The Psychoanalytic Study of the Child

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. Peter B. Neubauer, M.D.Paul M. Brinich, Ph.D. Wendy Olesker, Ph.D.A. Scott Dowling, M.D. Samuel Ritvo, M.D.Robert A. King, M.D. Robert L. Tyson, M.D.Anton O. Kris, M.D. Fred R. Volkmar, M.D.Steven Marans, Ph.D. Judith A. Yanof, M.D.Linda C. Mayes, M.D.

Kindly submit seven copies of new manuscripts by post

or as an email attachment in MS Word to

Robert A. King, M.D.

Yale Child Study Center

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Phone: (203) 785-5880

E-mail: [email protected]

ThePsychoanalytic

Studyof the Child

VOLUME SIXTY

Yale University PressNew Haven and London

2005

Copyright © 2005 by Robert A. King, Peter B. Neubauer, Samuel Abrams,

and A. Scott Dowling.

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v

Contents

INFANT-PARENT RESEARCH AND INTERVENTION

A. Scott DowlingIntroduction 3

Beatrice BeebeAlbert J. Solnit Award paper:Mother-Infant Research Informs Mother-InfantTreatment 7

Tessa Baradon“What Is Genuine Maternal Love?”: ClinicalConsiderations and Technique in PsychoanalyticParent-Infant Psychotherapy 47

Arietta Slade, Lois Sadler, Cheryl de Dios-Kenn,Denise Webb, Janice Currier-Ezepchick,and Linda MayesMinding the Baby: A Reflective Parenting Program 74

Judith Arons“In a Black Hole”: The (Negative) Space BetweenLonging and Dread: Home-Based Psychotherapywith a Traumatized Mother and Her Infant Son 101

Alexandra Murray HarrisonHerding the Animals into the Barn: A ParentConsultation Model 128

PSYCHOANALYTIC RESEARCH

Nick Midgley and Mary TargetRecollections of Being in Child Psychoanalysis: AQualitative Study of a Long-Term Follow-Up Project 157

Rona KnightThe Process of Attachment and Autonomy in Latency:A Longitudinal Study of Ten Children 178

CLINICAL STUDIES

Karen GilmorePlay in the Psychoanalytic Setting: Ego Capacity,Ego State, and Vehicle for Intersubjective Exchange 213

Lissa Weinstein and Laurence SaulPsychoanalysis As Cognitive Remediation: Dynamicand Vygotskian Perspectives in the Analysis ofan Early Adolescent Dyslexic Girl 239

Silvia M. BellA Girl’s Experience of Congenital Trauma: TheHealing Function of Psychoanalysis in the Adolescent Years 263

PSYCHOANALYTIC PERSPECTIVES ONTHE FUTURE AND THE PAST

Harold P. BlumPsychoanalytic Reconstruction and Reintegration 295

Cornelis HeijnOn Foresight 312

Index 335

vi Contents

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 empha-size the unity of purpose of their authors in furthering parent—young child research and clinical practice and to highlight the varietyof routes they have devised to provide creative and effective interven-tions.

When Peter Wolff (1959) described infant states, the stage was setfor the burgeoning field of infancy research. At about the same time,the important work of Chess and Thomas (1986) on temperamentspelled out more explicitly the notions of Anna Freud and othersthat infants differed constitutionally in their regulatory and reactivestyles—and that these differences had important, fateful conse-quences for the reactions they elicited in their caretakers. The find-ings of this research gradually made it possible to move beyond well-meant but fundamentally authoritarian recommendations for infantcare. This work thus set the stage for research that supports sugges-tions for care based on deepened developmental insight and on anappreciation of individual parent-infant differences.

There seems to be no end to the fruitfulness of infant research as itprovides descriptions of ever more complex competencies and in-nate capacities of infants and details the moment-to-moment interac-tions of infants with others with ever greater precision. There is uni-versal agreement that such studies yield a goldmine of data; there isless agreement about the interpretation of the data and their signifi-cance for development and functioning in later childhood and adult-hood. One area in which these data might be applied is that of par-ent-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 byRobert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).

3

Sally Provence, Albert Solnit, Peter Neubauer, and Selma Fraiberg,were grounded in psychoanalytic earth. One expression of their in-terest was the founding, with others from psychology and social work(and with the support of dedicated philanthropists), of Zero toThree, the foremost interdisciplinary advocacy organization for earlychildhood mental health (www.zerotothree.org/).

It is a mark of the ferment and creativity of the papers publishedhere that, alongside the commonality of their broad psychoanalyticorientation, emphasizing the central place of relationships in humandevelopment, the authors show wide variation in their techniques ofstudying infant-parent interaction, in their conceptualization of theclinical task of intervention, and in their specific techniques of inter-vention. It is our hope that these differing ideas, presented together,will stimulate a productive dialogue concerning both clinical andtheoretical aspects of providing assistance to infants and their par-ents.

The practitioners of parent-infant intervention are pragmatic inte-grationists as they strive to reach the goal of clinical effectiveness inpromoting developmental competence. Building on the techniquesof Selma Fraiberg—and in the grand tradition of providing socialsupport to troubled children and adults—they investigate new rolesfor the therapist, often combining drive/defense and object rela-tions theories in their techniques. The different kinds of dyadic dis-turbances targeted by the interventions described in this set of pa-pers also suggest the first tentative steps toward an implicit typologyor nosology of perturbed mother-infant interaction. From a practicalpoint of view, some of the interventions, such as Slade et al., involvelong-term work with quite troubled mothers who also struggle withpoverty, adversity, and trauma; others, such as Beebe, present short,focused interventions with better functioning mothers who sensedthat their relationship with their infant had become derailed in someimportant way. Two authors explicitly demonstrate the benefit ofcombining elements of modern attachment theory with psychoana-lytic developmental theory. To varying degrees the papers also ac-knowledge or assume integration of psychoanalytic concepts with Pi-agetian 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 (andwhat talents are required of the therapist) remain to be studied, aswell as determining the longer-term impact of the different modali-ties.

4 Introduction

Issues of therapeutic efficacy aside, the five papers collectively raiseprovocative questions about the fashion in which the second-to-sec-ond interactions of parents and their young children, often on anon-verbal level outside of conscious awareness, shape each dyad’senduring patterns of mutual influence and relating, and structurethe child’s internal object representations, affective and cognitiveself-regulation, and characteristic modes of coping with variousforms of instinctual arousal. By opening to scrutiny the fine-grainedstructure and texture of ongoing parent-infant interaction that makeup the quotidian stuff of early childhood life, these studies reveal thesubtle, multifaceted nature of empathic attunement (and the poten-tial derailments thereof). This work continues the long-standing psy-choanalytic agenda of understanding how the child’s mind becomesstructured in the context of mother-infant interactions (Loewald,1978; Ritvo & Solnit, 1958). How the consequences of these veryearly “procedural” (rather than “verbal”) modes of relating (and mis-relating) come to be represented in later childhood or adulthood;how they interact with temperament to shape drive, defense, andcharacter; and how they might be re-experienced and accessed in thetransference or counter-transference are all important unansweredquestions. The ongoing empirical study of these processes promisesto deepen our understanding of the links between psychoanalysisand developmental psychopathology.

For a number of years, researchers interested in infant develop-ment and in parent-infant interaction have made extensive use ofvideo recordings, sometimes reviewed in frame-by-frame detail.Three papers describe the use of such video recordings in researchbut then go on to demonstrate how the same video microanalytictechniques can be used clinically with parents as an aid to insight andas a guide to more effective methods of care. The paper by Harrisonextends these video analytic techniques, developed in infant re-search, to the study of parents in interaction with their young chil-dren.

These five papers are the beginning of a continuing dialogue inthese pages concerning interventions with parents and their youngchildren. It is our personal conviction that these studies are valuablenot only for the assistance they provide to practitioners in this fieldbut also for their contribution to a more adequate empirical studyand integration of physiological (“biological”), drive/defense (“struc-tural”), and interpersonal (“object relations”) perspectives in our un-derstanding of human psychology.

Introduction 5

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: Apsychoanalytic approach to the problems of impaired infant-mother rela-tionships. Journal of the American Academy of Child Psychiatry, 14:387–421.

Loewald, H. W. (1978). Psychoanalysis and the History of the Individual. NewHaven: Yale University Press.

Ritvo S. & Solnit A. J. (1958) Influences of early mother child interactionon identification processes. Psychoanalytic Study of the Child, 13:64–91.

Wolff, P. (1959) Observation on newborn infants. Psychosomatic Med. 21:110–118.

6 Introduction

Mother-Infant Research InformsMother-Infant Treatment*

BEATRICE BEEBE, Ph.D.

*Winner of the Albert J. Solnit Award, 2005

A brief mother-infant treatment approach using “video feedback” is de-scribed. This approach is informed both by psychoanalysis and by re-search on mother-infant face-to-face interaction using video micro-analysis. 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 thePsychoanalytic Study of Subjectivity, N.Y.C.; Faculty, Columbia University Psychoana-lytic Center; Faculty, Columbia Psychoanalytic Center Parent-Infant Program.This work was partially supported by NIMH grant R01-MH41675, the Fund for Psy-

choanalytic Research of the American Psychoanalytic Association, the KohlerStiftung, the Edward Aldwell Fund, and the Laura Benedek Infant Research Fund. Iam grateful for the help of my research team: Caroline Flaster, Donna Demetri-Fried-man, Nancy Freeman, Patricia Goodman, Michaela Hager-Budny, Sara Hahn-Burke,Elizabeth Helbraun, Allyson Hentel, Tammy Kaminer, Sandra Triggs Kano, LimorKaufman-Balamuth, Marina Koulomzin, Sara Markese, Lisa Marquette, Irena Milen-tejevic, Danielle Phalen, Alan Phalen, Jill Putterman, Jane Roth, Shanee Stepakoff,Sandra Triggs Kano, Rhonda Davis, Helen Demetriades, Greg Kushnick, PauletteLandesman, Tina Lupi, Jillian Miller, Michael Ritter, Stephen Ruffins, Claudia An-drei, Emily Brodie, Lauren Cooper, Lauren Ellman, Nina Finkel, Matthew Kirk-patrick, Adrienne Lapidous, Michelle Lee, Sandy Seal, Nicholas Seivert, Hwee SzeLim, and Marina Tasopoulos. I thank Frank Lachmann, Phyllis Ackman, Phyllis Co-hen, George Downing, Juliet Hopkins, Barbara Kane, Lotte Kohler, Ilene Lefcourt,Mary Sue Moore, Wendy Olesker, Lin Reicher, and Johanna Tabin for their clinicalconsultations. I thank my statistical team, Howard Andrews, Karen Buck, Patricia Co-hen, Henian Chen, Stanley Feldstein and Donald Ross. Joseph Jaffe has been an in-valuable consultant and advisor.


7

videotaped interactions which informed the interventions are pre-sented. In the second, knowledge of mother-infant microanalysis re-search informed the treatment, even though videotaping was not anoption. The respective “stories” of the presenting complaints, the videointeraction, and the parent’s own upbringing are linked. Specific rep-resentations of the baby that may interfere with the parent’s ability toobserve and process her nonverbal interaction with her infant areidentified. The mother has a powerful experience during the video feed-back of watching herself and her baby interact. Our attempts togetherto translate the action-sequences into words facilitates the mother’sability to “see” and to “remember,” fostering a rapid integration of im-plicit and explicit modes of processing.

Introduction

more than two decades of research on maternal distress,mother-infant interaction, and infant and child developmental out-comes have shown that infants suffer when a parent is distressed. Attimes parental distress stems from longstanding character psycho-pa-thology. Research on depressed mothers and their infants shows thatthese infants are at risk for insecure attachments and compromisedcognitive outcomes (Murray & Cooper, 1997). Maternal prenatalanxiety has been shown to predict behavior problems in the childrenat age 4 years (O’Connor, Heron, Golding, Beveridge, & Glover,2002). Maternal unresolved mourning has been specifically linked toinfant and childhood disorganized attachment, a form of insecure at-tachment that predicts childhood psychopathology (Lyons-Ruth,1998). But even highly competent parents can become destabilizedunder the impact of illness, loss, or other traumas, such as the loss of the husbands of 100 pregnant women from the 9/11 World TradeCenter tragedy (Beebe, Cohen, & Jaffe, 2002). In addition to mater-nal contributions, infants may also bring their own difficulties to therelationship, 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 psycho-analysis and by research on mother-infant face-to-face interaction us-ing video microanalysis. Two cases are presented. In the first, Cecil,descriptions of the videotaped interactions which informed the in-terventions are included. In the second, Nicole, I show how knowl-edge of mother-infant microanalysis research can inform a treatmenteven when videotaping is not an option. Whereas the implicit, proce-

8 Beatrice Beebe

dural mode of exchange addresses behavioral transactions which areusually out of awareness, the explicit, declarative mode refers to oursymbolic, verbalized narrative. In the discussion, I suggest that themother’s experience during the video feedback of watching herselfand her baby interact, and our joint attempts to translate the action-se-quences into words, facilitates the mother’s ability to “see” and to “re-member,” stimulating a rapid integration of procedural and declara-tive 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, Mar-

garet Mahler, Fred Pine, Anni Bergman, and Paulina Kernberg un-derstood the importance of intervention in the first years of life. Par-ent-infant therapy specifically has been known for several decades,spearheaded by Adelson and Shapiro (1975); Call (1963); Ferholtand Provence (1976); Fraiberg (1971, 1980); Greenacre (1971);Greenspan (1981); Lebovici (1983); Spitz (1965), Lieberman & Pawl(1993); and Weil (1970), among others. Although therapeutic inter-ventions are widely available for young children, mother-infant treat-ment remains less available.The last decade has shown great progress in conceptualizing meth-

ods of intervention with parents and infants. Both psychodynamicapproaches aimed at the mother’s representations and interactionalapproaches attempting to intervene into specific behavioral transac-tions are effective (see for example Brazelton, 1994; Fraiberg, 1980;Field et al., 1996; Hofacker & Papousek, 1998; Hopkins, 1992; McDo-nough, 1993; Marvin, Cooper, Hoffman, & Powell, 2002; Malphurs etal., 1996; Murray & Cooper, 1997; Seligman, 1994; Stern, 1995; vanden Boom, 1995). Many different kinds of mother-infant therapieshave been shown to predict positive outcomes (Cramer et al., 1990).Nevertheless, even in current approaches to mother-infant treat-

ment, the infant is in danger of being the “forgotten patient” (see Lo-jkasek, Cohen & Muir, 1994; Weinberg & Tronick, 1998). Weinbergand Tronick (1998) documented by video microanalysis that the in-fants of mothers with panic disorder, obsessive-compulsive disorder,and major depression were still in distress, even though the mothersreported improvement of their own symptoms with medication andindividual psychotherapy.Our approach to mother-infant treatment integrates psychody-

namic and interactional approaches within the context of feedbackon videotaped interactions. We address the mother’s representationsof and transferences to the infant as well as mother-infant interactionpatterns visible on videotape.

Mother-Infant Research and Treatment 9

Microanalytic research describing face-to-face patterns has beenextensively reviewed (see Beebe 2003, 2000; Beebe & Lachmann,2002; Stern, 1985, 1995). Two treatment cases informed by mircroan-alytic research have previously been presented in Beebe (2003) andCohen and Beebe (2002); see also Freeman (2001).

Face-to-Face Interaction Research

The video feedback treatment method attends to specific patterns ofmother and infant self- and interactive regulation which have beendocumented by three decades of video microanalysis research. Thiswork focuses on face-to-face interaction rather than the regulation offeeding and sleep (but see as an exception Sander, 1977) and is mostrelevant for infants 3 to 12 months. The importance of mother-infantface-to-face interaction for social and cognitive development is ex-tensively documented (see Belsky, Rovine, & Taylor, 1984; Cohn &Tronick, 1988; Cohn, Campbell, Matias, & Hopkins, 1990; Field,1995; Lewis & Feiring, 1989; Leyendecker, Lamb, Fracasso, Scholme-rich, & Larson, 1997; Martin, 1981; Malatesta et al., 1989; Lester, Hoff-man, & Brazelton, 1985; Stern, 1985; Tronick, 1989). This researchprovides a rich resource for the parent-infant clinician, but has nev-ertheless 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 part-ner and regulate inner state, in this view all interactions are a simultane-ous product of self- and interactive regulation, and each form of regulationaffects the other (Gianino & Tronick, 1988; Sander, 1977; Thomas &Malone, 1979). Both the individual and the dyad contribute to theorganization of behavior and experience.Interactive regulation is defined as bi-directional contingencies in

which each partner’s behavioral stream can be predicted from that ofthe other. It is a “co-constructed” process in which each partnermakes moment-by-moment adjustments to the other’s shifts in be-haviors, such as gaze, facial expression, orientation, touch, vocalquality, and body and vocal rhythms. Although the mother has thegreater capacity and range of resources, the infant is a very active par-ticipant in this exchange, bringing remarkable capacities to seek andavoid engagement (Beebe & Lachmann, 2002; Beebe & Stern, 1977;Stern, 1971, 1985; Tronick, 1989). This emphasis on the contribu-tion of both partners to the organization of the exchange avoids thetemptation to locate the source of difficulty in only one partner or

10 Beatrice Beebe

the other, for example, in maternal intrusiveness or in infant tem-perament difficulty.From birth and even in utero, infants perceive durations of events

and temporal sequences (DeCasper & Carstens, 1980). By the timeinfants are 3 to 4 months, when most of this research is conducted,infants perceive the existence and magnitude of contingencies andcan anticipate when events will occur (Haith, Hazan, & Goodman,1988; Jaffe et al., 2001; Watson, 1985). These capacities enable the in-fant to anticipate how each partner changes predictably in relationto the other’s changes, organizing “expectancies” of “how I affectyou,” and “how you affect me.” These infant capacities for the per-ception of sequence, contingency detection, and the anticipation ofevents underlie the generation of procedural, presymbolic represen-tations of interactive sequences (Beebe & Stern, 1977; Beebe, Lach-mann, & 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 “influ-ence” in their usual meanings is accurate. Mutuality usually connotesa positive interchange, but aversive interactions such as “chase anddodge” are also co-constructed, in the sense that each partner’s be-havioral stream can be predicted from that of the other (Beebe &Stern, 1977). The term “influence” can also be misleading becauseno conscious intention to influence the behavior of the partner is im-plied in these contingency analyses (although obviously the parenthas many conscious intentions to influence the infant). It is not acausal process but rather a probabilistic one. The interactions westudy are extremely rapid, with individual behaviors lasting on the av-erage 1/4 to 1/3 of a second; lag times between the onset of one indi-vidual’s behavior and the onset of the partner’s behavior are gener-ally within 1/2 second (Beebe, 1982; Cohn & Beebe, 1990; Stern,1971). Thus many aspects of these interactions occur out of aware-ness, often subliminally; they are “nonconscious,” rather than dy-namically “unconscious” (see Lyons-Ruth, 1998), although again, theparent has many dynamically unconscious motivations as well. Thuswe prefer the more neutral terms “bi-directional regulation” or “co-ordination” to describe these contingency analyses.Self-regulation is just as important as interactive regulation. While

participating in the interactive exchange, each partner must simulta-neously regulate his or her inner state. Both infant and parent bringconstitutional proclivities such as temperamental dispositions and


arousal regulation styles which affect self-regulation. Each partner’sself-regulation capacity and style affects the nature of the interactiveregulation, and vice-versa. Whereas one meaning of “co-construc-tion” is that each partner contributes to the interactive regulation, asecond meaning is that inner and relational processes are co-con-structed (see Beebe & Lachmann, 1998). Thus both partners cometo expect particular interactive patterns, associated with particularself-regulation processes. Infant expectancies of different patterns ofself- and interactive regulation provide one process by which paren-tal distress can be transmitted to the infant and alter the trajectory ofdevelopment.In applying this research to treatment, it is important to recognize

that ranges of “normal” interactions are more ambiguous than ex-tremes of difficulty, and there is no one optimal mode of interaction.Despite extensive research predicting developmental outcomes fromface-to-face interaction patterns, there are no official “norms,” andthis research is still in progress. All dyads use problematic patterns atsome moments, as adaptive modes of coping and defense in the con-text of specific interactive dilemmas.

The Infant’s Nonverbal Language

The use of “video feedback” as part of parent-infant psychotherapystill constitutes a new approach to mother-infant treatment, despitethe fact that Stern (1995; Cramer & Stern, 1988), McDonough(1993), Tutors (1991), and Downing (2004), among others, havebeen using variations of this technique for over a decade (for currentwork see for example Bakermans-Kranenberg, Juffer, & van Ijzen-doorn, 1998; Hofacker & Papousek, 1998; Malphurs et al., 1996; Mar-vin, Cooper, Hoffman, & Powell, 2002; van den Boom, 1995).Video feedback is introduced to the parent as a way of learning

about the infant’s “nonverbal language,” and of becoming aware ofthe ways the parent may respond. Video feedback is a remarkableclinical tool in the hands of an experienced “baby watcher” who isalso a sensitive clinician. Videotape played in slowed time, or frame-by-frame, acts like a “social microscope,” revealing subtleties and sub-liminal details of interactions which are too rapid and complex tograsp with the naked eye in ongoing time. It is difficult for anyone tobe aware of his or her nonverbal behavior. If the video feedback ishandled with great care to protect the parent’s self-esteem, it helpsthe parent to see how both infant and parent affect each other, mo-

12 Beatrice Beebe

ment-by-moment. Video feedback provides an opportunity for theparent to process and reflect on the difficult moments in the interac-tion, 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 de-tails of the mother-infant action language. The infant’s repertoireduring a face-to-face exchange is complex. There is a remarkablerange of behaviors at the infant’s disposal to initiate, maintain, dis-rupt, or avoid a face-to-face encounter (Stern, 1971, 1985). Themother 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 inan infant seat opposite the mother, who is seated in the same plane.Two cameras, one on each partner’s face and upper torso, generate asplit-screen view of the pair interacting.

gaze

We begin by observing gaze. Mothers tend to look at the infant’s facemost of the time, and it is the infant who typically engages in a look-look away cycle, looking at mother’s face for a period of time, look-ing away, and then looking back (Stern, 1971, 1974). As the etholo-gists note, looking into the face of a partner can be very stimulating;most animals do not sustain long periods of such looking unless theyare about to fight or make love (Chance & Larsen, 1996; Eibl-Eibesfeldt, 1970). Field (1981) verified that infants organize theirlook-look away cycle to regulate degree of arousal. She monitored in-fant heart rate during face-to-face play and showed that the momentthat the infant looks away is preceded by a burst of arousal in the pre-vious 5 seconds; following the infant’s gaze aversion, heart rate de-creases back down to baseline within the next 5 seconds, and thenthe infant returns to gazing at mother’s face. Thus infant gaze aver-sion is an important aspect of infant self-regulation. Brazelton, Koz-lowski, and Main (1974) first showed that mothers typically pace theamount of stimulation according to this gaze cycle, stimulating moreas the infant looks, and decreasing stimulation as the infant looksaway. Although these are typical patterns, we have also noted a pat-tern of mutual “eye love” (Beebe, 1973; Beebe & Stern, 1977) inwhich mothers and infants can sustain prolonged mutual gaze for up


to 100 seconds during periods of positive affect. These are the mo-ments, 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 infantswho present for treatment. If the mother feels that her infant doesnot like her or is not interested in her, she may pursue the infant, in-creasing rather than decreasing the amount of stimulation. In herpursuit or “chase,” mother may call the infant’s name, pull the in-fant’s hand, or in rare instances actually attempt to force the infant’shead to get the infant to look. Maternal “chase” behavior is counter-productive; the infant then requires more time to regulate arousaldown sufficiently to return to gazing at mother. Instead, if themother can be helped to give the baby a “time-out” to re-regulate,“cooling it” when the infant looks away, trusting her infant to returnto her, the infant will rapidly re-engage.

head orientation

We next observe infant head orientation to the mother: is the headoriented vis-à-vis, or displaced in the horizontal plane approximately30, 60, or 90 degrees away? In the 90-degree aversion, first describedby Stern (1971), the infant’s head is tucked into the chin, which takesconsiderable energy. Are head aversion movements in the horizontalplane complicated by oblique angles of the head down (or up) aswell? These increasing degrees of head aversion are described byethologists as degrees of severity of “cut-off” acts (Chance, 1962; Mc-Grew, 1972). They are “read” by the partner as active initiations ofdisengagement. As the infant turns away up to about 60 degrees, hecan still monitor the mother with his peripheral vision (trackingpresence, direction, and intensity of movement); by 90 degrees away,or arching, however, he may lose peripheral visual monitoring of hermovements. More usual gaze aversions retain head orientationwithin an approximately 30-degree angle from the vis-à-vis, retainingaccess 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 archingback, freezing (described by Fraiberg, 1982), or going limp and giv-ing up tonus. Beebe and Stern (1977) described split-second se-quences of “chase and dodge” in which maternal chase movementspredicted infant dodges, as the infant monitored her every move-ment through peripheral vision; but infant dodges also predictedmaternal chase behaviors, a reciprocal, bi-lateral interactive regula-

14 Beatrice Beebe

tion. Through increasing head aversions, arching, or going limp, thisinfant had a remarkable “veto power” over the possibility of a sus-tained, mutual gaze encounter.

face

If mother and infant together manage the infant’s look-look away cy-cle so that the infant can comfortably regulate arousal, periods of sus-tained mutual gaze with infant vis-à-vis orientation can be enjoyed.During these periods, facial and vocal communication take centerstage. By 3 to 4 months there is a flowering of the infant’s social ca-pacity. Although the innervation of the facial musculature is myeli-nated before the infant is born, the full display of facial expressionemerges only gradually from 2 to 4 months.The infant’s opening and closing of the mouth is a powerful and

continuous form of communication. Even without any hint of widen-ing or smiling, a fully opened mouth (“neutral gape”) is highly evoca-tive (Beebe, 1973; Bennett, 1971). A fully widened smile by itself,with closed lips, is only moderately positive. As increasing degrees ofmouth opening are added to a smile, positive affect increases up andup into the fully opened “gape smile,” hugely exciting for both part-ners. Mothers intuitively roughly match the infant’s increments, sothat both build to a peak of positive facial excitement. Often bothpartners excitedly vocalize at such moments, further increasing theintensity (see Beebe, 1973; Beebe & Lachmann, 2002; Stern, 1985;Tronick, 1989). In general, mothers and infants tend to match the di-rection of the other’s positive-to-negative affective change, increas-ing and decreasing together (Beebe et al., 2004). Rarely is there anexact match of expression. Elaboration (Fogel, 1993), echo, or com-plementing (Trevarthen, 1977) are better metaphors than matchingor imitation (Stern, 1985). Instead of the more romanticized notionthat mothers and infants exactly match, or are in exact “synch,” Tron-ick and Cohn (1989) have shown that a more flexible process ofmatch, mismatch, and re-match (disruption and repair) character-izes the exchange. Furthermore, a greater likelihood of rapid re-match (within 2 seconds) predicts secure attachment at one year. It isunusual for mothers to display no facial matching at all, particularlywhen infants are distressed. Malatesta et al. (1989) showed that un-usual responses such as maternal joy or surprise to infant anger orsadness predict toddler preoccupation with attempts to dampen neg-ative affect (compressed lips, frowning, sadness). We construe thesepatterns as “failures of facial empathy.”


vocalization

A key feature of the vocal exchange is a turn-taking structure. Bothpartners contribute to turn-taking by matching the brief “switchingpause” as turns are exchanged. Mothers contribute by slowing theirspeech rhythms, providing a great deal of repetition, and matchingthe intonation of the infant’s sounds. Vocal contours refer to the“shape” of the sound. Across cultures, a sinusoidal shape indicatesapproval and a rightward falling shape disapproval (Fernald, 1993).Mothers also optimally pause sufficiently to give the infant a turn. Onthe one hand, mothers who prattle continuously do not permit this;on the other hand, mothers who are silent partners can disturb thedevelopment of vocal turn-taking, an essential building block of lan-guage. When infants present for treatment with difficulty in sustain-ing mutual gaze and the face-to-face encounter, matching the in-fant’s vocal contours and rhythms can be an effective way to makecontact with the infant. Because the infant does not have to orient orto look, approximately matching the infant’s rhythms (vocal or mo-toric) is a non-intrusive way of helping the infant feel sensed: some-one 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 mile-stone in the infant’s development. In the Ainsworth “Strange Situa-tion” attachment test, mother and infant go through periods of freeplay, separations, and reunions (Ainsworth, Blehar, Waters, & Wall,1978). Based on the infant’s reactions, individual infants can be clas-sified as having a secure, insecure-avoidant, insecure-anxious-resis-tant, 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 theenvironment. The insecure-avoidant infant shows little distress atseparation, avoids mother at reunion, and continues to play on hisown. The insecure-anxious-resistant infant is very distressed at sepa-ration, but cannot be comforted by mother’s return and does noteasily return to play (Ainsworth et al., 1978). The insecure-disorga-nized infant simultaneously approaches and avoids the mother, suchas opening the door for her but then sharply ignoring her. Themother herself acts frightened or frightening, and typically has a his-tory of unresolved loss, mourning, or abuse (Lyons-Ruth et al., 1999;

16 Beatrice Beebe

Main & Hesse, 1990). In contrast, secure attachment at 1 year is asso-ciated with better peer relations, school performance, and capacityto regulate emotions, as well as less psychopathology in childhoodand adolescence (Sroufe, 1983).Disorganized attachment at 1 to 2 years is associated with opposi-

tional, hostile-aggressive, fearful and disorganized behavior, low self-esteem, and cognitive difficulties in childhood (Lyons-Ruth, Bronf-man & Parsons, 1999; Jacobson, Edelstein, & Hofmann, 1994).Over 50 studies have shown that the security of the child’s attach-

ment to the parent is dependent on the emotional availability of theparent, using global assessments and clinical ratings (see van Ijzen-dorn, 1997 for a review). Nevertheless, we still lack a full understand-ing of the origins of attachment, its modes of transmission, and therole of the infant (and infant temperament) in this process. Fewerthan a dozen studies have used microanalysis of videotape to predictattachment outcomes.Although infants typically vocalize only about 10% of the time at 4

months, vocalization is such a central means of communication thatthe way mothers and infants coordinate their vocal rhythms predictsinfant attachment. Jaffe, Beebe, Feldstein, Crown, and Jasnow (2001;Beebe et al., 2000) predicted 12-month attachment outcomes from 4-month vocal rhythm coordination, assessed with a technique thatsamples behavior every quarter of a second. As each individual short-ens or elongates the durations of sounds and silences, how tightly orloosely does the partner coordinate with adjustments in his or herown sound and silence durations? Midrange degrees of mother-in-fant and stranger-infant coordination at 4 months predicted secureattachment; very high and very low degrees of coordination pre-dicted insecure attachment classifications.This work led us to conceptualize interactive regulation on a con-

tinuum, with an optimal midrange, and two poles defined by veryhigh (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 threatexperienced by both mother and infant. At the very low pole of coor-dination, both partners are behaving relatively independently of theother, interpreted as a withdrawal or inhibition of interpersonalmonitoring. Although much research literature concentrates on theconcept that lowered interactive coordination is a risk condition forinfant development, a substantial body of work examining both highand low poles is now converging on an “optimum midrange model”


as well (see Belsky et al., 1984; Cohn & Elmore, 1988; Lewis & Feir-ing, 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 mostproblematic of attachment classifications. We interpreted the highcoordination on the part of both partners as vigilance, arousal, or hy-per reactivity. Our research film of Clara at 4 months dramatically il-lustrates a very disturbing mother-infant pair with very high vocalrhythm coordination; subsequently, at one year, Clara was classifiedas showing disorganized attachment. In the research film, Clara iscrying and flailing as the interaction begins. Mother excitedly re-peats her name. Clara’s crying rhythm and mother’s rhythmic repeti-tion of her name synchronize. Mother flashes big smiles at Clara asshe synchronizes with the cry rhythm, as if attempting to “ride” highnegative arousal into a more positive state. Both escalate, Clarascreaming more loudly, mother now frantically vocalizing and mov-ing Clara’s arms. Although most mothers would back off, this motherjust keeps going, and each partner continues to “top” the other. Bythe end Clara has thrown up, sobbing and writhing. In addition tovigilant vocal rhythm coordination, this interaction illustrates “mutu-ally escalating over-arousal,” a disturbance of the ability of the dyadto manage the infant’s distress.The optimum midrange model has direct clinical relevance. Vocal

rhythm coordination is an important means of attachment forma-tion and transmission. Whereas the midrange dyad retains more vari-ability and flexibility, the tightly coordinated dyad is less flexible andvariable. Too much predictability in the system may compromise flex-ibility and openness to change; too little may index a loss of coher-ence (Beebe et al., 2000). These concepts can be used in mother-in-fant treatments as a framework with which to evaluate interactivedifficulties and the process of change, in any modality (not just vocalrhythm), 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 maternalself-report depression and anxiety at 6 weeks and 4 months, mother-infant face-to-face interaction at 4 months, and infant attachment at12 months, in a community sample of 132 families (Beebe, Jaffe,Chen, Cohen, Buck, Feldstein, et al., 2003). Maternal depression andanxiety at infant age 6 weeks or 4 months did robustly affect patterns

18 Beatrice Beebe

of self- and interactive regulation at 4 months, but did not predict in-fant attachment outcomes at 1 year. Instead, it was the quality of the4-month mother-infant face-to-face interaction itself that predictedinfant attachment outcomes. The implication is that, in a communitysample, distressed maternal states of mind at 6 weeks or 4 months donot necessarily lead to insecure infant attachment outcomes unlessthere is also difficulty in the face-to-face interaction. This study pro-vides a further rationale for therapeutically supporting the quality ofthe mother-infant face-to-face interaction when mothers are dis-tressed, which may then prevent later insecure infant attachmentoutcomes. Such an effort is currently underway with the 9/11 wid-owed mothers and their infants, using brief videotape-assisted clini-cal interventions (Beebe et al., 2002).

self-regulation

From birth onward, self-regulation refers to the management ofarousal, the maintenance of alertness, the ability to dampen positiveor negative arousal in the face of over-stimulation, and the capacityto inhibit behavior (Beebe & Lachmann, 2002). Neonates differ intheir ability to regulate state (see for example Korner and Grobstein,1977; Brazelton, 1994). Infant temperament patterns, includingsleep, 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). Disturbancesof infant self-regulation can be noted in patterns of autonomic dis-tress (hiccupping; vomiting) and disorganized visual scanning, aswell as pulling the hair or ear, or a history of head-banging (Tronick,1989). Although maternal touch is a primary means of soothing adistressed infant, and extra handling is associated with diminished ir-ritability (Korner & Thoman, 1972), some infants with difficult tem-peraments 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, typi-

cally at 3 to 6 months of age, state regulation has stabilized and fluc-tuations in the management of an alert state have receded with matu-ration of the nervous system. At this point it is difficult to distinguishbetween infant constitutional processing difficulties that may haveexisted at birth from problematic interactive patterns. Infant tem-perament and self-regulation are already intertwined with interactiveregulation difficulties (see also Hofacker & Papousek, 1998). For this


reason, infant self-regulation is both a property of the individual andof the dyad.A study from our lab using second-by-second microanalysis of

videotaped face-to-face interactions showed that 4-month infantswho would be classified as insecure-avoidant at 12 months were al-ready distinctly different from infants who would be classified secure(Koulomzin, Beebe, Anderson, & Jaffe, 2002). These future “avoid-ant” 4-month infants showed: (1) more self touch; (2) the necessityto self-touch while looking at mother in order to look for durationscomparable to those of secure infants; (3) decreased range of facialexpression, with constriction toward a predominance of neutral; (4)a disruption of the capacity to coordinate gaze and head orientationinto a stable posture while smiling, so that infant gaze at mother oc-curred while head was “cocked for escape”; and (5) more “labile” be-haviors (lasting one second), in contrast to “stable” (lasting 2 sec-onds or more). This study describes infant self-regulation patternsthat are directly useful for identifying infants who are at risk foravoidant attachment. An examination of the mother’s contributionto the interactive process is planned.

distress regulation

Dyads show important differences in infant ability to manage mo-ments of heightened distress, and maternal management of infantdistress. Both partners bring capacities to soothe and dampen as op-posed to escalate distress. Obviously the mother has greater rangeand resources in this process. The pattern of “mutually escalatingover-arousal,” where each ups the ante, was illustrated above. In con-trast, an effective form of distress regulation is a partial or loosely coor-dinated “joining” or matching of the infant’s fuss or cry rhythm, with“woe face” and associated vocal “woe” contours (vocal empathy). Inthis process, the rhythm (but not the volume or intensity) of the cry-ing 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 casesmother and infant first play face-to-face, followed by infant andstranger. The stranger-infant interaction has been shown to be a sen-sitive predictor of infant attachment outcomes (Jaffe et al., 2001)and to discriminate treatment and control dyads (Weinberg & Tron-ick, 1998). Before the end of the first year, when some infants de-

20 Beatrice Beebe

velop “stranger anxiety,” the stranger is both a novel challenge and atthe same time an intensely interesting new partner. On the onehand, most 4-month infants are very sociable with the stranger, to thepoint where often the stranger has an initial advantage over themother. On the other hand, some infants are wary with the stranger,for example the infants of the treatment dyads in Weinberg andTronick’s (1998) study. We assess the infant’s capacity to engage thestranger and, if the interaction is stressful with the mother, the in-fant’s ability to “repair” with the stranger. The degree to which thestranger 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 integrationbetween the two modes” (Beebe, 2003, p. 34). Three orienting ques-tions organize our approach: (1) In the procedural bi-directional“action-dialogue,” how does each individual’s patterns of behavior af-fect those of the partner? (2) In the declarative mode, can the parentverbally 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 thereways in which the parent’s representation of the infant, and the par-ent’s own childhood history, may interfere with the ability to per-ceive 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 preferencethat the first meeting be a lab visit, because I can “see” more with theaid of the videotaped interaction. However if the parent prefers, Istart with an office visit. In the lab, infant with mother, father,stranger, and possibly nanny are videotaped in face-to-face interac-tion.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 asshe or he would at home. Each lab visit is followed within a few weeksby a two-hour feedback session in my psychotherapy office. Thistreatment format is extremely flexible. If a brief treatment is indi-cated, two to four lab visits and accompanying feedback sessions maybe adequate, as in the first case presented below (see also Beebe,2003). If a longer treatment is indicated, the same basic method isapplicable. Or, in the case of a more serious situation, two therapists


may easily collaborate, one proceeding with a standard individualtreatment, and one functioning in the role of the consultant for thevideo feedback consultations (see Cohen & Beebe, 2002). AnAinsworth attachment test, coded by someone blind to the infant’sstatus, is usually included in each treatment, somewhere between 12and 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 thesession, informed by the patterns of regulation documented by re-search microanalyses, described above. In the session I follow theparent’s lead, attempting to construct with the parent the “stories” ofthe presenting complaints and the parent’s own history. This initialpsychoanalytically informed conversation is a critical background toour ability to understand the “story” that unfolds in the videotape.Other important aspects of the parent’s history usually emerge dur-ing or after watching the videotape together. (It is extremely rare fora parent to refuse to view the videotape. In only two of approximately50 cases that I have seen have a parent refused. In those cases I un-derstood the refusal as an index of the level of trauma, and I simplyused my own microanalysis to inform the interventions.)In viewing the videotape I attempt to translate specific details of in-

teraction patterns revealed by microanalytic research into terms thatthe parent can use, based on a psychoanalytically informed view ofthe meaning of the parent’s complaints in relation to his or her ownfunctioning and history, and based on my understanding of any tem-perament or arousal-regulation difficulties the infant may have.Viewing a small portion of videotape, often at the beginning of theinteraction, usually is sufficient. Nonverbal interactions are highlyrepetitive, 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 theways in which this dyad already “finds” each other, enjoys each other,copes with disruptions, and negotiates repairs, is itself a powerfultherapeutic intervention. My first goal is to point out a successful mo-ment, using this example as an entry into learning to observe thesmall micro-moments of the interaction. Together we view the video-tape slowly, trying to see exactly when and how and in what sequenceeach partner oriented, looked, cooed, smiled, or increased a smile byopening the mouth or reaching the head forward. I try to help theparent identify the exact moments where the parent responds to the infant and the infant responds to the parent. My goal is to give

22 Beatrice Beebe

the parent “new eyes” to see the infant’s remarkable nonverbal lan-guage, and the infant’s ability to respond to minute, but neverthelessidentifiable, behaviors. Together we try to describe what we see, find-ing a “new language” for their exchange as well. I encourage the par-ent to put into words what he or she is feeling, and what the infantmay be feeling. Very likely I will play this positive portion severaltimes, at least once in slow-motion.As we proceed I illustrate how evocative minute infant facial ex-

pressions can be, moments when the parent matches the infant’s vo-cal contours, how the parent paces and pauses, facilitating the infant“taking a turn.” I note infant self-regulation and self-soothing behav-iors, and ways the pair manage moments of infant distress, as they oc-cur in the interaction. Having studied the videotape in detail in ad-vance, I will also have selected one or two central difficult interactionpatterns that I would like the parent to be able to see. Together wetry to observe the effects of each partner’s behaviors on the other inthese difficult moments. I again inquire into what the parent felt,what the parent thinks the infant felt, and the meaning these mo-ments have for the parent. It is here that the parent is likely to have aspontaneous insight into the problem. Being confronted with the im-plicit “action-dialogue” in the videotape often triggers the parent’sassociations to aspects of his or her history that the parent always“knew” but could not productively use in the current context withthe infant.Wherever possible I like to use research findings, illustrating with a

drawing, to help parents understand the infant’s behavior, shiftingattention away from “the right way to do it” to infants’ remarkable ca-pacities. I emphasize what this particular infant needs to stay opti-mally engaged. My role is often to give permission to do less, to slowdown, to wait. For example, with an infant who easily becomes over-aroused 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 parent’s childhood history, in an effort to un-derstand what may interfere with the parent’s ability to “see” the in-fant and the interaction. When specific representations of the infant(or “transferences”) seem to interfere with the parent’s ability to“see” the infant and how each partner affects the other, they areidentified. At the end of the session the parent is encouraged to trustwhat has been learned, and to try not to be too self-conscious. An-other videotaped assessment is scheduled in another month or two.


