999; Lieberman,
Weston, & Pawl, 1991; Seligman, 1994; Stern, 1995). Infant-parent
psychotherapy is today a highly valued and legitimate mode of psy-
Minding the Baby
79
choanalytically based treatment, and the infant mental health movementreflected in the emergence of organizations such Zero to
Three, The National Center for Infants, Toddlers, and Families, and
the World Association of Infant Mental Healthis well established
both in the United States and abroad. And, as attested to by all of the
papers in this section, neither the fact of the childs age, nor the fact
that the dyad presents for treatment are considered in any way impediments to analytic intervention. Indeed, the age of the child and
the mothers active participation in the work are seen as crucial to
progress and early structural change (Fraiberg, 1981). And, in contrast to traditional notions of psychoanalytic work, infant-parent psychotherapists routinely work in situations of risk and trauma, where
little about the environment can be contained or easily modulated.
Circumstances once considered unconventional (Seligman, 1994)
are now considered normative, albeit challenging, opportunities for
analytically oriented work.
Essential to the infant-parent psychotherapy model is the notion
that in a disrupted mother-baby relationship there is some basic distortion of the mothers capacity to represent the baby in a coherent
and positive way. Fraiberg introduced an idea that now underlies virtually all infant-parent work, namely that in troubled dyads the
mothers representation of the baby has been distorted by unmetabolized and unintegrated affects stemming from her own early and
usually traumatic relationship experiences. The goal of infant-parent
psychotherapy is to disentangle these affects from the relationship
with the baby. And, as in all psychoanalytic treatments, it is the relationship with the therapist that leads to shifts in the mothers representational world, and the ultimate freeing of the baby from the
mothers traumatic projections. The parent-therapist relationship in
an infant-parent psychotherapy isfrom a traditional psychoanalytic
perspectivesomewhat unusual, primarily because of the concrete
supports and guidance that are offered by the clinician within this
setting. At the same time, the notion of transference is crucial to understanding how this relationship unfolds, and in anticipating the
pitfalls inherent in the mothers coming to trust and rely upon the
clinician. Ultimately, and optimally, the therapist provides a crucial
and transforming alternative to the mothers previous relationships
with caregivers; the experience of being heard and valued by the clinician frees her and the baby as well.
Fraibergs work was to have an enormous impact outside of psychoanalysis as well. Beginning with the publication of her seminal papers, home visitingalthough widely practiced in Great Britain and
80
other Western countries since World War II, and in the tenements of
New York in the early 1900s by public health nurses (Wald, 1915)
has become one of the most common approaches to improving psychological and developmental outcomes in high-risk mothers and
babies across most of the United States. Certainly David Olds and his
colleagues Nurse Home Visitation program is the most effective and
valid of the many home visiting programs described in the literature
(Kitzman, Olds, Henderson, et al., 1997; Kitzman, Olds, Sidora, et
al., 2000; Olds, 2002; Olds, Hill, Robinson, Song, & Little, 2000). In
Olds model, experienced public health nurses conduct frequent
home visits to first-time high-risk mothers and their infants beginning in the end of the second trimester of pregnancy and proceeding to the childs second birthday. Like Fraiberg and her colleagues,
Olds emphasized that the development of a therapeutic relationship
with the home visitor is key to a number of positive mother and child
outcomes. Olds chose to use nurses rather than mental health professionals for a variety of reasons, the most central being his belief
that they are perceived by families as highly informed and helpful,
and are free of the stigma of mental health service providers. When
Olds first began his work, nurse home visitors did not receive any
training specific to mental health concerns; however, as the program
has evolved over the past twenty years, and the mental health needs
of families have emerged with great clarity, nurses have received
increasingly specific training regarding what might be called psychoanalytic concerns, namely how to think about and work with
the sequelae of severe trauma and relationship disruptions (Robinson, Emde, & Korfmacher, 1997; Boris, Nagle, Larrieu, Zeanah, &
Zeanah, 2002).
While the infant-parent psychotherapy and NHV approaches differ in emphasis, they are nevertheless rooted in the fundamental notion that changing the quality of the mother-child relationship
through a transforming relationship with a clinician is key to improving
outcomes for child and mother. In addition, both approaches provide a range of ego supports for the mother, so as to improve the
chances thatby completing her education, delaying further childbearing, and gaining secure employmentshe will be in the best position to surmount the multiple stresses associated with urban
poverty, and she will be able to serve as a secure base and facilitating
environment for her child. What the NHV program adds to the psychoanalytic model of parent-infant work, however, is the emphasis on
the body and on physical care; despite the fact that the issues of the
body played a central role in classical psychoanalytic theory, this is an
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81
aspect of development and of the mother-child relationship that has

not been effectively integrated into psychoanalytically based infantparent work. It is abundantly clear from the past two decades research that early trauma is profoundly disruptive to the developing
individuals sense of physical integrity and wholeness (Herman,
1992). Mind and body become inextricably intertwined, and the
pathology of biology, arousal, and self-care cannot easily be distinguished from disruptions at an internal, psychological level. For that
reason, we believed that it was essential to integrate the nursing
model with the infant-parent psychotherapy model into a singular,
unified model. We did this by creating a home visiting team that included both a pediatric nurse practitioner and clinical social worker.
The enhancement of reflective functioning was a central goal of
both the nursing and mental health aspects of the program. Thus, we
used a variety of techniquesdrawn from both nursing and infantparent psychotherapy approachesto deepen a mothers understanding and awareness of her babys mind, her babys body, her own
mind and body, and the exquisite and complex interrelationship
amongst all of these bodies and minds (Slade, 2002; Slade, Sadler, &
Mayes, in press).
Minding the Baby
The best way to describe Minding the Baby is through example,
which we will provide in the form of case material in the sections below. These cases1 will be used to describe some of the particular techniques we use to enhance reflective functioning within our model.
Before turning to the cases, however, we will describe the program
and its methods in a general way.
Minding the Baby is based in an urban community health center
that provides health care for an underserved population of families,
most of whom live at or below the poverty line, and are of diverse cultural and ethnic heritages, including African American, Caribbean
American, Puerto Rican, Mexican, and El Salvadoran. This link to
community health care services is crucial, because programs that are
not adequately linked to services provided by local health providers
and other community agencies risk becoming isolated and less effective. In addition, Minding the Baby services are provided by masters
level clinicians; we see this level of advanced training as crucial in
preparing clinicians to be able to assess and manage the complex
1. We have created composite cases for reasons of confidentiality.
82
clinical issues involved in working with highly disadvantaged and

traumatized populations.
First time mothers are recruited from prenatal care groups offered
at the health center. The Minding the Baby team is made up of a pediatric nurse practitioner and a clinical social worker; both are involved in the recruitment and initial evaluation process, and both see
mothers on a regular basis. Typically they alternate visits, beginning
in the last trimester of pregnancy. Families are seen weekly until the
babys first birthday, at which point visits are tapered to every other
week through the childs second birthday.2 In some cases, the
mother may be visited by both clinicians in one week, or by one visitor consecutively when there are physical or mental health crises. In
various times of crisis, visits may last hours, andwhen the home is
too chaotic or disruptedtake place in locations as diverse as the
neighborhood library or a fast food restaurant. Prior to beginning
the intervention, the clinicians receive extensive training in reflective functioning; this includes exposure to relevant background
materials in psychoanalysis and attachment theory, a comprehensive
review of Fonagys work, and in vivo training in recognizing and identifying different levels and types of reflective functioning. This training is offered jointly, so that the nursing and mental health approaches are always unified when considering the mother and baby.
Since many of the families served by the program include adolescent
mothers, the clinical team also receives extensive training and supervision regarding the particular developmental and behavioral characteristics of teen parents (Sadler, Anderson, & Sabatelli, 2001;
Sadler & Cowlin, 2003). Because thorough evaluation is crucial to
testing the efficacy of Minding the Baby, mothers and babies are assessed at regular intervals over the course of their participation in
the program using a range of standard psychological, psychiatric,
health, and developmental measures (see Slade et al.). Data from
these assessments allow us to evaluate change in a systematic way.
While space restrictions prohibit our elaborating the content and
process of home visits, (these are more fully described in Slade et al.
2005, and in Slade, Sadler, Mayes, Currier-Ezepchick, de Dios-Kenn,
Webb, Klein, Mitcheom, & Shader, 2004), we will briefly describe
what we see as the essential features of a reflective parenting program
(see too Goyette-Ewing, Slade, Knoebber, Gilliam, Truman, & Mayes,
2. This schedule of visits is determined largely by funding and personnel constraints, although extra visits are routinely offered in times of crisis or intensified demand.
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2003; Grienenberger, Popek, Stein, Solow, Morrow, Levine, Alexander, Ibarra, Wilson, Thompson, & Lehman, 2004; Slade, 2002). Our
ultimate goal is to help mothers acknowledge that the baby has a
body and a mind of his own, and to learnas a function of this
awarenessto tolerate and regulate the childs internal states. The
work almost always begins in the therapeutic relationship, with the
clinician holding the mother in mind so that she can begin to know
herself, only then slowly coming to know the child. We have found
that it is our clinicians willingness to witness the mothers world, to
witness her emotions and her body, to hold these in a safe way in the
here and now, that makes the mother feel heard and ready to know
the baby in all his complexity. This processand its various permutationsis manifest in the cases below.
Fonagy and his colleagues have described reflective functioning or
mentalization as occurring along a continuum, from an absence or
denial of mental states, to a simple capacity to recognize basic feelings and thoughts, to the emergence of true reflective awareness,
namely the capacity to understand behavior in terms of mental
states, and to understand both the nature and dynamic interplay of
mental states (Fonagy, Target, Steele, & Steele, 1998; Slade, Grienenberger, Bernbach, Levy, & Locker, 2004). Minding the Baby tries to
help mothers develop this capacity, with each of the clinicians doing
so in distinct, but complementary ways. The nurse provides ongoing
help in relation to physical health and caregiving, while the social
worker provides infant and parent mental health services and social
service support. At the same time, however, their roles overlap in a
number of ways, with both providing developmental guidance, crisis
intervention, parenting support, and a range of concrete supports
such as rides to work, emergency food, medical supplies, and the
like. As has been described again and again in the infant-parent psychotherapy literature, the very real needs of high-risk families require that they be helped at many levels at the same time; this demands constant flexibility and collaboration on the part of the
treatment team (Lieberman, 2003; Seligman, 1994).
As is true of all analytically based work, the development of a therapeutic relationship is at the heart of all parent-infant interventions.
However, establishing productive alliances with abandoned and traumatized women and their families is not easy. These alliances are regularly disrupted by powerful and elemental transferential reactions
on the part of mothers who have been betrayed and hurt by those
who cared for them. The home visitors are repeatedly inundated
with demands and crises (eviction, food shortage, domestic violence)
84
that require immediate action. So often clinicians struggle with rescue fantasies as well as feelings of futility and helplessness; often they
are intensely dysregulated by reports of violence to mothers and babies alike. The clinical teams ability to keep the infant in mind is
often challenged by the chaos, maternal pathology, and levels of extreme deprivation experienced by the family. Consistencythe
bedrock of any therapeutic workis difficult to achieve even at the
level of maintaining regularly scheduled visits. Add to all these complexities the fact that the multidisciplinary teamwhile sharing
common beliefs and valuesdoes not always share a common language. Although the construct of reflective functioning provides
common ground for discussion, as do the guiding principles of our
model, there are nevertheless crucial differences in approach that
must be managed against the backdrop of families prone to splitting
and disorganization.
The supervisory relationshipwhich sets the tone and parallels
developing therapeutic relationshipsbecomes critical to managing
these multiple levels of complexity. In Minding the Baby, the pediatric nursing specialist and clinical social worker are supervised
jointly; we see this approach as crucial to exploring the myriad diversions that threaten the clinical work. As a team, supervision is used to
set priorities, identify barriers, and explore alternative routes to enhance reflective capacities while addressing the concrete and physical needs of the family. Without supervision that is both clinically focused and personally validating, the teams own reflective capacities
are challenged and even diminished.
In the following sections, we will describe our work with Mia,
Iliana, and their babies. In some ways, theirs are similar stories: both
had babies as teenagers, and both of their childhoods were characterized by loss, trauma, and abandonment. At the same time, their
stories are different in important ways: they began the program with
different strengths and resources, and with very different openness
to internal experience. They differed in the degree to which they
had developed capacities for reflective functioning, in levels of ego
and self organization, and they struggled with different kinds and
depths of vulnerabilities; equally important, they had different levels
of support within their families and communities. Unsurprisingly,
their progress in a number of areas can be charted quite differently;
most important for our purposes in this paper are differences in the
development of mentalizing capacities in these two women. Both have
maderelative to their status at the beginning of the program
enormous progress. And yet both stories convey how complex and
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vulnerable progress is for women living with such enormous external

and internal burdens. Both stories also convey how such complexity
invariably requires multiple and flexible levels of care, care that we
feel is best provided by the integrated, multidisciplinary model offered by Minding the Baby.
mia
We first met Mia at age seventeen when she was seven and a half
months pregnant. Mia and her boyfriend Jaywho was eight years
her seniorwere living with his family in a situation that was both
chaotic and overwhelming. Mia had been forced to move out of her
home when her mother discovered Mia was pregnant. Mia had been
the great hope of her family; she had done extremely well in high
school, and was hoping to be the first member of her extended familys generation to go to college. But Mias hopes for the future had
been dashed by the conception of her unplanned baby. She dropped
out just months before her graduation from high school. The baby
solidified Mias already estranged status from her single mother, who
had disapproved of her boyfriend, whom she saw as certain to derail
her hopes and dreams for her daughter; as she put it: Youre just another teen mother statistic. Mia recalled, This never was supposed
to happen. Im breaking everyones hearts. What Mias solemn pregnancy story evoked but omitted in her whispery voice was that perhaps her heart, too, was broken.
When we met Mia, we found a young woman struggling to disavow
the reality of the baby and of her internal world on many levels. She
was doing everything she could NOT to think about her baby, and
was awkward, distracted, and almost dissociated when asked about
the baby. Oh . . . That. While there were small glimmers of anticipation of a new relationshipI talk to my belly, Mia could scarcely invest in this possibility. I just hope I still have it by the time its five.
(Her own mother had lost custody of her when she was five.) At the
same time, Mia showed a number of indices of what we might call latent capacities for reflective functioning. While these were scarcely
manifest in relation to her thinking about the baby, she was able to
reflect upon her initial denial of her pregnancy, and in so doing to
suggest a shift in her capacity to hold her complex emotions in mind:
I was in denial even up to my fifth month. I couldnt sleep, saying, I
know Im not pregnant. . . . I didnt know what to do. More striking
was her ability to describe her own complex fears and worries about
becoming a mother, andin particularher feelings of being lost
86
and overwhelmed. The depth and quality of her language, and her
capacity to vividly describe her pain led us to feel that as little as she
was able to imagine the baby, and keep any kind of a representation
of a relationship in mind as she prepared for motherhood, she was
able to give voice to her own anxieties and sense of confusion. This
proved to be a resource that was of great value to her once the baby
was born.
Both of our home visitors worked hard during the third trimester
to help the mother make room for the baby (Mayes & Cohen,
2001): preparing the room, planning for childcare, thinking through
labor and delivery. Mia had little conception of the childs concrete,
physical needs, and when encouraged, for instance, to wash a baby
doll in preparation for caring for her own child, she giggled uncomfortably and abandoned the activity, embarrassed. Signs of depressionwhich were to become far more pronounced after she gave
birthwere evident.
Mia gave birth to a healthy girl, Noni. While she had begun to
make amends with her own mother toward the end of her pregnancy,
she was still living with her boyfriends family. The home was dirty
and crowded with multiple relatives. The adults in the home were intrusive and often inappropriate; Mia had to guard her and the babys
food carefully. TVs blared and there was the din of the distant conversation. The progress that she had begun to make in pregnancy
reconciling a bit with her mother, beginning to give voice to her
fearsbegan to slip away, as Jay became disinterested in being with
the new mother and baby.
Her baby appeared well-cared for but Mia did not touch her readily, and Noni remained alone in her crib. Mia muttered, Shut up,
under her breath when Noni cried. Her movements were perfunctory and task-based. She admitted to crying daily, bathing less, and
not bothering to get dressed unless she had to go out. Mia was often
pale, her eyes puffy from crying. She spoke with eyes downcast, disgusted with her isolation and feeling of uselessness. Within one
month post-partum, the team felt that her depression had reached a
critical level (likely as a function of biological as well as other factors). As is very typical of the mothers we are working with, Mia was
averse to seeking psychiatric treatment, leaving us with little choice
but to address her severe depression in a way that respected her pace,
needs, and expressed wishes, but at the same time kept clearly in focus the very real possible risks to the baby. We decided that the social
worker should see Mia weekly, so as to provide the level of mental
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health services appropriate to the level of the psychiatric emergency.

At the same time, we did not decrease nursing visits, which she was
starting to use in a limited way. The last thing we wanted to do was
give her less of anything, and we felt that the nursing visits focus on
developmental guidance and parenting supportkeeping the baby
alive for her in the here and nowwas a crucial balance to the work
of uncovering and discovering the pain of her past.
With this shift, Mia began to find words for her despair, and she began to tell her story. While we had learned pieces of the story during
the evaluation period and the first months of the intervention, it was
only now, with the baby real, and Mias fragile denial and determination shattered under the weight of reality, that she began to tell us
about herself in a more detailed andfinally coherentway. Mia,
an only child, was born to a heroin addicted mother who was herself
a teenage mother. Mias father died of a drug overdose when she was
two; Mia was with her mother when she found him. When she was
five, following years of neglect, she was removed from her mothers
care and placed in foster care for two years. Remarkably, her mother
managed to get clean and bring Mia back to live with her. Despite her
own drug problems, Mias mother was a strong, determined woman
of enormous intelligence and perseverance who in her own way communicated a fierce loyalty and love for Mia. In many ways, Mias
mothers dreams had propelled her forward; at the same time, however, Mia sabotaged and bridled at these dreams (the pregnancy being a very clear example), and longed for the uncomplicated love
she had never had.
Over the course of the next few months, Mia began to forge a relationship with the social worker, giving voice to her feelings, and allowing herself to remember and describe moments and fears long
forgotten. Week after week came the small but significant indications
that the capacity to identify and reflect upon her internal states had
begun to take root. She could not talk about the baby, but she could
talk about her childhood experiences; slowly she found words for the
terror that was associated with these remembrances, and for her own
needs for comfort and support. These were feelings she had all but
deleted from her awareness. First came the memories, and the feelings, and then came the effort to make meaning. She began to create
a narrative, a story line that she could reflect upon, making meaning
of the present in light of the past. The social worker worried that
delving into such memories would be too painful and overwhelming
for Mia, and she watched vigilantly for signs of traumatic stress. She
88
did not push, but instead remained gently present, watching for
Mias glazing over, the sign that she had remembered and described
all that she could.
At four months of age, Noni was an attractive and communicative
baby, who in many ways managed to ignite Mias maternal capacities.
On occasion, she could elicit maternal traits in Mia such as affection,
playfulness, and pride. Mias competence and efforts to attend to the
routine care, if not the emotional care, of the infant, were highlighted and validated. Theres no one else that can comfort her like
you. Look how shes gazing right at you as if to say thanks. This
kind of comment, repeated multiple times over multiple home visits,
fed Mia on many levels, and acknowledged her importance to the
baby in ways that she herself could not yet recognize. Despite being
unable to recognize her babys experience, she was, however, able to
express complex feelings about her: I dont regret the baby, but I
wish I didnt have her so young.
At the same time that Mia could care for Noni competently and
sometimes lovingly, she could also be quite aggressive and harsh with
her. She had at this point no capacity to recognize or tolerate fear or
distress in her baby (having not yet been able to articulate her own
fears and need for comfort), especially fear and distress that she herself generated. Mias game of choice was to startle her infant, which
she would do in a variety of ways. She would loom into the babys face
quickly, smiling in a threatening way as she approached menacingly,
or she would shove a shrill squeaking toy intrusively in her face. Mia
delighted in this game, oblivious to Nonis startled grimace and
frozen expression. Noni would attempt a false, scared smile, as if she
needed to placate Mia and keep her at bay. Repeatedly, Mia raised
the threshold for tension, but did little to soothe the frightened baby,
re-enacting her own helplessness as a child. This scary experience
was repeated again and again, with the other adults finding similar
pleasure in startling and overwhelming Noni.
Equally disturbing was the fact that not only did Mia fail to recognize Nonis fear, but that she viewed Nonis response as false and manipulative. Whenever Noni would become distressednot only with
the startle game, but at times when she took a tumble or hurt
herselfMia would respond indignantly with some version of the
following: Faker! Big fake-crier! You dont fool anyone. Thus,
Nonis self-experience was both disavowed and distorted within the
context of her mothers response; it is these kinds of early relational
experiences that Fonagy and his colleagues (2002) so richly describe
as fundamental to a childs developing an abiding feeling of alien-
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ation and emptiness. Even in these early months we could see Noni
dissociated and frightened in interaction with her mother.
The next task was clearly to help Mia recognize her babys fear and
distress, feelings that were at this juncture too threatening for Mia to
see, even in her own history. We began by trying to elicit curiosity
about the babys intent, Why is she fake-crying? What could she
want by calling out to you? Focusing on the babys intentions helped
Mia slowly attend to the cues or events that led up to the babys distress. It also served as a chance to allow Mia to reflect upon her own
experience of the crying. How does it feel when you think Noni is
trying to trick you into paying attention to her? Her responses
opened up a discussion about the streets code of emanating fearlessness, denying needs, and feeling excited by fear. After revisiting
these themes many times over, Mia began to explore the times in
which she felt afraid, alone and/or felt like no one was taking her
needs seriously. Mia admitted that indeed her own obvious cries for
help in dealing with the overwhelming demands of straddling adolescence and motherhood were not being heard.
As the intervention proceeded, we did not approach these deficits
in Mias mentalizing capacities directly, of course, but rather began
by using the therapeutic relationship with the home visitors to give
voice to her own experiences of fear and distress. These therapeutic
relationships then became the platform from which she could view
the babys experienceher intentions and affectswith increasing
accuracy and clarity, without needing to distort or misinterpret as a
means of protecting her own fragile sense of self. Mias willingness to
hold the baby in mind was quite tenuous and fleeting at first, and
had to be nurtured in a variety of ways at all times, because her tendency to slip out of reflective awareness was so strong. Slowly, she began to be able to step out of automatic reactions and timidly observe
her childs feelings. Noni began to be able to express a more extended range of emotions toward her now more available mother.
When the baby was thirteen months old, Mia moved back into her
mothers home. She made the choice to move away from the father
of the baby because she believed it was a better environment for a
baby. When asked, Why now? she replied, Shes much happier. In the
other home, shed hold her hands over her ears, it was too much for her . . . I
wanted to for her. It was an easy decision. Mia was making links between the babys behavior (holding her hands over her ears) and internal dysregulation (too much for her), and she saw herself as instrumental in protecting the baby and providing her with a more
regulating and containing environment.
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tachment (Main & Solomon, 1986), but showed many signs of a secure attachment; this is a crucial marker of developmental and relational consolidation. Mia is still an adolescent, one who has suffered
a range of traumas in her short life. And yet, over the course of home
visits, we see the effects of these traumas diminishing in her day-today interactions with Noni. She finds pleasure in her, she plays with
her, she inhibits her own instincts to frighten and overwhelm. She
comforts her child and tolerates her distress. For the most part, Mia
can hold Noni in mind.
Despite Mias continuing struggles, when we contrast her behavior
with Noni at 4 months with the responsive and good enough
mother we see now, it seems evident that the slow effort to help Mia
keep Noni in mind has been successful, and we can feel somewhat
confident that there are protective factors in place for both Mia and
Noni that will make a big difference in both of their developments.
This in sharp contrast to Iliana, whose case we turn to next.
iliana
We met Iliana, 19 years old, at a group prenatal class in the second
trimester of her pregnancy. She was accompanied by the father of
her baby, a 20-year-old man with a previous history of substance
abuse and incarceration. During the two-hour class Iliana remained
attentive but maintained a skeptical distance from others in the
group. Indeed, distance and anger were to characterize Ilianas central struggles, both as they were manifested internally and in relation
to the team. In contrast to Mia, who from the beginning had some capacity to hold complex mental states in mind, Iliana was overtly more
angry, more defended, and much less able to tolerate and describe
her internal world. She had survived a childhood deeply marred by
chaos, poverty, and violence. Her mother had left the family when Iliana was five. Her father, deeply involved in drugs and alcohol, erratic and sometimes violent, had been her sole caregiver. She was sexually abused by her grandfather. However, the abandonment by her
motherof whom she spoke with bitterness and ragewas a defining moment for Iliana, a scar that would not heal. Ilianas defense
against pain was to threaten and push away anyone who got close to
her. She was proud of her toughness, her readiness to fight and establish her dominance on the street. She readily described herself as the
kind of person who would act before she thought, and was clearly
pleased at her capacity to frighten and intimidate people. At the
same time, though, impending motherhood had stimulatedas it so
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often doesthe wish to mother differently than she herself had

been mothered. Iliana wondered aloud if she could learn to be the
kind of mother the baby could count on. I know Ive got to change
and not just walk away or not talk when Im mad. Its not just me and
what I want anymore. This snippet of mentalization, in which she
linked her behavior to internal experience and recognized that her
own intentions and desires were changing, was brief and fleeting.
This was all we had to work with.
When Iliana revealed her pregnancy to her father and sisters she
was told that she was not fit to be a parent and was on her own. She
had only known the father of the baby for several months and the
pregnancy was unplanned. Their relationship was evidently troubled,
although it was not until much later in the work that we knew just
how troubled. She had little expectation of support from him
(maybe hell buy diapers) and obviously felt let down and alone.
Despite leaving high school during 10th grade, Iliana waslike
Miaclearly an intelligent and articulate young woman. Also like
Mia, she longed for work that would give her a sense of purpose and
meaning.
Unsurprisingly, it was very difficult to establish a therapeutic relationship with Iliana. Her armormanifested in her attitudewas
thick and tough. During the prenatal phase, she routinely failed to
show up for appointments. She never called to cancel, but when
phoned to reschedule, she always appeared interested in setting up
another meeting. We viewed this ambivalence in a positive light (at
least she was ambivalent), and she continued to reschedule appointments, well aware that she would fail to keep more than half of them.
We hoped that our continued presence signaled a willingness to
meet and work with her as she became ready and more trusting of us.
This was but the first sign of resistance that was to manifest itself continuously as treatment proceeded, and the first of many times that
our clinicians would have to remind themselves that her resistance
was based in fear rather than an outright rejection of intimacy.
Not surprisingly, the fear of closeness to others was reflected in her
relationship to her baby during pregnancy. I talk to it sometimes,
but I dont know why, she remarked. In this circumstance it was hard
to make baby real to the young mother-to-be, except as the reason
she had to stop hanging out at clubs. To stimulate her thoughts and
feelings we looked at pictures of newborns and discussed common
infant behavior that is often of concern for new parents. Looking at
the life-sized photo of a brand new baby, Iliana was finally able to
speak of her fears. Its hard to picture the baby. Ive never held a lit-
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tle baby. They are so small they look like they can break. And when
the baby criesI might get mad or nervous and just walk away! Embedded in these comments were signs of another set of difficulties
that were to recur throughout all phases of the treatment, namely Ilianas profoundly disrupted sense of her body. The new and frightening bodily sensations and discomforts of pregnancy made her feel
out of control and angry. She was terrified of labor, and particularly
frightened of the feelings of powerlessness and vulnerability that it
would engender; these feelings can be especially poignant in women
who have been sexually abused and who find labor retraumatizing.
As might be expected, Ilianas feelings about her own body were to
later define her feelings about and insensitivity to her babys body.
Giving birth was an empowering experience for Iliana. Anticipating the terror she would feel giving birth, the nurse practitioner developed a labor plan with Iliana that allowed her to make choices
ahead of time about medication, restraint, and other aspects of the
delivery (Simkins, 2002). The labor was difficult, but the labor
planwhich was supported fully by the midwifery teamallowed Iliana to feel in control of her experience. She was extremely proud of
herself, and her daughter was easy to feed and console. The new
mother held the babya girl named Luciaclosely, gazing warmly
into her eyes and imitating her facial expressions. We pointed out
how she was able to make the baby feel safe by holding her close and
how she was learning to read the infants cues to comfort her. Iliana
was enormously pleased that she could regulate the babys states to
reduce her crying episodes without becoming overwhelmed herself.
Given Ilianas tough veneer, and her enormous resistance to treatment, we had not allowed ourselves to hope for such an auspicious
beginning. But as so often happens, Iliana got an important developmental nudge from her easy little girl.
This positive beginning helped Iliana become more open to developing a relationship with the Minding the Baby team; however, unlike Miawho was able to form a relationship that allowed her to
move toward reflective understanding in relation to her babyIliana
and her relationship to us was defined by her concrete needs and demands on the one hand and by her angry resistance on the other. On
the one hand, there were moments when she could be tender toward
her daughter. At these times, however, Iliana was also reminded of
her own loss, of not having been nurtured and protected by her own
mother. Iliana said she longed to be a little girl all over again. Not to
have the childhood I did have, but to have someone take care of me.
As a consequence, she often could not tolerate the babys need for
94
care and comfort, and experienced Lucia as demanding and needy.

The babys distress irritated her, and she would handle her abruptly
and speak to her harshly. We observed her roughly awaken the baby
to change her diaper or harshly tell the baby to shut up when she
whimpered. She misattributed the babys facial expressions of discomfort as anger with her.
It seemed quite evident that any sign of distress in the baby
aroused her own feelings of sadness and helplessness and were thus
intolerable. It was very hard to help her at these moments, most
likely because our giving voice to the babys feelings made them even
more unbearable. She took our talking for the baby as criticism,
and responded with surly adolescent mumbling. Any hint of correction on our part (try though we might to remain benign and nonjudgmental) would trigger Ilianas hostility and defensiveness. At
such moments, she was extremely resistant to new ideas or ways of interacting with the baby. We had to work around her defenses.
Ilianas profoundly disrupted sense of her own body also interfered with her ability to see the babys needs as reasonable and separate from her own. Many times we would come to the home to find
her disheveled, her hair uncombed, wearing her torn nightclothes.
There were signs of neglect. Lucia was basically healthy, fed, and
clean, but Iliana routinely failed to follow through on caring for what
should have been routine physical care for her child. Lucia had
eczema, and on several occasions both mother and child had advanced cases of ringworm. With her eczema untreated, the baby often had a number of raised, scaly patches of skin and was irritable
and uncomfortable, which she would scratch continuously. Ignoring
the babys distress, Iliana instead complained of her own numerous
physical complaints, and reprimanded her daughter for scratching.
In thinking about how to help Iliana become more sensitive to her
childs bodily needs, we remembered that her relationship with the
midwife during her pregnancy allowed her to feel someone cared for
and she respected her body for the first time in her life. We wanted to
build on this new experience and find ways to demonstrate acceptance of the mothers body (and, therefore, her whole being) in a
caring way during home visits. Addressing Ilianas needs first, the
nurse practitioner spent time at each visit asking about her symptoms, using questions about her past and current activities, nutrition,
and abuse, to help the young woman make tentative connections between her feelings, symptoms, and self-care. We found that the more
the young mothers pain was acknowledged, heard, by the clinicians, the more able she was to understand her daughters needs and
experience.
Minding the Baby
95
Unlike Mia, who from the start couldat least in a limited way
engage in the struggle to understand her history, her relationships,
and her emotional experience, we had to approach Iliana through
her body, and through her concrete needs. She could not work at a
metaphoric or abstract level. When we tried to talk to her about her
feelings about her life experience, she would become enormously
sleepy and actually appear to doze off. Mentalization could only take
place at a very concrete, protosymbolic level (Werner & Kaplan,
1963). But as we did this, she began to involve us more directly in
helping her. It turned out that Lucias father had been abusing Iliana
throughout the pregnancy, and he was now continuing to physically
threaten her. This was the other side of Ilianas toughness: the paralyzed victim. Once she disclosed his abuse to us, she was able to use us
to help her obtain an order of protection, and to support her desire
to protect her baby. At this time she became more overtly dependent
upon the home visitors, and in particular needed a great deal of social service help to obtain a place to live as well as a variety of social
service benefits. Her extreme neediness was experienced by the
home visitors as a continuing volley of demands, within the context
of which they had to continuously work to keep the baby in mind
for Iliana. These demands only increased when we decreased the
number of regular home visits when Lucia turned one (a standard
transition in the Minding the Baby protocol). She responded with
overt indifference and appeared to pull sharply away, but she began
to call us nearly daily with minor and major crises. Iliana the tough
and defended young woman who needed no one could not get
enough of us.
Over time Iliana has slowly become more aware of her babys experience. When Lucia was 15 months old, Iliana, her new boyfriend,
and the baby moved into a tiny apartment of their own. Iliana complained that the toddler was always in the way. Always trying to do
what I am doing. It makes me crazy! The nurse practitioner brought
over a small plastic tub and a few containers for the little girl to play
in, and asked the mother to follow the babys lead while she herself
washed the dishes. Imitating her childs actions, Iliana suddenly
saw what the child was doing. In imitating her daughters splashes
and play with soap bubbles, she laughed and exclaimed, Oh! This is
fun! She had a sense of the childs internal experience at that moment and recognized that the sharing of the experience brought
them closer together. She was able to express this feeling to her child
by having a short conversation about what they were doing. This realization has sometimes spilled over into other parts of their life together. Recently Iliana laughingly described her daughter as being
96
her own little self. Iliana had been outside watering the flowers in
the garden, andanticipating her childs desire to be included
had dressed her in a swimsuit. She had understood and accepted her
babys desire to be nearby and involved with her, as well as to explore
her expanding world. The childs jubilant response served to reinforce and build on her mothers new capacities.
These moments of seeing the baby and taking pleasure in her have
been accompanied by other shifts as well. Iliana now uses her community health center for routine medical care instead of going to the
ER. She has a relationship with her primary care providers, facilitated by the nurse practitioner, who has served as a bridge between
clinic and mother in an ongoing way. For Iliana, who has in the past
tried to control her body and that of her babys as a means of regulating her fragile sense of self, the willingness to allow others to care for
her and her body is crucial.
As is captured in Ilianas own words at the opening of this paper,
we also began to see signs of limited reflective functioning across a
number of domains. While significantly less widespread and deeply
held than Mias capacity to understand and hold her baby in mind,
there were signs that she had begun to understand that there was a
baby to be known. She tentatively acknowledged that she had begun
to allow the home visitors to get to know her, and to witness her experience. She has acknowledged the power of her mothers abandonment and her own unrequited longings for love and simple care. She
began to talk about her childs needs and understanding as being different from her own. Thus, even though these reflective capacities
can easily disappear in an instant when she becomes angry or threatened, it is nevertheless becoming more natural to her to think about
the baby in this way.
At the same time, it is important to acknowledge that there are
profound limitations to Ilianas reflective capacities, even after nearly
two years of treatment. Unlike Mia, Iliana has not been able to develop and rely upon a narrativea story of herselfthat helps her
to contain and make sense of her complex emotional experience.
The understanding she does have often fragments under the intensity of her feelings. These kinds of phenomena have been described
by Fonagy (2000) as typical of individuals who have suffered extensive trauma and who would be diagnosed with a borderline personality disorder. This is certainly a meaningful way to describe Iliana. She
can still be openly neglectful of Lucia, and very harsh with her, although now she yells instead of slaps. Nevertheless, we worry that we
will have to get child protective services involved, as there continue
Minding the Baby
97
to be multiple signs that Lucia is often in danger, either from Ilianas

neglect or for Iliana herself. We understand the limitations of Ilianas
availability to treatment as a function of multiple factors, most prominent being past and ongoing trauma and the lack of a stable, loving
caregiver. In addition, Iliana had endured continuous disruptions in
her sense of bodily integrity and wholeness; often, these assaults had
been at the hands of those who were responsible for caring for her.
Discussion
As she approaches her childs second birthday, Mia has begun to
hold her child in mind. Ilianas abilities to do this are far more compromised and fragmented, although she too has discovered reservoirs of pleasure in and identification with her child that are crucial
and even miraculous. Developmentally, these young women began
Minding the Baby with significantly different capacities for reflective
functioning and mentalization, with Miawhile quite defended
the more ready of the two to think in a complex way about her interior life, and about the dynamic relationship between her feelings
and actions. While certainly no stranger to trauma, Mia had managed to escape the physical trauma and abandonment that had devastated Iliana, and had found crucial comfort and safety in her relationship with her mother, who in her own narcissistic fashion kept
her daughter in mind. From the standpoint of reflective functioning,
Iliana began the program without any evidence of such capacities,
and Mia began with at least rudimentary openness to acknowledging
mental states, and occasionally holding their interconnectedness in
mind.
Our multidisciplinary model allowed us to approach these differences in a flexible way, to balance the nursing and infant-parent psychotherapy approaches in response to different kinds of supports
these mothers needed at different times. Mia was more ready to
make use of a more traditionally therapeutic relationship with the
home visitors; the first real shift in her treatment came in beginning
to tell her own story to the social worker. She required relatively little
help with physical care, but instead relied upon the nurse practitioners expertise in parenting and child development. Iliana, on the
other hand, needed a great deal of practical help from the nurse
practitioner, and only when she had established an almost physical
dependency upon this concrete level of mothering from the team
was she able to begin to take in any developmental guidance or parenting support. She used the social worker to help her obtain social
98
services, again needing this kind of very concrete help to support any
reflective capacity whatsoever.
We think that the progress made by the mothers and babies in our
program has comefinallyfrom our home visitors capacity to
hold their bodies and feelings in mind, to witness their pain and
their anger without dysregulation and retribution, and to keep the
baby alive for the mother in the face of relentless chaos and uncertainty. As we hope we have been able to convey in our description of a
mentalization based, multidisciplinary mother-infant intervention
program, this is complex work indeed.
BIBLIOGRAPHY
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90
When Noni was 14 months old, 17 months after Mias entry into
the program, the social worker reviewed a videotape that had been
made of Noni and Mia interacting when Noni was 4 months old. Mia
was obviously troubled in watching the tape, and noted readily how
insensitive she had been to Nonis cuesI had no idea what she
wanted, I couldnt read her . . . I see now that her crying was to tell
me shed had enough . . . here I can see her face sad telling me what
I didnt know, that she may have been hungry or sleepy . . . Shes trying to tell me shes scared, and Im just in her face, scaring her.
While Mia tried throughout the sessions to minimize and deflect
some of the guilt she felt in recognizing her failure to hold Noni in
mind, she was nevertheless fully cognizant of the fact that she was ignoring signs of distress that she was readily able to identify in retrospect. This
reaction signified crucial progress to the treatment team.
The central focus of the work of both home visitors was to make
Noni and her internal world real to Mia, slowly and in a way she
could tolerate. At the same time, it is important to highlight the fact
that the work was taking place on many other levels as well. Mia was
overwhelmed by her living situation, and we worked in a variety of
ways to help her make Jays family home safer for the baby. This
meant she first had to recognize that the baby required safety and
that she could participate in providing that. Filters were provided
that protected the baby from the smoke in an environment where
everyone smoked cigarettes. She needed help with travel to and from
school, with birth control, with obtaining food for the baby, and with
basic caretaking skills. We brought toys and baby books, and taught
her how to play with the baby. She had several frightening blow ups
with Jay (who had a history of violence), which required our help in
sorting out. All reflective work took place against this backdrop of
concrete support and education: help in stress reduction, vocational
planning, safety procedures, medical care, and the like. Without
these levels of support, the therapeutic work would have been utterly
impossible.
Noni is now 20 months old, and Mia is living in her mothers clean
and orderly home. Jay is still firmly in the picture; indeed, he is often
present at home visits, and is proud of his understanding of development, as well as the mutual feelings of love and attachment that he
and Noni obviously have for each other. Noni is clearly a loved child,
cherished by the extended family on both sides. When seen in the
Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978), a laboratory based separation procedure that is used to assess infant attachment status, Noni was not classified as disorganized in relation to at-
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reflective functioning in a nursing/mental health home visiting program.
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manual. New Haven, Conn.: Yale Child Study Center.
Stern, D. N. (1995). The motherhood constellation: A unified view of parent-infant psychotherapy. New York: Basic Books.
Wald, L. (1915). The house on Henry Street. New York: Henry Holt and Company, Inc.
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In a Black Hole: The (Negative)

Space Between Longing
and Dread
Home-Based Psychotherapy with a
Traumatized Mother and Her Infant Son
JUDITH ARONS, LICSW
This paper offers fragments from the first year of a home-based motherbaby psychotherapy, in which I attempted to help a traumatized and
dissociated mother to emotionally engage with her infant son. The
treatment was organized in part around certain developmental objectives common to both attachment and psychoanalytic theory. These include: The ability to name and metabolize feelings, to evoke a soothing
maternal introject, and to relate to the partners mind as a separate,
understandable center of initiative and intention. In addition, attachment theory, with its emphasis on the critical psychobiological role of
containing fear and distress in infancy, was a useful guide in formulating the treatment. The paper reviews research findings on motherSenior faculty member of the Infant-Parent Training Institute at Jewish Family and
Childrens Service of Waltham, Massachusetts, and a lecturer at Simmons Graduate
School of Social Work, and member of the Boston Psychoanalytic Society and Institute and the Massachusetts Institute for Psychoanalysis.
I gratefully acknowledge Karlen Lyons-Ruth, Ph.D., for her invaluable clinical and
editorial input, George Ganick Fishman, M.D., for his untiring support, Sarah Birss,
M.D., and Ann Epstein, M.D., for teaching me so well, the Center for Early Relationship Support at the Jewish Family and Childrens Service of Waltham Massachusetts,
for making it possible, and Mary and John for showing me the way.
101
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Judith Arons
infant pairs described as frightened-disorganized, discusses some of the

challenges encountered in home-based mother-infant psychotherapy
and then discusses the case of Mary and John. The case illustrates how
mother-infant psychotherapy may interrupt the intergenerational
transmission of disorganized attachment by working within the couple
to name, metabolize and flexibly respond to painful, dissociated or
frightening experiences.
this paper offers fragments from the first year of a motherbaby psychotherapy in which I attempted to help a traumatized and
dissociated mother to emotionally engage with her infant son. My
work with Mary and John was organized in part around certain developmental objectives common to both attachment and psychoanalytic
theory. These include: the ability to recognize, to name, and to metabolize feelings; the ability to evoke a soothing maternal introject to
aid in containment and integration of self states; and the ability to be
aware of and to relate to the partners mind as a separate, understandable center of initiative and intention. Attachment theory, with
its emphasis on the critical psychobiological role of modulating and
containing fear and distress in infancy, was a useful guide in formulating the treatment with this terrified mother and her emotionally
disorganized son. In this first year of our work we attempted to expand emotional communication and to enhance feelings of security
and reliability both within the mother-baby couple and between
mother and therapist. The clinical cornerstone of my approach was
to track carefully to each individuals emotional state and to how
each of us co-regulated our present intersubjective experience
(Stern, 2004). Whenever possible we attended in the moment to the
relationship between mother and baby, mother and therapist, baby
and therapist, and baby, mother, and therapist together. This attention to relating in the present included my assumption that past and
deeply private psychic experiences were summoned by and also
helped to shape the current moment. The paper begins with a review
of research findings on mother-infant pairs in which the infants attachment is described as disorganized and the mothers caregiving as
frightened or helpless. I will briefly describe some of the challenges
of home-based mother-infant psychotherapy and then move on to
the case and discussion.
There are relatively few case studies describing the psychoanalytically informed treatment of frightened/disorganized mother-infant
couples, and we have little clinical data documenting the therapeutic outcomes of such interventions. It is my belief that within fright-
In a Black Hole
103
ened/disorganized dyads, mother-infant psychotherapy may interrupt the intergenerational transmission of disorganized attachment
by working within the couple to name, metabolize, and flexibly respond to painful, dissociated or frightening affective experiences.
The resulting increase in mother and babys affective competence
(Russell, 1998) paves the way for further growth of intersubjective relating between them.
The Infants Experience of Disorganized Attachment:
Research Findings
Disorganized attachment in infants is defined as the childs inability
under stress to maintain a consistent strategy that engages the primary caregiver in the service of regulating arousal and receiving
comfort and protection (Main and Hesse, 1990a). The babys relational strategy breaks down or cannot form, due to an irreconcilable
emotional paradox within the caregiving dyad: his primary attachment figure is at once the source of his fear and his refuge from it
(Main and Hesse, 1990a). In the research lab, stressful separationreunion experiences of the Strange Situation highlight the contradictory behaviors indicative of disorganized attachment. Despite upset
during her absence, the infant, upon reunion with mother, appears
to be dysphoric, apprehensive, or helpless, and he exhibits conflicted
behaviors that include wandering in a disoriented state, making slowmotion underwater movements, and approach-avoidance or stilling/
freezing in a dissociative-like response (Lyons-Ruth, Bronfman and
Atwood, 1999b, Lyons-Ruth and Jacobvitz, 1999a, Main and Hesse,
1990a, Main and Solomon, 1990b). Sometimes the infant exhibits an
unusual combination of attempts at approach coupled with odd or
inexplicable gestures (Lyons-Ruth and Jacobvitz, 1999a).
Frightened Mothers of Disorganized Infants:
Research Findings
Mothers who struggle with unresolved trauma and loss are at high
risk for unwittingly engendering attachment pathology in their infants. Researchers have categorized these mothers as hostile/helpless or frightened/frightening, and link mothers unresolved state
of mind with regard to trauma and loss to the formation of disorganized attachment in her infant (Main and Hesse, 1990a, Lyons-Ruth,
Bronfman, and Atwood 1999b). While researchers agree that there is
a correlation between mothers unresolved state and her ability to
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Judith Arons
provide responsive and consistent infant care, there is disagreement

on the mode of transmission of disorganized attachment. For example, Main and Hesse hypothesize that The traumatized adults continuing state of fear together with its interactive/behavioral concomitants (frightened/frightening behavior) is the mechanism
linking unresolved trauma to the infants display of disorganized/
disoriented behavior (1990a, p. 163). They speculate that when
mother is frightened or helpless her emotional withdrawal leads to
dysregulation in her infant. Taking a slightly different tack, LyonsRuth and colleagues speculate that the infants inability to maintain a
cohesive attachment strategy is actually the echo of his mothers contradictor affective cues (personal communication, 2002).
My discussion will focus on the frightened/disorganized subgroup
of mothers and their infants. Unlike mothers who display overt hostile or intrusive behaviors toward their babies, frightened mothers
appear dissociated, preoccupied, and tentative. On the behavioral
level mothers responses to the Strange Situation demonstrate subtle,
contradictory reactions to the childs bid for comfort and care, like
stepping away while speaking in a soothing tone (Lyons-Ruth, Bronfman and Atwood, 1999b, Schuengel and Bakermans-Kranenberg et
al., 1999). Her emotional cues are incongruent or non-responsive
sometimes with sudden loss of affect (Lyons-Ruth and Jacobvitz,
1999a, Schuengel and Bakermans-Kranenberg et al., 1999). She may
appear disoriented or confused by the childs behavior, or react to
baby in a helpless, frightened, deferential, or sexualized manner
(Main and Hesse, 1990a, Schuengel and Bakermans-Kranenberg et
al., 1999). On the representational level, mothers performance on
the Adult Attachment Interview reveals unmonitored lapses of reason and coherence in discourse, affective incongruence, intrusion
into consciousness of dissociated material, and multiple and discontinuous inner representations (Lyons-Ruth and Jacobvitz, 1999a,
Main and Hesse, 1990a). Liottis work has noted the similarity of
these responses to dissociative processes in adults (1999, 1992).
From a clinical perspective, mothers caretaking appears parent
centered and organized around her defensive exclusion of painful
feelings (Schuengel and Bakermans-Kranenberg et al., 1999, LyonsRuth, Bronfman and Atwood, 1999b). Along with unintegrated internal representations and difficulty regulating her own affect, mothers
unresolved state of mind impairs her ability to respond to babys cues
in a sensitive and non-conflicted way (Schuengel, and BakermansKranenberg et al., 1999) and impedes her capacity to repair affective
disruptions within the dyad (Lyons-Ruth et al., 1999). Mother de-
In a Black Hole
105
fends herself against the threat of her babys fearful expressions and
his need for comfort by restricting her awareness of his state (LyonsRuth, and Jacobvitz et al., 1999a). She is hindered in providing the
adequately attuned affective envelope that would instill an experience of felt security in her baby. Mother also shows impairment in
self-reflective functioning and in her ability to reflect upon her child
as a separate individual with a unique inner life. Self-reflective capacities are thought to be among the key mediators in the transmission
of secure attachment (Fonagy, 2001, Fonagy and Target, 1997, Fonagy and Steele, et al., 1991).
Frightened/disorganized mother-infant dyads teach us of the profound impact of attachment disturbance and chronic fear upon the
development of psychological processes and psychic integration. Disorganized attachment places infants at serious risk for impaired affect regulation and right brain development (Siegel, 1999, Schore,
2001a&b), the onset of dissociation in adolescence and adulthood
(Lyons-Ruth and Jacobvitz, 1999a, Lyons-Ruth, Bronfman and Atwood et al., 1999b, Liotti, 1999 & 1992, Bleiberg, 2002), excessively
caretaking, controling, or frankly aggressive behaviors (Lyons-Ruth
and Jacobvitz, 1999a, Lyons-Ruth, Bronfman and Atwood, 1999b,
Lyons-Ruth, Alpern and Rapacholi, 1993, Jacobvitz and Hazen, 1999,
Solomon, George, and DeJong, 1995), chaotic internal representations (Fonagy and Gergely, et al., 2002, Fonagy and Target, 1997, Liotti, 1999 & 1992, Main, 1991), impairment of mastery motivation,
autonomous exploration, and problem-solving (Bretherton and Waters, 1985), poor self-reflective functioning (Fonagy and Target,
1997, Fonagy and Steele, et al., 1991) and compromised cognitive
functioning (Moss and St. Laurent, et al., 1999).
Chronic and unresolved fear leaves its indelible imprint upon neurological and psychological functioning. The impact of chronic fear
on brain development and functioning, stress arousal systems, and
physical and mental health has been well documented. Negative sequelae of Type Two (chronic) trauma in childhood include relational disturbances, dissociation, profound affect dysregulation, inner fragmentation and compromised cognitive functioning, and
living with sickening dread or unremitting sorrow (Terr, 1991).
Some Challenges Encountered in
Mother-Infant Psychotherapy
Before discussing the specifics of therapeutic work with frightened/
disorganized dyads, I will broadly describe some of the challenges en-
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Judith Arons
countered in mother-infant work. Home-based mother-infant psychotherapy provides a living laboratory in which to substantiate or
to disprove the rich data generated in the infant research lab. Unlike
the relatively controlled conditions of the infant lab, mother-infant
intervention takes place in the freewheeling realm of the home. It
makes therapeutic use of improvisation and surprise. The work requires a holistic, versatile, and dialectical approach buttressed by all
that we have learned from relational, developmental, neurological,
and biological systems theories.
This is couples treatment in which one member is wordless and
communicates through the language of body and affect. Babys nonverbal communication drives the therapeutic triad deeply into the
affective, implicit domains of experience, while also stimulating exploration within the reflective, symbolized domains. Home-based
mother-infant treatment parallels the work that parents do daily in
raising their children: We attempt to feel what it is that baby is expressing, as we also try to name it, give it meaning, and hold it in
mind. Of course we also attempt to feel what the baby stimulates in
his mother, name it and hold it in mind, but this is a more familiar aspect of psychoanalytic work with adults.
The therapists experience is one of joining a constantly shifting
relational system that moves between poles of repetition and transformation (Lachmann, 2001). This system and the treatment are
filled with paradox. There is the infants press to develop, to accommodate, and to emerge as an individual within the mothers more
fixed psychic system. There is mothers need to be recognized as the
individual she is. She struggles with this need in the midst of her own
negative representations and in face of her babys real and constant
demands. Mothers childhood experiences tie her to the past, even
as she struggles to break these ties and move into the future with her
child. Her relationship with baby lays bare her difficulty in developing those processes that would help to contain painful feelings and
maintain consistent and sympathetic attachments. She longs to give
her child a better life, but is mired in chronic difficulties that take
time to recognize and to rework.
For the therapist, the responsibility of intervening in the life of a
very small child is great. She must live within the paradoxes of acting
versus waiting, proscribing behaviors versus enabling them to
emerge, moving into the future while honoring the past. Babys
needs are such that he cannot wait for his mother to change. His
presence in the session coupled with his developmental dynamism
and very real dependency exert tremendous pressure upon both
In a Black Hole
107
mother and therapist. This pressure stimulates intense transferencecountertransference responses, and lends transformative power to
mother-infant work.
The Frightened/Disorganized Dyad: A Clinical Perspective
Frightened/disorganized mother-infant pairs can present a confusing clinical picture and each dyad is unique. The pathogenic interactions that occur are more difficult to see than the easily observed hostile-coercive behaviors found in other disorganized couples. One
observes a number of positive mother-baby interactions and few
overt fear-inducing behaviors. In many cases one initially senses a
subtle climate of misattunement. The extent to which this climate reflects disorganization takes time to assess.
The frightened mothers eagerness for professional help can inflate assessment of her capacity for relatedness. In the home one begins to notice mother-baby interactions that are shaped according to
which emotions mother can tolerate. It is often the infant who is responsible for approaching her. Careful observation reveals a mixed
picture of maternal gentleness and sensitivity combined with affective miscommunications, or sudden loss of affect and attention.
When mother struggles with dissociative states or impaired relatedness, she will be unable to consistently keep her baby in mind. Emotional blank spaces or black holes may exist within the dyad. These
pockets of emptiness can be hard to observe in a rapidly moving relational scenario that also contains positive mother-baby relating. Unlike hostile mothers who may overwhelm baby with their intrusive
and undifferentiated responses to his distress, frightened mothers
may miss the distressed babys cues altogether, or respond in a contradictory, deferential, or helpless manner. This failure to provide
consistent affect regulation can send the infant into emotional freefall. During these moments he may be overwhelmed by uncontained
or unmirrored experience.
Mother and baby interact differently in the various domains of
care, which take time to observe and to assess. Negative or dysphoric
exchanges may stress mothers capacity to remain sensitively engaged
more than interactions that are positive or neutral. The distressed
baby who makes an intense emotional bid for his mothers comfort
and protection arouses different emotions in her than the baby who
rubs dinner in his hair or joyfully shares a toy. When difficult emotions or painful memories are aroused, mother may appear passive,
preoccupied, and unable to scaffold her babys experiences.
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Judith Arons
On the other hand, some of mothers responses are relaxed and

