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The Contemporary Psychodynamic Developmental

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Article  in  Child and adolescent psychiatric clinics of North America · January 2013

DOI: 10.1016/j.chc.2012.08.002 · Source: PubMed

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 1
2 The Contemporary Psychodynamic
3
4
D e v e l o p m e n t a l Pe r s p e c t i v e
5
6 a, b
Norka T. Malberg, PsyD *, Linda C. Mayes, MD Q2 Q3
7 Q4
8
9 KEYWORDS
10
 Mentalization  Attachment  Developmental psychoanalysis
11
 Developmental psychopathology
12
13
14 KEY POINTS
15
16  There is a shift toward a 2-person psychology approach that informs the understanding of
psychopathology from a developmental perspective.
17
 Advance in the scientific understanding of the intersubjective experience (namely from
18
social neuroscience) has fostered a greater deal of interdisciplinary collaboration and dia-
19 logue between developmental psychoanalysis and other fields.
20
 Attachment theory provides the opportunity for empiric and clinical knowledge to meet
21 and integrate into more cohesive and systemic intervention for children and families.
22
23
24
25
26 THE PSYCHODYNAMIC DEVELOPMENTAL PERSPECTIVE: PAST AND PRESENT
27
28 A developmental perspective has been part of psychoanalytic theory and clinical
29 thinking since its inception. Freud’s “Three essays on sexuality” (1905) outlined his
30 theory of psychosexual phases, introduced the idea of a staged developmental
31 ontogeny for libidinal change and orientation and set the scene for what was to be
32 a continuous reworking and evolution of his ideas in this area. Clinical experience,
33 and later close observation of children in the war nurseries, shaped the theories that
34 Freud, Anna Freud, and their followers put forward. Early on, the theoretical formula-
35 tions were also affected by prevailing concepts and then-current notions from fields
36 such as the physical sciences and neurology.1 However, Freud’s 1895 project seeking Q6
37 a unitary conception of mind and brain was suspended prematurely as a result of the
38 primitive state of neuroscience at the time. This early turning away from the influence of
39 other disciplines and a heavy reliance on insights from clinical practice and clinical intu-
40 ition guided the evolution of psychodynamic theory and its applications during most of
41 the 20th century. This departure from integration with other disciplines also may have
42 contributed to the prevalent perception of psychoanalysis as not adhering to a scientific
43 method for advancement of the field and for not possessing a robust evidence base.
44
45 a
Private Practice, Yale Child Study Center, 147 Bishop Street, New Haven, CT 06511, USA; b Yale
46 Child Study Center, 230 South Frontage Road, New Haven, CT 06519, USA Q5
47 * Corresponding author.
48 E-mail address: norka.malberg@yale.edu

Child Adolesc Psychiatric Clin N Am - (2012) -–-

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2 Malberg & Mayes

49 Abbreviations: PSYCHODYNAMIC DEVELOPMENTAL PERSPECTIVE

50
AAI Adult Attachment Interview
51
CPP Child-Parent Psychotherapy
52 MBT-A Mentalization Based Therapy - Adolescents
53 MBTG-A Mentalization Based Group Therapy for Adolescents
54 PIP Parent Infant Program
55
56 Contemporary psychoanalytic writers in the developmental tradition have identified
57 this turning away from the influence of other disciplines, and almost exclusive reliance
58 on clinical observation and intuition, as a threat to the healthy evolution and survival of
59 a psychodynamic approach to developmental psychopathology in the 21st century.2
60 As a result, they emphasize the need for a radical reappraisal of psychoanalysis’
61 epistemic framework in response to the current trends emerging from developmental
62 psychopathology.
63 Developmental psychopathology focuses on the interplay between normality and
64 pathology. Emphasizing a developmental framework for comprehending adaptation
65 and maladaptation across the life course, developmental psychopathology pursues
66 multiple levels of analysis and a multidomain approach to mapping development.3–5
67 Many of the basic tenets guiding developmental psychopathology are present in the
68 work of pioneers of the psychodynamic developmental tradition, such as Anna Freud.
69 Anna Freud struggled with the complex metapsychological question: What moves
70 development along, and is it inherently progressive and linear?6 It could be argued
71 that in essence, all of the psychoanalytic developmental theories are grounded in these
72 basic tenets: understanding the interplay between normality and pathology; mapping
73 multiple domains developing simultaneously; and taking a life course perspective.
74 The contemporary psychodynamic developmental perspective has set itself the
75 challenging and ambitious agenda of becoming a more explicitly integrative, develop-
76 mental psychopathological model of development from early infancy on through old
77 age. By integrative, we mean several things:
78
79 1. Integration of earlier psychoanalytic theories with contemporary ideas
80 2. Integration of the many disciplines that study development: biology, neurology,
81 cognitive and affective neuroscience, psychology, and education
82 3. Focusing not solely on an individual but also on the many systems that the indi-
83 vidual functions within
84 Contemporary psychodynamic perspectives on development are also systemic,
85 that is, understanding development as an interaction between endowment and envi-
86 ronment (all social support systems surrounding the child). This theoretical shift
87 departs from a classical view in which development is enshrined in stages and regres-
88 sion and psychosexual fixation are interpreted concretely, and moves toward a view of
89 development as a consequence of the continuous interaction between the person (in
90 terms of psychology and endowment) and the environment (in terms of the relation-
91 ship between the person and social systems) To predict development under this trans-
92 actional model, one must examine a system of interactional exchanges and continual
93 restructuring of individual psychology based on these exchanges.7
94 Advances in the fields of cognitive and social neuroscience and genetics have
95 informed this progression toward a more flexible, integrative, and systemic develop-
96 mental psychodynamic approach. In this context, psychoanalytic theory, as pointed
97 out by Fonagy and colleagues (2002),8 provides an essential counterweight to
98 advances in neuroscience and molecular genetics, preventing the oversimplification
99 of the study of mental disorders and normative lifespan development.