The Case of Cecil

may: first contact

In my first contact with Mrs. C. over the phone she told me that shehad an eight-year-old son and a 9-month-old baby boy, Cecil. Theolder son had always been easier and had seemed to match themother’s temperament. This second baby had been different fromthe beginning. “He is a friendly baby, but he is not focused on mewhen I play with him. Cecil looks past me, unless I energetically try toengage him. He seems happier by himself. He seems more con-nected to the babysitter than to me.” Mrs. C. thought that perhapsCecil needed a higher level of stimulation. Or perhaps she herselfhad disturbed the relationship initially, she wondered, by talking toher older son while nursing Cecil. Or maybe she had never given Ce-cil 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 contactwith me, with excited positive affect, and even had moments of a“gape smile.” The mother then took Cecil, tried to play with himface-to-face, and could not get Cecil to engage. Cecil never evenlooked at her. Mrs. C. said this was typical. Mrs. C. then tried a peek-a-boo game, putting the blanket over Cecil’s head. As the blanket cameoff, there was a moment of brief eye contact, but Cecil emerged fromthe blanket momentarily dazed, with a sober look. He then smiled athis mother briefly, and looked away.My suggestion in this initial meeting was that although the peek-a-

boo game did have a moment of “built-in” eye contact, it did notseem to engage Cecil. Instead of trying to force more contactthrough high arousal games, I suspected she would have more suc-cess if she followed Cecil’s lead for eye-contact, letting him go whenhe looked away, and waiting until he initiated gaze before trying toengage him. I explained that looking away is the baby’s naturalmethod of re-regulating his arousal when it has become a little toohigh. We agreed to do a split-screen lab videotaping, so that I couldtry to see more of the details of the interaction. From what I couldobserve in the office, I had difficulty understanding in more detailwhy 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 theinfant in a high chair. The standard instructions to the mother are to

24 Beatrice Beebe

play with the infant as she would at home. One camera is focused onthe mother’s face, and one on the infant’s face, producing a split-screen view, in which both partners can be simultaneously observed.In my microanalysis of the face-to-face play interaction, I observedthat 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 to-ward Cecil, with abrupt, rapid movements, each accompanied by astrong sound, “gheh!” At each maternal movement, Cecil blinked,with mild startles. Mother then moved into, “What’s that!” showingthe toy, making a series of “ooooh” sounds, and Cecil’s face showed ahint of a smile. As mother continued with, “Say hello, dolly, hello, Ce-cil, hi, baby,” Cecil’s face showed a hint of a slight mouth opening,and then receded into his more characteristic neutral expression, asif 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, andthen looked down. While he was still looking down, mother askedCecil to look at the toy, but Cecil stayed with his head down. Thenmother made an interesting noise, “gurooom!” and got Cecil’s atten-tion. Cecil responded with his own “ghum!”There was then a repetition of the earlier series of mother’s rapid

movements shaking the toy toward Cecil, each accompanied by astrong sound. At each Cecil blinked. Cecil then looked down andaway, 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 strategyin 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 vocalcontour (the contour of approval and flirtation): “Hello, Cecil; and doyou know what else?” This vocal contour is usually reserved for greet-ing, once eye contact has already been made. It was successful in gettingCecil to look at mother, and to pay attention to the new toy, as mothercontinued, “Look what’s here, the dolly, look at her, look at her.”However, just at this moment, Cecil’s face took on a negative frown

expression, and he looked down, moved his head down, thenaverted, moved his head farther down, and then uttered a fussysound. Finally he gave up body tonus and collapsed his head into hisstomach. Simultaneously with the collapsing tonus mother said,“Hello, Cecil” and gently tapped Cecil on the head with the toy. Ce-cil’s head collapsed further into his stomach.


This is a detailed description of approximately the first two min-utes of the interaction. At a more global level of description, in therest of the ten-minute session there were nice moments of mutualgaze, and some interest on Cecil’s part in the toys mother offered.However, often without pausing in her movements, or sounds,mother offered Cecil another toy, and yet another. Periodically Cecilcontinued to collapse, into his stomach, or over the side of the chair,and mother gently tapped him on the head with the toy. When theplay was more successful, there were nice long strings of vocal ex-changes, and the mother beautifully matched the contours of Cecil’ssounds. Several times Cecil showed intense interest and vocal excite-ment in a toy, and mother joined the excited sounds. However, Cecildid not smile. When Cecil became fussy, started to cry and shake hisbody, mother offered more toys.Overall, Cecil was low-key, with his face mostly neutral. Occasion-

ally there were some moments of eye contact, and some nice low pos-itive moments. Mother showed excellent capacity for vocal rhythmmatching, facial mirroring, and following the infant’s line of regardto an object of interest. But she did not give the baby a chance to re-spond, or to organize an interest in the toys on his own, and thus shedisrupted the baby’s initiative. She also disrupted the baby’s arousalregulation, over-arousing the baby by never pausing, offering one toyafter another, and then “chasing” the baby when he averted gaze. Iunderstood Cecil’s difficulty with eye contact and the restriction ofhis facial expressiveness toward neutral as the baby’s attempt to re-duce his arousal toward a more comfortable range, but at the ex-pense 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 increasingthe intensity of the stimulation. Cecil got even fussier, orienting away,averting gaze. Mother then called to Cecil in the “sinusoidal” vocalcontour usually reserved for greeting. Cecil did not respond. By theend Cecil was openly protesting the level of stimulation, very fussy,throwing to the floor all the toys that mother handed him, whilemother never paused.

stranger-infant interaction

Following the interaction with mother, I played with Cecil for threeminutes, while the mother watched the interaction over a TV moni-tor from another room. The infant’s ability to engage with a trainednovel partner is a critical aspect of the assessment. Those babies who

26 Beatrice Beebe

can “repair” the engagement with a novel partner are generally moreresilient, whereas those who generalize the difficulty to a novel part-ner are in more difficulty (see Field et al., 1988). In evaluating this in-teraction, I noted that my tempo was noticeably slower than that ofthe mother. I waited for Cecil to look at me before I attempted to en-gage him. When he did look, he quickly smiled broadly. But then Ce-cil became fussy. When I handed Cecil a toy, he quickly threw it onthe floor, and this was repeated over and over. In the process, Cecilwas 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 fewmoments of eye contact with me, with midrange positive affect, butthese were very brief. Each brief gaze encounter was followed by a se-quence of immediate averting, mild negative facial expression, look-ing down on the floor at an object, and then hanging limp, sidewaysover the chair, body tonus collapsed. Each time I waited, and hecame back into the engagement on his own. Once he looked, he be-came slightly excited, with a positive expression, and then immedi-ately became negative and averted, looking down. My overall impres-sion was that he easily over-aroused. On the other hand, he had thecapacity 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 todiscuss how things were going and to review the videotape. Themother had already watched the tape and she felt bad. She realizedthat she was “trying too hard” and it was not working. She saw me assmoother, quieter. I suggested that as we watched the tape, we couldtry to make quite specific just what she was doing when she felt shewas “trying too hard.” My own goal was to help the mother notice ex-actly what she did, and exactly what the infant did, as each respondedto the other. In essence, I wanted to give her new “eyes,” a new abilityto 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 shewanted, as well as to notice what did not work for her baby. I admiredher facial empathy, her vocal responsiveness, and her well-modulatedvocal contouring (see McDonough, 1993). She was quite surprisedwhen I pointed out the infant’s blinks and startles at the beginning ofthe interaction, in response to her abrupt movements with the toys.She was also surprised to see me point out very subtle facial expres-


sions of slight mouth openings, hints of shifts in cheek tonus, whichcan be expressions of interest and involvement, even when the infantis not smiling.We succeeded in defining the mother’s “trying too hard” as lack of

pausing in movement or voice, trying to get the infant’s attentionwhen he was turned away, and calling the infant in a “greeting” con-tour 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 faceof 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 emo-tionally or what she needed. And now Mrs. C. could see that she wasdoing the same thing with Cecil—setting the pace, and setting it toofast for him.We then discussed my description of Cecil’s face as too neutral,

and I showed her again a section of the videotape illustrating it. I re-enacted for her the face I saw in the baby. Mrs. C. said that all of asudden she saw Cecil’s face as like that of her own mother, who hadalways appeared impassive, hard to read, hard to reach. She saw thatshe now felt the same way about Cecil—that Cecil was hard to read,hard to reach, like her mother. And she saw that she would becomeanxious, and try harder with Cecil, as she had when her own motherhad been so difficult to read. In this interaction, the mother’s abilityto “see” Cecil’s “too-neutral” face seemed to be facilitated by watch-ing the videotape as well as watching my own entry into the baby’sneutral face. Now “seeing” Cecil’s neutral face seemed to trigger herprocedural “motor memory” of her own mother’s face.Together we saw how understandable it was that she could be treat-

ing Cecil the way her own mother had treated her by setting thepace, and that she could be seeing Cecil as like her own difficult andremoved mother. We both empathized with how hard it must havebeen for Mrs. C., as Cecil seemed to become more and more un-read-able. How natural it was to keep trying harder, as a way of reachinghim. And how counterintuitive it was to lower the stimulation, to “tryless hard,” to be slower and calmer, to wait, just when she was feelingmore and more desperate to reach Cecil.We both felt sad over Mrs. C.’s own difficult childhood, and the as-

pects of it that entered into her interactions with Cecil. But as we

28 Beatrice Beebe

parted we both felt encouraged by understanding what the difficultywas. Mrs. C. felt very positive about the experience, and stated thatshe thought she could shift what she was doing with Cecil now. I sug-gested that she try to trust herself with what she had learned, withoutbecoming overly self-conscious or self-critical. We agreed to do a fol-low-up split-screen videotaping and an Ainsworth “separation test” ina couple of months.

august: second filming, 12 months

There had been a long wait in the lab, and technical difficulty de-layed the beginning of the filming. Even without such delays, sittingin a high chair for ten minutes is hard for any active 12-month tod-dler. Once we got started, there was no sound track for a couple ofminutes. In evaluating the interaction, I observed that the motherwas slower and softer, and she paused in between her movementsand her vocalizations. Cecil made more eye contact, and it was moresustained. The mother did not push toys at Cecil; instead Cecil him-self took a toy and explored it, and mother was able to wait. Therewas clearly more room for Cecil’s own initiative.

Microanalysis of First Two Minutes of Mother-Infant Interaction

As the videotape began, Cecil was tired. He had been there a longtime, waiting for us to get going. Without the sound in this section, wesee Cecil rocking his body back and forth in the chair. Mother thenrocked her own body a bit too, matching the rhythm. Mother thenshowed Cecil a doll. Cecil concentrated on it, while mother held itquietly. After a few minutes, Cecil lost interest, and mother showedhim another toy. Cecil took the toy, held it close to his body, exploredit, again while mother waited quietly. Then there was an interruptionat the door. Mother was told that the sound was now working, and wasasked 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 pickedup. The mother was gentle, slow, and held him, but without takinghim out of the chair. Mother made a “woe face,” joining the infant’sdistress, and was very sorry that Cecil couldn’t get out yet. Cecil col-lapsed into his stomach, fussing, and mother matched the distresssounds. Mother then tried some puppet play, moving the puppetvery slowly, and Cecil briefly engaged. Then Cecil was distracted bythe sound of the camera moving, and mother joined his line of re-gard, explaining the noise. Cecil then made another bid to get out,


and mother joined Cecil’s vocal distress with similar sounds, andheld 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 Cecil’s face withher hands and saying, “where is Cecil?” This time the quality was to-tally different: slower and very successful. Cecil emerged smiling, andsustained the positive affect. Then Cecil was briefly quiet, andmother waited. Cecil then heard the noise of the camera again, andmother joined his line of regard, and waited. Now Cecil wanted toget out again, and this time I stopped the filming after seven min-utes. There was nothing the mother did in this second filming thatseemed to interfere with the infant’s capacity to play and to respond.

stranger-infant interaction

We then attempted a stranger-infant filming, but Cecil would havenone 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 Cecilsat in mother’s lap, and mother was instructed to “be the chair,” notto 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 en-gage him with was immediately thrown on the floor. However, atsome point he finally made a vocalization, a “spit” sound. Immedi-ately I matched this sound. And right away he looked at me andmade another, similar one. All of a sudden the whole tenor of the in-teraction had changed, and we were engaged in a fascinating vocaldialogue. As we continued to match and elaborate on each other’ssounds, at some point Cecil began to move his tongue as he made thesounds, and it came out as “la-ler, la-ler.” He was intensely visually en-gaged. I tried making the “la-ler” sound, and we both burst into bigsmiles, and giggled. Variations on this rich vocal dialogue continuedfor the next four minutes. Cecil had been enormously responsive tomy matching his vocalization. Since this form of engagement doesnot require the child to be visually engaged, it can potentially pro-vide a less intrusive or demanding means of making contact. His ownwillingness to elaborate on the jointly formed patterns was critical tothe success of the dialogue.Toward the end of the interaction Cecil began to be tired. Al-

though he had been having a spirited, at times elated, turn taking di-

30 Beatrice Beebe

alogue with me (as he sat in his mother’s lap), when he began to gettired, he arched away into his mother’s body, and avoided me. Butthen he was able to keep coming back to me, and to continue therhythm of the vocal exchange. These movements away from me werehis own self-regulatory efforts to manage his arousal within a com-fortable range. The success of his self-regulation efforts could beseen in his continuing ability to re-engage me, in cycles of vocal dia-logue, disruption, and then repair (see Tronick, 1989; Beebe & Lach-mann, 1994). This aspect of the interaction with me was used as partof the therapy. It was a demonstration of a way to make contact with-out forcing, intruding, or chasing. It also vividly showed the power ofvocal rhythm matching in making contact, since the child does nothave 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 visithad already been too long. Cecil was doing well, and all we needed todo 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 vaca-tion for three weeks and we had a lot of time to spend . . . I totally re-laxed with Cecil. I got to know him better. I stopped my agendas,stopped comparing him to his brother. He is a delightful baby; we arejust charmed by him, he is now so social. I had seen this side of himfrom time to time, but now it has really come out. He is more bondedwith me too, he wants mommy only. He seems terrific. I’m enjoyinghow different he is from his brother.

November

A letter: “You have played an absolutely pivotal role in my life. . . . Tobegin with, Cecil; our connection is deep and easy and full of joy. Heis an absolutely delicious, funny, charming, very loving little per-son. . . . you helped me relax and see him; I stopped focusing on whohe was not and on how he and I were not. . . . So, having discoveredCecil, I fell in love with Cecil. No surprise. . . . In retrospect, my feel-ing of self-reproach was based on some accurately sensed stuff. I intu-itively knew that I was not being with him or being emotionally re-


sponsive to him anywhere near as much as I can be. Now I am, and letme tell you, the difference is not minor.”

discussion of the c. case

We return here to the theme that parent-infant treatment occurs at aunique intersection of implicit and explicit modes of processing andfosters a greater integration between the two.Our three orienting questions provide a framework for conceptu-

alizing the treatment: (1) In the implicit mode of action-sequences,how does each partner affect the other? (2) In the explicit narrativemode, can the parent verbalize the nature of either partner’s effecton the other? (3) And does the parent’s representation of the infantinterfere with the ability to perceive the nonverbal action dialogue?From the presenting complaints it is clear that parents are aware ofsome aspect of the infant’s behaviors, and particularly ways in whichthe 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 one’sown behaviors which affect the infant. Often various representationsof the infant disturb this process further.Addressing the infant’s impact on the mother, Mrs. C. could ob-

serve as well as verbalize that her infant often did not look at her, orsmile 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 mother’s impact on her infant, Mrs. C. had not beenaware of the specific behaviors that we were able to describe together,for example, rapidly moving into the face, not pausing, continuallyoffering toys. Identifying these specific behaviors enabled Mrs. C. toobserve the moments in which they influenced the infant to disen-gage, for example, to startle, look away, collapse into the stomach, orinhibit 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 bothsides of the bilateral effects of each partner on the other. She actedlike her own mother, who had “set the pace,” and her infant seemedto 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 with-drawing from her, but she was not aware of how similar her infant’sbehavior was to that of her own in childhood. Thus she and her in-fant had “re-enacted” an aspect of her own history, the mother whosets the pace and the child who withdraws.

32 Beatrice Beebe

Similarly, the infant seemed to act like Mrs. C.’s own mother, sincethe infant had an “impassive” face, neutral, impossible to read, whichreminded Mrs. C. vividly of her own mother’s face. Mrs. C.’s responseto her own infant’s impassive face was very similar to her response toher mother’s face when she had been a little girl, that is, to becomeanxious and to try harder. Presumably the similarity of this interac-tion with ones in her childhood interfered with Mrs. C.’s ability to seethat her “trying harder” was just pushing her infant farther awayfrom her.These transferences were identified in the process of watching the

videotape. Being presented with the procedural level of action se-quences which are out of the mother’s awareness, presumably be-cause they are connected to painful childhood experiences, facili-tates the mother’s ability to see, and to remember. The mother is beingasked to make a unique integration of procedural and declarative in-formation, in an arena that has been out of awareness due to somekind of unresolved pain. This work allows the mother to shift her rep-resentation, for example, from the baby rejecting her, to the baby asover-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. Atthe outset of the treatment, Cecil could be described as preoccupiedwith self-regulation (looking away, showing lowered level of arousal,constricting the range of the face), with lowered levels of contingentcoordination with mother’s behaviors through facial, visual, and vo-cal behaviors, and with his initiative shut down, body collapsed.Mother could be described as a “high coordinator,” very contingentlyresponsive to the infant’s every move, with excellent facial-mirroringand vocal rhythm matching, but interacting with levels of stimulationthat were too high, with patterns that were spatially intrusive, that dis-turbed the infant’s initiative.Following the videotape intervention, the mother was able to move

from high- to more “midrange” coordination, less vigilantly respon-sive to every infant move. She was able to pause more, do less, wait,tolerate the infant’s disengagement without “chasing,” tolerate theinfant’s distress, and give the infant space to initiate play. Moments ofmatching were interspersed with “waiting” for the infant’s own moves(of self-regulation, or initiative), so that they did not seem “exces-sive,” or imposed. The infant for his part shifted from a “low-coordi-nator” and became more “midrange” in his level of contingent track-ing of the mother, more midrange in facial responsivity with bothpositive and negative expressions rather than a predominance of


neutral, more visually engaged, and much more active in initiatingplay with objects.

The Case of Nicole

The case of Nicole is a useful counterpoint to the Cecil case, which il-lustrates mild maternal intrusion coupled with some temperamentand arousal regulation difficulty in the infant. Nicole, on the otherhand, illustrates a maternal “absence of provision.” Because this fam-ily was from a distant city, and I happened to be traveling nearby, themother-infant pair was not evaluated in my lab, but rather in an of-fice, and they were only seen in person for one extended three-hourevaluation, together with a number of follow-up telephone consulta-tions. Since the problem turned out to be an absence of intimate en-gagement, rather than a complex misregulation of engagement be-tween infant and mother, it was a case in which a detailed videotapeevaluation was luckily not essential. In the Cecil case, I was not able todetect the problem without the videotape microanalysis. In the caseof Nicole, knowledge of the microanalysis research was neverthelessessential to the treatment.Mrs. N. was referred by her therapist, who described her as an anx-

ious new mother, strongly involved in her hard-driving career. Mrs.N. had become worried that her five-month-old baby was not as re-sponsive to her as she was to the Nanny, and she had requested a con-sultation with an infant “expert.” The therapist suggested that Mrs.N. probably had difficulty giving focused attention to her daughterbecause she had never gotten much herself.The first contact was a telephone session. Mrs. N. felt “discon-

nected” from her daughter. She described feeling crushed when shearrived home to see her daughter laughing and giggling with theNanny, but Nicole would not even look at her. “I’ve been going 100miles per hour all day, and Nicole has been with someone laid backwith nothing to do but to be with her. I take Fridays off, and it takesher quite a while to warm up. My husband does not think it is any-thing to worry about. But what will it do to her in the long-term? Ifeel like she does not love me, that I’m not good as a mother, I’m notas natural as the Nanny. How much I need her love. I envisioned adifferent reaction to me. She smiles more to my husband and theNanny 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 toher. Now I want to pick back up the domestic side, but it does not

34 Beatrice Beebe

come naturally.” I commented that evidently she did not have amodel of what it would be like to really enjoy one’s child: her motherresented children and domesticity. It was very understandable that itwould be hard for her to learn. “I don’t measure up to the Nanny;she knows exactly what to do. I don’t mind if she loves the Nanny, butI want her to love me more. It’s my nature to be doing three things atonce. Instead of being able to relax, and take the time to be with her,I’m on the phone. I tell myself, this is her time, don’t pick up thephone.” As she told me this, I sensed the rapid clip of her speech. Icommented on how aware she was that she needed to try to relax andslow down to be with Nicole. “I don’t like myself when I am with her. Ifeel like my mother when she’s running around like crazy and can’tget organized.” I said that evidently she had learned to be like hermother in this, and perhaps it had been a way of being close to herown mother. But now she’s not so happy about it, and she’s trying tohelp herself change it. We then discussed exactly what happens whenshe comes home from work. She nurses Nicole when she comes in,but the infant will not look at her. “Maybe it’s because I always hadthe phone in my ear when she was nursing. Have I hurt her now? Canit be fixed? Would I have had a better relationship with her if I hadbeen different? She did not deserve a mother like me.” And then shecried.I empathized with her agony over feeling that she had disturbed

her relationship with Nicole. I told her how important it was that shehad taken the step of calling me, and that she was struggling to find away to slow down to be with Nicole. She lamented that she did not doit right, and that she had been stupid. I said that we needed to find away of re-righting this without blaming. She responded that I had abeautiful 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 in-volved. This was the only contact in which I actually saw them in per-son because of the extremely long distance involved. Nicole at 5 1/2months was a big girl, and heavy. Mrs. N. propped her up at one endof the couch with a toy. As she was settling Nicole in, the infant’s bodyarched 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. Thebaby played with the toy, putting each different part of it in hermouth, quite placid and self-sufficient. She never looked at hermother or at me, nor did she look around the room, while her mothertalked to me about her work schedule and her dilemma of work vs.home life.


Nicole then needed her diaper changed. She had a large bowelmovement. Mrs. N. was gentle, solicitous, and managed it well. NowMother and Nicole were together on the couch, and Mrs. N. showedme a “pull-to-sit” game that she plays with Nicole, a game that herfriend had taught her. The baby clearly knew the game, anticipatingthe moves with her body, but she did not look at her mother, her faceshowed no animation, and at the last moment before attaining thesitting position, her head oriented up and 30 degrees away from thevis-à-vis. Mrs. N. then held Nicole lying across her lap on the infant’sback. This was the nicest connection they made, slow, both bodies re-laxed, both looking at the other, but without smiling. Mrs. N. thenbegan to talk about how terrible she felt: “Have I hurt her, what willbe 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 wasthe amount of time that she worked, as much as finding a way tomake a connection with Nicole. I explained that first I needed to playwith her to try to see her range of responsiveness. Nicole chortled,with high positive affect, sustaining long gazes with me. She was mar-velously socially engaged. From this interaction it was clear that thedifficulty was not an incapacity on the part of the infant. Evidently,the social engagements with her Nanny and her father were goingwell.I then set about trying to teach Mrs. N. how to engage Nicole. The

first thing I taught her was vocal rhythm “matching,” making soundscontingent on the baby’s sounds, both matching and elaborating onthe intonation, pitch, and rhythm. I chose this first because the childdoes not have to make eye contact in this mode of relating. Mrs. N.’ssounds were thin and squeaky. She did not give the sounds a robustprosody, she could not elaborate on them, and she did not put anywords to the sounds. She did not seem to know how to play. Icoached the sounds from the sidelines. Eventually the sounds shemade were adequate to make some contact with the baby. Nicole ori-ented to her a bit more, and returned some of Mrs. N.’s sounds withher own, beginning a rudimentary vocal dialogue. But Nicole did notlook 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 matchsome of my faces (gape smile, mock surprise). I tried to get her tomove her face in ways similar to the ways I moved mine (small incre-ments of open mouth, open a little more, then a little more; moving

36 Beatrice Beebe

the upper lip in and out of a purse etc.). She was unable to play withher face; her face was tight, flat, and unvarying. I then had the idea ofshowing her how to unlock her jaw, and how to massage her face. Iasked her if she would be interested in trying this. She agreed. In thisprocess she had an association to her mother’s angry, tight face, andshe became a little teary. I suggested that her reaction to hermother’s angry face was expressed in her own facial tightness andconstriction. She was receptive and felt sobered by this idea. The at-tention to the behavioral details of the procedural level, particularlythe constriction, seemed to trigger her representation, which wecould 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 herwhole body arched away from her mother. The infant made ab-solutely no eye contact. Gradually I taught Mrs. N. to slow down andto make some slow rhythmic sounds, and to do vocal rhythm match-ing if Nicole made any sound. When the infant would give her a darting glance, I taught her to give an exaggerated mock surprisegreeting. 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 par-

tial smiles to her mother. The gazes were not sustained. But Mrs. N.had a direct, powerful experience of getting some more responsefrom her baby. She could see that she was getting somewhere. She ex-pressed relief and gratitude that I had validated that something waswrong. I reminded her of the many things that were right as well: shehad a very gentle and affectionate capacity to hold Nicole and tofeed her, she did have some games she played with the infant, andmost of all, she wanted more contact with her.Ten days later we had a telephone session. “Now I make it totally

Nicole’s time when I get home. If I can slow down, we can connectbetter. 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 ex-pect her to demonstrate affection and attachment. When I don’t getit, I get worried. Sometimes she does not make any sounds, so I can’tmimic her.” I asked her if she could start it with occasional sounds ofher own. “My husband can walk in the room and connect with herright away. He is like the Pied Piper. It is hard for me. I feel bad that Idon’t connect the way he does. If I don’t get a lot of feedback, I feelunliked.” I asked if there was then a danger that she would feel re-jected and withdraw. She agreed, yes, very much. She then reportedthat Nicole is not as avoidant as she was: “She looks at me, she


watches, though she does not smile. She can concentrate on my facethough, that’s new.” She told me that Nicole was right there with her,looking at her face right now. I suggested she try a mock surprise ex-pression right now, and she did. I waited a moment while Mrs. N.played with her. She reported that Nicole looks but she does notsmile. “She will watch me now if I do interesting things with my face.But I noticed that if I’m tense I close my face up.” I said that it waswonderful that she was trying to engage her child with her face, andthat Nicole was clearly beginning to respond. I congratulated her onbecoming so aware of her own face, and able to notice when shecloses 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. I’m trying to getready, I’m in a hurry, and I do a dancing conversation in front of herface, all speeded up.” I commented on Mrs. N.’s increasing ability tonotice what she does and to see if it is disturbing Nicole’s ability toconnect with her. She then asked, “Have I lost my chance? When Ileft you, I felt so bad, and angry; I missed my chance. I should havestayed 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 “sinusoidal”-shaped “hello,” she and I saying it to each other, and she reportedthat Nicole was looking constantly at her while she made the sinu-soidal sounds.Then I asked her about feeling angry. She said that she was angry

her husband wasn’t encouraging her to quit work, and she was angrythat 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 donot have a good relationship with Nicole. She lights up for my hus-band. She is so responsive to the Nanny. But what you are saying tome is, it’s not too late for me to connect. I’ve never felt so insecure inmy life.” I empathized with her fear and distress. Then I told her howterrific it was that she was holding on to her hope to connect withNicole, 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 seeeach other in person because she and Nicole were doing so well: “Iam getting so much feedback from her, I am relaxing a little. Shesmiles more, looks more. I don’t feel crazy anymore. All of a suddenshe has started really vocalizing. The biggest thing you said was, focuson her. When I’m with her, I’m just giving her all my attention.”A telephone session one month after the initial three hour session

38 Beatrice Beebe

in person: “She’s wonderful, she’s happy, she’s more vocal, more ex-pressive, she’s really relating to me. Occasionally we have a badevening. But I’m more comfortable around her. I may be doing moreof her language. I try to slow it down for her. If I’m rushing, I noticeit. Then I just hand her to the Nanny, because I don’t want her tosense it. I imitate her sounds, but not all the time. If she initiates, andI respond, and make it even bigger, then she laughs.” I tell her howwonderful all this is, how thrilled I am that things are so much better.“I think we’re 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 mis-take not to come for a second consultation in person, and I said no, Ididn’t think so, because things were going so much better. We agreedthat she would call me if she had any more concerns. She thankedme profusely. I told her that it was so remarkable how quickly she andNicole were able to turn things around.

discussion of the n. case

This pair illustrates an absence of maternal provision of the usual “in-fantized” facial and vocal behaviors that engage infants in face-to-faceplay. Presumably the more adequate “provision” of the Nanny andthe father had to this point safeguarded the overall social develop-ment of Nicole. The mother’s frozen face and inhibition of maternal“play” behavior required me to figure out how to get the action-sequences going, how to “prime the pump.”Mrs. N.’s immediate transference to me in the first telephone con-

tact as having a beautiful voice set the stage for me to “provide” some-thing that seemed to have been absent for her. By teaching her spe-cific ways of engaging the infant, that is, vocal rhythm matching,vocal contouring, facial mirroring, and “cooling it” when the babylooked away, it is possible that she experienced a “provision” fromme. 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 thephone.The key to unlocking Mrs. N.’s capacity to mother Nicole was the

discovery of her traumatic reaction to her own mother’s face, whichwas then “carried” in a procedural form through her inhibition ofher own face with Nicole. In retrospect, the vocal modality proved tobe easier for Mrs. N. to develop with Nicole. Since the vocal modalitydid not require Nicole to look, it was initially easier to reach Nicolethis way. But Mrs. N. had also been so responsive to my voice, fromthe very first contact, and she carried on most of her relationship


with me over the telephone. It may be that the voice was a “non-trau-matized” mode for Mrs. N., compared to the face (M.S. Moore, per-sonal communication, August 18, 1999).

Discussion

Many different approaches to mother-infant treatment yield dra-matic progress (see for example Cramer et al., 1990; Fraiberg, 1980;Seligman, 1994; Stern, 1995) (but note that controlled clinical trialsare rare). Although the use of video feedback is growing, threedecades of microanalysis research on the mother-infant face-to-faceexchange is surprisingly under-utilized in current treatment ap-proaches. Microanalysis of behavior allows us to perceive the detailsof interactions which are usually too rapid to grasp with the nakedeye. These details provide the clinician with the ability to translatethe parent’s presenting complaints into specific behaviors which canthen be understood as an unfolding “story” of the relationship. Withthe additional perspective of the dyadic systems view of communica-tion (despite the mother’s obviously greater ability and range of re-sources) the clinician can continually attempt to understand howeach partner contributes to the exchange, how each affects theother. And the clinician can notice how the self-regulation strategiesand styles of both partners affect and are affected by the nature ofthe interactive exchange. With this perspective, for example, nega-tive interactions such as “chase and dodge” or “mutually escalatingover-arousal” can be seen as reciprocally responsive co-constructedforms of engagement. This systems view helps us remain empathic tohow 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 clinician’s sensi-tive ability to construct jointly with the parent a description of the ex-change, to help the parent use the behavioral details of the videodrama as a springboard for memories and associations, and to linkthe stories of the presenting complaints and the parent’s own historyto the video drama, form the core of the treatment. The clinician’scareful attention to the parent’s self-esteem, particularly feelings ofshame and humiliation, is essential.

The video feedback method does not disturb the dyad while they in-teract. Later, when the parent and I view the videotape, it is simulta-neously “immediate” and visually concrete, as well as somewhat “dis-tant” and safer, in that it is not happening right now (Lefcourt,personal communication, July 7, 1998). In the video replay we can

40 Beatrice Beebe

concentrate on a particular modality, and slow it down, whereas inthe live interaction all modalities, as well as words, flood the senses.Since the visual information speaks on its own, the therapist is free toemphasize different aspects, to underscore the positive elements aswell as identify derailments (Tabin, personal communication, Sep-tember 10, 1998). Because the mother is usually so motivated to en-gage her infant, she can make an effort to overcome any natural awk-wardness at seeing herself. We rarely know what we really look like aswe interact. Seeing oneself on videotape may operate like a “shock”to the unconscious, “perturbing” the system (Milyentijevic, personalcommunication, June 26, 1998; Kohler, personal communication,October 23, 1998). This “shock” may be part of the emotional powerof the video feedback method. The therapeutic viewing promotes acapacity to observe oneself in interaction, to think about the emo-tions seen in the video, and to reorganize representations (Beebe,2003, p. 45).

Both parents in the two cases presented felt that the treatment vali-dated their sense that “something was wrong.” Mrs. N. was able topersist in trusting her discomfort even though her husband did notthink there was a problem. This vague discomfort is the parent’s abil-ity to sense the impact of the implicit procedural mode and enablesthe parent to seek treatment. But the meaning of this discomfort isnot usually recognizable without help (Tabin, personal communica-tion, September 10, 1998). Procedurally organized interactive mem-ories that are unrecognized and unsymbolized often come to play arole in shaping the action-language of our intimate interactions aswell as the representations of our intimate partners. The psychoana-lytically oriented video feedback method goes directly to the core in-teractional dynamic that is out of awareness and provides a safe for-mat in which this dynamic can be verbalized and reflected on. Theparent can become more aware of the infant’s “mind” as well as herown (Fonagy et al., 2002). In this process implicit, procedural aspectsof the parent’s mode of relating to the infant which have remainedout of awareness can be translated into explicit, narrative forms ofunderstanding.

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46 Beatrice Beebe

“What Is GenuineMaternal Love?”

Clinical Considerations and Techniquein Psychoanalytic

Parent-Infant Psychotherapy

TESSA BARADON

The question of what is genuine maternal love was posed by a motherstruggling to understand and value the nature of her bond with hersmall baby. The question surfaced time and again in the context of thisdyad’s long-term parent-infant psychotherapy and has challenged meto examine my thinking and, indeed, has produced impassioned dis-cussions within the Parent Infant Project team at The Anna FreudCentre. In this paper I will address this question through sessional ma-terial of this mother and baby and discuss issues of technique in re-sponse 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 re-search) at the Centre; practicing therapist and supervisor, and writes and lectures onapplied psychoanalysis and parent-infant psychotherapy. Member of the Associationof Child Psychotherapists and the Association of Child Psychoanalysis, Inc.The Parent Infant Project team—Carol Broughton, Jessica James, Angela Joyce,

and Judith Woodhead—have provided valued collegial consultation during thecourse of this work and on the paper. I also want to thank Dilys Daws for her interest-ing comments.