flowing. Sometimes she responds positively to her infants desire to
connect and interacts warmly and spontaneously. At other times she
is able to react positively to babys attempts to structure their interactions, taking his lead and responding with appropriate feeling.
The infants of frightened/disorganized mothers may show relatively subtle signs of disorganization themselves. In situations where
mother and child do engage in some attuned interactions, the child
continues to request comfort and care. Disorganized attachment research indicates that the infants of frightened mothers may show a
superficially secure attachment strategy when stressed, but that unusual behaviors exist in conjunction with more normative ones.
Sometimes the disorganized babys approach-avoidance behaviors
can look more like ambivalence than the absence of a consistent attachment strategy.
The mothers of disorganized infants may present within a wide
spectrum of psychological functioning (Lyons-Ruth, personal communication, 2002), leading one to speculate that diagnosis and treatment may involve a sophisticated and subtle assessment of motherbaby interactions. In the following case vignette mothers severe
trauma history, her cognitively and affectively disjointed manner of
relating this history, her dual diagnosis of alcoholism and bi-polar
disorder, and her alienation from herself and her son are all consistent with the more severe spectrum of the disorganized dyads described in infant research. On the other hand, mother and son related to one another in a fair number of loving and mutually attuned
ways that were surprising in light of such a troubled history.
Mary and John: Initial Impressions
Mary, a thirty-two-year-old married mother of a twelve-month-old
son, was referred to The Center for Early Relationship Support by
her psychopharmacologist, after her recent discharge from an alcohol detox program. The Center for Early Relationship Support is
part of the Jewish Family and Childrens Service of Waltham, Massachusetts, and offers a variety of therapeutic services to parents and
infants, including home-based parent-infant psychotherapy. At the
time of referral Mary and John were also being followed by Child
Protective Services. Mary had been diagnosed with PTSD, alcoholism, post-partum psychosis, and bi-polar disorder. At our first
meeting she said, I want to be a good mother, to give my son more
than I got, but I dont know how. I had horrible mothering, no role
models. I am a drunk and a loser. I dont even feel that much for my
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109
son. I dont know who I am or what Im doing here. Mary was unable to claim her son or to acknowledge her motherhood, I cant
call myself his mother, I dont deserve him. Sometimes I think he
hates me and would be better off with someone else. Mary had been
sober for only twenty-eight days.
My visits to the home revealed Mary to be a sweet and tentative
mother who was struggling to stay sober and to care for her child.
John was a beautiful twelve-month-old with a shock of curly blond
hair and ice-blue eyes. He was cheerful, curious, and engaging. He
approached his mother for help and to share his toys, and they would
laugh or be silly together at his prompting. I observed Mary and
John sharing moments of pleasure, joy, and hilarity. Mary responded
well to the structure afforded by particular aspects of Johns daily
care. She showed sensitivity to his cues around eating and being diapered. In these domains John was never made to feel passive, ignored, or intruded upon by his mothers agenda. Mary would wait
patiently for John to signal the next spoonful or when it was time to
continue diapering or dressing him. These interactions included
much mutual gazing, turn-taking, and playful physical contact. Mary
could also be attentive and natural in her responses to Johns ebullient expressions, and he regularly looked at her and reached for her
to help him. As John interjected himself into the adults conversation
Mary would encourage him proudly and speak of what a good and
beautiful boy he was.
But coupled with these positive behaviors were more ominous interactions. John often crawled around the house with the pet dog,
dangerously unsupervised. He had difficulty focusing in on toys or
play, but could spend an hour amusing himself alone in his crib. In
these early home visits John would sometimes cry from the other
room in the middle of some mishap, as Mary, in a world of her own,
spoke to me of her terrible childhood experiences, her guilt, and her
urge to drink. Mary asked, Is it o.k. for him to play alone so much? I
dont want him to grow up with a black hole in the middle of him like
I have. Marys eyes spoke volumes of her fearful inner world, but her
narrative tone was one of disorienting cheer. In our first interview
she revealed the depth of her alienation, I wake up in the morning
and I wonder, whose baby is this, whose house is this, whose life is
this?
Throughout our initial meetings Mary revealed her painful story.
Her narrative was filled with contradictions, lapses in reasoning, and
affective incongruence. Sequencing of events was so confused that I
was unclear exactly what had happened to her and when.
Marys intense self-absorption and dissociated states initially placed
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John on the periphery of our conjoint work. I observed that she did
not seek John out as an emotional companion; it was he who initiated this type of contact. From time to time he could successfully engage her but I wondered how much work he had to do to make this
possible. Mary could not consistently help John transform his negative states to positive or neutral ones. When he was distressed she
would pick him up, but then put him down before he was sufficiently
calmed. Toys were often offered as comfort instead of her body or
voice. Mary often allowed John to get into highly charged emotional
states that were on the verge of decompensation. She was unable to
play with him; there were few spontaneous gestures of affection, and
she often asked if he would like to go up to bed.
I was uncomfortable with how little we included John in our initial
sessions. He was continuing to do all the reaching out for contact,
and I was caught between the imperative need to include him and
my concern that doing so would cause Mary to feel ashamed or overwhelmed.
History
After Johns traumatic birth (a mishandled forceps delivery resulting
in a subdural hematoma and seizures), Mary plunged into a post-partum psychosis, started to hear voices, and began to drink heavily.
Some months into the treatment I learned that for the first eight
months of his life, John was neglected and left alone for long periods
of time in his crib without food or diaper change. Mary would drink
and go to bed, covering my head so that I couldnt hear his cries.
For these first eight months Mary was living with her husband Peter
and his parents, all of whom were at work during the day. Peter was
unable to offer adequate protection or containment for his wife and
son. He was aware of Marys drinking, but desperate to keep his job
and needed to deny a drinking problem of his own. Then when John
was about three months, Peter demanded that Mary enter a detox
program, which she did. There were two unsuccessful hospitalizations during this time. A year into our treatment Mary shared that
she often cared for John in drunken blackout states, and lived in terror that she had physically injured him. During his first eight
months, John responded well to the evening return of his father and
grandparents, but there was tension between Mary and her parentsin law. When John was nine months Mary and Peter moved with him
into a home of their own. The move allowed Mary to be closer to her
father (a twenty years sober alcoholic), and enabled Mary to attend
Minding the Baby
99
Fraiberg, S. (1980). Clinical studies in infant mental health. New York: Basic
Books.
Freud, S. (1923). The ego and the id. S.E., v. XIX, p. 26.
Goyette-Ewing, M., Slade, A., Knoebber, K., Gilliam, W., Truman, S. &
Mayes, L. (2002) Parents first: A developmental parenting program. Unpublished Manuscript, Yale Child Study Center.
Grienenberger, J., Popek, P., Stein, S., Solow, J., Morrow, M., Levine, N.,
Alexandre, D., Ibarra, M., Wilson, A., Thompson, J. & Lehman, J.
(2004). The Wright Institute Reflective Parenting Program workshop training
manual. Unpublished manual, The Wright Institute, Los Angeles.
Heinicke, C., Fineman, N., Ruth, G., Recchia, L, Guthrie, D., & Rodning, C. (1999). Relationship-based intervention with at-risk first time
mothers: Outcome in the first year of life. Infant Mental Health Journal, 20,
349 374.
Heinicke, C., Fineman, N. R., Ponce, V. A., & Guthrie, D. (2001). Relation
based intervention with at-risk mothers: Outcomes in the second year of
life. Infant Mental Health Journal, 22, 431 462.
Herman, J. L. (1992). Trauma and recovery. New York: Basic Books.
Kitzman, H., Olds, D., Henderson, C., Hanks, C., Cole, R., Tatelbaum,
R., et al. (1997). Effect of prenatal and infancy home visitation by nurses
on pregnancy outcomes, childhood injuries and repeated childbearing.
JAMA, 278, 644 652.
Kitzman, H., Olds, D., Sidora, K., Henderson, C. R., Hanks, C., Cole, R.,
Luckey, D. W., Bondy, J., Cole, K., & Glazner, J. (2000). Enduring effects of nurse home visitation on maternal life course. JAMA, 283, 1983
1989.
Korfmacher, J., OBrien, R., Hiatt, S., & Olds, D. (1999). Differences in
program implementation between nurses and paraprofessionals providing home visits during pregnancy and infancy: A randomized trial. American Journal of Public Health, 89, 18471851.
Lieberman, A. F. (1997). Toddlers internalizations of maternal attributions
as a factor in quality of attachment. In Attachment and Psychopathology, eds.,
K. Zucker & L. Atkinson. New York: Guilford, pp. 277290.
Lieberman, A. F. (2003). Starting early: Prenatal and infant intervention. Paper
presented at Irving B. Harris Festschrift, Chicago, May 12, 2003.
Lieberman, A. F., Weston, D., & Pawl, J. (1991). Preventive intervention
and outcome with anxiously attached dyads. Child Development, 62, 199
209.
Lieberman, A., Silverman, R., & Pawl, J. (1999). Infant-parent psychotherapy: Core concepts and current approaches. In Zeanah, C. H. (Ed.) Handbook of Infant Mental Health, pp. 472485. New York: Guilford Press.
Mayes, L. C., & Cohen, D. (2002). The Yale Child Study Center guide to understanding your child. New York: Little Brown.
Olds, D. (2002). Prenatal and infancy home visiting by nurses: From randomized trials to community replication. Prevention Science, 3, 153 172.
Olds, D., Hill, P., Robinson, J., Song, N., & Little, C. (2000). Update on
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111
twice daily AA meetings. At that time Mary was frantic and depressed
about Johns behavior toward her. Until he was eleven months, John
rejected his mothers attempts to connect. He screamed when she
held him, would not gaze into her eyes, and would not smile at or
reach for her. One month into Marys sobriety John began to reach
out to her for comfort and to track her visually, but at thirteen
months he developed a strange rolling eye movement in her presence. John had been followed neurologically since birth and there
had been no sequelae from his early seizures or hematoma. The
strange eye movement was determined to be non-organic in nature.
Marys own childhood had been devastating. When she was a one
year old her schizophrenic mother attempted to drown her in the
bath and she required resuscitation. Mother then abandoned the
family and was in and out of young Marys life. For a time Mary was
passed among relatives so that her father could work. When father
remarried three years later (Mary was four) she lived through cruel
and degrading neglect at the hands of her stepmother, who locked
her in her room each day, refusing to feed her or allow her to use the
toilet. She was often locked outside of the house while her stepsiblings had after-school snack. In winter the kindness of an elderly
neighbor sheltered Mary from the cold.
Mary began to drink at age fourteen. But despite the depth of her
difficulties, during adolescence Mary felt she had the love of her paternal grandparents and recently sober father. She lost her fear of
her evil stepmother and became provocative and oppositional. She
successfully completed high school and college and went on to have
several interesting and responsible jobs. She fell in love with a gentle
if troubled young man, and married into a large family.
Formulating the Treatment
The initial treatment plan was to offer weekly mother-infant sessions
in the home in conjunction with twice daily AA meetings. But two
months into our work Mary began to reveal the depth of Johns neglect and the severity of her childhood trauma. Our mother-baby
work was heightening Marys affective numbing and flooding, and
she was struggling to stay sober. It became clear that weekly conjoint
sessions would not provide adequate containment to safely explore
Marys issues. With some concern about the complexity of combining therapeutic modalities, I offered her additional weekly individual
meetings in my office and telephone sessions as needed.
Mary and John each needed to feel held, known, and remem-
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bered. But how to provide a relationship in which this would be possible? How to untie this Gordian knot of longing and dread? Mary
had been brutalized and overlooked in childhood. Her subsequent
difficulties establishing evocative constancy, affect regulation, and reflective capacity meant that she would not have attained the level of
symbolic thought, verbal self-awareness, or affect tolerance necessary
to fully engage in a conventional interpretive psychotherapy.
I envisioned the individual work and mother-infant sessions as existing in a figure-ground relationship. My objective was to develop a
therapeutic relationship that would provide mother and son with the
experience of containment and safety. I hypothesized that as her fear
and distress diminished in her relationship to me, Mary would become more capable of recognizing and naming her own feelings and
of evoking a calming maternal introject to soothe herself and her
son. I hoped that Marys growing attachment to me (and my holistic
vision for her) would take integrative hold and help bridge the gap
between her current level of functioning and her emerging potential. The gains we made in individual and conjoint sessions informed
and reinforced one another and were articulated within the context
of mothers and sons developmental strivings.
In his book The Motherhood Constellation (1995), Stern describes the
dynamic interplay between representation and behavior: change in
one area affects change in the other. I hoped that in this urgent situation the combination of individual with conjoint sessions would maximize impact in both representational and behavioral domains and
modify the pathogenic enactive representations that crippled Marys
psychic functioning. Home-based mother-infant work offers a rich
tableau of implicit interaction and a profound sense of intimacy. It
integrates traditional psychoanalytic approaches with interventions
designed to have immediate impact upon mother and childs relating. Combining immediacy with enactment would afford us the opportunity to hold painful experiences in the moment, even as we
practiced new forms of relating. Within individual and conjoint sessions we could unpack those interactions in which older and more
troubled patterns held sway. In addition, Marys developmental
strides within our dyadic relationship could be transferred to the immediate interactive realm of mother and son.
But the developmental pathway we traveled was rocky and uncharted. Initially we did not know that the journey would require our
living through repeated painful and overwhelming states of desperation and danger.
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113
Attachment Crisis in the Treatment

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

came to accept that if we were to work deeply enough to stimulate
growth, the shadow of deadliness would have to fall across our relationship. We three had survived the specter of Marys past trauma
and its fearful visitation upon the next generation. Marys near death
as a wordless one year old had returned as her possible suicide in
front of John and myself. She spent our first interruption in a psychiatric hospital.
Living through this crisis marked a turning point. We had
glimpsed the gaping black hole of Marys longing and terror and
could now begin to build bridges across it. The following vignette,
taken from a mother-infant session three weeks after my return and
Marys discharge from hospital, illustrates how mother and son allowed me into their anxious and disorganized relating. It also
demonstrates my attempts to enhance their communication by combining traditional psychodynamic approaches with interventions on
an immediate interactive level.
Process Vignette
I arrive for a session in the home. John has just returned from daycare and seems
tired and cranky. He is standing in front of the refrigerator yelling more
cheese! over and over. He is spinning out of control. He reaches up for his
mother.
Mother: (stepping away from him and speaking sweetly.) Youve had enough
cheese, soon its dinnertime, lets go in the living room. (She turns to
walk into the living room. She appears tuned out, unable to hear or notice
him.)
John starts to scream, and throws himself on the floor sobbing. Cheese, mama,
more cheese! (His eyes are glassy, his face red and puffy with exertion, its
all I can do not to pick him up.)
Mother: (with false sympathy) No more cheese, sorry. (angrily) You have
to learn not to get so upset. Im getting frustrated.
John is up off the floor and asking to be held by mother. She picks him up but puts
him down before he can settle. He asks again to be held and then strikes her in
the face as she reaches for him. She puts him down again, more forcefully. John
staggers away while pitifully crying for his mother. He begins to wander aimlessly around the house, stumbling over his toys. He suddenly lies down on the
rug and becomes very quiet. Mother looks at me, frightened.
Therapist: O.K., lets try to figure out whats going on and what each one
of you is feeling right now. (I sit by John, as he lies exhausted on the rug.)
Mother: I feel frustrated and helpless to make him feel better. Im not a
good mother. I dont know how to handle this stuff. He confuses me, I
try one thing and another but nothing helps.
In a Black Hole
115
Therapist: Hard to handle this confusion and helplessness . . . When

you cant help him it must make you feel bad about yourself, and upset with him. You probably want to get away from it all . . .
Mother: He makes me so frustrated, like I cant do anything right, and
then he hits me . . . am I raising him to be spoiled? I just tune out, try
to stay away from him. I go upstairs and lock the stair gate, or come
into the kitchen to be alone. He cries and cries. Sometimes I try to
help him but it doesnt make any difference.
Therapist: Tell me about tuning out . . . whats that like, where do you
go?
Mother: I dont know, somewhere else. To a place where I dont feel
much . . . always hated it when there was arguing in my house, hated
all the upset. I could never please the evil stepmother anyway. No
one really cared how I felt, but I could check out . . .
Therapist: This must be so hard for you. As a child never pleasing anyone, now feeling you cant make John happy either . . . No one
helped you to manage your feelings when you were a child, scared
and alone. You must have handled it by tuning out . . . Kids have
pretty strong feelings . . .
Mother: He doesnt know how to let me help him. I dont know how to
do it . . . John has soothed himself a bit with a toy. As mother sits down, he
asks for her lap. As she again begins to hold him, he stiffens and arches away
from her. She makes a move to put him down again.
Therapist: Youre both upset and confused, but could we try to stay in
this upset place for a moment more, just to see what might happen
next? (Mother continues to hold him and John squirms but remains with her.
I come and sit on the couch very close them, almost touching Mary.)
Mother: (tentatively) I dont know if I should say something to him . . .
Therapist: Would you like to? What do you think he might need to
hear?
Mother: (speaking with real sympathy to John and holding him closer as they begin to look at one another.) I know you are angry about no more cheese,
Im sorry youre angry, but soon I will make your dinner. Now you are
starting to feel a bit better.
Therapist: Maybe John doesnt know how to get the help he needs when
hes angry or frustrated . . . maybe he gets scared . . . I thought you
looked scared too, a few minutes ago . . .
John relaxes in mothers lap and asks for his favorite stuffed animal, which I retrieve. Now John has his mothers lap, his thumb and his transitional object.
Both mother and son sit quietly together as the affect storm passes. Their bodies
relax into one another.
Therapist: Hard work today you guys! You had some good ideas about
how to calm him with your voice and your body. You let him know that
you could feel his anger, and that there might be a way back from that
with your help. Look at how he relaxes when you gather him in like
this. I can see that he feels safe and calm, how do you feel now?
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Mother: Maybe I can help him . . . Maybe I dont have to dread being
with him if there are things that I can do to help him to be happy and
grow.
The Frightened/Disorganized Mother-Infant

Paradigm as Illustrated in the Vignette
The vignette illustrates how Marys dissociation and contradictory
behaviors leave John feeling confused and uncontained. Marys initial unpredictable loss of affect makes John feel scared that he cannot
find his mother. She inadvertently renders him helpless to find the way
back from distress, because he can find no context for her inexplicable (endogenous) and non-contingent responses. With no reliable
way to re-connect, John has no means of resolving his frightening
lack of containment. In more attuned circumstances, he would learn
to know himself through sensitive connection to the one who knew
him. In the current relational context his alternatives are either to
exist alone within an unmirrored and inchoate psychic state, or to
join his mother in an alien one.
Johns disorganized attempts to engage his mother are also inexplicable and frightening to her. His behavior renders her helpless to
comfort him. Mary feels persecuted by Johns inconsolable demands
and the specter of her abusive stepmother. She escapes into a dissociated and withdrawn state. Anxiously preoccupied and coping with the
powerful affects that John arouses, Mary must get away from him, she
must abandon John in her mind. At moments like this he is in emotional
free fall, out of control and alone, just as Mary must have been, just as
she remains. In these intense emotional exchanges around Johns
need for comfort and protection, Mary both fears and dreads the
baby who arouses in her the raw feelings and traumatic memories that
are the legacy of her own childhood. John has become the message
and not the messenger, the ghost of her own past (Fraiberg, 1975).
Over time John will internalize both sides of these repeated and
confused interactive sequences, just as his mother did (Lyons-Ruth et
al., 1999, Liotti, 1999, Main and Hesse, 1990a). While it is difficult to
predict developmental pathways, it is likely that John would come to
experience himself as one who is both a persecutor and a victim. Repeated exposure to traumatic affect levels would likely impede his capacity to attain personal synthesis and to make meaning of experience, resulting in multiple and discontinuous inner representations
(Liotti, 1999). Johns vitality, self-assertion, and depth of feeling
could become a source of fear rather than of self-confidence. His
mothers inability to consistently respond to his basic needs for com-
In a Black Hole
117
fort and protection leave John vulnerable to feelings of shame, rage,

anxiety, and emotional confusion. With no way to make restitution,
he is perpetually without agency. His options include excessively controlling behavior and/or living in a state of chronic mourning (Socarides and Stolorow, 1984).
Interventions Illustrated in the Vignette
I attempted to offer in-the-moment engagement with mother and
baby as they negotiated highly charged and discordant interactions.
While both positive and negative interactive patterns were reflected
upon, the emphasis was on finding what worked and supporting
mothers positive role. Articulation of mothers constructive engagement offers her support as well as an increasing capacity to observe
the interaction. (You let him know that you could feel he was angry . . . you had some good ideas about how to calm him . . .) When
asked, a therapist may make suggestions around behaviors but the focus is not educational or directive.
Over time, observing and naming repetitive interactive patterns as
they occurred helped to enhance Marys feelings of mastery. Her increasing sensitivity and consistency toward Johns need for comfort
also allowed him to feel more competent and less frightened. Mary
was eventually able to see for herself that when she avoided John or
dissociated in his presence, his behavior grew more disorganized.
Predicting that which triggers interactive patterns renders them
knowable and containable. It also offers the possibility that some new
way of relating may be possible.
We worked to promote an atmosphere in which our threesome
could experiment with improvising behaviors and then watch what
might emerge between us. We attempted to make manifest the separate emotional experiences of mother and baby as the interaction
unfolded. With time we were able to introduce John as a continuous
presence in his mothers mind, while simultaneously articulating
how difficult this was for her to bear. We clarified Marys defensive
need to escape, and to reject or minimize Johns needs.
The initial interaction was driven by Marys defensive exclusion of
Johns escalating bids for comfort. I empathized with Mary, explored
her dissociated response to John, related these responses to her
childhood experiences, and gently clarified her projections onto her
son. In his vulnerability and need John had become Marys enraging
and menacing parent and her frightened/frightening and uncontainable self. John was the source of Marys guilt, the attacking other
who persecuted her with his relentless demands. It was difficult not
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to comfort John in his distress, but I believe that this would have
shamed his mother.
Feeling for Marys and Johns affective states and developmental
capacities within each interaction provided direction for the improvisation of new relational moves (Stern and Sander, et al., 1998). Improvisation addresses experience and change within the procedural
domain, and it provides an interactive format in which to modify
compulsive role assignments and to model containment. It is enhanced by the babys natural dynamism. It makes use of mothers
open sharing of feelings and fantasies, along with the babys emotional expressions, as they are experienced in the moment.
Marys softening of tone and defensive stance (He doesnt know
how to let me comfort him. I dont know how to do it . . .) signaled her
readiness to let me into her confusion around how to interact with
John. I began to wonder if something new could happen between us.
I believe that it was the lending of my physical presence (moving
back and forth between them) that offered the following unspoken
response to Mary: I can empathize with and hold both of your emotional states. I am free to move within your compulsive and confused
enactment. You can use me to bridge the gap between your current
level of interacting and something that will be more complex and
new. As I sat close to Mary and John on the couch, Mary continued
to relax her defended stance. Tentatively she mused, I dont know if
I should say something to him. At this point in the interaction a new
developmental level of relating was about to emerge.
Combining Individual Adult Work with Mother-Baby Sessions
Marys 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. Marys suicidal gesture
had delivered into our relationship all the uncontained emotions of
her childhood. I believed that we were going to have to feel our way
through the therapy and live through the unnamed terrors, giving
narrative voice to the process when we could. In the words of
Phillips, sometimes, stories are lived before they are told (quoted
in Holmes, 1996, p. 167).
giving voice
Mary struggled to put words to feelings and experiences. In the
mother-baby sessions at home I had began to gently draw her into my
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curiosity about Johns behavior and motivations. In individual sessions I expressed a similar curiosity about Mary. Together we created
a lexicon that captured the unique experiences of mother and baby.
It has been hypothesized that within the adult narrative lies the blueprint of early attachment experiences (Slade, 2001). The linguistic
structure of adult narrative traces the range of affective communication permitted within the earliest relationship and the childs need
to adapt to the attachment figures defensive constraints upon relating. Factual and affective incongruencies, unmonitored lapses in reason and logic, paucity of affectively charged descriptions and defensive idealizations, or minimization of cruelty and neglect indicate an
insecure and emotionally constricted attachment relationship (Main
and Hesse, 1990a, Slade, 2001, Holmes, 1996). I believe that the act
of creating a lexicon, coupled with capturing the specific experiences of mother and baby, helped to expand Marys emotional communication and her reflective functioning. Our widening conversation implied an increasing ability to express and to hold deep
feelings. Over time our shared language offered Mary a way to name
her own complex internal states and to feel more in control. It enabled her to speculate about and to feel for the inner life of her
child. During intense emotional exchanges between mother and son
our familiar phrases were a source of comfort and orientation for
Mary. We found it particularly helpful at such times to use expressions that conveyed active containment, such as getting your arms
around a feeling, gathering in a disorganized baby, or finding the
way back to a quiet and connected state.
metabolizing fear
Mary was afraid of everything. Her terrors had derailed her efforts after mastery and psychic wholeness. Toxic levels of fear occluded her
ability to create and to synthesize (inter)personal meaning. Fear had
interrupted her ability to attend or even to maintain a consistent
state of consciousness. Abuse and neglect had taught Mary to expect
that her feelings would be forgotten or obliterated. Frequently slipping into dissociated or empty states, Mary often did not know what
she felt.
We set out to explore the black hole left by Marys trauma, and
the overwhelming feelings and contradictory inner representations
it had spawned. With each frightening memory or state delivered
into the treatment we entered a new interpersonal negotiation. We
asked, how could Mary contain her upset around John? What feel-
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ings did he arouse in her? How could she use her relationships (with
me, her husband, and her AA sponsors) for soothing and containment?
Mary and I paid careful attention to how we made contact, and related this to patterns of emotional communication between mother
and son. Her initial requests to connect were subtle, often overridden by an expectation that she did not matter and could not be
known or contained by another. Mary had covered her childhood
devastation with an avoidant style and disorienting cheer, punctuated
by states of panic and emptiness. Her affective cues were as confusing
to me as they must have been to John. But eventually we were able to
frame our miscommunications within the context of Marys longing
to have her attachment needs met and her dread that I would rebuff
her. Gianino and Tronick, (1988) link the ability to repair affective
mismatches in infancy to the establishment of the attachment figure
as reliable and trustworthy. Experiences of disruption and repair also
contribute to the infants sense of mastery and control and to the development of a positive emotional core. I believe that within the
transference Marys increasingly secure attachment to me offered
her similar gains. Her diminishing fear led to an increased sense of
agency and inner cohesion and to a budding capacity to make reparation to her son.
Mary and I were able to name her intense feeling states (or absence of feeling), and give voice and shape to her chaotic inner representations. We observed the ways in which she dissociated during
powerful emotional eruptions around John, her confusing responses
to his need for comfort, and his disorganization in response. Consistent inquiry into Marys inner states introduced the notion that I
could know and remember her. At the same time we observed the
ways in which Marys intense and confusing experiences impeded
her ability to keep John in mind and to represent him as a separate
being. As her affect tolerance and self-reflective abilities increased,
Mary and I could more deeply explore the relational context in
which powerful feelings or defenses against them emerged. She
struggled to share her private terror, anger, and emptiness with me,
while valiantly attempting to make loving contact with her son.
Our conversations signaled to Mary that she could use our relationship to hold and metabolize her confusion and fear and to
gather in the disavowed parts of herself. As demonstrated in the vignette, genetic material was used to promote compassionate understanding and personal perspective. Within the first year of our work,
Mary minimized or dismissed transference interpretations, and they
In a Black Hole
121
did little to enhance our relating. But each new aspect of Marys experience, no matter how disturbing, was offered a place in our conversation. She began to send me e-mail messages about fantasies that
scared her. These messages I saved for her until she felt safe enough
to address them in person. We then began to anticipate the emergence of the evil stepmothers cruel and degrading voice within
Mary. We called this frightening figure out of the shadows, stared her
down, and told her that her days as a saboteur were numbered.
Marys need to defend against the feelings John aroused coupled
with her cognitive dysregulation (dissociation and transient thought
disorder) had rendered her unable to consistently attend to their relationship. In mother-baby sessions we worked to enhance responsive
relating by containing the fear and anger aroused by Johns need for
comfort. In individual sessions we explored how Marys attachment
needs within the transference paralleled those of her son. Mary was
the mother of a child she could not comfort and a child herself in
need of comfort.
Over time, as we co-constructed the scope and pace of what
emerged between us, Marys inner representations (terrifying mother
and terrified/enraged child, idealized rescuer and cruel saboteur)
existed side by side with a budding new way of our being together:
We became a collaborative therapeutic team. Less constricted by her
own defensive exclusion of painful affects, Mary developed freer access to her own inner world and to the emotional world of her son.
As she began to release John from her malevolent projections and
her need to control the fear he aroused, he emerged as a positive
force of nature, a baby to be loved and understood.
Conclusion
In cases of frightened/disorganized mother-infant couples, the combination of individual adult work along with mother-infant sessions
can significantly enhance the development of responsive emotional
communication and intersubjective sharing within the dyad.
During the first year of our work, Mary was able to transfer her
growing security of attachment to me onto her relationship with
John. The process has been slow and painful however. During our
first year of treatment there were several bouts of drinking, psychosis,
and suicidality, stimulated each time by my taking a vacation. But
Mary has been increasingly able to remain connected to me during
our interruptions, with fewer overwhelming states of abandonment
or deadly nothingness. She is feeling more at home in the fluid psy-
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Judith Arons
chic space that encircles attachment and separation. With the help of
psychotherapy, pharmacotherapy, and AA, she has not had a drink in
fourteen months.
Mary continues to use our relationship to hold her fear and her
rage. The frightening inner representations and emotions that inhabit her psychic landscape have emerged in full force. She has addressed violent fantasies of throwing her son out the window or
slashing his face with a knife. She has been able to use me as a secure
base around disorienting and psychotic flashbacks. Having partly
freed the mother-child relationship from the toxic intrusion of intolerable affects, we continue to address the need to name and to
metabolize such feelings in all areas of Marys life. We continue to
explore the emotional impact of mother and son upon one another
and their patterns of communication. Sometimes I am rocked by
Marys vacillating experiences of flooding and deadness. I continue
to worry and wonder about the impact of Johns early life upon his
future development. But the projections, dissociation, and affective
misattunements, so prevalent in Marys early relationship with John,
have abated.
Although prone to regression around his mothers psychic upsets,
John has responded beautifully to her increasing sensitivity and reliability. Much work remains to be done, but John now looks consistently to his mother for soothing and protection. His requests for
care and protection are not conflicted; they are the expressions of a
child who anticipates that comfort and aid will be forthcoming. Mary
feels more connected to herself and to her son. She takes great pride
in how John is developing as an individual, and the important role
she has played in this.
While an in-depth analysis of the multiple transferences of trauma
survivors is extremely relevant to this case, it exceeds the scope of my
discussion. Several authors have written about the fluid and unintegrated inner representations and discontinuous transferences of victim, victimizer, and rescuer in trauma survivors (Davies and Frawley,
1991, Liotti, 1999). It remains unclear whether Mary will be able to
analyze her murderous maternal transference toward me, or if this is
even advisable. It may be that in cases of severe early loss and trauma,
rage in the transference represents too great a threat to the therapeutic relationship and requires metabolizing and repair in displacement. To date, Mary has very much needed to keep me as a good
enough mother.
The difficulties in depicting mother-infant psychotherapy are similar to those one faces in describing human relating and development
In a Black Hole
123
in general. The case discussion must illuminate both intrapsychic

and interpersonal phenomenon. It must describe recursive and potentially emergent relational processes within a format that is predominantly linear, narrative, and deterministic. It should discuss both
implicit and explicit modes of relating, remembering, and meaningmaking as developmental constructs and as mutative factors within
the psychotherapy itself (Lachmann, 2001, Stern and Sander, et al.,
1998). To further complicate matters, the thousands of non-verbal
gestures, and affectively nuanced communications that would provide the reader with critical information, remain out of the participants awareness and cannot be recorded. But despite all these imperfections, case studies can bring to life the depth and complexity
of our work.
Finally, another difficulty in writing case material is that in an effort to create a narrative out of what is essentially a kaleidoscopic interpersonal experience, the case is rendered too neat and organized.
I understood the process of my work with Mary and John both prospectively and retrospectively. Some concepts came to me before or
during the time they emerged within the treatment, most did not
come to life conceptually until I had already acted intuitively and improvisationally. My application of concepts from attachment theory
and psychoanalysis helped shape the treatment, but is not intended
to impose a privileged position over other useful and creative approaches to mother-infant work.
I have offered vignettes from a mother-baby psychotherapy in
which I applied principles from attachment theory and psychoanalysis to help a troubled mother emotionally engage with her infant son.
A major function of the attachment system is to buffer the infants
stress so that he is free to grow within himself and secure in the exploration of his world. Mary and Johns relationship, colored by
chronic states of fear and emptiness, was the legacy of Marys childhood attachment trauma. Without interventions designed to respond to the attachment needs of both mother and son, they would
have had little opportunity to explore sensitive emotional relating or
creative and meaningful engagement.
In addition, attachment theory enhanced my understanding of
mothers developmental deficits and babys incipient developmental
stressors, and provided a logic to the interplay between my individual
work with mother and my work with mother and baby together. Central to my work with Mary and John was the development of three interrelated functions that any ordinary devoted mother (or other
caregiving figure) provides for her child: responsive engagement in
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Judith Arons
regulating her babys affect, her own capacity to evoke a compassionate and soothing maternal introject, and her ability to reflect upon
babys experience, to keep him continuously in mind. While these
concepts are not new to psychoanalysis, they nest nicely within attachment theory, which operationalizes them and grounds them in
empirical research.
Post Script
Recently, Mary and I were reviewing the progress that she and John
have made (John is now two and a half). She related that while packing up some of his infant clothes she had been overwhelmed with
how vulnerable John had been as a small baby, how he had needed
her, and she wasnt there. She remembered with great sorrow and remorse leaving him for long spells alone in his crib. Then she related
this story:
After school yesterday John and I were playing together in his room,
like I am trying to do more with him these days. He began a new
game: he put me in his big boy bed, covered me with his favorite
blanket, kissed me goodnight and went out of the room, closing the
door. Without thinking about it I began to cry, Mama! Mama, I am
scared, Mama! He rushed into the room, snuggled me with the
blanket, and kissed me softy, whispering, o.k. baby, dont cry baby,
dont cry, and went out. We repeated this game several times; each
time he came in and comforted me. Then it was his turn. He wanted
to be in his bed with the covers. I kissed him, said goodnight, and left
the room. He pretended to cry, Mama, come, Mama! I rushed in as
he had done, kissed him, and cozied him up with the blankets,
telling him that everything was all right. After doing this several
times he became quite relaxed and quiet. He looked so peaceful lying snugly in his blankets. And then, as I sat there on the edge of his
bed, I experienced a moment of grace. I realized that I can comfort
my child!
The child who no longer arouses intolerable feelings resides more

securely in his mothers heart and mind.
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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.
128
Herding the Animals into the Barn
129
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 sessionsfirst
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 psychologistsparticularly their use of micro-analysis of videotapes and certain organizing ideasand 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 childs psychological development.
The next section of this paper provides an overview of the PCM, including contrasts to more standard child psychiatric or psychoana-
130
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 approachthe 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 analystsand other cliniciansbut 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 developingthat is, obtaining and transforming into a usable
forminformation to address parents concerns. The second element is the use of micro-analysis of family interactive patterns as the
basis for formulations concerning the childs psychological problems.
131
role of the clinician as a consultant in evaluating

children with behavior problems
Parents come to the clinician with a problem, asking for help. Yet, in
the typical method of child psychological evaluation, there is no
clear delineation of the role of the clinician in relation to the parents. The child psychoanalytic and psychotherapy literature has of
course long acknowledged the importance of work with the parents
in a child psychotherapy or analytic case (Burlingham, 1951, Furman, 1957, Bernstein, 1995, Richmond, 1992). Yet, the role the clinician should assume in work with parents is often a matter of confusion.
I have concluded that it is useful to think of the therapist as a consultant to the parents, particularly in the initial evaluation. I use consultant here in the sense defined by psychoanalytic group theory, as
elaborated by the A. K. Rice Institute and Tavistock Clinic model of
group dynamics (Shapiro, 1978, 1991).
In this context, the clinician uses his or her knowledge and information to answer parents questions and make recommendations
that respond to parents concerns. The clinician as consultant does
not purport to know what is best for the child in this initial stage, but
rather attempts to help parents make decisions about their child in
accordance with their values and circumstances. This role is respectful to the parents as decision makers regarding their child and establishes the position of the child clinician as supporting, or scaffolding,
the parents in their active role as parents. It also implicitly acknowledgeswhat I believe to be the truththat 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
132
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 childs 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 childs 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 clinicians
repertoire. Although child clinicians will often note the parents
(usually the mothers) 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 toolsso useful to infant researcherscan 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 childs symptomatic behavior. Without dynamic systems
theory as a theoretical framework, I could not understand the relationship between certain interactive patterns and the childs problems. For example, I could not relate the childs self-regulatory problemssuch as temper tantrums or fearsto particular failures in
mutual regulation between the child and his parents. And, I could
not appreciate the connection between the childs 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 parentsas
clinicians sometimes doto 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 childs

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 childs development and the
family situation, andparticularly importanthelp 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 Seans capacity for pretend play,
and the meanings he makes of his experience as it is represented in
the play. The third meeting is for parents alone in which I answer their
questions and make recommendations regarding treatment and
other matters. I illustrate my impressions of the family with video
clips from the session. The three meetings are 45 50 minute appointments, though I usually schedule the third, the second parent
meeting, at a time when I can extend the meeting if desirable.
After describing the PCM approach, I give Mrs. R a chance to tell
me what she thinks of the general method. She says that it sounds interesting to her. I give her a chance to ask me questions. At this point
she has only one: What do we do in the family meeting? It would be
1. I now use the PCM for all my child evaluations, regardless of age or presenting
problem of the child. In evaluations of older children I use a family discussion instead
of play format.
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hard for him (Sean) to have his problems discussed in front of his
brother. He is easily shamed. I tell her that the play session is intended to be a pleasant experience. Usually I would not discuss
Seans problems directly. The information I need to answer Mr. and
Mrs. Rs questions will show up in the play. I say that I will direct the
session and take care not to let anyone be put on the spot. At the beginning of the session, I will explain that we are going to play in
partners, that Sean will begin as Dads partner, and his brother as
Moms partner. After five to ten minutes, I will tell everybody to
switch partners. Then after a similar time period, I will tell everybody
to play altogether. After another ten minutes of playing together, I
will tell everybody that Mom and Dad are going to sit in the two
chairs and have a conversation with each other while Sean and his
brother continue to play. This section is the last part of the play session. After this, I announce the end of the playtime, and we all pick
up the toys and say goodbye. The entire family play session takes
about 45 minutes.
Mrs. R says that she thinks this approach is just what she and her
husband are looking for. She then notes that she and her husband
are also concerned about the toll the family situation is taking on
Seans little brother, Mattie, and considering the whole family will
give them an opportunity to take Matties needs into account. I suggest that she talk to her husband about the approach I have described and get back to me about whether they would like to move
forward with the consultation. If they choose to carry on, we will
schedule the meetings. In suggesting that Mrs. and Mr. R talk about
the consultation together, I am putting the emphasis of the decisionmaking back on the parental couple. I am also giving them a chance
to reflect on the approach. The next day, Mrs. R calls and says that
she and her husband have decided they would like the consultation.
We schedule the first meeting.
conceptual framework
I have found it to be critical to have some conceptual framework for
evaluating the wealth of information available in the videotaped sessions used in the evaluation. Indeed, without some framework, the
material tends to be overwhelming. I have found conceptual frameworks developed by two developmental psychologists particularly
helpfulElisabeth Fivaz-Depeursinge and George Downingboth
of whom I have studied for some time. Although these conceptual
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frameworks work for me, it is possible that the choice of a particular

framework is less important than finding some useful means of making order from the extraordinarily rich material in videotapes of family sessions.
Lausanne Triadic Play Model
The specific organizational structure in the PCM is inspired by the
work of Elisabeth Fivaz-Depeursinge and colleagues (Fivaz et al.,
1994, Stern et al., 1996, Fivaz et al., 1999). The triangular framework
of the LTP includes observations of the famly at multiple levels of interactionparticipation, role, joint attention, and affective contact.
Particularly important from the point of view of the PCM is the capacity of the LTP to organize observations of the non-verbal communications in the family system in a systematic way. The triangular
framework of the LTP includes observations of the family at multiple
levels of interactionthe level of interaction involving the lower
body, the upper body, the orientation of face and gaze, and affective
expression. These observations lead to the description of various crucial functions in the family interactionthose of participation, role,
joint attention, and affective contact. Fivaz and colleagues explain
various functions of family interaction as embedded in one another, such that the orientation of the lower body is a basic requirement for participation, making possible the orientation of the upper
body as a definition of role, which in turn leads to the capacity for
joint shared attention through movement of the head and gaze, and
finally the establishment of affective contact through the communication of emotions in facial expression and tone of voice.
In addition to providing a framework for the observation of family
interactions in a four-step family play session, Fivaz and colleagues
also describe how to go about making observations. The first specific
focus of observation is the body position of the family members.
Next, the orientation of the face and the facial expression is noted,
and finally the orientation of the gaze (1999, pp. 1114). The observer also notes the affect expressed by family members. Is the affect
communicated by each family member happy, sad, or angry? Do family members exhibit a full range of affect, or is affective expression
constrained or inhibited? Is affect well modulated, or is it explosive
or tightly contained? The observer also notes examples of self and
mutual regulating behaviors, such as gaze aversion, self-touching, and
other body movements. How do the parents comfort their infant?
How do they comfort each other and themselves, and how does the
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infant comfort herself? Finally, how do the parents collaborate with

each other in the comforting and playing with their child?2
Video Micro-Analysis (George Downing)
A second useful framework for interpreting material as part of the
development of the PCM is the clinical work of George Downing and
his technique of video microanalysis. (Downing, 2000, 2005a, 2005b).
Downing provides means of organizing information from videotapes
from the point of view of five domains of clinical observation: (1)
connection; (2) autonomy; (3) organization of time and space; (4)
language; and (5) boundaries. Downing focuses his observations on
multiple ways of interactingusing body, face, and voice. (1) In
terms of connection, he notes the various ways the family members
make a connection with one another, using their bodies, their faces,
and their voices. He notes body positions and their function in the
interaction, for example, orientation of body in relation to one another. He will consider the interactional function of the orientation,
such as whether the partners make a play space between them with
their bodies. (2) In relation to autonomy, he notes the parents style of
encouraging the childs development of autonomy. For example, he
asks whether the child takes initiative in the play, and whether the
parent supports that initiative, or on the other hand, whether the
parent is inattentive to the childs expression of initiative or tries to
control it. (3) From the point of view of organization of space and time,
he notes how the families utilize the space of the room, and how they
manage the time constraints of the interview. Does the family use the
large space designated as the play area, or do they limit themselves to
a corner of the room? Do they settle down to play right away, or do
they spend so much time negotiating the setting up that they have little time to play? (4) In terms of boundaries, he notes how the family
members respect one anothers boundaries, and how they manage
the boundaries of the play interview. Do the parents respect the
childs personal boundaries, or do they intrude into them by touch2. The differences between the LTP, in which a structured seating arrangement of
the family members is part of the experimental design, and the PCM, which involves a
free-play situation, result in different ways of analyzing the observational data. For example, observations about body position in the PCM cannot be reliably coded, as they
can in the LTP. Yet, these observations may still be clinically useful.
The observations of mother-child, father-child play, sibling play, and parent conversation in the PCM are actually observations made of sub-systems of the family rather
than as observations of dyadic relationships. However, clinically relevant observations about the relationships in these subsystems can be made.
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ing the child or by moving the childs play objects without an invitation? Do the family members respect the play space presented to
them, or does the child stray into the part of the room where the
computer and the video equipment is? Does the parent make a clear
boundary between playtime and time to stop and pick up the toys?
(5) Apropos language, how is language used in the play sessionto
promote the play, to comfort, to criticize, or to control? What kind of
language does the parent useprimarily descriptive language such as,
Oh, you are putting that there or prescriptive language such as, Put
that there.
Downings model is based on developmental theory but is designed primarily as a clinical theory. In that sense, particularly, it has
been an important influence on my work on the PCM. I also owe
much of my skill in making observations about families and analyzing them to the consultations and discussions I have had with Downing during the past five years.
Other Theoretical Influences
The PCM as I have developed it derives from other aspects of developmental research, including the mini-reunion experience created
by the order of the partner play, in which the identified problem
child plays with the father first. This order offers the opportunity to
observe a mini reunion of the child with the mother. The PCM
does not, of course, replicate the experimental conditions related to
the strange situation of Attachment Theory. Nonetheless, my experience suggests that this design can elicit interesting observations
about the mother-child relationship corresponding in some way to
the findings of the strange situation test (Lyons-Ruth, 1991). Finally,
because it is a play session designed for preschool and early school
age children, the PCM also offers the opportunity to evaluate the
quality of the childs play and uses psychoanalytic theory to identify
and make sense of symbolic representations in the play. Psychoanalytic theory and developmental theory are thus both instrumental in
informing the observations obtained from the PCM.
In sum, the PCM draws primarily from developmental theory
particularly the observational research of Fivaz and colleagues and
the clinical model of Downingto make a number of important assessments. It offers a quick clinical assessment of the father-child relationship, the mother-child relationship, the sibling relationship,
and the marital relationship. The PCM also offers an assessment of
the way the family functions as a unit, the way the family makes transitions, the impact of the children on the marital relationship, and fea-
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tures of the childs play. The time spent in the family session is short,
but videotape transcription makes possible the recognition of repeated patterns on a micro level, contributing to the larger level behaviors that constitute an adaptation.
clinical case illustration of pcm:
first stepfirst parent meeting
Mr. and Mrs. R come in for the first parent meeting. They are an attractive couple in their late 30s. Mrs. R in particular looks tired and
stressed. Mr. R works in a demanding professional job. Mrs. R had a
comparable job before Seans two-year younger brother, Mattie, was
born but left her job at that point to become a full-time mother. They
explain that Sean was high maintenance from the beginning, but
that they didnt recognize it as a problem because they didnt know
what to expect from their first baby. They could tell that he was very
bright. They first realized that he had a problem when he was rejected from all the private elementary schools they applied to for 4year-old pre-kindergarten. The teachers in his preschool confirmed
that he had trouble paying attention and was disruptive during circle
time, but said that he was sweet, enthusiastic, and loved to learn. At
home, he was very dependent on his mother and anxious about being separated from her. He insisted on following her from one floor
of the house to another. He envied Matties possessions and competed fiercely with him for his parents attention, but he also played
happily with him for long periods. Play usually ended with Seans
teasing Mattie, or with his aggressive physical attacks on him. Sean
also complained about lumpy food, tags on the back of his shirts,
strong smells, and loud noises. Both parents agree that they are
noticing Seans immature behavior more now than they had even a
year ago. As Sean gets older, the discrepancy between his behavior
and that of his peers, and even that of his little brother, becomes
more apparent.
I ask about family stressors, and the Rs respond that the main
stresses are Seans behavior and the pressure of Mr. Rs job, which often keeps him at the office until the children are in bed. Family
neuro-psychiatric and developmental history is positive for mild to
moderate learning disabilities on the paternal side, acting out in adolescence and depression in one of Mrs. Rs siblings, and anxiety both
in maternal grandmother and in Mrs. R.
The generation of consultation questions is the crucial part of the
first meeting. Although Mr. R tends to defer to Mrs. R, I insist that
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both give me at least two questions. I write the questions down verbatim and put the paper where I can retrieve it for the final meeting.
Mrs. R asks, How to relieve his anxietyhe is fearful and anxious,
and how to develop strategies to deal with his behavior problems, e.g.
constant picking on his little brother. Mr. R asks, How to deal with
his negative effect on the familyhe wears his mother down. Mrs. R
adds, How do I get this kid motivated to do the things he needs to
do, like get himself dressed in the morning or go to the bathroom by
himself? Mr. R concludes, How do we help him with his confidence, self-esteem? Although sometimes I find I am able to answer
some of the parents questions immediately, in this case I think that a
family meeting is essential, and I tell the Rs that a family meeting will
help me answer their questions.
We discuss the family meeting. I repeat the description of the family meeting to Mr. and Mrs. R, concluding with a discussion of what to
tell the children about the meeting. After hearing Mr. and Mrs. Rs
ideas about how to best present the idea to their children, I suggest
that they refer to me by my first name rather than as doctor, so as
not to unnecessarily alarm the children, and suggest that they refer
to me as a lady who knows a lot about children and families and who
gives families ideas about how they can get along better together.
Then I suggest adding, And the way she does that is to have families
come and play at her house, and then go home again. She also uses a
camera to take a film so that she can remember what happened after
the meeting. We schedule a meeting time.
second stepfamily meeting
At the time of the family meeting, I arrange the room with toys appropriate for children of Seans and Matties agesa barn with farm
animals, a garage with cars and people, building blocks, and puzzles.
I meet the family in the waiting room and show them into the office.
Mr. R coaches the children to greet me politely, and they do. The
boys are very attractive children. Sean leads the way into the office.
He is excited and eager to see my toys. Mattie holds his mothers
hand. In the office I remind the family of the plan for the meeting. I
repeat the different parts of the meeting including the parents conversation and the camera. The camera is a small video camera that I
place on my lap; the monitor can be viewed in a brief downward
glance. I point out the camera to the family. Openness about the
filming of the meeting is particularly important from the point of
view of modeling trustworthy behavior in the family consultation. I
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tell them that in the beginning, Sean will be Dads partner and Mattie will be Moms partner.
Child and Father Play
Sean chooses the barn with farm animals, and he and Mr. R establish
themselves in front of the barn. Sean says to Mr. R, Lets herd them
into the barn, because there is a big storm coming! Mr. R asks,
Which ones? Which ones? and starts to pick up the animals. The
two of them are smiling and obviously happy to be together. They are
picking up the animals and talking about them. Interestingly, the animals do not get herded into the barn by the time of my call to
change partners, about five minutes later.
The next transition goes smoothly, with Mrs. R calling out to Sean,
Change buddies! Youre my buddy, Sean! and walking over to him,
while she helps Mattie and Mr. R find the toy garage. Sean calls out to
Mrs. R, Were going to herd the animals into the barn. Mrs. R says,
O.K., sits down beside the barn, and listens to Sean explain again
about herding the animals. Sean and Mrs. R also play together well,
though they both look somewhat uncomfortable and constrained.
Mrs. R does not look as if she is enjoying herself and is sitting back
with her hands folded most of the time. Again, in this seven-minute
play sequence, despite much talking about it, the animals do not get
herded into the barn.
When I call for the family to play together, the family makes another smooth transition, with Mrs. R making suggestions about how
they might combine the two types of play. They begin to play with the
garage and some of the farm animals. Mattie, Mr. R, and Mrs. R cluster around the garage and play with it for the entire period. Sean
plays on the periphery, connecting vehicles with their trailers, periodically joining the others and then removing himself again from the
central family play.
Finally, I ask for the family to make the transition of Mr. and Mrs. R
to the two chairs, so that they might have a conversation with each
other. Mr. and Mrs. R move to the chairs, and the boys continue their
play. Mattie goes to play with the barn, and Sean continues playing
with the cars and trailers. The parents are able to have a conversation
with each other, though now and then they are distracted and turn
their attention to the boys. They seem to anticipate a problem that
they must be ready to manage.
Then Mattie says, We have to herd the animals into the barn.
Theres a big storm coming. He begins to put the animals into the
barn. Sean comes over to the barn and starts to help him, but he is
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more erratic in his attention and his movements than his little
brother. Numerous times he grabs a toy away from Mattie; sometimes
Mattie objects, sometimes he does not. At one point, Sean declares,
The storm is over now, but Mattie responds, No, its not, and continues his work of herding. Sean moves back and forth from the
barn, to the activity of hooking up the cars and trailers. Finally, Mattie declares, Now theyre all insidesafe and sound. In a dramatic
conclusion to the course of events, Seans little brother is able to implement Seans stated agenda more effectively than either parent is
able to do alone with Sean.
How can we understand this interesting eventuality? As I consider
this question, I am thinking of the powerful metaphor of herding the
animals into the barn to find protection from the impending storm,
which I take to signify Seans dysregulated behavior and its effect on
the family. The whole family seems to resonate with this symbolic
theme. The conclusion of the family play is to find a safe place for all
the animals inside the barn, yet this is accomplished in an unexpected way. It is only when the constraining behavior patterns Sean
and his parents have created together are relegated to the background, and the parents allow the children to exercise their own
agency, that Seans agenda can be constructively engaged.3 Yet, a full
answer to the question must wait until later, since we must first return
to the model as a practical way of answering the parents questions.
third stepinterviewer viewing the tape
In this step, I view the tape alone. Initially I transcribed small tapes
from my digital video camera onto a VHS tape and viewed them on
my television monitor. I used my remote control to look at certain sequences in slow motion. Now, I capture clips from the digital videotape on my computer, using the program of final cut express. While
time consuming on my part, it makes the showing of the film to the
parents more efficient, since it isolates small sequences of the tape
that are immediately available for viewing. Also, the computer program allows for frame (about one thirtieth of a second) by frame
viewing easily. As I observe the tape, I look for patterns of behavior in
3. Sanders work has been extremely influential to my thinking and clinical work.
Both in his writings and in our discussions, Sanders conceptualization of agency as
emerging from the mutual regulatory competency of the dyadic system has been central to my understanding of children like Sean (Sander, 1985, 1995, personal communication, 2004).
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the different sections of the interview. Here I make use of Downings

technique of video micro-analysis to evaluate the play sequences of
father-Sean, mother-Sean, family together, and parental couple with
siblings. Although at first I would spend more time capturing the
clips and viewing the tapes than the duration of the family meeting,
now I can complete the process in about 30 minutes.
The initial transition into the play room is accomplished smoothly.
In this transition, the family values are demonstrated in Mr. Rs reminding the children of the rules of courtesy in greeting and the
boys willingness to comply. Seans capacity for enthusiastic engagement with a new situation is also clear. Mrs. R takes up the rear, perhaps showing a tendency toward reticence. Mattie stays back with
her; he could be expressing his own timidity, or taking care of his
mother.
Father-Child Play Sequence
1. ConnectionMr. R and Sean express their enjoyment at being
with each other in their facial expressions, their tone of voice, and
their affectionate physical contact. At one point, Sean leans comfortably against his fathers leg, and at another point, Mr. R puts his hand
on Seans shoulder. Father is oriented to Sean, but Seans body is at a
ninety-degree angle to his father. This seems to indicate some difficulty making contact. There is little visual monitoring of each other.
2. Organization of time and spaceFather is lying on the floor next
to Sean, and Sean is seated next to the barn, using the play space in a
comfortable manner. They use the play space available, and they begin and end at the time I direct them to play and then to change.
3. BoundariesNeither seems to intrude on the others space, nor
to take control from the other. However, an interesting pattern is created when Mr. R is showing Sean two animals, and Sean reaches over
his fathers extended arm to reach into the barn, glancing at the animals over his own arm. This unusual arrangement of bodies is more
evident in split second viewing and again seems to illustrate some
avoidance of direct connection.
4. LanguageWhen Mr. R speaks to Sean, he does not use prescriptive language; in other words, he does not give him orders. He primarily communicates his ideas as they come up in the play, for example reminding Sean of an animal they saw together on a family trip.
5. AutonomyIn spite of their mutual pleasure in the play, Seans expressed agenda of getting the animals into the barn is not implemented. This seems to be because Mr. R does not attend to Seans repeated requests that they do this. When I count, Sean refers to the
agenda of herding the animals into the barn six times in a one-minute
film clip, before his father begins to put the animals into the barn.
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The transition to the mother-child play sequence is also smooth. I

