Journal of the Royal Society of Medicine Volume 86 October 1993
Psychoanalytic and empirical approaches to developmental
psychopathology: can they be usefully integrated?
Peter Fonagy PhD DipPsych Freud Memorial Professor, University College London,
Research Co-ordinator, Anna Freud Centre, London, UK
Keywords: psychoanalytic theory; experimental research; developmental psychopathology; intergenerational patterns of attachment
The epistemic problem of psychoanalytic
psychotherapy: the validity of the case study
Data generated in the clinical psychoanalytic psycho-
therapeutic setting bears the dual epistemic burden
of confirming: (a) the analyst's understanding of the
patient; and (b) general psychoanalytic hypotheses
concerning the nature of human development, psycho-
logical abnormality and the existence and the
characteristics of numerous psychic mechanisms.
Freud's conviction that what will ultimately benefit
the patient is the discovery of the truth, led him to
place perhaps undue emphasis upon clinical data, in
particular, the patient's response to interpretation,
cumulatively or singly, as an indicator ofthe validity
of the psychoanalytic enterprise.
After all, his conflicts will only be successfully solved and
his resistances overcome if the anticipatory ideas he is given
tally with what is real in him' (p 452).
Grunbaum2,3, the eminent philosopher of science,
examined his argument in detail and found it, as
philosophers had before him4 5, crucially flawed.
More simply stated, the problem is that, by and large,
clinicians are dependent on their patients' responses
to interpretations and other aspects of the analytic
encounter to validate their view of their cases. Their
criteria for, so called, confirmatory responses may
vary from reliance on symptomatic improvement as
a primary indicator, to a more sophisticated search for
confirmation in the content of patients' associations
following interpretations and elaborating on the ideas
presented to him6 (p 363). The permissive nature of
all such strategies has resulted in an accumulation
of successful psychoanalytic and psychotherapeutic
case reports, which appear to support an array
of psychoanalytic propositions as well as diverse
therapeutic methods. Kazdin7 estimates that over
400 distinct psychotherapy techniques are currently
in use for treating psychological problems: 230 for
children and adolescents with mental disorder alone.
The abundance of clinicians claiming, on the basis of
case reports, that their theory and technique are
indispensable, is the gravest indictment of the logic of
case study methodology. It leaves open the possibility
that an unspecifiable, but possibly very substantial,
portion of coherent psychoanalytic generalizations,
which meet the hermeneutic criteria of consistency
and meaningfulness, are in all probability incorrect.
Correspondence to: Dr P Fonagy, Psychoanalysis Unit,
University College London, Gower Street, London WC1E 6BT,
UK
577
Case reports are the hallmark of nineteenth century Paper presented
clinical medicine which used clinical observation to.Section of
and phenomenology as its primary research tools. Psychiatry,
Behavioural approaches that arose out of twentieth 10 March 1992
century social and human science were antagonistic
to psychoanalysis, and repudiated clinical case reports
as part of the positivist critique of introspection. The
clinical work of psychologists came to be integrated
with experimental research methodology either in
random allocation treatment versus control group
designs or experimental manipulations of treatment
protocols within single-case investigations8. These
methodologies have their own limitations particularly
in attempting to reduce complex human emotional
processes to unambiguous and reliable quantitative
indicators which may appear to do little justice to the
richness of the phenomena they purport to encompass.
Psychoanalysts have taken an appropriately cautious
approach to methodological innovations with the
potential to endanger the fragile psychotherapeutic
process. Numerous features of experimental designs
are simply incompatible with the preconditions for
analytic work. The intrusion of video recording of the
most private of discourses in psychoanalytic sessions
with adult patients is just one example.
Its almost unique emphasis on anecdotal clinical
data, however, left the epistemology of psycho-
analysis and psychotherapy dependent on an out-
moded epistemic paradigm: enumerative inductivism.
Enumerative inductivism, finding examples consistent
with a proposition, is at most an educational device
and not a method of scientific scrutiny. It has been
discredited in many fields of social science because of
its lack of power to eliminate false positive observa-
tions. The almost universal application of this
epistemic tool in psychoanalytic writings has created
a situation where currently, psychoanalysis has no
means of discarding ideas once they have been
proposed and made to sound plausible.
The standard mode of psychoanalytic data acquisi-
tion, the psychotherapeutic treatment process, is
inimical to the consideration of alternative hypotheses.