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 Psychodynamic Developmental Perspective Q1 3

100 In recent years, different psychoanalytic schools of thought have converged in the
101 effort to formulate psychoanalysis as a relational theory. These approaches share, as
102 a common thread, the belief that the human mind is interactive, that is, inherently social,
103 rather than monadic, and that the psychoanalytic process should be understood as
104 occurring between subjects rather than within the individual. From this perspective,
105 mental life is seen through an intersubjective lens.8,9 This shift over the last 25 years,
106 in combination with the path-breaking work of researchers of infants10,11 documenting
107 intersubjectivity at the outset of human development, has contributed significantly to
108 the emergence of a new brand of developmental psychoanalytic psychology: an inter-
109 actional model, which, although retaining its focus on the investigation of mental
110 processes as experienced and constructed from a subjective perspective, also lends
111 itself to empiric inquiry through the integration of the explanatory lens of other disci-
112 plines including psychology, neuroscience, and genetics. A concrete example is the
113 collaborative work of contemporary psychoanalysts, developmental psychologists,
114 and cognitive neuroscientists in exploring the roots of adult borderline psychopa-
115 thology through the lens of attachment theory and its measurable constructs.8
116 Here the authors highlight seminal contributions in contemporary developmental
117 psychodynamic thinking and the treatment approaches these contributions foster.
118 This new brand of developmental psychoanalysis seeks to produce empiric evidence
119 that informs our understanding of the importance of the quality of the complex inter-
120 actions whereby children and their environments shape each other. It also seeks to
121 bring the empiric approach to the evaluation of treatments developed from the integra-
122 tion of clinical experience, basic research in psychology and neuroscience, and
123 systemic analysis of the child’s environment. Moving away from a monadic perspec-
124 tive to a relational and systemic view has facilitated development of psychothera-
125 peutic interventions in outreach settings, such as schools and prisons.
126
127
CLINICAL APPLICATIONS EXEMPLIFYING THE CONTEMPORARY PSYCHODYNAMIC
128
DEVELOPMENTAL PERSPECTIVE
129
130 An example of contemporary child psychoanalysis is the work of Jack Novick and
131 Kerry Kelly Novick (2010)12 in the United States. Their work, addressing the need for
132 a more defined framework for working with parents, is remarkably relevant in the
133 contemporary context in which an ecological approach to treatment has become
134 indispensable (strengthening all primary social supports surrounding the child) The
135 Novicks have recently coined the phrase emotional muscle (ego strength) to commu-
136 nicate to parents their pivotal role in their child’s ego development. By doing so, they
137 have embraced the challenging task of translating psychoanalytic thinking from a tech-
138 nical language into a language parents and teachers can understand. By helping these
139 adults view the child through a developmental lens, they aim to effect significant shifts
140 in the way the significant adults in a child’s environment understand and respond to
141 a child’s emotional and behavioral struggles from a developmentally informed stance.
142 Another example is found in the work of the Parent Infant Program at the Anna Freud
143 Center. This project illustrates the increased awareness of the need, in the era of
144 increasing health care costs and evidence-based medicine, to tailor the theory and
145 clinical practice of psychodynamic psychotherapy to the needs of specific populations
146 (in this case, parents and their infants) or to use in specific environments to increase
147 efficiency and effectiveness of treatment delivery (hostels, community settings, and
148 prisons). This means that psychodynamic psychotherapy is offered to populations
149 heretofore not always considered amendable to insight-oriented approaches (eg, fami-
150 lies in prisons, single adolescent mothers) and in settings outside the contained and