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

once she talks in an educative way to Sean about the difference in appearance between dairy cattle and beef cattle. This communication
is in response to Sean asking, Is that a deer? when Mrs. R is moving
an animal toward the barn. She also demonstrates a unusual vocal
turn-taking pattern that involves beginning her vocal turn immediately after Sean finishes his, a pattern associated with anxious overcontrol (Beebe, 1999).
5. AutonomyMrs. R demonstrates a clear intention to support
Seans autonomy. She listens intently when he explains his plan to
her. She helps him with the set-up of the plan and encourages him to
implement it. In response to Seans remonstrance, You have to help
me! she begins to put the animals into the barn. Yet, at several
points, Mrs. R expresses her skepticism about the potential success of
the agenda, framing it in terms of fitting all the animals into the
barn, and by the end of the ten-minute play sequence, just a few of
the animals have been put into the barn. Mrs. R seems to have anticipated failure in the enterprise, and her negative expectation has
been fulfilled.
When I announce the transition to the whole family playing together, Mrs. R, Sean, and Mattie look up at me. Mrs. R immediately
says, O.K., and begins to assist in the transition. Sean says, Yeah!
Daddy can play with the farm!, Mrs. R repeats that they are going to
look for a group activity, something they can all do together, and
Mr. R suggests that Sean can bring some of his animals to the garage
if they cant all fit in the barn. Sean initially rejects this idea, but
when Mattie moves over to the barn, Sean grabs it away from Mattie
and declares it locked, saying, Lets use the garage for another
barn. He again grabs the barn from Matties grasp and pushes Matties arm away from the barn. Just after Seans aggressive moves toward Mattie, Mr. and Mrs. R both simultaneously turn their faces
away from Sean and begin to orient their bodies toward the garage.
At the same time, Mattie turns away from the barn and also moves toward the garage. It seems clear that the family is attempting to avoid
conflict by complying with Seans demands. Yet, as they comply, they
in unison move away from him, leaving him alone.
Family Play Sequence
1. ConnectionMr. and Mrs. R and Mattie begin arranging the animals on the different floors of the garage. They communicate positive affect with their facial expressions and tone of voice. Sean plays
on the outskirts of the group. He has found several vehicle-trailer
pairs, and he occupies himself with trying to connect them. Now and
then, he joins the family group for a brief period, but then he returns
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to the cars. It seems clear that Sean attempts to regulate himself by

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

also goes smoothly. Mrs. R notifies the boys of what they are going to
do. Neither boy objects. Mr. and Mrs. R sit in the chairs and begin to
talk. This part of the session in particular demonstrates important
strengths of the familythe parents capacity to constitute a wellfunctioning relationship of their own, and the siblings ability to play
together creatively, despite Seans regulatory difficulties.
Sean continues his regulating play with the vehicles and trailers.
Mattie moves to the barn, which is on the other side of the room and
which he has not played with before. He says, using Seans exact
words and tone of voice, We have to herd the animals into the barn,
because a big storm is coming!4 He is oriented away from Sean, and
he speaks apparently to himself. Sean, however, approaches him and
attempts to join his play. Without looking at Sean, Mattie continues
to put animals into the barn. His attention is more focused and his
actions smoother and better coordinated than Seans. In ignoring
Sean, it is as if he recognizes that Sean could introduce a significant
disruption in his plan. When about half the animals have been put
back in the barn, Sean pronounces, The storm is over now. Without looking up or changing his position, Mattie responds, No, its
not, and continues putting animals into the barn. Sean, after a hesitation, leaves the cars and joins him. Finally, the animals are in the
barn. Leaning back, Mattie surveys the barn and says, Now they are
all in the barn, safe and sound. It is remarkable to me observing the
tape, as it was when I was observing the meeting itself, how Mattie is
able to accomplish Seans agenda by the end of the meeting. In fact,
it is now clear that although initially articulated by Sean, it is a family
agenda and all the family membersMr. and Mrs. R also, by allowing
the boys to play uninterruptedcooperate in its accomplishment.
the second parents meeting: the third of the three meetings
In this meeting, I take out the paper on which I have written Mr. and
Mrs. Rs questions about Sean. I intend to answer them in simple,
4. This observation gives evidence for the influence all family members have on
one another while playing in the same room at the same time, whether they are playing in dyads or all together.
147
practical answers that lend themselves to recommendations for action. First, however, I am going to give them my impressions of the
family meeting. I get out the tape.
I show Mr. and Mrs. R the transition into the playroom. I acknowledge the attractiveness of the family and the expression of their family values in the polite greeting. I point out the friendliness of Sean
and his interest and eagerness to engage in this new situation. Then I
show the clip of Mr. R and Sean. Again, I first address the positive features of the obvious pleasure the two of them take in playing together
and the affectionate and supportive attitude of Mr. R toward Sean. I
note Seans significant strengths in being able to create and express
such a compelling metaphor as herding the animals into the barn
to avoid an impending storm. I also point out Seans difficulties in
coordination, including the way he drops the animals, and his tendency to get distracted. Next, I note the multiple statements of Sean
indicating his agenda to herd the animals into the barn and Mr. Rs
inattentiveness to them. This is a powerful moment in the meeting.
Mr. R is deeply moved. He is astonished to appreciate this observation and wonders how he could have failed to attend to Sean in this
way.
The next clip I show them is that of Mother and Sean. I first point
out the evidence of Mrs. Rs devotion and sensitivity to her children,
including her helpful preparation of Sean and Mattie for the transition and her attentiveness as Sean is explaining his agenda to her.
Then, however, I note her obvious anticipation of failure in this activity with Sean. I suggest that this sad, discouraged reaction of hers may
not be an uncommon one. Mrs. R is also very moved. In contrast to
her husband, she is not at all surprised by my observation and agrees
that with Sean she often expects to fail.
I explain to Mr. and Mrs. R a little about self-regulation, especially
in the domains of motor activity, attention, and affect. I remind them
of what they have told me about Seans sensitivity to loud noises, irregular textures in his food, and scratchy things against his skin and
point out that these sensitivities are associated with regulatory difficulties such as the ones demonstrated in the film. I tell them that it is
clear that Sean is a child challenged by problems regulating himself,
but that I think the film gives us some ideas about how to help him
learn to regulate himself better and how to support him in his development. These ideas include learning ways of attending to him more
carefully and finding cause for hope in his getting better and developing in a healthy way. Toward the goal of elaborating these ideas
about how to help, we turn to their original consultation questions.
148
(1) The first question is Moms: How to relieve his anxietyhe is

fearful and anxious. I answer, Right now Sean tends to be an all or
nothing kind of guy. We would like to teach him new, more flexible
ways of making sense of his world. This, of course, is neither a complete answer, nor does it lead directly to a discrete intervention. However, it communicates a new perspective on Seans anxiety and his demanding behavior, and it indicates a direction toward constructive
actionteaching him ways of being more flexible. We have seen the
positive feature of his persistence in the agenda of herding the animals into the barn. We would now like to help him find other, more
flexible ways of working on his agenda so that he could feel confidence in their successful accomplishment. And we would like to find
ways of helping his parents support him in his agenda.
(2) The second question is also Moms: How to develop strategies
to deal with his behavior problems, e.g. constant picking on his little
brother. I answer, We need to come up with new limit setting strategies. This answer focuses on managing Seans aggression and impulsivity through regulating his high arousal states and his negative affect. It also stresses the need to change the controlling effect Sean
has on the rest of the family. This answer is also neither comprehensive nor specific. However, it leads toward a practical way of changing
the family relationship patterns that are not working and suggests
that I am available to help the parents make those changes. In this
answer, I am also addressing Mrs. Rs exhaustion in her efforts to
manage the boys aggression, as well as Mr. Rs sense of helplessness
about how to support his wife when he arrives on the scene of a sibling conflict after having been at work all day. Mrs. R might be able to
give up her role as the family manager if both she and Mr. R could
find more effective ways of helping Sean regulate his behavior.
(3) The third question is Dads: How to deal with his negative effect on the family. He wears his mother down. I point out that Mrs. R
identifies herself as a problem solver, but that this problem is not
the kind that can be solved by one person. For her to take this on
her own shoulders is too great a burden. I also point out that Mr. R
seems to withdraw into his work and feel helpless. I suggest that we
find new ways of the parents working together to make things better.
(4) The fourth question is Moms: How do I get this kid motivated
to do the things he needs to do? Mrs. R explains that Sean is unable
to dress himself or take on other age-appropriate skills of autonomy,
and she has been unsuccessful in helping him learn. I agree with the
Rs about how Sean needs experiences of mastery. Neuro-developmental disabilities have interfered with his achieving certain compe-
149
tencies necessary for age-appropriate autonomy. I explain, also, that

his difficulty managing strong feelings makes it hard for him to take
risks that threaten him with disappointment and frustration. We
need to find special ways of supporting him in achieving mastery of
skills of independence.
The Rs are thoughtful and interested in my answers to their questions. They ask for recommendations about how to implement some
of my ideas. I tell them that I think they need help working on these
changes, and that I would be glad to help them. Since the problems
are interfering with Seans development in a significant way, I recommend a therapeutic intervention that includes working with Sean directlyeither continued parent consultation with family meetings
or individual therapy. Mr. and Mrs. R say that they are interested in
trying to change the way the family members behave in relation to
one another, including their parenting behaviors, and that they
would prefer to continue to work with me in family consultation. I
agree, and we set a first meeting.
key differences in the consultation
You will notice that my comments to Mr. and Mrs. R include neither a
diagnosis nor an explicit formulation of Seans difficulties. That is
because those issues are not included in their consultation questions
to me. In this case, my initial formulation of Sean as a child with neurodevelopmental disorders complicated by family patterns of difficulty regulating him and supporting his agenda, informs my answers to the questions
they do ask me. I know that Sean has made sense of his life experience
and that the sense he has made includes rigid, all-or-nothing meanings that underlie his separation anxiety and his other fears. At this
point, I know that these meanings include that of a destructive
storm that threatens the living creatures of the farm, and I know
that Sean and his whole family fear that they might not find the
means to keep the animals safe.
The storm is the focal point of the meeting, to which the family
members return again and again. It has important symbolic meaning, demonstrated in each family members reaction to the threat of
the storm. Sean is afraid of the storm, but so is everybody else. His
mother, father, and brother either keep a distance from Sean or comply with his demands, in an effort to avoid the storm of his temper
outbursts. Fear of the storm helps explain Mr. Rs choice of more immediate subjects of joint attention rather than Seans main agenda. It
helps understand Mrs. Rs withdrawal and anxious efforts to manage
150
the family. It informs the observations of Seans sitting on his hands

to avoid potential grabbing movements. It explains Matties accommodation to Seans refusal to share the toys with him.
Yet, my fuller understanding of Seans problems depends on the
micro-analysis of the family meeting. Had Sean, in an individual session, represented his experience in the metaphor of the stormless
likely, perhaps, were he not in the midst of his familyI would have
interpreted the storm as Seans aggressive behavior and his fear of
the consequences of this behavior on his important relationships. I
would not, though, have seen evidence of crucial features of this behavior. I would not have appreciated the degree to which and the
ways in which Seans problems regulating his attention, his motor activity, and his affects contributed to the creation of the storm.
These observations are harder to make when the clinician is playing
with the child one on one. The family meeting illustratedin the micro-process with each parent, and in the sibling playthe extreme
struggle Sean exerts to regulate his behavior. The storminess of his
affective state and his attentional state underscores his impulsive
grabbing.
I also would not have seen how each individual family member respondshow the family as a whole respondsto the threat of the
storm. The family meeting illustrated the way his parents and
brother contributed to Seans dilemma by symbolically leaving him
outside the barn, when they felt helpless to deal with the storm. I
would not have understood in what ways the family system has created adaptations to the challenge of Seans behavior that backfire,
and make it even harder for them to help him grow. I would not have
seen Matties valiant efforts to recuperate the plan of herding the animals in order to save his family from the storm. Finally, I would not
have seen the significant strengths of the family, strengths that will be
essential in their attempts to achieve their goals.
The PCM includes valuable tools derived from infant observation
research to use in my clinical work. With videotape I can observe the
exchange between the child and the world of his family. However, I
cannot observe the childs inner world with videotape. His private
world is the territory of psychoanalysis. The opportunity to put together these two complementary views of the childthe inside and
outside viewsis an exciting opportunity. Often, the PCM evaluations go on to become psychotherapies, and sometimesas in the
case of Seanpsychoanalyses. Once the child is in individual therapy
or psychoanalysis, transference issues usually make family meetings
151
impossible. Beginning the evaluation with the PCM often gives me

the only chance I will have to capture this outside view.
Concluding Remarks
I would like to conclude by considering analogies between the quest
for useful means of helping troubled children and their families, and
Seans desire to herd the animals into the barn. Through his attempts to get the animals into the barn, Sean is drawing his familys
attention and my attention to the storminess of his internal world,
and to how that storm sometimes provokes him to behave. But as I
have pondered Seans stormy world, I have also thought about the
storm in psychoanalysis and recent efforts to bring together information from infant research and developmental theory into something
that is useful for the theory and practice of psychoanalysis and psychotherapy. The technical and theoretical tools that infant research
provide have enormous potential but must be integrated into psychoanalytic theory and technique in order for me and other clinicians to be able to make use of them in practice.
My work as a child psychiatrist and analyst for almost three decades
has shown me that the ways children grow and change are extremely
complex. No linear theory of causality is sufficient. Moreover, the
plurality of contemporary psychoanalytic theories lacks the necessary
coherence to provide the clinician with what he or she needs to make
sense of clinical material. Dynamic systems theorya theory that
provides a broad umbrella theory for therapeutic and developmental
changeincludes in its general principles coherence, as well as complexity. These considerations suggest that psychoanalysts and other
clinicians should attempt to provide coherence by developing useful
integrations. Indeed, the PCM that I have described in this paper
represents one effort to develop a useful integration of techniques
and theory to help children and their parents in the initialand importantdiagnostic phase.
Sean and his family are searching for greater flexibility in the
meanings they make of their experience together and apart. They
are trying to support each family members agency in their efforts at
creative elaboration of their private meanings, yet at the same time
striving to find ways of regulating themselves and also the family system, so that it does not come apart. In a similar way, analysts and
other clinicians would be well advised to be flexible, open to alternative perspectives, without fearing the loss of familiar concepts. The
152
self-organizing properties of dynamic systems suggest that there are

many ways of understanding the challenges of developmental processes, including those we engage in our work with patients. The
search is for ways of embracing complexity, while developing and
maintaining the coherence of our theories. In Seans metaphor, we
search for means of herding the animals into the barnbringing
the complexity of developmental processes into a coherent framework of psychoanalytic theory.
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PSYCHOANALY TIC RESEARCH
Recollections of Being in
Child Psychoanalysis
A Qualitative Study of a Long-Term
Follow-Up Project
NICK MIDGLEY, PsychD, and
MARY TARGET, PhD
To date there has been very little research looking at how former child
analytic patients have made sense of the experience of being in psychoanalytic treatment as children. Based on semi-structured interviews
with twenty-seven people who, as children, had been in intensive psychoanalysis at the Anna Freud Centre, London, between 1952 and
1980, this study uses a qualitative methodology to explore two central
themes: attitudes toward being in therapy and memories of therapy
and the therapist. This report presents the findings of the study in
narrative form, and argues that the recollections of former child analytic patients are an important, but under-used, source of knowledge
for an understanding of the psychoanalytic process.
In 1922, thirteen years after he published his first account of
the psychoanalytic treatment of a child, the case study of Little
Hans, Freud added a short postscript. In it he described a strapping
youth of nineteen who approached him and introduced himself as
the same person whom Freud had met when he was only five. He told
Nick Midgley, Anna Freud Centre, London, and Mary Target, Anna Freud Centre
and University College London.
157
158
Freud that he was perfectly well, and suffered from no troubles or

inhibitions. He had apparently come through his puberty without
any damage, despite the severest of ordeals, including the divorce of
his parents. Most remarkable of all, he told Freud that, even when he
read the case history, he could remember nothing of the analysis itself or anything described in the pages of Freuds work (1909:304).
Freud suggested that Hans memories were no longer available to
consciousness because of the repression barrier that had blocked any
recall of both his early childhood and, more specifically, of the analytic work undertaken by Hans father under the supervision of
Freud. Perhaps it was Hans lack of memory that has encouraged psychoanalysts (and researchers) to assume that former child analytic
patients will have little or no memory of their early experience of
analysis, leading to an almost complete absence in the professional
literature of any accounts of child analysis from the point of view of
the former patient him or herself.
Yet when we turn to the general child analytic literature, we discover that in many treatments some form of spontaneous followuplike that of Freud and little Hansdoes take place, and that in
a few instances some indications of how the child analysis has been
remembered is recorded. Far from suggesting that all memories are
over-taken by the repression barrier, there are hints that the child
analysisand the figure of the analyst in particularretain some
place in the memories of these adults.
For example, in Kochs (1973) review of twenty cases of follow-up
contact with former child patients, he reports that former child patients made some reference to their experiences of analysis, but with
little specificity and some distortion of memory. Some spoke of it as
being helpful, or remembered some aspect of the treatment room
or particular events (often connected to provocative or acting-out
episodes) but that much of the childrens experiences had receded
into the oblivion of the repressed (238). The only exception is one
child who, at follow-up, dwelt at some length on his experience,
vividly recalling his anger at the therapist for not understanding what
he was trying to communicate when enraged (238).
In a similar review, Beiser (1995) writes that of the thirteen intensive child analyses she carried out during her analytic career, in ten
cases follow-up data was available, in some cases up to forty years after
termination. But in only one case does Beiser explicitly report the
former child patients own memories of therapy: a boy who remembers playing Fox and Hounds with his therapist, while naming each
animal with an affectdepression, envy, anger, and happiness. The
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 therapists] desk (117).
Although she gives no other examples, Beiser observes that many
of the memories of therapy that these former patients retain were related to experiences of limit-setting by the analyst, and she wonders
whether the experience of gratification and frustration, inherent to
the analytic experience itself, encourages the process of internalization. She also notes that several of her former patients had entered
professions involving the care of children, and that they often retained an attitude of inquiry as to the meaning of behavior and feelings which the analyst had herself promoted (119).
The psychoanalytic literature also contains several case studies of
former child patients who have returned to analysis as adults (e.g.
Adatto 1966, Ritvo 1966, Ritvo and Rosenbaum 1983, Ostow 1993,
Babatzanis 1997, McDevitt 1995, Colarusso 2000, Parsons 2000,
Rosenbaum 2000). Most of these studies have been attempts to show
how core aspects of character seem to be continuous from childhood to adulthood (Cohen and Cohler 2000:9), so they have not focused primarily on the former child patients memories of therapy.
Nevertheless, a number of these case reports do remark on the place
the child analyst appears to have retained in the former patients
mind. In a review of several cases, Ritvo suggests that many of these
adults have maintained an internal representation of the child analyst as a source of self-awareness and self-understanding to which
they turned at times of internal crisis (1996:375), as well as an awareness that understanding the workings of the mind was the way to resolve their difficulties, and that the analyst was someone who knows
how to help them (2000:344).
While the focus of much of this follow-up literature is elsewhere,
the few glimpses we are given of the former patients memories of
their analyses are tantalizing: Ms B, who recalled many aspects of
her first analysis, especially in connection with her analysts interpretation of wishes to have a baby (Ritvo and Rosenbaum 1983:686);
Richard, in analysis with Melanie Klein as a young child, who almost forty years later remembers her as dear old Melanie, short,
dumpy, with big floppy feet, and with a strong interest in genitalia
(Grosskurth 1987:27273); the young woman who felt that, as an
adolescent in analysis, she had been able to get better because [the
analyst] was kind like her father, and who recalled particularly a
painting on the wall of the analysts office (Adatto 1966:500); and
Evelyne, who, in a follow-up interview at the age of thirty-four, re-
160
ported that she learned the art of good listening and communicating from her former analyst (Ritvo 1996:374).
To our knowledge, the only description of a child analysis written
by a former child patient her or himself is Peter Hellers A Child
Analysis with Anna Freud (1990). The book includes a reproduction of
the very sketchy process notes made by Anna Freud on Hellers childhood analysis in Vienna, which she sent to him a few years before her
own death. Heller chose to publish these, together with an account
of his own memories of his childhood in Vienna and his free associations to reading Anna Freuds notes.
In his introductory chapter, where Heller writes of his family and
his childhood, Heller expresses with great force his deep but ambivalent feelings toward Anna Freud and his analysis with her, which was
carried out in quite unusual circumstances. (Heller also attended a
special school run by Anna Freud and his later life was closely tied
up with that of Anna Freud and her circle). He describes his memories of Anna Freuds kindly severity (xxii) as she sat behind the
couch on which he lay (between the ages of nine and twelve), knitting or crocheting. He remembers that his analysis focused on the
loss of his mother and his problematic relationship to his father
(xlvi), and he describes how as a child he loved and revered [Anna
Freud] above all other humans (xxvii). Yet Heller is deeply ambivalent about the experience: he explains how, in analysis I wanted to
be loved . . . and like so many patients, I did not think I was loved
enough (xxvii).
Hellers account of his child analysis hints at the depth of feeling
he still retains about this period in his early life, and suggests that former child analytic patients can provide us with another point of view
on the psychoanalytic process, one which would complement the
many accounts of child treatments from the analysts point of view.
More particularly, they could provide us with the opportunity to discover how former analysands felt about being in therapy as children,
what they understood about why they were taken to see someone,
and what specific memories of the experience they have retained.
The desire to know more about this remarkably unexplored area was
what led us to carry out the current study.
Rationale and Aims of the Study
The research reported here is part of a larger project on the longterm outcome of child psychoanalysis (Target and Fonagy 2002),
which attempted to follow up all adults who were referred as chil-
161
dren to the Anna Freud Centre between 1952 and 1980. In total,
twenty-seven adults who had been in intensive psychoanalysis as children were interviewed as part of this project (see Appendix One). These
interviews were extremely wide-ranging and in-depth, exploring all
aspects of adult life and functioning as well as memories of childhood generally and the child analysis more specifically.
Out of this huge amount of data, this study makes use of only one
small partthe interviews which focused specifically on memories of
being in child analysis (Barth 1999). The approach chosen to analyze
these interviews was broadly-speaking qualitative. The relatively
small sample (twenty-seven participants), the nature of the data (verbatim transcripts of semi-structured interviews focusing on the subjective accounts of personal experience), and the topic itself (a relatively unexplored area where an exploratory approach is probably
more appropriate than a hypothesis-testing one) are all features that
have been widely recognized as appropriate for qualitative studies
(McLeod 1999).
Inevitably the detail and depth of memory retained by the participants of their child analyses varies enormously. Some of those interviewed had been as young as three and a half when they had been referred to the Centre; others were in late adolescence. Likewise the
period of time since the analysis had ended varied a great deal
from eighteen years to forty-two years, with the average length of
time being twenty-seven years. Some people refer to specific, but
quite major gaps in their memory, like being unable to remember
anything about starting or ending therapy, or whether they saw one
or two different therapists, or how often or for how long a period
they came. Only two people (aged four and a half and five at the time
of their respective referrals) claimed to have no memory at all of the
experience. Perhaps unsurprisingly, those whose memories were less
clear tended to be the ones who had been referred for therapy when
they were six or under, although this was not always the case. For example, one person who had been in therapy at the age of three and a
half for about two years, had quite clear memories of his therapy and
his therapist.
Results
In the course of the analysis of the data, a wide range of analytic
themes were generated (see Midgley 2003; Midgley, Target and
Smith, in press), and this paper will present only part of the
findingsthose which were related to the participants attitudes to-
162
ward being in child analysis, their memories of what actually took

place, and their feelings about the figure of the analyst him or herself. In the presentation of the material, verbatim excerpts from the
transcripts are included in order to convey the tone and complexity
of the individual narratives, and to give a more vivid sense of what the
interviewees experiences involved. Although not given in exact quantifiable terms, some sense will also be given of whether the themes
that emerged were common across many interviews, or were quite
particular to the experience of one or two interviewees; or whether
certain themes were especially common among men rather than
women, or those who had been in analysis at a certain age. The excerpts will be referenced in the following way: (Anthony, 10.10),
meaning that the quotation is from the interview with Anthony (all
names are changed), age ten years and ten months at the time of being referred for analysis.
attitudes toward being in therapy
A number of participants in the research suggested that being in psychoanalysis as a child was a relief because they were aware that things
were difficult, although few were specific about the nature of the difficulties. Five of the interviewees (all latency age or older at the time
of referral) spoke of their own sense that they needed to be in therapy, or the relief they felt that something was being done to make
things better, although most of them are not specific (in this interview, at least) about what they felt their difficulty was at the time. As
one puts it:
You know Id obviouslysomething had gone wrong and I was unhappy and everything, and I thought maybe, maybe this will make
things better, so really I was pretty determined to do it because I
thought I needed to. (Richard, 10.10)
About half of the interviewees (evenly spread across the age range)
commented that they did not really understand why they were taken
to therapy as children, and they described feeling that nobody had
really explained this to them. I was never really told why I was going
there (Susannah, 12.3) is a comment that recurs several times in different interviews, although the way different interviewees feel about
this varies.
In some cases the interviewees indicate that nobody had explained
to them why they were going, but this does not seem to have been a
difficulty for them, as they were able to make sense of it for themselves (e.g. Anna, 8.11). In several other cases, however, especially
163
among those who had been in therapy as adolescents, the fact that
they did not feel they understood why they were coming to the Anna
Freud Centre was a more serious obstacle, and made it harder for
them to make use of the therapy itself. In one womans case, her difficulty in understanding why she had been referred for therapy led to
a more negative attitude toward being in therapy:
I think that it would have been very helpful if it had been all explained to me if everything, the whole treatment was explained to
me . . . why I was there, the necessity of her to react to me in the way
she did . . . as I say at eleven I didnt have any choice about going. I
didnt choose to go and it was never explainedor as far as I remember it was never explained. (Tamsin, 12.6)
For another interviewee, who came into therapy as an adolescent,

this issue of not understanding why she was coming to therapy was
felt to be almost the main topic of the therapy itself:
Its strange because I didnt understand why I was theremy childhood wasnt brilliant, my adolescence wasnt brilliant, I wasnt getting on well with my parents, and I can only thinkbut nobody got
on well with their parents, I really didnt understand why I was there,
and that theme went on throughout the year, it was the constant, major theme of why am I here? (Heather, 17.5)
Of those who described this sense of not understanding why they

had come to therapy, a number expressed a wish that they had been
consulted more, that there was a negotiating kind of process, about
whats going to happen (Daniella, 13.9), or that they had been given
more information, at the time. I think at thirteen a bit more information would be useful, says one woman, thinking back to her experience (Susannah, 12.3), while another woman remembers feeling
that we never sort of assessed as we went along how it might have be
helping [. . .] and it might have been helpful for her to say Lets see
how you progress, lets see what value has been in it, lets see perhaps
lets talk to your parents together (Tamsin, 12.6). Without such a
process, being in therapy could feel as if it were actually a punishment for doing something wrong:
It felt, you know, I was like being punished every day and I didnt understand what good it was doing. (Tamsin, 12.6)
Commentary
From her earliest writings Anna Freud recognized that one of the
greatest differences between child and adult psychoanalysis was the
164
childs attitude toward being in therapy. Adults who have an emotional difficulty may sometimes decide to see a therapist; children
rarely do. If they do see a therapist, it is probably because they have
been asked (or told) to go by a teacher, a doctor, or a parent. Children may not be as troubled by their symptom as the adults around
them are; they may lack the same motivation to engage with the analytic process, and they are more likely to seek an external solution to
their difficulties (A. Freud 1965). All of these issues raise very specific
questionsperhaps even concernsabout what the childs attitude
toward being in therapy will be.
To a considerable degree, these concerns are confirmed by the
findings of this study. While there were a small number of participants in this study who described a sense that they needed to be in
therapy, and spoke of the relief they felt when their difficulties
were finally being addressed, very few referred to specific difficulties
or worries that led them to be in analysis; a large number of participants (about half) in retrospect described some feeling of not knowing why they were taken to therapy as children.
It is interesting that of those who expressed this feeling, a greater
proportion had either been under six or adolescent at the time of
their referral. It may be that for those who were referred at a very
young age their lack of understanding about why they had been in
therapy was more related to lack of memory or lack of understanding
at the time, whereas for those who were in adolescence the meaning
of these statements was different. This might seem to be confirmed
by the fact that it was predominantly the adolescent group for whom
this lack of understanding was seen (retrospectively) as having been
an obstacle to their engagement in therapy.
Of course the problem of engaging adolescents in psychotherapy
is a notorious one (Meeks 1971), and in general outpatient psychotherapy, it is generally accepted that there is a 40 to 60 percent
drop-out rate for this age group (Kazdin 1995, Wierzbicki and
Pekarik 1993). What comes across very powerfully from this data,
however, is a sense that these participants did not feel as if they had
been given enough information about why they were in therapy,
what was expected of them, and how the process workeda finding
that replicates recent studies into adolescents experiences of therapeutic inpatient units (Street and Svanberg 2003).
Although we have no objective data about what information
these young people had actually received at the time, this finding
seems to confirm some research suggesting that lack of preparation
can be an obstacle to children engaging in psychotherapy (Holmes
165
and Urie 1975) and that helping adolescents to understand why they
are coming, and how therapy is supposed to help them, is of great importance (Griffiths 2003). The need to attend to the childs understanding of why they are in therapynot just at the beginning, but as
an on-going processis perhaps one of the most important findings
of this study, given the degree to which these former child analytic
patients report a lack of understanding in this respect.
memories of therapy and the therapist
Among the twenty-seven people who took part in this study, there was
a fairly even spread between those who remember feeling predominantly positive about going to therapy, those who felt mixed, and
those who felt largely negative.
Interestingly, of those who spoke about coming for therapy at the
Anna Freud Centre in the most positive terms, the largest number
tended to come from the adults who had been in therapy as very young
or latency-age children, rather than as adolescents. This group spoke
about how it was fun, it was brilliant (Angela, 7.10), that it was a good
feeling to go (Phil, 9.3), or that they enjoyed spending time with [the
therapist] (Rupert, 3.9). For these people the emphasis is often on the
enjoyment they got from having this quite unique experience.
When describing the experience of being in therapy itself, most
people described it in terms of two main activities: playing and talking. Not surprisingly, those who describe the therapy in terms of
talking tended to be those who were referred at an older age,
whereas those who spoke in terms of playing were younger when
they had been referred for therapy.
Of those who remember coming to therapy in terms of playing,
the memories tend to be rather vague and generalized: painting,
playing with dolls or bricks, bits of plasticine or a book kept in a special cupboard. Several people describe some uncertainty about what
the purpose of the play was, and only in one case is the play described
in very positive terms as characterizing the essence of the experience
of being in analysis as a young child:
I saw it, you know, as my time to be with someone who was there to
play with me and sort of do whatever I wanted to do, and that was
hugely enjoyable. (Rupert, 3.9)
For several of the participants, the feeling that they could talk
aboutor dowhatever they wanted was what characterized being
in therapy, and this opportunity is described several times with a
sense of surprise and pleasure:
166
I think, initially, I think I liked the fact that it was one to one and
theI could do things here like art and craft that I couldnt do at
home or at school, and that seemingly you could do anything you
wanted. So it was like fun, it was brilliant, it was so, you know, whatever I wanted to do, I wanted to talk about, that was what I could do.
(Angela, 7.10)
For this particular woman the emphasis is on both being able to do

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

and others acknowledged that it enabled them to talk in a way that
was quite different to other situations with other people. A number
of people refer specifically to the fact that they were able to talk
about secret thoughts and feelings, and emphasize that they would
not be able to speak like this elsewhere, or that they would not be listened to in the same way:
Yeah, it was like a chance to go through things which, which I
couldnt go through with other people, because nobody had the patience or the time [laughs] to sit down and to listen to what was on my
mind so, to be able to do that was a privilege, it was something very
special. (Phil, 9.3)
While the quotation above describes the therapists attentive listening as helpful in its own right, others talk about things that the therapist did more actively. Although they do not use the word itself, several interviewees refer to something their therapist did which we
might understand as making an interpretation. In some cases, this
is a rather general comment about how the therapist would comment or mould what the child had said or done in their play (e.g.
Eva, 9.8) or would offer solutions to possible problems (Anthony,
167
10.10). One man talks about the way his therapist would mould
things and talks about things Id been talking about, like dreams or
whatever (Mark, 16) and goes on to describe what this felt like:
Sometimes, sometimes he came out with, Im pretty sure he would
come out with some very interesting sort of links, you know with what
I was saying, like, and Id say hey hang on a minute, thats absolutely right, you know. (Mark, 16)
Another woman refers to the comments that her therapist used

to make, and remarks on how, 20, 30 years later I can remember little comments [the therapist] made to something I said that she may
not have even thought was important, describing this as a powerful experience (Heather, 17.5).
In some cases, the therapists interpretation seems less about
what the therapist said, and more related to what the therapist did, a
particular action or response which had significance. One man remembers how he used to make things in his sessions, and that his
therapist used to dutifully walk down stairs and get whatever he
needed:
And then on some occasions Ill forget to ask her for something and
Ill say could you go and get me this and she had to go all the way
back down again [laughs]. Im sure I used to deliberately kind of just
see, you know, boundary again, just kind of see how far I could push
her and you know, she always used to go until there came a point
where she said Im not going to do that and I was like oh, why
not?, and she said something like because I dont want to. Uh,
OK . . . So my memory is quite fond of her, you know. (Neil, 10.4)
This man indicates that his own behavior was a kind of testing of
boundaries, and that his experience of the therapist setting limits was
an important one, and leads directly into his comment about his
fond feelings for the therapist.
When asked explicitly, about two thirds of those interviewed described some kind of positive feelings toward their therapist, and this
was especially true of those who came into therapy as young children.
A large number said simply that they liked their therapist, without
elaborating greatly on this. Others spoke about their therapist being
warm and friendly (Elaine, 6.4), or being a sympathetic person
(Jason, 7.1) and of themselves having real feelings of warmth toward the therapist (Neil, 10.4).
Among those who spoke about their therapist in these positive
terms, a few people expressed a more specific sense that they felt accepted, looked after, and listened to by their therapist. One man
168
spoke about how he appreciated the attention that his therapist

gave him (Bobby, 14.11), while a couple of the participants also describe, with obvious warmth, the sense of their having a unique relationship to their therapist, quite different from those with their parents, teachers, or other adult figures. One says:
I didnt really have any relationship with anyone else, but my therapist I was very close to. I felt I could tell her anything and she
wouldnt be cross. And everything I told my parents made them
cross. So that was quite nice. I felt accepted. (Marigold, 11.8)
In a similar way, another man describes his relationship to his therapist with the following words:
I felt I could be more relaxed, if you know what I mean, I mean open,
where I was not able to be relaxed with people in general. It was almost like I could feel, like, comfortable with her, like at ease with [my
therapist] yes, and, and also she wasnt in a positionyou see in a lot
of, especially with teachers . . . they tend to judge the children so, so I
was safe from judgement. (Phil, 9.3)
In contrast, several participants in the research describe feelings

about being in therapy which were often quite mixed and even contradictory. One woman describes her feelings about her therapist as a
typical sort of love-hate relationship (Angela, 7.10). Others speak
of the way that they liked their therapist, but felt hostile toward him
or her when they felt under pressure or were going through a difficult period in the therapy. One man describes particularly well the
way in which his feelings about the therapist could change depending on what was happening in the therapy, while also recognizing
that the hostile feelings were ultimately related to the difficulties of
the therapy, not the person of the therapist herself. He says:
I remember liking her, but I also remember being frustrated about
specific conversations and things, when she would query whether I
was feeling in a particular way or whatever, and you know, at the time
I felt it was a useless line of conversation, and then feeling annoyed
about that. But I seem to recall my overall feelings was that I liked her
[. . .] Sometimes, if I reacted adversely to a particular type of conversation, sometimes my feelings about that spilled over onto her personally, for a period of time. (Peter, 7.8)
While this man describes different feelings toward his therapist depending on what was happening in the therapy at the time, others
describe the way their feelings toward the therapist changed over
time. In some cases, an initial dislike gave way to more positive feelings:
169
I didnt like him at first, or I was scared of a man, [the therapist] was
strict and wouldnt do what I asked [. . .] And later I was very fond of
him, I remember later saying to him I think I might, I think I might
want do what you do for a living, some real feeling of warmth toward
him toward the end. (Neil, 10.4)
In contrast, for a significant minority of interviewees (just under a

quarter of the total, mostly latency-age or adolescent at the time of
therapy, and almost all women) their description of the therapy is
characterized by their non-engagement with the therapy. I wasnt really sharing anything with him. I was very closed (Joanne, 7.9); I
didnt talk about anythingsometimes things were really hard at
home (Dominique, 7.6); Id never open up, Id tell whopping great
lies because I didnt want her to know what I was really thinking or
feeling (Susannah, 12.3); I didnt really talk to herI used to sit
counting squirrels out of the window (Eva, 9.8).
Memories about non-engagement in therapy tended to be linked
with negative feelings about the therapist him or herself. Overall,
about one third of those who took part in the research expressed
some negative feelings about their therapist as a person. Interestingly, all of these people had been in therapy when they were either
latency-age or adolescent, and none of those in therapy as young
children spoke about their therapists in negative terms.
Most commonly among this group, interviewees spoke about a
sense that their therapist did not understand them. Whereas some
spoke about feeling not understood in a global sense, others suggested that there were only particular times when they did not feel
understood (e.g. Richard, 10.10). As one woman puts it:
I think, yeah, I felt he understood certain things but I think that, I
think I felt that maybe his priorities were not my priorities like, you
know, to him it seemed really important about my particular bodily
function, and to me it was why on earth is he interested in that? You
know, in that respect he wouldnt understand. (Angela, 7.10)
For two others, one of whom will be described further in the next
section, they felt the central issue that their therapist did not understand was the question of am I mad? As one of them puts it:
I felt, I think she said something like, well I think she said something
likeyoure coming here, isnt there something wrong? or something. I think that maybe we were at cross-purposes or something. Because I suppose on some level I was talking about whether I was completely bats and maybe she didnt realise that. (Daniella, 13.9)
170
For a number of interviewees, the negative feelings they had about

the therapy and the therapist were connected with the experience of
being asked questions: they asked me questions that I didnt want to
answer (Neil, 10.4), says one, while another remembers how the
therapist tried to pressure me to look at things I didnt want to look
at (Bobby, 14.11). One woman gives a more particular description
of this experience:
I think I liked [the therapist] but I think I found him really annoying
because he would ask me all these questions which I didnt necessarily want to answer [. . .] he used to ask me a lot of questions about my
bowel movementsor thats certainly what sticks in my mind
[laughs]so in my mind, its probably a complete distortion, but in
my mind I think he was a bit obsessed by my bowel movements but
[laughs] I dont know . . . (Angela, 7.10)
While these people describe feeling that these questions forced

them to think about things that may have been uncomfortable, others describe the experience as more negative, or as giving them a
sense that they did not know why they were being asked all these
questions. I thought she was interrogating me half the time (Susannah, 12.3), says one interviewee, while several refer to their uncertainty about what all the questions were for. One woman describes
her memory of being asked loads of questions and not knowing the
reason, and she remembers that some of the questions seemed to
have sexual overtones which she felt confused about (Elaine, 6.4);
another remembers how she used to wonder why they were asking
me all these questions, because I would stand there and I would be
playing with a doll or something and then I would think why are
they asking me this? (Lillian, 5.10).
For a small number of those interviewed, the therapists questions,
together with their sense that the therapist refused to respond to
their own questions, led them to experience the setting and the therapist in more explicitly negative terms. One participant put this especially clearly:
You see, I totally resented the process which was basicallypresumably its still the same, I dont knowbut she used to just sit and wait
for me to say something and I just resented that so much, and I got so
angry about it all that I dont think shemy feeling was how could
she ever know anything about me because she never asked any questions [. . .] You see if I didnt talk then she didnt talk so we just sat
there sometimes for the whole session not saying anything at all, and
I loathed it. (Susannah, 12.3)
171
A little later in the interview, however, the same woman described

how her therapist did ask questions, but that this was equally unsatisfactory:
She would ask me questions, and I would sort of think I knew what
she was trying toI thought she was interrogating me half the time
[. . .] Id tell whopping great lies because I didnt want her to know
what I was really thinking or feeling [. . .] And I felt she was prying, I
didnt want her to knowwhen she did ask the questions [laughs].
(Susannah, 12.3)
While several participants describe some negative feelings about

their therapy and their therapist as a person, the woman above is one
of a group of about six interviewees, almost all women who came into
therapy as latency-age children or in early adolescence, who describe
much more explicit, active feelings of dislike toward their therapists.
I thought he was revolting, says one (Joanne, 7.9), she drove me
demented, says another (Eva, 9.8), while another states that she simply hated her therapist (Anna 14, 8.11). Interestingly, none of them
elaborate that much on what it was they hated about their therapists.
One of them simply says it was because he was a man (Joanne, 7.9),
while another speaks about simply disliking everything about her
therapist.
Those in this same group also describe feeling that they were not
understood by their therapists, that they were not able (or did not
want) to share anything with their therapists, and that they did not
wish to be there. They all describe how they felt using quite similar
language: I just didnt want to go (Joanne, 7.9), I hated it (Susannah, 12.3), I was resentful about having to go, having to be there
every day (Dominique, 7.6), I didnt like it . . . I thought it was invading my own privacy (Sarah, 9.1). One woman gives a fuller description of how she felt and why:
I cant remember sharing my feelings with her; it was always resisting
sharing my feelings with her. I kept thinking it was a waste of time
and I kept trying to provoke her and I couldnt understand why I had
this little cupboard where I had some toys and crayons and I couldnt
understand why I had to go there and draw pictures or play with
dolls. Or I just thought that it was just meaningless, not understanding that what I was doing was being interpreted because I didnt have
any concept that behaviour could be interpreted. I just thought it
wasI didnt feel any better after going. (Tamsin, 12.6)
For this woman, as for some others, her negative feelings about the
therapy eventually led her to end her treatment prematurely.
172

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, although they may have had only a vague idea of what the
analysis was about. In The Technique of Child Psychoanalysis, Sandler et
al. acknowledge that for the young child the positive tie to the therapist probably forms the main basis for the therapeutic work
(1980:47), and the fact that those who were in analysis as small children almost all described it in terms of fun and as an opportunity
to play with an interested adult figure seems to confirm this. The
view of Sandler et al. seems to be confirmed by the findings of this
study:
To a child, analysis probably seems simply to be another one of those
strange activities that grown-ups enter into with children, responding
to whatever is put to them. The childs experience in treatment gradually enables him to sort out the meaningful differences [. . .] even if
he speaks of treatment as play. (1980:156)
But this study also tells us something more specific about what aspects of the experience of being in analysis as children were felt to be
important. For some participants in this research, there is a powerful
sense that the experience of being able to talk about whatever they
wanted to, in the presence of a sympathetic, non-judgmental listener,
was the essence of the therapeutic experience. The emphasis on the
experience of being accepted, listened to, and looked after by a therapist who is warm and non-judgmental appears to confirm once
again what Sandler et al. have written:
The child in analysis has a novel experience in that the therapist is an
adult who takes his feelings and expressions seriously over a significant period of time. This has the result that the therapist raises the
self-esteem of the child by saying, in effect, I regard you as someone
to be considered important, and I am not going to dismiss you out of
hand. I will listen to what you have to say. (1980:112/13)
This emphasis on being listened to and understood echoes much

of the research into patients views of adult psychotherapy, in which
the interpersonal qualities of the relationship are seen as considerably more important than any particular thing that the therapist said
or did (e.g. Llewelyn and Hume 1979). However the current study
also suggests that former child analytic patients remembered, and
valued, some of the particular comments or links that their analyst had said, indicating that a significant interpretation (Sandler et
173
al., Chapter 18) made in childhood can be remembered and valued

more than twenty years later in life.
However, for a considerable minority (about a quarter of the participants) the child therapy is remembered predominantly in terms
of their own non-engagement with the analytic process (counting
squirrels out of the window). This non-engagement is associated
with two factors in particular: a sense of being questioned, or even interrogated, by the analyst, whose questions did not seem to make
sense or did not give the child a sense of being understood; and in
a smaller number of cases, a general resentment of the analytic process itself, experienced as insulting, because the analyst was distant
and unresponsive and the child was left feeling misunderstood and
dis-empowered.
While in some cases these feelings were associated with a period of
the analysis when the child was being forced to confront things
they preferred to avoid, in other cases the feelings are more intense
and on-going, associated with a general non-engagement with therapy, a feeling of frustration about the analytic process. In a few cases,
especially among those who had been adolescents at the time of their
analysis, this led to intensely negative feelings both about being in
therapy and about the therapist as a person.
Analysts in the Anna Freudian tradition have also recognized that
the development of the negative transference in psychotherapy with
adolescents is particularly common, and especially likely to end in
premature termination of treatment (Meeks 1971:133). Moses
Laufer has written extensively about the particular difficulty when
the adolescent patient re-experiences the developmental breakdown
within the transference itself (Laufer 1989).
The accounts by some participants in this research of their intensely negative feelings are an important reminder that the psychoanalytic approach is not always successful or even appropriate. While
in some cases the negative feelings appear to have been transitory
and part and parcel of the therapeutic work, in other cases the feelings were on-going and unresolved, even at the end of therapy.
Whether such feelings were an aspect of the child him or herself or
were due to the nature of the analytic setting or failures on the part
of the analyst, it is not possible to be sure. But since, in some cases,
the feelings appear to have continued right through to the end of
the analysis, it appears as if such negative feelings could not always be
understood and used as part of the analytic process, and they often
led to premature termination and unsatisfactory outcome. This finding is an important reminder to child psychoanalysts that technique
174
needs to be geared carefully to the developmental level of the child,

especially how the treatment is introduced and the way that its aims
are presented.
Concluding Comments
By the very nature of being a long-term follow-up of child psychoanalysis, the participants in this study were describing experiences
that had happened to them at quite a young age and many years previously. Memory itself, as psychoanalysis knows only too well, is a
complex and over-determined process, and to what degree these
memories accurately reflect what happened in their child analyses
is open to question. There is a great likelihood that quite significant
aspects of the child analysissuch as its duration, or whether more
than one analyst was seen, or how the treatment endedwould be
described quite differently in the child case notes, and the difference
between these contemporary notes and the retrospective accounts
would be fascinating to compare and contrast. Future studies based
on the follow-up data already collected will attempt to compare these
participants memories of therapy with the clinical case-notes kept at
the Anna Freud Centre, as well as looking at smaller sub-groups
(such as those who were most or least happy with their experience of
child analysis) and comparing them using data related to initial diagnosis, outcome, current representations of attachment relationships,
and general adult functioning and mental health.
But although future studies may well complicate and enrich our
understanding, the uncertainties about the status of the memories
described in this study should not prevent us from attending to the
former child patients memories themselves. The voice of former
child analytic patients has been so strikingly absent in the clinical
and research literature, that we believe it is important to simply register this voice first, before we go on to further research that would allow us to explore the status of such accounts of the past within a
broader context. Most importantly, the current study appears to indicate that former child analytic patients, for the great part, do have
memories of certain aspects of their therapies (sometimes very clear
ones) and are able to give accounts of their analyses (sometimes very
eloquently). Since these accounts are in some important ways different from those of child psychoanalysts themselves, they are worth attending to for what they can teach us about the process and outcome
of child psychoanalysis.
175
Appendix. Participants in the Follow-up Study
NAME
Bobby
Daniella
Elsa
Richard
Tracy
Angela
Rupert
Marigold
Nathan
Sarah
Neil
Jason
Peter
Elaine
Heather
Phil
Eva
Anna
Anthony
Sheila
Dominique
Susannah
Mark
Lillian
Kevin
Joanne
Tamsin
AGE AT
REFERRAL
(Years, months)
LENGTH OF
ANALYSIS
(Years, months)
AGE AT
FOLLOW-UP
14.11
13. 9
5.2
10.10
6.11
7.10
3.9
11.8
4.8
9.1
10.4
7.1
7.8
6.4
17.5
9.3
9.8
8.11
10.10
4.0
7.6
12.3
16
5.10
11.11
7.9
12.6
3.8
4.2
2.2
4.6
1.2
1.10
2.0
3.1
1.5
3.3
3.1
3.9
2 .10
2 .0
0.9
4 .6
1.6
2.10
2.9
1.9
3.9
Missing data
3.10
3.4
5.3
1.6
1.8
42
36
36
29
29
32
34
31
41
29
33
45
32
39
42
33
29
34
37
46
41
39
40
36
39
35
35
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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.
178
Attachment and Autonomy in Latency
179
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 childs 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 intertwineweaving together a complex intermingling of id, ego, superego, self and
object structures, biological growth, and environmental influences at
each stage of developmentprovided the first complex framework
for psychoanalytic thinking about development and paved the way
for more modern, integrated thinking about childrens development.
A more complex examination of the latency age childs 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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Rona Knight
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 childs 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 Freuds (1965) challenge to continue the study of
the many complex factors that contribute to a childs 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.
181
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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Rona Knight
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 ChildrenRevised Edition (WISC-R), Bender-Gestalt, and
House-Tree-Person Drawings was used to assess each childs 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 childrens 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 Wechslers, Klopfers and Schafers scoring
systems and analysis for cognitive and projective data, each psychologist was asked to make clinical evaluations along ten dimensions
based on each childs 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-
183
lytic researchers who have documented reliability and validity for the
systematic investigation of these Rorschach measures. Both the Rorschach and TAT were also evaluated using Schafers sequence analysis (1954). Projective testing has traditionally been used in psychoanalytic research and has been proven to be a very effective clinical
measure (Holt & Luborsky, 1955).
One aspect of the Rorschach testing presented in this paper evaluated the childrens level and quality of object relationships. On the
Rorschach, the level of object relatedness was based on the subjects
ability to differentiate boundaries between objects, ranging from
merged to separate (Table I). Rating is based on the degree to which
an objects boundaries are described as distinct or separate from
one another. Merged responses indicate that the subject does not
feel himself as separate from the other, or yearns for an undifferentiated closeness. Separated responses indicate that the subject
experiences herself as separate and distinct from the other. Ledwith (1960) and Ames et al. (1974) have published many similar
TABLE I
Psychoanalytic Rorschach Profile
SCALE
LEVELS
SAMPLE RESPONSE
Object Relations
Differentiation
1. Merged
Monsters attached with two heads.