47

asked about her position on the different heuristic models ofthe mind, Anna Freud replied: “I definitely belong to the people whofeel free to fall back on the topographical aspects whenever conve-nient and to leave them aside and speak purely structurally when thatis convenient” (Sandler with Anna Freud, 1981). Parent-infant psy-chotherapy is a meeting point for the different disciplines addressinginfant development: psychoanalysis, attachment, and neurobiologi-cal research. In facilitating our understanding of the ebb and flow ofthe therapeutic construction, Anna Freud’s advocacy of conceptualflexibility in the aid of clinical expediency is often helpful.The therapist working with young babies growing up in an envi-

ronment of intergenerational deficits needs to understand the qual-ity of mothering and the baby’s predicament. Psychoanalytic con-cepts of “good enough parenting” and maternal failure, attachmentparadigms of “security” and “disorganization,” and neuropsychologi-cal discussion of relational trauma are useful frames of reference. Yetthere is an additional ingredient to do with love, captured by the pa-tient in her question: How can we integrate love into scientific andclinical discussion?“Genuine maternal love” for the mother who asked the question

was defined by selflessness. My clinical work has convinced me thatthe love of a mother for her infant and of a baby for his motherneeds both measure and passion. It contains the temperate—that 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 mother’s narcissistic love of herself in thebaby, her adoration of “His Majesty the Baby” (Freud 1914), and hercapacity to tolerate her hatred of her “bondage” to him (Winnicott1949). Thus, her identification with her baby and yet her ability todifferentiate between herself and her baby and allow individuation(Mahler et al. 1975) are required. Only then is the baby able to safelylove his mother, in the sense of moving from relating to object-use(Winnicott 1969) and development of a sense of self as real. At thesame time, “love” is not a static concept. In this paper I attempt to de-scribe the development of this mother’s love, matched by changes inher baby’s expressed love for her, and the interventions that mayhave contributed to this process.“Maternal failure” in psychoanalysis refers to intrapsychic pro-

cesses in the mother which violate their infant’s state of going-on-being, such as projection and attribution resulting in distortion ofself (Silverman and Lieberman 1999), failure to protect the infantfrom impingements (Winnicott 1962), inability to contain the infant

48 Tessa Baradon

through “maternal reverie” (Bion 1962). “Disorganized” attachmentdescribes a collapse of adaptive strategy when the infant is fright-ened, seen to develop in the context of mother’s unresolved traumaand lack of reflective functioning thereof (Lyons-Ruth 1999, Fonagy2001). “Relational trauma” depicts the neuropsychological disregula-tion of the infant in a situation in which danger emanates from theattachment relationship wherein the mother (a) disregulates the in-fant and (b) withdraws repair functions (Schore 2001, Perry et al.1995, Tronick and Gianino 1986), leaving the baby in an “intenselydisruptive psychobiological state” for extended periods of time(Schore 2001, p. 209). In this paper I consider those aspects of ma-ternal “failure” and relational trauma that resulted from the moth-er’s inability to meet her baby with passion and reverie. This in-cluded the negation of herself in him, dis-identification with his stateof dependency, and projection into him with consequent distortionof 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 intersubjectiveneeds? From the observation of babies in this predicament, this ma-ternal failure appears catastrophic. The infant patient, so danger-ously dependent on his mother’s/caretaker’s capacity to identify andunderstand, expresses extreme anxiety, fragmentation and, finally,retreat. Because the anxiety is embedded in their relationship—of-ten underpinned and driven by intergenerational patterns of relat-ing—it is enduring. Therefore the concept of cumulative trauma(Khan 1963), the repeated breaching of the adaptive and defensivestructures available to the immature ego, is pertinent.Extreme maternal depression can constitute a situation of rela-

tional trauma. Green (1986) discusses a situation where there is amutative transformation of the mother from a live, vital presence to adead detachment from her infant, and the trauma this inflicts on thebaby. This is a particular situation where the infant has had an earlyperiod of resonance and lost it in the face of maternal loss and de-pression. 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. Psychi-cally they display the “dead baby complex”—a decathexis of the ma-ternal object and apparent identification with the dead mother (Bol-las 1999). These babies lie slumped and blank. They seem careless ofthe maternal presence or non-presence beside them and appearnon-present in their own bodies. Their precocious defenses of avoid-

“What Is Genuine Maternal Love?” 49

ance of emotional engagement with the mother, freezing and disas-sociation (Fraiberg 1982, Perry 1997, Schore 1994) put them in astate of unrailed/derailed development. I suggest that this was thepredicament 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 par-ent and baby for the baby’s development. As an applied techniquewithin the psychoanalytic framework it has its roots in the ground-breaking work of Selma Fraiberg and her colleagues (Fraiberg 1980,Lieberman and Pawl 1999). In recent years a model has been devel-oped at the Anna Freud Centre (Baradon 2002, Baradon et al 2005,James 2003, Woodhead 2004), the defining feature of which is theuse of the analytic mind to scaffold the affective experiences and rep-resentations of parent and infant in relation to each other. Interven-ing at the procedural as well as declarative levels of self organization,the aim is to create meaning through validating and cohering theparent’s experience and responding to the baby’s requirement foran attentive, adult mind to meet his developmental and attachmentneeds.In our model, the therapist straddles numerous roles in relation to

her patients, both individually and collectively. She is a clinical “ob-server” (Rustin 1989), using observation as a mental stance and atechnique to inform her understanding of the parent’s and baby’s(emergent) mental models of attachment relationships. She is, inparallel, an analytic therapist, employing psychoanalytic frames ofreference and techniques in the work with what is manifest and con-scious in the room and with the hypothesised unconscious fantasiesand defenses underpinning these. Inevitably, she is a transferencefigure for the parent, sometimes benign but also at times perceivedas hostile and/or persecutory. The therapist is a “new object” (Hurry1998), offering a revitalizing attachment experience to parent andinfant. As a new object for the baby, the therapist is also a “develop-mentalist,” supporting the infant’s development through providingcontingent responses, stimulation, and regulation where the parent,at least temporarily, is unable to. In cases of severe maternal depres-sion and withdrawal the therapist may also be the only “live com-pany” (Alvarez 1992) for the child, providing the functions of “en-livening, alerting, claiming and reclaiming” (p. 197). Having thetherapist to love, until the mother is able to receive and scaffold hislove, may be pivotal for the baby’s psychic survival. And finally, thetherapist is an external affect regulator of the patients’ disregulated

50 Tessa Baradon

states, particularly crucial in light of research suggesting that exter-nal regulation of the infant’s immature developing emotional sys-tems during critical periods may influence the experience-depen-dent 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 therapist’s past and pre-sent attachments. The actual presence of an infant in the room in-tensifies the sense of immediacy and clinical (and of course legal) re-sponsibility toward the baby. With at least two, and often three,patients present—infant, mother, and father—the therapist’s atten-tion and receptivity are often pulled in different directions and heridentifications may shift between the infant and parent, challengingthe analytic stance. As always, the therapist’s countertransference isused and must be watched—her own hopes and despair, riven identi-fications between mother and baby, and her rescue fantasies. Aboveall, the therapist needs to maintain sufficient emotional resonancewith the mother, in the face of the acute emotional pain and helpless-ness of her infant. Without this there is no way for mother to empath-ically recognize the real infant as opposed to the infant within herwhom she often treats with cruelty.In the case under discussion, where the baby’s early attachment

needs were thwarted by his mother’s failure to embrace him with“genuine” love, considerations of clinical process and techniquewere particularly charged. On the one hand, mother sought the as-cetic and altruistic (A. Freud 1937) virtue of “genuine” love, devoidof all narcissistic investment and reward, and her severe depressionwas compounded by a sense of failing her own standards. On theother hand, her infant son was starved for the maternal appetite ofownership and adoration, and his experiences of going-on-beingwere distorted by her projections and hostility. These experiences oftrauma for both baby and mother required ongoing scaffolding andregulation from me, the therapist, and I needed to be alert to thechallenge to my capacities for “reverie” in my various roles and fromwithin.Thus the matrix of intersubjectivity, transference, and counter-

transference was extremely complex. It raised minute-by-minutequestions of technique. Which patient/what material should be priv-ileged at any given time, and in what domain of relational knowing


(Stern et al. 1998)—procedural (psychological acts) or symbolic(psychological words)—would the communication be most effec-tive?

Clinical Material

Ms G was referred by her obstetrician just before her baby was due,with concerns about her depressive mood. A psychiatric report at-tached to the referral mentioned a long-standing history of eatingdisorders and self harm, and a number of attempted suicides requir-ing hospitalizations, the latest one year previously. Consequent uponthe concern about this troubled young mother and her baby, a net-work of health and social service support was put in place.Ms G was in a stable relationship with D, the baby’s father. How-

ever, Ms G requested to attend without her partner, explaining that Dreassured her that she is a good mother and that she needed herfears to be heard and not brushed aside. Although we ask to includefathers in the therapy where possible, I decided it was important toenable this mother to indeed be “heard” in her request and to ex-plore the possibility of including the father after we had established atherapeutic alliance. In the course of the therapy father did becomeinvolved, but in this paper I will not discuss the work done with thetriad. 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 thetime of referral, we only met 3 weeks after baby Ethan was born. Avulnerable baby, he had required special care in the early postnatalweeks 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 mewith her face averted. She spoke in a near whisper, her low voice andwithdrawn facial expression camouflaging much of the terriblenessof what she was saying.

Ms G explained that she had never thought she would have childrenas she was afraid that she would damage them. I wondered whetherat the same time as being afraid to have a baby she had also perhapshoped for one. Ms G thought not. She explained that the likelihoodof conception was low as she has irregular periods because of her eat-ing disorder. I asked how she had felt in her pregnancy and she saidshe had not wanted it, and had continued smoking and bingeing.

52 Tessa Baradon

She had felt that the fetus was a parasite. She felt very guilty aboutthis. I asked whether these kinds of thoughts were continuing. At thisquestion Ms G became distressed, saying that she feels that she is“forced by him into an artificial position . . . of trying to be a goodmother, who loves her child and takes care of him.” Ms G said shedoes not feel like that much of the time. She added that she wouldnot harm him physically.Somewhere early in this conversation Ethan fretted a bit. Ms G im-

mediately picked him up with extreme care and held him to her, hislittle body slumped against the palm of her hand. She checked withme whether she could feed him. She snuck him under her shirt, care-ful to keep her breast hidden. The “feed” was quickly over and Ethanwent on sleeping. Ms G removed him from the breast and coveredherself up.We spoke about attending parent-infant psychotherapy. I won-

dered what she was hoping to get. She replied that she wanted a “fil-ter” so that her feelings don’t all come out on Ethan. I noted that Iwould not have been able to tell from her facial expressions and toneof voice when disturbing thoughts toward Ethan intruded during thesession, and that from this I could tell that she was really trying tokeep a tight grip on her feelings. Ms G reiterated her fear of damag-ing him through her depression as her mother, too, had been de-pressed and unavailable. I suggested that we would attend to boththe good things that happen between her and Ethan, such as hergentle 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 inthis session was Ms G’s sense of being damaged herself and, throughher very being with her baby, of damaging him. Her state of primarymaternal preoccupation had a particular quality to it: hypersensitiveto the baby via herself, it seemed that projection did not aid her to“feel herself into her infant’s place” (Winnicott 1956, p. 304) but thatthe infant was equated with her, as a disturbed extension of herself(King 1978). Moreover, his critical early hospitalization, in which herdread of damaging a child was actualized and exposed, seemed tohave been a trauma which confirmed a psychic equation betweenher inner and external worlds (Fonagy and Target 1996; Target andFonagy 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 behandled with care. On the one hand, I struggled with my own needto establish some contact with her averted face, as I strained to hearher whispers. I felt responsible for her very life, as I imagine rescueworkers feel in response to the sounds of life after disaster. In this


process of projective identification I assumed the omnipotence at-tributed to the “caregiver” in relation to the infantile self. At thesame time I was acutely aware of the danger-in-contact ricochetingbetween us during the session, manifested in her whispers and cau-tious handling of Ethan. My association was to a sea of shards inwhich any movement could be calamitous. Only later did I realizehow her history of self-cutting had penetrated my subconscious.Thus, from the beginning this was a dyad with whom I engaged in anintense and worried way, responding perhaps to her unconscious in-vitation to assume this mantle.In the second session Ethan, now 4 weeks old, was awake, a tiny lit-

tle thing with big blue eyes and a peaky face.

Initially he slept on his mother’s lap, fists tightly clenched. Ms Gstroked his hands but he did not relax his fists. A few times she priedthem open and stroked his palms. Ethan’s eyes flicked open when heheard a door slam and he started crying. He seemed to move quicklyinto a loud cry, with no fretting or working up toward the upset. Hecried hard. Ms G put him to the breast and he sucked, then fellasleep. She put him on the mat and he opened his eyes. I spoke tohim about his experience being in a big room and hearing mystranger voice and not knowing where it came from. Ethan staredfixedly toward the ceiling lights above him. After a while he turnedhis head slightly in his mother’s direction, and I confirmed that thatwas where his mummy was.

As I observed this tense baby, I wondered whether there washeightened sensitivity to invasive stimuli (lights, noise), carried overfrom the weeks in the special care baby unit. I also wonderedwhether he was already reacting to the conflicted and disregulatedquality of maternal emotion, transmitted and received through theministrations of care. His ordinary going-on-being seemed to bepunctuated with periods of disassociation—as expressed in fixing onthe lights, and “falling forever”—as 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 maternallove.We had 6 more sessions over the following 6 weeks leading to the

first break. The sessions acquired form and pace. Ms G sometimeslooked my way and I found it less of a strain to hear her. Ethan movedbetween brief periods of wakefulness and prolonged periods ofsleep. I found myself accommodating to their muted tone, character-istic of depressed mothers and their infants (Bettes 1988), by damp-ening my spontaneity, speaking slowly, riding the silences. But in-

54 Tessa Baradon

creasingly I also found my way to address the affects expressed ver-bally and in behaviors. Wary of the sadism of her superego and themasochism of her submission to it, I took care to acknowledge nega-tive affect as conflictual, and positive interactions were noted withouthollow reassurance that she was doing well. With Ethan I was rela-tively active, representing his mental states and communications, of-fering contingent responses, linking him up with his mother. I triedto balance offering myself to him for use as “live company” withawareness of Ms G’s envy of what she perceived I had to give Ethan,and which she had never received. At times indeed I felt rich in re-sources, 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 thewaiting room after the 2 week break, Ms G gave me a very quickglance of tenuous pleasure and then turned away with an avoidanceof my gaze and bodily withdrawal. I felt I had become dangerousagain during the break, even more so as I believed from her dartingpleasure that she had missed me. Ethan woke up as she put him onfloor beside her. He looked bewildered. We settled on the carpet andMs G placed Ethan against her feet, facing me. I thought she was insome way offering him as a “transitional object” for reengagement. Iadjusted my position so that Ethan could see my face directly. In sodoing, I was also placing myself in Ms G’s range of vision should shechose to raise her eyes.

I spoke to Ethan: “You’re not quite sure where you are, are you? . . .you haven’t been here for a while . . . have you?” He murmured. Iasked him if it all right to wake up in this room now, and Ms G re-minded me that the last time he was quite upset. I acknowledgedthis. Ms G asked Ethan if he wanted to sit down and placed him onher 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 gur-gling noise. He gave a big smile and looked into my eyes for a few sec-onds, then looked away. Then he looked back, pursing his lips, andeventually produced a rolling sound. In a lilting voice (“motherese”)I to him, “It’s a little conversation, isn’t it?” His face opened and hesmiled again, then looked away. I waited. After a few seconds heturned back to me. I said, “Are you ready to chat again? Hey . . .yes . . . yes . . . and when you’ve had enough you look away for awhile, don’t you?” Ethan gurgled again. Ms G looked down at Ethanand said, “He can be quite coquettish, sometimes he turns his head


and looks from the corners of his eyes.” I replied to Ethan, “mmm. . . hmm . . . I guess you’re taking a breather then, aren’t you, weadults do the same. Yah . . . Take a little break in a conversation, ah,otherwise it gets too much, doesn’t it?”

Ms G’s response to me in the waiting room suggested that thebreak had been experienced as an abandonment, in which I failedher as her primary figures had, and left her to struggle alone with dis-integration. Yet, she allowed me access to Ethan (suggesting somegoodness was retained) and through him, to herself. In talking toEthan I was engaging in a process of emotional regulation throughscaffolding his efforts at regulation (looking away) and placing themin the intersubjective domain. Using Ethan as a displacement, Icould model for Ms G the process of ordinary, developmental self-and interactiveregulation (Beebe et al. 2003) in the pacing of an in-teraction. I was struck that the coquettishness she attributed to himin fact described her own conflict between engaging with me andwithdrawing (e.g. when it “got too much”).

Later in the session Ethan was sleeping, with Ms G stroking his headand hand. She related a visit by friends who played with Ethan. Sheasserted that he was happier when with them. I wondered whethershe had felt the same when I was talking with Ethan earlier? Ms Gprevaricated, “I couldn’t see the expression on his face so I don’t . . .he does smile at me, but he often spends a lot of time seemingly juststaring at me with quite a pensive look on his face. . . .” I noted hislooking to her earlier. She replied that she worried: “Should he besmiling at me more? Obviously he does smile at me and not some-thing behind my shoulder that’s taken his interest.” I asked, “Whatare you like with people, do you carefully observe their expressions,maybe sensitive to what feelings they’re communicating towardsyou?” Ms G said that she was trained from an early age to be aware ofwhat somebody’s going to need or want. I asked whether she wasafraid sometimes of what he might see in her face. Ms G answeredslowly, “I’m sure . . . that . . . that in my face there’ll be the ambiva-lence that I often feel towards him . . . or my own difficult feelingsthat may have nothing to do with him.”

In my experience, a mother questioning her baby’s love for her isattributing her own conflicts to the baby. Ms G’s fear that Ethan al-ready preferred the company of others seemed multilayered, con-taining the fear of his rejection of her, a projection of her wish to getaway from him, and the rivalry with him over me. At this point I wasunsure whether words alleviated or intensified her conflict and I alsofelt that the urgency of Ethan’s need for her was overriding. I, there-

56 Tessa Baradon

fore, chose not to follow the route of interpretation and simply com-mented that he had been looking at her. Ms G was able to make useof my validation of Ethan’s desire for her to express her conun-drum—can she allow personalization: “Should he be smiling at memore?” This offered an opportunity to explore what Ethan might beavoiding. I learned that Ms G habitually scanned the object for theiraffective communications/demands and that, since Ethan’s needsand wants evoked her hatred, it felt dangerous for him to look intoher face/mind as he may see those emotions in it.

I was aware that she had not related to Ethan for some length of timeand asked whether she was feeling ambivalent about Ethan there andthen in the session? Ms G said she was not sure . . . perhaps her in-stinct was to touch him but she did not want him to feel smotheredby her. She wondered if she is not perhaps too disengaged with him. Isuggested that, on the contrary, I thought she was very engaged withhim but that she is protecting him from the toxicity that she felt waspassed to her by her mother and which she fears she may pass toEthan. Ms G nodded. She said she wanted to make it clear that hermother did the best she could at the time and added that of courseshe feels that it wasn’t good enough. I rushed in too quickly at thispoint, saying that perhaps in her attempts to protect Ethan she waskeeping a distance between them that prevented them from sponta-neous exchanges, such as laughing and playing together. Ms Greplied that Ethan may in years to come experience her as in a stateof severe depression or absent from him. Almost under her breathshe murmured that if she were to leave through dying she would notcome back. Ms G was quite tearful and picked Ethan up, caressinghim. Then she said that she is not sure whether she’s holding Ethanbecause he is a soft, comforting thing . . . and she put him down onthe floor, on his side facing away from her, and at a distance. Hesucked hard on his hand and just lay there, looking into space.

The whole interaction was extremely painful as baby and motherseemed quite unable to come together. The essential elements ofadoration and appetite for the baby were missing from Ms G’s love. Itseemed that his dependency, need, and desire for her resonated withthe representation of him as parasitic during pregnancy—depletingher of self-hood. The transference to Ethan was thus of a consumingobject like the mother of her childhood. This dilemma is likely tohave been accentuated by her feelings of abandonment by me dur-ing the break. In an identification with the aggressor (myself), feel-ings 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 ex-perience the maternal toxicity or disappointment in the object that


she suffered. In this way, distancing him was an act of love as well ascruelty. Ethan, to my concern, veered between disintegration andprecocious defense.I felt caught in the middle and responsible for the devastation, as

though during the break the therapy had replicated the hollow ma-ternal stance—the offer of dependency withdrawn. Thus my mater-nal “best” was in fact toxic also for Ethan via the impact it had on hismother. Certainly my “too quick” response contained a veiled criti-cism (also reversing the attack on me): in protecting Ethan fromdamage you are in fact killing off a live relationship. Obviously, I mayhave responded from the countertransferential reserves of my owntetchy narcissism. We also know from clinical experience that past re-lational trauma can be reproduced in the present therapeutic situa-tion, in the transference-countertransference transactions. Yet Ithink I was also “nudged” into the patient’s unconscious wish-gratify-ing role (Sandler 1976), as Ms G went on to speak of Ethan’s (and ofcourse my) possible future loss of herself. The habitual solution tooverwhelming dependency and inevitable disappointment was de-struction 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 awayfrom us. As he lay rigidly on his side looking into space, I felt I waswitnessing his emergent identification with the dead mother (Bollas1999)—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 expe-rience maternal feelings it was because of her “delight in his need(for her)” and that, therefore, her “motives are suspect.” Sheweighed her gratification about his complete dependency on heragainst her wish to walk away. “I have to keep asking myself what isthis about? Is it about me? About Ethan?” She dismissed my sugges-tion that it may be about both of them, and I commented on her fan-tasy that the ideal mother is selfless. Ms G confirmed this ascetic rep-resentation of the genuinely loving mother and said that the “idealmother could understand all the baby’s needs,” thus rearing “emo-tionally, mentally and physically strong children.” She said she washumbled now when she saw others managing to do this.Ms G’s repudiation of gratification as a constituent of the maternal

bond could be traced to her grievance with her mother, past and pre-

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sent, in which she felt “used” by her mother for her own narcissisticneeds. Moreover, she held her parents responsible for her damagedmental state and, even as an adult, had no real sense of volition tomodify 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 tothese tentative “protoconversations” with widened eyes, excited kick-ing, and large smiles. He seemed to gain efficacy as a partner; for ex-ample when he lost her attention he would call her back by lookingat her and cooing. When I pointed this out, Ms G said that friends vis-iting had commented that Ethan’s eyes followed her wherever sheis—tracking 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 lessambivalent parenting and Ethan aspects of “good enough” related-ness, and thus also development. Indeed, during this period in thetherapy, there were times in the sessions in which Ethan was a con-tented little baby.However, these quiet periods of regulated positive affect were also

the backdrop to rapid transition into states of inconsolable crying. Inoted that sometimes Ms G reached out to Ethan, and he, in the pro-cess of being attended to, became distressed. His tiny body becamerigid and he clawed at his mother’s body. At such times Ms G movedthrough a repertoire of feeding, winding, rocking, walking—seem-ing 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 sohard to soothe Ethan? Was he damaged at birth, would anothermother get it right? I tried to explore with her what happens to herwhen he cries. Ms G confirmed that she gets very upset. I suggestedthat sometimes Ethan’s cries feel like her own. Ms G became tearfuland then reprimanded herself for not always acting the adult withhim. I said that when they are both crying she no longer feels themother. I also spoke about the rage that she feels when he triggersher pain. Ms G whispered that she feels so guilty and ashamed.

Thus, it was becoming clearer the extent to which Ethan was thebarometer of her own emotional state. When his needs did not res-onate with her own conflicts, Ms G was able to respond. Unpre-dictably, however, his ordinary infantile needs could trigger or link inwith her own volatility. This is another aspect of relational trauma—where the quality of affective communication with the baby impartstrauma from the mother’s internal world to that of the baby.


Through the most careful observation of their affective interactionand of my own countertransference, I came to understand a particu-lar quality of interaction that was perilous to both. Ethan’s cries re-traumatized Ms G as her own unconsoled state as a small child cameflooding back. At this point he became the frightening child to hismother, re-evoking her own disorganized attachments (Main andHesse 1990). Unconscious conflict then permeated her ordinary ma-ternal ministrations of feeding, changing, and soothing, and Ethanwas disregulated by his mother’s care. Balint (1992) describes this as“unconscious communication”—direct communication between theunconscious mind of a mother and her infant, in which the baby per-ceives and internalizes aspects of the mother’s life of which she isherself unaware. And just as the meaning of her own affective statewas unrecognizable to Ms G, so Ethan’s communications could notbe understood and contained. Their distress ricocheted betweenthem, escalating to the point of collapse. What could I model in thesessions in terms of a holding response?

(session continued) . . . When Ethan got restless I spoke to him. Heresponded with attentive pleasure. At one point he cooed extraloudly and drowned out Ms G’s soft voice. I said playfully, “I couldn’thear your mummy there, do you mind!” Ethan kicked gleefully in re-sponse to my crooning voice and smiles at him. Ms G became verytearful. She said it was the ease with which I relate to Ethan and shehas 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 thereforeasked what could help her recognize the cues from Ethan aboutgood things he gets from her. Ms G’s face became very tense. I felt Ihad suddenly frightened her. I wondered whether Ethan’s love anddependency were difficult to recognize? Perhaps because she couldnot have these experiences as a child, as her mother was too de-pressed to be able to tolerate such feelings in her? Ms G whisperedshe did not want to repeat what had been her experience. I said thatI thought she was struggling between her wish for Ethan to have abetter experience and her fear of recognizing her importance in thisand thus his dependency on her. Ms G said forcefully that other peo-ple’s 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 ather. I said to him that he had called his mummy and she had gath-ered him up. Ethan sucked and chewed on his mother’s fingers. Thiswas 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 (inthe absence of such exchanges with his mother), and a mother who

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felt diminished by this, I was in a conundrum: to embrace the oneseemed to be a rejection of the other. It was as though I had to expe-rience the possibility that only one of the dyad could survive. If I wasunconsciously being faced with the choice between them I, equallyunconsciously, resisted it by replacing Ms G as the object of her son’slove. Perhaps I hoped that Ms G would allow herself the experienceof Ethan’s giving her pleasure and making her proud. Because shewas more able to respond to cues of distress but not those of joy in re-lation to her, he was missing out on swathes of exchanges aroundemotional sharing, crucial for his development (Stern 1985, Tre-varthen 2001). Indeed in this sense Ms G was not able to facilitateEthan’s development as an “emotionally, mentally, and physicallystrong child.”Yet, as the therapy progressed, it seemed that by my modeling

more playful exchanges with Ethan while emphasizing my “not-mother” status, Ms G was sometimes able to respond contingentlyand offer herself to be used by him.

separation-individuation

In the course of a longer-term therapy the infant naturally movesfrom a state of total dependency on the mother toward the begin-ning of separation-individuation. This offers opportunity to workwith the mother’s conflicts as they impact on her baby at each devel-opmental phase.In the treatment of Ethan and Ms G there were hints from the be-

ginning that separation, like dependency, was an area of extreme dif-ficulty. Ms G’s history held no personal experience of moderated sep-aration, only that of violent, mutually destructive rupture. The riskfor this dyad was that separation-individuation would plunge motherinto narcissistic despair and rage.Sleeping and feeding were ubiquitous arenas for expression of

conflicts over separation in Ms G’s history and were, perhaps in-evitably, 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 wokeher up. She moved Ethan to his Moses basket at her side, but keptvigil through the night. She recalled childhood fears of the dark andof sleeping alone and felt unable to tolerate Ethan’s cries when putinto a cot. At the same she felt driven to madness and despair by lackof sleep. D, with his own difficulties in this area, was unable to offersupport, and soon Ethan was restored to the parental bed. Ms G’schronic insomnia was thereafter channeled into nightime rumina-


tions as she waited for dawn so as to escape from the bed to a strongcoffee and cigarette.With Ethan waking hourly, sleep disturbances became woven into

the conflicts around feeding and weaning. Ms G repeatedly ex-pressed her feelings that feeding was the sole good thing she couldgive him and admitted her gratification that only she could providethis. However, these feelings also came into conflict with her experi-ence of his dependency as depleting. In the sessions I observed feed-ing encompass many regulatory functions, so that Ethan was put tothe breast when he cried, when he was tired, when they were both ata loss as to play. With feeding used to meet such a variety of situa-tions, it became difficult to tell when he was hungry.At around 5 months of age, Ethan’s weight began to drop and pro-

fessional concerns about failure to thrive emerged. Medical opinionmoved toward supplementary feeds, with a bottle also offering a pos-sibility of respite from the hourly feeds at night. Ms G came under in-creasing pressure to achieve some measure of weaning. Her internalsplit was thus effectively externalized, with the medical network andher partner now carrying for her the thrust for forced separation,while she maintained the ubiquitous place of breast-feeding. Itseemed important that at that point I did not ‘know’ what would bebest, and held neither a wish for Ms G to wean nor for her to con-tinue feeding.During this period, Ethan 6–9 months, many threads in the ther-

apy seemed to coalesce around the question of closeness versus dis-tance 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 pres-ence, for example crying when she left the room, and her inability tolet him cry. She said that before Ethan was born she spent much ofthe time alone. I wondered if that was her way of keeping her emo-tions on an even keel and she confirmed this. I suggested that havingEthan with her all the time meant that she has no means of regainingher “emotional balance” (her words). Thus the closeness was experi-enced as loss of self, provoking rage. Getting away was a relief at thatlevel, but it also brought with it the fear that she could disappearfrom 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 beclose to her today. Ms G said she did not know if she wanted himclose or not. She said her guilt at not really wanting his “relentless”

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closeness makes her try harder. I then witnessed this as Ms G finallyallowed Ethan—who had been struggling for a while to get into herlap—to find a place there. He crowed and cooed and bounced.From the outside their little “reunion” seemed pleasurable and yetMs G was talking about times when she feels she cannot go on. Iasked whether those were times when she harmed herself. She wassilent. Ethan seemed to get extremely boisterous in her embrace—sucking on her arm and blowing raspberries. He appeared to beboth kissing and biting her and I said this to him. My thought wasthat they both moved between intimacy to destructiveness with con-fusing rapidity and that, despite being with them, I could not tellwhat felt good and what bad.

It is interesting that at age 8 months, when biting could be consid-ered as a normal expression of desire (incorporation) and/or explo-ration, I attributed destructiveness to Ethan’s biting of his mother.Was I taking on Ms G’s attributions? In which case Ethan was subjectto my projections as well as his mother’s. Was I picking up on an ag-gressive quality of relating in Ethan that indeed would be a pointer toderailed development at this age? If so, why did I not follow thisthrough with an explication of his aggression as reactive to hismother’s unresolved ambivalence? Certainly, addressing his predica-ment would then need to have been privileged. In retrospect, I thinkthat my shifting identifications with mother and with baby were en-acted here through muddled, partial interpretations.Just as imaging the baby’s ordinary movement toward separateness

was not available to Ms G, she was also not able to manage a normalloss through establishing the triad of mother, father and baby (Daws1999). I noticed in the sessions that I felt increasingly forced to relateto Ethan, with Ms G watching and withdrawn, or to Ms G—withEthan either observing or dis-engaged. Thus, the father/therapistwas seen not as a gain but as a threat to the symbiotic tie. In the issueof weaning, the bottle symbolically represented the competent, thirdobject, and there was a concrete idea that the bottle would deliverEthan to his father. With this came powerful statements from Ms Gthat D and Ethan were doing so well together. There was affective un-dertone of not being needed anymore, and I was left with a concernthat intense pressure on her to wean could precipitate a crisis, pri-marily in terms of her desire to stay alive. My anxiety about a possiblesuicide attempt was high, and I checked that the network was inplace. In retrospect, I believe I was also caught up in powerful projec-tions around loss of myself, as we were approaching another break (9months into treatment).


Anticipating this loss Ms G thought she and Ethan would miss theirsessions with me, but she continued to insist that the solution was dis-engagement and self-sufficiency. Separation, as an intrapsychic pro-cess leading to growth, still felt beyond our reach.

enacting rupture

On their return after the holiday, Ms G appeared terribly thin andwan, while Ethan seemed to have gained bulk and weight. My firstthought was “he’s feeding off her!” He also looked strikingly like hisfather, as though fulfilling her fears of losing him to D. They each re-sponded to me with a measure of reserve.

Ethan took his time before he approached me: gazing at me from adistance and looking worried. After a while he gave me a smile and Ismiled back and asked whether he was beginning to forgive me forthe summer break. Ms G told me that on their holiday everyone hadadored Ethan and that he had gone easily to the men but not to thewomen who wanted to pick him up. I wondered whether she was link-ing Ethan’s reserve with me to this. She shrugged. I asked her whatshe made of her observation. She said, “It’s like being run over by ared car and then not liking red cars afterwards.” I said it seems tohave reinforced her fear that she was not a good mother and as a re-sult all women were like red cars to Ethan. Again she shrugged, thistime seemingly in agreement. Ethan was crawling about—initiallyenergetically but then looking lost. A number of times he headed to-ward his mother and then veered away. When he absolutely ran outof resources he crawled to her and tried to clamber onto her lap. MsG held him loosely, pulling away a bit and getting her hair out of hisclasp. She then abruptly stood up muttering that he needs a climbingframe, carried him over to one of the chairs and stood him there.Ethan looked tiny and forlorn across the room. I felt shocked. Shecame back to her place on the cushion. I said she was equating her-self with the chair, as though it was not her—his mother specif-ically—that he needed. She replied that she does not want him to de-pend on her for his happiness. Feeling very anxious about what I wasabout to say, I asked whether she wanted him to be independent ofher 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 per-haps she thought that in order to continue living she needed to feelthat she could kill herself. Ms G said everybody had their escaperoutes.Ethan had crawled back to our vicinity and was searching Ms G’s

bag. He pulled out a plastic container with food. We watched as hestruggled to get an apple out. I accompanied him with words: is hewanting the apple, can he get to it? He managed to extract the apple

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and tried to bite into it. I asked him if he can eat it, is it too big? I saidmaybe Ms G thought I was fussing too much. She moved closer tohim and asked him if he needed her to cut it for him, but Ethan hadin the meantime made indentations with his teeth. He chewed onthe apple for a while and then tried to get the bottle of baby foodout. Ms G watched him closely and I found it agonizing that she didnot capitalize on his interest. When she finally, tentatively offeredhim some food, he spat it out. She immediately put the bottle of foodaway. Shortly after this he began to cry.Ms G told me that at D’s insistence she had taken Ethan to a nurs-

ery that morning. I asked how they had felt about it. She said Ethanhad choked on a brick during his visit. She conveyed immense sad-ness. I said she seemed torn between loving Ethan and wanting hislove for her, and her fear that this dependency in both of themwould take away her escape route. I suggested that the long breakhad probably also brought up these feelings in relation to me. Ethanwas getting more upset and when picked up by Ms G he clung to herstrongly. I said to him that he was showing his mummy how much heneeded her and how frightened he gets when she thinks about leav-ing him. Ms G carried him over to the windowsill and sat him on it sohe could look out. Ethan calmed, and soon after this it was time toend. Ms G fled the room clutching Ethan in her arms.

The story of the holiday could have been taken entirely as a trans-ference communication: I had “run over” her dependence on meand left her, prematurely, to feed herself. Thus forsaken, she felt driv-en toward her habitual escape routes of self-denigration and self-harming, both to rid herself of her shaming infantile needs and as aretaliatory attack on me. Her rage with me was communicated in thenarrative of the red car and enacted in substitution of climbingframe/chair for self, that is, in her refusal to embrace Ethan—again,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 transfer-ence was in the forefront and needed addressing. However, my initialattempt to relate to my perceived dangerousness (via Ethan’s avoid-ance of me) was shrugged off. I reckoned that to pursue the transfer-ence and/or her defenses could be experienced by Ms G as retalia-tion on my part (Steiner 1994). In retrospect, it is the displacementsthat perhaps could have been taken up for it is there that the experi-ence of cruelty lay. Addressing her rage with me may have relievedEthan from the burden of carrying it.With the rupture (break) with me unsufficiently reflected upon,

what followed was Ethan’s performing a transference enactment of


failed self-feeding while the intergenerationally depriving motherstood by. By this point I was able to address the struggle to managealone, but although Ms G carefully watched Ethan, her active inter-vention came too late (like mine) and was rejected. I wonderedwhether in fact Ms G experienced me as empathic toward Ethanwhen I had been withholding toward her, and this perhaps con-tributed to her not helping him feed. I also thought she was possiblypunishing me through forcing me to witness her abandonment ofher child (which was painful to watch). In a similar vein, going tonursery was experienced as forced upon them, with life-threateningconsequences. However, Ms G’s sadness was here undefended and itgave coherence to the preceding narratives. Acknowledging theneed and the pain allowed some movement—by the end of the ses-sion Ethan was ensconced in Ms G’s embrace.The following session Ethan was unusually free and playful, partic-

ularly in relation to the apple. He held it, bit into it, he lay on the ap-ple and rolled around. I noted Ethan’s playfulness and Ms G said shetoo had noticed it—it was so different from his clinging. I suggestedthat he might be picking up that she and I were trying to work some-thing out and it was a relief to him. Ms G said, “maybe he is beingtrustful.”

“falling in love” as reparation

In one of her earliest sessions Ms G asked, “When does one know thatreparation 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 rup-ture, described above. In the sessions there was a shift, with Ms G tak-ing a slightly more reflective stance (i.e. less rumination and self re-proach) than hitherto. In the core relationship toward Ethan, sodominated previously by her ambivalence, there seemed to be a flow-ering of love. Between them there was a more robust link, which en-abled Ethan to move to and from his mother and to refuel from a dis-tance through gaze. Ethan also established his own little routine inthe sessions. He would start by checking out the toys and re-establish-ing himself with me—little smiles, crawling over to me, graduallyclimbing up to explore me. Then he would go over to Ms G’s largebag and get out his food parcel—an apple and berries in a plasticbag. He had to work hard to get his hand into the bag, but Ms G

66 Tessa Baradon

monitored his endeavors and encouraged him. Ethan then ate hisfruit, swallowing some and spitting some out. Gradually eating andplaying/exploring became somewhat more integrated, and hemoved 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 acloth she’d had as a comforter which had worn away—she wishedshe still had it to give to Ethan. I said it sounded that she was wantingto protect and comfort him for the years to come. She replied thatshe had a lot to make up. I said this made me think of the perfectpresent as representing a wish to make good their very difficult earlybeginning. Ms G spoke of reparation and I thought she was also re-pairing something for herself. Her emphasis was on her wish to pro-tect Ethan’s trust and expectations that people will respond to himkindly. I suggested she may have felt unprotected and that cruelty hither 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 alot of charitable work but she wishes she could have given the sameto her children. I said that perhaps she feels that sometimes both herparents didn’t really do their best and that some of the cruelty she ex-perienced came from them—and this is what is so hard for her. Ms Gstruggled 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 ini-tially asked him not to play with the cord and then went over andpicked him up. Ethan gleefully crawled back to the table and Ms Gbecame firmer in her tone of voice. I spoke about what was happen-ing between them, reflecting that he really enjoyed being gatheredup by his mother and had found a hide and seek game which hecould play with her.

This session was characterized by a sense of calmness and re-flection between Ms G and myself, the adults, and playful explorationon Ethan’s part. It felt that I was allowed to hold a position of the be-nign “third,” and this was perceived to be containing to both babyand mother.The quest for the perfect present seemed to capture Ms G’s regrets

about the lacks of their beginning together, and her wish to celebratetheir coming together through the love she had discovered withinherself for her child. In wishing to extend the “comforter” from herchildhood to him, she also had begun to mourn the lonely child-hood she had, and to relinquish some of the envy of her child for thematernal comfort he could still have in his. Ethan’s play with the tele-


phone cord seemed to represent hope for more genuine, encom-passing communication between them through which he could begathered up and contained.

Discussion

Ethan’s first birthday also heralded the end of our first year of worktogether—a good time to take stock. The wish, and failure as yet, tofind a “perfect present” seemed symbolic of what had been achievedand 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 shefelt had been done to her by the parenting she had received. In equalmeasure, although more hidden, was the fear of being damaged byher baby. This mutual threat was created through their very exis-tences in relation to each other. As Ms G said, “Can one damageone’s baby just by being available?” In the transference I was also of-ten a source of danger, most spectacularly around breaks when myunavailability confronted Ms G with her the extent of her depen-dency on me and my maternal failure to hold it. Ethan’s post-natalvulnerability—his smallness, sensitivity to lights and noise, seeminglylow threshold to “unpleasurable” experiences and the difficulties incomforting him—intensified the sense of fragility and risk. My coun-tertransference fantasy that we were constructing the therapeuticspace 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 forEthan. In the early months Ms G’s fear of, and guilty hatred for, herbaby’s dependency overrode her ability to accept more benign feel-ings in herself. She defensively adopted an ideal of altruism thatnegated not only her passions but also his. Ethan was forced into pre-cocious inhibition of attachment behaviors toward his mother. Histurning from her, and her failure to meet her ascetic standards, com-pounded her depression. In the course of the first year of therapythere was a lessening of Ms G’s preoccupation with the question of“genuine” maternal love and a move toward more ordinary, at times“good enough,” mothering. She seemed more able to acknowledgeand tolerate her wish to be central to Ethan and, albeit less consis-tently, her importance to him. Her gaze and facial expressions con-veyed growing adoration of him. What facilitated these changes?