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 4 Malberg & Mayes

151 controlled consulting room (homeless shelters, prisons). Furthermore, their work
152 reflects a departure from the monadic focus on internal conflicts so prominent in the
153 work of 20th century child psychoanalysts, such as Anna Freud and Melanie Klein.
154 There is a new emphasis on the integration of theory and technique to identify specific
155 components of technique that are particularly effective with specific groups of children.
156 The work of the Parent Infant Project exemplifies a tendency in contemporary child
157 analysis to develop interventions that can be manualized and replicated (2005). This Q7
158 project, nested within the Anna Freud Center’s developmental tradition, integrates
159 the classical components of psychoanalytic intervention, such as the use of interpre-
160 tation and verbalization of conflicting affects, with a relationally based approach to the
161 emotional needs of parents and their infants informed by neuropsychology and devel-
162 opmental psychology.13 The Parent Infant Program model, initially developed within
163 the confines of the consulting room, has now been replicated in hostels and prisons14
164 and represents a real example of the contemporary psychodynamic developmental
165 perspective’s emphasis on integration and of developmental psychoanalytic practice
166 in the trenches. Furthermore, this new brand of psychodynamic psychotherapy, in the
167 words of child psychoanalyst Anne Alvarez, is characterized by “the development of
168 a meta-theory which is more relational, less reductionistic and mechanistic and
169 more able to accommodate novelty, growth, change and the awareness of mind.”15,16
170
171
CONTEMPORARY PSYCHODYNAMIC DEVELOPMENTAL THEORY INTEGRATES THE
172
TRADITIONAL PSYCHOANALYTIC PERSPECTIVE WITH NEW RESEARCH
173
174 The developmental psychodynamic perspective has been influenced and transformed
175 in the last 2 decades by developments in neuroscience,17 an increasing awareness of
176 the clinical applications of attachment theory,8 and the emergence of clinical research
177 focusing on parent-infant interactions.18 These new developments enrich the traditional
178 psychoanalytic developmental perspectives from the work of child psychoanalytic
179 thinkers, such as Winnicott, Mahler, Anna Freud, and Melanie Klein. Their conceptual-
180 izations of the internal world of the child in the context of object relations continue to
181 provide a strong theoretical framework and inform the development of new ways of
182 organizing and integrating insights from both the clinic and research studies.
183 For instance, the contemporary concept of mentalization as elaborated by Bateman
184 and Fonagy19 integrates components of Winnicott’s understanding of the importance
185 of the quality of the first relationship with the evidence provided by contemporary
186 research from the fields of attachment and neuropsychology. In the same way, Mela-
187 nie Klein’s clinical insights into the role of parental projections onto the infant inform
188 the explanatory model of Bateman and Fonagy19 of the dyadic process from which
189 the borderline personality structure emerges.
190 Margaret Mahler’s work (1975)20 regarding the process of separation and individu-
191 ation in the context of the parent-child dyadic relationship provides a frame to observe
192 what contemporary writers such as Stern11 call the relational dance between mother
193 and young child. Finally, when considered in the context of environmental influences,
194 Anna Freud’s understanding of the fluid nature of development, as exemplified by her
195 concept of the developmental line, sets the stage for contemporary transactional
196 models of development.7 Thus, contemporary psychodynamic thinking has been
197 able to incorporate concepts that have emerged from detailed clinical observation
198 and integrate and validate them within a more comprehensive and flexible theoretical
199 working model.
200 Contemporary psychoanalytic developmental theory also emerges from an object
201 relations tradition in which psychological development is viewed as occurring in an

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 Psychodynamic Developmental Perspective 5

202 interpersonal matrix.21 Coming from this interpersonal angle, contemporary develop-
203 mentalists have tapped into the rich vein of research on attachment. The work of
204 attachment researchers such as Mary Main and colleagues 22–24 has provided empiric
205 support to Bowlby and Ainsworth’s original observations regarding the importance of Q8
206 the quality of the primary caregiver relationship. Furthermore, it has enabled contem-
207 porary psychodynamic thinkers to explore innovative ways of integrating empiric find-
208 ings into the design and implementation of clinical interventions.
209 An example of such integration is the work of Alicia Lieberman,25 who developed
210 Child-Parent Psychotherapy, informed by the findings of attachment research and
211 the work of child psychoanalyst Selma Fraiberg,26–28 on the intergenerational trans-
212 mission of trauma. Lieberman’s work has been applied to the needs of specific clinical
213 populations such as depressed mothers of toddlers.29 The interventions described by
214 Toth and colleagues29 focus on preventing the adverse longitudinal impact of maternal
215 depression on young children. This aim is achieved by focusing on the activation of the
216 mother’s reflective functioning found through extensive research to be a strong medi-
217 ator of attachment outcome in children.30 Reflective functioning refers to the mother’s
218 capacity to make sense of her young child’s internal experience by using her under-
219 standing of the child’s mental states (intentions, feelings, thoughts, desires, and
220 beliefs). Healthy capacity for reflective function lets the mother effectively anticipate,
221 perceive, and respond to the mental states driving the child’s behavior. A mother’s
222 reflective function allows her to anticipate, be curious about, and understand (or
223 guess) with more accuracy what the child wants and needs. Another way of thinking
224 about reflective function is that it allows the mother to understand which mental states
225 belong to her and which belong to her child. If all has gone well in her own develop-
226 ment, a mother/parent has the capacity to think of the young child as separate, with
227 his or her own emotional needs and states of mind that are nonetheless highly respon-
228 sive to the parent’s emotional states.
229 Bowlby, a psychoanalyst himself, felt that actual events such as loss and separation Q9
230 and the internal experience of loss/separation, affected the development of the child
231 and the later functioning of the adult. He emphasized the importance of understanding
232 infant-mother attachment as based on a primary and autonomous instinctual system
233 instead of a derivative of the drives. Because it emerged through observations of real-
234 life separations and losses in childhood, attachment theory reflects the emphasis on
235 an integrative view of human development that brings together internal and external
236 experience, relationships among children and adults, and a broader systemic view
237 of a child’s developmental environment.
238 Contemporary clinical researchers, working through the attachment lens and
239 working within the developmental psychodynamic tradition, such as Steele and
240 Steele,31 and Strathearn and colleagues32 have built on the efforts of Mary Ainsworth
241 (1969)33 who operationalized the study of the effect the quality of maternal care has on
242 the development of the child’s patterns of attachment. Ainsworth’s work on patterns
243 of attachment in the Strange Situation and Mary Main’s work on the Adult Attachment
244 Interview34 were pivotal in translating Bowlby’s theoretical contributions into opera-
245 tionalized and empiric language and facilitated a bridge between contemporary
246 attachment research and developmental psychoanalysis.
247 Mary Main’s research using the Adult Attachment Interview34 first suggested that
248 a child’s metacognitive capacity, that is, the ability to reflect on one’s experiences,
249 serves as a significant psychological protective factor. However, many of the
250 follow-up studies35,36 focused on the importance of a mother’s capacity to regulate
251 and organize thoughts and feelings about her own childhood history of receiving
252 care and this capacity’s link to her ability to regulate, organize, and respond sensitively