Siamese monkeys.
2. Merged to
Separating
A wall that is split open but still

attached to the ground.
3. Separate but
Connected
Connecting chairs.
Two crabs stuck together.
4. Separating/
Touching But
Distinct
Two animals back to back about to

go away from each other
5. Separate
Two people dancing together.

Two rabbits playing.
Rona Knight
184
TABLE II
Psychoanalytic Rorschach Profile
SCALE
LEVELS
SAMPLE RESPONSE
EGO
STABILITY
1. Death
A dead cat; A dead flower
2. Fragmentation
Crumbled rocks
A cup broken in pieces
Example of One
Boys Sequence:
Age 5People
Age 6Two shoes, two knees, two chins
Age 7Two ladies smashing pumpkins
Age 8People
THOUGHT
PROCESSES
3. Incipient
Fragmentation
Decaying leaf
Humpty-Dumpty falling
4. Enduring
and Solid
Person; Bear; A cooking pot
Contamination
Chinese dancers. Dogs playing patty-cake.

Chinese dog dancers.
Anthropomorphism Rabbits wearing their Easter hats having a

tea party.
A frog in a bow tie going to a ball.
Rorschach responses in their normal childrens protocols for this

age group.
A second aspect of the Rorschach testing appraised the integrity of
the childs self structure, which was evaluated by the degree to which
the object remained whole, intact, or alive (Table II). A fragmentation response on the Rorschach implies that the subject is in an unconscious feeling state of dis-integration. We usually think of frag-
185
mentation as indicative of a severe problem with self and object integrity. Its presence in these normal children during certain phases
of development suggests a normal, temporary break-down in the
antecedent mode of object-connection and the concomitant establishment of self-coherence, indicative of a change from an enduring
state to one that is experienced as not yet integrated. Fragmentation in normal latency childrens protocols also appears in Ledwith
(1960).1
Clinical Interview: Each child was administered a semi-structured clinical interview, developed for this research to gather information
about the following: 1) self-esteem, 2) ego ideal, 3) body image, 4)
quality of interpersonal relatedness, 5) narcissism, 6) conscious and
unconscious feelings and their discharge, and 7) coping mechanisms
and their functioning. The principal investigator administered the
clinical interview. Each interview was tape recorded and transcribed.
The clinical interviews were not scored for this research paper; the
childrens responses were used to confirm and deepen the understanding of the test data.
Parent Questionnaire: Every four to six months the parents of each
child were asked to complete a 16-page parent questionnaire developed for this research. The questionnaire elicited information about
the childs ongoing feelings and attitudes about him/herself, fantasy
and dream material, general mood, relationships with family and
friends, behavior and performance in school, parents feelings and
behavior toward the child, and information about the parents feelings about themselves. The childs mother was asked to fill out the
entire questionnaire. The childs father was encouraged to contribute information for this questionnaire, and he was required to fill
out the part of the questionnaire that concerned his feelings and attitudes about the child and himself. Responses from the questionnaire
have not been scored as yet but were used anecdotally to further our
understanding of the test data.
Observation of Child in Play with Peers: Each child was observed annually and videotaped for 12 hours in free play with a friend in the
childs house. This information was not used in the present study.
Teacher Questionnaire: Two thirds of the way through the school year,
each childs teacher was asked to complete a questionnaire about the
1. Bibring (1959) also found a dramatic difference between the disturbed Rorschach responses of pregnant women and their everyday good functioning in the real
world.
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Rona Knight
child. The teacher questionnaire elicited the teachers evaluation of

the childs general mood, school performance and behavior, and relatedness to peers, using a five-point rating scale, which was primarily
used in this paper to see how well the children were functioning in
school.
Procedure: The above measures were administered each year to each
child and their parents and teachers for the six-year period that each
child was studied.
Results
early latency: ages six to eight years
This clinical study delineates the processes of attachment and autonomy that occurred during the latency age period in these ten children. At age six years in the boys, and at age seven years in the girls,
the children began to develop an unconscious sense of being separate from their parents in a way that they had not experienced previously. This sense of separation was related to the denouement of the
oedipal period and their feeling pushed out into the world outside
their home. Along with this new sense of separateness came feelings
of disconnection, sadness, and anger. Although both sexes experienced this development, they had different timetablesthe boys entered this phase one year earlier than the girls.
Boys: At age six, a sense of separateness and lack of cohesion first
appeared in the boys responses. Three of the boys had Rorschach
testing at age five and were judged as not yet feeling separated and
had no fragmentation responses. However, between ages six to eight
all the boys were judged to be feeling separated from their objects.
All four boys had fragmentation responses on the Rorschach at age
six, which were less intense at age seven and were completely gone by
age eight. Typical of the advent and waning of a feeling of fragmentation was one boys responses to Card III on the Rorschach: at age five
he saw two whole people; at age six he saw two heads, two chins, legs
or knees, and shoes; at age seven he saw two ladies smashing pumpkins together; and at age eight he saw two people. Table III shows the
process of fragmentation and separation responses in the six- to
eight-year-old boys and girls.
At age six the boys had feelings of being alone, abandoned, and
not nurtured in the big world. TAT stories about feeling lost and
without parents were typical. Feeling little and damaged, they had
concerns about whether they could make it on their own, feeling in-
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TABLE III
Rorschach Fragmentation and Separation Responses
For Five- to Eight-Year-Old Children
BOYS
AGE FIVE
AGE SIX
AGE SEVEN
AGE EIGHT
Solid
All Fragmented
Some Fragmentation
Solid
Not Separated
Separated
Separated
Separated
GIRLS
AGE SIX
AGE SEVEN
AGE EIGHT
Solid
Fragmented
early 8:
some fragmentation
late 8: Solid
Not Separated
Separated
Separated
sufficiently supported by their parents. These responses were present

on the TAT and were also expressed in the conscious fears and
dreams these boys reported in the clinical interview. One boy worried about getting hit by a car while walking to school without a parent, and another dreamt about a dog that broke loose from his leash,
wound up with a bad family, and needed rescuing.
The six-year-old boys felt very angry and sad about being left alone
to fend for themselves. They associated separation with the death of
their parents. In the clinical interview they expressed fears about
people in their families getting hurt and killed and reported dreams
about their parents dying. One boys story to a TAT picture of a girl
leaving for school expresses these feelings: Somebody got killed in
her family. The grandfather. Then the father died and everyone else
in the family died, and so shes gonna get adopted. They just all died
cause they were real old, like 100 years old. (How old is the girl?)
Shes 19. These boys also experienced guilt about their underlying
fantasy that separation will lead to the death of their parents, which
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Rona Knight
often increased their worries. One boys dream at age six illustrates
this conflict: There is a monster coming to the house and I run out.
I worry about what will happen to the family when I run away from
the house.
Oedipal defeat and the resulting narcissistic injury added to the
six-year-old boys feeling rejected by their mother and not nurtured
by her. Mothers were often pictured as dead or hurt. The boys were
sad and angry about their loss and unconsciously expressed their depression in explosive discharge. The main defenses they used to cope
with all these affects were intellectual and obsessive-compulsive defenses. Their ego control, judging from their teachers high ratings
of their concentration and behavior, was good enough to hold these
feelings at bay during school hours; however, parents reported that
the boys behavior at home was often aggressive and difficult to manage.
At age seven, the boys sense of oedipal defeat and their concommitant oedipal feelings continued. Most of the boys still made the connection between separation and the death of their parents. The boys
felt a push to be independent but were scared about being lost or in
danger on their own. They found two ways to cope with their anxiety
about still feeling little and being able to manage on their own in the
world. The boys started to see their fathers as very human, capable of
making mistakes, but also able to help and/or protect their sons
from danger. They also began to use the defense of magic to help
them cope with their fears of getting lost in this new, larger, more
dangerous world. One boys TAT story at age seven describes his faith
in his father: A boy is sitting there with nothing to do. . . . He goes
bird watching and gets lost. Then his father was coming home and he
found him and brang him home. The boy felt scared when he was
lost and good when his father found him. His story to a TAT card
with no picture on it shows his use of magic: Theres a boy right here
and hes lost in the woods so the forest animals lead him home. He
feels relieved that the forest animals know where his home is. The
mother and father thank the forest animals.
The boys developmental push for independence at age seven led
to their feeling much more independent at age eight. The boys experienced a conflict over feeling more independent because they still
had the same worries and needs they felt the year before. Separation
was still experienced as getting lost in a big world and still included
the total loss of parental objects. One boy showed some regression
back to more typical six-year-old responses on the Rorschach after
the death of his uncle, which increased his anxiety over parental loss.
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, they were not yet as separated as the boys were at
this age. Their Rorschach protocols included responses like animals
and monsters with two heads, and a wall that split open but is still attached at the ground. Separating was associated with parents dying.
The following TAT story told at age six is representative of their separation concerns: The girl is going to school and shes staring at some
Indians coming. So shes going to run back to her family and tell her
family to run. Shes worried about the Indians killing her. Her parents are going to run but they get killed and she survives. None of
the girls had any fragmentation responses on a Rorschach at age six.
They were all still in the throes of the Oedipus complex, with the attendant concerns about body damage and death related to the oedipal struggle.
By age seven, five girls were feeling a lack of cohesion, with many
fragmentation responses in their Rorschach protocols. Five of the
seven-year-old girls showed evidence of having made a separation
based on their Rorschach responses and their TAT stories. They had
fantasies about going out into the world alone and having their own
houses. Their dreams and their conscious worries were about being
forcibly taken away from their homes by ghosts, monsters, and kidnappers, and separation often was associated with parental death.
The following TAT story told at age seven illustrates the girls feelings
of loss, sadness, and conflict around separating: This is a person crying cause her parents just died. And she came back to the house and
she dropped the keys on the floor and she started crying. She feels
sad, and shes thinking she wished she never moved away from her
parents home. At the end she finds out that this is a time that people
have to die. One girl had not achieved a sense of separation and also
had no fragmentation responses on the Rorschach. The absence of
unconscious feelings of a lack of integration and separation was paradoxical; for this girl separation meant total abandonment that led to
her own death, making her too anxious to tolerate a complete separation. While she was able to achieve appropriate separation in her
day-to-day life (based on teacher and parent questionnaires and clinical interviews), her responses on the projective testing indicated persistent unconscious difficulty in this area.
The seven-year-old girls were frequently preoccupied with pervasive loss, deprivation, and a need for nurturance. Like the boys, they
felt little in a big world. Oedipal defeat added to the girls sense of
loss. Stories in which men were perceived as dead, hurt, or deni-
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Rona Knight
grated were frequent. The anger that the girls felt about their loss
took the forms of oppositional behavior and aggression turned
against the self and siblings. The girls defended against these feelings
by denying and avoiding strong aggressive and libidinal feelings.
Some girls used repression and/or intellectual and obsessive-compulsive defenses to close off or constrict their feelings and impulses.
Their increased anxiety around aggressive impulses led them to a
conflict over good and bad behavior, exemplified by the following
TAT story told at this age: The girl is sad. Her mother sent her to her
room because she had been bad. I have been a nasty little girl, she
thought. And she went to her room and fell asleep on the bed. (What
had she done?) She hurt her little brother. She hit him. Despite
strong aggressive feelings, they do not have the sense of these impulses getting as out of control that the eight-year-old boys experience.
By age eight, the girls who had separated felt psychically impoverished and felt they had to work hard to perform, leaving all of them
feeling tired but hopeful of becoming more competent as they got
older. Like the boys at seven, the eight-year-old girls use benevolent
magic to manage their anxiety about their separation and scary independence in the big world. Nurturance needs continued to increase
at age eight, which added to their conflict between wanting to stay little and wanting to grow up. One girls TAT story nicely describes the
need and the conflict: This is a little boy, and hes sitting on the step
of a barn door sucking his fingers watching his father feed the animals. And hes thinking that he doesnt want to grow up. He wants to
stay little cause his mother just read him Peter Pan. . . .
Table IV outlines the findings for the six- to eight-year-old girls and
boys.
middle latencyage nine years
By age nine, the latency separation process converges for both the
boys and the girls. They felt both an external push to grow up from
their parents and an internal push to grow up. Both the boys and the
girls were made extremely anxious by their newfound separateness.
Projective tests at this age showed a breakdown of defenses. Contamination and anthropomorphic responses appear frequently on the
Rorschach as well as a reporting of visual and/or auditory responses
not actually present on the Rorschach or TAT cards. For example,
one girl saw talking and hearing vibrations on the Rorschach. The
high degree of anxiety and emotional disturbance seen on the
191
TABLE IV
Summary of Findings for Ages Six to Eight Years
BOYS
AGE 6
1. Feeling separate and fragmented

2. Feeling pushed out into the world
3. Separation equated with the death
of both parents
4. Feeling alone and abandoned
5. Sad about being alone and mad
about being kicked out
6. Depressed with explosive discharge,
defended against with intellectual
and obsessive-compulsive defenses
7. Aggressive and difficult to manage
at home
8. Concern about being able to make
it on their own
9. Feeling little and damaged
10. Oedipal defeat; mothers seen as
dead or hurt
11. Feeling not nurtured
AGE 7
1. Push to be independent
2. Concern about danger or getting
lost in the big world
of both parents
4. Sense of damage
5. Oedipal defeat; mother experienced as dead
6. Sad and mad about loss of mother
7. Fear of explosive discharge;
oppositional behavior at home
8. Nurturance needs
GIRLS
1. Not separated
2. Feeling pushed out into
the world
3. Separation equated with
the death of both parents
4. Concern about body damage and death
5. Strong Oedipus Complex
1. Feeling separate and fragmented

2. Feeling rejected and
pushed out into the world
3. Separation equated with
the death of both parents
4. Sad about the loss; sense
of deprivation
5. Oedipal defeat; Men seen
as hurt, denigrated or
dead
6. Feeling little and damaged
7. Nurturance needs
8. Oppositional behavior at
home; aggression turned
on the self and siblings
continued
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TABLE IV
Summary of Findings for Ages Six to Eight Years
BOYS
9. Magic used as defense
10. Fathers seen as helping sons

in world
AGE 8
1. Conflict over independence

2. Feeling small and damaged
3. Nurturance needs strong
4. Concerns about getting lost in
the big world
of both parents
6. Concern that aggression leads
to death
7. Oedipal concerns very present
GIRLS
9. Aggressive feelings defended against with denial,
avoidance, repression, intellectual and obsessivecompulsive defenses
10. Conflict over good and
bad behavior
1. Conflict over growing up
2. Feeling small and damaged
3. Nurturance needs continue to increase
4. Feeling psychically impoverished; having to work
hard to perform
5. Oedipal concerns; denigrating men
6. Fear of parental loss
7. Magic used as a defense
Rorschach is not manifested in the childrens typical conscious state

and functioning as described by teachers and in the clinical interview. Mothers of the boys, however, did describe more fighting with
their siblings during this age.
Girls: The nine-year-old girls became much more concerned with
moving away from their parents and toward their peers, exemplified
in the following TAT story: This girl is crying cause her family is going away on a trip, and she wants to go to her friends birthday party.
Shes gonna get to go to the sleepover party, and her parents and
brother will go away for the weekend, and she will get to sleep at her
friends house an extra day. The girls responded to the anxiety they
felt around their newfound separateness and autonomy with an increased need for nurturance and a yearning for an idealized childhood. While they all had a desire to grow up, they were very conflicted about it and had an intense wish to be taken care of like a
193
much younger child. The external pressure to grow up that they experienced made them very angry and anxious about their ability to
function on their own and resulted in lowered self-esteem. One girls
dream illustrates the anxiety at this age: I am on a bridge with my
friends. I have just left my mother on one side, and me and my
friends are going to the other side. As I am crossing the bridge it begins to unsnap, and I am terrified me and my friends will fall. My
friends parents are on the other side, and they snap the bridge back
together again, and we can safely get across. Their concern about
not getting enough nurturance and their yearning for it can be seen
in the following TAT story: This boy is sitting here waiting cause his
mother is out shopping, and hes really hungry. Theyre poor. He
feels really hungry cause his mother is taking so long. (What is going
to happen?) His mother is going to come home with a lot of food,
and he is going to eat lots.
Boys: The nine-year-old boys responses tended to have a more separate, alone quality. They made a point of noting that the people they
saw on the Rorschach were separating or separate. This more developed sense of separation and autonomy often made them feel a
sense of isolation and disconnection from people. This TAT story exemplifies the cold, isolating quality of the boys sense of separateness:
One day there was a blizzard. And a man got locked out of his house
in the blizzard. By the time someone found him he was in a coma.
The person that found him took him to the hospital. Then his father
came and tried to wake him up, but he couldnt. The next day he
came out of his coma and lived happily ever after. (How did he get to
be so alone outside?) He was locked out in the wilderness and he
didnt live near anyone. Someone going down a road saw him.
While they expressed an unconscious sense of separateness and isolation, they were able to maintain very caring relationships with their
peers.
The boys at age nine responded to their sense of separateness with
either a constriction that held their affects at bay but kept them isolated, or maintained a connection at the expense of feeling anxious.
Two boys were able to stay connected while feeling separate, although they were both disturbed sufficiently to see and hear things
that werent there during times when they were experiencing separation. This could be seen in the flow of associations through several
TAT cards. For example, one boys response to TAT Card 4 was a
story about a wife and husband who separate and divorce. When the
next card (TAT Card 3BM) was presented to him, he told a story
about a boy who has amnesia and a case of seeing things that arent
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there. The boy is scared by what is happening to him. His story to the
next card presented (TAT Card 7BM) was about a boy who is separating from his father to go off to college. Responses on the Rorschach
also show the boys disturbance around separating: It looks like two
Chinese dancers or people of some kind. They are separate. Maybe
two big dogs playing patty cake with their back feet and their front
feet. Maybe two big Chinese dog dancers. They just finished clapping
and are about to separate and then it looks like they are about to collide. They are slapping so hard the red stuff is the noise. The red and
the sharpness look like noise. Concurrent with the boys feelings of
separation, projective testing showed that their aggressive and sexual
feelings can feel intense and out of control because their autonomous defenses do not hold as well as before. At times these feelings actually got out of control. Parents reported an increase in the
boys fighting with their siblings at this age.
Table V shows the findings for the nine-year-old girls and boys.
TABLE V
Summary of Findings for Age Nine Years
BOYS
1. Intense feelings of separation
2. Sense of aloneness and isolation in the separateness
3. Weakened defenses
3. Anxiety about separation
4. Constriction of affect in alonenesstwo boys
Anxiety in connectednesstwo boys
5. Aggressive and sexual feelings that can feel out of control; increased fighting
with siblings
6. Caring relationships with friends
GIRLS
1. Intense feelings of separation
2. Push toward peers
3. Weakened defenses
4. Anger about being pushed to grow up
5. Anxiety about being able to function independently
6. Lowered self esteem
7. Increased nurturance needs
8. Conflict over growing up
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late latencypreadolescence
At ages ten and eleven another phase of separation and autonomy
begins to develop. This sense of separation is related to the hormonal/biological and cognitive changes occurring in preadolescence as well as attributable to the continued development of the
childrens feelings and experiences of attachment and separation experienced with their family and their peers. In this next phase, the
boys and girls diverge significantly, with the girls taking the lead in
the developmental process this time.
Girls Ages 10 and 11: The early latency phase of attachment and autonomy was revived and incorporated into this next phase of separation. At ages ten through eleven, concerns about connection and
separation re-occurred as the now late latency/preadolescent girls
began to experience the beginning of the adolescent separation-individuation phase described by Blos (1967). Typical responses on the
Rorschach were: two horseshoe crabs stuck together, two boys as the
same person going out on Halloween, and two animals back to back
about to go away from each other. This is a response that Ames et al.
(1974) also reported with their population of normal ten-year-olds.
Once again, fragmentation responses on the Rorschach appeared as
frequently as they did at age seven. This sense of a lack of integration
appeared in four out of the six girls Rorschach protocols at age ten,
and in five of the six girls protocols at age eleven. The one girl who
had no fragmentation responses at age seven, once again did not
have any. The variation of timing in this next separation phase suggests that this is a process that may occur over a longer period for
some children, and one that depends on the psychological, cognitive, hormonal, and physiological development of the individual
child. Based on mothers reports, five of the six girls were at Stage
Two of Tanners pubertal staging (1962) by age eleven, and one girl
had reached menarche at age ten years.
For the ten-and eleven-year-old girls, attachment and autonomy
meant a moving away from home base to create a life and world of
their own, with a knowledge that they could still return when they
wanted to or were needed at home. This is a very different scenario
from that of the seven-year-olds picture of separation, which entails
parental death. The following TAT story is an example of the different tone of this next phase: The ladys just thinking about her
friends and family, cause she just moved here, and she misses them.
She needs to find a job, but she doesnt know what kind of job she is
good at. Finally she decides shes going to be a shopkeeper. She
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thought she was old enough to move away so she moved. She will
start her own store and it will be okay. Frequently teachers were seen
as helping the girls achieve their goals, replacing parents, and friends
also filled in for family. The importance of the peer group for the
girls is demonstrated by the following story to the blank TAT card:
Gabrielle, age eleven, was starting to go to a new camp this year. She
was nervous. As she rode in the bus, she almost cried. But then she
thought of all her friends from school and cheered up. As it turned
out, it was the best summer of her lifefor friends, creativity, and
happiness. It was one of the best summers of her life, and she
couldnt wait til next summer.
This next phase of separation was not entirely free of fears and
conflicts. Three of the six girls had very real concerns about death,
which they applied to themselves and their loved ones. One girl had
the following dream about the possibility of death following separation: A week or two after we got our kitten, I had this dream that she
drowned. My friend dropped Lizzy [in the water] and we cried,
Shes drowned! I started diving underneath the water, and she was
at the bottom. I brought it up and started squeezing all the water out.
My friend appeared with the mother cat, and that made her feel better cause she was missing her mother.
Conflicts fused with anxiety about growing up were exceptionally
strong at ages ten and eleven. Contamination and anthropomorphic
responses were present in all of the girls Rorschach protocols, while
at the same time they were telling TAT stories about going off to college and being on their own. While change and separation were experienced as scary, these girls had a sense that they would survive it
and even fare well in the world. They didnt defend against these
feelings but tolerated the anxiety and sadness that comes with the
separation, bolstering themselves with a hope for a wonderful outcome. The one girl whose concern about separation was problematic
when she was seven was still concerned that she would not fare well
and described visions of homelessness, drudgery, and neglect, which
may be why she did not experience the more intense disconnection
that the other girls showed.
Along with this newfound sense of autonomy and its concomitant
feelings, oedipal concerns were more present again, and the girls experienced a surge of aggressive and sexual feelings that at times
would break through their defenses and overwhelm them. The girls
conflict about growing up at this point was also a response to their
anxiety about their intense sexual and aggressive feelings at this age.
They felt a need to be taken care of and nurtured by their mothers,
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whom they often experienced as either weak or unable to help them

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

girls
Images of connection and breaking
apart
Separation means moving away from
home
Suicidal ideation and concerns
about death
Teachers and friends replace family
Conflict over growing up
Nurturance needs
Strong aggressive and sexual feelings;
oedipal concerns
Not feeling fragmentedthree out

of four boys
11-year-olds: images of connection
and breaking apart
Separation means killing parents or
never seeing them again
Suicidal ideation and concerns about
death
Strong aggressive and sexual feelings;

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

sports, dance, karate, after school programs, etc., keeping them away
from the home many afternoons until dinner time and requiring
them to enter into a world of peers for most of their day.
This new sense of separation leads to feeling a lack of integration
and disconnection that is experienced unconsciously. A sense of an
unconscious, internal lack of integration may be a necessary part of
the separation process. The one girl who did not have any fragmentation responses had difficulties managing separation in her adolescence. One might hypothesize that each successive phase of separation along this developmental line has a period of wishing to merge
and a breaking apart that marks its inception. This corroborates the
analytic assumption that the development of an autonomous self requires a repeated process of identification and de-identification with
significant objects, as well as object removal and deidealization, all of
which can feel destabilizing.
This normal latency state of experiencing a lack of self-cohesion
may be a more advanced state similar to the one Stern (1985) described when he discusses the lack of organization the infant first experiences in the emergent sense of self, and Sander (1980) described
at the beginning of the mother-infant regulatory system that gets established in the neonatal period. Kohut (1971) also theorized a regression to a state of feeling fragmented when the child experiences
an absence of the narcissistically invested lost object, along with attempts to re-establish the union through visual fusion and other archaic forms of identification.
Feeling a lack of self-cohesion may also be a response to the conflict of independence. Experiencing a lack of integration is consciously expressed during normal developmental periods of separation. One mother reported that her seven-year-old daughter, during
a crying episode, screamed, I feel all in pieces! I have heard several
thirteen-year-olds, another developmental period of growing autonomy, describe their mothers as the tape that holds me together
when I feel in pieces (or unglued). When working with children
and adolescents in analysis, their expression of feeling a lack of selfcoherence may indicate that they are entering a period of transformation in development.
While these latency separation concerns are clearly tinged with
oedipal wishes, as they similarly are in early adolescence, they are
also about a yearning to merge, a desire to be attached and connected that has roots in the earliest phase of infancy (Pine, 1985;
Sander, 1980; Tyson and Tyson, 1990; Bowlby, 1969). This yearning
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for a merged closeness is well described by Homer (1992, p. 41):

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

styles of processing and expressing aggression at a very early age. The
need to defend against anger by turning it on the self may account
for the drop in self-esteem the girls showed beginning at age nine.
These findings may also be an additional reason for the drop in selfesteem that Gilligan (1982) found in her study of preadolescent girls.
Both the boys and the girls used the defense of aggression turned
against the self as they began to enter their early preadolescent separation phase; however, it sometimes had a quality of being a fantasized way to return or reunite with a lost object. This feeling was
clearly expressed in analysis by a young man with separation difficulties: Suicide and my mother are like the same thing; its a way out.
Its a moment when it seems like all of your problems are removed
from you and you dont have to grow up. I feel like I can get it any
time. I feel like there is an easier way. A further elaboration of the
suicide theme expressed by the girls at times was the feeling that to
lose your mother could mean the loss of ones own self, suggesting
the strong internal ties the girls have with their mothers. This study
suggests that suicidal ideationvery real thoughts and concerns
about death applied to oneself during the preadolescent phase of
separation-individuationis part of a normative process that is not
pathological or pathognomonic.
The responses of the children in this study suggest that the latency
and pre-pubertal phases of attachment and separation are filled with
intense experiences and feelings that can lead to significant disruption in self-coherence and ego functioning and to suicidal ideation
all derivatives of a normative process. Evaluating children in this age
group requires an understanding of the complexity of their normal
development in order to then determine pathology in a latency or
preadolescent child.
coping with separation
The childrens feeling of separation leading to more autonomous
functioning at the beginning of latency is enhanced by the development of concrete operational thinking, a higher level of cognition
(Piaget, 1967). This cognitive maturation allows the child to decenter and measure himself/herself against others and experience the
world as bigger and more challenging, leading to anxiety about going out into the world of school and peers, where they really are the
smallest, least knowledgeable children in that larger world.
All the children used fantasy and magic to help them cope with
203
fears of managing on their own as they felt more separated and alone
in the larger, challenging world. This supports Anna Freuds (1936)
and Sarnoffs (1976) finding that fantasy is used as a major defense
in the latency period, and the use of magic within that defense is significant. The boys in this study also felt they could rely on their fathers to help them manage difficulties in the world outside the family. One interesting finding was that the girls in the study did not feel
they could rely on their parents in the same way as the boys, and
demonstrated an oral neediness that grows in intensity throughout
the latency period as well as a sense of being tired at times by the task
of growing up. These findings are illustrated in the Harry Potter
stories (Rowling, 19982003). Harry has his god-father, his friend
Rons father and brothers, and several male teachers to help him
avoid dangers as he grows up in the magical world of Hogwarts.
Hermione, by contrast, has parents that are of no help to her, and
she has to study magic very hard (sometimes taking two classes at the
same time), relying on her wits to help her and Harry along the way
(Harry relies on her ).
The cultural and psychological implications that allow boys to see
their fathers as helping figures while girls cannot use their mothers
(or fathers) in a similar way during this phase of identification with
the same sex parent must be considered. All of the girls mothers
worked part-time in professional positions, yet the girls could not
imagine their mothers as helping figures in the world outside of the
home in their fantasy.
One possible explanation for the different reactions of the boys
and girls has to do with gender identification processes in early latency. Mahler (1981) addressed the gender difference in the first
separation phase, noting that the boy has his father to support and
maintain his personal and gender identity, while the girl, in her separation from the post-infancy mother, has a much more difficult and
complicated task to attain and maintain her sense of self because her
relationship with her mother carries the burden of threatening regressions.
In latency, boys identify with their fathers and their sense of their
fathers more competent position in the outside world. The girls
TAT stories often expressed a sense of tiredness related to independent functioning in the world. The girls in this study may have identified with their mothers tiredness from having to maintain two jobs
work and family care, and/or their mothers overriding maternal
function of being the main caretaker of the basic needs of the home
and children. Stephen King (1983) nicely expressed this male-female
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role dichotomy: What your mother leaves you is mostly good hardheaded practical adviceif you cut your toenails twice a month you
wont get so many holes in your socks; put that down you dont know
where its been . . . but its from your father that you get the magic,
the talismans, the words of power (p. 36). This component of the
girls identification with their mothers, when combined with their
lowered self-esteem, may sometimes leave them feeling that they are
not competent enough to be completely out in the world.
Another explanation for this gender difference may be found in
the remains of the late oedipal phase conflict. In this study, the early
latency boys unconsciously experienced their mothers as dead to
them, while the girls unconsciously experienced their fathers in this
same way. In their effort to break their oedipal tie to their fathers, the
girls need to distance themselves internally from their fathers, and
therefore do not have them as available as the boys do to help them
in their fantasy working through of the present stage of separation.
This might make the girls feel they have to bank on their own resources, which would increase nurturance needs in the face of moving out in the world without the internal reliance on their fathers.
Their increased need to rely more on their own resources may add to
their feelings of lowered self-esteem by the age of nine.
Two of the boys felt an intense sense of disconnection at age nine
that the girls didnt have. It is interesting to note that the two boys
who retained a sense of connection at age nine both had mild learning difficulties, requiring them to remain more dependent on their
mothers for help with their school work and the structuralization of
their environment. Chodorow (1989) suggested that the masculine
personality is founded on the denial of relational needs out of the
difference in social attachments that evolve out of the oedipal configuration, requiring the boy to more fully repress his primary relationship and, consequently, the degree of dependency attached to it.
While this finding supports her theoretical position, the relational
picture is more complicated.
The nine- to eleven-year-old boys in this study, while feeling internally disconnected and isolated, maintained caring peer relationships. Their unconscious feelings of disconnection seemed to be a response to their internal experience of separation, but did not
necessarily lead to a denial of relational needs in their peer relationships. Their attachment and loyalty to a primary, close male friend
was much more constant than the girls friendships were during
these years. However, the quality of the connection did seem to be dif-
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Because of the small number of homogeneous subjects who were

studied in depth, this study can only generate hypotheses about the
developmental process for all children in this age group; however,
the convergence of data from a variety of sources makes the results
compelling and ring true with our analytic observations. While there
is value in small N studies (Jones, 1993), additional studies on large
numbers of children from different cultural, racial, and socioeconomic groups are necessary to validate the ideas proposed in this paper. Therefore, these findings can only be applied cautiously to a
more varied cultural, cognitive, or socioeconomic group.
At the beginning of latency, the children in this study began to develop an unconscious sense of being separate from their parents in a
way that they had not experienced previously. Although both sexes
experienced this development, they had different timetablesthe
boys entering this phase one year earlier than the girls. Several possibilities could account for the gender difference in the latency process of the development of attachment and autonomy. Olesker
(1990), studying separating toddlers, reported that mothers were
more likely to push boys toward independent behavior and keep girls
closer longer. She suggested that this might lead the girls to enter the
oedipal period less well separated from their mothers than the boys.
In addition, boys may enter the latency separation period with a history of a more established separation than the girls may because they
have had to establish a predominantly male gender identity that is
different from that of their mother. This forces them into a differentiation pattern earlier than the girls and may promote earlier
development of separation and independence. Buxbaum (1980)
suggested another factor that may influence this developmental difference. She proposed that the girls oedipal phase might not be as
violent as the boys, in that girls dont have to give up their original
love object. This may explain why the girls may have a different
timetable, allowing them to remain in the oedipal phase for a longer,
more comfortable period.
The mothers of the early latency age boys and girls described what
felt like an instinctual desire to push their children out into the
world. One mother characterized her feelings of pushing her daughter into activities outside the home: I feel like a mother bird pushing
her out of the nest. The biological clock (Shapiro and Perry, 1976)
that gives latency its start may also be present in the parents responsive need to push their children out into the world of peers. Although both parents and children were ambivalent about this new
phase of separation and autonomy, all of these parents registered
205
ferentthe girls talked to each other more and shared fantasies in

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

card; she told a story about a seven-year-old-girl having a birthday
party during which the children played pin the tail on the donkey
(note the disconnected donkey). The disturbance in defense functioning seen at age nine continued, as the girls newly established
ego functions were further bombarded by their drives and the additional stress of a new phase of separation. Mahler (1972) has reported the defensive use of rageful, distancing behaviors in girls toward their mother during separation. This time parents reported
that their girls had become very difficult, were easily angered, easily had hurt feelings and became upset, had frequent mood swings,
and mothers reported a significant increase in mother-daughter confrontations. The girls did manage to maintain their high functioning
in school, as teachers continued to praise their abilities and behavior.
This preadolescent phase of separation is certainly related to a biological clock driven by a major change in hormonal functioning,
which starts earlier for girls than for boys. While only one boy was
clearly in early puberty and showed fragmentation responses at ages
ten and eleven, all of the boys were internally preoccupied with connection and separation, just as the girls were. Because data collection
in the present study stopped after age eleven, it is not possible to
know when the other three boys would have felt the same breakdown
in self-coherence that the girls did at ages ten and eleven. One may
assume that this next phase of separation is biologically driven, since
the one boy who did feel fragmented was in early puberty, while the
others still looked like latency boys at age eleven. This finding suggests that boys tend to remain in a late latency/prepubertal stage of
development longer than girls do. The biological time-table that contributes to these two waves suggests a discontinuous process of attachment and autonomy separate from underlying dynamic conflicts, albeit not unaffected by them.
stages and phases of latency
The stages and phases of latency have been described in the literature in many different ways, as discussed in the introduction to this
paper. The results of this study suggest another theoretical addition
to the phases of latency related to the development of attachment
and autonomy. In the proposed model, the early latency phase would
be between six and eight years in boys and seven to eight years in
girls, when the latency child begins a new phase of separation and autonomy from his/her primary objects. Middle latency would occur at
207
age nine, when both boys and girls consolidate their more independent and autonomous functioning. Late latency/preadolescence
would begin at age ten in girls and ten/twelve years in boys, when
another phase of separation and autonomy begins. If this theoretical
hypothesis holds true, then girls have a much shorter period of latency development than most boys do, and consequently dont have
as much time to consolidate their growth during this developmental
phase before they have to cope with another major developmental
shift to preadolescence.
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CLINICAL STUDIES
Play in the Psychoanalytic Setting

Ego Capacity, Ego State, and Vehicle
for Intersubjective Exchange
KAREN GILMORE, M.D.
The psychoanalysis of an 8-year-old boy who does not play is presented

to illustrate the centrality of the state of playing for meaning-making
and communication in treatment. Developmental research links affect
regulation, narcissistic balance, and the capacity for make-believe to
the early intersubjective exchange between mother and infant. The intersubjective dialogue between patient and analyst in the state of
playing is a crucial component of child analysis and its absence both
reflects and compounds ego vulnerability in the child and presents a
daunting technical challenge to the analyst.
Sohere I am in the dark alone,
Theres nobody here to see:
I think to myself,
I play to myself,
And nobody knows what I say to myself;
Here I am in the dark alone,
What is it going to be?
I can think whatever I like to think,
I can play whatever I like to play,
Training and supervising analyst and Head of Child Division, Columbia University
Center for Psychoanalytic Training and Research.
Presented as the Robert Kabcenell Memorial Lecture, New York Psychoanalytic Institute, March 9 2004.
213
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Karen Gilmore
I can laugh whatever I like to laugh,
Theres nobody here but me.
From In the Dark, by A. A. Milne
in this communication, i describe my efforts to understand a

latency age boy, Andy, whose analysis has been remarkable in my experience because of its absence of thematic content and emergent
intersubjective exchange in the form of play (Birch 1997). Through
discussion of one boys particular difficulties, I hope to demonstrate
how analytic work with prepubertal children is facilitated by the
childs capacity to achieve a shared state of play where meaning
making, affect modulation, and mental representation of intolerable
psychic experience becomes bearable and achieves therapeutic effect. The absence of play creates formidable obstacles to therapeutic
progress and indicates serious ego-impairment in the child.
Play in Psychoanalysis
In child work, the evaluation of childs capacity to play and the process of playing typically yield an invaluable trove of information
about the individuals psychological and cognitive development, dynamics, diagnosis, and interpersonal relatedness. The child clinician
expects that, despite possible inhibitions and constrictions, pseudomaturity or chaotic impulsivity which may deform the playing function, the child patient will usually produce some form of play that
can serve as a shared intermediate region, (a term borrowed from
Freuds 1914 metaphor of the transference as playground) where
the action of the analysis can safely unfold. Play has been addressed
extensively in the analytic literature even before Freuds immortal
description of the Fort-da game (1920); with the advent of ego psychology and observational studies of infants and children, it has
been increasingly privileged as serving a central role in child development. No longer reduced to merely a discharge or wish-gratifying
phenomenon, it is conceptualized as a complex normative growthpromoting capacity that evolves with cognitive and psychological development (Marans et al. 1993, Solnit 1987). Its crucial position in
the analytic treatment of children has also been described extensively in the clinical literature where it has been analogized to the
transference (Battin 1993), termed a creative workshop for action
(Mahon 1993), and yet distinguished from the enactments that directly draw the analyst into a dramatization of unconscious fantasy,
which, of course, are also prevalent in child analysis (Chused 1991).
215
Child analysts are very well acquainted with the coercive as well as
the generative effects (Ogden 2004) that accompany playing out a
child patients narrative. Like enactments, i.e. symbolic interactions
between analyst and patient which have unconscious meaning to
both (Chused 1991), play typically reveals that the analyst is both
playing a role in, and serving as author of, someone elses unconscious fantasy (Ogden 2004) that inevitably reverberates with her
own.
However, play differs from enactments in that it is, either implicitly
or explicitly, make-believe. Playing in the analytic setting establishes a space without real consequences (Freud 1917) where communication between the child and analyst can occur at the developmental level of the child in a state that is demarcated as meaningful
and yet not real. While both action and verbalization are involved,
what is optimally achieved is an intersubjective exchange in the mutual state of playing where transformation of the childs anxieties and
defenses can be accomplished by the analysts clarifications, reciprocal engagement, and interpretive work. This phenomenon is comparable to the analytic third as conceptualized by Ogden (2003) or by
Bromberg as space for thinking between and about the patient and
the analyst (1999) in adult work. In child analysis, this state is concretely anchored to favored play objects endowed with layers of
meaning, both explicit and unconscious (Abrams 1988), and it is
represented in the idiosyncratic play themes that emerge and evolve
as a product of the child and the analysts conscious and unconscious
communication in the course of an analysis.
But more fundamental than these tangible artifacts is the intersubjective mutual state of playing that characterizes each patient/analyst relationship and that sustains and is in turn transformed through
the metaphors of the evolving play narratives and props. Because the
playing analyst, to be truly effective, must fully engage in playing
(Birch 1997, Yanof 1996, Cohen and Cohen 1993), the play is inevitably co-created and contains elements from the unconscious of
both patient and analyst, although the patients contribution is privileged by the nature of the endeavor. Beyond mastering the typical
countertransference anxieties around regression and instinctual discharge, child analysts ideally have remastered the capacity to play
without condescension or self-consciousness and to maintain a consciousness divided between the analytic and the playing function
wherein the analyst is tuned into that particular childs inner life.
In child work where playing is prominent, there are layers of diagnostic, dynamic, and transference meanings within the play, as well as
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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. I believe that the child analyst, more than any other professional who
works with children, most consistently attempts to enter the childs
inner world and go beyond the typical array of self-protective barriers that children present to grown-ups. Both child patient and analyst
must be willing to engage wholeheartedly (Birch 1999, Yanof 1996)
in the conceptual world (Cohen and Cohen 1993) that the childwith-the-analyst creates. Over time, the analyst readily launches herself into the singular world of her patients state of playing, a world
whose rhythms, rules, and rituals as well as opportunities for therapeutic work are unique and to some extent idiosyncratic to the particular individual and the dyad; among these are the pathological
adaptations that can be addressed best by being in that world with
the child. This state includes unconscious communication and intuitive leaps that can result in dramatic shifts in the childs tolerance
for affects and rejected self-representations.
As for the child patient, even young children know, within a short
time, that playing with an analyst is a very different business from
playing alone or even with another child or adult. Playing with the
analyst is all at once revealing the self, drawing the other into a private world, and tolerating an openness to a dialogue which now subjects his psychic experience to modification and mentalization
here used to mean the establishment of links between drive-affect
and mental representation that are gradually identified and elaborated verbally (Lecours and Bouchard 1997). Of course, children differ a great deal in their guardedness around this threshold, but
bridging it is a crucial moment in the treatment. This is the moment
where the child admits the analyst into his private world, by no
means without its own resistances and defensive organizations, but
the juncture marks a point where the treatment relationship reaches,
to borrow a favorite video game metaphor, the next level.
Insights from Developmental Studies
Before describing the work with Andy, I will frame the discussion
against a backdrop of a selective review of some pertinent formulations of how early experience within the mother-baby relationship
serves as the birthplace for shared intersubjectivity which in turn
stimulates the interrelated set of ego-capacities that are at question
here, allowing a more informed speculation about how Andys par-
217
ticular history and endowment disadvantaged him. While much of