68 Tessa Baradon

Perhaps “falling in love” could start to take root only after therewas some measure of surviving the destruction and despair broughtfrom her past primary relationships into her present ones. By thethird quarter of the year Ethan, although delayed, was making up theearly impingements and developmental tests confirmed he was ontrack. Thus Ms G’s psychic reality of the inevitability of damagecould, sometimes, be challenged by a different, external voice.Ethan, for his part, seemed to capitalize on the openings in their re-lationship and became more forward in expressing his desire for her.This, too, was a positive reinforcement which Ms G could at timesperceive.In the transference relationship with me I, too, was surviving her

destructiveness and was not retaliating with narcissistic demands ofmy own. Thus Ms G was meeting with a different “motherhood con-stellation” (Stern 1995) from the persecutory internal one, one inwhich the intergenerational mother could be experienced as con-taining and repairing of the damaged child.The clinical process, as the sessional material indicates, took place

in the procedural and symbolic domains. Interpretations—usingwords as a means of giving meaning—were 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, themisattuned emotional “dance” between mother and baby was re-peated in the interactions between the three of us. In time, I becamebetter at matching and repair of the spontaneous gestures and af-fects that constitute “authentic person-to-person connection” (Sternet al. 1998, p. 904) and this then framed the developing relationshipsbetween 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 myselfas someone who could simply be with mother and baby and could re-flect on them in relation to each other without fear of damage, seemsto have been important. For quite some time it seemed that only inmy mind could their survival as a dyad be contemplated. This raisedthe question of which patient should be privileged from moment tomoment—Ethan, mother, father (present or absent), the relation-ships? At times I left a session feeling that more work should havebeen done with Ethan, for example to enhance his efficacy in engag-ing his mother. At other times I felt that the focus should stay with MsG, to address her depression and the defenses and distortions thatconstituted her zone of safety but also derailed the relationship withEthan. Despite the compelling nature of Ms G’s narrative, it was cru-


cial to keep Ethan in my mind at all times, so as not to slip into indi-vidual therapy in the presence of the baby. These issues were all themore urgent given Ethan’s young age and the chronicity of Ms G’sdifficulties, 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 re-lationship. It seemed that the quality of love Ms G was able to offerEthan was contingent on her emotional state at any given time andthe extent of preoccupation with herself. Often Ethan had to makedo with the crumbs of emotional availability that penetrated her de-pression and withdrawal. Not able to love herself in her baby, or to al-low his appeallingness to reflect on her, Ms G could not really enter-tain exuberant passion and appetite in her relationship with Ethan.Moreover, to be “consumed by the other” was only too real a threatand to be avoided at all costs. Thus Ethan was not able to safely expe-rience himself as an object of hatred as well as of love. His own ac-tions directed at separation-individuation were still, at times, subjectto transferential attributions that frightened Ms G and evoked her re-jection of him. In turn, Ms G’s fluctuating emotional state, and par-ticularly when she became extremely depressed, could be frighten-ing for Ethan, betrayed initially in disintegrative crying, and later inoccasional veering away in the midst of approach or a momentaryfreezing 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 affec-

tive quality of her love for her baby as described above. In presentingthe question she was disclosing her knowledge that something wasgoing very wrong for them. At the same time, bringing the questioninto the therapy also underlined Ms G’s commitment to do better byher baby: whatever her state of mind, however conflicted she wasabout the therapy, Ms G and Ethan attended their sessions withoutfail. In using the therapeutic space to risk intimacy, Ms G and Ethanwere constructing their particular version of “genuine” love—some-what more measured and a little more vibrant at the end of the yearthan at the beginning.For myself—I was intrigued by this question in the context of my

work with attachment disorders. It seems an important concept tohold in mind in the course of the therapy with mothers and babies.In the face of conscientious maternal care, it provides a frameworkfor understanding a particular quality of “maternal failure” and ensu-ing relational trauma for the baby. It also suggests an outline of the

70 Tessa Baradon

clinical process that may be needed to free up object hunger and toencourage the risks of appetite and dependency, identification, andindividuation 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 vis-iting program, was initiated to help young, at-risk new mothers keeptheir babies (and themselves) “in mind” in a variety of ways. The in-tervention—delivered by a team that includes a nurse practitionerand clinical social worker—uses 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 De-partment of Children and Families; and Linda Mayes, Yale Child Study Center.This work was supported by a generous grant from the Irving B. Harris Founda-

tion, and grew out of a collaborative effort between the Yale Child Study Center, theYale School of Nursing, and the Fair Haven Community Health Center. Other mem-bers of the research team who have been essential to our progress are Michelle Pat-terson, Betsy Houser, Megan Lyons, and Alex Meier-Tomkins. We would also like tothank Jean Adnopoz, the Director of Family Support Services at the Yale Child StudyCenter, as well as Sean Truman, both of whom were instrumental in getting the pro-gram off the ground. Finally, we wish to thank the administration and staff at FairHaven Community Health Center, particularly Katrina Clark, Kate Mitcheom, KarenKlein, and Laurel Shader, who along with many other members of the pediatric andobstetric services gave Minding the Baby a home.


74

that is, we work with mothers and babies in a variety of ways to de-velop mothers’ reflective capacities. This approach—which is anadaptation of both nurse home visiting and infant-parent psychother-apy models—seems particularly well suited to highly traumatizedmothers and their families, as it is aimed at addressing the particularrelationship disruptions that stem from mothers’ early trauma and de-railed attachment history. We discuss the history of psychoanalyticallyoriented and attachment based mother-infant intervention, the theo-retical assumptions of mentalization theory, and provide an overviewof the Minding the Baby program. The treatments of two teenage moth-ers and their infants are described.

Sometimes my daughter is just really nice and gener-ous, and she likes giving me hugs and stuff . . . some-times, just for nothing, she’ll walk up to me and hug meso tight in my neck and it feels so good . . . ’cause Inever had that when I was little . . .She probably doesn’t understand why she’s getting

me mad. ‘Cause she’s so tiny she probably doesn’t un-derstand. But, that’s kind of what I think about, youknow, you can’t compare your capacity to hers, ’causeshe’s still so small, she doesn’t understand what she’sdoing wrong.I usually try to hide my anger. I try not to let anyone

see those feelings. I did that for a long time beforeDenise and Cheryl came along. That’s when I startedopening up and talking to them. Because I had so muchbuilt in I couldn’t hold it anymore.

—Iliana, 19, mother of Lucia, age 13 months

I look at this tape of me and Noni, and she’s so little . . .I can’t believe she’s so big now . . . It’s so hard to watchthis . . . I see now that maybe her crying was to tell meshe’d had enough . . . here I can see her face sad tryingto tell me what I didn’t know, that she may have beenhungry or sleepy. The whole time she cried, I had noidea what she wanted.

—Mia, age 19, mother of Noni, age 14 months

these young mothers are struggling to find words for the in-ner life—their baby’s and their own; tentatively, poignantly, theyglimpse the other, and themselves. They look for ways to describewhat is inside, what can be known, what can be held in mind, andwhat can be contained. They hold the past next to the present, the

Minding the Baby 75

self next to the other. And as they discover their babies, they are dis-covering themselves for the first time.Mia and Iliana joined Minding the Baby—a relationship based

mother-infant intervention program—in their third trimester ofpregnancy. Both had been in different ways abandoned and betrayedby their own mothers when they were but babies themselves. Theyhad lived their whole lives against the backdrop of trauma, withintheir own families and within the culture of their violent, impover-ished, and chaotic communities. Knowing others and their mindshad been fraught with terror, disappointment, and rage. And nowthey were faced with the enormous challenge of holding their ownchildren in mind, children who had been born at a time when theywere still children themselves.The crucial human capacity to understand the mind of the other,

to make meaning of behavior—one’s own and others—in light of un-derlying mental states and intentions, is essential to the development ofsocial relationships, and most particularly intimate relationships(Fonagy, Gergely, Jurist, & Target, 2002). Fonagy and his colleagueshave referred to this interpersonal and intrapersonal capacity as thereflective function, and they suggest that it is essential to affect mod-ulation and regulation; experiences that can be known and under-stood, held in mind without defensive distortion, can be integratedand contained.The capacity to mentalize, or envision mental states in the self and

other, emerges out of early interpersonal experience, particularly theexperience of being known and understood by one’s caregivers. Thechild discovers himself in the eyes and mind of his caregivers, and de-rives a sense of security and wholeness from that understanding(Fonagy et al., 2002; Fonagy, Steele, Steele, Leigh, Kennedy, Mat-toon, & Target, 1995; Fonagy & Target, 1998). The child’s discoveryof himself depends largely upon the caregiver’s capacity to hold, tol-erate, and re-present the range of his diverse and contradictory men-tal states. Thus, a parent’s reflective awareness is inherently regulat-ing and containing for the child. Importantly, though, it is alsoregulating and containing for his caregiver. Parenting is a fraughtand complex enterprise, and without developed capacities for re-flective functioning, parents are vastly more prone to impulsivity, dis-organization, and dysregulation in relation to their child (Slade,2002, in press, 2005).Trauma interferes in a number of profound ways with the develop-

ment of reflective capacities (Fonagy et al., 1995, 2002). Parents whohave been traumatized find their children’s needs and fears over-

76 Arietta Slade and others

whelming and profoundly evocative, and as a result often find it diffi-cult to read the most basic cues without distortion or misattribution(Fraiberg, 1981; Lieberman, 1997). At a most basic level, the defen-sive processes enlisted in the face of trauma fragment the develop-ment of stable, coherent representations of the self and other. Whatwe see in the words of the mothers quoted above are tentative effortsto form such representations, and allow themselves moments ofknowing the self and the other. Mia’s evaluation of her own failure tounderstand what her 4 month old infant was feeling provides a clearexample of how difficult this can be.Minding the Baby, a relationship based home visiting program de-

veloped out of an interdisciplinary collaboration between the YaleChild Study Center and the Yale University School of Nursing, wasinitiated 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 as-sumption that—in addition to being relationship based and interdis-ciplinary—our program would focus on the development of moth-ers’ mentalizing capacities. Based on Fonagy and his colleagues’work of the last decade (see Fonagy et al., 2002, for a review), weknew that—by virtue of early relationship histories that were univer-sally characterized by attachment disruption and trauma—the re-flective capacities of these women would be compromised. Further-more, we believed that addressing the deficits and defenses that hadled to such disrupted functioning would be vital to the developmentof healthy mother-child relationships. Obviously, while parenting isnot the only factor contributing to the regularity and evenness of in-fant development (temperament and biology being but two of themyriad endogenous and exogenous factors that can affect develop-ment), we believed that enhancing parental reflective functioningwould help mothers facilitate their children’s development in crucialways.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 de-velopment of reflective functioning or mentalizing capacities. Inessence, these approaches—which Fonagy and Bateman have mostextensively developed for work with borderline patients—are de-signed to very explicitly help patients make sense of mental states. Itis this model that has informed the development of Minding theBaby.We also began with the assumption that when working with infants,

containment and regulation take place not just at a mental level, but

Minding the Baby 77

at a physical level as well. The knowledge of mental states, thought socrucial to responsive caregiving, is preceded and indeed foundedupon 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 capacityfor re-experiencing unintegrated states, but this depends on the con-tinuation of reliable maternal care or on the build-up in the infant ofmemories of maternal care beginning gradually to be perceived assuch . . . The infant becomes a person, an individual in his own right.Associated with this attainment is the infant’s psychosomatic exis-tence, which begins to take on a personal pattern; I have referred tothis as the psyche indwelling in the soma . . . the infant comes to havean inside and an outside, and a body-scheme. In this way meaningcomes to the function of intake and output; moreover, it graduallybecomes meaningful to postulate a personal or inner psychic realityfor the infant. (p. 45)

In other words, the child comes to know his body through the hands of hismother. As we can see from Mia’s reflections on her inability to ac-knowledge her baby’s most essential needs for sleep or food, eventhe recognition of physical states can be compromised in trauma-tized mothers whose own bodies have in a variety of ways often been asource of trauma. Thus, we wanted to help our mothers come to feelsafe and confident in knowing their babies’ bodies as well as theirminds, to feel that they could contain and regulate their babies’ phys-ical states, and then slowly, with time, come to know their babies’mental states.In the sections below, we will begin by briefly describing the essen-

tial principles and methods of Minding the Baby, as the program hasevolved from its original inception three years ago. We will then pre-sent two cases in an effort to exemplify the approach intrinsic to ourreflective parenting program.

Mother-Infant Intervention: A Brief Overview

Thanks to the remarkable and groundbreaking work of SelmaFraiberg, clinicians have been working in a psychoanalytic way withmothers 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-parentpsychotherapy is today a highly valued and legitimate mode of psy-


choanalytically based treatment, and the infant mental health move-ment—reflected in the emergence of organizations such Zero toThree, The National Center for Infants, Toddlers, and Families, andthe World Association of Infant Mental Health—is well establishedboth in the United States and abroad. And, as attested to by all of thepapers in this section, neither the fact of the child’s age, nor the factthat the dyad presents for treatment are considered in any way im-pediments to analytic intervention. Indeed, the age of the child andthe mother’s active participation in the work are seen as crucial toprogress and early structural change (Fraiberg, 1981). And, in con-trast to traditional notions of psychoanalytic work, infant-parent psy-chotherapists routinely work in situations of risk and trauma, wherelittle about the environment can be contained or easily modulated.Circumstances once considered “unconventional” (Seligman, 1994)are now considered normative, albeit challenging, opportunities foranalytically oriented work.Essential to the infant-parent psychotherapy model is the notion

that in a disrupted mother-baby relationship there is some basic dis-tortion of the mother’s capacity to represent the baby in a coherentand positive way. Fraiberg introduced an idea that now underlies vir-tually all infant-parent work, namely that in troubled dyads themother’s representation of the baby has been distorted by unmetab-olized and unintegrated affects stemming from her own early andusually traumatic relationship experiences. The goal of infant-parentpsychotherapy is to disentangle these affects from the relationshipwith the baby. And, as in all psychoanalytic treatments, it is the rela-tionship with the therapist that leads to shifts in the mother’s repre-sentational world, and the ultimate “freeing” of the baby from themother’s traumatic projections. The parent-therapist relationship inan infant-parent psychotherapy is—from a traditional psychoanalyticperspective—somewhat unusual, primarily because of the concretesupports and guidance that are offered by the clinician within thissetting. At the same time, the notion of transference is crucial to un-derstanding how this relationship unfolds, and in anticipating thepitfalls inherent in the mother’s coming to trust and rely upon theclinician. Ultimately, and optimally, the therapist provides a crucialand transforming alternative to the mother’s previous relationshipswith caregivers; the experience of being heard and valued by the clin-ician frees her and the baby as well.Fraiberg’s work was to have an enormous impact outside of psycho-

analysis as well. Beginning with the publication of her seminal pa-pers, home visiting—although widely practiced in Great Britain and

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other Western countries since World War II, and in the tenements ofNew York in the early 1900s by public health nurses (Wald, 1915)—has become one of the most common approaches to improving psy-chological and developmental outcomes in high-risk mothers andbabies across most of the United States. Certainly David Olds and hiscolleagues’ Nurse Home Visitation program is the most effective andvalid of the many home visiting programs described in the literature(Kitzman, Olds, Henderson, et al., 1997; Kitzman, Olds, Sidora, etal., 2000; Olds, 2002; Olds, Hill, Robinson, Song, & Little, 2000). InOlds’ model, experienced public health nurses conduct frequenthome visits to first-time high-risk mothers and their infants begin-ning in the end of the second trimester of pregnancy and proceed-ing to the child’s second birthday. Like Fraiberg and her colleagues,Olds emphasized that the development of a therapeutic relationshipwith the home visitor is key to a number of positive mother and childoutcomes. Olds chose to use nurses rather than mental health pro-fessionals for a variety of reasons, the most central being his beliefthat they are perceived by families as highly informed and helpful,and are free of the stigma of mental health service providers. WhenOlds first began his work, nurse home visitors did not receive anytraining specific to mental health concerns; however, as the programhas evolved over the past twenty years, and the mental health needsof families have emerged with great clarity, nurses have received increasingly specific training regarding what might be called “psy-choanalytic concerns,” namely how to think about and work with the sequelae of severe trauma and relationship disruptions (Robin-son, Emde, & Korfmacher, 1997; Boris, Nagle, Larrieu, Zeanah, &Zeanah, 2002).While the infant-parent psychotherapy and NHV approaches dif-

fer in emphasis, they are nevertheless rooted in the fundamental no-tion that changing the quality of the mother-child relationshipthrough a transforming relationship with a clinician is key to improvingoutcomes for child and mother. In addition, both approaches pro-vide a range of ego supports for the mother, so as to improve thechances that—by completing her education, delaying further child-bearing, and gaining secure employment—she will be in the best po-sition to surmount the multiple stresses associated with urbanpoverty, and she will be able to serve as a secure base and facilitatingenvironment for her child. What the NHV program adds to the psy-choanalytic model of parent-infant work, however, is the emphasis onthe body and on physical care; despite the fact that the issues of thebody played a central role in classical psychoanalytic theory, this is an


aspect of development and of the mother-child relationship that hasnot been effectively integrated into psychoanalytically based infant-parent work. It is abundantly clear from the past two decades’ re-search that early trauma is profoundly disruptive to the developingindividual’s sense of physical integrity and wholeness (Herman,1992). Mind and body become inextricably intertwined, and thepathology of biology, arousal, and self-care cannot easily be distin-guished from disruptions at an internal, psychological level. For thatreason, we believed that it was essential to integrate the nursingmodel with the infant-parent psychotherapy model into a singular,unified model. We did this by creating a home visiting team that in-cluded 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, weused a variety of techniques—drawn from both nursing and infant-parent psychotherapy approaches—to deepen a mother’s under-standing and awareness of her baby’s mind, her baby’s body, her ownmind and body, and the exquisite and complex interrelationshipamongst 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 be-low. These cases1 will be used to describe some of the particular tech-niques we use to enhance reflective functioning within our model.Before turning to the cases, however, we will describe the programand 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 cul-tural and ethnic heritages, including African American, CaribbeanAmerican, Puerto Rican, Mexican, and El Salvadoran. This link tocommunity health care services is crucial, because programs that arenot adequately linked to services provided by local health providersand other community agencies risk becoming isolated and less effec-tive. In addition, Minding the Baby services are provided by master’slevel clinicians; we see this level of advanced training as crucial inpreparing clinicians to be able to assess and manage the complex

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1. We have created composite cases for reasons of confidentiality.

clinical issues involved in working with highly disadvantaged andtraumatized 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 pe-diatric nurse practitioner and a clinical social worker; both are in-volved in the recruitment and initial evaluation process, and both seemothers on a regular basis. Typically they alternate visits, beginningin the last trimester of pregnancy. Families are seen weekly until thebaby’s first birthday, at which point visits are tapered to every otherweek through the child’s second birthday.2 In some cases, themother may be visited by both clinicians in one week, or by one visi-tor consecutively when there are physical or mental health crises. Invarious times of crisis, visits may last hours, and—when the home istoo chaotic or disrupted—take place in locations as diverse as theneighborhood library or a fast food restaurant. Prior to beginningthe intervention, the clinicians receive extensive training in re-flective functioning; this includes exposure to relevant backgroundmaterials in psychoanalysis and attachment theory, a comprehensivereview of Fonagy’s work, and in vivo training in recognizing and iden-tifying different levels and types of reflective functioning. This train-ing is offered jointly, so that the nursing and mental health ap-proaches are always unified when considering the mother and baby.Since many of the families served by the program include adolescentmothers, the clinical team also receives extensive training and super-vision regarding the particular developmental and behavioral char-acteristics of teen parents (Sadler, Anderson, & Sabatelli, 2001;Sadler & Cowlin, 2003). Because thorough evaluation is crucial totesting the efficacy of Minding the Baby, mothers and babies are as-sessed at regular intervals over the course of their participation inthe program using a range of standard psychological, psychiatric,health, and developmental measures (see Slade et al.). Data fromthese 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 describewhat 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 con-straints, although extra visits are routinely offered in times of crisis or intensified de-mand.

2003; Grienenberger, Popek, Stein, Solow, Morrow, Levine, Alexan-der, Ibarra, Wilson, Thompson, & Lehman, 2004; Slade, 2002). Ourultimate goal is to help mothers acknowledge that the baby has abody and a mind of his own, and to learn—as a function of thisawareness—to tolerate and regulate the child’s internal states. Thework almost always begins in the therapeutic relationship, with theclinician holding the mother in mind so that she can begin to knowherself, only then slowly coming to know the child. We have foundthat it is our clinicians’ willingness to witness the mother’s world, towitness her emotions and her body, to hold these in a safe way in thehere and now, that makes the mother feel heard and ready to knowthe baby in all his complexity. This process—and its various permuta-tions—is manifest in the cases below.Fonagy and his colleagues have described reflective functioning or

mentalization as occurring along a continuum, from an absence ordenial of mental states, to a simple capacity to recognize basic feel-ings and thoughts, to the emergence of true reflective awareness,namely the capacity to understand behavior in terms of mentalstates, and to understand both the nature and dynamic interplay ofmental states (Fonagy, Target, Steele, & Steele, 1998; Slade, Grienen-berger, Bernbach, Levy, & Locker, 2004). Minding the Baby tries tohelp mothers develop this capacity, with each of the clinicians doingso in distinct, but complementary ways. The nurse provides ongoinghelp in relation to physical health and caregiving, while the socialworker provides infant and parent mental health services and socialservice support. At the same time, however, their roles overlap in anumber of ways, with both providing developmental guidance, crisisintervention, parenting support, and a range of concrete supportssuch as rides to work, emergency food, medical supplies, and thelike. As has been described again and again in the infant-parent psy-chotherapy literature, the very real needs of high-risk families re-quire that they be helped at many levels at the same time; this de-mands constant flexibility and collaboration on the part of thetreatment team (Lieberman, 2003; Seligman, 1994).As is true of all analytically based work, the development of a thera-

peutic relationship is at the heart of all parent-infant interventions.However, establishing productive alliances with abandoned and trau-matized women and their families is not easy. These alliances are reg-ularly disrupted by powerful and elemental transferential reactionson the part of mothers who have been betrayed and hurt by thosewho cared for them. The home visitors are repeatedly inundatedwith demands and crises (eviction, food shortage, domestic violence)

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that require immediate action. So often clinicians struggle with res-cue fantasies as well as feelings of futility and helplessness; often theyare intensely dysregulated by reports of violence to mothers and ba-bies alike. The clinical team’s ability to keep the “infant in mind” isoften challenged by the chaos, maternal pathology, and levels of ex-treme deprivation experienced by the family. Consistency—thebedrock of any therapeutic work—is difficult to achieve even at thelevel of maintaining regularly scheduled visits. Add to all these com-plexities the fact that the multidisciplinary team—while sharingcommon beliefs and values—does not always share a common lan-guage. Although the construct of reflective functioning providescommon ground for discussion, as do the guiding principles of ourmodel, there are nevertheless crucial differences in approach thatmust be managed against the backdrop of families prone to splittingand disorganization.The supervisory relationship—which sets the tone and parallels

developing therapeutic relationships—becomes critical to managingthese multiple levels of complexity. In Minding the Baby, the pedi-atric nursing specialist and clinical social worker are supervisedjointly; we see this approach as crucial to exploring the myriad diver-sions that threaten the clinical work. As a team, supervision is used toset priorities, identify barriers, and explore alternative routes to en-hance reflective capacities while addressing the concrete and physi-cal needs of the family. Without supervision that is both clinically fo-cused and personally validating, the team’s own reflective capacitiesare 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: bothhad babies as teenagers, and both of their childhoods were charac-terized by loss, trauma, and abandonment. At the same time, theirstories are different in important ways: they began the program withdifferent strengths and resources, and with very different opennessto internal experience. They differed in the degree to which theyhad developed capacities for reflective functioning, in levels of egoand self organization, and they struggled with different kinds anddepths of vulnerabilities; equally important, they had different levelsof 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 thedevelopment of mentalizing capacities in these two women. Both havemade—relative to their status at the beginning of the program—enormous progress. And yet both stories convey how complex and


vulnerable progress is for women living with such enormous externaland internal burdens. Both stories also convey how such complexityinvariably requires multiple and flexible levels of care, care that wefeel is best provided by the integrated, multidisciplinary model of-fered by Minding the Baby.

mia

We first met Mia at age seventeen when she was seven and a halfmonths pregnant. Mia and her boyfriend Jay—who was eight yearsher senior—were living with his family in a situation that was bothchaotic and overwhelming. Mia had been forced to move out of herhome when her mother discovered Mia was pregnant. Mia had beenthe great hope of her family; she had done extremely well in highschool, and was hoping to be the first member of her extended fam-ily’s generation to go to college. But Mia’s hopes for the future hadbeen dashed by the conception of her unplanned baby. She droppedout just months before her graduation from high school. The babysolidified Mia’s already estranged status from her single mother, whohad disapproved of her boyfriend, whom she saw as certain to derailher hopes and dreams for her daughter; as she put it: “You’re just an-other teen mother statistic.” Mia recalled, “This never was supposedto happen. I’m breaking everyone’s hearts.” What Mia’s solemn preg-nancy story evoked but omitted in her whispery voice was that per-haps 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. Shewas doing everything she could NOT to think about her baby, andwas awkward, distracted, and almost dissociated when asked aboutthe baby. “Oh . . . That.” While there were small glimmers of anticipa-tion of a new relationship—“I talk to my belly,” Mia could scarcely in-vest in this possibility. “I just hope I still have it by the time it’s five.”(Her own mother had lost custody of her when she was five.) At thesame time, Mia showed a number of indices of what we might call la-tent capacities for reflective functioning. While these were scarcelymanifest in relation to her thinking about the baby, she was able toreflect upon her initial denial of her pregnancy, and in so doing tosuggest a shift in her capacity to hold her complex emotions in mind:“I was in denial even up to my fifth month. I couldn’t sleep, saying, ‘Iknow I’m not pregnant.’ . . . I didn’t know what to do.” More strikingwas her ability to describe her own complex fears and worries aboutbecoming a mother, and—in particular—her feelings of being lost

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and overwhelmed. The depth and quality of her language, and hercapacity to vividly describe her pain led us to feel that as little as shewas able to imagine the baby, and keep any kind of a representationof a relationship in mind as she prepared for motherhood, she wasable to give voice to her own anxieties and sense of confusion. Thisproved to be a resource that was of great value to her once the babywas 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 throughlabor and delivery. Mia had little conception of the child’s concrete,physical needs, and when encouraged, for instance, to wash a babydoll in preparation for caring for her own child, she giggled uncom-fortably and abandoned the activity, embarrassed. Signs of depres-sion—which were to become far more pronounced after she gavebirth—were 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 boyfriend’s family. The home was dirtyand crowded with multiple relatives. The adults in the home were in-trusive and often inappropriate; Mia had to guard her and the baby’sfood carefully. TVs blared and there was the din of the distant con-versation. The progress that she had begun to make in pregnancy—reconciling a bit with her mother, beginning to give voice to herfears—began to slip away, as Jay became disinterested in being withthe new mother and baby.Her baby appeared well-cared for but Mia did not touch her read-

ily, and Noni remained alone in her crib. Mia muttered, “Shut up,”under her breath when Noni cried. Her movements were perfunc-tory and task-based. She admitted to crying daily, bathing less, andnot bothering to get dressed unless she had to go out. Mia was oftenpale, her eyes puffy from crying. She spoke with eyes downcast, dis-gusted with her isolation and feeling of uselessness. Within onemonth post-partum, the team felt that her depression had reached acritical level (likely as a function of biological as well as other fac-tors). As is very typical of the mothers we are working with, Mia wasaverse to seeking psychiatric treatment, leaving us with little choicebut to address her severe depression in a way that respected her pace,needs, and expressed wishes, but at the same time kept clearly in fo-cus the very real possible risks to the baby. We decided that the socialworker should see Mia weekly, so as to provide the level of mental


health services appropriate to the level of the psychiatric emergency.At the same time, we did not decrease nursing visits, which she wasstarting to use in a limited way. The last thing we wanted to do wasgive her less of anything, and we felt that the nursing visits’ focus ondevelopmental guidance and parenting support—keeping the babyalive for her in the here and now—was a crucial balance to the workof uncovering and discovering the pain of her past.With this shift, Mia began to find words for her despair, and she be-

gan to tell her story. While we had learned pieces of the story duringthe evaluation period and the first months of the intervention, it wasonly now, with the baby real, and Mia’s fragile denial and determina-tion shattered under the weight of reality, that she began to tell usabout herself in a more detailed and—finally coherent—way. Mia,an only child, was born to a heroin addicted mother who was herselfa teenage mother. Mia’s father died of a drug overdose when she wastwo; Mia was with her mother when she found him. When she wasfive, following years of neglect, she was removed from her mother’scare and placed in foster care for two years. Remarkably, her mothermanaged to get clean and bring Mia back to live with her. Despite herown drug problems, Mia’s mother was a strong, determined womanof enormous intelligence and perseverance who in her own way com-municated a fierce loyalty and love for Mia. In many ways, Mia’smother’s dreams had propelled her forward; at the same time, how-ever, Mia sabotaged and bridled at these dreams (the pregnancy be-ing a very clear example), and longed for the uncomplicated loveshe had never had.Over the course of the next few months, Mia began to forge a rela-

tionship with the social worker, giving voice to her feelings, and al-lowing herself to remember and describe moments and fears longforgotten. Week after week came the small but significant indicationsthat the capacity to identify and reflect upon her internal states hadbegun to take root. She could not talk about the baby, but she couldtalk about her childhood experiences; slowly she found words for theterror that was associated with these remembrances, and for her ownneeds for comfort and support. These were feelings she had all butdeleted from her awareness. First came the memories, and the feel-ings, and then came the effort to make meaning. She began to createa narrative, a story line that she could reflect upon, making meaningof the present in light of the past. The social worker worried thatdelving into such memories would be too painful and overwhelmingfor Mia, and she watched vigilantly for signs of traumatic stress. She

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did not push, but instead remained gently present, watching forMia’s glazing over, the sign that she had remembered and describedall that she could.At four months of age, Noni was an attractive and communicative

baby, who in many ways managed to ignite Mia’s maternal capacities.On occasion, she could elicit maternal traits in Mia such as affection,playfulness, and pride. Mia’s competence and efforts to attend to theroutine care, if not the emotional care, of the infant, were high-lighted and validated. “There’s no one else that can comfort her likeyou. Look how she’s gazing right at you as if to say ‘thanks.’” Thiskind of comment, repeated multiple times over multiple home visits,fed Mia on many levels, and acknowledged her importance to thebaby in ways that she herself could not yet recognize. Despite beingunable to recognize her baby’s experience, she was, however, able toexpress complex feelings about her: “I don’t regret the baby, but Iwish I didn’t 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 withher. She had at this point no capacity to recognize or tolerate fear ordistress in her baby (having not yet been able to articulate her ownfears and need for comfort), especially fear and distress that she her-self generated. Mia’s game of choice was to startle her infant, whichshe would do in a variety of ways. She would loom into the baby’s facequickly, smiling in a threatening way as she approached menacingly,or she would shove a shrill squeaking toy intrusively in her face. Miadelighted in this game, oblivious to Noni’s startled grimace andfrozen expression. Noni would attempt a false, scared smile, as if sheneeded to placate Mia and keep her at bay. Repeatedly, Mia raisedthe threshold for tension, but did little to soothe the frightened baby,re-enacting her own helplessness as a child. This scary experiencewas repeated again and again, with the other adults’ finding similarpleasure in startling and overwhelming Noni.Equally disturbing was the fact that not only did Mia fail to recog-

nize Noni’s fear, but that she viewed Noni’s response as false and ma-nipulative. Whenever Noni would become distressed—not only withthe startle game, but at times when she took a tumble or hurtherself—Mia would respond indignantly with some version of thefollowing: “Faker! Big fake-crier! You don’t fool anyone.” Thus,Noni’s self-experience was both disavowed and distorted within thecontext of her mother’s response; it is these kinds of early relationalexperiences that Fonagy and his colleagues (2002) so richly describeas fundamental to a child’s developing an abiding feeling of alien-


ation and emptiness. Even in these early months we could see Nonidissociated and frightened in interaction with her mother.The next task was clearly to help Mia recognize her baby’s fear and

distress, feelings that were at this juncture too threatening for Mia tosee, even in her own history. We began by trying to elicit curiosityabout the baby’s intent, “Why is she fake-crying? What could shewant by calling out to you?” Focusing on the baby’s intentions helpedMia slowly attend to the cues or events that led up to the baby’s dis-tress. It also served as a chance to allow Mia to reflect upon her ownexperience of the crying. “How does it feel when you think Noni istrying to trick you into paying attention to her?” Her responsesopened up a discussion about the “street’s” code of emanating fear-lessness, denying needs, and feeling excited by fear. After revisitingthese themes many times over, Mia began to explore the times inwhich she felt afraid, alone and/or felt like no one was taking herneeds seriously. Mia admitted that indeed her own obvious cries forhelp in dealing with the overwhelming demands of straddling ado-lescence and motherhood were not being heard.As the intervention proceeded, we did not approach these deficits

in Mia’s mentalizing capacities directly, of course, but rather beganby using the therapeutic relationship with the home visitors to givevoice to her own experiences of fear and distress. These therapeuticrelationships then became the platform from which she could viewthe baby’s experience—her intentions and affects—with increasingaccuracy and clarity, without needing to distort or misinterpret as ameans of protecting her own fragile sense of self. Mia’s willingness tohold the baby in mind was quite tenuous and fleeting at first, andhad to be nurtured in a variety of ways at all times, because her ten-dency to slip out of reflective awareness was so strong. Slowly, she be-gan to be able to step out of automatic reactions and timidly observeher child’s feelings. Noni began to be able to express a more ex-tended range of emotions toward her now more available mother.When the baby was thirteen months old, Mia moved back into hermother’s home. She made the choice to move away from the fatherof the baby because she believed it was a better environment for ababy. When asked, “Why now?” she replied, “She’s much happier. In theother home, she’d hold her hands over her ears, it was too much for her . . . Iwanted to for her. It was an easy decision.” Mia was making links be-tween the baby’s behavior (holding her hands over her ears) and in-ternal dysregulation (too much for her), and she saw herself as in-strumental in protecting the baby and providing her with a moreregulating and containing environment.

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tachment (Main & Solomon, 1986), but showed many signs of a se-cure attachment; this is a crucial marker of developmental and rela-tional consolidation. Mia is still an adolescent, one who has suffereda range of traumas in her short life. And yet, over the course of homevisits, we see the effects of these traumas diminishing in her day-to-day interactions with Noni. She finds pleasure in her, she plays withher, she inhibits her own instincts to frighten and overwhelm. Shecomforts her child and tolerates her distress. For the most part, Miacan hold Noni in mind.Despite Mia’s 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 Miakeep Noni in mind has been successful, and we can feel somewhatconfident that there are protective factors in place for both Mia andNoni 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 secondtrimester of her pregnancy. She was accompanied by the father ofher baby, a 20-year-old man with a previous history of substanceabuse and incarceration. During the two-hour class Iliana remainedattentive but maintained a skeptical distance from others in thegroup. Indeed, distance and anger were to characterize Iliana’s cen-tral struggles, both as they were manifested internally and in relationto the team. In contrast to Mia, who from the beginning had some ca-pacity to hold complex mental states in mind, Iliana was overtly moreangry, more defended, and much less able to tolerate and describeher internal world. She had survived a childhood deeply marred bychaos, poverty, and violence. Her mother had left the family when Il-iana was five. Her father, deeply involved in drugs and alcohol, er-ratic and sometimes violent, had been her sole caregiver. She was sex-ually abused by her grandfather. However, the abandonment by hermother—of whom she spoke with bitterness and rage—was a defin-ing moment for Iliana, a scar that would not heal. Iliana’s defenseagainst pain was to threaten and push away anyone who got close toher. She was proud of her toughness, her readiness to fight and estab-lish her dominance on the street. She readily described herself as thekind of person who would act before she thought, and was clearlypleased at her capacity to frighten and intimidate people. At thesame time, though, impending motherhood had stimulated—as it so

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often does—the wish to mother differently than she herself hadbeen mothered. Iliana wondered aloud if she could learn to be thekind of mother the baby could count on. “I know I’ve got to changeand not just walk away or not talk when I’m mad. It’s not just me andwhat I want anymore.” This snippet of mentalization, in which shelinked her behavior to internal experience and recognized that herown 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.” Shehad only known the father of the baby for several months and thepregnancy was unplanned. Their relationship was evidently troubled,although it was not until much later in the work that we knew justhow troubled. She had little expectation of support from him(“maybe he’ll buy diapers”) and obviously felt let down and alone.Despite leaving high school during 10th grade, Iliana was—likeMia—clearly an intelligent and articulate young woman. Also likeMia, she longed for work that would give her a sense of purpose andmeaning.Unsurprisingly, it was very difficult to establish a therapeutic rela-

tionship with Iliana. Her armor—manifested in her attitude—wasthick and tough. During the prenatal phase, she routinely failed toshow up for appointments. She never called to cancel, but whenphoned to reschedule, she always appeared interested in setting upanother meeting. We viewed this ambivalence in a positive light (atleast she was ambivalent), and she continued to reschedule appoint-ments, well aware that she would fail to keep more than half of them.We hoped that our continued presence signaled a willingness tomeet 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 con-tinuously as treatment proceeded, and the first of many times thatour clinicians would have to remind themselves that her resistancewas 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 don’t know why,” she remarked. In this circumstance it was hardto make baby “real” to the young mother-to-be, except as the reasonshe had to stop “hanging out at clubs.” To stimulate her thoughts andfeelings we looked at pictures of newborns and discussed commoninfant behavior that is often of concern for new parents. Looking atthe life-sized photo of a brand new baby, Iliana was finally able tospeak of her fears. “It’s hard to picture the baby. I’ve never held a lit-


tle baby. They are so small they look like they can break. And whenthe baby cries—I might get mad or nervous and just walk away!” Em-bedded in these comments were signs of another set of difficultiesthat were to recur throughout all phases of the treatment, namely Il-iana’s profoundly disrupted sense of her body. The new and frighten-ing bodily sensations and discomforts of pregnancy made her feelout of control and angry. She was terrified of labor, and particularlyfrightened of the feelings of powerlessness and vulnerability that itwould engender; these feelings can be especially poignant in womenwho have been sexually abused and who find labor retraumatizing.As might be expected, Iliana’s feelings about her own body were tolater define her feelings about and insensitivity to her baby’s body.Giving birth was an empowering experience for Iliana. Anticipat-

ing the terror she would feel giving birth, the nurse practitioner de-veloped a labor plan with Iliana that allowed her to make choicesahead of time about medication, restraint, and other aspects of thedelivery (Simkins, 2002). The labor was difficult, but the laborplan—which was supported fully by the midwifery team—allowed Il-iana to feel in control of her experience. She was extremely proud ofherself, and her daughter was easy to feed and console. The newmother held the baby—a girl named Lucia—closely, gazing warmlyinto her eyes and imitating her facial expressions. We pointed outhow she was able to make the baby feel safe by holding her close andhow she was learning to read the infant’s cues to comfort her. Ilianawas enormously pleased that she could regulate the baby’s states toreduce her crying episodes without becoming overwhelmed herself.Given Iliana’s tough veneer, and her enormous resistance to treat-ment, we had not allowed ourselves to hope for such an auspiciousbeginning. But as so often happens, Iliana got an important develop-mental nudge from her easy little girl.This positive beginning helped Iliana become more open to devel-

oping a relationship with the Minding the Baby team; however, un-like Mia—who was able to form a relationship that allowed her tomove toward reflective understanding in relation to her baby—Ilianaand her relationship to us was defined by her concrete needs and de-mands on the one hand and by her angry resistance on the other. Onthe one hand, there were moments when she could be tender towardher daughter. At these times, however, Iliana was also reminded ofher own loss, of not having been nurtured and protected by her ownmother. Iliana said she longed to “be a little girl all over again. Not tohave the childhood I did have, but to have someone take care of me.”As a consequence, she often could not tolerate the baby’s need for

Minding the Baby 93

care and comfort, and experienced Lucia as demanding and needy.The baby’s distress irritated her, and she would handle her abruptlyand speak to her harshly. We observed her roughly awaken the babyto change her diaper or harshly tell the baby to “shut up” when shewhimpered. She misattributed the baby’s facial expressions of dis-comfort 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 thusintolerable. It was very hard to help her at these moments, mostlikely because our giving voice to the baby’s feelings made them evenmore unbearable. She took our “talking for the baby” as criticism,and responded with surly adolescent mumbling. Any hint of “correc-tion” on our part (try though we might to remain benign and non-judgmental) would trigger Iliana’s hostility and defensiveness. Atsuch moments, she was extremely resistant to new ideas or ways of in-teracting with the baby. We had to work around her defenses.Iliana’s profoundly disrupted sense of her own body also inter-

fered with her ability to see the baby’s needs as reasonable and sepa-rate from her own. Many times we would come to the home to findher disheveled, her hair uncombed, wearing her torn nightclothes.There were signs of neglect. Lucia was basically healthy, fed, andclean, but Iliana routinely failed to follow through on caring for whatshould have been routine physical care for her child. Lucia hadeczema, and on several occasions both mother and child had ad-vanced cases of ringworm. With her eczema untreated, the baby of-ten had a number of raised, scaly patches of skin and was irritableand uncomfortable, which she would scratch continuously. Ignoringthe baby’s distress, Iliana instead complained of her own numerousphysical complaints, and reprimanded her daughter for scratching.In thinking about how to help Iliana become more sensitive to her

child’s bodily needs, we remembered that her relationship with themidwife during her pregnancy allowed her to feel someone cared forand she respected her body for the first time in her life. We wanted tobuild on this new experience and find ways to demonstrate accep-tance of the mother’s body (and, therefore, her whole being) in acaring way during home visits. Addressing Iliana’s needs first, thenurse practitioner spent time at each visit asking about her symp-toms, using questions about her past and current activities, nutrition,and abuse, to help the young woman make tentative connections be-tween her feelings, symptoms, and self-care. We found that the morethe young mother’s pain was acknowledged, “heard,” by the clini-cians, the more able she was to understand her daughter’s needs andexperience.