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 6 Malberg & Mayes

253 to her child’s attachment needs (comfort, safety, and closeness). This was a significant
254 shift toward an emphasis on the impact of the quality of the relationship on the child’s
255 emotional and social development and on defining a developmental environment.
256
257 THE MENTALIZATION CONSTRUCT: AN EXAMPLE OF THE INTEGRATION OF THEORIES
258 AND RESEARCH IN THE EVOLUTION FROM THE TRADITIONAL TO THE
259 CONTEMPORARY PSYCHODYNAMIC DEVELOPMENTAL PERSPECTIVE
260
261 Following on the work of the attachment researchers, Fonagy and colleagues,37 in an
262 attempt to integrate psychoanalytic ideas with emerging findings from the fields of
263 social cognition, neuroscience, and attachment research defined the construct of
264 mentalization, namely, the capacity to understand the behaviors of self and others
265 in terms of underlying mental states and intentions. The mentalization-based ap-
266 proach to psychotherapy has emerged as an integrative model that provides the clini-
267 cian with a new lens through which to observe clinical phenomena and construct case
268 formulations.
269 Mentalization, developed as an empirically testable construct, is measured as reflec-
270 tive functioning, an overt manifestation in narrative of an individual’s mentalizing
271 capacity.30 A primary caregiver who is able to hold on to complex mental states is
272 able to hold her child’s internal affective experience in mind, thereby facilitating her
273 understanding of her child’s behavior with respect to his or her own feelings and inten-
274 tions. The caregiver functioning from this reflective stance imparts meaning to the
275 child’s affective experiences in a way that promotes regulation. In this way, a caregiver
276 fosters emotional security in her child. Mentalization capacity in the caregiver is vital to
277 maintain and facilitate a range of progressive developmental processes in the child.
278 Consequently, the absence of this experience of parental reflective functioning is
279 seen as underlying the development of various forms of psychopathology.8 By opera-
280 tionalizing reflective functioning as a measure of mentalizing capacity and studying the
281 impact of parental reflective function on a child’s development, researchers have
282 shown the importance of the caregiver’s mentalizing capacity in the developmental
283 outcome of the child. This has shifted the attention of child psychoanalysts and psycho-
284 dynamic therapists toward working with parents and the importance of exploring the
285 personal meaning of parenting and how it influences reflective capacities.
286 The emerging field of cognitive neuroscience provides another source of support for
287 the role of mentalization as development progresses in the context of relationships.
288 Specifically, the neurologically based research taken up by attachment theorists8,38,39
289 articulated the role of attunement in early relationships in the development of affect
290 regulation and the capacity to engage in relationships. Strong evidence now shows
291 the negative impact of neglectful or abusive early relationships on development and
292 an association with a diverse range of adverse neurodevelopmental outcomes,
293 including long-term cognitive and academic delays40 and on the overall development
294 of a child’s brain architecture.41
295
296 THE MENTALIZATION-BASED INTERVENTION
297
298 Psychoanalysis is the only psychological treatment which sets itself the ambitious
299 goal of restructuring the components of the individual’s adaptation, and aims to
address all aspects of the patient’s personality. Perhaps because of the scope
300
of its ambitions, attempts at operationalizing the process and outcome of child
301 analysis are at very early stages of development. (By operationalizing, we mean
302 the explicit specification of aspects of the treatment, or of methods of recording
303 information.)42

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 Psychodynamic Developmental Perspective 7

304 Faced with the reality of a need for more evidence to support the efficacy of clinical
305 treatments coupled with demands for shorter yet effective treatments, the
306 mentalization-based approach to psychodynamic psychotherapy seeks to integrate
307 principles from classical psychodynamic theory and technique, such as Anna Freud’s
308 understanding of the developmental nature of psychological defenses, with the
309 contemporary psychodynamic developmental perspective grounded in research and
310 clinical observation. Mentalization-based treatment reflects a trend toward achieving
311 a stronger link between research and clinical practice and an integration of systemic
312 understanding of child psychopathology into psychodynamic thinking.
313 Over the course of the 20th century, no clear definitions emerged to distinguish
314 psychoanalysis from psychodynamic psychotherapy. The easiest distinction made
315 between these 2 modalities had to do with the frequency of sessions (a psychoanalytic
316 case had a minimum of 4 sessions weekly), whereas a psychodynamic psychotherapy
317 intervention tended to range from once per week to twice per week. In addition,
318 although the overall aims of both modalities were guided by the same overarching theo-
319 retical principles, the treatment goals themselves tended to be more ambitious for the
320 psychoanalysis of a child, namely, a more focused effort on structural changes in the
321 psyche. Technique also differed in that the emergence of the transference in the consul-
322 ting room was explored more deeply in psychoanalysis. Psychodynamic psycho-
323 therapy tended to be somewhat more focused on how specific aspects of the child’s
324 functioning obstructed or facilitated progressive development and adaptation to the
325 challenges in the child’s environment. With these distinctions between the 2 common
326 modalities used with children, there are continued efforts to define and operationalize
327 who can benefit from which modality and what the components are that define effica-
328 cious treatments.
329 As an initial response to this need, Fonagy and Target42 carried out a retrospective
330 review of 763 cases of children and adolescents treated at the Anna Freud Center with
331 the aim of exploring the effectiveness of child psychodynamic treatment, but most
332 importantly to determine which children seemed to benefit most from a most intensive
333 psychoanalytic approach. Before this retrospective review, only a handful of studies
334 had attempted to explore the effectiveness of insight-oriented treatments for children.
335 Heinicke and Ramsey-Klee43 had evaluated psychoanalytic treatment for latency chil-
336 dren referred for learning disturbances and academic deficiencies. The frequency of
337 treatment was either 1 or 4 sessions per week or a period at each frequency. The
338 results of that study showed that both intensities of treatment led to gains in self-
339 esteem, adaptation, and the capacity for relationships, but the gains were significantly
340 greater and better maintained for the more intensive treatment. A second study by
341 Moran and colleagues44 examined the efficacy of child psychoanalytic interventions
342 with children with brittle diabetes. A group of 11 patients treated in 3- to 4-times
343 weekly psychoanalytic psychotherapy alongside medical management were com-
344 pared with patients receiving the usual psychological assessment and medical
345 management without any psychotherapy. The group treated with psychoanalytic
346 psychotherapy showed significant improvement in blood glucose control: a strong
347 indicator of the value of the intensive psychotherapy intervention. The psychotherapy
348 had focused on the personal meaning of the illness and its impact on personality func-
349 tioning and development. Central to the work was the development of a reliable and
350 predictable intensive psychotherapeutic relationship.
351 The results of the retrospective study by Fonagy and Target42 suggested that chil-
352 dren with anxiety disorders (with or without comorbidity) showed greater improvement
353 than those with other conditions and greater improvements than would be expected
354 based on studies of untreated outcome.45 More than 85% of 299 children with anxiety