Andys relevant personal early history was indistinct due to his parents relative lack of awareness, the absence of imaginary play and
even typical infantile play (such as peek-a-boo) with either parent was
noteworthy.
Findings from allied disciplines underscore the importance of the
earliest relationship for many facets of future development. The vast
research and theoretical literature that has sprung up around infant
observation and the developmental sciences underscore the importance of the mother-infant relationship and intersubjectivity for the
establishment of very fundamental ego capacities, such as affect regulation, symbolic capacity, self-experience, and implicit procedures
that characterize object-relatedness. Infant observers and cognitivedevelopmental scientists have been able to illuminate the steps in the
emergence of affect recognition, mutual regulation, self-reflective
and symbolic capacity in the context of the earliest interaction with
the caretaker, demonstrating the significant contribution of the environmental surround (Stern 1985). Given the nature of our contemporary child patient population, which, like Andy, is distinguished by
a variety of disorders alternately called developmental, regulatory and the like, these findings provide fascinating corroborative
data and suggest new ways of thinking about and addressing these
fundamental deformations that clearly predate the Oedipus and profoundly affect its unfolding.
A number of seminal papers written by psychoanalysts and psychoanalytically informed baby watchers from previous decades, such as
Anna Freud, Winnicott, Weil, Mahler, Sander, Emde, Pine, and
Shapiro, adumbrate these contemporary conceptualizations and facilitate their contextualization within our psychoanalytic metapsychology. All of these writers observed and privileged the interaction
between the infants equipment and early experiential factorsan
interaction that aggravates or attenuates initial tendencies (Weil
1970). Weil termed this the basic core which establishes the earliest
regulatory stability; this regulatory stabilityor relative lack of stabilitycontains directional trends for all later functioning (p. 242
43, my italics). Neurotic conflict is ubiquitous but rests on a substructure that predates its appearance and does not originate in conflict
but rather represents a transactional adaptation.
This idea and its variants rephrase in concrete ego psychological
terms Winnicotts principle: there is no such thing as an infant,
that is, the infant and the maternal care together form a unit
(1960). Winnicotts work elaborates the notion that the inherited
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Karen Gilmore
potential of the infant cannot become an infant without the maternal care, which in infancy is guided predominantly by maternal empathy. This maternal matrix facilitates the tolerance of anxiety,
structured integration of the personality, the dawn of intelligence
and the beginning of the mind (p. 45). Winnicotts ideas also underscore the fact that neurotic conflict as it emerges in childhood occurs
in a mind already stamped by its interaction with its particular environment, the product of a complex transaction that begins within
the first days of life.
As the study of the self began to eclipse the ego in the literature,
the emergence of the self as a developmental accomplishment increasingly occupied infant observers and researchers (Mahler and
McDevitt 1982, Stern and Sander 1980, Emde 1983, Pine 1982). In
1985, Stern drew upon his infant observational studies to posit that a
very early existential sense of self, or rather a number of senses of
self, predate language development and self-reflective capacities
and are both revealed by subsequent development and transformed
by it. Among the senses he identified are the senses of agency, of
physical cohesion, of continuity in time, of having intentions in
mind . . . the sense of a subjective self that can achieve intersubjectivity with another, the senses of creating organization and the sense of
transmitting meaning (pp. 67). The presence of the other is crucial for self-regulation of affect and somatic experience and indeed
has a central role in defining the infants primary self-state. Between
seven and nine months, the human infant discovers that the other
has a mind of her own and that that mind can be engaged in sharing
subjective experience. Indeed, infancy research offers a series of elegantly simple paradigms, such as Tronicks still face, the visual cliff,
and theory of mind studies, that underscore the parallel strands of
the infants and young childs expectation of mutuality and engagement with the significant other even as he is increasingly able to realize the fundamental separateness of the others mental state, ranging
from beliefs and desires to available mental contents that inform him
about the world.
The notion that the same interpersonal process that produces
emotional recognition and regulation, reflective function, and self
and object constancy also is central for the birth of symbolic capacity
and imaginary play began with Anna Freuds Normality and Pathology
in Childhood (1965). The very young infant neither distinguishes self
from object nor is able to manipulate symbols and . . . the emergence
of each process is importantly interrelated with that of the other
(Drucker 1979). For example, social referencing referred to above,
219
i.e. looking at the mothers face for affective guidance, is a developmental milestone that highlights the presence of self-other differentiation. Moreover, it shows that the infant is available to receive the
attribution of meanings to objects and circumstances from the
mother, an essential step in the development of symbolic capacity
and imagination. The infant relates not only to the world as perceptually specified, but also to someone elses psychological relation to
that same world . . . [More important than mere information about
the world], this configuration of experience affords an infant the opportunity to learn that given objects and events can have multiple,
person-related meanings. The meaning-for-me is not necessarily the
meaning-for-her (Hobson 1993). This remarkably rich developmental moment captures as in a freeze-frame the complex process
whereby the infant learns to use the mothers affective signal to
guide both his own affect and his actions, a process which, when internalized, provides a key component of future self-regulation of affect. In addition, this same moment illuminates the infants recognition of separateness, the intersubjectivity of his mental state as he
obtains the required affective guidance from his mothers expression, and the process through which meanings of things are conferred by minds. With these developments comes the possibility that
objects and their meaning can be assigned and transformed by creative invention on a personal, interpersonal, or cultural level. Thus,
the child achieves the developmental level required for symbolic
play.
Another tradition within infant observational studies underscores
the crucial role of contingency detection, an infant capacity that is
demonstrable within the first months of life. Interestingly, this capacity has also been shown to figure as a key component in the development of narcissistic integrity and the capacity for make-believe.
Broucek, reviewing the relevant research prior to 1979, observes that
the infants discovery that a contingency exists between his own activity and the occurrence of external events is a fundamental building
block in the infants development of self-feeling and narcissistic integrity; violations of contingency expectation early in life can instigate withdrawal and avoidance, infantile defenses against traumatic
helplessness and impotence. This is beautifully demonstrated in
Tronicks still-face experiment where violation of the infants expectations that his mothers facial expression will vary in response to his
own communicative expressiveness results in disorganization and
withdrawal (Gergely and Watson 1996).
In more recent studies, Gergely (1996) calls upon the infants sen-
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 infants emotion-expressive displays during affect-regulative interactions to explicate how the infant develops awareness of his own
affects, recognizes the nature of his mothers affects, learns to selfregulate his emotional state based on parental mirroring, and comes
to distinguish real affect from pretend (i.e. marked) affect. This
very detailed study suggests that the interaction with the parent
around emotional displays is midwife to both the infants self-regulatory capacities and the infants entry into the world of make-believe.
Even as the infant is distinguishing between his mothers face reflecting what she sees (Winnicott 1965) in his own face and his
mothers face expressing her own affect, he achieves the associated
developmental milestone of distinguishing, by their markedness,
mock displays of emotion, those playful exaggerated expressions of
surprise, fear, delight, and so on, from real ones. With these miraculous achievements, the infant engages in the excited interplay of
emotional expression with the parent, correctly interpreting mock
surprise, anger, and sadness and ultimate re-creating these play affects. This, of course, constitutes a vital step toward symbolization
and the world of make-believe.
In tandem with the increasing emphasis on the crucial interpersonal context of the infants developing capacitiesto recognize
and regulate his own affective states (Gergely and Watson 1996), to
appreciate and distinguish the mind of his caretaker from his own, to
identify his unique intentionality and agency (Fonagy and Target
1998), and to freely access the developmentally crucial world of
make-believe where mentalization can occurthere is a growing accumulation of data to suggest biological and genetically based
sources of psychopathology. Many of the children we see today have
been examined systematically in terms of their ego equipment and
their genetic pedigrees, and we often face the conundrum of understanding their psychopathology in the context of contributions from
markedly uneven ego functioning which is developing in a complex
transaction with conflict. While the stability of findings from neuropsychiatric testing is variable depending on the age of the child, as
well as on dynamic and educational factors, there is no doubt that
these variations feed into, as well as reflect, psychopathology and
color the interchange with the environment throughout life. I believe that the impact of these features are far more powerful in presentations in childhood than in adulthood for a number of reasons,
including the obvious one that adults have developed more stable
221
ego organization and adaptations and are rarely called upon to perform in as many diverse arenas as the average school child. The adult
will presumably manifest less distress and symptomatology around
chronic exposure to impossible environmental demands and can
avoid confrontation with areas of relative weakness by his choice of
profession and pastimes. The child analyst thus faces a diagnostic
and clinical challenge where the multiple transactions among nature, nurture, history, on-going development, and environmental expectations and demands are all intermingled and clearly contribute
to the childs suffering.
In the following, I will tell you more about Andy who, despite early
indications to the contrary, fell within what I consider to be the usual
contemporary range of analyzable childhood psychopathology, i.e.
he fell within the spectrum of neurotic/developmentally uneven/
dysregulated patients who are the staple of contemporary child analytic practice. The degree to which his psychology was influenced by
a documented developmental strain due to markedly uneven cognitive and physical maturation is, I believe, both considerable and commonplace. Elsewhere, I and others (Gilmore 2000, Greenspan 1989,
Cohen 1991) have suggested that our current thinking, enhanced by
our greatly improved assessment techniques, allows us to take into account the impact of developmental idiosyncrasy on the evolving
structure of the mind; that is, we are able to identify and consider the
way that the unique individual developmental profile shapes and organizes the evolving personality and defines its potential. I would
speculate that Andys extraordinary degree of uneven ego endowment, with marked delays in coordination, visuo-spatial integration,
and sustained alert attentiveness, and his low thresholds for frustration and stimulation tolerance impacted his sense of efficacy and his
availability for easy interpersonal exchange from the outset. His vulnerabilities diminished his opportunities for the early repeated experience of joy, self-satisfaction, and parental admiration in the routine
fine and gross motor accomplishments of early childhood. These
considerations, plus the report of maternal depression in the first
year of life and his parents orientation toward emotionality in general, support hypotheses about the complex bio-psycho-social underpinnings of this boys particular difficulties when he presented in
early latency, which included the absence of unstructured play, intolerance of affect, impulsivity, and a markedly constricted inner life.
The working hypotheses which thus guided Andys treatment accumulated over the course of my work with him. I offer them here in
advance to show the interweaving of the developmental, diagnostic,
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Karen Gilmore
and dynamic issues as they served to light the way in what sometimes
seemed a discouraging darkness. To my way of thinking, they represent a complex series of interacting influences which determined,
exacerbated, triggered, and were recruited by each other:
1. Andy did not play because innate constitutional factors, especially
his limited capacity to sustain quiet alertness and focus (ADHD) and
his reduced proclivity toward object relatedness (non-verbal learning
disability), diminished his availability for early engagement with his
mother, where affect regulation and imaginary play find their origins.
2. Andy did not play because his mother was depressed during the crucial first year of life and was unable to engage her hard-to-engage
child.
3. Andy did not play because his sense of personal agency and his
pleasure in his own productions were compromised by his motor and
visuo-motor deficits.
4. Andy did not play because ego weaknesses, interference in maternal attunement, and, possibly, constitutional factors, heightened his
fear of his affects and his difficulty developing signal function.
5. Andy did not play because his narcissistic fragility and sense of internal impoverishment inhibited the development of fantasy and the
expression of creativity.
6. Andy did not play because affective expression was devalued in his
family and precocious intellectuality was strongly prized. Obsessional
defenses against his constitutionally determined impulsivity were reinforced by his intellectual, workaholic parents; coupled with his
perfectionism and his fear of his own affects, these defenses further
squelched his freedom to play creatively.
Over the course of the two years of treatment to date, I came to

conceptualize the core of Andys pathology as a complex disturbance
in his ego organization, one that remained as an on-going (although
also evolving and transforming) limitation in his development. His
clinical presentation, corroborated by his history, showed that he
had on-going difficulty establishing and maintaining an intersubjective state where self-discovery, emotional exploration, and creativity
are engendered, where his inner world can be made manifest without crippling self-consciousness, a state that we rely on as child analysts and that we usually get to experience directly or sometimes only
indirectly, as with highly oppositional children. His analysis has indeed been marked by fierce resistance, behind which lay anguished
loneliness, narcissistic fragility, and mistrust of adultsall attributable to the factors outlined above. Furthermore, Andy used his constitutionally based tendency to tune out as a powerfully opaque
223
ego-state of pseudo-autonomy, resistance, and disengagement; these

factors conspired against Andys experiencing an open exchange
with me.
Andy
When Andys parents first sought consultation, he was just short of 8
years old and had been on stimulant medication for about 6 months.
Consistent with his parents orientation toward cognitive approaches,
he had had no prior contact with a child psychiatrist; when his school
had urged his parents to seek an evaluation for his hyperactivity, distractibility, and fine and gross motor delays, his parents consulted a
pediatric neurologist. Neuropsychiatric test results corroborated an
extraordinary degree of developmental unevenness with a 41 point
difference in his superior verbal and low average performance IQ;
most significantly depressed were the scores on tasks that required visuo-motor integration and visual memory. His attentional lapses and
difficulties with organization were felt to impair his capacities across
the board, but with most damaging effect on his weak performance
scores. Attention deficit disorder, grapho-motor delays, and visuomotor learning disability were diagnosed; his affect dysregulation
and low frustration tolerance were attributed primarily to the combined impact of these disorders. Andys distractibility and hypermotility were viewed as serious impediments to his learning and medication was recommended and begun.
However, despite his teachers report of significant improvements
in his learning, Andys overall state worsened over the year to the
point that there was now an urgent need for psychiatric input. On
stimulants, Andy was more impulsive, rather than less, and his emotional instability was becoming unmanageable. New and peculiar behaviors included his refusal to swallow his saliva, which he retained in
his mouth and spat out at intervals. His behavior at recess was increasingly reclusive; he removed himself from contact with other
children, paced, and twirled about, seemingly lost in fantasy. His
meltdowns and impulsivity spilled over to the classroom, to the point
where his teachers felt that they needed extra help dealing with him
in class. His nighttime enuresis, typically occurring once or twice per
week, had increased and he also began wetting and soiling at school.
At home his oversensitivity to slights and misunderstandings, his
frustration with homework, and his insomnia were all worsening.
Talk of suicide and reckless behaviors finally frightened his parents;
the consultation with me was arranged after Andy bolted from home
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one night and ran several blocks, across busy intersections, before being apprehended by a policeman.
What was most striking in my conversation with his concerned parents was their lack of awareness of Andys mental life or, for that matter, of subjective or interpersonal experience in general. Well educated, well intentioned, and exceedingly busy professionals, they
conveyed bewildered sympathy for their sons situation, reacting with
dismay tinged with a kind of abashed perplexity and frustration, but
at the same time suggesting that everyone was exaggerating the seriousness of his disturbance. They complied with the schools insistence on a shadow teacher but viewed it as alarmist. This posture
previewed their reaction to the recommendation for analysis. Later
in the first year of treatment, Andys mother, who was herself in an
on-going treatment, acknowledged her own significant depression
during Andys first year of life precipitated by her fathers death. She
also articulated a tension between herself and her husband and indeed his entire extended family. She had come to recognize that as
she increasingly gave voice to her feelings, she felt peripheralized as
an excessive worrier, a mother hen, in a culture characterized by a
casual but somewhat implacable denial of danger and distress and a
humorous disregard for anyone who was frightened or who visibly
emoted. The mother seemed unable to sustain her position in the
face of this attitude, lapsing into a kind of hapless posture, as if,
Woody Allen-like, she was just being neurotic.
This quality in Andys parents highlighted to me how much we as
analysts rely on parents to provide a context for our growing understanding of their child. The idiosyncrasies of their own dynamics and
the dynamics of their relationship as it emerges willy-nilly in the consulting room, their reflections on their own psychologies and their
personal histories, their complaints about each other or their child,
their blind spots, kindnesses, and cruelties accrue in our experience
of the parents and facilitate our capacity to understand our patients
experience. In meeting with parents, I am often aware of a process of
identification with my child patient, which emerges as a reverie about
what it feels like to be both the present-day child and the very young
infant of these people: what are the rituals of interaction, the shared
assumptions, the unspoken expectations about engagement, the
ease and continuity of on-going experience (Pine 1982)?
Parents transparency in terms of their representation of themselves, their relationship, and the portrait of their child that develops
in the course of the work reflects their willingness to openly engage
with the analyst in helping their child; to some extent this corre-
225
sponds to their own self-reflective capacity, as well as to the particularities of their individual dynamics and psychopathology. As suggested above, the parents own reflective function has been robustly linked to secure attachment (Main and Hesse 2000) and to the
childs capacity to experience his drives and affects as mental contents (Lecours and Brouchard 1997) and to maintain a theory of
mind. Andys parents opacity adumbrated the powerful interference within the analysis, that is, the absence of the medium of play.
Work with the parents over the course of Andys treatment involved a
process of establishing an arena of communication which capitalized
on their considerable intellect and investment in his cognitive development. For example, at one point, his mother observed that she was
able to reinvigorate his fathers commitment to the treatment by reminding him of how much Andys fine motor skills had improved,
presumably because we drew together.
Early in our relationship, Andy announced: Im an oxymoron,
proof of which, he suggested, was his wish to die, while everyone
wanted just the opposite for him. He then proceeded to demonstrate his global determination to do the opposite; for example, he
insisted that any activity he agreed to participate in must be done lefthanded and claimed to be left-handed, which he is not. He did not
play and he seemed most emphatically unwilling to talk, even about
the mundane facts of his life. When I tried to explore any topic, especially one that bore on him and his mind, he would silence me by saying, Stop talking, Im trying to think . . . and then, after multiple
false starts that seemed to lack specific content, he insisted that he
couldnt explain what he was thinking and besides, you wouldnt understand. He spat surreptitiously into the garbage can. He attempted some drawing and coloring, but in such microscopic dimensions that he became agitated and inconsolable as his attempts
proved unsatisfactory. On other occasions he would simply stand
stock-still and stare at the clock. Even after Andy settled into the routine of treatment, he consistently began our sessions by flopping himself upside down on a chair or floor cushion with his buttocks in the
air facing me, a posture I have suggested is his opposite way of declaring that Im the butt-face. While this behavior ultimately yielded
to interpretation, there is no doubt that Andy relied on oppositionality as a defense against the variety of encroachments that beset him
when he first presented and which continued to threaten his tenuous
narcissistic balance, among which I include myself. But as his oppositionality alternated with a worrisome potential for compliance, also
expressed in presenting his butt submissively to me, I recognized the
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Karen Gilmore
polar manifestations of his oppositional defense against exposure of

a poorly developed sense of self, a threatened sense of agency and a
personal agenda that is organized primarily around maintaining his
fragile narcissistic balance. Andy relied on the other as a form to submit to, to mold to, or to repulse, but he could not seem to use the
other for mutuality and progressive development. He repeatedly retreated from the establishment of mutual engagement and, despite
his considerable intelligence and verbal agility, he shrank from the
opportunity to establish better internal regulation through bringing
his experiences under the modulating influence of metaphorical
and/or verbal symbolization in playing, an activity that is, of course,
the sine qua non of child analysis.
Andys resistance during this introductory phase reached a peak of
anguish and despondency when he spent a session wedged into the
small entry hall of the office, refusing to go farther and bellowing for
his mother who was sitting in the waiting room 10 feet away. His nonstop screaming brought the neighbors to my door in alarm! When
his mother repeated, Andy, just come in here, Im here waiting for
you, he finally replied, Something in me wants to do that, but another part says I cant after all this; I wont let me. What more vivid
demonstration of his sense of aloneness and his inability to make use
of his mother in his struggle with affects! This episode came to epitomize for me the great divide between Andy and his mother around
the communication and translation of overwhelming emotion into
manageable experience. It also illuminated how his oppositionality
had hardened within the breach into a monument of stony isolation.
The assessment period did not auger well for analytic work: indeed, it seemed to me as if he had come to experience everything
coming from a supposedly helpful person as a poisonous, murderous, or disintegrating intrusion; understandably, he was desperate to
refuse and resist. One issue seemed obvious: Andy deeply resented
and was determined to expel the hated medication and the implication of severe disturbance that he read into it and that it seemed to
have the power to create. In this initial phase of the treatment then,
my goal was to listen to Andys action and find a better solution to
his medication problem. While not perfect, a marked improvement
was achieved by changing his stimulant and adding an SSRI, since his
agitation seemed driven by anxiety and despondency, although it remained unclear whether I was medicating an iatrogenic or endogenous disorder.
In the following 3 months, I saw Andy twice per week, with a very
gradual diminution of his symptoms, but without a better sense of his
227
inner life. When he told me in response to a question, that he

couldnt talk about certain things with me yet because he didnt
know me well, I felt more optimistic, because such a statement implied a less rigid and guarded stance and supported the hope that he
might be able to feel safe with me. But he remained aimless and profoundly impaired in his capacity to play. It was not that his play was
primitive, perseverative, stereotypic, chaotic, or lacked key features,
such as characterizations and narratives, upon which the dynamic
child clinician typically depends in order to diagnose, explore conflict, and analyze. It was not that he relied on the typical rote play of
the well-defended latency child. He only very rarely resorted to the
use of prepackaged games, board games or cards, and mostly at my
instigation; those moments were, with Andy, treasured opportunities
to view his management of competitive feelings. But they were few
and far between. In most sessions, Andy just seemed stymied, unable
to sustain the pretend mode in any form.
What was there, deep within Andy? This remained puzzling to me.
I was strongly in agreement with his parents wish to taper him off
medication as the summer approached so that we could reassess
Andy without the distorting effect of both the stimulant and the
SSRI. After the medications were removed and with an increased frequency of sessions that I proposed as a trial, my experience of Andy
continued to be curiously blank, as if I were in the company of a
highly mobile, courteous spinning top. The Andy that gradually
emerged was manifestly far less disturbed, dysphoric, and remote but
remained unable to generate any play. Andy seemed to acquiesce to
our sessions and his self-described oxymoronic behavior, with its reflexive oppositional stance, abated; the only hint of oppositional feeling remaining was in his momentary hesitation in putting down his
book in the waiting room when I beckoned him into the playroom.
When I addressed this whisper of resentment, he seemed eager to
spare my feelings and to attribute his reluctance to his absorption in
reading. I later understood that any allusion to feeling on my part,
even in the remote form of I see you are still letting me know you
arent so happy to be here worried him.
It was as if both of us had to be affect-neutral to maintain Andys
equilibrium. In general, despite his earlier presentation, Andy
seemed exceedingly careful and polite, quickly undoing the rare and
minimal expressions of anger or hostility by his characteristic phrase,
Im only kidding. Whereas the Andy of the past seemed to define
himself by anger, refusal, and resistance, the Andy of the present, apparently divested of oppositionality, seemed shapeless and aimless,
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Karen Gilmore
with little or no affective expression. Once in the playroom, he would

rock on the rocking chair, wheel about on the wheeled chair, or jump
free-form about the room, often colliding into various projects of
other children but without a discernable intent to destroy, usually
quite apparent in the palpable rivalries of our child patients. The
content of the hours was almost impossible to recount; there was conversation but the evolution of themes that could knit our work together was curiously absent. Moreover, the atmosphere in the sessions, formerly distinguished by passionate refusal, frustration, and
despondency, was now curiously flat. The dramatic opening presentation of desperate expulsion of poisonous intrusions gave way to an
implicit demand for me to fill him up and enliven him. He said with
some resentment that since I did not give him ideas, I was of no
value as a playmate. My presence did not even promise the simple advantage of a compliant other at his service, i.e. with no play agenda
but Andys own. Indeed by not providing a play agenda, I denied him
the necessary borrowed scaffolding (or content) for what Andy
called playing to take place.
While I did not minimize the potentially inhibiting impact of my
other agenda, that of knowing him, developing a relationship with
him, and in this way, gaining understanding for both of us, I came to
feel that the apparent paucity of internal resources was pervasive in
Andys experience. It often found expression in his lament that my
playroom (which is rather overloaded with play material for all ages)
was too small and had nothing in it worth doing (Anna Freud 1965).
Even worse, I began to sense that the paucity of ideas that Andy
manifested had colonized my mind. I had the demoralizing impression that I had no ideas about him dynamically, I had no insights or
hunches; I began to feel that I complained about his not playing with
me the way he did, although much less often, about my office.
To reiterate the absence of the usual culprits: Andy seemed, at least
superficially, less depressed than he had been on antidepressant
medication, he did not appear grossly inhibited in any obvious way,
he did not appear chaotic, he was no longer adamantly oppositional
and resistant, and he was able to play with peers when they provided
direction. For example, he reported great enjoyment of role-playinggames (RPGs) but said he was a poor dungeon master (i.e. he
could not direct the play) and was therefore unable to import such
play into our sessions. At home, his play consisted almost exclusively of video and computer games whose complex story lines he
would borrow on rare occasions, in order to attempt an RPG with
me. These petered out quickly and never got carried over to the next
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day. In fact it was the rare exception that a motif generated one day
was taken up the next; there was none of the often preemptory drivenness of the child patient who is playing out important thematic
conflicts in displacement, who comes in knowing just where the play
left off and easily reestablishes continuity.
Andy returned to school without any medication and when 4
months later, Strattera, a new non-stimulant ADHD medication, was
finally introduced, his parents and I agreed to try it. I hoped that
Andy would accept this medicine because it had an initial sedative
effect and could provide relief for his chronic sleep onset insomnia. Overall, on a relatively low dose of Strattera, Andys insomnia,
marked hyperkinesis, and restlessness improved; moreover, the Strattera seemed to have little effect on Andys conscious experience, and
therefore did not generate the same resistant response that he was
able to mount to the stimulants. Nonetheless he told me some time
later that while he appreciated the improved sleep, he didnt like the
idea of medicine, whether he actually noticed it or not.
Andys progress in the past two years of treatment has been considerable, with a dramatic cessation of disruptive meltdowns, improvement in frustration tolerance and in overall functioning. But the analytic relationship continues to feel to him like a judgment of
abnormality and a deprivation because I do not provide ideas for
play and do not assert my personal agenda beyond the attempt to
know him.
I began to think about Andys quality of relatedness, his transference in the broad sense, and to consider how rarely I experienced intersubjectivity (Birch 1997) or even a sense of his desire for joint visual attention (Scaife and Bruner 1975), that typical developmental
marker of the infant who is just beginning to appreciate the idea that
mothers mind differs from his own and must be actively engaged. In
the assessment period, he frequently responded to my interest in
what was on his mind as if I were, like the intrusive medication, trying
to disrupt his control of his thoughts. While this seemed to improve
to the extent that he did not forcibly attempt to silence me, he was
unable to generate any activity where we engaged in mutual discovery and elaboration of meaning. Often, when he engaged in some
motor task like tracing a picture, I would realize that he had gradually turned his back to me. Other activities he proposed, often in response to my observation of his disengagement, were attempts to
trick me, by definition an avoidance of a shared mental state. Without my intervention, Andy most readily lapsed into his default position, his tuning out state of mind, a state as closed to introspection
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as it was to my inspection, but which protected him from any experience of interpersonal desire or vulnerability. I regularly observed
Andys use of this tuning out to slip into an ego-state unavailable
for communication and intersubjectivity; at times this appeared as a
visible shift in his attention which in some children marks the intrusion of inner fantasy or preoccupation. While I initially approached
these disappearances with the confidence that he was internally occupied, I came to realize that Andys access to his inner life was also
compromised; he described a frustrated, stymied feeling, a sense of
pressure, and an absence of specific content. Andy certainly was not
eager to engage in an open communication with me, but this was at
least in part because he simply did not have the tools to do so. In order to even establish contact I had to break through his self-absorbed
inwardness with my increasingly plaintive refrain, Play with me!
Over time, I was able to show Andy how he made me the left-out little
one in this passive to active enactment where I was yearning to make
contact with someone so withdrawn or preoccupied that I was quite
unnoticed. I could also sample the frustration and anger that this neglect engendered. While Andy concurred with the fact of this connection by saying, My parents never play with me; thats why I dont
know how to play with you, he demurred about the associated affect,
once again denying his loneliness and distress.
It was clear that for Andy, emotional expression was fraught with
potentially catastrophic narcissistic consequences. As mentioned earlier, he interpreted any sign of intensity in me with alarm and did his
best to neutralize his own emotions. Only unmodulated disruptive affects (Lecours and Bouchard 1997) could force themselves into full
expression, as in his so-called melt-downs, those inarticulate chaotic tantrums, which at this point were rare events and hardly ever occurred in my view. Affects that were better contained and potentially
verbalizable were apparently experienced as intolerably demeaning,
and were vigorously disavowed. I was struck over and over again by
Andys effort to be objective and to eschew the range of emotion that
most people experience. In fact, in the treatment relationship, his
mirroring my neutrality was far more successful than my capacity to
maintain it! In one session, I recalled his apparent willingness to be
wildly out of control in the opening months of our acquaintance;
but, when the dust settled, he admitted to almost no emotions at all.
To this he replied, maybe other people have more, but I just have
two big emotions: frustration and embarrassment.
Andys stance was clearly an identification with and an attempt to
please his father, but this identification had a far-reaching impact on
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his ego functioning: it amounted to a wholesale disavowal of a range

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

elicit in me by his remarkable absence in my presence, he was able
to identify and admit to more feelings and more nuance of feelings.
The intensity of his competitive dynamic, wherein his aggressive wish
to triumph and lord it over his opponent was in perpetual struggle
with his anxiety about maintaining the relationship and consequent
submissiveness, was clearly present in this struggle with me over affect expression, and we were gradually able to recognize it in relation
to a range of narcissistic and oedipal conflicts. I was also able to suggest my dynamic hypothesis about the premium placed on affectneutrality as representing Andys identification with his father and a
position of masculine strength within the family.
Despite this work, the competitive struggle with me made him veer
away from openly depending on me to sort out painful feelings; instead, he would transpose his feelings of loss and/or anxiety into a diatribe about treatment, my lack of forthrightness about myself, and
the implicit accusation of abnormality that the treatment comprised. It was almost as if Andy intuited that a transference complaint, no matter how stereotypic, would lure me away from seeing
the hot spot where he was acutely suffering at that moment; he thus
substituted friction with me to indirectly achieve his shameful wish
for closeness, a pattern demonstrated outside of the treatment in his
relationships with his mother and brother. For example, on one occasion, I addressed his palpable suffering while his brother was at
camp and his parents were traveling for work. It was clear to me that
Andy was enduring even greater loneliness than usual. He adamantly
denied my observation and attributed his tears to his frustration at
having to see me so often. This was all the more striking because our
schedule had been disrupted by his day camp and we had met only
once that week. On another occasion, when he was bereft at the
painful yearly change of au pair, he shifted way from acknowledging
his loss and resumed his litany of reproaches to me. In one fascinating hour when Andy (I fear accurately) read my attempts to connect
as a critical complaint, he said with considerable bitterness, that in
fact, he was with me just like I was with him: You dont give your
ideas, so I wont give mine. You see as much of me as I see of you. If
you dont tell me anything about you and if you dont start anything,
if you dont show your feelings, why should I? Here again his oppositionality seemed pronounced, taking the form of an imitative
pseudo-analytic stance; but I sensed behind that a painful sense of
deficiency and a deep narcissistic wound created by our differing status in the treatment and his conflicted wish that I love him and pur-
233
sue him. The transference meanings of his complaint, i.e. its history
in his relationship to his father, was less available than its defensive
function in the here and now. I had ample opportunity to see that
this posture protected him against the frightening feeling that he
couldnt think of anything, that his thoughts and intentions seemed
to drift out of his mind, that his attempts at creativity were strained
and empty, and that he was just an ordinary sad and lonely kid, and
therefore unlovable. Not unexpectedly, these rare moments of openly
expressed resentment toward me, which of course were at once displacements of painful states experienced in relation to others, expressions of on-going transference themes, and a way to engage with
me and keep me at a distance all at once, were typically followed by a
rapprochement which was certainly motivated in part by guilt and
anxiety. When I observed once more how difficult it was for him to
talk about feelings with me and to feel comfortable having feelings
about me, he said with great poignancy,
One is the loneliest number that youll ever do
(But) Two can be as bad as one,
Its the loneliest number since the number one.
(From One, by Three Dog Night)
Without the precious medium of the playing state, it is a challenge

indeed to represent these many layered issues to such a child in a way
that usefully examines his oedipal and sibling rivalries, narcissistic injury, and shameful sense of inadequacy, while recognizing his real
disabilities arising from his maturational unevenness as well as their
role in his developmental lag in tolerance of intersubjectivity and affective expression.
Discussion
While the psychoanalytic view of play acknowledges its importance in
the elucidation of the childs inner world and mental conflicts in the
treatment, there is at least an equal emphasis (A. Freud 1965,
Neubauer 1994, Solnit 1987, Abrams 1993, Mayes and Cohen 1993,
Friedman and Downey 2000) on its crucial role in development,
since play provides the opportunity to try on identifications, to practice gender roles, to master developmental challenges and personal
trauma, to overcome helplessness, to modulate drive derivatives, and
so on. A child who does not play is not only manifesting a symptom,
he is suffering from an on-going developmental handicap that has
widespread reverberations. The ability to play is a developmentally
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determined capacity with strong biological foundations serving a

range of social, interpersonal, and intrapsychic functions, and observable in the young of all human cultures, mammals, and birds
(Friedman and Downey 2000). Although my intention here is not to
iterate the mental building blocks of this complex function, I draw
your attention to just a few: the regression in the service of the ego
that affects all the agencies of the mind and permits greater access to
irrational fantasy content, the displacement in the service of the ego,
the willing suspension of a number of ego and superego functions
such as reality testing, critical self-consciousness and censorship, the
associated tolerance of otherwise unacceptable impulses and affects,
and, of course, the array of cognitive and motor capacities required
to enact the roles or manipulate the props of the play. These features
differ in prominence and amplitude depending on the developmental phase and the psychology of the individual child.
In emphasizing the crucial and ubiquitous development-promoting features of the capacity to play, I believe that the many excellent
psychoanalytic contributions on the subject have underemphasized
the unique nature of play in the psychoanalytic setting. Just as Lewin
(1955) observed that there are several types of free association depending on the context and intention, so there are differences in
play from one setting to another; the play with a peer, the play with a
parent, and the play of the child alone all share many features but
differ from playing with the analyst, in that the latter is a communication and an invitation into the childs subjective experience addressed to a person whose declared goal is to learn about that world
for the purpose of understanding and helping the child to understand himself. While this circumstance may bear complex relationships to transference and resistance, it exists as fundamental premise
in any session in which the child is playing. As child clinicians well
know, there are some children who play in life but refuse, for brief or
sustained periods, to play in our playrooms, and some children who
play nowhere but with the analyst. These variations reflect the childs
posture toward the threshold of engagement with the analyst, variously understood to be affected by disturbances in attachment history, oppositionality and overt resistance, profound narcissistic vulnerability, shame, or superego severity. But the childs capacity to
play with the analyst also reflects his freedom to achieve, in the presence of his particular analyst, a state of playing that is intrinsic to
some of its components but is more than the sum of those parts; it is
an altered state of consciousness (Birch 1997) with a much closer relationship to unconscious mentation, more like the secondary elabo-
235
ration of a dream with a less exacting requirement for logic and reality, even in latency-age children fully capable of concrete operational
thought. Moreover, this state is more or less porous to the analysts
playing participation, as the child dictates how much input the analyst is permitted, and the analyst assumes a playing state informed by
her growing knowledge of the patient and her appreciation of the
boundaries of play in its interface with direct expression of drive derivatives and consequential action. Inevitably, the analysts play state
is also informed by her own unconscious mentation and her countertransference toward the particular patient. The resilience and stability of the playing state are unique to the individual child and his relationship to the specific analyst, because once the state of playing is
produced in the treatment it becomes an intersubjective medium
with its own conventions and its objects, whose historical meanings
are gradually transformed as they become incorporated into the history of this new relationship, just as transference paradigms and historical memories show plasticity and evolution in the course of adult
analysis (Rizzuto 2003).
In regard to this evolution, I believe that despite the considerable
controversy about the therapeutic value of playing in and of itself
(Mayes and Cohen 1993, Scott 1998, Cohen and Solnit 1993), the
transformation that child analysis facilitates and which the child patient anticipates, is achieved primarily through verbalization while in the
state of playing. Child analytic literature certainly abounds with clinical reports where a significant therapeutic benefit is gained by the facilitation of previously inhibited or chaotic playing without explicit
interpretation of conflict (Birch 1997, Mayes and Cohen 1993, Slade
1994). Nonetheless, in all such instances, the analysts verbalizations
are a central, transforming element, much like the mothers transformation of the infants chaotic experience into discrete affects, recognizable self-states, and familiar interpersonal exchange by her naming and dialogical prosody. As Rizzuto (2003) declared in a recent
paper on the transformation of self-experience in adult treatment,
Analysis is the second instance in life in which another person tries persistently to ascertain the internal experiences and needs of the subject by naming, describing and interpreting them with his or her own
speech. (p. 293)
I believe that the same process occurs in the play dialogue of child
analysis; in a comparable way, narratives about the self are made coherent, disavowed self-representations are clarified and modified to
permit reintegration, nameless and disorganizing anxieties are named
and organized, and dissociated self-states are open to contact both
236
Karen Gilmore
intrapsychically and interpersonally through the analysts participation and verbalizations within the state of playing.
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Psychoanalysis As
Cognitive Remediation
Dynamic and Vygotskian Perspectives
in the Analysis of an
Early Adolescent Dyslexic Girl
LISSA WEINSTEIN, Ph.D., and
LAURENCE SAUL, M.D.
The interface of neurocognitive problems and dynamic concerns are

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

of the City University of New York, lecturer on the faculty of the Columbia Center for
Psychoanalytic Research and Training, and a graduate of the New York Psychoanalytic Institute. Dr. Saul is a Clinical Instructor in Psychiatry at the Weill Medical College of Cornell University and an Attending Psychiatrist at New York Presbyterian
Hospital. He is a faculty member of the Columbia Center for Psychoanalytic Research
and Training.
An earlier version of this paper was given on June 16, 2001, at the New Paltz, New
York conference: Brainstorms: Psychoanalysis Meets Neurobiology in Development, sponsored by the Association for Psychoanalytic Medicine.
239
240
with learning. As the act of learning becomes separate from the personal and affective context in which it took place, the child gains access to other, more normative, functions of play. These functions include the development of the capacity to separate meaning from action
and the ability to understand words as generalized categories which
represent objects, rather than being part of the specific object named.
These two capacities, fundamental to the development of abstract
thought, will support reflective awareness and help modulate affective
states. The abilities furthered in play also act to remediate one component of dyslexiathe difficulty separating context from more abstract
bits of knowledge. Finally, the child learns to play at reality, often
trying on the new role of student. As Vygotsky notes, play is essential
in allowing the child to become aware of what she knows. For a dyslexic
child, for whom reading may never become completely a part of procedural memory, becoming conscious of what he knows may also enhance mastery of the skills of phonological processing, albeit more
slowly than normally developing readers. The pleasure in play and the
repetition it generates aids the internalization of the task and the development of automaticity.
Introduction
the emotional problems of learning disabled children often
bring them to psychoanalytic treatment, and in recent years the view
that analysis is not the treatment of choice for children with neurocognitive difficulties (Giffin, 1968) has gradually shifted (Arkowitz,
2000; Garber, 1988, 1989; Migden, 1998; Rothstein & Glenn, 1998).
The existing clinical papers often fail to precisely delineate the nature of the neurocogntive problems, eventuating in a hodgepodge of
diagnoses lumped under the rubric of learning disabilities, even
though the factors that make analysis helpful to children with language based learning problems may be quite different from the
mechanisms that are mutative for children whose problems in processing perceptual stimuli form the core of their difficulties (Rourke,
1985). Lacking a clear rationale for why analysis might be helpful, it
becomes impossible to evaluate the necessity for any changes in technique. With few exceptions (e.g. Cohen & Solnit, 1993), papers focus
on the affective difficulties rather than the manner in which analysis
alters or enhances ego functions which support learning.
The current paper examines the interface of neurocognitive problems and dynamic concerns in the analysis of an early adolescent
dyslexic girl and tries to specify those aspects in the analytic context
Psychoanalysis As Cognitive Remediation
241
which were mutative. Developmental dyslexia, the most common

neurobehavioral disorder affecting children, seems an ideal starting
point for a discussion of the interactions of neurocognition, dynamics and development, because its organic basis is clearly demonstrated by significant differences in the temporo-parieto-occiptal brain
regions between people with dyslexia and those who are not reading
impaired (McCandless & Noble, 2003; Shaywitz, 2003).
Natalie was 12 years old when she was referred for psychoanalysis
to address long standing disturbances in her sense of self and others
which stemmed from her learning difficulties and traumatic history.
No effort will be made to examine the entire complex of dynamic
factors in her analysis; nor is it our intention to present an ideal analytic treatment, as a rocky course may be inevitable in the treatment
of learning disabled children (Rothstein & Glenn, 1998). Instead,
the focus of examination will be one curious factdespite intensive
cognitive remediation prior to beginning analysis, Natalie continued
to have difficulties with spelling, reading, and school performance.
After a relatively brief period of analytic treatment, she was increasingly able to access reading and spelling skills that everyone had assumed she did not possess. Natalie made this remarkable progress
despite the fact that she was not currently being tutored in reading.
Before embarking on the case material, analytic perspectives on
play will be briefly reviewed. The case presentation will first document
the nature of Natalies early speech and language delays and her
learning problems in order to support the diagnosis of specific reading disability before attempting to articulate Natalies unconscious associations to her dyslexia as they emerged in the transference. In the
discussion, a multifactor model is proposed to explain how psychoanalysis, a treatment not directed at cognitive change, can enhance
the capacity to learn even in cases of clearly documented neurologically based deficits. The necessity for the interpretation of unconscious conflict is integrated with the work of Lev Vygotsky, a Russian
constructivist thinker and early member of the Russian Psychoanalytic
society, who noted plays dual role in helping the child to restructure
cognition and embrace the constraints of reality.
Review of the Literature
The psychoanalytic theory of play has focused heavily on content and
why only certain events (often unpleasant ones) are chosen for reproduction. Relying on Freuds (1918) notion of the repetition compulsion as a way to bind traumatic overstimulation, Waelder (1933),
defining trauma operationally as an onslaught of more events in a
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relatively brief period of time than the immature ego can handle,
suggested that children, being passive, must suffer experiences that
they cannot absorb and which they attempt to master through repetition. In addition to the disappointments of reality, play also helps the
child cope with trauma generated internally, either by the upsurges
of the drives or via the heightened pressures of the superego. Play
aids mastery by turning passive to active. It allows the child to alter
the outcome of the experience or to change his role. Rather than a
suffering victim or an anxious onlooker, the child can instead be a
world creator. In addition, the reenactment of an experience in itself
constitutes a switch from passive to active. The observed repetitions
in play allow for the fact that the childs weak ego can master reality
only a little bit at a time and are necessitated by the childs limited capacity for verbalization and his inability to link thoughts together
through cognitive work. The actual play is a compromise formation.
By offering the most satisfying solution between the desire for pleasure, the demands of reality, and the conscience, play strives to make
up for anxieties and deficiencies at a minimum risk of danger. Although popular notions oppose play and reality, from Freud (1918)
onward (e.g. Plaut, 1979; Oremland, 1997, 1998; Ostow, 1998; Solnit,
1987) analytic writers have recognized the role of reality in shaping
play. Winnicotts (1974) notion of transitional space also suggests a
role for play in the structuring of external and internal reality in addition to the interpretation of play which focuses on meaning. More
recently, theorists have noted the contribution of play in the creation
of new representations, suggesting that play in itself acts as a force in
getting development back on track (Mayes & Cohen, 1993; Neubauer, 1993; Scott, 1998; Slade, 1994). Although this structuring role
of play has been noted particularly in children with ego deficits (Cohen & Solnit, 1993), cognition and its relationship to play has been
largely ignored in the psychoanalytic literature with only a few exceptions (e.g. Santstefano, 1978)
Case Presentation
presenting problem
Natalies mother sought psychological testing at age 12 years and two
months because of Natalies worsening irritable, withdrawn, and aggressive behavior both at home and at school. Natalie frequently
screamed, cried, hit, and kicked. She directed these outbursts mainly
at her sister, who was 3 years her junior, but also at her parents and
243
peers. Shortly prior to the start of treatment, Natalie threw a butcher

knife toward her sister, missing her. Natalies interactions with her
peers at school, although far less dramatic, provoked them into antagonizing and ostracizing her. Testing resulted in a recommendation for psychoanalysis. Natalie was highly opposed to psychopharmacological intervention.
developmental history
Natalie was the product of a planned, uncomplicated pregnancy with
an induced delivery at 41 weeks that required forceps. Fine and gross
motor milestones were within normal limits, but there was a notable
delay in language. Natalie did not speak her first words until 18
months or speak in full sentences until 4 years of age. Speech therapy
was begun at 4 years and continued until she was 11. From early in
childhood, Natalie struggled with articulating her thoughts and feelings and she was described as a highly anxious child who was needy
of her mothers attention. Psychological testing at age 8 years, initiated because of her distress over not reading, led to transfer to a specialized school for learning disabled youngsters. Medical history was
significant only for seasonal environmental allergies. Menarche was
at age 11 years and 10 months.
Two weeks after Natalies birth, Natalies mother returned to her
career full time. Natalies paternal grandmother moved from Eastern Europe to become Natalies primary caretaker, as her mother often did not arrive home until 10:00 p.m. This non-English speaking
woman was stern and cold but reliable.
Natalies father was also a constant presence. Although highly intelligent, he was an alcoholic who was unable to keep a job. Particularly close with Natalie, her father read her Greek mythology and
studied American Civil War tactics and strategy with her. Natalie frequently witnessed her father vomiting and passing out in a drunken
stupor. She also regularly witnessed verbally and physically violent altercations between her parents. Once, when Natalie was 7 years old,
her father lay down in front of his family, held a steak knife to his
throat, and threatened to kill himself. Natalie saw her mother sustain a fractured arm and, at another point, a subdural hemorrhage
from fathers beatings. Father also frequently exhibited bruises his
wife had inflicted on him. Natalies sister attempted to break up the
battles by getting physically between her parents while Natalie, in
sharp contrast, would run to her room and remain under her bed
covers.
244
When Natalie was 11 years old, her mother had the police remove
Natalies intoxicated father and placed an order of protection
against him because of verbal threats. Natalie never asked to see him.
Visitations were started 6 months later because Natalies sister requested to see him, and visitations continued sporadically. A few
months after Natalies father was removed from the home, Natalies
paternal grandmother died. Therefore, she suffered two major losses
simultaneously. These apparent precipitants closely preceded Natalies increasingly withdrawn, intermittently violent, and hypersensitive behavior which led to her mother seeking help.
psychological testing
Several evaluations provided ample evidence for the diagnosis of developmental dyslexia. An educational evaluation completed at age 8
demonstrated receptive and expressive linguistic difficulties rather
than oromotor problems. Natalie failed to initiate a lot of language,
had trouble sequencing her thoughts, and had difficulty with word
retrieval and naming. Phonological processing was impaired. This
skill (the ability to hear and sequence the sounds within words) is the
central deficit found in reading disorders (Morris et al., 1998; Shaywitz, 2003). Natalie had poor auditory discrimination, could not
identify medial vowel sounds, and had poor memory for phonemes.
While she needed the scaffolding provided by a listener in order to
organize her thoughts, the more object related and para-verbal aspects of communicative language (prosody, eye contact, and turn
taking) were intact. In sum, Natalie met the criteria for double deficit
dyslexia (Wolfe, 1999), a term used to identify children who show
problems in both rapid automatized naming and phonological processing, and who, typically, are very difficult to remediate.
A second evaluation, completed at age 12 years, 2 months when
Natalie was in 7th grade, supported the earlier impression of a
dyslexic child of average to high average intelligence, with a fairly focalized language disorder. The WISC III yielded a Full Scale IQ of
103, with a Verbal IQ of 106, and a Performance IQ of 99.
The subtest scores were as follows:
Verbal Scale
Information
Similarities
Arithmetic
Vocabulary
Comprehension
Digit Span
11
10
12
12
10
7
Performance Scale
Picture Completion
Picture Arrangement
Block Design
Object Assembly
Coding
10
14
11
9
5
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Despite the apparent evenness of the major subscale scores, there

was considerable variability amongst her abilities. While verbal skills
ranged from the average to high average, visual perceptual and visual
spatial performance skills varied from a defective performance on a
task of cross modal integration to a very superior performance on a
task where she has to sequence cartoon pictures of interpersonal interactions. Thus, Natalies ability to understand the motivational
states of others, as well as to process complex perceptual material was
intact.
In structured settings, Natalies oral language was not impaired.
Voice quality, pitch rate, volume, and fluency were within normal limits. Natalies ability to follow complex multipart directions were
within the average range and her lexicon, as measured by her ability
to form word classes, was average. She had no trouble processing semantic relationships and was able to answer questions about paragraphs that had been read to her. Tests of reasoning and problem
solving were in the superior range. Informal assessments of oral expression were deemed normal for her age.
Reading/decoding skills were several grade levels below average,
as was mathematical computation, a finding compatible with a diagnosis of dyslexia as computations (unlike mathematical concepts) often tap semantic/linguistic abilities rather than the visual-spatial
skills. Reading comprehension was above grade level, suggesting that
the act of decoding was what barred the way to comprehension in
timed settings. The qualitative nature of Natalies performance, her
tendency to misread or skip small function words (such as the, was, or
but) which are not directly representational, also spoke to the presence of a developmental reading disorder. A writing sample showed a
difficulty using vowel sounds, poor punctuation, poor sequencing of
sounds within words (breath day for birth day), and omission of
sounds (presten for present). In short, the testing provided strong
evidence of classic dyslexia with problems in decoding, spelling, and
written expression.
Natalies functioning was more compromised in ambiguous situations than in structured ones and her sparse, ten response Rorschach
showed her difficulty in mobilizing her cognitive equipment in new
situations. None of her responses involved a sophisticated integration of the components. The lack of human movement responses
suggested that it was difficult for Natalie to utilize internalized images of others which might serve as templates for behavior or support her ability to delay her impulses. Instead, Natalies Rorschach
resembled that of a much younger child with few content categories,
246
little ability to integrate her emotional responses to a situation with a

more cognitive viewpoint, and a tendency to become emotionally
overwhelmed and cognitively impaired in situations of stress.
course of treatment
Natalie began treatment at age 12. Literally within the first few minutes of treatment with her male analyst, Natalie introduced a transference theme that would be continually elaborated throughout her
analysis: her need to maintain distance (particularly from men) in
order to feel safe. The early manifestation of this theme took place
primarily in the behavioral realm: Natalie kept her coat on during
the first session, claiming she didnt want to see a psychoanalyst because she had other things [she] wanted to do . . . like kick boxing.
In a dramatic demonstration of her wish to be the aggressor, rather
than a victim, Natalie punched her sister in the mouth on the way
home from her second analytic session. Shifting identifications between victim and victimizer reverberated in her fantasy life as well, as
Natalie described a music video where men on strings were manipulated by a woman puppeteer and another video where a woman who
tries to leave her boyfriend is beaten to death. The analyst tied these
two videos together, noting that women better maintain control of
men or theyll end up dead.
Continuing her posture of not getting involved Natalie kept her
coat on for the first weeks of treatment, refusing to discuss personal
stuff. Similarly, she isolated herself with peers, voicing a desire to be
unique and different from the boring popular crowd. When speaking of her family, Natalie expressed both despair and a wish to remain distant. For example, she claimed July fourth as a favorite holiday because the fireworks are like paint in the sky bursting, and you
dont know what its going to look like. This contrasted to all the
family based holidays she hated like Thanksgiving, where you just
get a big stomach ache, Christmas where theres so much pressure
to get the right gift, or the absolute worst holiday, Valentines Day,
with its associated themes of love and kisses. Natalie then decided
that she would write an article for the school newspaper entitled, X
Valentines Day. She added that she wanted to X dating, marriage,
and having babies as well. Natalie agreed with the offered interpretation that up close, those things had not worked out so well for her.
After the third week, Natalie took off her coat, but continued to
struggle against becoming absorbed in the analytic relationship. In
response to an observation that she didnt like showing off, she
247
agreed that she preferred to blend into a crowd and did not like to
be closely observed, alluding to her fears of being seen in the analytic
encounter. During sessions, turning passive to active, she would pull
her hat over her head, turn away from the analyst, or even sleep. Natalie alternated between attempts at contact and a need to lessen the
amount of experienced stimulation through physical distance. She
chose to sit in the analysts swivel chair which allowed her to sit very
close by him and quickly turn away when necessary. She alternated
between talking engagingly and playing catch or being by herself, remaining silent for entire sessions during which she would refuse to
respond, even to direct questions. Often, silent sessions followed
ones in which she had been particularly talkative. The analysts countertransference responses illuminated the nature of the conflicts
aroused. He felt relieved when Natalie talked and careful not to confront her or her anger, as well as worried that he had caused her periods of retreat by being too aggressive with his interpretations.
That the highly charged feelings emerging in the treatment contained sexual fantasies of seduction and pursuit was made clear when
after 6 months in treatment, an analogous situation surfaced in Natalies school life. She excitedly reported being stalked by two boys
in her class. When the analyst wondered out loud whether the incident might be flattering as well as scary, Natalie threw a ball harder
and harder toward the analyst until it was impossible to catch. The
analysts premature interpretation of Natalies underlying sexual
wishes led to the fortification of her defensive strategies and a regression to action where violent, castrating wishes were expressed directly. In the following session, Natalie found a spare tie in the analysts closet and put it around her own neck. Gleaming with pleasure,
Natalie threatened to cut the tie in a highly condensed metaphorical statement which included elements of castration as well as her efforts to defend against her dependency. It is also noteworthy that in
moments of high affective intensity, words did not hold her and she
quickly moved to highly symbolic and expressive actions to regulate
her feelings. In addition to action, Natalie would also remove herself
from the more passionate arena of verbal interaction and seek solace
in a calmer visual perceptual world, painting vivid scenes of serene,
inanimate content.
Usually ill at ease with her desires to be seen, Natalie began to express an interest in acting. She performed Shakespeare soliloquies
for her analyst and simultaneously blushed and smiled with pride at
the applause he would give. At this point, Natalies exhibitionistic desires were not interpreted. Rather, the analyst allowed Natalie to ex-
248
perience that wishes could be expressed and contained in the analytic situation without dire consequences. This stance seemed to support Natalies ability to tolerate previously disavowed affects.
Several months later, at her beach club, Natalie began taking photographs of a 15-year-old boy she had a crush on. She then sold the
prints for $5 each to girls at the art school where she was taking
classes during the week. The analyst, exclaimed, Now, youre doing
the stalking! She brought in prints of this boy, drooled over them,
and drew portrait after portrait of him. She was frustrated with this
boys lack of enthusiasm with her but was determined not to let this
fact get in the way of her talking and thinking about him incessantly.
The analyst pointed out that it appeared as if it didnt matter what
this boy thought of Natalie. You are the stalker. You are in control.
Natalie replied jokingly, Hey, dont spoil my fun. While Natalie felt
freer to express her sexual and voyeuristic interest in a peer, she remained defended against recognition of any excitement about her
analyst.
The reasons for this became obvious as Natalies experience of herself in relation to her father in particular and men in general continued to be further elaborated in the analysis in the transference.
Upon returning from a vacation, the analyst was asked by Natalie to
go back to Iraq where she imagined he had been playing pool and
drinking beers with your good friend Haddam Hussein . . . Youre
buddies. The analyst said, I guess you want to keep a safe distance
from a dangerous, beer guzzling, take over the world kind of guy like
me. In later sessions, she imagined the analyst was plotting with Hussein to blow up some countries. The analyst noted how untrustworthy and dangerous he seemed to her. Natalie responded. Youre not
Hussein, youre Barney, referring to the goofy pre-school TV character who teaches the letters of the alphabet. He was too adorable and
clearly inept: Do you see purple dinosaurs on Wall Street or at a
desk getting a fax? Natalie quipped. It was at this juncture that
Natalies conflict around men being either dangerously abusive and
exciting, or harmlessly castrated and ineffective crystallized in the
transference.
In another variation upon this same theme, over a year into the
analysis, Natalie complained of being stuck with Mr. Tingle, a
male version of a comedy movie character, Mrs. Tingle, a sadistic
high school teacher. Natalie went on to say that she felt Youre poking at me. Looking at me under a microscope. The analyst said, So
Im the teacher from hell. Forcing you to talk about things you dont
want to. Natalie retorted, Yeah, Mr. Tingle, and I dont want to!
249
Natalies excitement became intolerable to her and she swiftly emasculated the therapist, turning him back into the ineffectual dinosaur:
Or you could be Barney, just add a tail.
A few months later, Natalie began to describe how she had always
been scared of her current 8th grade male teacher because of his
reputation as strict and demanding. The analyst noted that when he
thought of a scary man for Natalie, her father came to mind. Natalie
remarked, I hate my father! But hes not scary. Hes just a moron . . . The analyst replied, In the same way that you call your father names, youve called me a few. Natalie said, Yea, Mr. Tingle
and yea, Barney. The analyst remarked, There seems to be two
sides to me for you, this scary teacher or this wimpy dinosaur. Natalie retorted, Youre not scary, youre just chubby. Youre a chubby,
chubby man. The analyst became acutely aware of feeling emasculated and pointed out, So now youre having more funat my expense, of coursewith me being chubbythe wimpy Barney side of
me. Natalie laughed. The analyst further mused, Perhaps you feel
safer around my possible scary side by turning me into a chubby and
bumbling dinosaur. Natalie grinned.
A year and a half into the analysis, in the context of angrily calling
the analyst names, Natalie began to articulately reveal how her
mother degraded her father. For example, while mother and daughters went to a beach spot during summer weekends, mother had father do menial jobs for her like walk the dogs and clean the bathtub
to earn money so that he could take out his daughters with the
money. Natalie got worked up thinking about how her jackass father
cant even work at Barnes and Noble to help us out. Hes a goodfor-nothing drunk.
As the historical roots of her bivalent attitudes toward her father
were becoming more conscious, Natalies mother reported that Natalie was expressing a new desire for physical contact, affection, and
comfort. This contrasted sharply with her lifelong pattern of physical
avoidance, withdrawal, and difficulty being soothed. In school as
well, Natalies teacher reported that she was blossoming, with decreasing moodiness and impulsivity, and a lessening tendency to provoke attacks from peers. Even more curious was her teachers report
that Natalie was beginning to absorb academic material in a new way,
given that scholastic performance had not been a focus of treatment
to date.
As her fear and excitement about being with a man continued to
be evoked, tolerated, and addressed in the relatively calm context of
the therapeutic relationship, a new aspect of Natalies relationship to
250
her father began to manifest in the transference. She started to use