Unlike Mia, who from the start could—at least in a limited way—engage in the struggle to understand her history, her relationships,and her emotional experience, we had to approach Iliana throughher body, and through her concrete needs. She could not work at ametaphoric or abstract level. When we tried to talk to her about herfeelings about her life experience, she would become enormouslysleepy and actually appear to doze off. Mentalization could only takeplace at a very concrete, protosymbolic level (Werner & Kaplan,1963). But as we did this, she began to involve us more directly inhelping her. It turned out that Lucia’s father had been abusing Ilianathroughout the pregnancy, and he was now continuing to physicallythreaten her. This was the other side of Iliana’s toughness: the para-lyzed victim. Once she disclosed his abuse to us, she was able to use usto help her obtain an order of protection, and to support her desireto protect her baby. At this time she became more overtly dependentupon the home visitors, and in particular needed a great deal of so-cial service help to obtain a place to live as well as a variety of socialservice benefits. Her extreme neediness was experienced by thehome visitors as a continuing volley of demands, within the contextof which they had to continuously work to keep the baby in mind for Iliana. These demands only increased when we decreased thenumber of regular home visits when Lucia turned one (a standardtransition in the Minding the Baby protocol). She responded withovert indifference and appeared to pull sharply away, but she beganto call us nearly daily with minor and major crises. Iliana the toughand defended young woman who needed no one could not getenough of us.Over time Iliana has slowly become more aware of her baby’s expe-

rience. When Lucia was 15 months old, Iliana, her new boyfriend,and the baby moved into a tiny apartment of their own. Iliana com-plained that the toddler was “always in the way. Always trying to dowhat I am doing. It makes me crazy!” The nurse practitioner broughtover a small plastic tub and a few containers for the little girl to playin, and asked the mother to follow the baby’s lead while she herselfwashed the dishes. Imitating her child’s actions, Iliana suddenly“saw” what the child was doing. In imitating her daughter’s splashesand play with soap bubbles, she laughed and exclaimed, “Oh! This isfun!” She had a sense of the child’s internal experience at that mo-ment and recognized that the sharing of the experience broughtthem closer together. She was able to express this feeling to her childby having a short conversation about what they were doing. This real-ization has sometimes spilled over into other parts of their life to-gether. Recently Iliana laughingly described her daughter as “being

Minding the Baby 95

her own little self.” Iliana had been outside watering the flowers inthe garden, and—anticipating her child’s desire to be included—had dressed her in a swimsuit. She had understood and accepted herbaby’s desire to be nearby and involved with her, as well as to exploreher expanding world. The child’s jubilant response served to rein-force and build on her mother’s 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 com-munity health center for routine medical care instead of going to theER. She has a relationship with her primary care providers, facili-tated by the nurse practitioner, who has served as a bridge betweenclinic and mother in an ongoing way. For Iliana, who has in the pasttried to control her body and that of her baby’s as a means of regulat-ing her fragile sense of self, the willingness to allow others to care forher and her body is crucial.As is captured in Iliana’s own words at the opening of this paper,

we also began to see signs of limited reflective functioning across anumber of domains. While significantly less widespread and deeplyheld than Mia’s capacity to understand and hold her baby in mind,there were signs that she had begun to understand that there was ababy to be known. She tentatively acknowledged that she had begunto allow the home visitors to get to know her, and to witness her expe-rience. She has acknowledged the power of her mother’s abandon-ment and her own unrequited longings for love and simple care. Shebegan to talk about her child’s needs and understanding as being dif-ferent from her own. Thus, even though these reflective capacitiescan easily disappear in an instant when she becomes angry or threat-ened, it is nevertheless becoming more natural to her to think aboutthe baby in this way.At the same time, it is important to acknowledge that there are

profound limitations to Iliana’s reflective capacities, even after nearlytwo years of treatment. Unlike Mia, Iliana has not been able to de-velop and rely upon a narrative—a story of herself—that helps herto contain and make sense of her complex emotional experience.The understanding she does have often fragments under the inten-sity of her feelings. These kinds of phenomena have been describedby Fonagy (2000) as typical of individuals who have suffered exten-sive trauma and who would be diagnosed with a borderline personal-ity disorder. This is certainly a meaningful way to describe Iliana. Shecan still be openly neglectful of Lucia, and very harsh with her, al-though now she yells instead of slaps. Nevertheless, we worry that wewill have to get child protective services involved, as there continue


to be multiple signs that Lucia is often in danger, either from Iliana’sneglect or for Iliana herself. We understand the limitations of Iliana’savailability to treatment as a function of multiple factors, most promi-nent being past and ongoing trauma and the lack of a stable, lovingcaregiver. In addition, Iliana had endured continuous disruptions inher sense of bodily integrity and wholeness; often, these assaults hadbeen at the hands of those who were responsible for caring for her.

Discussion

As she approaches her child’s second birthday, Mia has begun tohold her child in mind. Iliana’s abilities to do this are far more com-promised and fragmented, although she too has discovered reser-voirs of pleasure in and identification with her child that are crucialand even miraculous. Developmentally, these young women beganMinding the Baby with significantly different capacities for reflectivefunctioning and mentalization, with Mia—while quite defended—the more ready of the two to think in a complex way about her inte-rior life, and about the dynamic relationship between her feelingsand actions. While certainly no stranger to trauma, Mia had man-aged to escape the physical trauma and abandonment that had dev-astated Iliana, and had found crucial comfort and safety in her rela-tionship with her mother, who in her own narcissistic fashion kepther 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 acknowledgingmental states, and occasionally holding their interconnectedness inmind.Our multidisciplinary model allowed us to approach these differ-

ences in a flexible way, to balance the nursing and infant-parent psy-chotherapy approaches in response to different kinds of supportsthese mothers needed at different times. Mia was more ready tomake use of a more traditionally therapeutic relationship with thehome visitors; the first real shift in her treatment came in beginningto tell her own story to the social worker. She required relatively littlehelp with physical care, but instead relied upon the nurse practi-tioner’s expertise in parenting and child development. Iliana, on theother hand, needed a great deal of practical help from the nursepractitioner, and only when she had established an almost physicaldependency upon this concrete level of mothering from the teamwas she able to begin to take in any developmental guidance or par-enting support. She used the social worker to help her obtain social

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services, again needing this kind of very concrete help to support anyreflective capacity whatsoever.We think that the progress made by the mothers and babies in our

program has come—finally—from our home visitors’ capacity tohold their bodies and feelings in mind, to witness their pain andtheir anger without dysregulation and retribution, and to keep thebaby alive for the mother in the face of relentless chaos and uncer-tainty. As we hope we have been able to convey in our description of amentalization based, multidisciplinary mother-infant interventionprogram, this is complex work indeed.

BIBLIOGRAPHY

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Bateman, A. W. & Fonagy, P. (2004). Psychotherapy for borderline personalitydisorders: Mentalization based treatment.Oxford: Oxford University Press.

Boris, N., Nagle, G., Larrieu, J. A., Zeanah, P. D., & Zeanah, C. H. (2002).An innovative approach to addressing mental health issues in a nurse home visit-ing program. Paper presented at the Tulane University Health SciencesCenter, New Orleans.

Fonagy, P. (2000). Attachment and borderline personality disorder. Journalof the American Psychoanalytic Association 48:1129–1146.

Fonagy P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation,mentalization,and the development of the self. New York: Other Books.

Fonagy, P., Steele, M., Moran, G., Steele, H., & Higgitt, A. (1991). Thecapacity for understanding mental states: The reflective self in parent andchild and its significance for security of attachment. Infant Mental HealthJournal, 13, 200–217.

Fonagy, P., Steele, M., & Steele, H. (1991). Maternal representations of at-tachment during pregnancy predict the organization of infant-mother at-tachment at one year of age. Child Development, 62, 891–905.

Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Mattoon, G., &Target, M. (1995). Attachment, the reflective self, and borderline states:The predictive specificity of the Adult Attachment Interview and patho-logical emotional development. In Attachment Theory: Social, Developmentaland Clinical Perspectives, ed. S. Goldberg, R. Muir, & J. Kerr. Hillsdale, N.J.:Analytic Press, pp. 223–279.

Fonagy, P., & Target, M. (1998). Mentalization and the changing aims ofchild psychoanalysis. Psychoanalytic Dialogues 8:87–114.

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective function-ing manual, version 5.0, for application to adult attachment interviews. London:University College London.


When Noni was 14 months old, 17 months after Mia’s entry intothe program, the social worker reviewed a videotape that had beenmade of Noni and Mia interacting when Noni was 4 months old. Miawas obviously troubled in watching the tape, and noted readily howinsensitive she had been to Noni’s cues—“I had no idea what shewanted, I couldn’t read her . . . I see now that her crying was to tellme she’d had enough . . . here I can see her face sad telling me whatI didn’t know, that she may have been hungry or sleepy . . . She’s try-ing to tell me she’s scared, and I’m just in her face, scaring her.”While Mia tried throughout the sessions to minimize and deflectsome of the guilt she felt in recognizing her failure to hold Noni inmind, she was nevertheless fully cognizant of the fact that she was ig-noring signs of distress that she was readily able to identify in retrospect. Thisreaction 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 shecould tolerate. At the same time, it is important to highlight the factthat the work was taking place on many other levels as well. Mia wasoverwhelmed by her living situation, and we worked in a variety ofways to help her make Jay’s family home safer for the baby. Thismeant she first had to recognize that the baby required safety andthat she could participate in providing that. Filters were providedthat protected the baby from the smoke in an environment whereeveryone smoked cigarettes. She needed help with travel to and fromschool, with birth control, with obtaining food for the baby, and withbasic caretaking skills. We brought toys and baby books, and taughther how to play with the baby. She had several frightening blow upswith Jay (who had a history of violence), which required our help insorting out. All reflective work took place against this backdrop ofconcrete support and education: help in stress reduction, vocationalplanning, safety procedures, medical care, and the like. Withoutthese levels of support, the therapeutic work would have been utterlyimpossible.Noni is now 20 months old, and Mia is living in her mother’s clean

and orderly home. Jay is still firmly in the picture; indeed, he is oftenpresent at home visits, and is proud of his understanding of develop-ment, as well as the mutual feelings of love and attachment that heand Noni obviously have for each other. Noni is clearly a loved child,cherished by the extended family on both sides. When seen in theStrange Situation (Ainsworth, Blehar, Waters, & Wall, 1978), a labo-ratory based separation procedure that is used to assess infant attach-ment status, Noni was not classified as disorganized in relation to at-


home visiting for pregnant women and parents of young children. CurrentProblems in Pediatrics, 30,109–141.

Olds, D., Robinson, J., O’Brien, R., Luckey, D., Pettitt, L., Henderson,C., Ng, R., Sheff, K., Korfmacher, J., Hiatt, S., & Talmi, A. (2002).Home visiting by paraprofessionals and by nurses: A randomized con-trolled trial. Pediatrics, 110, 486–496.

Robinson, J., Emde, R., & Korfmacher, J. (1997). Integrating an emotionalregulation perspective in a program of prenatal and early childhoodhome visitation. Journal of Community Psychology, 25, 59–75.

Sadler, L. S., Anderson, S. A., & Sabatelli, R. M. (2001). Parental compe-tence among African American adolescent mothers and grandmothers.Journal of Pediatric Nursing, 16, 217–233.

Sadler, L. S., & Cowlin, A. (2003). Moving into parenthood: A program fornew adolescent mothers combining parent education with creative physi-cal activity. Journal of Specialists in Pediatric Nursing, 8, 62–70.

Seligman, S. (1994). Applying psychoanalysis in an unconventional context:Adapting infant-parent psychotherapy to a changing population. Psycho-analytic Study of the Child, 49, 481–500.

Simkin, P. (1992). Overcoming the legacy of childhood sexual abuse: Therole of caregivers and childbirth educators. Birth, 19, 224–225.

Slade, A. (2002). Keeping the baby in mind: A critical factor in perinatalmental health. In a Special Issue on Perinatal Mental Health, A. Slade, L.Mayes, & N. Epperson, Eds. Zero to Three, June/July 2002, 10–16.

Slade, A. (in press 2005). Parental reflective functioning: An introduction.Attachment and Human Development.

Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A.(2003). Addendum to the reflective functioning scoring manual for use with theParent Development Interview. New York: City University of New York.

Slade, A., Sadler, L. S., & Mayes, L. (2005). Minding the Baby: Enhancingreflective functioning in a nursing/mental health home visiting program.In L. Berlin, M. Cummings, & Y. Ziv, Eds. Enhancing early attachments,pp. 152–177. New York: Guilford Publications.

Slade, A., Sadler, L. Mayes, L., Ezepchick, J., Webb, D., De Dios-Kenn, C.,Klein, K., Mitcheom, K. & Shader, L. (2004). Minding the baby: A workingmanual. New Haven, Conn.: Yale Child Study Center.

Stern, D. N. (1995). The motherhood constellation: A unified view of parent-in-fant psychotherapy. New York: Basic Books.

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Werner, H., & Kaplan, B. (1963). Symbol formation. New York: Wiley.Winnicott, D. W. (1965). Maturational processes and the facilitating environ-

ment. New York: International Universities Press.


“In a Black Hole”: The (Negative)Space Between Longing

and Dread

Home-Based Psychotherapy with aTraumatized Mother and Her Infant Son

JUDITH ARONS, LICSW

This paper offers fragments from the first year of a home-based mother-baby psychotherapy, in which I attempted to help a traumatized anddissociated mother to emotionally engage with her infant son. Thetreatment was organized in part around certain developmental objec-tives common to both attachment and psychoanalytic theory. These in-clude: The ability to name and metabolize feelings, to evoke a soothingmaternal introject, and to relate to the partner’s mind as a separate,understandable center of initiative and intention. In addition, attach-ment theory, with its emphasis on the critical psychobiological role ofcontaining fear and distress in infancy, was a useful guide in formu-lating the treatment. The paper reviews research findings on mother-

Senior faculty member of the Infant-Parent Training Institute at Jewish Family andChildren’s Service of Waltham, Massachusetts, and a lecturer at Simmons GraduateSchool of Social Work, and member of the Boston Psychoanalytic Society and Insti-tute and the Massachusetts Institute for Psychoanalysis.

I gratefully acknowledge Karlen Lyons-Ruth, Ph.D., for her invaluable clinical andeditorial 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 Relation-ship Support at the Jewish Family and Children’s Service of Waltham Massachusetts,for making it possible, and Mary and John for showing me the way.


101

infant pairs described as frightened-disorganized, discusses some of thechallenges encountered in home-based mother-infant psychotherapyand then discusses the case of Mary and John. The case illustrates howmother-infant psychotherapy may interrupt the intergenerationaltransmission of disorganized attachment by working within the coupleto name, metabolize and flexibly respond to painful, dissociated orfrightening experiences.

this paper offers fragments from the first year of a mother-baby psychotherapy in which I attempted to help a traumatized anddissociated mother to emotionally engage with her infant son. Mywork with Mary and John was organized in part around certain devel-opmental objectives common to both attachment and psychoanalytictheory. These include: the ability to recognize, to name, and to me-tabolize feelings; the ability to evoke a soothing maternal introject toaid in containment and integration of self states; and the ability to beaware of and to relate to the partner’s mind as a separate, under-standable center of initiative and intention. Attachment theory, withits emphasis on the critical psychobiological role of modulating andcontaining fear and distress in infancy, was a useful guide in formu-lating the treatment with this terrified mother and her emotionallydisorganized son. In this first year of our work we attempted to ex-pand emotional communication and to enhance feelings of securityand reliability both within the mother-baby couple and betweenmother and therapist. The clinical cornerstone of my approach wasto track carefully to each individual’s emotional state and to howeach of us co-regulated our present intersubjective experience(Stern, 2004). Whenever possible we attended in the moment to therelationship between mother and baby, mother and therapist, babyand therapist, and baby, mother, and therapist together. This atten-tion to relating in the present included my assumption that past anddeeply private psychic experiences were summoned by and alsohelped to shape the current moment. The paper begins with a reviewof research findings on mother-infant pairs in which the infant’s at-tachment is described as disorganized and the mother’s caregiving asfrightened or helpless. I will briefly describe some of the challengesof home-based mother-infant psychotherapy and then move on tothe case and discussion.

There are relatively few case studies describing the psychoanalyti-cally informed treatment of frightened/disorganized mother-infantcouples, and we have little clinical data documenting the therapeu-tic outcomes of such interventions. It is my belief that within fright-

102 Judith Arons

ened/disorganized dyads, mother-infant psychotherapy may inter-rupt the intergenerational transmission of disorganized attachmentby working within the couple to name, metabolize, and flexibly re-spond to painful, dissociated or frightening affective experiences.The resulting increase in mother and baby’s affective competence(Russell, 1998) paves the way for further growth of intersubjective re-lating between them.

The Infant’s Experience of Disorganized Attachment:Research Findings

Disorganized attachment in infants is defined as the child’s inabilityunder stress to maintain a consistent strategy that engages the pri-mary caregiver in the service of regulating arousal and receivingcomfort and protection (Main and Hesse, 1990a). The baby’s rela-tional strategy breaks down or cannot form, due to an irreconcilableemotional paradox within the caregiving dyad: his primary attach-ment figure is at once the source of his fear and his refuge from it(Main and Hesse, 1990a). In the research lab, stressful separation-reunion experiences of the Strange Situation highlight the contradic-tory behaviors indicative of disorganized attachment. Despite upsetduring her absence, the infant, upon reunion with mother, appearsto be dysphoric, apprehensive, or helpless, and he exhibits conflictedbehaviors that include wandering in a disoriented state, making slow-motion underwater movements, and approach-avoidance or stilling/freezing in a dissociative-like response (Lyons-Ruth, Bronfman andAtwood, 1999b, Lyons-Ruth and Jacobvitz, 1999a, Main and Hesse,1990a, Main and Solomon, 1990b). Sometimes the infant exhibits anunusual combination of attempts at approach coupled with odd orinexplicable gestures (Lyons-Ruth and Jacobvitz, 1999a).

Frightened Mothers of Disorganized Infants:Research Findings

Mothers who struggle with unresolved trauma and loss are at highrisk for unwittingly engendering attachment pathology in their in-fants. Researchers have categorized these mothers as hostile/help-less or frightened/frightening, and link mother’s “unresolved” stateof mind with regard to trauma and loss to the formation of disorga-nized attachment in her infant (Main and Hesse, 1990a, Lyons-Ruth,Bronfman, and Atwood 1999b). While researchers agree that there isa correlation between mother’s unresolved state and her ability to

“In a Black Hole” 103

provide responsive and consistent infant care, there is disagreementon the mode of transmission of disorganized attachment. For exam-ple, Main and Hesse hypothesize that “The traumatized adult’s con-tinuing state of fear together with its interactive/behavioral con-comitants (frightened/frightening behavior) is the mechanismlinking unresolved trauma to the infant’s display of disorganized/disoriented behavior” (1990a, p. 163). They speculate that whenmother is frightened or helpless her emotional withdrawal leads todysregulation in her infant. Taking a slightly different tack, Lyons-Ruth and colleagues speculate that the infant’s inability to maintain acohesive attachment strategy is actually the echo of his mother’s con-tradictor affective cues (personal communication, 2002).

My discussion will focus on the frightened/disorganized subgroupof mothers and their infants. Unlike mothers who display overt hos-tile or intrusive behaviors toward their babies, frightened mothersappear dissociated, preoccupied, and tentative. On the behaviorallevel mother’s responses to the Strange Situation demonstrate subtle,contradictory reactions to the child’s bid for comfort and care, likestepping away while speaking in a soothing tone (Lyons-Ruth, Bronf-man and Atwood, 1999b, Schuengel and Bakermans-Kranenberg etal., 1999). Her emotional cues are incongruent or non-responsivesometimes with sudden loss of affect (Lyons-Ruth and Jacobvitz,1999a, Schuengel and Bakermans-Kranenberg et al., 1999). She mayappear disoriented or confused by the child’s behavior, or react tobaby in a helpless, frightened, deferential, or sexualized manner(Main and Hesse, 1990a, Schuengel and Bakermans-Kranenberg etal., 1999). On the representational level, mother’s performance onthe Adult Attachment Interview reveals unmonitored lapses of rea-son and coherence in discourse, affective incongruence, intrusioninto consciousness of dissociated material, and multiple and discon-tinuous inner representations (Lyons-Ruth and Jacobvitz, 1999a,Main and Hesse, 1990a). Liotti’s work has noted the similarity ofthese responses to dissociative processes in adults (1999, 1992).

From a clinical perspective, mother’s caretaking appears parentcentered and organized around her defensive exclusion of painfulfeelings (Schuengel and Bakermans-Kranenberg et al., 1999, Lyons-Ruth, Bronfman and Atwood, 1999b). Along with unintegrated inter-nal representations and difficulty regulating her own affect, mother’sunresolved state of mind impairs her ability to respond to baby’s cuesin a sensitive and non-conflicted way (Schuengel, and Bakermans-Kranenberg et al., 1999) and impedes her capacity to repair affectivedisruptions within the dyad (Lyons-Ruth et al., 1999). Mother de-

104 Judith Arons

fends herself against the threat of her baby’s fearful expressions andhis need for comfort by restricting her awareness of his state (Lyons-Ruth, and Jacobvitz et al., 1999a). She is hindered in providing theadequately attuned affective envelope that would instill an experi-ence of “felt security” in her baby. Mother also shows impairment inself-reflective functioning and in her ability to reflect upon her childas a separate individual with a unique inner life. Self-reflective capac-ities are thought to be among the key mediators in the transmissionof secure attachment (Fonagy, 2001, Fonagy and Target, 1997, Fon-agy and Steele, et al., 1991).

Frightened/disorganized mother-infant dyads teach us of the pro-found impact of attachment disturbance and chronic fear upon thedevelopment of psychological processes and psychic integration. Dis-organized attachment places infants at serious risk for impaired af-fect 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 At-wood et al., 1999b, Liotti, 1999 & 1992, Bleiberg, 2002), excessivelycaretaking, controling, or frankly aggressive behaviors (Lyons-Ruthand 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 representa-tions (Fonagy and Gergely, et al., 2002, Fonagy and Target, 1997, Li-otti, 1999 & 1992, Main, 1991), impairment of mastery motivation,autonomous exploration, and problem-solving (Bretherton and Wa-ters, 1985), poor self-reflective functioning (Fonagy and Target,1997, Fonagy and Steele, et al., 1991) and compromised cognitivefunctioning (Moss and St. Laurent, et al., 1999).

Chronic and unresolved fear leaves its indelible imprint upon neu-rological and psychological functioning. The impact of chronic fearon brain development and functioning, stress arousal systems, andphysical and mental health has been well documented. Negative se-quelae of Type Two (chronic) trauma in childhood include rela-tional disturbances, dissociation, profound affect dysregulation, in-ner fragmentation and compromised cognitive functioning, andliving with sickening dread or unremitting sorrow (Terr, 1991).

Some Challenges Encountered inMother-Infant Psychotherapy

Before discussing the specifics of therapeutic work with frightened/disorganized dyads, I will broadly describe some of the challenges en-


countered in mother-infant work. Home-based mother-infant psy-chotherapy provides a “living laboratory” in which to substantiate orto disprove the rich data generated in the infant research lab. Unlikethe relatively controlled conditions of the infant lab, mother-infantintervention takes place in the freewheeling realm of the home. Itmakes therapeutic use of improvisation and surprise. The work re-quires a holistic, versatile, and dialectical approach buttressed by allthat we have learned from relational, developmental, neurological,and biological systems theories.

This is couples treatment in which one member is wordless andcommunicates through the language of body and affect. Baby’s non-verbal communication drives the therapeutic triad deeply into the affective, implicit domains of experience, while also stimulating ex-ploration within the reflective, symbolized domains. Home-basedmother-infant treatment parallels the work that parents do daily inraising their children: We attempt to feel what it is that baby is ex-pressing, as we also try to name it, give it meaning, and hold it inmind. Of course we also attempt to feel what the baby stimulates inhis mother, name it and hold it in mind, but this is a more familiar as-pect of psychoanalytic work with adults.

The therapist’s experience is one of joining a constantly shiftingrelational system that moves between poles of repetition and trans-formation (Lachmann, 2001). This system and the treatment arefilled with paradox. There is the infant’s press to develop, to accom-modate, and to emerge as an individual within the mother’s morefixed psychic system. There is mother’s need to be recognized as theindividual she is. She struggles with this need in the midst of her ownnegative representations and in face of her baby’s real and constantdemands. Mother’s childhood experiences tie her to the past, evenas she struggles to break these ties and move into the future with herchild. Her relationship with baby lays bare her difficulty in develop-ing those processes that would help to contain painful feelings andmaintain consistent and sympathetic attachments. She longs to giveher child a better life, but is mired in chronic difficulties that taketime to recognize and to rework.

For the therapist, the responsibility of intervening in the life of avery small child is great. She must live within the paradoxes of actingversus waiting, proscribing behaviors versus enabling them toemerge, moving into the future while honoring the past. Baby’sneeds are such that he cannot wait for his mother to change. Hispresence in the session coupled with his developmental dynamismand very real dependency exert tremendous pressure upon both

106 Judith Arons

mother and therapist. This pressure stimulates intense transference-countertransference responses, and lends transformative power tomother-infant work.

The Frightened/Disorganized Dyad: A Clinical Perspective

Frightened/disorganized mother-infant pairs can present a confus-ing clinical picture and each dyad is unique. The pathogenic interac-tions that occur are more difficult to see than the easily observed hos-tile-coercive behaviors found in other disorganized couples. Oneobserves a number of positive mother-baby interactions and fewovert fear-inducing behaviors. In many cases one initially senses asubtle climate of misattunement. The extent to which this climate re-flects disorganization takes time to assess.

The frightened mother’s eagerness for professional help can in-flate assessment of her capacity for relatedness. In the home one be-gins to notice mother-baby interactions that are shaped according towhich emotions mother can tolerate. It is often the infant who is re-sponsible for approaching her. Careful observation reveals a mixedpicture of maternal gentleness and sensitivity combined with affec-tive miscommunications, or sudden loss of affect and attention.When mother struggles with dissociative states or impaired related-ness, she will be unable to consistently keep her baby in mind. Emo-tional blank spaces or “black holes” may exist within the dyad. Thesepockets of emptiness can be hard to observe in a rapidly moving rela-tional scenario that also contains positive mother-baby relating. Un-like hostile mothers who may overwhelm baby with their intrusiveand undifferentiated responses to his distress, frightened mothersmay miss the distressed baby’s cues altogether, or respond in a con-tradictory, deferential, or helpless manner. This failure to provideconsistent affect regulation can send the infant into emotional free-fall. During these moments he may be overwhelmed by uncontainedor unmirrored experience.

Mother and baby interact differently in the various domains ofcare, which take time to observe and to assess. Negative or dysphoricexchanges may stress mother’s capacity to remain sensitively engagedmore than interactions that are positive or neutral. The distressedbaby who makes an intense emotional bid for his mother’s comfortand protection arouses different emotions in her than the baby whorubs dinner in his hair or joyfully shares a toy. When difficult emo-tions or painful memories are aroused, mother may appear passive,preoccupied, and unable to scaffold her baby’s experiences.


On the other hand, some of mother’s responses are relaxed andflowing. Sometimes she responds positively to her infant’s desire toconnect and interacts warmly and spontaneously. At other times sheis able to react positively to baby’s attempts to structure their interac-tions, taking his lead and responding with appropriate feeling.

The infants of frightened/disorganized mothers may show rela-tively subtle signs of disorganization themselves. In situations wheremother and child do engage in some attuned interactions, the childcontinues to request comfort and care. Disorganized attachment re-search indicates that the infants of frightened mothers may show asuperficially secure attachment strategy when stressed, but that un-usual behaviors exist in conjunction with more normative ones.Sometimes the disorganized baby’s approach-avoidance behaviorscan look more like ambivalence than the absence of a consistent at-tachment strategy.

The mothers of disorganized infants may present within a widespectrum of psychological functioning (Lyons-Ruth, personal com-munication, 2002), leading one to speculate that diagnosis and treat-ment may involve a sophisticated and subtle assessment of mother-baby interactions. In the following case vignette mother’s severetrauma history, her cognitively and affectively disjointed manner ofrelating this history, her dual diagnosis of alcoholism and bi-polardisorder, and her alienation from herself and her son are all consis-tent with the more severe spectrum of the disorganized dyads de-scribed in infant research. On the other hand, mother and son re-lated to one another in a fair number of loving and mutually attunedways 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-oldson, was referred to The Center for Early Relationship Support byher psychopharmacologist, after her recent discharge from an alco-hol detox program. The Center for Early Relationship Support ispart of the Jewish Family and Children’s Service of Waltham, Massa-chusetts, and offers a variety of therapeutic services to parents andinfants, including home-based parent-infant psychotherapy. At thetime of referral Mary and John were also being followed by ChildProtective Services. Mary had been diagnosed with PTSD, alco-holism, post-partum psychosis, and bi-polar disorder. At our firstmeeting she said, “I want to be a good mother, to give my son morethan I got, but I don’t know how. I had horrible mothering, no rolemodels. I am a drunk and a loser. I don’t even feel that much for my

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son. I don’t know who I am or what I’m doing here.” Mary was un-able to claim her son or to acknowledge her motherhood, “I can’tcall myself his mother, I don’t deserve him. Sometimes I think hehates me and would be better off with someone else.” Mary had beensober for only twenty-eight days.

My visits to the home revealed Mary to be a sweet and tentativemother who was struggling to stay sober and to care for her child.John was a beautiful twelve-month-old with a shock of curly blondhair and ice-blue eyes. He was cheerful, curious, and engaging. Heapproached his mother for help and to share his toys, and they wouldlaugh or be silly together at his prompting. I observed Mary andJohn sharing moments of pleasure, joy, and hilarity. Mary respondedwell to the structure afforded by particular aspects of John’s dailycare. She showed sensitivity to his cues around eating and being dia-pered. In these domains John was never made to feel passive, ig-nored, or intruded upon by his mother’s agenda. Mary would waitpatiently for John to signal the next spoonful or when it was time tocontinue diapering or dressing him. These interactions includedmuch mutual gazing, turn-taking, and playful physical contact. Marycould also be attentive and natural in her responses to John’s ebul-lient expressions, and he regularly looked at her and reached for herto help him. As John interjected himself into the adults’ conversationMary would encourage him proudly and speak of what a good andbeautiful boy he was.

But coupled with these positive behaviors were more ominous in-teractions. John often crawled around the house with the pet dog,dangerously unsupervised. He had difficulty focusing in on toys orplay, but could spend an hour amusing himself alone in his crib. Inthese early home visits John would sometimes cry from the otherroom 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 herurge to drink. Mary asked, “Is it o.k. for him to play alone so much? Idon’t want him to grow up with a black hole in the middle of him likeI have.” Mary’s eyes spoke volumes of her fearful inner world, but hernarrative tone was one of disorienting cheer. In our first interviewshe revealed the depth of her alienation, “I wake up in the morningand I wonder, whose baby is this, whose house is this, whose life isthis?”

Throughout our initial meetings Mary revealed her painful story.Her narrative was filled with contradictions, lapses in reasoning, andaffective incongruence. Sequencing of events was so confused that Iwas unclear exactly what had happened to her and when.

Mary’s intense self-absorption and dissociated states initially placed


John on the periphery of our conjoint work. I observed that she didnot seek John out as an emotional companion; it was he who initi-ated this type of contact. From time to time he could successfully en-gage her but I wondered how much work he had to do to make thispossible. Mary could not consistently help John transform his nega-tive states to positive or neutral ones. When he was distressed shewould pick him up, but then put him down before he was sufficientlycalmed. Toys were often offered as comfort instead of her body orvoice. Mary often allowed John to get into highly charged emotionalstates that were on the verge of decompensation. She was unable toplay with him; there were few spontaneous gestures of affection, andshe often asked if he would like to go up to bed.

I was uncomfortable with how little we included John in our initialsessions. He was continuing to do all the reaching out for contact,and I was caught between the imperative need to include him andmy concern that doing so would cause Mary to feel ashamed or over-whelmed.

History

After John’s traumatic birth (a mishandled forceps delivery resultingin a subdural hematoma and seizures), Mary plunged into a post-par-tum psychosis, started to hear voices, and began to drink heavily.Some months into the treatment I learned that for the first eightmonths of his life, John was neglected and left alone for long periodsof time in his crib without food or diaper change. Mary would drinkand go to bed, “covering my head so that I couldn’t hear his cries.”For these first eight months Mary was living with her husband Peterand his parents, all of whom were at work during the day. Peter wasunable to offer adequate protection or containment for his wife andson. He was aware of Mary’s drinking, but desperate to keep his joband needed to deny a drinking problem of his own. Then when Johnwas about three months, Peter demanded that Mary enter a detoxprogram, which she did. There were two unsuccessful hospitaliza-tions during this time. A year into our treatment Mary shared thatshe often cared for John in drunken blackout states, and lived in ter-ror that she had physically injured him. During his first eightmonths, John responded well to the evening return of his father andgrandparents, but there was tension between Mary and her parents-in law. When John was nine months Mary and Peter moved with himinto a home of their own. The move allowed Mary to be closer to herfather (a twenty years sober alcoholic), and enabled Mary to attend

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Fraiberg, S. (1980). Clinical studies in infant mental health. New York: BasicBooks.

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. Unpub-lished 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 trainingmanual.Unpublished manual, The Wright Institute, Los Angeles.

Heinicke, C., Fineman, N., Ruth, G., Recchia, L, Guthrie, D., & Rod-ning, C. (1999). Relationship-based intervention with at-risk first timemothers: 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). Relationbased intervention with at-risk mothers: Outcomes in the second year oflife. 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 nurseson 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 ef-fects of nurse home visitation on maternal life course. JAMA, 283, 1983–1989.

Korfmacher, J., O’Brien, R., Hiatt, S., & Olds, D. (1999). Differences inprogram implementation between nurses and paraprofessionals provid-ing home visits during pregnancy and infancy: A randomized trial. Ameri-can Journal of Public Health, 89, 1847–1851.

Lieberman, A. F. (1997). Toddlers’ internalizations of maternal attributionsas a factor in quality of attachment. In Attachment and Psychopathology, eds.,K. Zucker & L. Atkinson. New York: Guilford, pp. 277–290.

Lieberman, A. F. (2003). Starting early: Prenatal and infant intervention. Paperpresented at Irving B. Harris Festschrift, Chicago, May 12, 2003.

Lieberman, A. F., Weston, D., & Pawl, J. (1991). Preventive interventionand outcome with anxiously attached dyads. Child Development, 62, 199–209.

Lieberman, A., Silverman, R., & Pawl, J. (1999). Infant-parent psychother-apy: Core concepts and current approaches. In Zeanah, C. H. (Ed.) Hand-book of Infant Mental Health, pp. 472–485. New York: Guilford Press.

Mayes, L. C., & Cohen, D. (2002). The Yale Child Study Center guide to under-standing your child. New York: Little Brown.

Olds, D. (2002). Prenatal and infancy home visiting by nurses: From ran-domized trials to community replication. Prevention Science, 3, 153–172.

Olds, D., Hill, P., Robinson, J., Song, N., & Little, C. (2000). Update on

Minding the Baby 99

twice daily AA meetings. At that time Mary was frantic and depressedabout John’s behavior toward her. Until he was eleven months, Johnrejected his mother’s attempts to connect. He screamed when sheheld him, would not gaze into her eyes, and would not smile at orreach for her. One month into Mary’s sobriety John began to reachout to her for comfort and to track her visually, but at thirteenmonths he developed a strange rolling eye movement in her pres-ence. John had been followed neurologically since birth and therehad been no sequelae from his early seizures or hematoma. Thestrange eye movement was determined to be non-organic in nature.

Mary’s own childhood had been devastating. When she was a oneyear old her schizophrenic mother attempted to drown her in thebath and she required resuscitation. Mother then abandoned thefamily and was in and out of young Mary’s life. For a time Mary waspassed among relatives so that her father could work. When fatherremarried three years later (Mary was four) she lived through crueland degrading neglect at the hands of her stepmother, who lockedher in her room each day, refusing to feed her or allow her to use thetoilet. She was often locked outside of the house while her stepsib-lings had after-school snack. In winter the kindness of an elderlyneighbor sheltered Mary from the cold.

Mary began to drink at age fourteen. But despite the depth of herdifficulties, during adolescence Mary felt she had the love of her pa-ternal grandparents and recently sober father. She lost her fear ofher “evil stepmother” and became provocative and oppositional. Shesuccessfully completed high school and college and went on to haveseveral interesting and responsible jobs. She fell in love with a gentleif troubled young man, and married into a large family.

Formulating the Treatment

The initial treatment plan was to offer weekly mother-infant sessionsin the home in conjunction with twice daily AA meetings. But twomonths into our work Mary began to reveal the depth of John’s ne-glect and the severity of her childhood trauma. Our mother-babywork was heightening Mary’s affective numbing and flooding, andshe was struggling to stay sober. It became clear that weekly conjointsessions would not provide adequate containment to safely exploreMary’s issues. With some concern about the complexity of combin-ing therapeutic modalities, I offered her additional weekly individualmeetings in my office and telephone sessions as needed.

Mary and John each needed to feel held, known, and remem-


bered. But how to provide a relationship in which this would be pos-sible? How to untie this Gordian knot of longing and dread? Maryhad been brutalized and overlooked in childhood. Her subsequentdifficulties establishing evocative constancy, affect regulation, and re-flective capacity meant that she would not have attained the level ofsymbolic thought, verbal self-awareness, or affect tolerance necessaryto fully engage in a conventional interpretive psychotherapy.

I envisioned the individual work and mother-infant sessions as ex-isting in a figure-ground relationship. My objective was to develop atherapeutic relationship that would provide mother and son with theexperience of containment and safety. I hypothesized that as her fearand distress diminished in her relationship to me, Mary would be-come more capable of recognizing and naming her own feelings andof evoking a calming maternal introject to soothe herself and herson. I hoped that Mary’s growing attachment to me (and my holisticvision for her) would take integrative hold and help bridge the gapbetween her current level of functioning and her emerging poten-tial. The gains we made in individual and conjoint sessions informedand reinforced one another and were articulated within the contextof mother’s and son’s developmental strivings.

In his book The Motherhood Constellation (1995), Stern describes thedynamic interplay between representation and behavior: change inone area affects change in the other. I hoped that in this urgent situa-tion the combination of individual with conjoint sessions would max-imize impact in both representational and behavioral domains andmodify the pathogenic enactive representations that crippled Mary’spsychic functioning. Home-based mother-infant work offers a richtableau of implicit interaction and a profound sense of intimacy. Itintegrates traditional psychoanalytic approaches with interventionsdesigned to have immediate impact upon mother and child’s relat-ing. Combining immediacy with enactment would afford us the op-portunity to hold painful experiences in the moment, even as we“practiced” new forms of relating. Within individual and conjoint ses-sions we could unpack those interactions in which older and moretroubled patterns held sway. In addition, Mary’s developmentalstrides within our dyadic relationship could be transferred to the im-mediate interactive realm of mother and son.

But the developmental pathway we traveled was rocky and un-charted. Initially we did not know that the journey would require ourliving through repeated painful and overwhelming states of despera-tion and danger.

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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 inter-ruption she was dismissive of suggestions that we explore the possibleimpact upon her of our separation. A few days before our break,Mary called me in an inebriated and near blackout state. Her voicewas that of a desperate and confused little girl. As she spoke I couldhear John playing near her. “I’m sorry, I can’t go on; I’m such a loser.Everyone is better off without me. They’ll be angry at me for a whileand then they will forget. I am holding a knife and I don’t think I cancontrol myself. I want to cut myself. I want to die. No I don’t, please,please, help me . . . can you help me? I am so scared . . . No, it’s toolate for me, I am hopeless, it’s all hopeless.”

Mary felt that John was better off without her and that he wouldsoon “forget her,” as no doubt she thought I had also done. Despitemy efforts during that phone call, she was unable to use me as asoothing presence; it appeared that all our work was lost. Maryplaced the phone down as I listened in utter helplessness, trying todiscern if John was all right and what had happened to his mother. Icalled 911 on my cell phone and did not hang up until I heard theEMTs arrive. Mary had passed out on the couch with John playingquietly at her feet. Usually an active child, fourteen-month-old Johnhad apparently understood that something dangerous was happen-ing and that he should stay by his mother.