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 8 Malberg & Mayes

355 and depressive disorders no longer suffered any diagnosable emotional disorder after
356 an average of 2 years of treatment. The study concluded that children with severe or
357 pervasive symptoms, such as overanxious disorder, or comorbid disorders benefited
358 from an intensive psychotherapy approach, whereas focused anxiety symptoms, such
359 as phobias or obsessive-compulsive disorder, improved more or less equally with
360 once- or twice-weekly sessions.
361 These studies suggested that the psychodynamic approach to working with chil-
362 dren and adolescents is efficacious and effective. At the same time, these studies
363 also underscored the need for operationalization and specificity of technique. In
364 response to this, during the last 2 decades, psychodynamic treatment modalities
365 have begun to integrate the clinical experience of the 20th century with an operation-
366 alized and, usually, manualized foundation. Mentalization-based treatment is an
367 example of a treatment modality that includes both integrative and evidenced-
368 based developmental psychodynamic framework.
369 Mentalization-based treatment is based on the mentalization construct, that is,
370 understanding one’s own and another’s mental states as measured by reflective func-
371 tioning, as a foundation for a psychodynamic therapy that can be further operational-
372 ized and thus more readily manualized. Most of the interventions included in
373 mentalization-based therapy seek to enhance the child’s capacity to mentalize, but,
374 most importantly, they also seek to activate the reflective functioning capacities of
375 the systems (family, school, hospital) supporting the child in his efforts to achieve
376 progressive development. In other words, the mentalization-based approach with
377 children and adolescents seeks to46–48:
378
 Enhance reflective processes (perspective taking, curiosity, and flexibility)
379
 Strengthen impulse control (affect regulation)
380
 Increase awareness of others as separate and intentional beings (inquisitive
381
stance)
382
 Develop the capacity to play (playfulness and joyful moments)
383
 Work in parallel with, or in the context of, the systems supporting the child to acti-
384
vate reflective functioning (mentalizing the system)
385
386 By taking into consideration the child’s attachment history and his past and current
387 psychological and social functioning, this intervention, developed under a relational
388 developmental approach, seeks to restore developmental progress and strengthen
389 the child’s capacity to function more effectively in relationships. This contemporary
390 psychodynamic approach seeks to accomplish this goal by taking a more focused
391 relational and ecological approach.
392
393
CLINICAL EXAMPLE: REFLECTIONS ON CONTEMPORARY PSYCHODYNAMIC
394
TECHNIQUE IN THE OUTREACH CONTEXT
395
396 As early as 1966, Anna Freud, in her article, “Interactions between Nursery School and
397 Child Guidance Clinic,” highlighted the importance of establishing a dialogue between
398 educators and child mental health providers. She spoke of the benefits of integrating
399 the insights from clinical practice with those coming from education regarding chil-
400 dren’s learning and developmental processes in the context of schools. In the same
401 fashion, she spoke of the importance of establishing further interdisciplinary dialogue
402 with doctors, nurses, lawyers, and social workers.49
403 Contemporary developmental psychoanalysis has continued to develop interventions
404 based on Anna Freud’s goal of integrating knowledge from other fields to inform our
405 practice. For example, recent findings50 linking the impact of early relationships to

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 Psychodynamic Developmental Perspective 9