Simple information overload may explain part of the
problem. Clinicians in the past, for example, have
understandably attributed their patients' positive
therapeutic responses to the therapeutic effects
of those aspects of their clinical work which they
presuppose, on the bases of their favoured theory, to
be most germane, rather than to a host of possible
alternative factors more prominent in other theoretical
models. The complexity of psychotherapeutic clinical
work militates against the ready identification of the
effective components of any one treatment. Clinicians
maintain an exclusive focus on the mental world of
578 Journal of the Royal Society of Medicine Volume 86 October 1993
patients whilst constantly scanning their own sub-
jective reactions to gain access to unconscious
communications from them. They browse through
their theoretical knowledge domain as well as their
store of personal analytic experience, both as patients
and as analyst, in order to evolve an understanding
of the patient's material.
Spence9 draws our attention to how deeply fact and
interpretation are enmeshed in the case study by
comparing it with historical archives. Typical case
reports have a closed texture. They communicate a
unitary story through well chosen anecdotes, narrative
persuasion and singular explanation. They solicit
conviction. Facts are created by assembling a story.
No data are given (deliberately) that could support
alternative formulations. By contrast historical
archives raise more questions than answers and
readily lend themselves to alternative interpretations.
Psychoanalytic data uses argument by authority (ie
it is so because it has been said to be so) which tends
to inflate the status of prevailing theories. We judge
case reports both aesthetically and clinically and then
proceed to confuse the two judgements.
The epistemic weakness of clinical data points to the
need for extra-clinical verification of psychoanalytic
propositions. The assumptions of psychoanalytic
developmental theory require confirmation through
the elaboration of research paradigms borrowed from
the social sciences which permit the elimination or
confirmation of hypotheses. This paper attempts to
illustrate the usefulness of integrating a psychoanalytic
theoretical stance with an empirical approach with
an example from my work with Miriam and Howard
Steele on intergenerational patterns of attachment.
Intergenerational patterns of attachment
The following is an overview of the design and
analysis of an extra clinical investigation with
considerable relevance to psychoanalytic constructs
(for a fuller report see Fonagy et al.'0. The notion
of intergenerational concordance in relationship
patterns has a distinguished history in the psycho-
analytic literature'1-'6.
Fraiberg et al.'2 wrote
In every nursery there are ghosts ... Even among families
where the loved ones are stable and strong, the intruders
from the parental past may break through the magic circle
in an unguarded moment, and a parent and his child may
find themselves re-enacting a moment or a scene from
another time with another set of characters ... While none
has issued an invitation the ghosts take up residence and
conduct the rehearsal of the family tragedy from a tattered
script12 (pp 387-8).
Fraiberg explains that the ghost represents the
repetition of the past in the present. Fraiberg and her
colleagues identify more clearly than perhaps anyone
before them how the conflicted past of the parent will
be repeated with the child.
Fraiberg recognizes that 'history is not destiny',
that we all know parents who manage to overcome
brutality, desertion, poverty and death and yet these
appear not to imperil their bond to the child and the
child's bond to them.
Many maltreated children become effective parents,
despite the considerable risk for intergenerational
transmission of abuse. Laying the basis for the
development of good parenting skills in such children
is one of the most important indications of long-term
resilience. Competent parenting is a critical test of
adult development and an area of great vulnerability
in children who had little opportunity to internalize
adequate models of parenting. Kaufman and Zigler20,
in their comprehensive review, estimate the risk
of transgenerational transmission of abuse to be at
least 30%, three times the risk of transgenerational
concordance faced by the child of a schizophrenic
parent2l.
What does determine whether the conflicted past
of the parent will be repeated with the child? The
predictors identified by past investigations include:
a supportive spouse, financial security, physical
attractiveness, high IQ, positive school experiences,
strong religious affiliations, a sense of efficacy in the
parenting role and a sense of optimism about the
child20,22
Fraiberg et al.'2, tackling the problem from a
psychoanalytic standpoint, argue that the answer to
the question must lie in the defences used by the
parent to cope with a difficult past. Denial ofthe affect
that was associated with trauma and the victim's
identification with the perpetrator are considered
as the two characteristic defences used by abused
parents who are not able to withstand the need to
inflict their own pain upon their child.