During those moments I understood the terror and isolation thatMary must have felt so often in childhood. Caught in a transference-countertransference storm, I had become the abandoning motherwho filled her with uncontainable and terrifying feelings. Mary feltcompelled to enact this role with her son. In contradiction to themalevolent power that I unwittingly possessed, my helplessness mademe feel that I did not really exist. Mary could not remember eitherJohn or myself and was sure that we would soon forget her. I won-dered how often John might feel similar chaotic states of victim-vic-timizer, of absolute destructive power and utter non-existence. Wait-ing in silence on the phone, I struggled through my own fear to keepall of us alive within my mind.

Later on I understood that it had been my role to bear witness toand to memorialize a dangerous attachment crisis for which Maryand John would have no explicit memory or language. Mary had de-livered into our threesome the nameless dread of her infancy; that


she would be the victim/perpetrator of abandonment or murder. Icame to accept that if we were to work deeply enough to stimulategrowth, the shadow of deadliness would have to fall across our rela-tionship. We three had survived the specter of Mary’s past traumaand its fearful visitation upon the next generation. Mary’s near deathas a wordless one year old had returned as her possible suicide infront of John and myself. She spent our first interruption in a psychi-atric hospital.

Living through this crisis marked a turning point. We hadglimpsed the gaping black hole of Mary’s longing and terror andcould now begin to build bridges across it. The following vignette,taken from a mother-infant session three weeks after my return andMary’s discharge from hospital, illustrates how mother and son al-lowed me into their anxious and disorganized relating. It alsodemonstrates my attempts to enhance their communication by com-bining traditional psychodynamic approaches with interventions onan immediate interactive level.

Process Vignette

I arrive for a session in the home. John has just returned from daycare and seemstired and cranky. He is standing in front of the refrigerator yelling “morecheese!” over and over. He is spinning out of control. He reaches up for hismother.

Mother: (stepping away from him and speaking sweetly.) “You’ve had enoughcheese, soon its dinnertime, let’s go in the living room.” (She turns towalk into the living room. She appears tuned out, unable to hear or noticehim.)

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, it’sall I can do not to pick him up.)

Mother: (with false sympathy) “No more cheese, sorry.” (angrily) “You haveto learn not to get so upset. I’m getting frustrated.”

John is up off the floor and asking to be held by mother. She picks him up but putshim down before he can settle. He asks again to be held and then strikes her inthe face as she reaches for him. She puts him down again, more forcefully. Johnstaggers away while pitifully crying for his mother. He begins to wander aim-lessly around the house, stumbling over his toys. He suddenly lies down on therug and becomes very quiet. Mother looks at me, frightened.

Therapist: “O.K., lets try to figure out what’s going on and what each oneof 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. I’m not agood mother. I don’t know how to handle this stuff. He confuses me, Itry one thing and another but nothing helps.”

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Therapist: “Hard to handle this confusion and helplessness . . . Whenyou can’t help him it must make you feel bad about yourself, and up-set with him. You probably want to get away from it all . . .”

Mother: “He makes me so frustrated, like I can’t do anything right, andthen he hits me . . . am I raising him to be spoiled? I just tune out, tryto stay away from him. I go upstairs and lock the stair gate, or comeinto the kitchen to be alone. He cries and cries. Sometimes I try tohelp him but it doesn’t make any difference.”

Therapist: “Tell me about tuning out . . . what’s that like, where do yougo?”

Mother: “I don’t know, somewhere else. To a place where I don’t feelmuch . . . always hated it when there was arguing in my house, hatedall the upset. I could never please the “evil stepmother” anyway. Noone really cared how I felt, but I could check out . . .”

Therapist: “This must be so hard for you. As a child never pleasing any-one, now feeling you can’t make John happy either . . . No onehelped you to manage your feelings when you were a child, scaredand alone. You must have handled it by tuning out . . . Kids havepretty strong feelings . . .”

Mother: “He doesn’t know how to let me help him. I don’t know how todo it . . .” John has soothed himself a bit with a toy. As mother sits down, heasks for her lap. As she again begins to hold him, he stiffens and arches awayfrom her. She makes a move to put him down again.

Therapist: “You’re both upset and confused, but could we try to stay inthis upset place for a moment more, just to see what might happennext?” (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 don’t 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 be-

gin to look at one another.) “I know you are angry about no more cheese,I’m sorry you’re angry, but soon I will make your dinner. Now you arestarting to feel a bit better.”

Therapist: “Maybe John doesn’t know how to get the help he needs whenhe’s angry or frustrated . . . maybe he gets scared . . . I thought youlooked scared too, a few minutes ago . . .”

John relaxes in mother’s lap and asks for his favorite stuffed animal, which I re-trieve. Now John has his mother’s lap, his thumb and his transitional object.Both mother and son sit quietly together as the affect storm passes. Their bodiesrelax into one another.

Therapist: “Hard work today you guys! You had some good ideas abouthow to calm him with your voice and your body. You let him know thatyou could feel his anger, and that there might be a way back from thatwith your help. Look at how he relaxes when you gather him in likethis. I can see that he feels safe and calm, how do you feel now?”


Mother: “Maybe I can help him . . . Maybe I don’t have to dread beingwith him if there are things that I can do to help him to be happy andgrow.”

The Frightened/Disorganized Mother-InfantParadigm as Illustrated in the Vignette

The vignette illustrates how Mary’s dissociation and contradictorybehaviors leave John feeling confused and uncontained. Mary’s ini-tial unpredictable loss of affect makes John feel scared that he cannotfind his mother. She inadvertently renders him helpless to find the wayback from distress, because he can find no context for her inexplica-ble (endogenous) and non-contingent responses. With no reliableway to re-connect, John has no means of resolving his frighteninglack of containment. In more attuned circumstances, he would learnto know himself through sensitive connection to the one who knewhim. In the current relational context his alternatives are either toexist alone within an unmirrored and inchoate psychic state, or tojoin his mother in an alien one.

John’s disorganized attempts to engage his mother are also inex-plicable and frightening to her. His behavior renders her helpless tocomfort him. Mary feels persecuted by John’s inconsolable demandsand the specter of her abusive stepmother. She escapes into a dissoci-ated and withdrawn state. Anxiously preoccupied and coping with thepowerful affects that John arouses, Mary must get away from him, shemust abandon John in her mind. At moments like this he is in emotionalfree fall, out of control and alone, just as Mary must have been, just asshe remains. In these intense emotional exchanges around John’sneed for comfort and protection, Mary both fears and dreads thebaby who arouses in her the raw feelings and traumatic memories thatare the legacy of her own childhood. John has become the messageand not the messenger, the “ghost” of her own past (Fraiberg, 1975).

Over time John will internalize both sides of these repeated andconfused interactive sequences, just as his mother did (Lyons-Ruth etal., 1999, Liotti, 1999, Main and Hesse, 1990a). While it is difficult topredict developmental pathways, it is likely that John would come toexperience himself as one who is both a persecutor and a victim. Re-peated exposure to traumatic affect levels would likely impede his ca-pacity to attain “personal synthesis” and to make meaning of experi-ence, resulting in multiple and discontinuous inner representations(Liotti, 1999). John’s vitality, self-assertion, and depth of feelingcould become a source of fear rather than of self-confidence. Hismother’s inability to consistently respond to his basic needs for com-

116 Judith Arons

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 con-trolling behavior and/or living in a state of chronic mourning (So-carides and Stolorow, 1984).

Interventions Illustrated in the Vignette

I attempted to offer in-the-moment engagement with mother andbaby as they negotiated highly charged and discordant interactions.While both positive and negative interactive patterns were reflectedupon, the emphasis was on finding what worked and supportingmother’s positive role. Articulation of mother’s constructive engage-ment offers her support as well as an increasing capacity to observethe interaction. (“You let him know that you could feel he was an-gry . . . you had some good ideas about how to calm him . . .”) Whenasked, a therapist may make suggestions around behaviors but the fo-cus is not educational or directive.

Over time, observing and naming repetitive interactive patterns asthey occurred helped to enhance Mary’s feelings of mastery. Her in-creasing sensitivity and consistency toward John’s need for comfortalso allowed him to feel more competent and less frightened. Marywas eventually able to see for herself that when she avoided John ordissociated in his presence, his behavior grew more disorganized.Predicting that which triggers interactive patterns renders themknowable and containable. It also offers the possibility that some newway of relating may be possible.

We worked to promote an atmosphere in which our threesomecould experiment with improvising behaviors and then watch whatmight emerge between us. We attempted to make manifest the sepa-rate emotional experiences of mother and baby as the interactionunfolded. With time we were able to introduce John as a continuouspresence in his mother’s mind, while simultaneously articulatinghow difficult this was for her to bear. We clarified Mary’s defensiveneed to escape, and to reject or minimize John’s needs.

The initial interaction was driven by Mary’s defensive exclusion ofJohn’s escalating bids for comfort. I empathized with Mary, exploredher dissociated response to John, related these responses to herchildhood experiences, and gently clarified her projections onto herson. In his vulnerability and need John had become Mary’s enragingand menacing parent and her frightened/frightening and uncon-tainable self. John was the source of Mary’s guilt, the attacking otherwho persecuted her with his relentless demands. It was difficult not


to comfort John in his distress, but I believe that this would haveshamed his mother.

Feeling for Mary’s and John’s affective states and developmentalcapacities within each interaction provided direction for the improvi-sation of new “relational moves” (Stern and Sander, et al., 1998). Im-provisation addresses experience and change within the proceduraldomain, and it provides an interactive format in which to modifycompulsive role assignments and to model containment. It is en-hanced by the baby’s natural dynamism. It makes use of mother’sopen sharing of feelings and fantasies, along with the baby’s emo-tional expressions, as they are experienced in the moment.

Mary’s softening of tone and defensive stance (He doesn’t knowhow to let me comfort him. I don’t know how to do it . . .) signaled herreadiness to let me into her confusion around how to interact withJohn. I began to wonder if something new could happen between us.I believe that it was the lending of my physical presence (movingback and forth between them) that offered the following unspokenresponse to Mary: “I can empathize with and hold both of your emo-tional states. I am free to move within your compulsive and confusedenactment. You can use me to bridge the gap between your currentlevel of interacting and something that will be more complex andnew.” As I sat close to Mary and John on the couch, Mary continuedto relax her defended stance. Tentatively she mused, “I don’t know ifI should say something to him.” At this point in the interaction a newdevelopmental level of relating was about to emerge.

Combining Individual Adult Work with Mother-Baby Sessions

Mary’s suicidal crisis lent great urgency to our top priority: To estab-lish a therapeutic relationship that would offer open and responsiveemotional contact and modulation of fear. Mary’s suicidal gesturehad delivered into our relationship all the uncontained emotions ofher childhood. I believed that we were going to have to feel our waythrough the therapy and live through the unnamed terrors, givingnarrative voice to the process when we could. In the words ofPhillips, sometimes, “stories are lived before they are told” (quotedin Holmes, 1996, p. 167).

giving voice

Mary struggled to put words to feelings and experiences. In themother-baby sessions at home I had began to gently draw her into my

118 Judith Arons

curiosity about John’s behavior and motivations. In individual ses-sions I expressed a similar curiosity about Mary. Together we createda lexicon that captured the unique experiences of mother and baby.It has been hypothesized that within the adult narrative lies the blue-print of early attachment experiences (Slade, 2001). The linguisticstructure of adult narrative traces the range of affective communica-tion permitted within the earliest relationship and the child’s needto adapt to the attachment figure’s defensive constraints upon relat-ing. Factual and affective incongruencies, unmonitored lapses in rea-son and logic, paucity of affectively charged descriptions and defen-sive idealizations, or minimization of cruelty and neglect indicate aninsecure and emotionally constricted attachment relationship (Mainand Hesse, 1990a, Slade, 2001, Holmes, 1996). I believe that the actof creating a lexicon, coupled with capturing the specific experi-ences of mother and baby, helped to expand Mary’s emotional com-munication and her reflective functioning. Our widening conversa-tion implied an increasing ability to express and to hold deepfeelings. Over time our shared language offered Mary a way to nameher own complex internal states and to feel more in control. It en-abled her to speculate about and to feel for the inner life of herchild. During intense emotional exchanges between mother and sonour familiar phrases were a source of comfort and orientation forMary. We found it particularly helpful at such times to use expres-sions that conveyed active containment, such as “getting your armsaround” a feeling, “gathering in” a disorganized baby, or “finding theway back” to a quiet and connected state.

metabolizing fear

Mary was afraid of everything. Her terrors had derailed her efforts af-ter mastery and psychic wholeness. Toxic levels of fear occluded herability to create and to synthesize (inter)personal meaning. Fear hadinterrupted her ability to attend or even to maintain a consistentstate of consciousness. Abuse and neglect had taught Mary to expectthat her feelings would be forgotten or obliterated. Frequently slip-ping into dissociated or empty states, Mary often did not know whatshe felt.

We set out to explore the “black hole” left by Mary’s trauma, andthe overwhelming feelings and contradictory inner representationsit had spawned. With each frightening memory or state deliveredinto the treatment we entered a new interpersonal negotiation. Weasked, how could Mary contain her upset around John? What feel-


ings did he arouse in her? How could she use her relationships (withme, her husband, and her AA sponsors) for soothing and contain-ment?

Mary and I paid careful attention to how we made contact, and re-lated this to patterns of emotional communication between motherand son. Her initial requests to connect were subtle, often overrid-den by an expectation that she did not matter and could not beknown or contained by another. Mary had covered her childhooddevastation with an avoidant style and disorienting cheer, punctuatedby states of panic and emptiness. Her affective cues were as confusingto me as they must have been to John. But eventually we were able toframe our miscommunications within the context of Mary’s longingto have her attachment needs met and her dread that I would rebuffher. Gianino and Tronick, (1988) link the ability to repair affectivemismatches in infancy to the establishment of the attachment figureas reliable and trustworthy. Experiences of disruption and repair alsocontribute to the infant’s sense of mastery and control and to the de-velopment of a positive emotional core. I believe that within thetransference Mary’s increasingly secure attachment to me offeredher similar gains. Her diminishing fear led to an increased sense ofagency and inner cohesion and to a budding capacity to make repa-ration to her son.

Mary and I were able to name her intense feeling states (or ab-sence of feeling), and give voice and shape to her chaotic inner rep-resentations. We observed the ways in which she dissociated duringpowerful emotional eruptions around John, her confusing responsesto his need for comfort, and his disorganization in response. Consis-tent inquiry into Mary’s inner states introduced the notion that Icould know and remember her. At the same time we observed theways in which Mary’s intense and confusing experiences impededher ability to keep John in mind and to represent him as a separatebeing. As her affect tolerance and self-reflective abilities increased,Mary and I could more deeply explore the relational context inwhich powerful feelings or defenses against them emerged. Shestruggled 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 rela-tionship to hold and metabolize her confusion and fear and togather in the disavowed parts of herself. As demonstrated in the vi-gnette, genetic material was used to promote compassionate under-standing and personal perspective. Within the first year of our work,Mary minimized or dismissed transference interpretations, and they

120 Judith Arons

did little to enhance our relating. But each new aspect of Mary’s ex-perience, no matter how disturbing, was offered a place in our con-versation. She began to send me e-mail messages about fantasies thatscared her. These messages I saved for her until she felt safe enoughto address them in person. We then began to anticipate the emer-gence of the “evil stepmother’s” cruel and degrading voice withinMary. We called this frightening figure out of the shadows, stared herdown, and told her that her days as a saboteur were numbered.

Mary’s need to defend against the feelings John aroused coupledwith her cognitive dysregulation (dissociation and transient thoughtdisorder) had rendered her unable to consistently attend to their re-lationship. In mother-baby sessions we worked to enhance responsiverelating by containing the fear and anger aroused by John’s need forcomfort. In individual sessions we explored how Mary’s attachmentneeds within the transference paralleled those of her son. Mary wasthe mother of a child she could not comfort and a child herself inneed of comfort.

Over time, as we co-constructed the scope and pace of whatemerged between us, Mary’s inner representations (terrifying motherand 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 herown defensive exclusion of painful affects, Mary developed freer ac-cess to her own inner world and to the emotional world of her son.As she began to release John from her malevolent projections andher need to control the fear he aroused, he emerged as a positiveforce of nature, a baby to be loved and understood.

Conclusion

In cases of frightened/disorganized mother-infant couples, the com-bination of individual adult work along with mother-infant sessionscan significantly enhance the development of responsive emotionalcommunication and intersubjective sharing within the dyad.

During the first year of our work, Mary was able to transfer hergrowing security of attachment to me onto her relationship withJohn. The process has been slow and painful however. During ourfirst year of treatment there were several bouts of drinking, psychosis,and suicidality, stimulated each time by my taking a vacation. ButMary has been increasingly able to remain connected to me duringour interruptions, with fewer overwhelming states of abandonmentor deadly nothingness. She is feeling more at home in the fluid psy-


chic space that encircles attachment and separation. With the help ofpsychotherapy, pharmacotherapy, and AA, she has not had a drink infourteen months.

Mary continues to use our relationship to hold her fear and herrage. The frightening inner representations and emotions that in-habit her psychic landscape have emerged in full force. She has ad-dressed violent fantasies of throwing her son out the window orslashing his face with a knife. She has been able to use me as a securebase around disorienting and psychotic flashbacks. Having partlyfreed the mother-child relationship from the toxic intrusion of in-tolerable affects, we continue to address the need to name and tometabolize such feelings in all areas of Mary’s life. We continue toexplore the emotional impact of mother and son upon one anotherand their patterns of communication. Sometimes I am rocked byMary’s vacillating experiences of flooding and deadness. I continueto worry and wonder about the impact of John’s early life upon hisfuture development. But the projections, dissociation, and affectivemisattunements, so prevalent in Mary’s early relationship with John,have abated.

Although prone to regression around his mother’s psychic upsets,John has responded beautifully to her increasing sensitivity and relia-bility. Much work remains to be done, but John now looks consis-tently to his mother for soothing and protection. His requests forcare and protection are not conflicted; they are the expressions of achild who anticipates that comfort and aid will be forthcoming. Maryfeels more connected to herself and to her son. She takes great pridein how John is developing as an individual, and the important roleshe has played in this.

While an in-depth analysis of the multiple transferences of traumasurvivors is extremely relevant to this case, it exceeds the scope of mydiscussion. Several authors have written about the fluid and uninte-grated inner representations and discontinuous transferences of vic-tim, victimizer, and rescuer in trauma survivors (Davies and Frawley,1991, Liotti, 1999). It remains unclear whether Mary will be able toanalyze her murderous maternal transference toward me, or if this iseven advisable. It may be that in cases of severe early loss and trauma,rage in the transference represents too great a threat to the thera-peutic relationship and requires metabolizing and repair in displace-ment. To date, Mary has very much needed to keep me as a “goodenough mother.”

The difficulties in depicting mother-infant psychotherapy are simi-lar to those one faces in describing human relating and development

122 Judith Arons

in general. The case discussion must illuminate both intrapsychicand interpersonal phenomenon. It must describe recursive and po-tentially emergent relational processes within a format that is pre-dominantly linear, narrative, and deterministic. It should discuss bothimplicit and explicit modes of relating, remembering, and meaning-making as developmental constructs and as mutative factors withinthe psychotherapy itself (Lachmann, 2001, Stern and Sander, et al.,1998). To further complicate matters, the thousands of non-verbalgestures, and affectively nuanced communications that would pro-vide the reader with critical information, remain out of the partici-pants’ awareness and cannot be recorded. But despite all these im-perfections, case studies can bring to life the depth and complexityof our work.

Finally, another difficulty in writing case material is that in an ef-fort to create a narrative out of what is essentially a kaleidoscopic in-terpersonal experience, the case is rendered too neat and organized.I understood the process of my work with Mary and John both pro-spectively and retrospectively. Some concepts came to me before orduring the time they emerged within the treatment, most did notcome to life conceptually until I had already acted intuitively and im-provisationally. My application of concepts from attachment theoryand psychoanalysis helped shape the treatment, but is not intendedto impose a privileged position over other useful and creative ap-proaches to mother-infant work.

I have offered vignettes from a mother-baby psychotherapy inwhich I applied principles from attachment theory and psychoanaly-sis to help a troubled mother emotionally engage with her infant son.A major function of the attachment system is to buffer the infant’sstress so that he is free to grow within himself and secure in the ex-ploration of his world. Mary and John’s relationship, colored bychronic states of fear and emptiness, was the legacy of Mary’s child-hood attachment trauma. Without interventions designed to re-spond to the attachment needs of both mother and son, they wouldhave had little opportunity to explore sensitive emotional relating orcreative and meaningful engagement.

In addition, attachment theory enhanced my understanding ofmother’s developmental deficits and baby’s incipient developmentalstressors, and provided a logic to the interplay between my individualwork with mother and my work with mother and baby together. Cen-tral to my work with Mary and John was the development of three in-terrelated functions that any “ordinary devoted” mother (or othercaregiving figure) provides for her child: responsive engagement in


regulating her baby’s affect, her own capacity to evoke a compassion-ate and soothing maternal introject, and her ability to reflect uponbaby’s experience, to keep him continuously in mind. While theseconcepts are not new to psychoanalysis, they nest nicely within at-tachment theory, which operationalizes them and grounds them inempirical research.

Post Script

Recently, Mary and I were reviewing the progress that she and Johnhave made (John is now two and a half). She related that while pack-ing up some of his infant clothes she had been overwhelmed withhow vulnerable John had been as a small baby, how he had neededher, and she wasn’t there. She remembered with great sorrow and re-morse leaving him for long spells alone in his crib. Then she relatedthis 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 newgame: he put me in his big boy bed, covered me with his favoriteblanket, kissed me goodnight and went out of the room, closing thedoor. Without thinking about it I began to cry, “Mama! Mama, I amscared, Mama!” He rushed into the room, snuggled me with theblanket, and kissed me softy, whispering, “o.k. baby, don’t cry baby,don’t cry,” and went out. We repeated this game several times; eachtime he came in and comforted me. Then it was his turn. He wantedto be in his bed with the covers. I kissed him, said goodnight, and leftthe room. He pretended to cry, “Mama, come, Mama!” I rushed in ashe had done, kissed him, and cozied him up with the blankets,telling him that everything was all right. After doing this severaltimes he became quite relaxed and quiet. He looked so peaceful ly-ing snugly in his blankets. And then, as I sat there on the edge of hisbed, I experienced a moment of grace. I realized that I can comfortmy child!

The child who no longer arouses intolerable feelings resides moresecurely in his mother’s heart and mind.

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Herding the Animalsinto the Barn

A Parent Consultation Model

ALEXANDRA MURRAY HARRISON, M.D.

Initial assessments of children with psychological problems are impor-tant both to develop appropriate diagnoses and to provide the basis forproductive discussions with parents on treatment alternatives. Thispaper develops an assessment method referred to as the Parent Consul-tation Model (PCM) that emphasizes the use of videotape micro-analy-sis and developmental theory to provide critical information to parentsas well as to the clinician in this important initial stage. The paperprovides a description of the PCM and an expanded example of the useof the PCM, including illustrations of how these methods can be usedto organize information and engage parents in the initial consulta-tion. The paper concludes with some observations on the role of newtechniques and ideas in psychotherapy and psychoanalysis.

Introduction

I receive a telephone call from a mother who sounds dis-tressed. 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, GeorgeDowning, Louis Sander, Beatrice Beebe, and Dawn Skorcewski. I also would like to ex-press my appreciation to the Boston Process of Change Study Group; my years of par-ticipation in the Group inspired the development of many ideas in this paper.


128

She explains that her 4-year-old son is disruptive at school and doesnot follow directions. At home he is fearful, demanding of her atten-tion, and constantly picking on his little brother. In the past, my ini-tial interactions with the mother and father would have been rela-tively brief, primarily designed to provide background on theproblem as a prelude to seeing the child in individual sessions—firstin a diagnostic session and then, if therapy appeared warranted, as apatient in psychotherapy or psychoanalysis. I would of course discussmy initial observations and recommendations with the parents, andget information from them about major constitutional and environ-mental factors that affect their son; but the tools I had to obtain thatimportant information would be limited to my own observations ofthe child and parents in the initial sessions and the parents’ own de-scriptions of key events and circumstances.I describe my past interactions with parents and potential child pa-

tients in this initial diagnostic stage, because over the past ten years Ihave changed my approach to the initial evaluation of children withpsychological problems. This shift in approach is the result of learn-ing from key techniques used by infant researchers and developmen-tal psychologists—particularly their use of micro-analysis of video-tapes and certain organizing ideas—and parallels a shift in the tools Iuse in the evaluation of potential cases for psychotherapy and psy-choanalysis.Micro-analysis of videotapes of family meetings or of therapeutic

sessions allows one to uncover key verbal and non-verbal interactionsthat simply could not be discovered without the benefit of detailedex post analysis. Developmental theories provide a means of organiz-ing these detailed observations into coherent patterns. Colleaguesand I have recently discussed the ways in which these techniques canbe useful in psychotherapy and psychoanalysis (Harrison 2003, Har-rison and Tronick, forthcoming). This paper discusses the ways inwhich these same tools of videotape micro-analysis and developmen-tal theory can be used in the initial assessment and discussions withparents regarding therapeutic interventions. Indeed, I refer to thismethod as a Parent Consultation Model (PCM), to emphasize theimportance of providing critical information to the parents as well asto the clinician in this key initial stage. Moreover, this collaborativeor interactive model can usefully be continued beyond the initial di-agnostic stage and become part of the ongoing process of engagingparents in their child’s psychological development.The next section of this paper provides an overview of the PCM, in-

cluding contrasts to more “standard” child psychiatric or psychoana-

Herding the Animals into the Barn 129

lytic evaluations. The following section provides an overview of sev-eral methods that have been developed by developmental re-searchers to organize the information that can be developed fromdetailed observation of videotaped sessions. The next section thenprovides an expanded example of the use of the PCM, including il-lustrations of how these methods can be used to organize informa-tion and engage parents in the initial consultation. The final sectionprovides some concluding observations on the role of new tech-niques and ideas in psychotherapy and psychoanalysis.

The Parent Consultation Model

It is useful to begin a description of the PCM by considering the “tra-ditional” child clinical evaluation and two elements that seem rela-tively poorly handled in the traditional approach—the clarity of therole of the clinician in relation to the parents in the evaluation, andthe observation of family patterns. These elements set the stage for adescription of the PCM and some of the key conceptual frameworks Ihave 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 in-fant researchers, I was already an experienced child psychiatrist andpsychoanalyst in private practice, and a teacher of child psychiatryfellows and analytic candidates. My methods for the evaluation ofchild cases were typical of most child therapists. I would first see theparents to hear their concerns about their child and to obtain someof the developmental and family history, and I would then see thechild at least twice in individual sessions. I believe this general approach is still typical among many child psychiatrists and child an-alysts—and other clinicians—but I have come to appreciate its limi-tations in the light of the relatively new tool of videotape micro-analy-sis. In particular, although present in the traditional approach, twoelements come to the fore when one begins to use videotape micro-analysis 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 familyand for developing—that is, obtaining and transforming into a usableform—information to address parents’ concerns. The second ele-ment is the use of micro-analysis of family interactive patterns as thebasis for formulations concerning the child’s psychological problems.

130 Alexandra Murray Harrison

role of the clinician as a consultant in evaluatingchildren with behavior problems

Parents come to the clinician with a problem, asking for help. Yet, inthe typical method of child psychological evaluation, there is noclear delineation of the role of the clinician in relation to the par-ents. The child psychoanalytic and psychotherapy literature has ofcourse long acknowledged the importance of work with the parentsin a child psychotherapy or analytic case (Burlingham, 1951, Fur-man, 1957, Bernstein, 1995, Richmond, 1992). Yet, the role the clini-cian 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 con-

sultant to the parents, particularly in the initial evaluation. I use “con-sultant” here in the sense defined by psychoanalytic group theory, aselaborated by the A. K. Rice Institute and Tavistock Clinic model ofgroup dynamics (Shapiro, 1978, 1991).In this context, the clinician uses his or her knowledge and infor-

mation to answer parents’ questions and make recommendationsthat respond to parents’ concerns. The clinician as consultant doesnot purport to know what is best for the child in this initial stage, butrather attempts to help parents make decisions about their child inaccordance with their values and circumstances. This role is respect-ful to the parents as decision makers regarding their child and estab-lishes the position of the child clinician as supporting, or scaffolding,the parents in their active role as parents. It also implicitly acknowl-edges—what I believe to be the truth—that there is no one answer toquestions of etiology and treatment of childhood psychological problems.Another advantage of assuming the role of a consultant to the par-

ents is that it makes it possible to delineate a clear boundary betweenthe evaluation and the subsequent therapy. In contrast, the “tradi-tional” model often does not provide a clear differentiation betweenthe evaluation and the therapy, especially if the “evaluation” includesmultiple individual sessions with the child. This ambiguity about theboundary between evaluation and therapy may stem in part from thedifficulty that psychoanalytically oriented clinicians sometimes havein formulating clearly what they can offer, and why the parentsshould choose psychotherapy or psychoanalysis rather than someother form of treatment or assistance (Tuckett, 2004).

micro-analysis of family patterns

Once the clinician assumes the role of consultant to the parents, thetask is to answer the parents’ questions and make recommendations


responsive to the parents’ concerns. To accomplish these tasks, theclinician needs to acquire relevant data and to use some theory orconceptual approach to make sense of those data. In the past, thedata I used were mainly observations of the child’s play, and my clini-cal theory was based on psychodynamic theory. In contrast, my datafor evaluations now comes largely from videotaped family play ses-sions, and my psychoanalytic interpretations of the data are aug-mented by micro-analytic technique and dynamic systems theory.Using videotape micro-analysis technique and dynamic systems

theory, current developmental research has demonstrated the pow-erful contribution of family interaction patterns to the developmen-tal process, and therefore to the child’s adaptive behavior (Fivaz,1999, Fivaz, 1994, Stern, J., 1996, Beebe, 1994, 1997, Jaffe, 2001, Fo-gel, 1993, Tronick, 1989, Tronick, 1998, Stern, D., 1985, 1998). How-ever, these valuable resources are not usually part of the clinician’srepertoire. Although child clinicians will often note the parent’s(usually the mother’s) behavior with the child in the waiting room,or the behavior of the parents in the parent sessions, observation offamily interaction is not done in a systematic manner. Yet, these theo-retical and technical tools—so useful to infant researchers—can alsobe available to child clinicians.The shifts in the sources of my data and their effects on my techni-

cal and theoretical tools has significantly changed what I see when Ievaluate troubled children, and how I intervene to help them andtheir families. My previous method of evaluating children did not in-clude a family meeting. Without a videotaped family meeting, I didnot have the data to “unpack” the complex interactive patterns thatunderlie a child’s symptomatic behavior. Without dynamic systemstheory as a theoretical framework, I could not understand the rela-tionship between certain interactive patterns and the child’s prob-lems. For example, I could not relate the child’s self-regulatory prob-lems—such as temper tantrums or fears—to particular failures inmutual regulation between the child and his parents. And, I couldnot appreciate the connection between the child’s problems and dif-ficulties negotiating agency in the family, such as in patterns of over-control or withdrawal.Knowing in general terms that patterns such as over-control or

withdrawal exist in families of children with psychological problemsis helpful. Yet, the usefulness of that knowledge is limited in terms ofhelping parents. It is not helpful, for example, to tell parents—asclinicians sometimes do—to “be less controlling.” In videotape mi-cro-analysis, on the other hand, the data are visual. For that reason


and because it includes otherwise invisible observations of the child’sbehavior in interaction with his family, this information is more im-mediately relevant to parents than experience-distant psychody-namic formulations, and easier to use in answering their questionsabout their child.

what i do now: the parent consultation model of theevaluation of psychological problems in young children1

As a means of describing the PCM, let me return to the phone callfrom the mother I will call Mrs. R. After Mrs. R tells me her concernsabout her son, whom I will call “Sean,” I say, “Let me tell you how Iwork, and you can see if it fits what you are looking for.” She agrees. Itell her that I offer parents a consultation in three sessions. The firstsession is for parents alone, so that I can hear their concerns about theirchild, find out some facts about their child’s development and thefamily situation, and—particularly important—help the parents gen-erate questions for me as their “consultant” about children. The sec-ond session is a family meeting with every family member present, notjust Sean. It is a play session, and its major purpose is to provide op-portunities for me to gather data that I can use to answer the parents’questions as their consultant. To provide the optimum means of de-veloping this information, the family meeting is videotaped. The or-ganization of the family meeting is designed to give me a glimpse ofevery relationship in the family and the way various family memberswork together, as well as how the entire family functions. The familymeeting also allows me to observe Sean’s capacity for pretend play,and the meanings he makes of his experience as it is represented inthe play. The third meeting is for parents alone in which I answer theirquestions and make recommendations regarding treatment andother matters. I illustrate my impressions of the family with videoclips from the session. The three meetings are 45–50 minute ap-pointments, though I usually schedule the third, the second parentmeeting, 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 in-teresting to her. I give her a chance to ask me questions. At this pointshe 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 presentingproblem of the child. In evaluations of older children I use a family discussion insteadof play format.

hard for him (Sean) to have his problems discussed in front of hisbrother. He is easily shamed.” I tell her that the play session is in-tended to be a pleasant experience. Usually I would not discussSean’s problems directly. The information I need to answer Mr. andMrs. R’s questions will show up in the play. I say that I will direct thesession and take care not to let anyone be put on the spot. At the be-ginning of the session, I will explain that we are going to “play inpartners,” that Sean will begin as Dad’s partner, and his brother asMom’s partner. After five to ten minutes, I will tell everybody toswitch partners. Then after a similar time period, I will tell everybodyto play altogether. After another ten minutes of playing together, Iwill tell everybody that Mom and Dad are going to sit in the twochairs and have a conversation with each other while Sean and hisbrother continue to play. This section is the last part of the play ses-sion. After this, I announce the end of the playtime, and we all pickup the toys and say goodbye. The entire family play session takesabout 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 husbandare also concerned about the toll the family situation is taking onSean’s little brother, Mattie, and considering the whole family willgive them an opportunity to take Mattie’s needs into account. I sug-gest that she talk to her husband about the approach I have de-scribed and get back to me about whether they would like to moveforward with the consultation. If they choose to carry on, we willschedule the meetings. In suggesting that Mrs. and Mr. R talk aboutthe consultation together, I am putting the emphasis of the decision-making back on the parental couple. I am also giving them a chanceto reflect on the approach. The next day, Mrs. R calls and says thatshe 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 forevaluating the wealth of information available in the videotaped ses-sions used in the evaluation. Indeed, without some framework, thematerial tends to be overwhelming. I have found conceptual frame-works developed by two developmental psychologists particularlyhelpful—Elisabeth Fivaz-Depeursinge and George Downing—bothof whom I have studied for some time. Although these conceptual


frameworks work for me, it is possible that the choice of a particularframework is less important than finding some useful means of mak-ing order from the extraordinarily rich material in videotapes of fam-ily sessions.

Lausanne Triadic Play Model

The specific organizational structure in the PCM is inspired by thework of Elisabeth Fivaz-Depeursinge and colleagues (Fivaz et al.,1994, Stern et al., 1996, Fivaz et al., 1999). The triangular frameworkof the LTP includes observations of the famly at multiple levels of in-teraction—participation, role, joint attention, and affective contact.Particularly important from the point of view of the PCM is the ca-

pacity of the LTP to organize observations of the non-verbal commu-nications in the family system in a systematic way. The triangularframework of the LTP includes observations of the family at multiplelevels of interaction—the level of interaction involving the lowerbody, the upper body, the orientation of face and gaze, and affectiveexpression. These observations lead to the description of various cru-cial functions in the family interaction—those of participation, role,joint attention, and affective contact. Fivaz and colleagues explainvarious functions of family interaction as “embedded” in one an-other, such that the orientation of the lower body is a basic require-ment for participation, making possible the orientation of the upperbody as a definition of role, which in turn leads to the capacity forjoint shared attention through movement of the head and gaze, andfinally the establishment of affective contact through the communi-cation 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 colleaguesalso describe how to go about making observations. The first specificfocus 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. 11–14). The ob-server also notes the affect expressed by family members. Is the affectcommunicated by each family member happy, sad, or angry? Do fam-ily members exhibit a full range of affect, or is affective expressionconstrained or inhibited? Is affect well modulated, or is it explosiveor tightly contained? The observer also notes examples of self andmutual regulating behaviors, such as gaze aversion, self-touching, andother body movements. How do the parents comfort their infant?How do they comfort each other and themselves, and how does the


infant comfort herself? Finally, how do the parents collaborate witheach 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 thedevelopment of the PCM is the clinical work of George Downing andhis technique of video microanalysis. (Downing, 2000, 2005a, 2005b).Downing provides means of organizing information from videotapesfrom 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 onmultiple ways of interacting—using body, face, and voice. (1) Interms of connection, he notes the various ways the family membersmake a connection with one another, using their bodies, their faces,and their voices. He notes body positions and their function in theinteraction, for example, orientation of body in relation to one an-other. He will consider the interactional function of the orientation,such as whether the partners make a play space between them withtheir bodies. (2) In relation to autonomy, he notes the parent’s style ofencouraging the child’s development of autonomy. For example, heasks whether the child takes initiative in the play, and whether theparent supports that initiative, or on the other hand, whether theparent is inattentive to the child’s expression of initiative or tries tocontrol 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 theymanage the time constraints of the interview. Does the family use thelarge space designated as the play area, or do they limit themselves toa corner of the room? Do they settle down to play right away, or dothey spend so much time negotiating the setting up that they have lit-tle time to play? (4) In terms of boundaries, he notes how the familymembers respect one another’s boundaries, and how they managethe boundaries of the play interview. Do the parents respect thechild’s personal boundaries, or do they intrude into them by touch-


2. The differences between the LTP, in which a structured seating arrangement ofthe family members is part of the experimental design, and the PCM, which involves afree-play situation, result in different ways of analyzing the observational data. For ex-ample, observations about body position in the PCM cannot be reliably coded, as theycan in the LTP. Yet, these observations may still be clinically useful.The observations of mother-child, father-child play, sibling play, and parent conver-

sation in the PCM are actually observations made of sub-systems of the family ratherthan as observations of “dyadic relationships.” However, clinically relevant observa-tions about the relationships in these subsystems can be made.

ing the child or by moving the child’s play objects without an invita-tion? Do the family members respect the play space presented tothem, or does the child stray into the part of the room where thecomputer and the video equipment is? Does the parent make a clearboundary between playtime and time to stop and pick up the toys?(5) Apropos language, how is language used in the play session—topromote the play, to comfort, to criticize, or to control? What kind oflanguage does the parent use—primarily descriptive language such as,“Oh, you are putting that there” or prescriptive language such as, “Putthat there.”Downing’s model is based on developmental theory but is de-

signed primarily as a clinical theory. In that sense, particularly, it hasbeen an important influence on my work on the PCM. I also owemuch of my skill in making observations about families and analyz-ing them to the consultations and discussions I have had with Down-ing during the past five years.