406 development in the brain provides strong support for one of the basic tenets of the devel-
407 opmental psychodynamic school of thought, that of the importance of the child psycho-
408 therapist as a new developmental object with whom the child can relate in a different
409 way. However, this research also sheds light on the importance of working with parents,
410 teachers, and other people in the child’s social support system to strengthen those
411 relationships in a way that promotes the feeling of well being and growth in the child.
412 The following clinical example is an illustration of this cross-fertilization with other
413 fields and the emergence of specific constructs from attachment theory, which inform
414 our practice, enhancing our capacity to be effective in outreach contexts. This
415 example comes from an early intervention project in the United Kingdom developed
416 under the aegis of the Anna Freud Center and developed by child psychotherapists
417 from the developmental psychodynamic tradition. The project aimed to promote the
418 activation of reflective functioning in parents and teachers by inviting them to reflect
419 on their own experiences and how they influence their understanding and responses
420 to young children’s challenging behaviors. The main goal of the Primary School
421 Prevention Project is to prevent early exclusion from school. Early exclusion usually
422 results from the educational system’s incapacity to contain and manage a young
423 child’s behaviors and emotional difficulties. At the time of referral, the child is observed
424 in the context of school and a series of diagnostic meetings take place with teachers,
425 caregivers, and the child. The relationship between the child, his teacher, and his
426 parents is observed through joint sessions. This evaluation informs the choice of treat-
427 ment modality. The project offers short-term mentalization-based work with the child,
428 parent-child sessions, joint meetings with teachers and parents, and individual parent
429 meetings depending on the diagnostic formulation resulting from the initial meetings.
430
431
432 JOEY
433
434
Joey was referred by his kindergarten teacher. He was a sweet-looking 5 year old,
435
who had recently become unmanageable in his classroom setting. He had begun to
436
hit others and spit at teachers when disciplined, he refused to sit in circle time, and
437
constantly defied the teacher’s authority. His mother, a single 22-year-old woman
438
from Sudan, felt at a loss for how to help her son. At home, Joey was well behaved,
439
helpful, and very mindful of other people’s feelings according to his mother. She
440
described having stomach aches every morning worrying about Joey’s behavior
441
at school and being at work and becoming anxious every time her cell phone
442
rang, fearing it was the school asking her to pick up her child. She was concerned
443
about losing her job as a result, and spoke of her lack of social supports. Ms. Taylor,
444
Joey’s teacher, was a well-intentioned young teacher in her second year of practice
445
who had become increasingly concerned about Joey’s frequent school absences.
446
Before beginning work with Joey, the therapist met with both Joey’s mother and
447
Ms. Taylor to explore their understanding of Joey’s difficulties. In addition, the ther-
448
apist observed Joey’s behavior in his classroom and in the playground. The Child
449
Behavior Checklist and the Strengths and Difficulties inventory were also given to
450
mother and teacher to monitor their perception and understanding of the child’s
451
difficulties. The therapist met twice with Joey and once with Joey and his mother
452
to assess his ego functioning and developmental progress in general. Most impor-
453
tantly, the therapist arranged individual meetings with Joey to try to shed light onto
454
his own understanding of his difficulties and how they influence the way he thought
455
of himself in the context of relationships (eg, bad boy, unlovable?).
456

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 10 Malberg & Mayes

457
Joey related well to the therapist, he appeared contained and able to play and
458
experience moments of shared joy with the therapist and his mother. However,
459
on the playground, he struggled to read his peers’ cues and seemed to be waiting
460
“for the other shoe to drop” as described by Ms. Taylor. Similarly, in the context of
461
the classroom, Joey seemed lost. He misread Ms. Taylor’s feedback as punishing
462
and persecutory, and, in response, he would retaliate by trying to assert his power
463
physically.
464
The psychotherapist arranged weekly mother-child sessions in parallel with meet-
465
ings with Joey’s mother and Ms. Taylor. In addition, the therapist met individually
466
every other week. As the work progressed, it became clear that Joey and his mother
467
were socially isolated, and this had contributed to Joey’s hunger for attention and
468
exclusivity in all his relationships. Ms. Taylor began to communicate more with
469
Joey’s mother and include her as a volunteer in class during her day off from
470
work. In addition, a plan to contain him so as not to call his mother so frequently
471
was put in place, and Joey became part of a playgroup after school for young chil-
472
dren with social skills difficulties. Joey flourished, and his mother became a very
473
involved member of the school community. Ms. Taylor also began to help Joey’s
474
peers to see the “other Joey” by giving him leadership roles in the classroom.
475
This represented a significant shift in her management of the child as she began
476
to be able to reflect on the meaning of his behaviors instead of reacting to them,
477
often in a punitive and, what she perceived as ineffective, fashion. During her
478
consultations with the therapist, Ms. Taylor was able to explore her own emotional
479
responses to Joey and reflect on how they influenced her understanding of the child
480
and his behavior.
481
482
483
484
By providing a supportive reflective (mentalizing) environment for both Ms. Taylor
485
and Joey’s mother, the therapist was able to understand the emotional needs behind
486
Joey’s behaviors. His challenging behavior was a communication to the world
487
regarding his mother’s loneliness and anxiety and his sense of feeling burdened by
488
it. On the other hand, by providing a secure base for his mother to explore her own
489
past experiences and think about the impact of her struggles on her child, the therapist
490
was able to give Joey’s mother an emerging sense of agency (a voice) and activated
491
her capacity to differentiate her own emotional needs from those of her child. As
492
a result, Joey’s mother was able to become a more confident and predictable parent
493
and help her son feel safe and contained.
494
495
496
APPLICATION OF CONTEMPORARY DEVELOPMENTAL PSYCHODYNAMIC THEORY AND
497
TECHNIQUE WITHIN THE CONTEXT OF MULTIMODAL TREATMENT PLANS
498
499 Joey’s case is a good example of how contemporary research from attachment has
500 integrated itself into a strong preexisting clinical psychodynamic developmental tradi-
501 tion. It provides the strength of a clear and evidence-based conceptual framework,
502 one that considers the intrapersonal and interpersonal origins of challenging behavior
503 and psychopathology and is guided by a fluid and flexible model of development. By
504 assuming a systemic approach to clinical formulation and treatment planning, the
505 clinician in this case was able to encourage the process of mentalizing the needs of
506 the child in the family and the school system in the process encouraging a reflective
507 and holding environment for the child and his difficulties.