Our own hunch is that the quality of the mental
representation ofothers, particularly the complexity of
those representations and the representation of the
self's relationship to them, may be a further important
moderating influence. We decided to pursue this
question in the framework provided by attachment
theory'4'6
The design of the study
Research in this area was substantially advanced by
the development of a semi-structured interview for
classifying the adults' mental representation con-
cerning relationships. Mary Main's Adult attachment
interview23 asks a series of questions and probes
designed to elicit as full a story as possible about the
individual's childhood attachment experiences and
evaluations of the effects of those experiences on
present functioning. The interview starts by asking
subjects to identify five adjectives that would describe
their relationship with mother/father, then elicits
experiences that in the subject's view relate to the
adjectives. The interview goes on to ask about
separations, episodes of illness, injury, possible abuse
and neglect.
The interviews are classified into one of three major
groups: autonomous-secure, designated F for free;
dismissing-detached, designated D; or preoccupied-
entangled, designated E. In transcripts classified as
autonomous the interviewee shows awareness of
his/her past and is moreover aware of how past
relationship experiences link with one's current state
of mind. Thus, they either present a believable picture
of the parent(s) providing a secure base or a highly
coherent account of adverse childhood experiences
which they appear to have moved beyond and gone
some way toward forgiveness of their parents.
Detached individuals idealize their childhood, have
few memories and cannot present a convincing,
coherent picture of their experience. The significance
of negative experiences, to the extent that they are
acknowledged, tend to be denied. In some dismissing
interviews, grandiosity and a devaluing of object
relationships may be most characteristic.

Their interview of entangled adults indicates a the regulation of mental processes underlying social
current preoccupation with childhood experiences,
present anger with the parents and a very muddled
way of speaking. Whilst an insightless and muddled
state of mind is the hallmark of such interviews, an
unconvincing analytic attitude may also appear in
them.
Both types of insecure interviewees (D and E)
share the common characteristic of incoherence. The
following are common features: (1) contradictions
between adjectives (eg loving, warm) offered and
experiences recalled; (2) irrational and bizarre
reasoning; (3) losing the line of the narrative,
irrelevancies; and (4) run-on sentences, sometimes in
excess of 100 words. Typical incoherent narrative is
confused, long, difficult to follow and lacking in
objectivity.
We administered the Adult Attachment Interview
(AAI), along with a number of other instruments, to
100 mothers and 100 fathers expecting their first
child. They were followed up at 12 and 18 months
after the birth of a child (attrition rate < 5%). We used
a second instrument from the attachment field, the
Strange Situation, to operationalize the parent-infant
relationship. Ainsworth's laboratory technique24
referred to in the literature as the 'strange situation'
presents the infant with an accumulation of anxiety-
provoking circumstances which elicit behaviours that
normally cause the child to seek comfort from his
mother. Differences between mother-infant dyads can
be seen after the two brief separations when the child
and mother are reunited. The children tend to react
in characteristic ways.
(1) Approximately half of the infants greet their
mother and seek proximity and/or contact with her
before returning to exploratory play. These children
are classified as securely attached (B).
(2) Roughly a quarter ofthe infants appear to avoid
proximity with the mother. They do not seek contact
with her and what interactions do occur are distant
or they mix strategies of approach with avoidance (A).
(3) A third group, roughly 12%, typically approach
the parent in distress but refuse to be comforted and
continue to display signs of ambivalence, anger or
passivity (C).
(4) A small group of infants show confusion and
disorganization upon reunion with the parent (D).
Longitudinal studies examining the sequelae of the
quality of attachment in infancy have shown, that
security during the flrst 2 years predicts many of the
attributes of well adjusted and resilient children.
These included advantages in: social behaviour25,
affect regulation26 and cognitive resourcefulness27'28.
In the Minnesota Longitudinal Mother-Child Project,
children securely attached at 1 year and 18 months
were rated as more socially competent and higher in
ego-resilience than those with insecure attachment
histories29.
Insecure (anxious, ambivalent or disorganized)
attachment of the child to its parents, on the other
hand, has been identified as an important marker of
psychosocial deprivation, particularly of neglect and
maltreatment30O33. The bizarre and inconsistent
behaviour of the D pattern is most characteristic of
the severely deprived, maltreated child"435. Main
and Solomon36 have described such children's reaction
to reunion as lacking in strategy. Maltreatment
appears to fundamentally jeopardize the organization
and development ofthe attachment relationship and
Journal of the Royal Society of Medicine Volume 86 October 1993 579
behaviour37.
The design of the project called for the administration
ofthe strange situation at 12 months with mother and
at 18 months with father. Sixty per cent of mothers
and 66% of fathers in the sample had F (free/
autonomous), ie secure interviews and 40% and 34%
were rated insecure, ie D or E.