the analyst as a teacher, albeit this time one who remained more separate from the frightening aspects of her teacher/father. She
brought schoolwork into the sessions, using the analyst as a homework helper or stayed after sessions to complete her assignments in
his presence. She increasingly viewed the analyst as the nurturing father who read to her and acted as a comforting, organizing, and
soothing physical presence who would sit with her quietly observing
while she worked. She asked to be quizzed on vocabulary words or
geographical locations. The studying was, of course, used to regulate
the comfortable space between her and the analyst, helping her to
defend against awareness of sexual excitement by taking an active
stance. However, it was a far more productive compromise formation
than merely keeping her coat on, as it incorporated elements of sublimation and identification rather than just turning passive to active.
It is equally important that the studying served the adaptive purposes
of learning. In short, Natalie had begun to play the student.
In behavior typical of the teacher game (Ross, 1965), common in
early school development, Natalie frequently switched roles and began actively examining being the teacher as well as the student. She
would test her analyst, taking particular sadistic pleasure if he didnt
know an answer. In her outside academic life, Natalie began to shine,
making particular strides in the area of written language and speech.
Natalie was moved to the most challenging reading group, and other
children asked to be in her group, because she was the best speller.
She was chosen to represent her class at 8th grade graduation by giving the senior speech. At this point, (1 years into treatment),
Natalie did not hold back the excitement of her triumph at being
chosen and not only practiced the speech before her analyst, but
went into a blow by blow account of the audience responses. Natalie
had also gradually became quite comfortable in the transference
with her desires to do the looking. Toward the end of treatment,
over 2 years into the analysis, Natalie began to avidly use the analyst
as a model (primarily his hands) for her drafting class assignments.
She acknowledged that this was a way of remembering her analyst. In
this example, it is interesting that Natalies mode of internalizing the
analyst still involved a concrete representation, rather than the analysts words or the function of reflection.
However, Natalie also became increasingly able to symbolize and
take a reflective stance about her learning problems. In describing
George Orwells novel, Animal Farm, Natalie focused on Clover the
horse, who had strong feelings but couldnt figure out how to put
251
those feelings into words. When her analyst made the analogy between herself and Clover, she was able to say that problems learning
really suck. While Natalie was able to voice these feelings after having some academic success, clearly her analysis had been instrumental in making her educational interventions increasingly assessable.
Natalie was accepted to several mainstream private schools and ultimately attended a competitive public school specialized for the arts.
Natalie was very proud that she was one of the few students with
learning disabilities admitted. Because of financial difficulty, Natalies mother requested that treatment be terminated after 2
years. Natalie was thriving at school both academically and with
peers. Although there was certainly more analytic work to be done
around her conflicts with her mother and father, Natalie was developmentally back on track. In the final weeks of analysis, Natalie requested that the analyst teach her how to play poker. This was pleasurable for both analysand and analyst as Natalie had become a
model student. She anticipated missing our homework sessions.
Particularly determined to learn to shuffle, before the last session
Natalie was an expert.
At 12 years of age, Natalie presented as a young adolescent with
affective symptomatology, an oppositional defiant disorder, learning
problems and a history of traumatic overstimulation. Her symptoms
resulted from three interweaving factors: a biologically based learning disorder and alterations in the timing of the maturation of her
speech and language, her chronically traumatic home life, and her
entrance into adolescence. Exposed to a greater than normal degree
of aggressive stimulation, these traumatic experiences shaped the
way she perceived herself and interacted in relationships, for example via identification with the aggressor, and placed considerable
strain on defenses already compromised by processing difficulties. Finally adolescence, with its heightened drive pressure further increased the demands on her stressed ego resources.
Natalies language difficulties affected her not only in school, but
throughout her development, making it harder for her to access
words as a mediating force during critical periods (Migden, 1998).
Offering new gratifications and connections, speech usually helps
the child to master the waning symbiotic ties and the loss of the accompanying feelings of omnipotence and safety. Conceptualized
thus, language is a central aspect of the separation process. For Natalie, early separation from her mother resulted both in object loss as
well as the loss of an optimal linguistic environment because her English exposure was curtailed when she was cared for by a non-English
252
speaking grandmother. In addition, without language, Natalie had a

more limited array of impulse control mechanisms. Because she
could not interpolate words as a form of trial action, it was harder for
her to distance from the immediacy of a situation (Lewis, 1977).
Finally, Natalies need for support in order to function cognitively
intensified the relationship with her learning partner, her brilliant,
but erratic, father. Her learning difficulties prolonged the necessity
for an intimate relationship, slowed efforts at separation, and made
the repression of oedipal impulses more difficult. All these factors
made it more likely that the autonomous functions (Hartmann,
1954), in her case language and to a lesser degree perception, would
be drawn into conflict. Given these complicating factors in Natalies
development, how are we to understand the helpfulness of psychoanalytic intervention, particularly as it relates to her school performance?
Discussion
While developmental dyslexia can be conceptualized as a deficit
(Winner, 2001), some children are able to make use of compensatory strategies and others are not. Psychoanalysis, with its unique
observational vantage point on the question of motivation, potentially offers some answers that predictions based on the severity of
neurocognitive deficits alone cannot. As analysts, we learn the specific connotations of the disability for the child by accessing the personal landscape and its presuppositionshow events, whether external ones such as the behavior of caretakers or internal ones such as
the perception of bodily or intellectual processes, are woven into a
web of meaning, which then become: the starting point for further
causalities. Analysis is a science of subjective experience, and how
one interprets neurophysiological events is imperfectly correlated
with the events themselves. Like A. R. Luria (1979), who chose to humanize and make whole the most puzzling of neuropsychological entities, psychoanalysts are engaged in a romantic science that seeks
not only to abstract general laws but to describe human ordinariness
in all its glory and detail. To base an understanding of a dyslexic
child solely on the delineation of the neural pathways that mediate
the reading process falls prey to the same misconceptions as thinking
that internal representations are isomorphic copies of real external
events. Events in the outer world and those in the internal environment meld, with neurophysiology and the transactions around the
developmental crises of childhood mutually influencing each other
253
in a manner that is truly individual and not easily subject to regular

laws. While it is possible to argue that Natalies improvement in reading was due to an increased ability to use contextual cues that accompanies adolescence, it is not usual for spelling skills to improve.
Along with slow reading speed, spelling difficulties remain one of the
indicators of compensated dyslexia. It is our argument that the analysis allowed Natalie to access skills that had been acquired during previous remediation efforts, but had remained dormant or blocked by
conflict.
The literature offers numerous general statements about the psychological functioning of dyslexic children. For example: they are
more vulnerable to states of overstimulation which generates trouble
with impulse control and difficulties with affect regulation (Arkowitz,
2000); suffer poor self esteem and alterations in their object relations
(Migden, 2002); and have a tendency to rely on weaker or more
primitive defensive structures (Rothstein & Glenn, 1998). All of the
above general statements are to some degree true about Natalie, but
what is more salient is that her inability to learn, or to retrieve what
she knew, was also a way of warding off an affective awareness of the
traumatic overstimulation of events with her father.
the association of learning with conflict and the
regulation of affective intensity
While defending against sexual excitement with aggression is typical
of early adolescence, in Natalies case, this defense was also supported by experiences with her father which had left her feeling that
men were violent and untrustworthy and should be responded to in
kind. For Natalie knowing became drawn into conflict when she
saw her father (her teacher) act violently toward her mother. Learning became connected with sadomasochistic fantasies about sexuality. Additionally, his threatening to kill himself right around the time
she was learning to read may have functioned as a specific trauma
which further interfered with the development of automaticity in
reading. Given the minds tendency to associate like-valenced affects,
Natalie was unable to learn because of the disruptive effects of what
she experienced as her fathers seductiveness, her own excitement,
and her aggressive responses. As learning became libidinized, there
was an inhibition of function, which led to her trouble with looking
as well as with its oppositeexhibiting.
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,
254
about which she wished to remain blind. The defensive efforts that
interfered with retrieving memories of her fathers frightening violence and the painful affects they would arouse also interfered with
other information that for associative reasons shared the same address (Westen & Gabbard, 2002). Although unconscious, the memories remained in a state of activation that accounted for their continuing effects. In Natalies case these events, associated with the
process of learning, affected her motivation to learn. Natalies dyslexia came to function as an anlage, a model based on constitution
around which the defenses can crystallize. Not knowing became a defense; in choosing it as a defense, she also turned passive to active.
These dynamics were revealed when they were re-externalized in
the transference which, because of its connection to affect, functions
as a powerful anamnestic tool. In the analysis, Natalie was thrilled
and repulsed by sexuality and furious at being reminded of her interest. The Janus faces of Mr. Tingle and Barney explicate Natalies repeated experience of intense excited attachment coupled with
fears/desires of being attacked/attacking. Natalie experienced pleasure both as the terrorized girl and as the emasculating female. Of
significance is that both Barney and Mr. Tingle were teachers, one
sadistically drilling facts into her, the other an emasculated and useless wimp. Becoming a student and learning was either dangerously exciting or doomed to devastating disappointment. Natalies
fusion of sexuality and aggression is determined by her age, but also
by her history. I dont love you, she says, as she kicks her male analyst. I dont love you, she says to her father as she fails to learn to
read.
It was harder for Natalie to use language as a tool to abstract and
distance herself from her experience. She alternated between excitement, talkativeness, and silence. When she could not talk, she withdrew into a world of art work. Natalies neurophysiological weakness
left her with a tendency to focus on the non-linguistic aspects of the
environment; she had a strong reaction to tone and prosody in language and maintained a strong attachment to the visual world where
she could retreat when her affective stability was disrupted. She also
regressed to action as a mode of expression.
The analysis allowed Natalie to access language for what had been
inchoate and in so doing to connect a variety of associated, previously unconscious memories into cognitive structures. When her
conflicts with the father were repeated in the transference and interpreted, Natalie was able to look and to learn, to spell and to remember. She was helped, through the mechanism of the transfer-
255
ence to work through the exhibitionistic and voyeuristic wishes that

were tied into reading and learning. What was implicit memory became explicit. While part of the explanation is that she no longer
needed to use so much of her available energy for defense, her improvement can be understood in other terms than as a transfer of energy within the ego system.
a hole is to dig: play as a tool of cognitive structure
Up until this point, our understanding of how analysis helped Natalies cognitive functioning has relied on an understanding of conflict and the use of interpretation to understand her play. Vygotsky
(1933/1978) offers an additional perspective, suggesting that play
aids structuralization by allowing a child to become less tied to situational constraints and to act independently of what he sees. To a
young child, perception cannot be separated from meaning, motor
activity, or motivation. Thus, an object is what it is used for, or even
the context in which it has been used. One prosaic example: a 2
year old child hears his mother curse when she accidentally dents her
car by backing into a mail truck. The next day the child, sitting on his
ride-on toy, curses as he pedals backward. Very matter of fact, he explains to his shocked nanny, Im backing up. I say Fucking damn
it as if the curse were simply part of going in reverse, rather than
representing an angry feeling.
This connection between an object and its context was more poetically articulated by Ruth Krauss and Maurice Sendak, when they tell
us A Hole is to Dig, in their classic childrens book: A First Book of
First Definitions. In play, however, objects will inevitably have novel
uses and the same object will have multiple uses. Krauss and Sendak
understood this developmental point as well. Over the course of
their book a hole changes from something that is to dig to something you could hide things in, or sit in and a place for a mouse to
live in, a thing to look through, and when you step in it, you go
down. As multiple connections, varied perspectives, and experiences with objects accrue, they form new grids of meaning separate
from any one action and there is a consequent shift from action to semantics. Vygotskys conception is virtually identical to Rappaports
(1951) description of the shift from the drive-organization to the
conceptual organization of memory.
Initially, to a child, a word is part of the object it names: the word
ice cream causes the child to see, to taste the food behind the
sounds. In play, however, a dust mop can be Black Beauty; using the
256
old object in a new way acts as a pivot to disentangle perceptual qualities or action done on the object from the meaning of the object. At
first, the play object must share some similarities with the represented object (i.e. the mop is Black Beauty because you can ride it
between your legs), but gradually, semantic qualities come to override perceptual ones and the word horse, which bears no similarity
at all, even to the Black Beauty mop, can be used to represent horse
in the creation of stories about horses. These shifts can be described
at any one time as the product of a ratio between object/ meaning
and action/ meaning. As the meaning of the object and its place in
the play narrative becomes central and the perceptual qualities of
the object become subordinate, the child becomes able to exist
above the field for a moment, capable of stepping back. Vygotsky parallels this shift to the change in the childs ability to observe his oral
language after acquiring grammatical forms and written language.
A vital transitional stage toward operating with meanings occurs
when a child first acts with meanings as with objects (as when he acts
with the stick as though it was a horse). Later, he carries out these
acts consciously. This change is seen too, in the fact that before a
child has acquired grammatical and written language, he knows how
to do things, but does not know that he knows. . . . Thus, through
play the child achieves a functional definition of concepts or objects
and words become parts of a thing. (Vygotsky, 1978, p. 99)
In this way, play allows the meaning of a situation (both conscious

and unconscious) to emerge more fully and then, translated into action, to become amenable to thought and self reflection. In their
usual prescient manner, Krauss and Sendak end their book of first
definitions with A book is to look at, thus intuiting the parallel that
Vygotsky makes consciously between play and the acquisition of skills
which allow for the extraction of meaning from text.
In Natalies case, the process of learning is associated with the context of her excited, but threatening relationship with her father.
When she begins the analysis (in itself a type of learning situation,
which children frequently confuse with school) she reacts as she does
to all men/teachers and is unable to take anything in from the analyst. She responds to his verbal interpretations in action; she cuts his
tie, turns away from him, or hits out at others. The fact that the analyst does not respond to her provocations or collude with the underlying unconscious fantasies (i.e. that men will frighten and violate)
allows the original context of her fears to emerge. She is helped by
the relatively calm affective climate that develops as the analyst allows
257
Natalie to titrate the level of stimulation so it remains tolerable to

her. As Natalie begins to separate her image of the analyst from that
of her father and gradually to separate the act of learning from the
context in which it originally took place, she becomes able to use the
analysts words in a new way. As language gains ascendancy over action, she is able to make increasing use of his interpretations.
Natalies ability to use the analyst develops in tandem with a
change in her play. Early on, Natalie is unable to symbolize. Emotion
is expressed in action and there is no as if quality to her involvement in the transference. Her defensive strategies consist mostly of
instinctual vicissitudes such as turning active to passive and reversal.
Over time, her responses become increasingly sublimated and distanced from her physical body, eventuating in her story about Clover,
with whom she shares a partial identification as being unable to put
his feelings into words.
A second central point in Vygotskys work is that play is intimately
tied to reality and the development of self regulation. Vygotksy would
agree that symbolic play includes an aspect of wish fulfillment as play
develops at the time that the child becomes aware of desires that can
neither be immediately gratified nor forgotten. However, he was not
focused on motivation in the psychoanalytic sense of hidden desire
nor the need to deny reality through imagination. For Vygotsky, motivation is the bridge between a nascent developmental achievement
and its final form. Because imaginative play evolves into play with
rules, Vygotsky started his investigation searching for the origin of
this trajectory, noting that in all play the child invokes rulesthe
rules of role based behaviors as the child has observed them. The
child is literally playing with reality (Vygotsky, 1978), by trying on
the actions that define important others, such as mother, dentist,
teacher, or student. Only actions that fit these roles will be acceptable
to the play. During the act of play, rules of behavior which are observed and imitated but not necessarily conscious or available to reflection are made conscious and explicit. They can then be internalized and used for self regulation and delay.
Thus, play is instrumental in the acceptance of the demands of reality. In analytic terms, it promotes the development of the superego
by furthering the creation of an internal agency which guides the
childs behavior so that prohibitions are no longer imposed only
from the outside. While the child would not participate in play if it
did not involve pleasure, now the child willingly subordinates himself
to the rules of reality and renounces immediate gratification as a new
form of desire developsto act in accordance with the rules. Now
258
the childs desire centers on her role, on a fictitious I that relates to

the rules of external reality and takes them in, making them her own.
In Natalies analysis, this development is seen most clearly in her
teacher play. As Ross (1965) notes, the teacher game allows both object cathexis (of the teacher by the student) and identification (with
the teachers role) and employs these psychic mechanisms interchangeably. In this way the process of learning can be separated from
fixed roles and internalized. In play, the child acts ahead of her average age. Thus, play exists in the childs zone of proximal development, offering a measure of the difference between the childs actual
developmental level and her potential. In this zone, functions such as
abstract thinking and the childs relation to reality are in the process
of maturing. The areas where play is essential, namely in the development of abstract, semantically dominant, and more emotionally distant attitudes, are also those which analytic writers have noted to be
impaired in dyslexic children.
Conclusion
It is our contention that play in analysis functions in essentially two
ways for language based learning disabled children. First, learning
disabled children, with their increased need for external cognitive
support and structure, find it more difficult to separate from figures
that are associated with learning, and learning is more likely to become entwined with conflict. Undoubtedly, even in the absence of an
aggressive father, learning is an everyday trauma inflicted by parents
and teachers on a daily basis. Therefore, play in analysis must initially
function in the transference to externalize and interpret conflicts associated with learning. If this task of working through in the transference is successful, then the child is able to make use of play for purposes of learning and for the development of cognitive structures
where meaning is super ordinate to the immediate perceptual situation. This offers the opportunity to separate objects from the actions
done upon them and ultimately to distinguish meaning from action,
thus allowing the child to take an abstract attitude. This development, in itself, provides remediation for one aspect of the dyslexia,
the difficulty separating context from more abstract bits of knowledge.
Secondly, play in analysis functions to enable the child to join the
analyst in becoming learning partners where roles of student and
teacher are tried on, rehearsed, and eventually internalized. Several authors have noted this common type of play in learning dis-
259
abled children, a play very close in nature to reality (Cohen & Solnit,
1993). It has been suggested that in addition to functioning as an object in the service of transference repetition, the analyst also functions in a role as a new object which has some overlap with teaching
(Freud, 1974; Wilson & Weinstein, 1996; Weinstein, 2002). This
teaching role allows for the internalization of insight. Both aspects of
the analytic role are heightened and intertwined for the dyslexic
child. As the analyst functions as an object in the service of repetition, conflicts around learning will be re-evoked as the traumatic situations accompanying learning come closer to consciousness. Once
these conflicts are interpreted, as they were with Natalie, then the
child can begin to use the analyst as a partner (new object) in
play/learning. During this phase, interpretation is probably less required, as the child is finally able to make use of play for cognitive
structuring and for developing a decontextualized abstract attitude.
These skills are notably essential for learning to read as well as other
modes of symbolization.
Beyond the mutative aspects of interpretation, by allowing Natalie
to titrate the level of stimulation, the analytic context also supported
her ability to access knowledge she already possessed. Thus the analyst acted neither exclusively as a developmental new/real object nor
as transference object, but as both depending on the context of the
treatment at any one point.
Although it is beyond the scope of this paper to offer technical prescriptions, some differences in the way play and the analytic context
may function for learning disabled children should be highlighted.
First, learning disabled children may need to play beyond the usual
age than that of other children, both inside and outside of the analytic context. In the context of the analysis, play that might traditionally be considered resistance (i.e. doing homework in the sessions)
may, in fact, be a sign of progress in the treatment and essential in
the remediation of the learning problems. Third, although it would
be impossible to judge whether the nonverbal aspects of the interaction are more salient than the interpretive ones, a possibility suggested by the Boston Change Process Study Group (2002), it is clear
that the regulation of a tolerable state of affective stimulation becomes necessary before the analytic work can take place. Finally, interpretation is most successful if geared to the childs cognitive abilities, either by adjusting ones use of syntax, using shorter words, or
even allowing for an enhanced role for action in the treatment. The
necessity for factoring in the childs level of cognitive development in
the formulation of interpretations as well as the interrelationship be-
260
tween language development and the childs ability to reflect on her

own actions and feelings has earlier been discussed by Lewis (1977),
although he did not apply his findings directly to learning disabled
children.
Combining the analytic and the Vygotskian notions of play potentially offers a more comprehensive picture of the nature and utility of
play for the learning disabled child. First: play is pleasurable. It allays
anxiety by turning passive to active or by changing the outcome of
traumatic situations through the transference. Second: play allows the
learning disabled child the space to take in the reality of the outside
worldto play the student, to learn the difficult spellings and phonemes. As part of the fictitious I in play, she can work hard at something without humiliation, she can begin to learn the part of the
student I who can fight against great odds, by borrowing the
strength of the characters in play. Through play, the transference sets
up a new possibility for separating action from meaning. The tie between perception and meaning is ineluctable to a young child, and
probably even in an older child under situations of stress or high affective tone, which engender regressions. Learning as an act can now
be separated from its situational constraints. The child can begin to
think about learning, to think about thinking. As the implicit meaning is analyzed, play can move from the pathological to the normative.
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Wolf, Maryanne (1999). What time may tell: Towards a new conceptualization of developmental dyslexia. Annals of Dyslexia, 49:3 28.
A Girls Experience of
Congenital Trauma
The Healing Function of Psychoanalysis
in the Adolescent Years
SILVIA M. BELL, Ph.D.
This paper addresses the centrality of conflict in psychic trauma, as evidenced in the psychoanalytic treatment of an adolescent girl with a
congenital life-threatening and disfiguring condition that necessitated
multiple surgical procedures in early childhood. The focus is twofold:
to elucidate certain characteristics of analysis in the adolescent phase
that promote the integration of early trauma; and to shed light on the
modes of therapeutic action of psychoanalysis. Case material is presented indicative of the psychic consequences of early medical traumata, including the impairment of the egos capacity to utilize anxiety
as a signal function that mobilizes defense, the failure of repetition to
effect mastery of the trauma, the predominant use of aggression in the
interest of defense, and distortions in self and object representations.
The author offers evidence to show that conflicts over aggression and
oedipal desires, characteristic of adolescent girls who have not been
subject to trauma, were involved in the defensive function of her paTraining and Supervising Analyst, and Associate Supervisor in Child and Adolescent Analysis, Baltimore-Washington Institute for Psychoanalysis; Clinical Assistant
Professor of Psychiatry, University of Maryland School of Medicine.
I gratefully acknowledge the invaluable contribution of my discussions with Dr.
Alan B. Zients, whose insight and support were instrumental in my treatment of this
patient. I thank also Drs. Boyd Burris and Charles Brenner for their thoughtful critique of an earlier version of this manuscript.
263
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Silvia M. Bell
tients pervasive sense of defectiveness. She postulates that the interpretation of conflict and defense is the analysts attuned response to the
mind of the patient, and points to the resulting increase in the capacity to observe and to exercise volitional control over heretofore unconscious, automatic mental processes as evidence of the mutative function of dynamic interpretation.
in a recent publication, harold blum (2003c) reminds us that
psychoanalysis began with the concept of psychic trauma. The classic
definition (Freud, 1926) emphasizes a psychic state that results when
the ego has been flooded and overwhelmed by stimulation emanating from danger, be it internal or external. Psychic trauma, then,
refers to the experience of the ego which is helpless to cope with a
state of excitation that has annihilating power. Trauma can be caused
by an exceptional event, taking place at a particular point in time, or
it can be an ongoing life circumstance. In either case, it has an organizing effect. Memory of the trauma is registered both consciously
and unconsciously. Blum states that it has both verbal and non-verbal elements, the latter reflected in sensory, affective, motor, actingout, and somatic phenomena (p. 418). When the trauma is imposed
by congenital conditions, it inherently marks the development of the
ego and of object relations. It is important, cautions Blum, to differentiate the traumatic event, the internal traumatic situation, and
posttraumatic sequelae (p. 416). This speaks to the central role of
the childs internal experience of the trauma, which is represented
in unconscious fantasy, as it marks subsequent development and affects adaptation.
While the benefit of psychoanalytic treatment for patients with a
history of trauma is unquestionable, the nature of therapeutic action
in psychoanalysis has been the focus of active controversy. One aspect of disagreement that surfaced in a recent publication (IJP,
2003), centers around whether the mutative function is inherent in
the analysis of transference and in genetic interpretation and reconstruction of the unconscious conflicts and trauma of childhood
(Blum, 2003a, p. 500), or whether change results from the experience of self with other, where the crucial component is the provision of a perspective or a frame for interpreting subjectivity (Fonagy,
2003, p. 506). In the first, or traditional conceptualization, interpretation and reconstruction, though inexact, play a crucial role in the
process of addressing the best possible approximation to the patients unconscious fantasies and the traumatic realities of life
(Blum, 2003a, p. 512). While not excluding the therapeutic effect of
Healing Function of Psychoanalysis
265
the patients experience of safety as the trauma is revisited in the

presence of the nonjudgmental figure of the analyst, the emphasis is
on the analysis of unconscious retarding and inhibiting forces that
are inherent consequences of trauma (ibid.). The second view, expounded by Fonagy (2003), emphasizes instead the deep exploration of subjectivity from alternative perspectives that the patient
has heretofore not had ready conscious access to apart from the analytic encounter (p. 506). This view privileges the importance of implicit, that is, non-declarative, memory representations from past relationships. Dynamic (i.e., intrapsychic) conflict is not considered
pathognomonic, and reconstruction of past trauma is significant
only to the extent that it leads to generating a coherent historical
self-narrative. The curative aspect of psychoanalytic treatment is ascribed to the process of reworking current experiences in the context
of other . . . perspectives(ibid., emphasis mine), which results in
the active construction of a new way of experiencing self with other
(Fonagy, 1999, p. 218). Psychoanalysis works by effecting changes in
implicit relational structures that represent non-conscious influences of the past on the present. It is the analysts attention to the
patients currently repudiated feelings in the analysis (Fonagy, 2003,
p. 507), rather than the interpretation of their unconscious derivatives, that promotes intrapsychic reorganization.
This paper discusses the psychoanalytic treatment of an adolescent
girl born with a life-threatening, disfiguring congenital condition
that necessitated multiple surgical interventions in childhood. The
focus is twofold: to elucidate certain characteristics of analysis in the
adolescent phase that promote the integration of early trauma; and
to shed light on the mutative aspects of a psychoanalytic intervention
that focuses on the interpretation of conflict/compromise.
Clinical Presentation
I first met Beccah when she was 14. She came to our scheduled appointment dressed in Spandex running shorts and a sports bra. She
approached me quickly with a broad smile when I greeted her in the
waiting room, and made a point to bring her face very close to mine
as she went past me to enter the consultation room. Before sitting
down, she faced me and asked, Can you tell? Tell? I asked. Yes,
can you tell that Ive had something wrong with my face? In response, I said that that seemed to be very much on her mind. Yes,
she said, Ive had surgery on my lip and my face many times, and a
lot of work on my skin. This launched her into a description of her
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Silvia M. Bell
history of many surgical interventions aimed at repairing and reconstructing her features as a result of disfiguring birth defects. Her initial, rather provocative take charge attitude, clearly a reaction to
defend against the anxiety that our meeting stirred up in her, turned
into a description of experiences of early trauma, that impressed me
for its balance and forthrightness. She reflected on her fear of pain
and hospitalizations (Ive had to weather it for my own good.); on
her endurance of rejection (Its amazing how much Ive changed,
and I still remember how it feels being looked at funny.); and on the
difficult relationship with her parents (My parents dont know how
to work things out. My mother cries about me, and all I want is for
her to feel proud of me). She spoke, with embarrassment, about her
concern that she does not know how to handle boys, and described
her conflict about an intense neediness for attention that rendered
her vulnerable (I know that I need to please, especially boys, because its so important that they like me. So maybe if someone were
to force himself on me, I might not be able to stop him.)
This rather dramatic first meeting, revealed key elements of Beccahs adaptation that remained central considerations for the duration of our work. Beccah presented as an attractively built, vivacious
adolescent whose pretty eyes and bright expression diverted attention away from the minor remnants of her previous deformities, now
confined to relatively unobtrusive facial scarring and skin discoloration that she ameliorated with the skillful application of make-up.
She behaved as an action-oriented young lady, who took charge of
the session; in particular, of the impact she wanted her appearance to
make on me. While there were no obvious physical signs of what had
been, for much of her childhood, a salient appearance, now it was
her manner and style that cut a striking figure.
In this session, she gave a coherent autobiographical account that
included the consciously stored aspects of her painful childhood,
and she was self-reflecting enough to include observations about her
feeling states and motivationshe had experienced fear and pain
for her own good. She expressed a wish to confide in, even seek
nurturing from me, as she spoke of her compromised sense of confidence in light of her early experiences of rejection. As feelings of defectiveness and hopelessness surfaced, she turned to chastising
thoughts about her mother, who was not able to express a sense of
pride in her, in a defensive maneuver that helped to regulate affect.
In these respects, she was responding like a well-functioning adolescent. However, the exposure in her manner of dress and her confrontational style evinced a deeper struggle marked by self-conscious-
267
ness, insecurity, and vulnerability to deep narcissistic hurt, that was

revealed in her question, Can you tell? In fact, her actions upon first
meeting me were an attempt to master anxiety that also expressed
her conflictshe was exposing herself actively to avoid the pain she
expected in the form of rejection from me, and masking her sadness
and anger in a casual, yet tough demeanor. There was a readymade transference to me as judgethe female who, like the
mother, would scrutinize her with a critical eye. She reacted by assuming a provocative, almost oppositional postureshe came
dressed as she wished, not as she might be expected to look, rushing
toward me, yet ready to run away.
As we would discover together, there was a deeper meaning to her
question about whether I could tell. Her question revealed her own
confusion around internal representations, which rendered her vulnerable in relationships with others: she couldnt tell. Beccah was
aware that she couldnt get away from remembering how it feels being looked at funny. Despite the cosmetic success that had changed
her external appearance, unconscious aspects of her internal experience prevented her from integrating a healthier image of herself.
She exposed her new female body, but she spoke of her sense of defectiveness and of her fear of sexuality. Her presentation communicated an almost desperate need to figure out what others thought of
her now, as she sought to make sense of the confusing images of herself, past and present. In a shift expectable in adolescence, she made
clear that her longing search for mothers admiring gaze had now
turned to seeking acceptance in the eyes of a boy.
history
Beccah was born in an Eastern European country, with facial deformities and serious birth defects, including complete cleft lip and
palate, and multiple benign soft tissue tumors which involved the
face, the vascular system, and obstructed the airways and bowel. Her
parents, both professionals who had been educated in the United
States and counted many friends and relatives here, recognized that
her medical needs would be extensive, and took immediate action to
relocate. Indeed, Beccah required multiple surgical interventions in
the first four years of life, and her condition was considered life
threatening. Her medical status stabilized after age five, and she was
essentially healthy thereafter. However, she underwent staged periodic facial cosmetic surgery between the ages of five and twelve to
approximate a normal appearance. These interventions became less
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Silvia M. Bell
invasive as she grew older but represented, nevertheless, an inescapable specter in her childhood experience.
Infancy was a highly stressful period for mother and infant; Beccah
had projectile vomiting, cried excessively and had poorly regulated
sleep-wake cycles. As her rhythms stabilized in her second year, the
relative respite from anxious concern over her status was periodically
broken by emergency hospitalizations for various complications in vital organ systems. Despite Beccahs medical history, the parents reported an otherwise normal accomplishment of developmental milestones. Beccah was a charming, active little girl in early childhooda
stoic patient who seemed to find the strength to maintain a sense of
relatedness toward others, and the resilience to tolerate her hospitalizations. Periodically, however, she had angry outbursts, was demanding, and not easily soothed. A maternal aunt, who lived in close proximity, provided daytime care for her since infancy, given the mothers
decision to pursue her career. Beccah turned to her aunt for comfort, and experienced her as a refuge when she felt embattled with
her parents. Beccahs developmental history would have been considered unremarkable, were it not for the enormous achievement it
represented for this little girl to function competently, academically,
and socially, through the grammar school years.
Beccah was the older of two children. Her brother, four years her
junior, was described as healthy, aggressive, and irreverent like his father. Beccah took pride in being the smart one, whose academic accomplishments far surpassed his. The children shared an interest in
sports, in identification with the father, and there were no obvious
conflicts between them. The father was a self-acknowledged no-nonsense person, who wanted his children to be strong and active.
Threatened by Beccahs history of damage and suffering, he focused
on his daughters present status and denied the psychological impact
of her early appearance and medical vulnerability. His affirmation
that there was nothing the matter with Beccah now, obviated what
comfort this conflicted girl might have garnered from his seemingly
supportive comment, since it was delivered by way of a complaint:
What is her problem? She looks fine! He railed at his wife for making too many excuses for her, and it was clear that Beccah was at the
center of marital conflict.
The mother, more attuned to her daughters emotional distress,
was the one seeking psychological help for her. She had the competent demeanor of one experienced in the handling of emergencies,
but she could verbalize her awareness of underlying anxiety and conflicted feelings about this child who had brought so much trauma
269
into their lives. She was undergoing psychotherapeutic treatment to

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

through impulsive action that imperiled her safety. It became clear
that the nature of her conflicts required a more intensive intervention that would promote the development of her capacities for introspection, and provide her with the opportunity to integrate her
chaotic early experience. Beccah had established a therapeutic alliance with me by the time that we started psychoanalytic treatment,
ten months after our original meeting.
Beccah responded to the intensification of the treatment by becoming more conversational and less introspective in a defensive maneuver to maintain distance from affect. My indication that we would
meet four times per week felt like an increased interest in heran
approach that triggered anxiety at an unconscious level. In a displacement of the conflict, she developed a fascination with a boy. She
had picked him up at the beach after he made an obscene remark
about her body. In her sessions, she recounted the details of their interaction, which took place primarily over the phone. This behavior
was a compromise that allowed her to counter the regressive pull
generated by the analytic experience, as she talked excitedly to me,
about him. She phoned him repeatedly, hounding him with demands for attention, and stimulating him with seductive stories
about her provocative behavior. His tough manner and provocative
sexual comebacks fascinated and terrified her, and triggered a defensive identification with the aggressor. She developed a verbally abusive stance towards him, demeaning his socioeconomic status and his
academic ability. He became a good-for-nothing, with no culture
and no morals.
This relationship was an enactment of her experience of past relationships, which she expected would be repeated with me. Whereas
she had often felt victim to surprise and hurt in response to the reaction of others, now she created a sadomasochistic entanglement in
which she exacted and suffered pain and humiliation. The excitement generated in the interaction defended against her belief that
no nice boy (or nice doctor) could genuinely like her, and
against the dread that the wished-for closeness was inevitably linked
to abuse. A relationship with a boy she regarded as more defective
than she was, ameliorated the sense of being damaged and bad that
was exacerbated by my recommendation to increase the frequency of
our sessions. In fact, whilst she consciously regarded me as a trustworthy confidante, her relationship with this boy expressed in displacement her unconscious fear of what would happen between uswe
would hurt and disappoint each other.
271
These complex dynamics needed to be addressed gradually. My

early interventions aimed to help her to observe her affect in relation to her actions, and to begin to consider her use of defense to
regulate her internal state (turning passive into active, and identification with the aggressor). When a boy notices you, something happens inside and you feel that you need to find out what he thinks of
you. Maybe you rush to find out, to stop yourself from worrying. She
replied insightfully, When I get attention, I dont know what I feel; I
cant figure it out; I cant make sense of myself or what is going on.
In this early period, rather than explore directly the nature of her
fantasies and self- and other-representations, the interventions
aimed to help her to consider her sense of confusion. We noted not
only the disorganizing quality of her anxiety but also its genetic aspect: Not knowing how you feel now may be showing us what it was
like for you when you were little, and you couldnt figure out what
kind of attention you were getting. Thinking about her experience
in the past created a respite from the intense anxiety generated in
the moment, and thus it facilitated her capacity to observe her internal state. Mindful of her observation in our first session that she had
had to weather fear and pain for her own good, a statement referring to elective but necessary painful cosmetic surgery, I reconstructed that sometimes it was hard for her to distinguish whether
the attention she gets is helpful or destructive, because in the past
even good attention was tied up with so much bad feeling. She reflected, Ive had to put up with so much pain, I never know whether
the pain is for my own good or not. Maybe I dont want to think
about it. The internal confusion she experienced when she was the
focus of attention was an automatic reaction based on past experiences that were encoded in implicit, non-verbal memory. However,
Beccah was also inhibited by unconscious conflict pertaining to complex feelings about the need to subject her self to medical procedures and cosmetic changes in order to be normal.
Beccah was caught up in impulsive externalization that defended
against new and old reactions to her body that were exacerbated by
adolescencethe painful sense of defectiveness of her childhood
body and the frightening wishes related to her new female body. We
noticed that focusing on what a boy thought of her, kept her from letting herself know more about what she was feeling. This led her to
observe that something happens inside when a boy is interested. I
cant let it go. She reflected on not being able to tell me that her
boyfriend had made a vulgar comment about her breasts, which she
found pleasing and scary. Rushing at him with excitement, as she had
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Silvia M. Bell
done with me on our first appointment, she defended against feelings of vulnerability and helplessness that surfaced with his attention.
She recognized that she felt attractive some times, but then doubted
that anyone could find her attractive. With sadness, she added, Ive
had such bad luck, born with all these birth defects I have to live with
the rest of my life. I have this need to get attention from guys and
then I let them abuse me. Im so angry inside. I noted to myself that
she had turned to thoughts of pain and damage after she had allowed herself to acknowledge her new, attractive body, and her exciting, seductive behavior.
Beccahs traumatic history predisposed her to repetition, in an attempt at mastery where she had felt the helpless victim. When confronted with a situation that called up a sense of defectiveness, as in
meeting someone new, she called attention to herself. She projected
her sense of defectiveness and became provocative and aggressive to
defend against the disappointment of not being lovable. She invited
hurt through teasing, thus enacting her sadistic wishes, and then isolated the affective content of the interaction. Often, her behavior
elicited the rejecting response she had dreaded in response to her
appearance. Our work gradually elucidated the complex meaning of
her feelings of defectiveness. On the one hand, the implicit record of
painful experiences in face-to-face interaction now mobilized anxiety
and depressive affect around looking at her self and being looked at.
We learned, however, that feelings of defectiveness also surfaced as a
defensive turning against the self in the service of maintaining equilibrium when sexual feelings, which she experienced as dangerous,
came to the fore.
As our work progressed, Beccah verbalized feelings more directly,
and her tendency to enact became less ubiquitous. Sadness and despair, affects kept in abeyance by her aggressive stance, surfaced. She
commented: Only dirtballs are interested in me; Im the one they
abuse, but they choose somebody else for a girlfriend. She told me
of her recent encounter with her first grade teacher who, not having
seen her in the intervening years, asked unfelicitously, What happened to you? In the safety of the analytic work, we explored Beccahs painful experience of looking and being looked at. We reconstructed that she had learned from the look of others that her
appearance could inflict an emotional response that elicited a reaction that was incongruous with what she was feeling, and caused her
pain. While her provocative actions seemed to cry out look at me!,
her manner was a defensive maneuver that startled and interfered
with close scrutiny. Her salient behavior deflected the onlookers
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gaze away from her face. Looking and being looked at were highly
charged affective moments, which mobilized fantasy and conflict.
She began to recognize that her own looking was compromisedshe
looked to others as mirrors of herself, because she could not see the
young woman in the mirror as herself. As our work progressed, we
considered the meaning of her searching in my eyes, as she had done
on our first meeting; a search that repeated her experience with her
mothers eyes.
Beccah had enrolled in a course to make porcelain dolls, and she
brought them to her sessions. She was critical of her work, and
showed me that she could not get the face quite right. The connection with her wish to have the perfect face with a flawless complexion
was unconscious. She did not recognize that her newfound interest
represented her experience of remaking her own face. After sharing
in her interest in porcelain dollsthat is, keeping our work in the
displacementI noted the unremitting quality of her concern about
not getting the dolls face quite right, and I asked her whether she
was curious about it. She asked my opinion, what did I think about
the face? I replied that her checking now how I felt about the dolls
face reminded me of her question, can you tell? We addressed her
externalization; her checking what others felt kept her confusing
feelings about herself temporarily out of mind. She connected with
her anxiety upon meeting people, I have this constant knot in the
pit of my stomach; so much, that I dont even know its there. At our
next appointment, she brought a porcelain baby doll. Now aware
that her behavior had meaning beyond an interest in the hobby, she
said, I like babies. I worry about having babies in the future. We explored her worry that she could not have a normal babya worry
which, although connected to her pervasive sense of being damaged,
was also an expression of normal conflicts about the dangers of growing up and being female. This work was also a harbinger of conflicted
feelings about her mother, who had not passed on a normal body to
her.
The transference deepened, and Beccahs response to the treatment setting gave us an added, unexpected opportunity to reconstruct the genetic aspects of her pervasive feelings of vulnerability.
My office was located at the end of a U-shaped corridor in a suite
with four other offices. After several months of treatment, I still often
found her roaming the hallway. She seemed momentarily surprised,
even startled at my presence, and then responded by assuming a casual, distracted demeanor that resolved into a broad smile denying
deeper feeling. As I wondered with her whether she experienced a
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Silvia M. Bell
discomfort in the waiting room that compelled her to move around,

she recognized a mounting feeling of anxiety as she waited for me
passively, that compelled her to check out the place. Beccah became aware of an internal state of alarm, and she recognized that, despite her frequent checking, she felt confused and could not make
sense of the office space. I considered that, in the regressive state
promoted by the analytic process, Beccah was enacting an earlier,
non-verbal memory. I interpreted that her experience in the office
with me gave us further clues about what it might have been like for
her as a little girl, when she repeatedly found herself in strange,
frightening doctors spaces waiting for something to be done to her.
Her anxiety, which must have felt intolerable then, now impelled her
to take charge but still impaired her effective mastery of the situation. She recognized that waiting brought up fears that I would not
come for her, and that a stranger with harmful intent might appear
instead. She was abandoned and helpless. She responded to this insight by making a map of the office. She also started setting an alarm
to signal the end of our appointments before the time was up. I like
to know when youre going to tell me its time to go, she stated. As
Beccah understood that fantasies of rejection and abandonment
were mobilized in the treatment, she felt increasingly able to take
charge and this, in turn, furthered our exploration of her internal
experience.
As the transference deepened, she remembered an episode
when her incision opened up after abdominal surgery when she
was a toddler. She described, as if telling an exciting, funny story, her
aunts panic and ensuing confusion, as she was alone to handle this
emergency. Her account had the quality of bringing me into the family lore; it revealed how humor had been used to cope with trauma. I
felt the importance of respecting the affective tenor of her communication, which defended against the traumatic impact of that moment. I commented, after acknowledging the humorous quality of
her story, that remembering how her aunt had experienced this moment helped her to put aside what it had been like for her. She responded by disclosing her worry that someone could come through
the window and attack us. As we explored this fear, she revealed her
chronic difficulty sleeping in her bed at night. She slept on the floor,
or on a sofa, with a TV on. In keeping with her massive denial and
isolation of affect, this behavior was automatic and she was not aware
of the feelings that necessitated her avoiding her bed. She recalled
that, as a child, she needed to hear that there were people around
her who could rescue her if she stopped breathing. She realized that
275
she lived with a pervasive fear that she might die. We noted that she
was worried about whether I would or could protect her from harm.
Gradually, the fantasy that I might assault her, which was emerging in
the transference, became amenable to interpretation.
Beccah spoke of the comforting feeling of hearing the sound of
voices from the TV at night; they helped her to feel safe. I had registered that her memories, which depicted her mothers unavailability
and her aunts helplessness, had triggered a fantasy of assault that
elaborated on her feelings in the waiting room. I said: Perhaps the
sound of voices from the TV may even feel safer than a voice up
close. I interpreted that fearing that someone might come through
the window to attack us had something to do with a fear about being
alone with me. She reflected thoughtfully: I tell you so much. You
could do something that would hurt me. In the months that followed, Beccah explored her confusion about her mother, who
seemed to be in charge of her well-being and yet so helpless to protect her, and whose interventions she experienced both as life-saving
and as murderous assaults. Her awareness of feeling vulnerable with
me gave us an entry to explore her aggressive feelings. The fantasy of
the intruder who would attack us, was a compromise that included
the projected aspects of her rage at me, the powerful doctor-mother
who, by providing treatment, exacerbated her feelings of being damaged. It was also a harbinger of the deepening paternal transference.
As the treatment progressed, Beccah focused more actively in
sports, and she brought evidence of her success, indeed her stellar
performance, as recognized in newspaper clippings, ribbons, and citations. We noted, however, that she felt a great pressure to maintain
an unblemished record. Every event was a new challenge, as if her
previous success did not serve to ameliorate her blemished self-concept. She reported a worry that people out there wanted her to
lose, a projection of her enviousness that also reflected her expectation of punishment. Winning was of paramount importance, yet
fraught with conflict. Noting her anxiety prior to a particular equestrian competition, I wondered if these events recalled her experience
of her cosmetic surgeries, so fraught with promise and risk. The exploration of her exaggerated sense that so much was riding on the
outcome, led Beccah to recognize that she dreaded failure as evidence that it was all her fault. This insight allowed her to connect
with her sadness about needing reconstructive surgery, and to recognize that, although her body had undergone a process of change, her
old feelings of being faulty and at fault remained unchanged. She expressed anger at her mother who, in contrast to her athletic, aggres-
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sive father who did not see anything wrong with her, was felt as the
mirror reflecting her defectiveness.
Beccah accessed her conflicted feelings about her father before
she could fully address the complexity of her reactions to her
mother. Her bisexual conflict was openly manifest in this period in
her analysis, as she focused on sports in an effort to identify with her
father and disavow her dangerous, defective femininity. The identification with him did not offer lasting comfort, however. She reported
shouting matches between them; he was insensitive and didnt care
about her feelings. He is an angry person ready for a fight. Beccahs wishes for closeness with her father stimulated oedipal conflict
and called forth the dual threats of rejection from father and abandonment from mother. We recognized that anger maintained closeness between them, and defended against intimacy and disappointment. She added, Im afraid that Im just like him, and nobody will
be able to set limits on me. The identification with his intact image
seemed to bolster a sense of hope about her own strength, also experienced in her horseback riding, and was a relief from the complex
feelings in relation to her mother. However, it also promoted fantasies of unbridled impulse, which increased her sense of vulnerability.
The intensification of Beccahs feelings towards her father led to
an increase in her nighttime fears. She revealed that she had asked
her mother to sleep with her, as when she was a little girl. In the
course of our exploration of her regressive response to oedipal pressures, she painfully uncovered her confusing feelings toward her
mother. Sometimes she felt reassured of the much-needed mothers
love and approval. Often, she experienced mother as abandoning,
helpless to create a haven of safety where she would feel protected.
She developed a concern about her mothers health and well-being.
Her sense of defectiveness seemed to intensify with her fear of her
destructive wishes toward her mother. How can I be so angry with
my mother when I have been the cause of so much pain? she
protested, and proceeded to turn against herself as the defective one.
Being the damaged one also defended against the frightening wishes
to surpass her mother by becoming the young woman with the beautiful body who would bear the healthy, porcelain-skin child.
As our work progressed, Beccahs appearance and demeanor
changed. She began wearing age-appropriate, stylish outfits and
joined the preppy crowd. There was a shift in the transference, and
wishes for me as the oedipal father surfaced. She talked about being
glad that I was not a male doctor. I would worry what he might do to
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me; there are movies about this. I commented that thinking about
things that happened in the movies kept her from considering her
thoughts about me, right here. Her fantasy of my sexual feelings toward her, manifested in sadomasochistic wishes, condensed oedipal
components and a developmentally expectable erotic interest in me.
I interpreted that the excitement of thinking about an abusive relationship between us distracted her from considering other feelings
that surfaced as we worked together. I spoke to her excitement as a
defense against her worry about feeling unloved, if I did not reciprocate her interest and longing for me.
In conjunction with the process of object removal, which had been
delayed by conflict, Beccah developed an idealized view of me that
promoted her capacity to relinquish her mother. She became curious
about my interests, my salary, my education, and admired that I had
become my own boss. She imitated me in her manner of dress, identified with me in considering career choices; she felt that I was smart,
reliable, and interested in her: You never forget anything I say. At a
time when development required that she relinquish mother in order to attain a separate and independent sense of herself as female, I
provided the necessary unblemished female substitute.
Noticing an adult female patient who had left the office, Beccah
pondered whether she used the couch, and asked to try it. The
couch was weird but, as if it were a test of her readiness to face her
growing up, she was determined to use it. She reacted against the relative restraining quality of it, as adolescents are prone to do, but I was
aware of her unconscious association to a sick bed, and to her fears of
dying, that led her mostly to sit in the middle of the couch with her
back leaning against the wall. She told me about having set appropriate limits on a boy: Youll be proud of me when I tell you this! I responded to the identification (you are very pleased too, thinking
that we share in that feeling), while mindful of the defensive aspects
of her remark. She came to one of her appointments dressed like a
hippie and asked whether I had been one, thus revealing her burgeoning interest in my body and my sexuality as she tried to reconstruct and imitate me in my adolescence. She replied to herself,
Nah, youre too conservative. I dont think so. You go too much by
the rules. I wondered with her whether she thought of me in that
way to feel safe from a worry that I might do something surprising
and scary. She said: Its a relief. She mentioned getting a learners
permit, and jokingly added that we could go driving together. I commented that she was thinking about things we might do together outside of the office. She mused that it was good that it was just the two
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of us in the officethen she didnt need to decide what to call me,

whether by my title or by my first name. I said that by not calling me
anything she wasnt letting us know more about what made the
choice difficult. We noted a sense of risk that prevented her from
speaking freely about her wishes for a special closeness with me.
She came to our next appointment wearing very high heels, and
told me that her mother borrows them. But she does not fit into my
clothes. Do you like them? she asked in a challenging tone. The
erotic wishes from the previous session had given way to the lesser
risk of the defiant stance. I replied that she wonders whether I like
what she has and whether, like her mother, I might also want what
she has. She exposed herself as she flipped over on the couch, sat up,
and pranced around the room. Then she took off her shoes and
picked her toenails, first littering and then cleaning up the debris
from her body. She had brought greasy food that she spilled/contained/cleaned up; all the while as if she were oblivious to me. I felt
this provocative behavior as action language that expressed the multiple dangers she experienced around her wish to become a woman,
a wish that brought up closeness as well as competition between us.
At this point in the transference, I was experienced as the longed-for,
eroticized, dangerous witch-mother who could become malignant in
my envy. Her messy, regressive behavior defended against the risks inherent in the wish to be the woman who might incur my retaliation; a
risk fueled by her projected envy. She needed to remain the little girl
who would incur my wrath for her messiness, so as to avoid my retaliation against her femaleness.
In a subsequent session, Beccah reported that she had gotten good
grades; then she pointed to a run in her brand new stockings. I hate
runs. I am so bothered by little things! She showed me that it looked
just like the hyperplastic scar on her abdomen, from one of her procedures. She told me she has many others like it. I cant wear a twopiece bathing suit; I will have to have more plastic surgery. She
started picking on a scab and said, Im lengthening the healing process. I know that. Im attacking my skin. I noted to myself that, as she
was more in touch with her wishes to be like me and liked by me, her
conflicted feelings about her self-representation were coming to the
fore with an increase in depressive affect. While I was mindful of the
defensive aspects of this behavior, I felt that, in light of her past history, the fantasies and realistic concerns about her vulnerable femaleness were surfacing in the image of the fragility of her stockings. Beccah was now aware of her feelings, and she was able to
explore more directly her fears about being a woman. She spoke
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about the worry that her menstrual flow would not stop, and of her
fear of dying in sexual intercourse, or in childbirth. Her past history
of defectiveness accentuated the developmentally expectable concerns about her changing body, and stimulated the certainty of future trauma. As a little girl she had relied on her mother or her
grandmother to take over her body in order to feel safe; becoming a
woman meant giving up that tie to them, and taking charge of her
own bodya body that had felt unreliable as a child, and was undergoing a risky process of change.
Beccahs behavior toward me became more erratic. She reported
that her mother had commented on her progresswe dont fight
any morebut now she was angry with me. I was weird and out of
touch with kids her age. She told me that she spoke on the phone
with her boyfriends mother every day; Ive never met her. I dont
care what she thinks. I pointed to the worry about letting her self
tell me more because she might care too much about what I think.
She became more resistant. I dont have the maturity for this analysis. Youre trying to connect things up. I dont want to do that. I dont
want to remember. Then she told me that there are pictures of her
back then all over the house, and upsetting stories from her
mother about how people used to react to her. Letting herself experience with me her wishes and worries about her femaleness had mobilized in the transference the manifestation of a fantasy that I, like her
mother, wished to ensnare her in the past in order to keep her from
moving forward.
The work in this period gave us further access to the defensive
function of the defective view of her self. Beccah was aware of still
looking at other peoples reactions to her in order to get a clearer
sense of her self, as if what she saw in the mirror was not convincing.
She expressed despair about whether she would ever feel good
enough. I ventured that she seemed aware that, no matter what image was reflected back, something was interfering with letting herself
change the old picture in her mind. Maybe being her new, grown up
self felt scary and she kept herself looking back. She brought an album of photographs of a recent family event and used each photograph to evaluate herselfher expression was weird in this one,
there she looked deformed, her hair was not right on the next one.
Then she found a good one and said, gleefully; Look at my face
there, clearly taking pleasure and pride in her image. I clarified her
ambivalent feelings: Sometimes you cant stand looking at yourself,
and sometimes you like what you see. As if my words had touched on
something that brought up discomfort, she dismissed her pleasure
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and remarked: Theres only one good one. We were thus able to
observe that expressing to me the feeling that she liked what she saw
had mobilized a need to take the good feeling away.
Beccah developed a relationship with a boy. Her boyfriend was a
nice guy, but he is adopted. His adopted status fascinated her; she
saw it as his secret defectiveness. In that sense, he was more defective
than sheher parents had not given her up, she was valuable to
them.
The threat of abandonment and loss, so prominent in her thoughts
about her boyfriends history, was also a central aspect in her conflict
about growing up. Her relationship with this boy stimulated heterosexual feelings that signaled the potential disruption of her childhood tie to her mother, and resulted in an exacerbation of her anxiety. The impulse to call him repeatedly resurfaced; she felt miserable
and sought his constant reassurance. One day she broke out in great
anger at me: Despite all this work, I still feel so insecure! What good
is this analysis anyway? And how can I trust that you really like me
when you didnt know me back then? I said, You worry that something about my seeing you back then would change what I feel about
you now.
Beccah came to her next session carrying the framed pictures of
herself as a child that her mother displayed in the home. She
propped them in front of me, all the while scrutinizing my face. Can
you understand, she asked, why its hard for me to make sense of
how I look now? Its like, to me, Im the same, Im me then and now.
I felt the poignancy of this moment. She had brought the childhood
pictures to the office as if reclaiming ownership of her experience. I
understood intuitively at that moment the importance of my role as
trusted observer of her struggle, a struggle she was proclaiming and
was determined to work through, albeit in the context of the analytic
experience that granted me a vital role. She pointed to the many defects of old, and commented on the few vestiges that remained, symbols of past and present. I said, You wonder whether I see an old you
thats not right, or a changed you that makes you acceptable, and
how that makes me feel about you, the 16-year-old girl in front of
me. I still dont believe anyone could find me attractive, she said.
This session was powerful for both of us. Beccah exposed her vulnerability in the wish that she would feel undamaged as she displayed
her defects, a gesture no longer masked and distorted by the defensive provocative stance she had displayed in our first meeting. I was
moved by her presence, aware of feeling sorrow and pain for the little girl who had been subject to the experiences betrayed in the pic-
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tures. But, I was also responding to the strength and courage of the
young person before me. I do not doubt that Beccah was impacted by
the affective tenor of that session, in which I served as witness to her
increasing appreciation and acceptance of her struggle (Poland,
2000). Beccah was now telling herself. However, in order to understand the psychic meaning of her action, it is necessary to place it
in the rich context within which it manifested, and consider what
compelled Beccah to bring the pictures to me at this point in her
treatment.
Beccah had been expressing openly her experience of being lovable in the context of the growing relationship with a boy. As those
feelings, harbingers of her developing femininity, deepened, the
threat of the loss of the childhood experience with mother mobilized
intense conflict. Testing my response to her as a child at this time, a
move which could be regarded to serve in the interest of acquiring a
new way of seeing herself with me, was in effect a maneuver that
put a halt, albeit temporarily, to dangerous developmental wishes to
experience herself as a young woman in my presence. A stormy period ensued during which Beccah enacted the sadomasochistic fantasies pertaining to her early relationship with her mother. Fears
about her vulnerability to illness became prominent. She worried
that her immune system was down, and that her body could not
fight infection. A simple cold triggered fears that she would not be
able to breathe. She put down our work; talking was not doing anything. I was helpless and ineffectual. Her agitation switched to cool
withdrawal. She came to the office barefoot. My mother made a
comment, Do you think its dangerous to walk around barefoot? I
can decide what to do. I said that maybe she wanted for me to worry
about the danger, and then she wouldnt have to worry about her decision. She reported that she had eaten her lunch during her biology
lab. We were dissecting a rat. The teacher said there was a possibility
of bacterial contamination. If I get sick, I could pass it along. Like
the rat on the dissecting table, Beccah felt dangerous to herself and
to others. While, on the one hand, she felt that her mother was responsible for her defectiveness, she also struggled with the fantasy
that she was the one at fault, who hurt her mother with her defectiveness. She wanted me/mother to rescue her from herself because,
without maternal controls, she could not trust that she could be safe.
She assaulted me with my helplessness while exacerbating her own
sense of vulnerability; she was thus enacting with me in the transference the sadomasochistic symbiotic fantasy that kept her locked in a
sense of defectiveness.
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As these issues were addressed, Beccah gained in self-confidence;