Other Theoretical Influences

The PCM as I have developed it derives from other aspects of devel-opmental research, including the mini-reunion experience createdby the order of the partner play, in which the identified problemchild plays with the father first. This order offers the opportunity toobserve a “mini reunion” of the child with the mother. The PCMdoes not, of course, replicate the experimental conditions related tothe “strange situation” of Attachment Theory. Nonetheless, my expe-rience suggests that this design can elicit interesting observationsabout the mother-child relationship corresponding in some way tothe findings of the strange situation test (Lyons-Ruth, 1991). Finally,because it is a play session designed for preschool and early schoolage children, the PCM also offers the opportunity to evaluate thequality of the child’s play and uses psychoanalytic theory to identifyand make sense of symbolic representations in the play. Psychoana-lytic theory and developmental theory are thus both instrumental ininforming the observations obtained from the PCM.In sum, the PCM draws primarily from developmental theory—

particularly the observational research of Fivaz and colleagues andthe clinical model of Downing—to make a number of important as-sessments. It offers a quick clinical assessment of the father-child re-lationship, the mother-child relationship, the sibling relationship,and the marital relationship. The PCM also offers an assessment ofthe way the family functions as a unit, the way the family makes transi-tions, the impact of the children on the marital relationship, and fea-


tures of the child’s play. The time spent in the family session is short,but videotape transcription makes possible the recognition of re-peated patterns on a micro level, contributing to the larger level be-haviors that constitute an adaptation.

clinical case illustration of pcm:first step—first parent meeting

Mr. and Mrs. R come in for the first parent meeting. They are an at-tractive couple in their late 30s. Mrs. R in particular looks tired andstressed. Mr. R works in a demanding professional job. Mrs. R had acomparable job before Sean’s two-year younger brother, Mattie, wasborn but left her job at that point to become a full-time mother. Theyexplain that Sean was “high maintenance” from the beginning, butthat they didn’t recognize it as a problem because they “didn’t knowwhat to expect” from their first baby. They could tell that he was verybright. They first realized that he had a problem when he was re-jected from all the private elementary schools they applied to for 4-year-old pre-kindergarten. The teachers in his preschool confirmedthat he had trouble paying attention and was disruptive during circletime, but said that he was sweet, enthusiastic, and loved to learn. Athome, he was very dependent on his mother and anxious about be-ing separated from her. He insisted on following her from one floorof the house to another. He envied Mattie’s possessions and com-peted fiercely with him for his parents’ attention, but he also playedhappily with him for long periods. Play usually ended with Sean’steasing Mattie, or with his aggressive physical attacks on him. Seanalso complained about lumpy food, tags on the back of his shirts,strong smells, and loud noises. Both parents agree that they arenoticing Sean’s immature behavior more now than they had even ayear ago. As Sean gets older, the discrepancy between his behaviorand that of his peers, and even that of his little brother, becomesmore apparent.I ask about family stressors, and the Rs respond that the main

stresses are Sean’s behavior and the pressure of Mr. R’s job, which of-ten keeps him at the office until the children are in bed. Familyneuro-psychiatric and developmental history is positive for mild tomoderate learning disabilities on the paternal side, acting out in ado-lescence and depression in one of Mrs. R’s siblings, and anxiety bothin 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


both give me at least two questions. I write the questions down verba-tim and put the paper where I can retrieve it for the final meeting.Mrs. R asks, “How to relieve his anxiety—he 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 withhis negative effect on the family—he wears his mother down.” Mrs. Radds, “How do I get this kid motivated to do the things he needs todo, like get himself dressed in the morning or go to the bathroom byhimself?” Mr. R concludes, “How do we help him with his confi-dence, self-esteem?” Although sometimes I find I am able to answersome of the parents’ questions immediately, in this case I think that afamily meeting is essential, and I tell the Rs that a family meeting willhelp me answer their questions.We discuss the family meeting. I repeat the description of the fam-

ily meeting to Mr. and Mrs. R, concluding with a discussion of what totell the children about the meeting. After hearing Mr. and Mrs. R’sideas about how to best present the idea to their children, I suggestthat they refer to me by my first name rather than as “doctor,” so asnot to unnecessarily alarm the children, and suggest that they referto me as “a lady who knows a lot about children and families and whogives families ideas about how they can get along better together.”Then I suggest adding, “And the way she does that is to have familiescome and play at her house, and then go home again. She also uses acamera to take a film so that she can remember what happened afterthe meeting.” We schedule a meeting time.

second step—family meeting

At the time of the family meeting, I arrange the room with toys ap-propriate for children of Sean’s and Mattie’s ages—a barn with farmanimals, 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. Theboys are very attractive children. Sean leads the way into the office.He is excited and eager to see my toys. Mattie holds his mother’shand. In the office I remind the family of the plan for the meeting. Irepeat the different parts of the meeting including the parents’ con-versation and the camera. The camera is a small video camera that Iplace on my lap; the monitor can be viewed in a brief downwardglance. I point out the camera to the family. Openness about thefilming of the meeting is particularly important from the point ofview of modeling trustworthy behavior in the family consultation. I


tell them that in the beginning, Sean will be Dad’s partner and Mat-tie will be Mom’s partner.

Child and Father Play

Sean chooses the barn with farm animals, and he and Mr. R establishthemselves in front of the barn. Sean says to Mr. R, “Let’s herd theminto the barn, because there is a big storm coming!” Mr. R asks,“Which ones? Which ones?” and starts to pick up the animals. Thetwo of them are smiling and obviously happy to be together. They arepicking up the animals and talking about them. Interestingly, the ani-mals 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! You’re my buddy, Sean!” and walking over to him,while she helps Mattie and Mr. R find the toy garage. Sean calls out toMrs. R, “We’re going to herd the animals into the barn.” Mrs. R says,“O.K.,” sits down beside the barn, and listens to Sean explain againabout 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 backwith her hands folded most of the time. Again, in this seven-minuteplay sequence, despite much talking about it, the animals do not getherded into the barn.When I call for the family to play together, the family makes an-

other smooth transition, with Mrs. R making suggestions about howthey might combine the two types of play. They begin to play with thegarage and some of the farm animals. Mattie, Mr. R, and Mrs. R clus-ter around the garage and play with it for the entire period. Seanplays on the periphery, connecting vehicles with their trailers, peri-odically joining the others and then removing himself again from thecentral 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 eachother. Mr. and Mrs. R move to the chairs, and the boys continue theirplay. Mattie goes to play with the barn, and Sean continues playingwith the cars and trailers. The parents are able to have a conversationwith each other, though now and then they are distracted and turntheir attention to the boys. They seem to anticipate a problem thatthey must be ready to manage.Then Mattie says, “We have to herd the animals into the barn.

There’s a big storm coming.” He begins to put the animals into thebarn. Sean comes over to the barn and starts to help him, but he is


more erratic in his attention and his movements than his littlebrother. Numerous times he grabs a toy away from Mattie; sometimesMattie objects, sometimes he does not. At one point, Sean declares,“The storm is over now,” but Mattie responds, “No, it’s not,” and con-tinues his work of herding. Sean moves back and forth from thebarn, to the activity of hooking up the cars and trailers. Finally, Mat-tie declares, “Now they’re all inside—safe and sound.” In a dramaticconclusion to the course of events, Sean’s little brother is able to im-plement Sean’s stated agenda more effectively than either parent isable 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 theanimals into the barn to find protection from the impending storm,which I take to signify Sean’s dysregulated behavior and its effect onthe family. The whole family seems to resonate with this symbolictheme. The conclusion of the family play is to find a safe place for allthe animals inside the barn, yet this is accomplished in an unex-pected way. It is only when the constraining behavior patterns Seanand his parents have created together are relegated to the back-ground, and the parents allow the children to exercise their ownagency, that Sean’s agenda can be constructively engaged.3 Yet, a fullanswer to the question must wait until later, since we must first returnto the model as a practical way of answering the parents’ questions.

third step—interviewer viewing the tape

In this step, I view the tape alone. Initially I transcribed small tapesfrom my digital video camera onto a VHS tape and viewed them onmy television monitor. I used my remote control to look at certain se-quences in slow motion. Now, I capture clips from the digital video-tape on my computer, using the program of final cut express. Whiletime consuming on my part, it makes the showing of the film to theparents more efficient, since it isolates small sequences of the tapethat are immediately available for viewing. Also, the computer pro-gram allows for frame (about one thirtieth of a second) by frameviewing easily. As I observe the tape, I look for patterns of behavior in


3. Sander’s work has been extremely influential to my thinking and clinical work.Both in his writings and in our discussions, Sander’s conceptualization of agency asemerging from the mutual regulatory competency of the dyadic system has been cen-tral to my understanding of children like Sean (Sander, 1985, 1995, personal commu-nication, 2004).

the different sections of the interview. Here I make use of Downing’stechnique of video micro-analysis to evaluate the play sequences offather-Sean, mother-Sean, family together, and parental couple withsiblings. Although at first I would spend more time capturing theclips 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. R’s re-minding the children of the rules of courtesy in greeting and theboys’ willingness to comply. Sean’s capacity for enthusiastic engage-ment with a new situation is also clear. Mrs. R takes up the rear, per-haps showing a tendency toward reticence. Mattie stays back withher; he could be expressing his own timidity, or “taking care of” hismother.

Father-Child Play Sequence

1. Connection—Mr. R and Sean express their enjoyment at beingwith each other in their facial expressions, their tone of voice, andtheir affectionate physical contact. At one point, Sean leans comfort-ably against his father’s leg, and at another point, Mr. R puts his handon Sean’s shoulder. Father is oriented to Sean, but Sean’s body is at aninety-degree angle to his father. This seems to indicate some diffi-culty making contact. There is little visual monitoring of each other.2. Organization of time and space—Father is lying on the floor nextto Sean, and Sean is seated next to the barn, using the play space in acomfortable manner. They use the play space available, and they be-gin and end at the time I direct them to play and then to change.3. Boundaries—Neither seems to intrude on the other’s space, norto take control from the other. However, an interesting pattern is cre-ated when Mr. R is showing Sean two animals, and Sean reaches overhis father’s extended arm to reach into the barn, glancing at the ani-mals over his own arm. This unusual arrangement of bodies is moreevident in split second viewing and again seems to illustrate someavoidance of direct connection.4. Language—When Mr. R speaks to Sean, he does not use prescrip-tive language; in other words, he does not give him orders. He pri-marily communicates his ideas as they come up in the play, for exam-ple reminding Sean of an animal they saw together on a family trip.5. Autonomy—In spite of their mutual pleasure in the play, Sean’s ex-pressed agenda of getting the animals into the barn is not imple-mented. This seems to be because Mr. R does not attend to Sean’s re-peated requests that they do this. When I count, Sean refers to theagenda of herding the animals into the barn six times in a one-minutefilm clip, before his father begins to put the animals into the barn.


The transition to the mother-child play sequence is also smooth. Iannounce the transition, and each family member responds in acharacteristic way. Sean turns away from the activity, bending overfarther toward the barn, as if to manage the confusing and stimulat-ing experience of the transition. Mr. R turns smoothly away fromSean and toward Mattie, whose small hand can be viewed in thecrook of his father’s arm as he guides his father into his new positionas his partner. Mrs. R supports my directive and helps manage thetransition, saying—“Change buddies! You’re my buddy, Sean!” Seancalls out to her as she crosses the room, “We’re herding the animalsinto the barn!” and then turns away again, bending over the toy. Asshe approaches him, Mrs. R displays a pattern similar to Sean’s,though subtler. She turns toward Mr. R and Mattie, pointing out aninteresting toy to them as she moves toward Sean and sits down be-fore him. It is not until after she completes this communication thatshe turns to Sean and focuses on him intently, as he repeats his wishto herd the animals into the barn.

Mother-Child Play Sequence

1. Connection—Sean and Mrs. R are seated at a greater distancefrom each other than Sean and his father had been, and there is asense of anxious constraint in their behavior. After Mrs. R’s carefulattention to Sean when she looks directly at him as he explains hisagenda, there is little eye contact between them. Sean expresses en-thusiasm about the play in his face and voice, but Mrs. R expresses lit-tle positive affect, presenting a look of earnest concern, instead.They do not touch each other.2. Organization of time and space—Mrs. R quickly initiates an organiz-ing activity, taking the animals and in orderly fashion placing them ac-cording species in front of the barn. She inquires what kind of animalSean wants to herd into the barn, further assisting him in organizinghis intention. Mrs. R and Sean make a good play space between them.3. Boundaries—Mrs. R and Sean seem to be particularly attentiveabout maintaining adequate distance between them. In fact, they ex-press anxiety about physical closeness. For much of the play se-quence Mrs. R sits with her hands clasped, and Sean frequently pullshis hands back out of the play space, at one time sitting on his hands.Micro-analysis of the videotape demonstrates a moment lasting afraction of a second in which Sean extends his arm suddenly, makinga grabbing motion toward his mother and the animal she is holding.This movement is not apparent during normal time; it is very quick,and Sean’s hand remains empty. However, it is after this movementthat Sean pulls his hands way back and Mrs. R puts down the animaland clasps her hands. No gaze is exchanged during this event.


4. Language—Mrs. R does not use prescriptive language to Sean, butonce she talks in an educative way to Sean about the difference in ap-pearance between dairy cattle and beef cattle. This communicationis in response to Sean asking, “Is that a deer?” when Mrs. R is movingan animal toward the barn. She also demonstrates a unusual vocalturn-taking pattern that involves beginning her vocal turn immedi-ately after Sean finishes his, a pattern associated with anxious over-control (Beebe, 1999).5. Autonomy—Mrs. R demonstrates a clear intention to supportSean’s autonomy. She listens intently when he explains his plan toher. She helps him with the set-up of the plan and encourages him toimplement it. In response to Sean’s remonstrance, “You have to helpme!” she begins to put the animals into the barn. Yet, at severalpoints, Mrs. R expresses her skepticism about the potential success ofthe agenda, framing it in terms of fitting all the animals into thebarn, and by the end of the ten-minute play sequence, just a few ofthe animals have been put into the barn. Mrs. R seems to have antici-pated failure in the enterprise, and her negative expectation hasbeen fulfilled.

When I announce the transition to the whole family playing to-gether, Mrs. R, Sean, and Mattie look up at me. Mrs. R immediatelysays, “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 tolook for “a group activity,” something they can “all do together,” andMr. R suggests that Sean can bring some of his animals to the garageif they can’t all fit in the barn. Sean initially rejects this idea, butwhen Mattie moves over to the barn, Sean grabs it away from Mattieand declares it “locked,” saying, “Let’s use the garage for anotherbarn.” He again grabs the barn from Mattie’s grasp and pushes Mat-tie’s arm away from the barn. Just after Sean’s aggressive moves to-ward Mattie, Mr. and Mrs. R both simultaneously turn their facesaway from Sean and begin to orient their bodies toward the garage.At the same time, Mattie turns away from the barn and also moves to-ward the garage. It seems clear that the family is attempting to avoidconflict by complying with Sean’s demands. Yet, as they comply, theyin unison move away from him, leaving him alone.

Family Play Sequence

1. Connection—Mr. and Mrs. R and Mattie begin arranging the ani-mals on the different floors of the garage. They communicate posi-tive affect with their facial expressions and tone of voice. Sean playson the outskirts of the group. He has found several vehicle-trailerpairs, and he occupies himself with trying to connect them. Now andthen, he joins the family group for a brief period, but then he returns


to the cars. It seems clear that Sean attempts to regulate himself byfrequent, periodic distancing from the family group. He uses therepetitive motor activity of hooking up the truck and trailer as an-other regulating activity. This activity also has the symbolic meaningof “connecting.” After a few initial attempts, his family members donot actively try to engage him in what they are doing. As a result, heremains relatively disconnected from the family group.2. Organization of time and space—The family organizes itself in asmall space, without much freedom to move about the floor. Whilethis was also true during the “partner play sequences,” it is more obvi-ous with the whole family playing together. The family is able to be-gin, elaborate, and complete a play sequence within the time of-fered.3. Boundaries—The boundaries between interacting members ofthe threesome including Mr. R, Mrs. R, and Mattie seem comfort-able. There is affectionate physical contact but not intrusiveness andcontrol. The boundary between Sean and the family group is strik-ingly different. He intrudes into Mattie’s attempted play with thebarn, 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 fa-ther’s hand out of the way with the other, though it is not apparentthat his father’s hand was in the way.4. Language—The family uses language appropriately in a descrip-tive or suggestive manner. However, sometimes Sean uses languageto control his family members, for example when he tells the otherswhat the cow is “supposed to” do, and when he tells them, “Put ithere!” In response to his commands, Mrs. R, Mr. R, and Mattie say,“O.K.”5. Autonomy—In the family play, Sean seems to intrude on Mattie’sagency, in particular. Frequently, he takes toys away from Mattie orgives him orders about what to do. Mr. and Mrs. R have two ways ofresponding to this behavior. They allow Mattie to comply with Sean’scommands, or they move to minimize the amount of control Seancan exercise. An example of the former is when they turn to thegarage in response to Sean’s claiming possession of the barn at thebeginning of the family play. An example of the latter is when Mrs. Rtakes the cow that Mattie has been playing with, and that Sean hasjust grabbed from him, and replaces it where Mattie can reach it.Mrs. R seems to be maintaining constant vigilance over Sean’s con-trolling behavior. Sean takes the initiative at several points in theplay, and the family makes efforts to respond to his ideas. Frequently,however, he interrupts his participation in the group play and turnto connecting the vehicle and trailer. The other family members al-low him to do so without explicit recognition. It seems that the familyhas difficulty supporting the agency of both boys—Mattie, because


of Sean’s intrusive behavior toward him, and Sean, because of his dif-ficulty maintaining a focus of joint attention and other regulatorydifficulties and because of the family’s response to his controlling be-havior.

The transition to the parents sitting together to have a conversationalso goes smoothly. Mrs. R notifies the boys of what they are going todo. Neither boy objects. Mr. and Mrs. R sit in the chairs and begin totalk. This part of the session in particular demonstrates importantstrengths of the family—the parents’ capacity to constitute a well-functioning relationship of their own, and the siblings’ ability to playtogether creatively, despite Sean’s 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 andwhich he has not played with before. He says, using Sean’s exactwords 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, andhe speaks apparently to himself. Sean, however, approaches him andattempts to join his play. Without looking at Sean, Mattie continuesto put animals into the barn. His attention is more focused and hisactions smoother and better coordinated than Sean’s. In ignoringSean, it is as if he recognizes that Sean could introduce a significantdisruption in his plan. When about half the animals have been putback in the barn, Sean pronounces, “The storm is over now.” With-out looking up or changing his position, Mattie responds, “No, it’snot,” and continues putting animals into the barn. Sean, after a hesi-tation, leaves the cars and joins him. Finally, the animals are in thebarn. Leaning back, Mattie surveys the barn and says, “Now they areall in the barn, safe and sound.” It is remarkable to me observing thetape, as it was when I was observing the meeting itself, how Mattie isable to accomplish Sean’s agenda by the end of the meeting. In fact,it is now clear that although initially articulated by Sean, it is a familyagenda and all the family members—Mr. and Mrs. R also, by allowingthe boys to play uninterrupted—cooperate 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. andMrs. R’s questions about Sean. I intend to answer them in simple,


4. This observation gives evidence for the influence all family members have onone another while playing in the same room at the same time, whether they are play-ing in “dyads” or all together.

practical answers that lend themselves to recommendations for ac-tion. First, however, I am going to give them my impressions of thefamily meeting. I get out the tape.I show Mr. and Mrs. R the transition into the playroom. I acknowl-

edge the attractiveness of the family and the expression of their fam-ily values in the polite greeting. I point out the friendliness of Seanand his interest and eagerness to engage in this new situation. Then Ishow the clip of Mr. R and Sean. Again, I first address the positive fea-tures of the obvious pleasure the two of them take in playing togetherand the affectionate and supportive attitude of Mr. R toward Sean. Inote Sean’s significant strengths in being able to create and expresssuch a compelling metaphor as “herding the animals into the barn”to avoid an impending storm. I also point out Sean’s difficulties incoordination, including the way he drops the animals, and his ten-dency to get distracted. Next, I note the multiple statements of Seanindicating his agenda to herd the animals into the barn and Mr. R’sinattentiveness to them. This is a powerful moment in the meeting.Mr. R is deeply moved. He is astonished to appreciate this observa-tion and wonders how he could have failed to attend to Sean in thisway.The next clip I show them is that of Mother and Sean. I first point

out the evidence of Mrs. R’s devotion and sensitivity to her children,including her helpful preparation of Sean and Mattie for the transi-tion and her attentiveness as Sean is explaining his agenda to her.Then, however, I note her obvious anticipation of failure in this activ-ity with Sean. I suggest that this sad, discouraged reaction of hers maynot be an uncommon one. Mrs. R is also very moved. In contrast toher husband, she is not at all surprised by my observation and agreesthat 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 themof what they have told me about Sean’s sensitivity to loud noises, ir-regular textures in his food, and scratchy things against his skin andpoint out that these sensitivities are associated with regulatory diffi-culties such as the ones demonstrated in the film. I tell them that it isclear that Sean is a child challenged by problems regulating himself,but that I think the film gives us some ideas about how to help himlearn to regulate himself better and how to support him in his devel-opment. These ideas include learning ways of attending to him morecarefully and finding cause for hope in his getting better and devel-oping in a healthy way. Toward the goal of elaborating these ideasabout how to help, we turn to their original consultation questions.


(1) The first question is Mom’s: “How to relieve his anxiety—he isfearful and anxious.” I answer, “Right now Sean tends to be an all ornothing kind of guy. We would like to teach him new, more flexibleways of making sense of his world.” This, of course, is neither a com-plete answer, nor does it lead directly to a discrete intervention. How-ever, it communicates a new perspective on Sean’s anxiety and his de-manding behavior, and it indicates a direction toward constructiveaction—teaching him ways of being more flexible. We have seen thepositive feature of his persistence in the agenda of herding the ani-mals into the barn. We would now like to help him find other, moreflexible ways of working on his agenda so that he could feel confi-dence in their successful accomplishment. And we would like to findways of helping his parents support him in his agenda.(2) The second question is also Mom’s: “How to develop strategies

to deal with his behavior problems, e.g. constant picking on his littlebrother.” I answer, “We need to come up with new limit setting strate-gies.” This answer focuses on managing Sean’s aggression and impul-sivity through regulating his high arousal states and his negative af-fect. It also stresses the need to change the controlling effect Seanhas on the rest of the family. This answer is also neither comprehen-sive nor specific. However, it leads toward a practical way of changingthe family relationship patterns that are not working and suggeststhat I am available to help the parents make those changes. In thisanswer, I am also addressing Mrs. R’s exhaustion in her efforts tomanage the boys’ aggression, as well as Mr. R’s sense of helplessnessabout how to support his wife when he arrives on the scene of a sib-ling conflict after having been at work all day. Mrs. R might be able togive up her role as the family manager if both she and Mr. R couldfind more effective ways of helping Sean regulate his behavior.(3) The third question is Dad’s: “How to deal with his negative ef-

fect on the family. He wears his mother down.” I point out that Mrs. Ridentifies herself as a “problem solver,” but that this problem is notthe kind that can be “solved” by one person. For her to take this onher own shoulders is too great a burden. I also point out that Mr. Rseems to withdraw into his work and feel helpless. I suggest that wefind new ways of the parents working together to make things better.(4) The fourth question is Mom’s: “How do I get this kid motivated

to do the things he needs to do?” Mrs. R explains that Sean is unableto dress himself or take on other age-appropriate skills of autonomy,and she has been unsuccessful in helping him learn. I agree with theRs about how Sean needs experiences of mastery. Neuro-develop-mental disabilities have interfered with his achieving certain compe-


tencies necessary for age-appropriate autonomy. I explain, also, thathis difficulty managing strong feelings makes it hard for him to takerisks that threaten him with disappointment and frustration. Weneed to find special ways of supporting him in achieving mastery ofskills of independence.The Rs are thoughtful and interested in my answers to their ques-

tions. They ask for recommendations about how to implement someof my ideas. I tell them that I think they need help working on thesechanges, and that I would be glad to help them. Since the problemsare interfering with Sean’s development in a significant way, I recom-mend a therapeutic intervention that includes working with Sean di-rectly—either continued parent consultation with family meetingsor individual therapy. Mr. and Mrs. R say that they are interested intrying to change the way the family members behave in relation toone another, including their parenting behaviors, and that theywould prefer to continue to work with me in family consultation. Iagree, and we set a first meeting.

key differences in the consultation

You will notice that my comments to Mr. and Mrs. R include neither adiagnosis nor an explicit formulation of Sean’s difficulties. That isbecause those issues are not included in their consultation questionsto me. In this case, my initial formulation of Sean as a child with neuro-developmental disorders complicated by family patterns of difficulty regulat-ing him and supporting his agenda, informs my answers to the questionsthey do ask me. I know that Sean has made sense of his life experienceand that the sense he has made includes rigid, all-or-nothing mean-ings that underlie his separation anxiety and his other fears. At thispoint, I know that these meanings include that of a destructive“storm” that threatens the living creatures of the farm, and I knowthat Sean and his whole family fear that they might not find themeans 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 mean-ing, demonstrated in each family member’s reaction to the threat ofthe storm. Sean is afraid of the storm, but so is everybody else. Hismother, father, and brother either keep a distance from Sean or com-ply with his demands, in an effort to avoid the storm of his temperoutbursts. Fear of the storm helps explain Mr. R’s choice of more im-mediate subjects of joint attention rather than Sean’s main agenda. Ithelps understand Mrs. R’s withdrawal and anxious efforts to manage


the family. It informs the observations of Sean’s sitting on his handsto avoid potential grabbing movements. It explains Mattie’s accom-modation to Sean’s refusal to share the toys with him.Yet, my fuller understanding of Sean’s problems depends on the

micro-analysis of the family meeting. Had Sean, in an individual ses-sion, represented his experience in the metaphor of the storm—lesslikely, perhaps, were he not in the midst of his family—I would haveinterpreted the storm as Sean’s aggressive behavior and his fear ofthe consequences of this behavior on his important relationships. Iwould not, though, have seen evidence of crucial features of this be-havior. I would not have appreciated the degree to which and theways in which Sean’s problems regulating his attention, his motor ac-tivity, and his affects contributed to the creation of the “storm.”These observations are harder to make when the clinician is playingwith the child one on one. The family meeting illustrated—in the mi-cro-process with each parent, and in the sibling play—the extremestruggle Sean exerts to regulate his behavior. The storminess of hisaffective state and his attentional state underscores his impulsivegrabbing.I also would not have seen how each individual family member re-

sponds—how the family as a whole responds—to the threat of thestorm. The family meeting illustrated the way his parents andbrother contributed to Sean’s dilemma by symbolically leaving himoutside the barn, when they felt helpless to deal with the storm. Iwould not have understood in what ways the family system has cre-ated adaptations to the challenge of Sean’s behavior that backfire,and make it even harder for them to help him grow. I would not haveseen Mattie’s valiant efforts to recuperate the plan of herding the an-imals in order to save his family from the storm. Finally, I would nothave seen the significant strengths of the family, strengths that will beessential 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 theexchange between the child and the world of his family. However, Icannot observe the child’s inner world with videotape. His privateworld is the territory of psychoanalysis. The opportunity to put to-gether these two complementary views of the child—the inside andoutside views—is an exciting opportunity. Often, the PCM evalua-tions go on to become psychotherapies, and sometimes—as in thecase of Sean—psychoanalyses. Once the child is in individual therapyor psychoanalysis, transference issues usually make family meetings


impossible. Beginning the evaluation with the PCM often gives methe only chance I will have to capture this “outside view.”

Concluding Remarks

I would like to conclude by considering analogies between the questfor useful means of helping troubled children and their families, andSean’s desire to herd the animals into the barn. Through his at-tempts to get the animals into the barn, Sean is drawing his family’sattention and my attention to the storminess of his internal world,and to how that storm sometimes provokes him to behave. But as Ihave pondered Sean’s stormy world, I have also thought about thestorm in psychoanalysis and recent efforts to bring together informa-tion from infant research and developmental theory into somethingthat is useful for the theory and practice of psychoanalysis and psy-chotherapy. The technical and theoretical tools that infant researchprovide have enormous potential but must be integrated into psy-choanalytic theory and technique in order for me and other clini-cians 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 extremelycomplex. No linear theory of causality is sufficient. Moreover, theplurality of contemporary psychoanalytic theories lacks the necessarycoherence to provide the clinician with what he or she needs to makesense of clinical material. Dynamic systems theory—a theory thatprovides a broad umbrella theory for therapeutic and developmentalchange—includes in its general principles coherence, as well as com-plexity. These considerations suggest that psychoanalysts and otherclinicians should attempt to provide coherence by developing usefulintegrations. Indeed, the PCM that I have described in this paperrepresents one effort to develop a useful integration of techniquesand theory to help children and their parents in the initial—and im-portant—diagnostic phase.Sean and his family are searching for greater flexibility in the

meanings they make of their experience together and apart. Theyare trying to support each family member’s agency in their efforts atcreative elaboration of their private meanings, yet at the same timestriving to find ways of regulating themselves and also the family sys-tem, so that it does not come apart. In a similar way, analysts andother clinicians would be well advised to be flexible, open to alterna-tive perspectives, without fearing the loss of familiar concepts. The


self-organizing properties of dynamic systems suggest that there aremany ways of understanding the challenges of developmental pro-cesses, including those we engage in our work with patients. Thesearch is for ways of embracing complexity, while developing andmaintaining the coherence of our theories. In Sean’s metaphor, wesearch for means of “herding the animals into the barn”—bringingthe complexity of developmental processes into a coherent frame-work of psychoanalytic theory.

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PSYCHOANALYTIC RESEARCH

Recollections of Being inChild Psychoanalysis

A Qualitative Study of a Long-TermFollow-Up Project

NICK MIDGLEY, PsychD, andMARY TARGET, PhD

To date there has been very little research looking at how former childanalytic patients have made sense of the experience of being in psycho-analytic treatment as children. Based on semi-structured interviewswith twenty-seven people who, as children, had been in intensive psy-choanalysis at the Anna Freud Centre, London, between 1952 and1980, this study uses a qualitative methodology to explore two centralthemes: “attitudes toward being in therapy” and “memories of therapyand the therapist.” This report presents the findings of the study innarrative form, and argues that the recollections of former child ana-lytic patients are an important, but under-used, source of knowledgefor an understanding of the psychoanalytic process.

In 1922, thirteen years after he published his first account ofthe psychoanalytic treatment of a child, the case study of “LittleHans,” Freud added a short postscript. In it he described a “strappingyouth of nineteen” who approached him and introduced himself asthe same person whom Freud had met when he was only five. He told

Nick Midgley, Anna Freud Centre, London, and Mary Target, Anna Freud Centreand University College London.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 byRobert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).

157

Freud that he “was perfectly well, and suffered from no troubles orinhibitions.” He had apparently “come through his puberty withoutany damage,” despite the severest of ordeals, including the divorce ofhis parents. Most remarkable of all, he told Freud that, even when heread the case history, he could remember nothing of the analysis it-self or anything described in the pages of Freud’s work (1909:304).

Freud suggested that Hans’ memories were no longer available toconsciousness because of the repression barrier that had blocked anyrecall of both his early childhood and, more specifically, of the ana-lytic work undertaken by Hans’ father under the “supervision” ofFreud. Perhaps it was Hans’ lack of memory that has encouraged psy-choanalysts (and researchers) to assume that former child analyticpatients will have little or no memory of their early experience ofanalysis, leading to an almost complete absence in the professionalliterature of any accounts of child analysis from the point of view ofthe former patient him or herself.

Yet when we turn to the general child analytic literature, we dis-cover that in many treatments some form of spontaneous follow-up—like that of Freud and little Hans—does take place, and that ina few instances some indications of how the child analysis has beenremembered is recorded. Far from suggesting that all memories areover-taken by the repression barrier, there are hints that the childanalysis—and the figure of the analyst in particular—retain someplace in the memories of these adults.

For example, in Koch’s (1973) review of twenty cases of follow-upcontact with former child patients, he reports that former child pa-tients made some reference to their experiences of analysis, but withlittle specificity and some distortion of memory. Some spoke of it asbeing “helpful,” or remembered some aspect of the treatment roomor particular events (often connected to provocative or acting-outepisodes) but that much of the children’s experiences had “recededinto the oblivion of the repressed” (238). The only exception is onechild who, at follow-up, “dwelt at some length on his experience,vividly recalling his anger at the therapist for not understanding whathe was trying to communicate when enraged” (238).

In a similar review, Beiser (1995) writes that of the thirteen inten-sive child analyses she carried out during her analytic career, in tencases follow-up data was available, in some cases up to forty years aftertermination. But in only one case does Beiser explicitly report theformer child patient’s own memories of therapy: a boy who remem-bers playing Fox and Hounds with his therapist, while naming eachanimal with an affect—depression, envy, anger, and happiness. The

158 Nick Midgley and Mary Target

man also reports his memory of an incident when his analyst “toldhim it was unacceptable to put his feet or chocolate-smeared handson [the therapist’s] desk” (117).

Although she gives no other examples, Beiser observes that manyof the memories of therapy that these former patients retain were re-lated to experiences of limit-setting by the analyst, and she wonderswhether the experience of gratification and frustration, inherent tothe analytic experience itself, encourages the process of internaliza-tion. She also notes that several of her former patients had enteredprofessions involving the care of children, and that they often re-tained an “attitude of inquiry as to the meaning of behavior and feel-ings” which the analyst had herself promoted (119).

The psychoanalytic literature also contains several case studies offormer 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 showhow “core aspects of character seem to be continuous from child-hood to adulthood” (Cohen and Cohler 2000:9), so they have not fo-cused primarily on the former child patients’ memories of therapy.Nevertheless, a number of these case reports do remark on the placethe child analyst appears to have retained in the former patient’smind. In a review of several cases, Ritvo suggests that many of theseadults have maintained an internal representation of the child ana-lyst as a “source of self-awareness and self-understanding to whichthey turned at times of internal crisis” (1996:375), as well as an aware-ness that “understanding the workings of the mind was the way to re-solve their difficulties, and that the analyst was someone who knowshow 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 oftheir analyses are tantalizing: Ms B, who “recalled many aspects ofher first analysis, especially in connection with her analyst’s interpre-tation of wishes to have a baby” (Ritvo and Rosenbaum 1983:686);“Richard,” in analysis with Melanie Klein as a young child, who al-most forty years later remembers her as “dear old Melanie,” “short,dumpy, with big floppy feet,” and with “a strong interest in genitalia”(Grosskurth 1987:272–73); the young woman who felt that, as anadolescent in analysis, she had been able to “get better because [theanalyst] was kind like her father,” and who recalled particularly apainting on the wall of the analyst’s office (Adatto 1966:500); and“Evelyne,” who, in a follow-up interview at the age of thirty-four, re-

Recollections of Being in Child Psychoanalysis 159

ported “that she learned the art of good listening and communicat-ing from her former analyst” (Ritvo 1996:374).

To our knowledge, the only description of a child analysis writtenby a former child patient her or himself is Peter Heller’s A ChildAnalysis with Anna Freud (1990). The book includes a reproduction ofthe very sketchy process notes made by Anna Freud on Heller’s child-hood analysis in Vienna, which she sent to him a few years before herown death. Heller chose to publish these, together with an accountof his own memories of his childhood in Vienna and his “free associa-tions” to reading Anna Freud’s notes.

In his introductory chapter, where Heller writes of his family andhis childhood, Heller expresses with great force his deep but ambiva-lent feelings toward Anna Freud and his analysis with her, which wascarried out in quite unusual circumstances. (Heller also attended aspecial school run by Anna Freud and his later life was closely tiedup with that of Anna Freud and her circle). He describes his memo-ries of Anna Freud’s “kindly severity” (xxii) as she sat behind thecouch on which he lay (between the ages of nine and twelve), knit-ting or crocheting. He remembers that his analysis focused on theloss of his mother and his “problematic” relationship to his father(xlvi), and he describes how as a child he “loved and revered [AnnaFreud] above all other humans” (xxvii). Yet Heller is deeply ambiva-lent about the experience: he explains how, “in analysis I wanted tobe loved . . . and like so many patients, I did not think I was lovedenough” (xxvii).

Heller’s account of his child analysis hints at the depth of feelinghe still retains about this period in his early life, and suggests that for-mer child analytic patients can provide us with another point of viewon the psychoanalytic process, one which would complement themany accounts of child treatments from the analyst’s point of view.More particularly, they could provide us with the opportunity to dis-cover 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 waswhat 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 long-term outcome of child psychoanalysis (Target and Fonagy 2002),which attempted to follow up all adults who were referred as chil-


dren to the Anna Freud Centre between 1952 and 1980. In total,twenty-seven adults who had been in intensive psychoanalysis as chil-dren were interviewed as part of this project (see Appendix One). Theseinterviews were extremely wide-ranging and in-depth, exploring allaspects of adult life and functioning as well as memories of child-hood generally and the child analysis more specifically.

Out of this huge amount of data, this study makes use of only onesmall part—the interviews which focused specifically on memories ofbeing in child analysis (Barth 1999). The approach chosen to analyzethese interviews was broadly-speaking “qualitative.” The relativelysmall sample (twenty-seven participants), the nature of the data (ver-batim transcripts of semi-structured interviews focusing on the sub-jective accounts of personal experience), and the topic itself (a rela-tively unexplored area where an exploratory approach is probablymore appropriate than a hypothesis-testing one) are all features thathave been widely recognized as appropriate for qualitative studies(McLeod 1999).

Inevitably the detail and depth of memory retained by the partici-pants of their child analyses varies enormously. Some of those inter-viewed had been as young as three and a half when they had been re-ferred to the Centre; others were in late adolescence. Likewise theperiod of time since the analysis had ended varied a great deal—from eighteen years to forty-two years, with the average length oftime being twenty-seven years. Some people refer to specific, butquite major gaps in their memory, like being unable to rememberanything about starting or ending therapy, or whether they saw oneor two different therapists, or how often or for how long a periodthey came. Only two people (aged four and a half and five at the timeof their respective referrals) claimed to have no memory at all of theexperience. Perhaps unsurprisingly, those whose memories were lessclear tended to be the ones who had been referred for therapy whenthey were six or under, although this was not always the case. For ex-ample, one person who had been in therapy at the age of three and ahalf for about two years, had quite clear memories of his therapy andhis therapist.

Results

In the course of the analysis of the data, a wide range of analyticthemes were generated (see Midgley 2003; Midgley, Target andSmith, in press), and this paper will present only part of thefindings—those which were related to the participants’ attitudes to-


ward being in child analysis, their memories of what actually tookplace, and their feelings about the figure of the analyst him or her-self. In the presentation of the material, verbatim excerpts from thetranscripts are included in order to convey the tone and complexityof the individual narratives, and to give a more vivid sense of what theinterviewees’ experiences involved. Although not given in exact quan-tifiable terms, some sense will also be given of whether the themesthat emerged were common across many interviews, or were quiteparticular to the experience of one or two interviewees; or whethercertain themes were especially common among men rather thanwomen, or those who had been in analysis at a certain age. The ex-cerpts will be referenced in the following way: (Anthony, 10.10),meaning that the quotation is from the interview with “Anthony” (allnames are changed), age ten years and ten months at the time of be-ing referred for analysis.

attitudes toward being in therapy

A number of participants in the research suggested that being in psy-choanalysis as a child was a relief because they were aware that thingswere difficult, although few were specific about the nature of the dif-ficulties. Five of the interviewees (all latency age or older at the timeof referral) spoke of their own sense that they needed to be in ther-apy, or the relief they felt that something was being done to makethings better, although most of them are not specific (in this inter-view, at least) about what they felt their difficulty was at the time. Asone puts it:

You know I’d obviously—something had gone wrong and I was un-happy and everything, and I thought maybe, maybe this will makethings better, so really I was pretty determined to do it because Ithought 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 takento therapy as children, and they described feeling that nobody hadreally explained this to them. “I was never really told why I was goingthere” (Susannah, 12.3) is a comment that recurs several times in dif-ferent interviews, although the way different interviewees feel aboutthis varies.

In some cases the interviewees indicate that nobody had explainedto them why they were going, but this does not seem to have been adifficulty for them, as they were able to make sense of it for them-selves (e.g. Anna, 8.11). In several other cases, however, especially


among those who had been in therapy as adolescents, the fact thatthey did not feel they understood why they were coming to the AnnaFreud Centre was a more serious obstacle, and made it harder forthem to make use of the therapy itself. In one woman’s case, her diffi-culty in understanding why she had been referred for therapy led toa more negative attitude toward being in therapy:

I think that it would have been very helpful if it had been all ex-plained to me if everything, the whole treatment was explained tome . . . why I was there, the necessity of her to react to me in the wayshe did . . . as I say at eleven I didn’t have any choice about going. Ididn’t choose to go and it was never explained—or as far as I remem-ber 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 wasfelt to be almost the main topic of the therapy itself:

It’s strange because I didn’t understand why I was there—my child-hood wasn’t brilliant, my adolescence wasn’t brilliant, I wasn’t get-ting on well with my parents, and I can only think—but nobody goton well with their parents, I really didn’t understand why I was there,and that theme went on throughout the year, it was the constant, ma-jor theme of “why am I here?” (Heather, 17.5)

Of those who described this sense of not understanding why theyhad come to therapy, a number expressed a wish that they had beenconsulted more, that there was “a negotiating kind of process, aboutwhat’s going to happen” (Daniella, 13.9), or that they had been givenmore information, at the time. “I think at thirteen a bit more infor-mation would be useful,” says one woman, thinking back to her expe-rience (Susannah, 12.3), while another woman remembers feelingthat “we never sort of assessed as we went along how it might have behelping [. . .] and it might have been helpful for her to say ‘Let’s seehow you progress, let’s see what value has been in it, let’s see perhapslet’s talk to your parents together’” (Tamsin, 12.6). Without such aprocess, being in therapy could feel as if it were actually a “punish-ment” for doing something wrong:

It felt, you know, I was like being punished every day and I didn’t un-derstand what good it was doing. (Tamsin, 12.6)

Commentary

From her earliest writings Anna Freud recognized that one of thegreatest differences between child and adult psychoanalysis was the


child’s attitude toward being in therapy. Adults who have an emo-tional difficulty may sometimes decide to see a therapist; childrenrarely do. If they do see a therapist, it is probably because they havebeen asked (or told) to go by a teacher, a doctor, or a parent. Chil-dren may not be as troubled by their “symptom” as the adults aroundthem are; they may lack the same motivation to engage with the ana-lytic process, and they are more likely to seek an external solution totheir difficulties (A. Freud 1965). All of these issues raise very specificquestions—perhaps even concerns—about what the child’s attitudetoward being in therapy will be.