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 Psychodynamic Developmental Perspective 11

508 Many of the components highlighted through the elaboration of Joey’s case are
509 present in additional models presented in the next sections. The following examples
510 represent only a small sample of a larger shift in the application of psychodynamic
511 developmental principles to the current needs of clinical populations and the social
512 systems supporting them. There is an increasing acknowledgment of the need for
513 interventions that are integrative, systemic, and, most importantly, replicable and
514 accessible. Furthermore, these examples represent a shift from a focus on developing
515 interventions based on work in the consulting room to the development of replicable
516 applications developed based on the needs of specific systems (eg, hospitals and
517 schools) and specific populations (eg, substance abusing mothers).
518
519 CLINICAL INTERVENTION EXAMPLE: THE MOTHERS AND TODDLERS PROGRAM
520
521 The Mothers and Toddlers Program51 is an attachment-based parenting intervention
522 for substance abusing mothers. The program offers a 20-week individual therapy
523 intervention that aims to help substance-using mothers develop more balanced repre-
524 sentations of their children and improve their capacity for reflective functioning. It
525 seeks to intervene individually with mothers to improve their capacity to respond
526 sensitively to their young children’s cues, to respond to and soothe their children
527 when distressed, and to foster the progressive social and emotional development of
528 their children. All of these aims address characteristics of reflective functioning. The
529 therapists focus on the mother’s own expectations for her role as a parent and her
530 own needs as she tries to understand both what it means to be a parent and what
531 her infant/child needs. Before treatment, mothers’ attachment patterns as well as
532 the quality of their attributions regarding their children’s behaviors are assessed. Clini-
533 cians also obtain a baseline measure of children’s behavioral profiles. The intervention
534 seeks to identify and address intergenerational patterns of insecure attachment
535 behavior reflective of the parent’s own troubled, neglectful, or abusive childhood.
536 By tackling intergenerational transmission of representations, this intervention offers
537 the opportunity for a new developmental experience to the parent, one that allows
538 her to consider new ways of responding and interacting with her child and responding
539 to her own feelings as a parent. As shown by the preliminary findings of this project,
540 not only did mothers display improvement in their representational balance and reflec-
541 tive functioning capacities, but their children also showed significant improvements in
542 their behavior and their overall socioemotional development.51
543
544 PEACEFUL SCHOOL PROJECT
545
“Connected, reflective people make safe non coercive communities”52
546
547 The Peaceful School Project is a good example of contemporary psychodynamic
548 interventions serving the needs of children in their communities from a developmental
549 psychodynamic perspective with a powerful systemic lens. Designed to address
550 bullying, its major guiding psychological construct is mentalization. The project
551 focuses on the importance of identifying unconscious power dynamics in the school
552 system and the impact they have on the development of coercive social forces that
553 reduce an individual’s capacity to think in mental states. As a result, behavioral mani-
554 festations (aggressive actions) become the primary way of responding to a collective
555 lack of felt agency within a nonmentalizing culture. This project works with teachers
556 and other school personnel as well as with parents and their children and seeks to acti-
557 vate the capacity to identify what is behind the bullying behavior and shift the response
558 of the home and school environment to the child toward a more mentalizing stance. In

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 12 Malberg & Mayes

559 this way, the project accomplishes an increase sense of agency on all participants and
560 fosters an ethos of “thinking about feeling and thinking about thinking” when con-
561 fronted with nonthinking, aggressive behaviors.
562 Based on empiric evidence from the attachment field, Twemlow and colleagues53 Q11
563 put forward the hypothesis that an integrative approach to intervention can have broad
564 application to the understanding of social problems, such as violence and neglect of
565 young children (eg, by attempting to mentalize the system through active and explicit
566 identification of bullying patterns in the school system using the “helpful bystander”
567 concept). The helpful bystander has the power to play a key role in preventing or stop-
568 ping bullying directly by discouraging the bully, defending the victim, or redirecting the
569 situation away from bullying. This project was able to highlight the impact of feeling
570 recognized (seen and heard) on the child’s capacity for self-regulation. As described
571 by the authors: “feeling recognized as an individual creates an analogue of the secure
572 base experience and permits the activation of associated mental models with confi-
573 dence to experience distress knowing that it will not overwhelm or permanently
574 dys-regulate one’s one capacity to function.”53
575 The project also tackles the question of how to collaborate and work with the sup-
576 porting systems around the child, that is, parents and teachers. The Peaceful Schools
577 Program offers long-term psychodynamic psychotherapy to both children and families
578 and works actively with schools and teachers in identifying the patterns of behavior in
579 staff and attitudes in the system that facilitate the emergence of bullying within the
580 system. By choosing a clearly central construct, such as the concept of mentalization,
581 a capacity central to all psychotherapeutic and human endeavors, the intervention
582 provides clear goals and treatment planning around a main goal, that of activating
583 the reflective capacities of the system and the child through a parallel relational
584 process respectful of the developmental and psychosocial needs of all involved in
585 the process. Furthermore, by creating a common and accessible language for
586 everyone in the system, interdisciplinary collaboration is possible and effective.
587
588 CLINICAL APPLICATION WITH ADOLESCENTS AND THOSE SUPPORTING THEM
589
590 Working clinically with adolescents represents a challenge to the clinician, as many
591 primitive states of minds, loaded with anxiety, are awakened in the clinician as well
592 as in the supporting systems (eg, school staff, parents, pediatricians). Recently,
593 a series of outcome studies have been developed to examine interventions with
594 adolescents informed by both classical and contemporary developmental psychody-
595 namic theory and technique. The authors briefly review the work with 2 challenging
596 subsets of this population: self-harming and chronically ill adolescents.
597
598 An Intervention with Self-harming Adolescents
599 The work of Trudie Rossow in the United Kingdom with self-harming adolescents from Q12
600 a mentalization-based approach has produced valuable clinical insights regarding the
601 importance of integration of modalities when working with self-harming adolescents.
602 One of the landmarks of her intervention is the exploration of what Fonagy has termed
603 the alien self, namely, an internal representation of the self that emerges when a signif-
604 icant portion of it has been developed and experienced in the context of a relational
605 exchange filled with parental negative projections and little experience of a primary
606 object attempting to have one’s mind in their mind and remaining curious and inquis-
607 itive as to the intentions, wishes, and feelings of the child.54 Like many other Q13
608 mentalization-based interventions, Rossow’s work48 seeks to help the young person Q14
609 and his family improve his or her awareness of his or her own mental states and the