The inter-generational predictions were powerfully
confirmed. Almost three-quarters of the children
whose mothers' interviews, carried out before they
were born, indicated either detachment (D) or pre-
occupation (E), responded to them in an avoidant or
inconsolable way on their return following a brief
episode of separation. This contrasted with 80% of
children of autonomous (F) mothers who responded
by visible reductions of their anxiety when mother
returned. Only 27% of children of detached or
entangled mothers responded this way. This implies
that mothers whose representation of their childhood
is insecure in the third trimester of pregnancy
seem destined to have a child who has an insecure
relationship with them.
A somewhat weaker, yet statistically still highly
significant pattern emerged for fathers. Only 18% of
children with autonomous fathers behaved in an
avoidant or resistant manner towards them upon
reunion whilst half the children of the fathers with
detached or preoccupied interviews did so.
Remarkably, each parent's interview concerning
their own childhood only predicted the child's
attachment classification with them. Only associations
between mother's AAI and infant-mother attachment
and father's AAI and infant-father attachment were
statistically significant (P<0.0001 in both cases).
There was absolutely no indication that the security
status of either parent affected the child's relationship
with the other parent. Father had no observable
influence on the infant-mother relationship and the
influence of mother's security on the infant-father
dyad was also negligible. Nor was there any hint
of an association between the Strange Situation
classification with the two parents once the influence
of parental security had been taken into account.
The interpretation of the results
The strong association suggests that each parent
transmits their representation ofchildhood relation-
ships independently of the actions of the other parent.
On the basis of manifestations of the parent's model
of relationships the child develops and maintains
distinguishable sets of mental representations of
relationship expectations with each of his or her
caregivers. This striking fact is also reflected in the
finding of independence between the strange situation
behaviour of the child with the two caregivers. We
do not yet know if, how and when such separate
internal working models combine to become a general
or global characteristic of the child.
That parents' influence on the child remains specific
at least for the first 2 years may be highly adaptive.
The insulation of the internal working models of
young children allows for the creation of a secure
internal working model alongside one or more highly
insecure ones. We may anticipate that this is the case
for the resilient maltreated child. This is a critical
part of an Attachment Theory account of why the
presence of even a relatively remote, but stable and
responsive figure in the child's early life can be a
580 Journal of the Royal Society of Medicine Volume 86 October 1993
protective factor, foster a secure internal representa-
tion of relationships and contribute to the child's
resilience3843. It appears that even the small child
has the capacity to independently encode, differentiate
and isolate the internal working models of primary
caregivers.
So how is the 'ghost' passed from one generation to
the next? We believe that cross-generational prediction
was possible because attachment security in infancy
is based on parental sensitivity to, and understanding
of, the infant's mental world4". The parents' capacity
to understand their infant is rooted in the construction
of coherent mental representations based on the
parents' own attachment history. The coherence of the
parents' perception of past relationships derives from
having been the subject of accurate observation of
their own mental states as infants and children.
Through those experiences they could develop the
capacity to have a plausible view of themselves and
important figures as essentially human, whose
actions are explained by the presumption of mental
states: thinking, feeling, wishing, believing, wanting
and desiring45,46.
These findings call for replication and extension, yet
the implication is clear: Fraiberg's assertion that
infantile experiences of parents make themselves
felt in the transition to parenthood could be tested
and has received solid empirical support. In more
general terms, psychoanalytic theory and empirical
developmental psychopathology can be usefully inte-
grated33'47-49
It proved possible to 'measure the ghost in the
nursery' because the necessary research tools were
available. The priority for psychoanalytic research
must be to 'tool-up' to develop research instruments
suitable for examining unconscious function. A few
years ago the choice of paradigms was less than
inspiringe. With the development of new technologies
in psychology and the allied fields of neuroscience,
particularly artificial intelligence, the testing of
psychoanalytic hypotheses will become an access-
ible goal. There are cognitive scientists who are
sympathetic to psychoanalytic ideas51'52. They take
the psychoanalytic model seriously, not because their
clinical experience is consistent with psychoanalytic
predictions, but rather because their independently
developed cognitive models fit in with models of the
mind developed by Freud and his followers. Perhaps
it will be cognitive scientists rather than psycho-
analysts, who will ultimately resolve the epistemic
difficulties of psychoanalysis by drawing up boundaries
for psychoanalytic speculations concerning the func-
tioning of the human mind.
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(Accepted 23 February 1993)