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

interpreted that thinking about many people was a way not to think
about the worry about being all alone, now that our work would
come to an end.
The final weeks of the termination phase were stressful. She
started to miss her sessions. She had taken a job and was going to
the lounge to talk with her friends. I interpreted that she was leaving
me before we terminated, because of the worry about what feelings
might come up on our final good-bye. During her last sessions, she
reflected thoughtfully on her reaction to ending: It really did sink in
that Im going away to college. I was missing appointments here to
try it out on my own, but I didnt want to know about it. As we
worked through old and new feelings about being on her own, she
reflected on her gains. Im proud of myself now; I told this guy off
who was after me. I dont chase guys any more, and I dont have to
have people prove they like me. I feel calmer all around. I have more
esteem for myself. While Beccah could have profited from further
analytic work, she left for college rooted in a sense of being a young
woman with much to offer, a view of her self that would stand her in
good stead to meet the challenges ahead.
Discussion
This presentation details the analytic treatment in adolescence of a
girl who suffered pervasive trauma, originating from a congenital
condition that persisted for many years and necessitated multiple invasive medical interventions. Beccahs history involved all of the elements common to traumarepeated assaults of intolerable magnitude that inflicted pain, helplessness, and chaos on an ego incapable
of mobilizing adequate defensive action. At the inception of the
analysis, she functioned like a highly traumatized youngster. She
tended to enact in order to defend against sudden, disorganizing
anxiety, while sadness and rage locked her in a fixed view of herself as
defective. She projected her hostile view of herself onto others, and
her relationships became battlegrounds that expressed her inner turmoil. She went through a period of action-filled adolescence,
where she acted outrageously to counteract worries about the dangers of adolescence.
Blos (1962) describes the central role of regression in adolescence.
The adolescent reworks the tie to the parents in the interest of individuation and disengagement from infantile dependency, a process
that involves the need to solidify the image of ones own personality
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Silvia M. Bell
as the parental figures are relinquished. Both Blos (1962) and Winnicott (1971) state that, because of the centrality of regression, adolescence is a phase that facilitates the opportunity to undo developmental arrests and promotes restructuralization. Earlier conflicts and
fantasies that interfere with successful individuation, and can become further structuralized in pathological outcomes, now are
uniquely available for observation. The data from Beccahs analysis
attests to the importance of the adolescent period as one that provides a propitious opportunity for psychoanalytic intervention. Experiences involving her new female body, and the intensification of drives that safeguard individuation, provided a context that promoted
our exploration of the crippling conflicts that were interfering with
the process of psychic differentiation. Given the mental capacities of
adolescencethe ability to think beyond the concrete aspects of the
present, to consider past, future, and the possibleBeccah was able
to rework the governing childhood adaptations, and effectively utilize the forces that promote development.
Accounts of female adolescent development (Dahl, 1995; Ritvo,
1984, 1989) attest to the vicissitudes of this phase, which were much
exacerbated for Beccah given her past conflicts. The girls entry into
adolescence is characterized by a resurgence of the preoedipal object tie to the mother; she responds to the major shifts in physical,
and mental, functioning, as well as to the intensification of drive impulses, by seeking emotional closeness with the protective mother of
early childhood. With the onset of menarche, there is a heightening
of anxiety over the inability to control the body that intensifies the
girls neediness of mothers help with bodily care. These longings
stimulate fears of passive submission to the mother, and reactivate
earlier conflicts about merger with/engulfment by her. Beccahs experience of life-death dependency on mothers ministrations and
protection was reactivated in this phase of development, and it
threatened to keep her locked in a pervasive posture of defectiveness
that defended against separateness. The immediacy of these feelings
in the context of the concomitant drive toward separateness made
the reworking of separation-individuation issues more accessible to
analytic intervention
The girls awareness that she is beginning to possess a body like the
mothers may further stimulate fantasies of merging with her (Ritvo,
1989). A replay of the struggles of the anal period can ensue, and oppositional feelings, aversion, and estrangement from the mother
take over. When the resurgence of sadism is too powerful, the girl
may defensively externalize the sadism onto her mother. Rather than
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fearing her own murderous impulses, she then feels endangered by

the mothers rage (Dahl, 1995). Competitive feelings may surface defensively to establish a more comfortable distance, but this can lead
the girl to experience her development as a destructive surpassing of
the mother (Dahl, 1995; Laufer, 1986). Moreover, the regressive pull
to the mother who took care of the body is a harbinger of an erotic
entanglement with her. The girl may ward off the homosexual danger by turning to precocious heterosexuality (Ritvo, 1984). However,
the mother may remain fixed unconsciously as the erotically longedfor object the girl is inadequate to satisfy. In a projection, she experiences her mother as a jealously possessive, envious, malignantly
destructive witch-mother who fascinates and imprisons her (Dahl,
1995, p. 196). In order to mask and protect her heterosexual longings, the girl regresses to a messy, disorganized presentation that safeguards her from a fantasized attack.
Beccahs focus on her body, and the nature of the conflicts around
developmental progression that emerged in the analytic exploration,
are in keeping with these expectable characteristics of adolescent development, albeit marked in specific ways by her history of early
trauma. The analytic work with Beccah attests to the pervasive, ongoing power of annihilation fears and traumatic anxiety, as they influenced her internal experience. Fears of being overwhelmed,
merged, penetrated, fragmented and destroyed (Hurvich, 2003,
p. 579), characteristic in individuals who have experienced an insufficiency of safety (Sandler, 1960), were intrinsic to Beccahs affective
state. Laub and Lee (2003), referring primarily to the psychic consequence of acts of cruelty, state that trauma creates a strong impulse
to repeat destruction (p. 460). Beccah understood on a conscious
level that the trauma befalling her was not a premeditated act of cruelty. Nevertheless, she experienced it unconsciously as damaging actions against her body and self that had resulted because of her
mother, and because of herself. In the state of total dependency of
infancy and early childhood, her mother was the defective/intact
mirror of her damaged self, a rescuing lifeline unable to provide a
haven of safety, or to help her with the regulation of suffering. Now
in adolescence, she experienced sadomasochistic fantasies about surpassing her mother, which interfered with the development of a view
of herself as an attractive young woman.
Several authors have demonstrated that self and object representations are crystallized around experiences of early medical trauma
that lock mother and child in a sadomasochistic relationship. Kennedy (1986), describing the analysis of an adolescent boy who suf-
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Silvia M. Bell
fered from phimosis requiring surgery at age two, detailed how the
perception of the mother as a vicious attacker, whose longed-for attention and concern could be attained only by suffering and pain
and by relinquishing his penis, absorbed, restructured and organized
a whole range of earlier experiences and conflicts (p. 217218).
Beccahs affect storms, which she enacted in her relationships with
others, can be conceptualized as expressions of her internal representation of self and objectsa systematic repetition of the relationship between a persecutory, scolding, and derogatory object, and a
rejected, depressed, and impotent self (Kernberg, 2003, p. 520).
However, as Goldberger (1995) points out in her account of the
analysis of a five-year-old-girl who suffered medical trauma, the picture is more complex. The child who, out of medical necessity, has
experienced painful maternal ministrations, develops an attachment
to being handled in painful ways; in fact, the gratification obtained
from such relationships is something which is feared, but also looked
to have repeated (p. 268) so as to prevent object-loss. The analytic
work with Beccah revealed that sadistic fantasies around her early experience (that her mother caused/wished her trauma; that she damaged her mother through her defectiveness), and conflict (rooted in
oedipal and pre-oedipal wishes wishes that mandated punishment)
interfered with the appropriate restructuring of her internal representations, and kept her locked in a regressive posture of being the
defective child. The excitement of her sadomasochistic entanglements, as well as the unconscious connections between healthloss
of motherabandonment/death, that interfered with the development of an adequate view of herself, required careful interpretation
and working through.
Hoffman (2003) comments on the prominent role of aggression in
enactment and defense in the traumatized person, in particular the
predominant use of identification with the aggressor and turning
passive into active. A posture of nonchalant bravado is a characterologic defense in traumatized youngsters, serving to obscure intense object hunger, and passive libidinal object longings, as well as
to ward off expectations of repeated rejection and loss (Steven
Marans, as reported in Mazza, 2003). Goldberger (1995) comments
that the incessant need to repeat the traumatic experience is a hallmark behavior of the victimized child. The data from Beccahs analysis gives evidence of the pervasive nature, and complex function, of
repetition.
Repetition, which is a function we observe in play, provides normally a much-needed opportunity to re-experience a situation, this
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time as the active agent rather than helpless victim. This experience
promotes the gradual assimilation and mastery of anxiety. When
trauma is involved, however, the capacity to utilize anxiety as signal
function is impaired. The ego is, once again, overwhelmed and cannot mobilize defense in response to the affect generated in the process of repetition. Loewald (1971) regards the revival of the experience in the analysis as an active recreation on a higher organizing
level which makes resolution of conflict possible (Moore and Fine,
1990). Hence, one of the functions of the analytic intervention is the
restoration of the egos capacity to utilize anxiety for adaptation
(Yorke, 1986). Beccahs treatment created an opportunity for contained repetition, where she was able to take an affective sample of
these basic danger situations, to experience them in miniature (Yorke,
1986). Blum (2003c), underscoring the importance of genetic reconstruction, states that re-experiencing a trauma in the context of the
safety of the analytic situation effects changes in adaptive capacity
that are more congruous with present reality. As the record of Beccahs treatment elucidates, reconstruction did not refer to the accurate recall of past events, nor to a simplistic ascription of causation
between early factors and later pathology, but to the recovery of affective experiences which, when understood in light of what was
known of the relevant dimensions of her childhood (i.e., within a
genetic context), facilitated the capacity to distinguish between reality and fantasy, past and present, cause and effect (Blum, 2003a,
p. 500).
Certain authors who write about the impact of early trauma (cf.
Mazza, 2003) stress that it interrupts the development of healthy omnipotence, prevents the establishment of self-soothing and self-regulating capacities, and disrupts the capacity to recognize mental states
and to find meaning in ones own and others behavior. Referring to
Fonagys concept of mentalization (Fonagy et al., 2002), many assert that the major goal of treatment is to facilitate the development
of the capacity to conceptualize and make sense of situations, affect
and behavior. The clinical material elucidates that Beccahs capacity
for affect regulation was seriously compromised, and it had a disorganizing impact on her ability to comprehend her internal and external experience. In the early phase of our work, she experienced a
resurgence of the traumatizing childhood feelings that accompanied
her many overwhelming experiences pertaining to her medical
needs. The affective impact of these experiences, which were recorded at a procedural (i.e., non-verbal) level, were actualized in the
transference as she felt disoriented in my physical space, and she ex-
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perienced me as a dangerous intruder. My interventions aimed to

help her to make sense of herself in the present, by promoting connections between relevant information that was known or inferred
from her history, and her internal experience then and now, thus
meaningfully integrating past and present at a conscious level. Beccah became less impulsive as she became more cognizant of her internal state, and she could begin to identify, and label her affects,
and connect them with her thoughts and her behavior. This work
took place in a context of safety, what Fonagy refers to as a therapeutic secure base (2003), and it promoted the development of a sense
of containment, which facilitated the use of affect as signal function.
While these interventions promoted mentalization, and provided
her with a new experience of self with other, which Fonagy (2003)
asserts are the mutative factors in psychoanalysis, the unfolding of
the clinical material provides evidence of the persistence of the dynamic unconscious as manifested in the pathologic compromise formations that continued to inhibit the developmental process. Unconscious fantasy and conflict that were integral to her experience
of childhood became increasingly highlighted as the central aspects of
her misery.
As the interpretive work addressed dynamic conflict, Beccahs capacity to regress and access earlier fantasies and their related affects,
deepened. Interpretations that focused her attention on the sense of
danger attached to her excitement about her new female body, reactivated fantasies that ensnared her and her mother in irreparable defectiveness. Dahl (2002) states that conflicts over aggression and
oedipal desires are defensively concealed by disguising oneself as little and devalued in relation to the hated, beloved, and feared archaic
mother. Beccah began a complex enactment of the experience of being the defective child with mother by bringing her childhood image
for me to see. This defensive reaction to the intensification of separation wishes and drive derivatives, brought her in contact with her
inner-most feelings and earliest childhood fantasies. The immediate
response to seeing the pictures with me was the resurgence of depressive affect. (I still dont believe anyone could find me attractive.) Despite the fact that our work provided an opportunity for a
corrective experience (implicit and explicit) to being looked at in
childhood, Beccah would be unable to integrate a new image of herself until we had addressed the conflicts that surfaced more poignantly in subsequent sessions. Beccah enacted her sense of the utter
unreliability of her body, of the helplessness and destructiveness of
her mother, of her fantasy of herself as dangerous and damaging,
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which represented the affective experience of her early years and her
adaptation to it.
In the course of the analysis, Beccah came to appreciate that she
experienced her developmentally appropriate wishes in a context of
danger that reflected her earlier adaptation to her painful past. We
uncovered that she adhered to a devalued view of herself for complex reasons intended to restrict her functioning. Because the meaning of this experience became accessible to interpretation in the context of our work, she was able to achieve a new integration that
reworked the heretofore sadomasochistic aspects of her relationship
with her mother, and relinquished the defensive use of defectiveness
that interfered with adolescent development. As a result, her affect,
her behavior, and the quality of her thought processes increasingly
reflected changes indicative of a modification in the constellation of
intrapsychic factors that determines adaptation. By the time treatment discontinued, she gave eloquent testimony about the differences she experienced in herself.
The interpretive work functioned to promote insight, and permitted her to achieve conscious solutions to those conflicts that, when
they were unconscious, threatened to mobilize anxiety (Gray, 1988,
p. 44). Specifically, Beccahs attention was directed to the defensive
function of her sense of defectiveness, which could be observed by
her as we noted her tendency to turn to disparaging images of herself
in order to inhibit strivings that felt dangerous. While, as Gray emphasizes, profound unconscious changes take place as a result of the
influence of the experience of the analyst-patient dyad, the therapeutic aim of a focus on the analysis of resistance, to quote Gray, is to reduce the patients potential for anxiety, as differentiated from an aim
that merely seeks to reduce the patients anxiety (Gray, 1988, p. 41).
In Beccahs case, depressive affect was also a target, as it became involved in compromise formations that relied on turning aggression
against her self in a depressive response intended to relieve anxiety
(Brenner, 1982).
Each instance when the patient can confirm the connection between their sense of danger and the activities of the mind intended
to relieve that feeling strengthens the capacity to exercise volitional
control over internal forces (Busch, 1999). For example, when Beccah recognized that her aggressiveness protected her from the worry
about being overwhelmed by fear, she was better able to evaluate her
anxiety and could establish more satisfying relationships with others;
when she realized that she experienced being healthy as a harbinger
of loss, and understood that thoughts of defectiveness kept her safe
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from strivings she experienced as dangerous, she was free to pursue

her goals and wishes. Given that fantasy and conflict were pervasive
and persistent at the inception of treatment, the significant changes
in the patients psychic function subsequent to interpretations aimed
at the pathologic aspects of compromise can be considered evidential criteria that validate the mutative action of dynamic interpretation in psychoanalysis (Boesky, 1988).
The psychoanalytic method engages complex verbal and non-verbal processes of the mind. Analysis is an experience where the
patient increasingly exposes these processes, about which he/she remains unaware pending intervention from the analyst. The psychoanalytic intervention requires a specific kind of matching between
the mind of the analyst at work, as it facilitates the elaboration of the
patients mental processes and elucidates them, and the mind of the
patient at work, engaged in an effort at self-healing (Jacobs, 1988,
p.66). The congruence of these processes creates a context that enhances the patients capacity for self observation, promotes the affective reliving of inner experience, and stimulates the integration of
present in light of past experience that lends meaning to mental
functioning. Beccah was able to look forward to leaving home to attend college, because she had gained insight into her inner reality,
and a sense of her capacity for conscious management of internal impulses.
BIBLIOGRAPHY
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41:352 365.
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PSYCHOANALY TIC
PERSPECTIVES ON THE
FUTURE AND THE PAST
Psychoanalytic Reconstruction
and Reintegration
HAROLD P. BLUM, M.D.
Psychoanalytic reconstruction has declined in theoretical and clinical

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

and Supervising Analyst, New York University Psychoanalytic Institute.
Given as the Freud Lecture, Germany, November 1, 2002, and originally published
in German under the title Psychoanalytische Rekonstruktion und Reintegration in
Zeitschrift fur Psychoanalytische Theorie und Praxis/Journal for Psychoanalytic
Theory and Practice 2/2003 (XVIII) 2003 Stroemfeld Verlag, Frankfurt am Main/
Basel, published here in English with the permission of Stroemfeld Verlag.
295
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Harold P. Blum
in its second century, psychoanalysis has moved in many new

directions, often with increasing distance from its origins and core
formulations. Psychoanalytic reconstruction has been treated either
with neglect or declining interest as attention has turned to other
psychoanalytic issues and agents of change. Psychoanalysis itself is
not regarded as particularly popular in many parts of the world today, and reconstruction has particularly fallen out of favor as there
has been more immediate attention and emphasis on the here and
now, inside and outside psychoanalysis. Actually, analysts and patients have pondered the question of where the patient was coming
from, and how he or she got there. It is not only the adopted child
who is curious about his/her origins, but all persons and peoples.
Nations have legends about their origins, which are constructions
compounded of fact and fantasy. Freud (1919, p. 83) asserted: analytic work deserves to be recognized as genuine psychoanalysis only
when it has succeeded in removing the amnesia which conceals from
the adult his knowledge of his childhood . . . This cannot be said
among analysts too emphatically or repeated too often . . . anyone
who neglects childhood analysis is bound to fall into the most disastrous errors. The emphasis which is laid here upon the importance
of the earliest experiences does not imply any under-estimation of
the influence of later ones. Extending my previous work on the theoretical and therapeutic value of reconstruction (Blum, 1980, 1994,
2000), this paper supports reconstruction as inherent to the psychoanalytic point of view and virtually all clinical work. In my view, reconstruction is not only reciprocal to transference interpretation in the
present, but it is a complementary agent which guides and integrates
interpretations and reorganizes and restores the continuity of the
personality.
Reconstruction for Freud was both a technique, a means toward
the goal, and a goal of psychoanalysis. Experience such as the birth
or death of a sibling had an impact on the patients life, permanently
influencing the personality. Freud (1937, p. 26) illustrated such a
prototypical reconstruction, Up to your nth year you regarded yourself as the sole and unlimited possessor of your mother; then came
another baby and brought you grave disillusionment. Your mother
left you for some time; and even after her reappearance she was
never devoted to you exclusively. Your feelings toward your mother
became ambivalent, your father gained a new importance for you . . .
and so on.
A genetic interpretation shows that a current symptom, behavior,
thought, feeling, or trait is derived in some way from childhood. It is
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specific and focal, and it traces, for example adult obesity, to childhood conflicts concerning feeding and object loss. Genetic interpretations are fostered by the regressive character of free association
and transference. Reconstruction would encompass broader considerations, e.g. of dependent relationships, concurrent parental regression, inability to mourn and accept loss, identification with the
lost object, etc.
Reduction of the transference to its childhood roots and the accumulated analytic data converge in a reconstruction, which in turn
furthers the analytic process. Contrary to the current position in
some analytic quarters, that such genetic data are co-determined by
the analysts suggestion or countertransference, the childish character of the transference, the patients childish traits, features, fixations, and irrational childish fantasies point to the childhood locus of
pathogenesis and the patients psychopathology. Although analytic
work requires the reconstruction of childhood (Freud, 1937), this
does not mean that any two reconstructions by two different analysts
will be identical. Each analyst will select, organize, and interpret the
data with some degree of theoretical and personal preference. The
analysts countertransference may make it difficult to analyze the
transference, or from another point of view, it may provide further
insight into the patients conflicts, the transference, and the patients
resistance in the analytic process. The analysts analytic attitude, self
analysis, education, and experience should contain and limit the analysts human subjectivity, retaining good enough objectivity.
Analytic theory does not derive entirely from adult regressive
states, which do not reproduce earlier states unaltered, but has long
been complemented by infant observational research and child
analysis. The reconstruction of childhood takes into account affective, cognitive, and moral development. Reconstruction considers
the overlap and sequence of developmental phases, and the unique
quality of individual endowment and experience. Because of the theoretical implications of reconstruction, it has been used from the beginnings of psychoanalysis to propose, confirm, or challenge a theoretical or developmental hypothesis.
As analysis proceeds, the wealth of associations, memories, transference reactions, etc. provide a foundation for the process of reconstruction. Usually there are a number and variety of reconstructions
rather than one grand encompassing reconstruction. Like interpretation, reconstruction is neither arbitrary nor capricious nor dogmatic. All too often what is depicted as analysis in popular distortions
and misconceptions is a parody of the psychoanalytic process. A cari-
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cature of the psychoanalyst as insensitive, insistent, robotic, and selfserving is deployed to defend against the authentic yet disturbing
nature of analytic insights. Self-protection is preferred to self-knowledge. When a reconstruction is offered to the patient, it is a product
of prior analytic work, tentative and always an approximation. Psychoanalysis and the process of reconstruction are not based on faith,
dogma, or conjecture, but on evidence, inference, and further confirmation or alteration with new data. Fragmented, dissociated, and
repressed memories emerge and have to be differentiated from
screen memories and pseudo-memories. Screen memories are often
similar to the patients constructions.
Our knowledge of memory has significantly advanced in the recent decade. Bridges are under construction between psychoanalysis
and neuroscience, and both disciplines should benefit. Several memory systems are now recognized. These systems appear to have their
respective modes of registration, storage, and retrieval with interrelated functions and controls. Autobiographical memory is closely
connected to declarative, explicit, usually conscious verbal memory
for persons and places and general knowledge. Procedural, implicit
memory for skills, e.g. riding a bicycle, playing the piano, is not conscious, though not repressed, and is not modified as a consequence
of psychoanalysis. At this time the dynamic unconscious has not been
definitely delineated within any specific memory system or configuration. Traumatic memory is an exception, however, and appears to
be processed differently from other memory. Severe trauma alters
the structure and the memory function of the hippocampus. Unconscious traumatic memory is essentially formed in the amygdala (Le
Doux, 2002), which appears to instigate automatic fight-flight reactions to stress. These findings illuminate the complexity of memory
and the necessity of reconstruction superseding the limitations of
discrete memory.
Patients sometimes offer reconstructions before the analyst. In any
case, reconstruction will be invoked in analysis unless the past continues to be resisted and avoided. If the past and present have not been
meaningfully interconnected, then the patients defenses have not
been sufficiently diminished. The past will continue to influence the
present, but the past may also defend against the present. A patient,
for example, preferred to reconstruct her childhood strife with her
mother, rather than scrutinize her derivative overprotection and
over-indulgence of her daughter. Any confrontation with her daughter was to be strenuously avoided. The present as well as the childhood past may be viewed through a glass darkly.
Before the reconstruction is verbalized and offered to the patient,
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the psychoanalyst has been building a mental construction of the patients childhood. Based on the patients presenting symptoms and
character, the life history described by the patient, and the initial
transference reactions of the patient along with the analysts countertransference responses, construction evolves. Construction is an initial preliminary formulation, which goes on silently in the analysts
mind, particularly concerning the nature of the patients psychopathology and its relationship to pathogenesis. Construction is thus
an initial set of hypotheses about the patients unconscious conflicts
and character structure which is not shared with the patient and
which develops during the opening phase of psychoanalysis (Greenacre, 1975; Blum, 1994). Differentiated here from construction, reconstruction is generally formulated after the opening phase of analysis and is shared and shaped with the patient.
In the material that follows I shall focus primarily on reconstruction. This will allow a deeper understanding of the significance of the
child that lives on within the adult, the persistence of childish features and fixations within the adult personality, and the revival of
childhood in the patients regressive responses. This is not to say that
the child in the adult is ever revived as he/she actually existed in
childhood. Childish reactions in the adult may or may not serve their
original defensive and adaptive functions, and there may have been
developmental transformation of meaning and function. The adults
present personality and life situation influences the form and content of childhood revivals. Reconstruction of the patients past is necessary to demonstrate the persistent influence of the childhood past
in the present, but contemporary reconstruction also demonstrates
the influence of the present in the way the past is revived, re-experienced, and understood. The archeological metaphor which Freud
originally used in his description of reconstruction as reclaiming the
buried past is still apt in many respects. His work of construction, or
if it is preferred, of reconstruction, resembles to a great extent an
archeologists excavation of some dwelling-place that has been destroyed and buried or of some ancient edifice. . . . except that the analyst works under better conditions and has more material at his
command to assist him, since what he is dealing with is not something destroyed but something that is still alive . . . (Freud, 1937,
p. 259). Patient and analyst develop rational conviction about a reconstruction based upon analytic knowledge, observations, inferences and their cohesive integration. Reconstructions have transference and counter-transference meaning, however, so a patients
reaction to reconstruction becomes part of the analytic process.
Some of the main features of clinical reconstruction will be illus-
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Harold P. Blum
trated in the following clinical material. The primary case report is

that of the analysis of a white male in his thirties who held an academic position. He was gaining increasing recognition and was developing a consulting practice, which made private psychoanalysis possible. He sought treatment because he suffered from intermittent
depression with feelings of poor self-esteem. He was quite conflicted
and indecisive with respect to their relationship. He felt that the
analysis was necessary, and he anticipated it would be painful to expose his vulnerabilities. He hoped to develop a more positive confident self-image, and greater self-esteem and to become more successful in his life goals. He was completely nave about analysis and at the
same time, seemed to have an intuitive grasp of what was expected of
him. He was fascinated with the idea of everything means something.
During the first half year the patient remained interested, enthusiastic, and motivated. He was very intelligent and seemed very cooperative. This honeymoon period did not last and what then emerged
was a person who expressed himself in two different ways, almost as if
he were two different people. Frequently his language was crude,
with poor grammar and frequent curses and obscenities. On the
other hand, he would make frequent literary allusions, quoting
Shakespeare, Proust, Joyce, and other authors. He was capable of using a very large excellent vocabulary and subtle expressions, just as
he was capable of using crude language riddled with profanity. He alternated between curiosity and indifference regarding his two contrasting language styles. He also had two different ways of relating to
the analyst, and similar expectations of how the analyst would relate
to him. He expected his analyst to be in either a crude and uncontrolled dangerous closeness, or to be more distant and cultivated. He
indicated that he was afraid he would become too dependent on the
analyst and analytic process. The analysis had become one of the
most important things in his life.
The patient then revealed a secret, which he had withheld at the
beginning of analysis. He not only had two languages, but there were
two women in his life. While living with his girlfriend, presumably exclusively, he actually saw other women, primarily his ex-fiancee. His
lover had resumed sexual relations with the patient during the time
that he was living with his present girlfriend. He actually became
closer to his former fiancee whom he began to visit regularly. He was
afraid to reveal this to his girlfriend for fear that she would reject
him. He was divided between his two conscious loves, his present and
former girlfriend. This had now become intolerable. His divided love
301
and loyalties, and his guilt toward these women, were major reasons
for his seeking psychoanalysis.
When his girlfriend learned about his affair with his former fiancee, she repeatedly told the patient that had hurt her deeply, and
then she broke off all contact with him. Separation reactions activated in the transference. He was reluctant to leave sessions, and on
Friday would cheerfully state, have a nice weekend.
The intrigues in his personal life entered the analytic situation. He
confessed guilt about reading a magazine report about a mass murder in the waiting room. Although he was afraid of getting caught, he
had somehow left the magazine open to that page. He then recalled
that in adolescence he had found his fathers pornographic pictures.
Disgusted, but excited, he masturbated with these pictures. He was so
afraid of being discovered that he replaced them exactly as he found
them. He thought his parents were shameful hypocrites. When he
had asked for the analysts card, he was unconsciously referring to his
fathers pornography, wondering if the analyst were trustworthy or a
lascivious hypocrite.
This led to feelings about morality and specifically religion. He
wondered if the analyst were Jewish. He had grown up in an antiSemitic milieu with contempt of Jews. In a Catholic college he had
told a fellow that he had no use for any Jews and this person declared, Im Jewish. The patient was stunned and mortified. In his
view, though weaklings, Jews could be ruthless and they did the dirty
work (like servants). Later he began to examine the many stereotypes of his childhood. He was unconsciously afraid that the possibly
Jewish psychoanalyst would encourage immoral thoughts and acts.
On the couch he was vulnerable; he felt feminine and was homophobic. The patient was dimly aware of his fear of all women and preferred to think of them as asexual Madonnas. As a child he had wondered about sounds coming from the thin partition of his parents
bedroom, and as an adolescent he audited their sexual relations and
was sexually aroused. His adolescence was burdened by guilt and
fears of punishment.
At this point the analyst could reconstruct the patients reactivated
primal scene fantasy and sibling experience during his childhood
and adolescence, which reflected in all his current relationships. He
had slept in the same room as a sister until puberty, undressing together. His removal from their bedroom at puberty convinced him of
his sinfulness and motivated his urge to confession in church and
later in analysis. His masturbation while looking at the parental
pornography was unconsciously incestuous, and he was fearful of the
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Harold P. Blum
incestuous voyeurism, exhibitionism, and sibling sex play. He was

guilty and anticipated punishment for his incestuous fantasies. The
secret of his affair was tied to the secrecy of the primal scene, his sibling experience, and his unconscious fantasy of impregnating sister
and mother. After this reconstruction he could understand his fear
of intimacy. The patient spoke again of the hypocrisy of his parents,
their own crude behavior, their not setting limits, and their implicit
condoning of inappropriate sibling intimacy. His attention turned to
his irrational fear of the analysts cruel and dirty impulses and then
to recollections of parochial school. The priests and nuns were supposed to be kindly but they were frequently cruel. They too were unreliable hypocrites. He then described physical abuse, endless repetitions of prayers, and penance for minor infractions. He had despised
the Jews in part as a defense against his ambivalence toward the
Christian authorities of his childhood and adolescence.
The analysis deepened in its middle phase after a vacation. The
idealization of wealth was introduced when the patient had difficulty
in paying the analyst, ostensibly because he did not have an envelope
in which to enclose the check. The bare check would be nude, not
proper, but pornographic. Payment led to associations about dirty
money, greed, and the analyst becoming enriched through the patients efforts and expense. A very important childhood theme then
affectively emerged in the center of analytic work. The patient had
grown up in New England, mostly on large estates in which his parents worked as servants. He was the son of servants, within a socioeconomic class system. The analyst reconstructed the influence of
the servant experience on his fear of being compliant and dependent, his fragile self-esteem and compensatory striving for social status and affluence. His father was a tyrant at home but deferential and
subservient toward his rich employers. The patient too had to know
his place. He recalled with humiliation and rage how his father made
him walk to the back door, the servants entrance, and how he hated
being a caddy, carrying golf clubs for affluent adults to earn extra
money. The patient had played with a Jewish employers son, but they
were not allowed to eat together in the main dining room, nor did he
know proper etiquette. The primary house of his childhood was actually a cottage on an estate, servants quarters. He realized this accounted for the lack of boundaries and privacy since the few small
rooms had flimsy walls. The two different styles of language and manners, which had appeared in the transference, could now be reconstructed as related to his early experience, that of observing two
classes, his parents and the estate owners with different styles of lan-
303
guage and dress. He identified with his parents of the servant class
and also with the aristocratic parents. He had not been aware of his
dual identifications, languages, and ambivalent attachments. He had
lived in two worlds which were dissociated; ego integration was possible only after reconstruction of his childhood.
Reconstruction elaborated how he and his family were filled with
awe, envy, and resentment of the aristocrats. The have-nots attempted to devalue what they did not have. He should have been
rich, and what a better life he would have if he were the son or
adopted son of the nobility. Yet his identification with the cultivated,
educated, refined aristocrats proved to be a very important factor in
the patient seeking higher education and developing many cultural
interests. He displayed the superficial accoutrements of affluence,
and elegance but he knew that deep inside he had a servant mentality. Secrecy had also referred to the social devaluation of servants,
which he regarded with shame and humiliation. Moreover, servants
knew some of their employers secrets, and could know too much.
Acting servile and submissive was unconsciously associated with being feminine, with being Jewish. Anything that reminded him, or was
suggestive of being submissive or subjugated, enraged and frightened the patient. He transiently thought of quitting analysis rather
than lying compliantly on the couch. He needed to be clean and
neat, not only because of his guilt, but because of the dirty work of
his parents. His father had done manual labor, and his mother probably served as a maid. He felt compassion and pity, but also contempt, for manual laborers and for the lower class. He identified not
only with the values of the aristocracy but also with their condescending, haughty superiority toward their servants. He admired and idealized their prestige and power. He wanted to realize grandiose omnipotent fantasies and to never again be subjected to being humble
and humiliated.
A flood of painful memories returned, integrated in the reconstruction of the patients childhood as the son of servants. The
wealthy estate owners had referred to his parents by their first names
or without a name. The patient saw this as a lack of respect, treating
his belittled parents as if they were children. He thought that one of
the reasons they worked on different estates was that his parents had
been summarily dismissed from some of their jobs. Apparently some
of the estates were owned by descendents of the Robber Barons, influential individuals who inherited great wealth from the financial
manipulations of their forebears. The estate owners, partially through
projection, feared that their servants would engage in theft. The pa-
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Harold P. Blum
tient had fantasies of acquiring great wealth by defrauding the rich.

In the analysis he wondered about concealing his still rising income
so that he would not have to raise the fee. In fantasy he was the
greedy thief, the Robber Baron, a role formerly assigned to his analyst and Jews. He realized that he, his parents, and the aristocrats all
had a common religionthey worshiped wealth.
These various associations and interpretations were followed by
further enlarged reconstruction to which the patient contributed.
The analysis then veered further into the arena of shame, guilt, and
humiliation. The analyst pointed out that the patients view of his servant parents was that they had to swallow their pride. As servants they
had been fed and swallowed a steady diet of denigration. The patient
had a fleeting coprophagic fantasy; he identified with his degraded
parents, but also was hungry for money and its power. On one level
he regarded his parents as shameless, but he identified with their
silent compliant acceptance of shame and humiliation. The patient
wanted to erase, reverse, and revenge the humiliations. The analyst
reconstructed the patients organizing his life around overcoming
any narcissistic injury, obtaining narcissistic supplies, and becoming
an aggrandized aristocrat. As a consequence of the reconstruction,
many of his disconnected thoughts, memories, and feelings were organized into a cohesive, coherent, meaningful constellation. He
could reflect on the family life of servants. He had fantasized that he
was not the child of the servants, but the masters. He was of, or destined to be, the nobility. The reconstruction unified what had been a
double identity, prince and pauper, servant and master. He had two
languages, two sets of parents, two women, and two polarized sets of
attitudes toward people and society. His self and object world had
been split between idealized and denigrated childish representations. In a parallel reconstruction, he had taken upon himself or had
been delegated by his parents to redress their narcissistic mortification, to overcome the family shame, and turn humiliation into pride
and glory. He rebelled against any idea of being subservient toward
his analyst. He would not be treated with contempt by his analyst or
any authority, but would rise to the superior status to which he was
entitled, like the landed aristocracy.
The patient could see that some memories defended against much
more disturbing memories of his adolescence and childhood. The
secrecy of his ex-wifes illegitimate child, the secrecy of sibling sex
play, the secrecy of the primal scene were associated with the childs
secrecy and confusion concerning his parents denigrated status.
Why their job dismissals and moves? Servants had no job security and
305
no status. Were they actually fired because they committed robberies? Frequently paid in cash, they avoided income tax. Did they
deserve punishment? Were they without self-respect, and/or secretly
enjoying humiliation? What had led to their becoming servants? Did
his parents also idealize and identify with the aristocracy, basking in
their reflected glory, while denying their own devaluation? Did they
wish to be adopted as he did by the estate owners and analyst in a familial family romance just as he had, now manifest in wishes to be
adopted by the analyst (Freud, 1909; Frosch, 1959)? The reconstruction gave him insight into his thoughts and feelings about the past
and his plans for the future. It allowed greater access to the negative
feelings of guilt, shame, and humiliation, his low self-esteem, his fear
of failure, and his drive for success.
The reconstruction elucidated to the patients intrapsychic fantasies and responses to his pre-adult experiences. He was less confused by his pendulum-like swings between his feeling affluent and
indigent, aristocrat and servant, master and slave. The reconstruction did not compete with nor defend against transference interpretation, but advanced understanding of both transference and genetic
interpretation. The recovery of dissociated, forgotten, and repressed
memories reciprocally facilitated reconstruction.
Although Freud noted that reconstruction may serve as a convincing surrogate for a memory that could not be retrieved from repression, his basic premise was developmental and dealt with a forgotten
piece of childhood. Freud reconstructed a part of the analysands development, with pathogenic or progressive ramifications. Freuds
(1937) formulation went far beyond a single memory or element:
What we are in search of is a picture of the patients forgotten years
that shall be alike trustworthy and in all essential respects complete
(p. 258). Freud added that the task of the analyst is to make out what
has been forgotten from the traces which it has left behind, or more
correctly, to construct it. Freud (1920) anticipated the contemporary developmental issues in reconstruction, and early differentiated
between genetic and developmental perspectives.
So long as we trace the development from its final outcome backwards, the chain of events appears continuous and we feel we have
gained in insight, which is completely satisfactory or even exhaustive.
But if we proceed the reverse way, if we start from the premises inferred from the analysis and try to follow these up to the final result,
then we no longer get the impression of an inevitable sequence of
events, which could not have been otherwise determined. We notice
at once that there might have been another result, and that we might
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Harold P. Blum
have been just as well able to understand and explain the latter. The
synthesis is thus not so satisfactory as the analysis. (p. 167)
The problem of reconstructing developmental steps and sequences, of tracing the over-determined numerous factors of pathogenesis both evokes and challenges reconstruction. The issues of genetic fallacy and adultomorphic myth are further complicated by the
possible confusion of pathological regression, normal development,
and deviant development; by the number of factors and varied
strength of forces involved; and by the discontinuities which have to
be bridged. Reconstruction is made possible by the wealth of information provided by the analysis. But it is never a singular, veridical
red thread of connections. The reconstructive inferences depend
upon the totality of analytic data, and not just the transference alone,
on the elaboration and remodeling of the reconstruction in the crucible of the analytic process. How could this patient understand his
master-slave fantasies, his feelings of emasculation and inferiority, his
overall preoccupation with narcissistic injury and self-aggrandizement without the affective reconstruction of his childhood?
Some of the unresolved analytic issues in this case are of great interest. The genetic interpretations, and the reconstruction to which
they were attached, did not fully explain the patients psychopathology. So far the classical explanation of the patients disorder was in
terms of oedipal conflict. Were there not also primary narcissistic
and pre-oedipal issues, which were important antecedents of later
conflict? Of course the further back into the pre-oedipal period a reconstruction is attempted, the more speculative it inevitably becomes. The earlier the level of reconstruction, the greater the level
of conjecture. What was his early experience with his mother? She
was stoic in her menial work of cleaning and laundering. Some of the
ambivalence toward his father may have been transferred and displaced from his mother. She was not described in warm terms and
was regarded as rigid and unempathic. She was quite possibly depressed during his early childhood, hardly playful. It is likely that his
feeding, sleeping, and toilet training were rigidly controlled. Was his
mother the prototype of the rigid, insensitive, callous nun? Mother
could be a Madonna-like figure who protected him from his own impulses, but also an exciting and emasculating prostitute. He stated,
Im uncomfortable with cracks in the edifice I have created.
Women were cracked, tempting, and dangerous; they were split into
degraded pairs of prostitutes and nuns. Only after more analysis
could he admit that some of the clergy were dedicated and effective
307
educators. There were few if any parties in his childhood, and holidays were not celebrated. He had never had a birthday party, though
the patient was aware that the aristocrats children on the estate had
such parties. His father was not sure about his sons birthday.
The atmosphere of home was somber. His parents relationship
was not marked by overt affection and friendship, and they were little
interested in their childrens feelings. If he did not like the food he
was offered, he was expected to eat it without complaint, so that his
preferences were largely ignored. In later childhood he was painfully
ashamed of his parents and strenuously defended against feelings of
shame. His parents conveyed their feelings of denigration to their
son, but they and the aristocrats encouraged both his later achievement and entitlement.
Transference analysis and reconstruction were synergistic rather
than competitive or adversarial. The reconstruction was regarded as
mutative, making a decisive difference in clinical analysis . . . the
past within the present is transformed forging a new vision of reality
(Blum, 1994, p. 150). In the process of reconstruction, self-representations as well as object representations from various phases of life
are re-evaluated and reintegrated into new and more realistic representations. Not only were the defenses modified, but also the patients apperception of his/her inner and outer world.
In clinical situations where there has been massive psychic trauma,
there may be ego regression and damage to cognitive and affective
processes. What the patient cannot remember and articulate has to
be laboriously reconstructed. Somatization reactions and non-verbal
communication may be at least initially of great importance. Reconstruction may contribute to the retrieval and reorganization of fragmented, distorted, memories, as well as filling in memory gaps.
Without the reconstruction of memory what is indescribable and ineffable may be somatized, enacted, or acted-out through the children, the next generation. To avoid a collusion of silent avoidance,
reconstruction is required of the trauma, terror, and panic, of the
feelings of helplessness, and of the void of protecting or rescuing objects (Grubrich-Simitis, 1981; Krystal, 1991; Blum, 1994). An attempt
is made to clarify the details of the traumatic situations, and when
necessary, to uncover the intergenerational transmission of trauma,
with analytic awareness of inevitable unknowns and ambiguities.
Only then can traumatic reality and its fantasy elaboration be integrated into the relatively intact personality. The verbal reconstruction coalesces with step-by-step working-through of trauma and
terror. This permits the massive trauma of the past, recalled and re-
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constructed, to belong to the past rather than the ever present. Further analytic reconstruction may encompass prior and subsequent
traumatic experience, telescoped into the maelstrom of massive
trauma.
I shall now turn to the early facilitating value and integrative
effects of reconstruction psychoanalysis and in insight oriented psychoanalytic psychotherapy. While it is true that reconstruction is not
necessarily a part of psychotherapy as it is in psychoanalysis, reconstruction is often utilized to help the patient become aware of the
power and persistence of childhood fantasy and experience into
their adult lives. Transference and current reality may take precedence, but at the same time, reconstruction may be necessary to illuminate the transference and the current reality situation, which the
patient has helped to create. A borderline patient, who is bitterly critical and contemptuous of the analyst, may not respond to the analysts attempts to show the patient that the attacks on the analyst are
irrational and unjustified. The psychoanalyst regards the patients
criticism as part of transference fantasy, whereas the patient believes
that the analyst truly merits criticism. The analyst has a negative
counter-transference, about which he is inwardly conflicted. The patient has succeeded in eliciting the psychotherapists hostility, justifying in his mind his criticism of the analyst. A transference-countertransference stalemate might ensue.
There are different approaches to such thorny problems, but early
reconstruction can be very helpful, to the psychoanalyst as well as to
the patient. This is a departure from the general use of reconstruction after the initial phase of therapy. The exception here is not
meant to detract from Freuds (1940) counsel, we never fail to make
a distinction between our knowledge and his knowledge. We avoid
telling him at once things we have often discovered at an early stage,
and we avoid telling him the whole of what we think we have discovered. We reflect carefully over when we shall impart the knowledge
of one of our constructions to him . . . which is not always easy to decide (p. 178).
Where the patient has experienced a pathogenic relationship with
a parent involving regular overdoses of criticism, contempt, and disparagement, the therapist could point out that the patient had experienced withering criticism long before his treatment. His feelings of
mistreatment derived not from the present, but predominantly from
the past with his parent. The patient has identified with the aggressor
and was treating the therapist to the same disparagement to which he
was subjected. The patient had become the critical parent and the
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analyst is treated as the child whom the parent holds in contempt of