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 Psychodynamic Developmental Perspective 13

610 mental states of others. The intervention integrates explicit and implicit techniques for
611 encouraging the reflective capacities of the young person and the family. Family inter-
612 ventions consist of focused and experiential approaches to psychoeducation, insight,
613 and modeling of a reflective and inquisitive stance in the psychotherapist. By working
614 in the “here and now” with the young person and the family, the intervention seeks to
615 provide a new relational experience for the young person and the family. Within this
616 new relational experience, internal representations can be revisited, hopefully result-
617 ing in more coherent narratives of the self in the context of relationships and, most
618 importantly, increasing a sense of agency. With this should come an improved
619 capacity for mentalized affectivity, the ability to think while experiencing strong, acti-
620 vating feelings. Preliminary results show support of the initial clinical hypothesis with
621 significant reduction of young people’s self-harming behaviors and improvement of
622 parent’s reflective capacities46,48
623
624 Working with Chronically Ill Adolescents
625 Like Rossow, Norka Malberg’s group works46,48 with chronically ill adolescents,
626 specifically young people experiencing end-stage renal disease who exhibit difficulties
627 adhering to critical but onerous medical regimes. The mentalization-based group
628 therapy for adolescents approach focuses on activating the capacity for reflective
629 functioning in chronically ill adolescent patients by using a group modality. This 12-
630 week intervention seeks to create a secure base, a relational laboratory, from which
631 to explore the impact of chronic illness on the internal representations of the young
632 patient. The intervention seeks to scaffold the process of activating reflective func-
633 tioning while respecting the defensive structures needed to endure the stress and
634 trauma provoked by the ongoing exposure to chronic illness. The intervention incorpo-
635 rates technical aspects of more classical psychodynamic interventions, such as
636 explicit exploration of defensive strategies and open identification and verbalization
637 of affects. However, the mentalization construct, and the language developed around
638 it, provides a useful conduit for collaboration and parallel processes with parents and
639 health professionals supporting the young person. Parenting groups and discussion
640 groups with nurses in which participants are invited to mentalize around issues of
641 medical adherence in the young patients are run parallel to the group work with the
642 adolescents. Results of an initial pilot study showed significant improvement in bio-
643 logic measures of medical adherence as well as reports of improved quality of inter-
644 actions in the medical unit between parents, nurses, and patients.55 These findings
645 highlight the need for interventions that introduced a clearer developmental under-
646 standing of the emotional needs of chronically ill adolescents but also explore, in
647 a structured and safe setting, the multiple meanings present in the relational
648 exchanges surrounding the patient.
649 These projects, the Mothers and Toddlers Program, Peaceful Schools, mentalization-
650 based therapy approach for self-harming adolescents, and a group therapy program for
651 chronically ill adolescents, are examples of integration of theory and research from
652 multiple disciplines and efforts to operationalize theoretical and technical constructs.
653 Operationalization facilitates replication and promotion of interventions with an increas-
654 ingly firm evidence base. These projects are the product of contemporary develop-
655 mental psychodynamic thought.
656
657
SUMMARY
658
659 Here are reviewed the changes in psychodynamic approaches to child development
660 over the last 8 decades since Anna Freud and others began applying psychoanalytic

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 14 Malberg & Mayes

661 understanding to working therapeutically with children. Although Anna Freud and her
662 colleagues initially were forced to work in real world settings as they helped children
663 during the London blitz, much of the earliest psychodynamically oriented work with
664 children occurred in the consulting room and playroom with careful attention to the
665 meaning of the child’s play and his or her emerging inner world. As psychodynamic
666 developmental theory has evolved and taken on a developmental psychopathology
667 perspective that acknowledges the constant interplay between biology/endowment
668 and experience/environment, child psychoanalysts and developmentally oriented
669 clinicians have once again returned to real world settings, including schools and
670 hospitals, drug-treatment facilities, prisons, and community centers. Additionally,
671 with the incorporation of attachment theory and mentalization perspectives has
672 come a greater emphasis on a systematic perspective and on studying the impact
673 of psychodynamically oriented treatments with children and families, operationalizing
674 treatment approaches, and developing a robust evidence base. Data are accumu-
675 lating regarding the implementation and impact of mentalization-based treatments.
676 Child psychoanalysts and psychodynamically oriented clinicians are using a range
677 of techniques borrowed from different treatment approaches and models of effective-
678 ness. These new models, or approaches, to psychodynamic treatment with children
679 and families or in community settings also necessarily require new approaches to
680 training child mental health clinicians. Additionally, the contemporary psychodynamic
681 developmental perspective offers better opportunities for collaborations across clin-
682 ical disciplines, including developmental psychology and neuroscience.
683
684
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NORKA T. MALBERG, PsyD, Clinical Faculty, Private Practice, Yale Child Study Center, New Haven,
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LINDA C. MAYES, MD, Arnold Gesell Professor in the Child Study Center and Professor of
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