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

universal fantasies and the universals of life experience, but there are
always individual variations. This is exemplified in the family romance of the son of servants. A reconstruction should be internally
consistent and cohesive, logical and lucid, and closely linked to the
prevailing unconscious conflicts and analytic issues. While it may replace gaps in memory, reconstruction has a different contemporary
position in the theory of technique, deriving from and applying the
genetic and developmental points of view in clinical psychoanalysis.
In contemporary psychoanalysis, reconstruction has largely supplanted reliance on the recovery of repressed memory. Patterns are
more important in general than are single memories, with the major
exception of shock trauma. Reconstruction also has an important
current research dimension, testing and potentially integrating analytic data with the findings of infant developmental studies.
Validation and conviction are not necessarily achieved. Either analyst, analysand, or researcher may be much more convinced of the validity of a reconstruction than the other persons. While Freud at
times shifted positions concerning the relative importance of fantasy
and real experience, he never relinquished the importance of
trauma. Freud (1926) referred to the sometimes irrefutable evidence that these occurrences which we inferred really did take
place and he then stated, The correct reconstruction, you must
know, of such forgotten experiences of childhood always has a great
therapeutic effect, whether they permit of objective confirmation or
not (p. 216). Unlike the past when non-analytic data tended to be
dismissed or scorned as impediments or contaminants in the analytic
process, such concerns are no longer regarded as entirely appropriate. External confirmation can be analytically useful and contribute
to rational validation and conviction of correct reconstruction
(Good, 1998). Patients are stimulated to check and correct reconstructions whenever possible through objective evidence, e.g. of documents and the reports of relatives and witnesses. It is remarkable
how often psychoanalytic reconstructions are confirmed and expanded with extra-analytic evidence. However, no source or selection
of data is inherently free of distortion. The legal system has painfully
learned that eyewitness reports may not be reliable.
The past is not only rediscovered but is recreated in clinical psychoanalysis. Memory is remodeled. The past has taken on elaborate
new meanings, which did not exist in childhood. Moreover, developmental transformations may not be retrievable in their pristine form.
The second look (Novey, 1968) at childhood is through analytic
311
eyes with the refraction of an adult lens. Though the analytic autobiography is further illuminated and integrated by a particular reconstruction, there are no guarantees in analysis of valid reconstruction
or interpretation. Psychoanalysis requires tolerance and evaluation
of alternative considerations. Ambiguity and perplexity are part of
psychoanalytic work and the quest for greater insight. In addition to
Freuds (1911) two principles of mental function, the pleasure and
reality principles, we live and work with the uncertainty principle
(Heisenberg, 1958).
BIBLIOGRAPHY
Blum, H. (1980). The value of reconstruction in adult psychoanalysis. Internat. Psychoanal., 61:39 54.
(1994). Reconstruction in Psychoanalysis. Childhood Revisited and Recreated. New York: International Universities Press.
(2000). The reconstruction of reminiscence. J. Amer. Psychoanal.
Assn., 47:1125 1144.
Freud, S. (1909). Family romances. S.E., 9.
(1919). A child is being beaten. S.E., 17.
(1920). The psychogenesis of a case of homosexuality in a woman.
S.E., 18.
(1926). The problem of lay analysis. S.E., 20.
(1937). Constructions in analysis. S.E., 23.
(1940). An outline of psychoanalysis. S.E., 23.
Frosch, J. (1959). Transference derivatives of the family romance. J. Amer.
Psychoanal. Assn., 7:503 520.
Good, M. (1998). Screen reconstructions: Traumatic memory, conviction,
and the problem of verification. J. Amer. Psychoanal. Assn., 46:149 183.
Greenacre, P. (1975). On reconstruction. J. Amer. Psychoanal. Assn., 23:693
771.
Grubrich-Simitis, I. (1981). Extreme traumatization as cumulative trauma:
Psychoanalytic investigations of the effects of concentration camp experiences on survivors and their children. Psychoanal. Study Child, 36:415 450.
Heisenberg, W. (1958). Physics and Philosophy. New York: Harper.
Krystal, H. (1991). Integration and self-healing in post-traumatic states: A
ten year retrospective. Amer. Imago, 48:93 118.
Laub, D. (1998). The empty circle: Children of survivors and the limits of reconstruction. J. Amer. Psychoanal. Assn., 46:508 529.
LeDoux, J. (2002). Synaptic Self: How Our Brains Become Who We Are. New
York: Viking.
Novey, S. (1968). The Second Look. Baltimore: Johns Hopkins University
Press.
On Foresight
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If a man carefully examines his thoughts he will be surprised to find how much he lives in the future. His well
being is always ahead.
Ralph Waldo Emerson
it seems that only man imagines the winter of his discontent, or the glorious summer. No other living being can hold an
imagined future before the mind, and has the responsibility of its opportunities and dangers. But we who have this comforting and tormenting companion of inner thought extending beyond the moment are never long distracted from glancing toward our horizon,
whether in anxiety or hope, impassioned thought or quiet reverie.
Even when not pondering in this vein with full deliberation, we often
discover weve been quietly including the future anyway. The psychology of the future is less developed in psychoanalytic thought,
however, than that of past.1
Although there are studies on related topics such as judgment and
anticipation, and although attention to the future is implicit in much
analytic writing, I found no papers on the specific concept of foresight in the analytic literature.
Loewald states that it is the fear of molding the patient in our own
image that has prevented analysts from coming to grips with the future. In addition, reconstruction of the past, and recovery of repressed, has been so useful a focus of clinical work. The neurotic part
of us is in the grip of the past. In fact, one way to view neurosis is as a
truncation of realistic foresight, as the past is repeated over and over
again, which validates our imagined fears over and over again.
The fact that foresight has often been the province of astrologers,
seers, psychics, etc., may also have discouraged serious scientists from
attention to the subject.
This paper is an introductory effort to explore our concern about
the future and to consider what might be reasonable possibilities and
limitations of our attempts at foresight. It is not about knowing
events in advance, about prediction of specifics, about foreknowledge. It is about forms of anticipation that do not transcend our
senses, experience, and judgment. A mature imagination has much
to contribute when its limitations are recognized.
1. Emde (1995) notes, It is only very recently that our contemporary behavioral
sciences have become aware that a future orientation in our psychology has been
grossly neglected in the twentieth century. A multitude of studies have been done
concerning the influence of present and past events on behavior, but we have neglected the influence of the future.
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Freud observes the difficulties of prediction during the flow of analytic work:
So long as we trace the development from its final outcome backwards, the chain of events appears continuous, and we feel we have
gained insight which is completely satisfactory and even exhaustive.
But if we proceed to reverse the way, if we start from the premises inferred from the analysis and try to follow these up to the final result,
then we no longer have the impression of an inevitable sequence of
events which could not have been otherwise determined . . . the
chain of events can always be recognized with certainty if we follow
the line of analysis, whereas to predict along the lines of synthesis is
impossible. (Freud 1920)
However, in analysis we do often sense a direction, envision a horizon, and feel that some possibilities exist more than others. These
delicate impressions, however, dont elbow their way in to focused attention, often dont come in verbal language, and are easily overlooked. They are more like a quiet breath, or a passing fantasy or
fleeting image, but may be of surprising value when noted. Sometimes we have a fantasy or image, on the edge of awareness2 that
later appears in the patients associations.3
Often, however, we pay little attention to such impressions. We feel
that conscious, secondary process, deliberate thought is the locus of
higher mental functions such as insight. The characteristics of conscious, secondary process thought work toward differentiating, separating, categorizing, analyzing, and focus, all processes that restrict
the breadth of gaze while also removing us from full involvement.
They objectify and detach us from what we study. Primary process
thought blends and synthesizes, makes ideas collide, spill over, intermingle, come together, and influence each other over a wide field in
a manner in which we remain immersed. One isolates, the other
unites, one narrows, the other broadens. In one we step back and observe, in the other we find ourselves involved.
Primary process, however, is in practice still viewed with more skepticism among us, and also is not as easily studied since it goes on in a
silent realm, revealing its manifestations more than its workings. Secondary process, on the other hand, makes greater use of the lan2. Robert Gardners phrase suggests psychic events that one may easily attend to or
not. This often depends on delicate circumstances of the moment, such as the state of
the therapeutic alliance or the tactfulness of the analysts wonderings.
3. Bennett Simon, M.D., has made such an event the subject of an interesting article in Psychoanalytic Inquiry. See Bibliography.
On Foresight
315
guage and symbols familiar in the logic and reasoning of conscious

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

finding a relevant message, many of us have that event hovering in
mind, and this influences how we view the future. Religion and poetry each aim at trying to make our present and future more meaningful and the inevitable end more tolerable. Love and death are often the subjects of poetry, and when talking of love the theme of time
and perishing is close by, as in these few lines from the famous poem
by Andrew Marvell To His Coy Mistress.
But at my back I always hear
Times winged chariot hurrying near:
And yonder all before us lie
Deserts of vast eternity.
Thy beauty shall no more be found;
Nor, in thy marble vault, shall sound
My echoing song: then worms shall try
That long preserved virginity,
And your quaint honor turned to dust,
And into ashes all my lust.
The graves a fine and private place,
But none, I think, do there embrace.
Now therefore, while the youthful hue
Sits on thy skin like morning dew, [. . .]
(The Oxford Book of English Verse, 1902)
The message is not a complicated one. A lesser poet of our day

might say something like hey, lets get with it babe, but the arresting images of the poem bring a power and depth of meaning to the
argument. Here words are used to evoke images, and the images side
by side build a complex new meaning that neither image has alone.
Poetry brings together what is usually unrelated, in this case love and
death, beauty and perishing, and this synthetic act seems typical of
mechanisms we think of as primary process. MacLeish writes, One
image is established by words which make it sensuous and vivid to the
eyes or ears or touchto any of the senses. Another image is put beside it. And a meaning appears which is neither the meaning of one
image nor the meaning of the other nor even the sum of both but a
consequence of botha consequence of both in their conjunction,
in their relation to each other. And later, regarding the effect of coupled images, To carry experience itself alive into the heart is an
extraordinary achievement, an achievement neither science nor philosophy has accomplished (MacLeish 1960, pp. 65, 67). This seems
to be brought about by a process akin to condensation, but here it is
used in the creation of new meaning rather than for disguise. Poetry
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, symbolization, condensation, displacement. Images carry affect in a way that other symbols cannot do.4
You will probably have imagined by now that I have been trying to
suggest some of the ways that images and primary process modes of
thought may be important in how we process information consciously and unconsciously. The emergence of images and primary
process in regression of thought and for purposes of disguise has
been emphasized and well developed in analytic thought, but this
may be only an aspect of their importance. Perhaps a way to welcome
primary process mechanisms that is more comprehensive and less
tentative than regression in the service of the ego would extend
our reach as analysts.
In Keats, Frost, Emily Dickinson, Shakespeare we repeatedly feel
the search for the eternal moment, the timelessness of the primary
process, in the continually perishing beauty of the world. Paul Ricoeur writes:
because history is tied to the contingent it misses the essential,
whereas poetry, not being the slave of the real event, can address itself directly to the universal, ie: to what a certain kind of person
would likely or necessarily say or do. (Ricoeur 1995)
Poetry has a truth arising from its ability to reach beyond the welter of daily events into the essence of things and the timelessness of
the truth it finds seems to include some concern to help us bear the
unbearable aspect of the future. As poetry leaps into what is timeless
it includes essences of past, present, and future. The Wasteland, by
T. S. Eliot had a profound impact not only as a statement of the present day but of ominous trends leading into the future.
A Brief Diversion into History
While the contingent events of history in themselves may miss the
essential, or draw us away into details, we also do infer from these
events some important truths. Machiavelli, in The Prince, discusses
the disadvantages of using auxiliaries and mercenaries in warfare,
and writes:
4. Pinchas Noy has written about the need to concretize in order to carry affect.
The intellectualization of the obsessional bores us because of its distance from the
moment of real experience.
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Cornelis Heijn
But mans little foresight will initiate a project which at the start
seems good, but it does not notice the poison that is underlying
it: . . .
And so whoever does not recognize evils when they arise in a principality is not truly wise, and this ability is given to few.
[He goes on to describe causes leading to the overthrow of the Roman Empirea principal one being the employment of Gothic mercenaries.] (Machiavelli, p. 177)
History provides many examples of the success and failure of foresight. We owe much to James Madison in the design of our Constitution. His profound knowledge of good and evil in human affairs, and
his awareness that greed and power would be avidly sought unless
contained, along with intensive study of the various structures of government that attempt to channel such motives, enabled him more
than anyone to see the long-range implications of the various plans
put forward at the Convention.
Early in his career Napoleon had shown a high degree of foresight.
Later, in the Russian campaign, when his army of 433,000 was destroyed and only 10,000 half-frozen and starving men escaped, we see
many examples of the deterioration of this faculty, of valuable foresight ignored or rejected, and of foresight used to ultimate victory by
the opposing General Kutuzov. This is described in the remarkable
journal of General Caulaincourt, one of Napoleons closest aides.
Once he had an idea implanted in his head, the Emperor was carried
away by his own illusion. He cherished it, caressed it, became obsessed with it, one might say he exuded it from all his pores. . . .
Never have a mans reason and judgment been more misguided,
more led astray, more the victim of his imagination and passion, than
the reasoned judgment of the Emperor on certain questions. (Caulaincourt 1935, p. 28)
Caulaincourt anticipated the probable course of the campaign. He

knew the vast area into which the Russians could withdraw, the fierce
cold of the Russian winter, and the terrible revenge peasants would
inflict on any stragglers. He describes the disastrous result of failing
to provide for such small necessities as horseshoes with spikes, suitable for travel on ice. Horses were unable to haul wagons up frozen
inclines and many supplies had to be abandoned.
The Russian campaign was after Napoleons great successes but
while he was still a relatively young man. He had been famous for his
ability to visualize how a battle was likely to evolve the next day. But
foresight is a fragile process, easily lost or perhaps disrupted by the
On Foresight
319
hubris that may flower with success. Its loss was revealed in many ways
in the months to come.
. . . the Emperor could not or would not show a trace of foresight.
There is no doubt that we should have preserved much more undamaged if we had made the necessary sacrifices in time. But to two
or three unfortunate horses we allotted guns and waggons that
needed six, and by not abandoning one or two guns and waggons at
the proper time, we lost four or five a few days later. We planned for
the day only; and because we refused, as the saying is, to give the devil
his due, we paid heavily in the end to the enemy. (Caulaincourt,
p. 208)
Although the focus of this paper is the concept and process of foresight, Napoleons campaigns suggest another subject of importance,
that of the factors that influence its adaptational use. In one of her
last books, The March of Folly, Barbara Tuchman describes how great
events are often determined by people who cling, through vanity or
what she calls wooden-headedness, to plans seen by others at the
time to be unworkable. Britains loss of the American Colonies, the
intransigence and corruption of the Renaissance Popes that led to
the Reformation, the Vietnam war, the Japanese attack on Pearl Harbor, which someone described as destined only to awaken a sleeping
giant, all took place when those in power would not listen to reasonable foresight. Her meticulous gathering of evidence is compelling,
and one senses that she was doing what she could to awaken a world
moving mindlessly toward great dangers.5
Toynbee emphasizes the need for a currently felt challenge to
evoke creative response. Apparently he feels our imagination mostly
slumbers when long-range adaptation is concerned, and this contributes to the rise and fall of civilizations.
5. Such problems envelop us today, as science and technology grow in power, controlled by an economic system that feeds on the demand for constant growth and
ever increasing private profit, with little consideration of long range consequences to
a finite and fragile world. So we see the problems of global warming, environmental
destruction, genetic engineering, rapid transmission of world diseases, enormous inequality of wealth, loss of species, changes in family structure brought on by economic forces, all with little effective consideration of risks until they appear as crises.
Science has been so triumphant that we may have lost perspective about its limitations, some of which lie particularly in the difficulty of applying the scientific method
to highly complex interdependent systems in which small changes may have massive
but often slowly developing effects. Yet in idealizing science we have also given up
much of our reliance upon expert experience, and upon the foresight of wisdom.
Thus we run great dangers with calmness.
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Lack of foresight makes us more merry. (Oxford English Dictionary)

In warm climates, nature being bountiful, there is no need of foresight. (Oxford English Dictionary)
On a more optimistic note we have in the recent past the example

of George Kennan. An article in the New York Review of Books, April 26,
2001, entitled A Memorandum for the Minister describes how in
1932 Kennan, then a 28-year-old member of the delegation at Riga,
Latvia, analyzed the deficiencies of the radical Soviet policies then
being implemented in Russia. It showed how destruction of the existing tradition and ideals that ground a coherence of life, on the one
hand, and how the failure to provide new sources of psychological
and moral elements necessary for a healthy society were likely to
cause the eventual failure and collapse of the Russian-Communist
system. This perspective became the basis of our containment policy,
which reflected an understanding of these inherent deficiencies.
As head of the policy planning group at the State Department
when Marshall was Secretary, Kennan was also the primary architect
of the Marshall Plan. It is hard to think of another person whose foresight and wisdom has had such a vast and benevolent effect on events
of the last century.
Analysts know the hazards of believing that we know what would be
best for another person. Jane Austen illustrates the wisdom of humility in this regard with a beautiful passage from her last novel, Persuasion. Advised by a well-meaning aunt, Lady Russell, Anne had sacrificed a deep love when she was young. As the years went by, as the
bloom of youth faded, but confidence in her own judgment grew,
Anne felt she had made the most unfortunate mistake of her life. It is
an all too common story. She would not give such advice in a similar
situation.
How eloquent would Anne Eliot have been, how eloquent, at
least, were her wishes on the side of early warm attachment, and a
cheerful confidence in futurity, against the over-anxious caution
which seems to insult exertion and distrust Providence! (Austen,
p. 34)
Loewald also expressed faith in our ability to use our faculties with
hopeful confidence, and places it at the very center of analytic work.
He finds that the possibility of beneficial change springs from the analysts appreciation of the unknown, undeveloped potential, on the
analysts vision of the patients future.
The parent ideally is in an empathic relationship of understanding
the childs particular stage in development, yet ahead in his vision of
On Foresight
321
the childs future and mediating this vision to the child in his dealings with him . . .
The child, by internalizing aspects of the parent, also internalizes
the parents image of the child . . . (Loewald 1960, p. 20)
He comments on the many ways such interactions occur and writes:

In analysis, if it is to be a process leading to structural changes, interactions of a comparable nature (comparable to parent-child interactions) have to take place . . . the analyst relates . . . always from the
viewpoint of potential growth, that is, from the viewpoint of the future. (Loewald 1960, p. 21)
What a lovely project it would be to explore how we develop and

communicate this vision of the patients future, how we come to see
the potentials of character, of intellect and feeling, and nourish them
while respecting their freedom, and how we responsibly imagine a
small kernel of talent blossoming with maturity.6 It would take considerable artistry to provide examples because such interactions are
subtle and complex.
These examples are presented to suggest that we are deeply concerned about the future and that much of life is influenced in the
light of our assessment of that great unknown.
In addition, much remains to be learned about the functional
properties of the image, the major medium of the primary process. It
may be useful to consider more deeply the role of the primary process in addition to that of disguise and defensive regression. It seems
likely that these three issues, the future, the function of the image in
thought, and the primary process, are all related.
The Form That Foresight Takes in Conscious Life
How do we experience a view of what may become manifest in the future? The future is all tendency and possibility, but these are at least
6. James Engell, in a beautiful scholarly book The Creative Imagination, writes: Coleridge deals with one of the most curious and fascinating properties of the imagination: it is even more powerful as an idea when described in its own terms. If the
imagination is a higher power than reason (as the Romantics said), and every higher
power includes the lower power, then reason cannot express its comprehension of
the imaginative power. He quotes Coleridge, They and they only can acquire the
philosophic imagination, the sacred power of self-intuition, who within themselves
can interpret and understand the symbol, that the wings of the air-sylph are forming
within the skin of the caterpillar: those only who feel in their own spirits the same instinct which impel the chrysalis of the horned-fly to leave room in its involucrum for
antennae yet to come. They know and feel, that the potential works in them, even as
the actual works on them. (Engell 1981, pp. 346 47)
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Cornelis Heijn
in part expressions of what we know from the past and what we see today. To approach a vision of the future is to embrace in thought and
feeling many variables that differ in weight and quality, to have easy
access to different contexts, and to weigh facts that are constantly
changing. What form may this take? As with so many human issues,
Shakespeare provides a rich example. In Richard II, the King has neither consolidated his power nor gained the confidence of his subjects. His decisions vacillate. He has just banished a powerful Lord,
and then gone to quell a rebellion in Ireland. The Queen feels disaster approaching, without being able to specify why, or what form it
might take.
Lord Bushy urges her to lay aside life-harming heaviness.
Queen: I cannot do it, yet I know no cause
Why I should welcome such a guest as grief, . . .
Some unborn sorrow, ripe in fortunes womb,
Is coming towards me; and my inward soul
With nothing trembles; at something it grieves.
After some time news comes that the exiled Lord Bolingbroke has
landed with an army and the other Lords are flocking to him. The
Kings power is quickly evaporating.
Queen: Now hath my soul brought forth her prodigy;7
And I, a gasping new-delivered mother,
Have woe to woe, sorrow to sorrow joind.
Lord Bushy: Despair not, Madam.
Queen: Who shall hinder me?
I will despair, and be at enmity
With cozening hope, he is a flatterer,
A parasite, a keeper back of death. (Shakespeare, p. 44)
The Queen is feeling disaster ahead without being able to name

specific causes or outcome. Her realism, refusal to accept false hope,
her trust in her own feelings without elaborating them into specific
fantasied disasters as a paranoid person would do so exuberantly, all
seem noteworthy. Her character seems comparable to that of Oedipus or Hamlet in its requirement that she see the world without illusions. She is sensing tendencies, directions that are probably in their
essence if not predictable in their particulars, in a complex situation,
at some level of thinking that is not logical in a way we could describe
but that has validity even as it is nourished in unknown ways. Some
7. The Yale Shakespeare Edition of The Tragedy of King Richard the Second, edited by
Robert T. Petersson, explains that prodigy as used here means monster.
On Foresight
323
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 hasnt 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.
Thoreaus 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.
312
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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 Goghs 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 systemsthese 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 Goghs 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.
On Foresight
325
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 Platos 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 wont 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
327
The Study of Mental Imagery

David Hume asserted in the eighteenth century that a mental image
was only the trace of a perception, not modified by processes of an
active mind. The subject evoked little interest until William James
ridiculed this view, and devoted several chapters in his great text on
psychology to the functions of mental imagery in thinking and creativity. Later, however, Watson declared that only observable behavior was deserving of serious study, and such airy nothings as mental
images were again neglected by psychology until the poverty of the
strict behaviorist view became apparent.
About thirty years ago a debate broke out over the question of how
to define the basic elements of information storage and processing
within the brain. One group, including many who were interested in
the computer as a model, argued that there were no depictive, or image-like representations in the brain, and that images we experience
are an epiphenomenon of information processing that is at the basic
level propositional. Another group felt that images are not epiphenomena but are actively involved in memory and thought. A convergence of findings from many studies, and conclusively from Positron
Emission Tomography, have shown that visual images are anatomically localized in the visual cortex, and similarly in other areas where
vision is broken down and processed, in a pattern similar to their location on the retina, and these areas are used in reverse in the creation of mental images.13 So it seems that there are at least two
anatomical systems for processing information, one involving the
symbols, signs, and rules of language and the other, a more private
and solitary one, for mental images.
The Image in Analytic Thought
Freud described the mechanisms of symbolization, condensation,
and displacement which seem among his most important and enduring discoveries. His focus was on their role in the service of disguise
of the conflicted and repressed, as these were believed to induce a regression to the visual. Analytic interest has subsequently been
weighted toward the recovery of the repressed and interpretation of
13. This debate and its resolution are admirably described in Image and Brain, S.
Kosslyn.
It no longer seems beyond possibility that some day an external observer will be
able to view anothers 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.
On Foresight
329
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 Freuds
idea that the denier first forms a normal, conscious percept and later
disavows and distorts the percept. Evaluation, judgment, development of implications are going on in a pre-verbal mode of thinking
out of consciousness (Dorpat 1985, p. 28).
Joseph Weiss (1993) finds the unconscious control hypothesis
most consistent with clinical experience. This assumes that a person
is unconsciously able to use his higher mental functions and brings
repressed contents to consciousness when he unconsciously decides
he may safely experience them. This points away from emphasis of
correct interpretation to emphasis on unconscious judgments of
safety for release of repressed and clinical progress. These authors all
seem convinced that higher mental functions operate in the unconscious.
Although our age considers the scientist as the highest form of rational man, and the scientific method as the surest way to truth, scientific discovery, as distinct from method, appears often to rely on
processes that are not conscious and deliberate, and that involve
thinking with images. There are many anecdotes about this in biographies of scientists, sometimes told with embarrassment because
dreaming is not always recognized by a serious scientist as an honorable way to think.
One morning, as Einstein got out of bed, he imagined a man
falling off the roof past his window, and realized that he could not
tell from the percept alone whether the man was falling or the house
was rising, an image including the concept of relativity. In response
to an inquiry about his thought processes, he said, The words of the
language, as they are written or spoken, do not seem to play any role
in my mechanism of thought. The physical entities which seem to
serve as elements in thought are certain signs and more or less clear
images which can be voluntarily reproduced and combined. . . .
Conventional words or other signs have to be sought for laboriously
only in a secondary stage (1974, pp. 25 26).
Edison, ever the inventor, invented a way to capture his hypnagogic hallucinations because he found they often contained the solution to a problem he had been pondering. He took frequent cat-naps
in his chair, holding steel balls in his hands over metal plates on the
floor. At the moment of sleep onset, when all the muscles relax, they
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Cornelis Heijn
would make a great clatter and wake him up while the hallucination
was still vivid.
Our thought when expressed in words is more open to our examination than is our thinking in images. How often do we inquire
about the formal qualities of dreams, their skill and accuracy? Perhaps some of us dream with the fidelity of Vermeer, others with the
skill of a Sunday painter.
Books by Arthur Koestler and Harold Rugg outline steps in the creative process. This usually begins with intense study and conscious efforts to solve a problem, then follows a continuing sense of puzzlement, a feeling that things do not fit. Eventually there is a turning
away from the problem, and at an unpredictable point what Rugg
calls a flash of insight and Koestler the Eureka phenomenon ensues, usually during some not fully alert focused state, one that Rugg
calls trans-liminal. 14 While there are many descriptions of the phenomenon, it is very difficult to study the underlying process.
When we dwell in the secondary process we are aware that past and
future exist and feel the affects of grief and hope that accompany
awareness of time. When our experience is connected to primary
process we feel no past or future in the same reflective sense, and
people long gone may appear as they were. We dwell then outside of
time or, as Loewald says, in eternity, the absence of time. Remote aspects from the full granary of related past experience may enter the
present.
The potentials of having at our aid all the related experience of
our lives, fresh and vital in the immediate moment, to be felt and
worked with in a plastic medium capable of an infinite variety of
shades, forms, and intensities, all with deep involvement but without
the distraction of troubling feelings of loss, disappointment, ambition, or the limitations of time, such as we feel when awake, would
seem a great advantage for some issues, allowing integration of related experience, help from past experience. Perhaps wisdom, beyond intelligence and knowledge, depends upon such thinking involving the primary process.
In the dream as in a good play we have this intense absorption in
what is happening and the relevant events from all our life experience seem to be effortlessly before us, drawn together as by a magnet, in a fluid medium capable of infinite variation and great preci14. This immediacy of insight may have contributed to the belief that some people
of genius seem to work effortlessly. In fact, while talent is needed, hard work and
much preparation are essential preparation for creative work.
On Foresight
331
sion. We have no sense of authorship even as we are the director,

painter, and only audience of our dream. Awareness of todays reality
is in suspension, and we cant step back from the dream reflectively
and ask if our thinking partakes of our usual standards of logic, honesty, balance, and earnestness. That sort of detached critical thinking
seems absent from the dream state. One man did remark on the exquisite beauty and realism of the women in his dreams, and on the
blends of deep color that seemed to reflect mood as truly as in a
Bergman film. The rational part of us, however, tends to dismiss the
dream upon awakening. Why we would be so grasped and take so seriously something that we then may dismiss as just a dream is not
entirely clear.
A man prior to analysis had always dismissed his anxiety dreams as
nightmares, and was glad to be removed from them on waking up. As
he became more introspective he wondered if they were trying to
warn him about something worth attending to. Eventually he
thought they were wiser than he was. They seemed repeatedly to be
trying to alert him to the possibility that he might continue to fritter
away his precious time, indeed his life. They returned at moments of
important choice to the theme of the undone thesis, the first major
instance of avoidance due to anxiety, an avoidance that had resulted
in a half-hearted and failed effort and lifelong regret. At times of potential achievement in later life his dreams might offer him a second
chance at courses he had neglected, but then would show him forgetting to go to class or sleeping through the exams. He felt that his
dreams kept him in touch with both the opportunities and danger in
his current situation, the danger that he might again avoid a challenge.
Finally, we might renew an inquiry into what standards of honesty,
realism, and judgment can guide our thoughts when we think in images. It is true that the logical forms and structures of verbal language are lacking but this is inherent in the formal qualities of images, and is not in itself reason to question the integrity and balance,
honesty or realism, of thought in this mode.
Musings and Concluding Remarks
Psychoanalysts and their patients know the difficulties of gaining insight, which never seems complete and is always subject to revision.
In this arduous quest, however, the relevant facts are at least potentially available to the resourceful and determined inquirer since they
all lie within the present or the past. Even so, with our varying per-
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ceptions, imperfect judgment, revision of memory, skill at self-deception, tendency to leap to theory or preconceived explanation, etc.,
the gaining of insight is full of difficulty and must always be tentative.
Much understanding of life escapes our best efforts and remains a
mystery. We know this well in analytic work but it is equally true of
human behavior on the larger scale. Historical events are not only
difficult to foresee but explanations after the fact often seem simplistic and inadequate, often following the personal predilections of the
historian.
Imagine then the added difficulty achieving reliable foresight,
where the problem is still developing in a constantly changing world
and some relevant facts have yet to be born. Here we sense the need
for abilities and qualities of character in a new dimension of realism
and imagination.
I have gradually come to feel that some of the distinctions between
consciousness and the unconscious, and between primary and secondary process lie more in the nature of the medium of thought
than in the quality and validity of thought. It has been more useful
clinically to work as if we can be as sane, honest, and integrated in
our imagery as in our wordiness. The idea of the dream as a normal
psychosis or as lacking in judgment leads us away from the positive
value of the dream and other mental images. I think I worked better
when I saw us all struggling to find meaning, and to reveal and conceal from others and ourselves in any of the modes we have available.
I worked best when I thought of analysis not as a science of suspicion but as a science of discovery. To view the patient as split into
such different portions as to require a science of suspicion leads to
such notions as resistance, pleasure principle vs. reality principle,
censor, dream work as disguise, and analyst as general, surgeon,
hunter or trapper. To experience it as a science of discovery, while
still with ample difficulty, leads to notions of acceptance rather than
hard earned neutrality, to mutuality in the process of inquiry, to curiosity and wonder, and to the analyst as good traveling companion,
gardener, wilderness guide, or assistant analyst to the patient who is
the true analyst.15 One of my last patients said that her analysis had
been like a treasure hunt. While pain, sorrow, and chance of
tragedy cannot be eliminated, analysis can also be a joyous adventure.
15. The concept of analyst as assistant-analyst to the patient originated with Robert
Gardner.
On Foresight
333
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Selye, H. (1964). From Dream to Discovery: On Being a Scientist. McGraw Hill.
Shakespeare, W. (1921). The Tragedy of King Richard the Second. Yale University Press.
Simon, B. (1987). Confluence of Visual Image between Patient and Analyst;
Communication or Failed Communication. Psychoanalytic Inquiry. 1:471
488.
Stevens, W. (1982). Study of Images I. The Collected Poems. Vintage Books
Edition. Originally published by Alfred A. Knopf, Inc., 1954.
Tuchman, B. (1984). The March of Folly. Knopf.
Waelder, R. (1960). Basic Theory of Psychoanalysis. International Universities
Press.
334
Cornelis Heijn
Weaver, W. (1955). Science and People. Science. 122:1256. Charles Scribners Sons.
Weiss, J. (1988). Testing Hypotheses about Unconscious Mental Functioning. Int. J. Psa. 69:8795.
(1993). Empirical Studies of the Psychoanalytic Process. J.A.P.A.
41:730.
West, T. (1997). In the Minds Eye: Visual Thinkers, Gifted People with Dyslexia
and Other Learning Difficulties. Prometheus Books.
Index
Abandonment, 266, 269, 274 276, 280

282, 286
Abusive behavior, 269 270, 272, 302
Adolescents. See also Latency development:
attitudes toward therapy, 164 165, 169
171, 173; cognitive remediation, 239
260; latency development, 179 180;
neurocognitive problems, 239 241; psychic trauma, 263 290; relational trauma,
251
Adult Attachment Interview, 104
Adult narratives, 119
Aggressiveness: as defense mechanism,
263, 266 267, 269 272, 275 276, 281
283, 286, 288 290; latency development,
179, 188, 190 192, 194, 196 198, 201
202; Natalie (case study), 246 250, 253
254
Ainsworth, M., 16
Alcoholism, 110 111
Ames, L., 183, 195, 205
Analytic third, 215
Anger management, 201202, 227, 231
232, 267269. See also Aggressiveness
Animal Farm (Orwell), 250 251
Anna Freud Centre, 50, 161
Anthropomorphism, 184, 190, 195196
Anxiety. See also Death anxiety: Andy (case
study), 232; as defense mechanism, 263,
266 267, 269 275, 287290; latency development, 188 194, 196; maternal distress, 8, 18; relational trauma, 49 50;
Sean (case study), 138 139; separationindividuation, 282284
Attachment theory: frightened/disorganized attachment, 102108, 120 124; latency development, 178 207; maternal
love, 4849; parent-infant interactions,
1620; Strange Situation attachment
test, 16, 90 91, 103 104, 137
Attention deficit hyperactivity disorder
(ADHD), 222, 223
Austen, J., 320
Autobiographical memory, 298
Autonomy: consolidation process, 205; latency development, 178 207; play ses-
sions, 136, 142, 144, 145 146; Sean (case

study), 148 149
Aversion movements, 1415, 135, 284
Balint, E., 60
Bateman, A. W., 77
Beebe, B., 14, 17
Behavior observations. See also Facial expressions: body orientation, 135 136;
gaze, 1314, 135; head orientation, 14
15; video microanalysis, 1323, 4041,
135 137, 142152; vocalizations, 1618,
23, 26, 3031, 36, 39
Beiser, H., 158 159
Bender-Gestalt, 182
Bergman, A., 9
Bi-directional regulation, 11
Birth defects, effect of, 266 268, 272273,
278 280, 289 290
Black holes, 107, 119
Blatt, S., 182
Blos, P., 180, 195, 205, 283 284
Blum, H., 264, 287
Body awareness, 9397, 267, 271272,
278 279, 284 285
Body orientation, 135 136
Bornstein, B., 180
Boston Change Process Study Group, 259
Boundaries, 136 137, 142, 143, 145
Brazelton, T. B., 13
Bromberg, P., 215
Broucek, F., 219
Burke, W., 182
Buxbaum, E., 199
Case studies: Andy, 221233; Beccah, 265
290; Cecil, 24 34; Ethan, 5270; Iliana,
91 97; Little Hans, 157158; Mary and
John, 108 124; Mia, 85 91; Natalie,
242258; Nicole, 34 40; Sean, 138 152
Caulaincourt, A., 318 319
Center for Early Relationship Support, 108
Chase and dodge behavior, 14, 26, 33, 40
Chess, S., 3
Child Analysis with Anna Freud, A (Heller),
160
335
336
Index
Childhood analysis, 296 311

Chodorow, N. J., 204
Closeness versus distance, 62 63
Cognitive development, 179 180, 214,
258 260
Coherence, 151, 185 186, 198 200, 206
Cohn, J., 15
Conceptual frameworks, 134 138
Conflict/compromise interpretations,
264 267, 270 273, 275, 281282, 284,
288 289
Conflicts in learning, 258 260
Congenital trauma, 263 290
Conscious insight, 324, 328 332
Construction, 299
Contamination, 184, 190, 196
Contingency detection, 219 220
Coping mechanisms, 179, 188, 202205,
225 226
Countertransference: Ethan (case study),
58, 68; Mary and John (case study), 113;
Natalie (case study), 247; parent-infant
interactions, 51; reconstruction process,
295 311; state of playing, 215, 235; therapists role, 107
Creative Imagination, The (Engell), 321
Creativity, 324, 330
Crown, C., 17
Culver, C. See Malatesta, C.
Dahl, E. K., 288
Dead baby complex, 49 50
Death anxiety, 187192, 195 198, 201202
Dependency, 55 66
Depression, 8, 18, 49 54, 86 87, 221222,
300
Developmental theories, 129, 137
Disconnection, 34, 37, 145, 193, 200, 204
Disorganized attachment, 48 49, 52 54,
60, 102108, 113 117
Dissociation. See Frightened caregiving
Dissolution of the Oedipus Complex, The
(Freud), 179
Distress: infant distress, 60 61, 89 91, 94,
107; maternal distress, 89, 1819, 60
61, 88; regulation patterns, 89 90
Distress regulation, 20
Dorpat, T., 329
Downing, G., 12, 134, 136 137
Dreams, 328332
Dyadic systems. See Parent-infant interactions
Dynamic systems theory, 132, 151152
Dyslexia, 239 241, 244 245, 252254,
258 259
Edison, T. A., 329 330

Ego: Andy (case study), 230 231; capacities, 263 264, 287; ego capacities, 216
217, 220 223; and Freud, S., 78; latency
development, 179 180; reconstruction
process, 303, 307; regression, 234; state
of playing, 214, 216 217, 242; uneven
functioning, 220 223, 230 231
Einstein, A., 329
Eliot, T. S., 317
Emde, R., 217, 313
Emerson, R. W., 313
Emotional issues, 62, 6870, 116 123,
220 221, 230 233
Empathic attunement, 5
Enactments, 214 215. See also Fantasy formation
Engell, J., 321
Erikson, E., 180
Facial expressions: mirroring, 15, 26, 36
37, 39; parent-infant interactions, 15, 23,
2728, 135; separation-individuation,
218 220; stranger-infant interactions,
2627
Faith, 323
Family interaction patterns, 131152
Fantasy formation: Andy (case study), 222;
Beccah (case study), 271273; conflict
interpretations, 288; incestuous fantasies, 301 302; latency development,
179, 187189, 192198, 201203; Natalie (case study), 246 247, 253; psychic
trauma, 264; reconstruction process,
296 297, 307, 309 310; separation-individuation, 282, 284, 288; sexuality, 276
281, 285 286, 288; social status, 303
305; state of playing, 214 215
Fear, 8889, 9293, 119 121. See also Disorganized attachment; Frightened caregiving
Feldstein, S., 17
Ferenczi, S., 326
Field, T., 13
First Book of First Definitions, A (Krauss and
Sendak), 255 256
Fivaz-Depeursinge, E., 134 135, 137
Flexibility, 148, 151
Fonagy, P., 76, 77, 83, 265, 287288
Foresight, 312 332
Former child patients: attitudes toward
therapy, 162165; feelings about therapist, 166 173; memories of therapy,
158 162, 165 174; non-engagement,
169, 173; participants, 175
Index
Fragmentation, 184 187, 189, 191192,
195, 200, 205 206
Fraiberg, S., 4, 50, 7880
Freedman, S., 180
Freud, A.: attitudes toward therapy, 163
164; fantasy formation, 203; and Heller,
P., 160; infant psychoanalysis, 3, 9, 48; latency development, 179, 180, 203; parent-infant interactions, 217, 218
Freud, S.: ego, 78; imagery symbolism,
327328; latency development, 178
179; prediction difficulties, 314; reconstruction process, 296 297, 299, 305
306, 308 311; repetitive activities, 241;
repression barrier, 157158, 305; state of
playing, 214 215, 242
Friedman, G., 182
Frightened caregiving, 102108, 113 117.
See also Fear
Future, influence of, 312 332
Gaze, 1314, 135
Genuine maternal love, 4771
Gergely, G., 219 220. See also Fonagy, P.
Gianino, A., 120
Gilligan, C., 202
Goldberger, M., 286
Gorlitz, P., 182
Green, A., 49
Greenberg, R., 328
Greenspan, S., 181
Harry Potter stories (Rowling), 203
Head orientation, 1415
Heller, P., 160
Helpless caregiving. See Frightened caregiving
Hesse, E., 104
Hoffman, L., 286
Hole Is to Dig, A (Krauss and Sendak), 255
Home-based mother-infant psychotherapy,
101124
Homer, T., 201
Home visits, 7982
House-Tree-Person Drawings, 182
Hume, D., 327
Hypersensitivity, 53 54
Images, impact of, 316 317, 326 331
Imaginary play. See Fantasy formation;
Make-believe; Play
Improvisation, 117118
Interactive regulation, 11, 19, 56
Internalization, 159, 267, 274, 285, 287
288
337
Interpersonal connections, 136, 142, 143,

144 145
Intersubjective exchanges, 215 219, 229
230, 235
Intuition, 322 323
Irma dream, 328
Isolation, 193 194, 204, 226, 232, 246, 269
Jaffe, J., 17
James, W., 327
Jasnow, M., 17
Jewish Family and Childrens Service, 108
Joseph, E., 328
Jurist, E. See Fonagy, P.
Kantrowitz, J. L., 182
Kennan, G., 320
Kennedy, H., 285 286. See also Sandler, J.
Kernberg, P., 9
King, S., 203 204
Klein, M., 9, 159
Klopfer, B., 182
Koch, E., 158
Koestler, A., 330
Kohlberg, L., 179 180
Kohut, H., 180, 200
Kozlowski, B., 13
Krauss, R., 255 256
Kutuzov, M., 318
Language usage: dyslexia, 244 245, 252
254; learning disabled children, 239
241; play sessions, 137, 142, 144, 145; relational trauma, 251254
Latency development, 178 207
Laub, D., 285
Laufer, M., 173
Lausanne Triadic Play Model, 135 136
Learning disabled children, 239 260
Ledwith, N., 183, 185
Lee, S., 285
Lewin, B., 234
Lewis, M., 260
Little Hans, 157158
Loewald, H. W., 201, 287, 313, 320 321,
330
Longitudinal study of latency development: analytical discussion, 198 201;
anger management, 201202; background information, 178 181; early latency, 186 190; gender differences,
186 207; late latency, 195 198, 205
206; methodology, 181186; middle latency, 190 194; results, 186 198; timeline, 206 207
338
Index
Long-term follow-up project of child analyses, 157175

Loss, 186 192, 232
Luria, A. R., 252
Lyons-Ruth, K., 104
Machiavelli, N., 317 318
MacLeish, A., 316
Magic, use of, 188, 190, 192, 202204
Mahler, M., 9, 203, 206, 217
Main, M., 13, 104
Make-believe, 215, 218 220
Malatesta, C., 15
March of Folly, The (Tuchman), 319
Marshall, G. C., 320
Marvell, A., 316
Maternal failure, 48 49
Maternal love, 4771
Mathematics, 325 326
Memories of therapy, 158 162, 165 174
Memory, reconstruction process, 295 311
Mental imagery, 327 331
Mentalization theory: fantasy formation,
220; Iliana (case study), 95 98; Mia
(case study), 87 90; Minding the Baby
program, 81 85; parent-infant interactions, 7677; psychic trauma, 287288;
state of playing, 216
Metabolizing feelings, 112, 119 122
Metraux, R. See Ames, L.
Midrange regulation model, 33
Milne, A. A., 213 214
Minding the Baby program, 74 98
Mini-reunion experience, 137
Modell, A. H., 201
Motherhood Constellation, The (Stern), 112
Mutuality, 11, 218, 226
Napoleon I, Emperor of the French, 318
319
Narcissistic balance: Andy (case study),
222, 225 226, 230 233; contingency detection, 219; psychic trauma, 267; reconstruction process, 304, 306
National Center for Infants, Toddlers, and
Families, The, 79
Neubauer, P., 4
Neurocognitive problems, 239241
Neurotic conflict, 217218
Non-engagement, 169, 173, 222223, 228
230
Nonverbal language, 1213, 21 34, 106,
135, 247
Normality and Pathology in Childhood
(Freud), 218
Noy, P., 317

Nurse Home Visitation program, 80
Nurturance, 186 194, 196, 198, 204
Object relations theories, 179 180, 183
185, 218 219, 255 256, 263 264
Oedipus complex, 276 277, 284 286, 306.
See also Latency development
Ogden, T., 215
Olds, D., 80
Olesker, W., 199, 201
Oppositionality, 225 227, 232, 267, 284
Orwell, G., 250 251
Overstimulation, 19, 2528, 40, 251, 253.
See also Self-regulation
Parental history: Beccah (case study), 267
269; Cecil (case study), 28, 32 35; Ethan
(case study), 53, 58 59; Iliana (case
study), 91; Mary and John (case study),
110 114; Mia (case study), 87; Natalie
(case study), 243 244, 253 254; reconstruction process, 301304, 306 307;
video microanalysis, 40
Parent Consultation Model (PCM), 128
152
Parent-infant interactions. See also Minding
the Baby program: behavior observations, 13 41, 135 137, 142152; Cecil
(case study), 24 34; ego capacities, 216
217, 220 223; face-to-face interactions,
1012, 1820; frightened/disorganized
attachment, 102124; Iliana (case
study), 91 97; intersubjectivity exchanges, 217220; intervention techniques, 3 5; Mary and John (case study),
108 124; maternal love, 4771; Mia
(case study), 85 91; mind-body awareness, 78 81, 83; Nicole (case study), 34
40; Parent Consultation Model (PCM),
128 152; perception, 11; psychotherapy
interventions, 4871, 79 98, 101124;
regulation patterns, 1112, 1920, 24
34, 55 56, 217220; temperament, 3,
5, 19; treatment methodology, 2123;
video microanalysis, 713, 4041, 129
138
Pearlman, C., 328
Pearson correlation coefficient, 182
Peer relationships, 180, 204 205
Perry, R., 180
Persuasion (Austen), 320
Phonological processing, 244
Piaget, J., 179 180
Pine, F., 9, 217
Index
Play: lack of play, 221233; learning disabled children, 239 241, 258 260; object relationships, 255 256; regulation
patterns, 257258; state of playing, 213
236; therapeutic value, 233 236, 241
242, 258 260
Play sessions, 133 137, 139 141
Poetry, 315, 316 317
Preadolescence, 195 198, 202, 205 206
Primary process thought, 314, 316 317,
330, 332
Prince, The (Machiavelli), 317 318
Provence, S., 4
Psychic trauma, 76 77, 263 290, 298 311
Psychological testing, 181, 182185, 244
246
Puberty, 195, 197, 206
Rangell, L., 328
Rappaport, D., 255
Reconstruction process, 295 311
Reflective awareness function: frightened/
disorganized attachment, 105; Iliana
(case study), 9598; Mary and John
(case study), 119; Mia (case study), 87
90; Minding the Baby program, 81 85;
parent-infant interactions, 76 77; psychic trauma, 7677; state of playing, 216,
218, 225
Regression, 179, 215, 254, 269, 282, 283
286
Rejection, 266 267, 274. See also Abandonment
Relational trauma: Beccah (case study),
270; Ethan (case study), 59 60; Iliana
(case study), 9197; Mary and John
(case study), 110 123; Natalie (case
study), 242244, 249, 251, 253 254;
parent-infant interactions, 48 49, 51,
7681, 104 105
Reparation, 6668, 120
Repetitive behavior, 269, 272, 286 287
Representational/behavioral domains, 112
Repressed memories. See Reconstruction
process
Repression barrier, 158
Richard II (Shakespeare), 322
Ricoeur, P., 317, 326
Ritvo, S., 159
Rizzuto, A., 235
Rodell, J. See Ames, L.
Rorschach tests, 182190, 192197, 205,
245 246
Rowling, J. K., 203
Rugg, H., 330
339
Sadomasochism, 269 270, 277, 281, 284

286, 289
Safety issues, 274 275, 285
Sander, L., 200, 217
Sandler, J., 172173
Sarnoff, C., 180, 203
Schafer, R., 183
Scientific method, 324 325, 329
Scoring systems, 182183
Secondary process thought, 314 315, 324,
329 330, 332
Self-esteem: dyslexia, 253; latency development, 193, 194, 202, 204; parents, 40; reconstruction process, 300
Selflessness, 48
Self-other differentiation, 218 220, 263
265, 271, 285 286, 288
Self-regulation: aggressiveness, 266, 271;
Cecil (case study), 24 34; challenging
behaviors, 145 147; frightened/disorganized attachment, 105; importance, 11
12; Mia (case study), 8990; parent-infant interactions, 1920, 24 34, 55 56,
135 136; psychic trauma, 287; self-other
differentiation, 217220; state of playing, 257258; traditional evaluation process, 132
Sendak, M., 255 256
Separation-individuation: adolescence,
277; aggressiveness, 282284, 288; Ethan
(case study), 61 64, 70; gender differences, 186 207; latency development,
180 183, 186 207; parent-infant interactions, 218 220
Sexuality: Beccah (case study), 267, 269
270, 272, 276 279, 284 285; as defense
mechanism, 269 270; fantasy formation,
284 285, 288; latency development, 179,
194, 196 198; Natalie (case study), 247
250, 253 254
Shakespeare, W., 322
Shapiro, T., 180, 217
Shepard, B. See Malatesta, C.
Solnit, A., 4
Space/time organization, 136, 142, 143,
145
Stern, D., 14, 112, 200, 218
Stevens, W., 326
Stranger-infant interactions, 2021, 2627,
30 31
Strange Situation attachment test, 16, 90
91, 103 104, 137
Study of Images, The (Stevens), 326
Suicide. See Death anxiety
Sullivan, H., 180
340
Index
Symbolism. See Images, impact of; Mathematics; Poetry

Tanner, J. M., 195, 197
Target, M. See Fonagy, P.
Teacher game, 250, 258
Technique of Child Psychoanalysis, The (Sandler et al.), 172173
Teen parents, 82
Tesman, J. See Malatesta, C.
Testing, psychological, 181, 182185, 244
246
Thematic Apperception Test (TAT), 182
183, 186 190, 192198, 203, 206
Therapists role: Ethan (case study), 53
71; Minding the Baby program, 8284;
state of playing, 214 216, 234 236, 258
260; traditional evaluation process, 130
133; transferences, 51, 79 80, 106 107
Thomas, A., 3
Thoreau, H., 312
Three Essays, The (Freud), 179
To His Coy Mistress (Marvell), 316
Toynbee, A., 319 320
Traditional evaluation process, 130 133
Transferences: Cecil (case study), 32 33;
distance theme, 246 250; erotic interpretations, 309; Ethan (case study), 57
58, 6470; Mary and John (case study),
113, 120 122; negative transference,
173; Nicole (case study), 39; paternal/
maternal transferences, 32 33, 275 282;
psychic trauma, 264 265, 267, 273 275,
287288; reconstruction process, 295
311, 315; relationship issues, 246 250,
254 257; state of playing, 214 216, 235,
258 260; therapists role, 50 51, 79,
106 107; transference complaints, 232
233
Traumatic memory. See Psychic trauma
Triangular frameworks, 135 136
Tronick, E., 9, 15, 120, 218, 219
Tronicks still face experiment, 218, 219
Tuchman, B., 319
Turn-taking structure, 16, 23

Tutors, E., 12
Tyson, R. See Sandler, J.
Unconscious communication, 60
Unconscious foresight, 314, 315, 329, 332
Verbalizations, 231, 235, 242
Video feedback techniques: behavior observations, 13 34, 40 41, 135 137,
142152; family interaction patterns,
131152; microanalysis, 5, 4041, 129
138; nonverbal language, 1213; parentinfant interactions, 712; treatment
methodology, 2123
Vision. See Foresight
Vocal rhythm coordination, 1618, 23, 26,
3031, 36, 39
Vulnerability, 266 267, 268, 272283
Vygotsky, L., 241, 255 257
Waelder, R., 241242
Walker, R. See Ames, L.
Wasteland, The (Eliot), 317
Watson, J., 327
Wechsler Intelligence Scale for Children
(WISC), 244
Wechsler Intelligence Scale for Children
Revised Edition (WISC-R), 182
Weil, A., 217
Weinberg, K., 9
Weiss, J., 329
Williams, M., 180
Winnicott, D. W., 78, 217218, 242, 284
Wolff, P., 3
Words, impact of, 325 326
World Association of Infant Mental Health,
79
Yale Child Study Center, 77
Yale University School of Nursing, 77
Yeats, W. B., 3
Zero to Three, 4, 79

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INFANT-PARENT RESEARCH AND INTERVENTION

Who can tell the dancer from the dance?

Sally Provence, Albert Solnit, Peter Neubauer, and Selma Fraiberg,

Issues of therapeutic efficacy aside, the five papers collectively raise

Chess, S. & Thomas, A. (1986) Temperament in Clinical Practice. New York:

Mother-Infant Research Informs

Clinical Professor of Psychology in Psychiatry, Columbia University; Faculty, N.Y.U.

more than two decades of research on maternal distress,

Mother-Infant Research and Treatment

dural mode of exchange addresses behavioral transactions which are

Microanalytic research describing face-to-face patterns has been

Mother-Infant Research and Treatment

the other, for example, in maternal intrusiveness or in infant temperament difficulty.

arousal regulation styles which affect self-regulation. Each partners

Mother-Infant Research and Treatment

ment-by-moment. Video feedback provides an opportunity for the

Mother-Infant Research and Treatment

tion. Through increasing head aversions, arching, or going limp, this

A key feature of the vocal exchange is a turn-taking structure. Both

Mother-Infant Research and Treatment

Mother-Infant Research and Treatment

reason, infant self-regulation is both a property of the individual and

Mother-Infant Research and Treatment

velop stranger anxiety, the stranger is both a novel challenge and at

may easily collaborate, one proceeding with a standard individual

Mother-Infant Research and Treatment

Mother-Infant Research and Treatment

Mother-Infant Research and Treatment

sions of slight mouth openings, hints of shifts in cheek tonus, which

Mother-Infant Research and Treatment

parted we both felt encouraged by understanding what the difficulty

Mother-Infant Research and Treatment

Mother-Infant Research and Treatment

neutral, more visually engaged, and much more active in initiating

Mother-Infant Research and Treatment

come naturally. I commented that evidently she did not have a

Mother-Infant Research and Treatment

Mother-Infant Research and Treatment

Mother-Infant Research and Treatment

concentrate on a particular modality, and slow it down, whereas in

maternal insecurity make a difference? Infant Mental Health Journal, 19

Mother-Infant Research and Treatment

Fogel, A. (1993). Two principles of communication: Co-Regulation and

Mother-Infant Research and Treatment

Lieberman, A., & Pawl, J. (1993). Infant-parent psychotherapy. In C.

Stern, D. (1995). The motherhood constellation. New York: Basic Books.

The question of what is genuine maternal love was posed by a mother

asked about her position on the different heuristic models of

What Is Genuine Maternal Love?

through maternal reverie (Bion 1962). Disorganized attachment

What Is Genuine Maternal Love?

(Stern et al. 1998)procedural (psychological acts) or symbolic

What Is Genuine Maternal Love?

I felt that the central verbal and affective communication to me in

As I observed this tense baby, I wondered whether there was

What Is Genuine Maternal Love?

Ms Gs response to me in the waiting room suggested that the

In my experience, a mother questioning her babys love for her is