To a considerable degree, these concerns are confirmed by thefindings of this study. While there were a small number of partici-pants in this study who described a sense that they “needed” to be intherapy, and spoke of the “relief” they felt when their difficultieswere finally being addressed, very few referred to specific difficultiesor worries that led them to be in analysis; a large number of partici-pants (about half) in retrospect described some feeling of not know-ing why they were taken to therapy as children.

It is interesting that of those who expressed this feeling, a greaterproportion had either been under six or adolescent at the time oftheir referral. It may be that for those who were referred at a veryyoung age their lack of understanding about why they had been intherapy was more related to lack of memory or lack of understandingat the time, whereas for those who were in adolescence the meaningof these statements was different. This might seem to be confirmedby the fact that it was predominantly the adolescent group for whomthis lack of understanding was seen (retrospectively) as having beenan obstacle to their engagement in therapy.

Of course the problem of engaging adolescents in psychotherapyis a notorious one (Meeks 1971), and in general outpatient psy-chotherapy, it is generally accepted that there is a 40 to 60 percentdrop-out rate for this age group (Kazdin 1995, Wierzbicki andPekarik 1993). What comes across very powerfully from this data,however, is a sense that these participants did not feel as if they hadbeen given enough information about why they were in therapy,what was expected of them, and how the process worked—a findingthat replicates recent studies into adolescents’ experiences of thera-peutic inpatient units (Street and Svanberg 2003).

Although we have no “objective” data about what informationthese young people had actually received at the time, this findingseems to confirm some research suggesting that lack of preparationcan be an obstacle to children engaging in psychotherapy (Holmes


and Urie 1975) and that helping adolescents to understand why theyare coming, and how therapy is supposed to help them, is of great im-portance (Griffiths 2003). The need to attend to the child’s under-standing of why they are in therapy—not just at the beginning, but asan on-going process—is perhaps one of the most important findingsof this study, given the degree to which these former child analyticpatients 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 wasa fairly even spread between those who remember feeling predomi-nantly positive about going to therapy, those who felt mixed, andthose who felt largely negative.

Interestingly, of those who spoke about coming for therapy at theAnna Freud Centre in the most positive terms, the largest numbertended to come from the adults who had been in therapy as very youngor latency-age children, rather than as adolescents. This group spokeabout how “it was fun, it was brilliant” (Angela, 7.10), that it was “a goodfeeling” to go (Phil, 9.3), or that they “enjoyed spending time with [thetherapist]” (Rupert, 3.9). For these people the emphasis is often on theenjoyment they got from having this quite unique experience.

When describing the experience of being in therapy itself, mostpeople described it in terms of two main activities: playing and talk-ing. 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 whenthey 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 spe-cial cupboard. Several people describe some uncertainty about whatthe purpose of the play was, and only in one case is the play describedin very positive terms as characterizing the essence of the experienceof being in analysis as a young child:

I saw it, you know, as my time to be with someone who was there toplay with me and sort of do whatever I wanted to do, and that washugely enjoyable. (Rupert, 3.9)

For several of the participants, the feeling that they could talkabout—or do—whatever they wanted was what characterized beingin therapy, and this opportunity is described several times with asense of surprise and pleasure:


I think, initially, I think I liked the fact that it was one to one andthe—I could do things here like art and craft that I couldn’t do athome or at school, and that seemingly you could do anything youwanted. So it was like fun, it was brilliant, it was so, you know, what-ever 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 doand to say whatever she wanted, but for others (again, mostly thosewho were slightly older children when they came to therapy) it ismore specifically the opportunity to talk that characterizes their ex-perience of therapy: “I’d just chat away about anything and every-thing” (Susannah, 12.3); “I just remember talking and things” (Lil-lian, 5.10); “talking about things, how it affected me” (Phil, 9.3).

As one interviewee makes very clear, this “talking” was not thesame as the “talking” that might go on elsewhere; not only was thecontent sometimes different, but so too the way in which the talkingevolved:

And sometimes I would just sit there [laughs] and not say anythingfor about ten minutes and then, he would just say “well,” you know,and then I’d start talking about anything that came to my mind, youknow, it’s very, very difficult, it’s really difficult. (Mark, 16)

While recognizing the difficulty of this process, this intervieweeand others acknowledged that it enabled them to talk in a way thatwas quite different to other situations with other people. A numberof people refer specifically to the fact that they were able to talkabout “secret” thoughts and feelings, and emphasize that they wouldnot be able to speak like this elsewhere, or that they would not be lis-tened to in the same way:

Yeah, it was like a chance to go through things which, which Icouldn’t go through with other people, because nobody had the pa-tience or the time [laughs] to sit down and to listen to what was on mymind so, to be able to do that was a privilege, it was something veryspecial. (Phil, 9.3)

While the quotation above describes the therapist’s attentive listen-ing as helpful in its own right, others talk about things that the thera-pist did more actively. Although they do not use the word itself, sev-eral interviewees refer to something their therapist did which wemight understand as “making an interpretation.” In some cases, thisis a rather general comment about how the therapist would com-ment 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,


10.10). One man talks about the way his therapist would “mould”things and “talks about things I’d been talking about, like dreams orwhatever” (Mark, 16) and goes on to describe what this felt like:

Sometimes, sometimes he came out with, I’m pretty sure he wouldcome out with some very interesting sort of links, you know with whatI was saying, like, and I’d say “hey hang on a minute,” that’s ab-solutely right, you know. (Mark, 16)

Another woman refers to the “comments” that her therapist usedto make, and remarks on how, “20, 30 years later I can remember lit-tle comments [the therapist] made to something I said that she maynot have even thought was important,” describing this as a “power-ful” experience (Heather, 17.5).

In some cases, the therapist’s “interpretation” seems less aboutwhat the therapist said, and more related to what the therapist did, aparticular action or response which had significance. One man re-members how he used to make things in his sessions, and that histherapist used to “dutifully walk down stairs” and get whatever heneeded:

And then on some occasions I’ll forget to ask her for something andI’ll say “could you go and get me this” and she had to go all the wayback down again [laughs]. I’m sure I used to deliberately kind of justsee, you know, boundary again, just kind of see how far I could pushher and you know, she always used to go until there came a pointwhere she said “I’m not going to do that” and I was like “oh, whynot?,” and she said something like “because I don’t 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 ofboundaries, and that his experience of the therapist setting limits wasan important one, and leads directly into his comment about his“fond” feelings for the therapist.

When asked explicitly, about two thirds of those interviewed de-scribed some kind of positive feelings toward their therapist, and thiswas especially true of those who came into therapy as young children.A large number said simply that they “liked” their therapist, withoutelaborating 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” to-ward the therapist (Neil, 10.4).

Among those who spoke about their therapist in these positiveterms, a few people expressed a more specific sense that they felt ac-cepted, looked after, and listened to by their therapist. One man


spoke about how he “appreciated the attention” that his therapistgave him (Bobby, 14.11), while a couple of the participants also de-scribe, with obvious warmth, the sense of their having a unique rela-tionship to their therapist, quite different from those with their par-ents, teachers, or other adult figures. One says:

I didn’t really have any relationship with anyone else, but my thera-pist I was very close to. I felt I could tell her anything and shewouldn’t be cross. And everything I told my parents made themcross. So that was quite nice. I felt accepted. (Marigold, 11.8)

In a similar way, another man describes his relationship to his ther-apist 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 al-most like I could feel, like, comfortable with her, like at ease with [mytherapist] yes, and, and also she wasn’t in a position—you see in a lotof, especially with teachers . . . they tend to judge the children so, so Iwas safe from judgement. (Phil, 9.3)

In contrast, several participants in the research describe feelingsabout being in therapy which were often quite mixed and even con-tradictory. One woman describes her feelings about her therapist as a“typical sort of love-hate relationship” (Angela, 7.10). Others speakof the way that they liked their therapist, but felt hostile toward himor her when they felt under pressure or were going through a diffi-cult period in the therapy. One man describes particularly well theway in which his feelings about the therapist could change depend-ing on what was happening in the therapy, while also recognizingthat the hostile feelings were ultimately related to the difficulties ofthe therapy, not the person of the therapist herself. He says:

I remember liking her, but I also remember being frustrated aboutspecific conversations and things, when she would query whether Iwas feeling in a particular way or whatever, and you know, at the timeI felt it was a useless line of conversation, and then feeling annoyedabout that. But I seem to recall my overall feelings was that I liked her[. . .] Sometimes, if I reacted adversely to a particular type of conver-sation, sometimes my feelings about that spilled over onto her per-sonally, for a period of time. (Peter, 7.8)

While this man describes different feelings toward his therapist de-pending on what was happening in the therapy at the time, othersdescribe the way their feelings toward the therapist changed overtime. In some cases, an initial dislike gave way to more positive feel-ings:


I didn’t like him at first, or I was scared of a man, [the therapist] wasstrict and wouldn’t do what I asked [. . .] And later I was very fond ofhim, I remember later saying to him “I think I might, I think I mightwant do what you do for a living,” some real feeling of warmth towardhim toward the end. (Neil, 10.4)

In contrast, for a significant minority of interviewees ( just under aquarter of the total, mostly latency-age or adolescent at the time oftherapy, and almost all women) their description of the therapy ischaracterized by their non-engagement with the therapy. “I wasn’t re-ally sharing anything with him. I was very closed” (Joanne, 7.9); “Ididn’t talk about anything—sometimes things were really hard athome” (Dominique, 7.6); “I’d never open up, I’d tell whopping greatlies because I didn’t want her to know what I was really thinking orfeeling” (Susannah, 12.3); “I didn’t really talk to her—I used to sitcounting squirrels out of the window” (Eva, 9.8).

Memories about non-engagement in therapy tended to be linkedwith negative feelings about the therapist him or herself. Overall,about one third of those who took part in the research expressedsome negative feelings about their therapist as a person. Interest-ingly, all of these people had been in therapy when they were eitherlatency-age or adolescent, and none of those in therapy as youngchildren spoke about their therapists in negative terms.

Most commonly among this group, interviewees spoke about asense that their therapist did not understand them. Whereas somespoke about feeling not understood in a global sense, others sug-gested that there were only particular times when they did not feelunderstood (e.g. Richard, 10.10). As one woman puts it:

I think, yeah, I felt he understood certain things but I think that, Ithink I felt that maybe his priorities were not my priorities like, youknow, to him it seemed really important about my particular bodilyfunction, and to me it was “why on earth is he interested in that?” Youknow, in that respect he wouldn’t understand. (Angela, 7.10)

For two others, one of whom will be described further in the nextsection, they felt the central issue that their therapist did not under-stand 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 somethinglike—“you’re coming here, isn’t there something wrong?” or some-thing. I think that maybe we were at cross-purposes or something. Be-cause I suppose on some level I was talking about whether I was com-pletely bats and maybe she didn’t realise that. (Daniella, 13.9)


For a number of interviewees, the negative feelings they had aboutthe therapy and the therapist were connected with the experience ofbeing asked questions: “they asked me questions that I didn’t want toanswer” (Neil, 10.4), says one, while another remembers how thetherapist “tried to pressure me to look at things I didn’t want to lookat” (Bobby, 14.11). One woman gives a more particular descriptionof this experience:

I think I liked [the therapist] but I think I found him really annoyingbecause he would ask me all these questions which I didn’t necessar-ily want to answer [. . .] he used to ask me a lot of questions about mybowel movements—or that’s certainly what sticks in my mind[laughs]—so in my mind, it’s probably a complete distortion, but inmy mind I think he was a bit obsessed by my bowel movements but[laughs] I don’t know . . . (Angela, 7.10)

While these people describe feeling that these questions forcedthem to think about things that may have been uncomfortable, oth-ers describe the experience as more negative, or as giving them asense that they did not know why they were being asked all thesequestions. “I thought she was interrogating me half the time” (Susan-nah, 12.3), says one interviewee, while several refer to their uncer-tainty about what all the questions were for. One woman describesher memory of “being asked loads of questions and not knowing thereason,” and she remembers that some of the questions seemed tohave “sexual overtones” which she felt confused about (Elaine, 6.4);another remembers how she used to wonder “why they were askingme all these questions,” because I would stand there and I would beplaying with a doll or something and then I would think “why arethey asking me this?” (Lillian, 5.10).

For a small number of those interviewed, the therapist’s questions,together with their sense that the therapist refused to respond totheir own questions, led them to experience the setting and the ther-apist in more explicitly negative terms. One participant put this espe-cially clearly:

You see, I totally resented the process which was basically—presum-ably it’s still the same, I don’t know—but she used to just sit and waitfor me to say something and I just resented that so much, and I got soangry about it all that I don’t think she—my feeling was “how couldshe ever know anything about me because she never asked any ques-tions” [. . .] You see if I didn’t talk then she didn’t talk so we just satthere sometimes for the whole session not saying anything at all, andI loathed it. (Susannah, 12.3)


A little later in the interview, however, the same woman describedhow her therapist did ask questions, but that this was equally unsatis-factory:

She would ask me questions, and I would sort of think I knew whatshe was trying to—I thought she was interrogating me half the time[. . .] I’d tell whopping great lies because I didn’t want her to knowwhat I was really thinking or feeling [. . .] And I felt she was prying, Ididn’t want her to know—when she did ask the questions [laughs].(Susannah, 12.3)

While several participants describe some negative feelings abouttheir therapy and their therapist as a person, the woman above is oneof a group of about six interviewees, almost all women who came intotherapy as latency-age children or in early adolescence, who describemuch more explicit, active feelings of dislike toward their therapists.“I thought he was revolting,” says one (Joanne, 7.9), “she drove medemented,” says another (Eva, 9.8), while another states that she sim-ply “hated” her therapist (Anna 14, 8.11). Interestingly, none of themelaborate 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 hertherapist.

Those in this same group also describe feeling that they were notunderstood by their therapists, that they were not able (or did notwant) to share anything with their therapists, and that they did notwish to be there. They all describe how they felt using quite similarlanguage: “I just didn’t want to go” (Joanne, 7.9), “I hated it” (Susan-nah, 12.3), “I was resentful about having to go, having to be thereevery day” (Dominique, 7.6), “I didn’t like it . . . I thought it was in-vading my own privacy” (Sarah, 9.1). One woman gives a fuller de-scription of how she felt and why:

I can’t remember sharing my feelings with her; it was always resistingsharing my feelings with her. I kept thinking it was a waste of timeand I kept trying to provoke her and I couldn’t understand why I hadthis little cupboard where I had some toys and crayons and I couldn’tunderstand why I had to go there and draw pictures or play withdolls. Or I just thought that it was just meaningless, not understand-ing that what I was doing was being interpreted because I didn’t haveany concept that behaviour could be interpreted. I just thought itwas—I didn’t feel any better after going. (Tamsin, 12.6)

For this woman, as for some others, her negative feelings about thetherapy eventually led her to end her treatment prematurely.


Commentary

It appears from this study that those who remembered their childanalyses in the most positive way were often in analysis as quite youngchildren, although they may have had only a vague idea of what theanalysis was about. In The Technique of Child Psychoanalysis, Sandler etal. acknowledge that “for the young child the positive tie to the thera-pist probably forms the main basis for the therapeutic work”(1980:47), and the fact that those who were in analysis as small chil-dren almost all described it in terms of “fun” and as an opportunityto play with an interested adult figure seems to confirm this. Theview of Sandler et al. seems to be confirmed by the findings of thisstudy:

To a child, analysis probably seems simply to be another one of thosestrange activities that grown-ups enter into with children, respondingto whatever is put to them. The child’s experience in treatment grad-ually enables him to sort out the meaningful differences [. . .] even ifhe speaks of treatment as “play.” (1980:156)

But this study also tells us something more specific about what as-pects of the experience of being in analysis as children were felt to beimportant. For some participants in this research, there is a powerfulsense that the experience of being able to talk about whatever theywanted to, in the presence of a sympathetic, non-judgmental listener,was the essence of the therapeutic experience. The emphasis on theexperience of being accepted, listened to, and looked after by a ther-apist who is “warm” and “non-judgmental” appears to confirm onceagain what Sandler et al. have written:

The child in analysis has a novel experience in that the therapist is anadult who takes his feelings and expressions seriously over a signifi-cant period of time. This has the result that the therapist raises theself-esteem of the child by saying, in effect, “I regard you as someoneto be considered important, and I am not going to dismiss you out ofhand. I will listen to what you have to say.” (1980:112/13)

This emphasis on being listened to and understood echoes muchof the research into patients’ views of adult psychotherapy, in whichthe interpersonal qualities of the relationship are seen as consider-ably more important than any particular thing that the therapist saidor did (e.g. Llewelyn and Hume 1979). However the current studyalso suggests that former child analytic patients remembered, andvalued, some of the particular “comments” or “links” that their ana-lyst had said, indicating that a “significant interpretation” (Sandler et


al., Chapter 18) made in childhood can be remembered and valuedmore than twenty years later in life.

However, for a considerable minority (about a quarter of the par-ticipants) the child therapy is remembered predominantly in termsof their own non-engagement with the analytic process (“countingsquirrels out of the window”). This non-engagement is associatedwith two factors in particular: a sense of being questioned, or even in-terrogated, by the analyst, whose questions did not seem to makesense or did not give the child a sense of being “understood”; and ina smaller number of cases, a general resentment of the analytic pro-cess itself, experienced as “insulting,” because the analyst was distantand unresponsive and the child was left feeling misunderstood anddis-empowered.

While in some cases these feelings were associated with a period ofthe analysis when the child was being “forced” to confront thingsthey preferred to avoid, in other cases the feelings are more intenseand on-going, associated with a general non-engagement with ther-apy, a feeling of frustration about the analytic process. In a few cases,especially among those who had been adolescents at the time of theiranalysis, this led to intensely negative feelings both about being intherapy and about the therapist as a person.

Analysts in the Anna Freudian tradition have also recognized thatthe development of the negative transference in psychotherapy withadolescents is particularly common, and especially likely to end inpremature termination of treatment (Meeks 1971:133). MosesLaufer has written extensively about the particular difficulty whenthe adolescent patient re-experiences the developmental breakdownwithin the transference itself (Laufer 1989).

The accounts by some participants in this research of their in-tensely negative feelings are an important reminder that the psycho-analytic approach is not always successful or even appropriate. Whilein some cases the negative feelings appear to have been transitoryand part and parcel of the therapeutic work, in other cases the feel-ings were on-going and unresolved, even at the end of therapy.Whether such feelings were an aspect of the child him or herself orwere due to the nature of the analytic setting or failures on the partof 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 ofthe analysis, it appears as if such negative feelings could not always beunderstood and used as part of the analytic process, and they oftenled to premature termination and unsatisfactory outcome. This find-ing is an important reminder to child psychoanalysts that technique


needs to be geared carefully to the developmental level of the child,especially how the treatment is introduced and the way that its aimsare presented.

Concluding Comments

By the very nature of being a long-term follow-up of child psycho-analysis, the participants in this study were describing experiencesthat had happened to them at quite a young age and many years pre-viously. Memory itself, as psychoanalysis knows only too well, is acomplex and over-determined process, and to what degree thesememories accurately “reflect” what happened in their child analysesis open to question. There is a great likelihood that quite significantaspects of the child analysis—such as its duration, or whether morethan one analyst was seen, or how the treatment ended—would bedescribed quite differently in the child case notes, and the differencebetween these contemporary notes and the retrospective accountswould be fascinating to compare and contrast. Future studies basedon the follow-up data already collected will attempt to compare theseparticipants’ memories of therapy with the clinical case-notes kept atthe Anna Freud Centre, as well as looking at smaller sub-groups(such as those who were most or least happy with their experience ofchild analysis) and comparing them using data related to initial diag-nosis, outcome, current representations of attachment relationships,and general adult functioning and mental health.

But although future studies may well complicate and enrich ourunderstanding, the uncertainties about the status of the memoriesdescribed in this study should not prevent us from attending to theformer child patients’ memories themselves. The voice of formerchild analytic patients has been so strikingly absent in the clinicaland research literature, that we believe it is important to simply regis-ter this voice first, before we go on to further research that would al-low us to explore the status of such accounts of the past within abroader context. Most importantly, the current study appears to indi-cate that former child analytic patients, for the great part, do havememories of certain aspects of their therapies (sometimes very clearones) and are able to give accounts of their analyses (sometimes veryeloquently). Since these accounts are in some important ways differ-ent from those of child psychoanalysts themselves, they are worth at-tending to for what they can teach us about the process and outcomeof child psychoanalysis.


BIBLIOGRAPHY

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Babatzanis, G. (1997). The analysis of a pre-homosexual child with atwelve-year developmental follow-up. Psychoanal. St. Child 52:159–189.

Beiser, H. (1995). A follow-up of child analysis. Psychoanal. St. Child 50:106–121.


Appendix. Participants in the Follow-up Study

AGE AT LENGTH OF REFERRAL ANALYSIS AGE AT

NAME (Years, months) (Years, months) FOLLOW-UP

Bobby 14.11 3.8 42Daniella 13. 9 4.2 36Elsa 5.2 2.2 36Richard 10.10 4.6 29Tracy 6.11 1.2 29Angela 7.10 1.10 32Rupert 3.9 2.0 34Marigold 11.8 3.1 31Nathan 4.8 1.5 41Sarah 9.1 3.3 29Neil 10.4 3.1 33Jason 7.1 3.9 45Peter 7.8 2 .10 32Elaine 6.4 2 .0 39Heather 17.5 0.9 42Phil 9.3 4 .6 33Eva 9.8 1.6 29Anna 8.11 2.10 34Anthony 10.10 2.9 37Sheila 4.0 1.9 46Dominique 7.6 3.9 41Susannah 12.3 Missing data 39Mark 16 3.10 40Lillian 5.10 3.4 36Kevin 11.11 5.3 39Joanne 7.9 1.6 35Tamsin 12.6 1.8 35

Cohen, J. & Cohler, B. (eds.). (2000). The Psychoanalytic Treatment of Livesover Time. (San Diego: Academic Press).

Colarusso, C. (2000). A child-analytic case report: A 17-year follow up. InCohen, J. and Cohler, B. (eds.), The Psychoanalytic Treatment of Lives overTime (San Diego: Academic Press).

Freud, A. (1965). Normality and Pathology in Childhood. (New York: Int. Univ.Press).

Freud, S. (1909). Analysis of a phobia in a five year old boy. In J. Strachey(ed.), The Standard Edition of the Complete Psychological Works of SigmundFreud, Vol. 10. (London: Hogarth Press).

Griffiths, M. (2003). Terms of engagement. Reaching hard to reach ado-lescents. Young Minds, 62:23–26.

Grosskurth, P. (1986). Melanie Klein. Her World and Her Work. (New York:Knopf).

Heller, P. (1990). A Child Analysis with Anna Freud. (Madison: Int. Univ.Press).

Holmes, D. & Urie, R. (1975). Effects of preparing children for psychother-apy. J. Cons. and Clin. Psychology, 43:311–318.

Kazdin, A. (1995). Bridging child, adolescent and adult psychotherapy: Di-rections for research. Psychotherapy Research, 5:258–277.

Koch, E. (1973). Observations on follow-up contacts with former child ana-lytic patients. J. Amer. Acad. Child Psychiatry, 12:223–246.

Laufer, M. (1989). Why psychoanalytic treatment for these adolescents? InLaufer, M. and Laufer, E. (eds.), Developmental Breakdown and Psychoana-lytic Treatment in Adolescence: Clinical Studies. (New Haven: Yale UniversityPress).

Llewelyn, S. & Hume, W. (1979). The patient’s view of therapy. Br. J. of Med.Psychology, 52/1.

McDevitt, J. (1995). A childhood gender identity disorder: Analysis, pre-oedipal determinants, and therapy in adolescence. Psychoanal. St. Child50:79–105.

McLeod, J. (1999). Practicioner Research in Counselling. (London: Sage).Meeks, J. (1971). The Fragile Alliance: An Orientation to the Outpatient Psy-chotherapy of the Adolescent. (Baltimore: Williams and Wilkins).

Midgley, N. (2003). Memories of Therapy: A Qualitative Study of the Retro-spective Accounts of Child Psychoanalysis. Unpublished D.Psych disserta-tion, University College London.

Midgley, N., Target, M. & Smith, J. (in press). ‘The outcome of child psy-choanalysis from the patient’s point of view: A qualitative analysis of along-term follow-up study’. Psychology and Psychotherapy: Theory, Practice, Re-search.

Ostow, M. (1993). Play, dream, fantasy and enactment in Bornstein’s “ob-sessional child,” then and now. In Cohen, D., Neubauer, P. and Solnit, A.(eds.), The Many Meanings of Play: A Psychoanalytic Perspective. (New Haven:Yale University Press).

Parsons, M. (2000). The search for a good-enough self: From fragmenta-


tion toward cohesion in a young adult’s second analysis. In Cohen, J. andCohler, B. (eds.), The Psychoanalytic Treatment of Lives over Time. (San Diego:Academic Press).

Ritvo, S. (1966). Correlation of a childhood and adult neurosis: Based onthe adult analysis of a reported childhood case. Int. J. Psychoanal. 47:130–131.

Ritvo, S. (1996). Observations on the long-term effects of child analysis.Psychoanal. St. Child, 51:365–385.

Ritvo, S. (2000). Double-dipping: Child analysands return as young adults,In Cohen, J. and Cohler, B. (eds.). The Psychoanalytic Treatment of Lives overTime (San Diego: Academic Press).

Ritvo, S. & Rosenbaum, A. (1983). Reanalysis of child analytic patients. J.Amer. Psychoanal. Assn. 31:677–688.

Rosenbaum, A. (2000). The case of Charlie: Analysis during transition. InCohen, J. and Cohler, B. (eds.). The Psychoanalytic Treatment of Lives overTime. (San Diego: Academic Press).

Sandler, J., Kennedy, H., & Tyson, R. (1980). The Technique of Child Psycho-analysis: Discussions with Anna Freud. (Cambridge, Mass.: Harvard Univer-sity Press).

Street, C. & Svanberg, J. (2003). Room for improvement: Adolescents’views on impatient care. Young Minds, 62:27.

Target, M. & Fonagy, P. (2002). The history and current status of outcomeresearch at the Anna Freud Centre. Psychoanal. St. Child, 57:27–59.

Wierzbicki, M. & Pekarik, G. (1993). A metaanalysis of psychotherapydropout. Professional Psychology: Research and Practice, 24:190–195.


The Process of Attachment andAutonomy in Latency

A Longitudinal Study of Ten Children

RONA KNIGHT, Ph.D.

The findings in this clinical, longitudinal study describe the process ofattachment and autonomy as it unfolds during the latency period ofdevelopment. Ten normal boys and girls were studied from ages sixthrough eleven. A separate timetable of latency development for boysand girls is suggested. The differences in the boys’ and girls’ separa-tion responses, which include feelings of a lack of self-coherence, loss,anger, neediness, movement toward peers and defense functioning, aredelineated and discussed.

every psychoanalytic theory must have at its base a develop-mental framework in order to give meaning to the ideas it proposesand the psychopathology it attempts to explain. Freud (1905) pro-posed a timetable of sexual and aggressive instinctual development

Child, Adolescent, and Adult Psychoanalyst; Founding Member and Senior Facultyat the Berkshire Psychoanalytic Institute; Faculty at the Boston Psychoanalytic Insti-tute; Supervising Analyst at the Massachusetts Institute of Psychoanalysis.

I want to express my gratitude to the children and parents who participated in thisstudy. I am indebted to Lillian Schwartz, Ph.D., who volunteered her time and consid-erable knowledge to help me score and evaluate all the psychological testing and forher thoughtful contributions to this paper. I would like to thank Dr. Anna Wolff forher many thoughtful readings of this paper, the IPA Research Program (1998) fortheir advice and encouragement, and Drs. A. Scott Dowling, Anton Kris, SamuelAbrams, Peter Neubauer, and Paul Brinich for their helpful suggestions.The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,


178

in infancy through adolescence to support his theory of the mind. In“The Three Essays” Freud (1905) concluded that the phase of child-hood between the Oedipus complex and adolescence was a latencyperiod: a lull between the two sexual waves of development, a time inwhich sexuality advances no further and the sexual instincts are di-minished in strength and repressed. He conceptualized latency as aperiod of dynamic defense, noting the uses of sublimation, reactionformation, repression, and whole body responses as a way of redirect-ing the activity of the child’s sexual and aggressive impulses. In thissame paper, Freud also regarded the latency period as very impor-tant in determining adolescent object choice. He viewed the devel-opment of object choice as diphasic: the first wave occurring fromage two to five, and the second occurring in puberty, with latency asthe middle ground during which time the sexual object choice andthe sexual aims underlying it are transformed into relationshipsbased on affection, admiration, and respect (1905, p. 200). Over theyears he added fantasy formation (1911) and regression (1916) asdefenses used in the latency period.

Freud had different ideas, at different times, as to the actual causeof latency. As early as 1905 he wrote: “this development is organicallydetermined and fixed by heredity” (p. 177). The idea of latency as adefensive reaction to the events of the Oedipus complex and as a pre-ordained, biological, and hereditary developmental phase exist sideby side in The Dissolution of the Oedipus Complex (1924), and Freudwrote that “The justice of both these views cannot be disputed. More-over, they are compatible” (p. 173).

Anna Freud (1936) wrote that by the age of seven years, the latencychild has all the major defenses available as coping mechanisms, not-ing fantasy as a significant defense in latency. Her concept of devel-opmental lines (1963) that are separate but also intertwine—weav-ing together a complex intermingling of id, ego, superego, self andobject structures, biological growth, and environmental influences ateach stage of development—provided the first complex frameworkfor psychoanalytic thinking about development and paved the wayfor more modern, integrated thinking about children’s develop-ment.

A more complex examination of the latency age child’s play, fan-tasy, and cognitive development has helped make us more aware ofthe wealth of psychological issues which the six- to eleven-year-oldchild must experience and master in the areas of psychosexual devel-opment, object relations, separation, autonomy, and ego and super-ego development. Piaget (1932, 1967) and Kohlberg (1963) helped

Attachment and Autonomy in Latency 179

map out the development of cognition and moral judgment in thisage group. Sullivan (1940) focused on the interpersonal shift to peerrelations in latency and spoke of a “juvenile era” which, as Freud hadproposed, had lasting importance in terms of future adolescent andadult relationships. Shapiro and Perry (1976) presented evidence ofthe ways physiological growth promotes autonomous cognitive func-tioning that allows for more mature ego functioning in latency.Charles Sarnoff (1976) examined the interplay of psychosexual andcognitive development in the latency age child.

The stages and phases of latency have been discussed in the litera-ture in different ways. Erikson (1950) considered latency as an era ofindustry in which cognitive and physical skill development becomeimportant factors in shaping the child’s positive sense of self andforming successful relationships with peers. Bornstein (1951) di-vided latency into two phases tied to superego functioning. Williams(1972) divided latency into three stages according to id, ego, andsuperego development and dominance. Sarnoff (1976) divided la-tency into three cognitive organizing periods.

Renewed interest in object relations theories raised interestingquestions concerning the ways in which latency age children con-tinue to confront and resolve developmental issues pertaining to ob-ject relationships within the realms of attachment and autonomy(Oremland, 1973; Glenn, 1991). Kohut (1984) described the twin-ship self-object experience during latency as a need to feel a sense ofsameness with others as the school-aged child ventures out of thehome more and into the world of peers, and Freedman (1996) cor-roborated that clinical finding in her study of latency children. Al-though Blos (1967) described adolescence as “the second phase ofseparation-individuation,” the results of this study suggest that thedevelopment of separation-individuation is a process that continuesthrough the latency period.

Taking up Anna Freud’s (1965) challenge to continue the study ofthe many complex factors that contribute to a child’s development,psychoanalysts working in development (Sander, 1980, 2002; Mayes,2001; Abrams & Solnit, 1998; Tyson & Tyson, 1990; Stern, 1985;Emde, 1984, 1988; Galatzer-Levy, 2004; and others) have begun tothink of development as both continuous and discontinuous, withthe development of discontinuities “occurring within a series of pro-gressively differentiated hierarchical psychological organizationsthat arise over time” (Abrams, 2003, p. 175). This view of develop-ment requires an understanding of the individual parts as well as theinterweaving of the many different structures of the mind.

180 Rona Knight

This research is an attempt to understand the complexity of devel-opment as applied to the six- to eleven-year-old child. This contribu-tion is the first in a series of papers that will report and discuss thefindings of a clinical, hypothesis generating, longitudinal study of tennormal children who were evaluated yearly from the ages six througheleven. The purpose of this study was to begin to better understandthe development of the inner world of the normal latency age child,informed by psychoanalytic concepts and theories. The present pa-per focuses on attachment and the separation process that leads toautonomy in latency, thus the selection of data intentionally high-lights this theme, although other aspects of development are en-twined with it. While there are research advantages of focusing on asingle element of development, as I have done with attachment andautonomy, a comprehensive understanding and integration of all as-pects of development is essential to achieve a balanced view. I hopeto be able to provide that as I continue to analyze all the data fromthis study.

Method

Subjects: Four boys and six girls participated in this study. Each childwas followed from age six through age eleven, for a total of six yearsfor each child. Only children who fell within the normal range of psy-chological functioning at age six were chosen. A determination ofnormal psychological functioning was made using the following cri-teria: 1) a normal six-year-old profile on psychological testing (WISC-R, Rorschach, TAT, Bender Gestalt, Figure Drawings); 2) chronologi-cal age and phase behavior of a six-year-old based on a clinicalinterview with the child. The initial diagnostic clinical interview fol-lowed the framework outlined by Greenspan (1981) as well as his for-mulations for normal six-year-old psychological development.

Children were selected from the suburban Boston area and were inthe middle to upper-middle, white socioeconomic class. To be in thestudy a child must have had an intact family unit at age six, no historyof severe or moderate psychological problems requiring professionalhelp, no physical abnormalities, chronic illness, or significant learn-ing disability. Only children whose families could be expected to stayin the Boston area and whose parents had no chronic illness, physicaldisabilities, or moderate to severe psychological problems were se-lected. All the families remained intact throughout the study.

The children who participated in the study were extremely brightand very verbally expressive. Their average I.Q. was 134 at age six. A


small, homogeneous group of children was specifically chosen sothat they could be studied in depth as well as provide internal validitywithin the subject group.Instruments: A multiple measures design was chosen to measure in-depth conscious and unconscious thoughts and feelings betweenchildren and within each child for each age as well as over the entiresix year period studied.Psychological Testing: A battery of psychological tests including theRorschach, Thematic Apperception Test (TAT), Wechsler IntelligenceScale for Children—Revised Edition (WISC-R), Bender-Gestalt, andHouse-Tree-Person Drawings was used to assess each child’s person-ality profile annually for six years. The principal investigator (a childand adult psychologist and psychoanalyst) administered the test bat-tery. The tests were scored and evaluated by the principal investiga-tor and a psychoanalytically oriented senior psychologist who was anexpert in child testing. Each year of the children’s testing was scoredseparately and only after all the years of testing were completed, in an attempt to keep tester and rater bias to a minimum. Interrater re-liability using the Pearson correlation coefficient ranged from 0.81to 0.93 for all measures and was 0.87 for the separation measures dis-cussed in this paper. Using Wechsler’s, Klopfer’s and Schafer’s scoringsystems and analysis for cognitive and projective data, each psychol-ogist was asked to make clinical evaluations along ten dimensionsbased on each child’s responses on the test battery: 1) quality of in-terpersonal relatedness, 2) self-esteem, 3) ego ideals, 4) body image,5) degree of narcissism, 6) conscious and unconscious feelings andtheir discharge, 7) defensive functioning, 8) cognitive functioning,9) gender identity, and 10) degree and kind of experienced intrapsy-chic conflict. Each of these dimensions was rated on a five-point scaleas well as descriptively. They were chosen to gain information aboutthis age group that would elucidate developmental aspects of psycho-sexual and structural theory, object relations theory, and self-psy-chology. At the time of administration of the testing and during thescoring, neither of the two psychologists were aware of the hypothe-ses that resulted from examining the present findings after all theyears of testing were scored and evaluated.

The Rorschach and TAT tests were used because they tap into un-conscious fantasies and processes (Schafer, 1954). The Rorschachwas scored using the Klopfer (1962) scoring system and an object re-lations and ego function scoring system that I adapted for childrenand which combines those used by Blatt (1976; 1988), Burke, Fried-man, Gorlitz (1988), Kantrowitz (1975; 1989), and other psychoana-

182 Rona Knight

lytic researchers who have documented reliability and validity for thesystematic investigation of these Rorschach measures. Both the Ror-schach and TAT were also evaluated using Schafer’s sequence analy-sis (1954). Projective testing has traditionally been used in psychoan-alytic research and has been proven to be a very effective clinicalmeasure (Holt & Luborsky, 1955).

One aspect of the Rorschach testing presented in this paper evalu-ated the children’s level and quality of object relationships. On theRorschach, the level of object relatedness was based on the subject’sability to differentiate boundaries between objects, ranging frommerged to separate (Table I). Rating is based on the degree to whichan object’s boundaries are described as distinct or separate fromone another. Merged responses indicate that the subject does notfeel himself as separate from “the other,” or yearns for an undif-ferentiated closeness. Separated responses indicate that the subjectexperiences herself as separate and distinct from “the other.” Led-with (1960) and Ames et al. (1974) have published many similar


TABLE I

Psychoanalytic Rorschach Profile

SCALE LEVELS SAMPLE RESPONSE

Object Relations 1. Merged Monsters attached with two heads.Differentiation Siamese monkeys.

2. Merged to A wall that is split open but still Separating attached to the ground.

3. Separate but Connecting chairs.Connected Two crabs stuck together.

4. Separating/ Two animals back to back about to Touching But go away from each otherDistinct

5. Separate Two people dancing together.Two rabbits playing.

Rorschach responses in their normal children’s protocols for thisage group.

A second aspect of the Rorschach testing appraised the integrity ofthe child’s self structure, which was evaluated by the degree to whichthe object remained whole, intact, or alive (Table II). A fragmenta-tion response on the Rorschach implies that the subject is in an un-conscious feeling state of dis-integration. We usually think of frag-

184 Rona Knight

TABLE II

Psychoanalytic Rorschach Profile

SCALE LEVELS SAMPLE RESPONSE

EGO 1. Death A dead cat; A dead flowerSTABILITY

2. Fragmentation Crumbled rocksA cup broken in pieces

Example of OneBoy’s Sequence:

Age 5—PeopleAge 6—Two shoes, two knees, two chinsAge 7—Two ladies smashing pumpkinsAge 8—People

3. Incipient Decaying leafFragmentation Humpty-Dumpty falling

4. Enduring Person; Bear; A cooking potand Solid

THOUGHTPROCESSES Contamination Chinese dancers. Dogs playing patty-cake.

Chinese dog dancers.

Anthropomorphism Rabbits wearing their Easter hats having atea party.A frog in a bow tie going to a ball.

mentation as indicative of a severe problem with self and object in-tegrity. Its presence in these normal children during certain phasesof development suggests a normal, temporary break-down in the antecedent mode of object-connection and the concomitant estab-lishment of self-coherence, indicative of a change from an enduringstate to one that is experienced as not yet integrated. Fragmenta-tion in normal latency children’s protocols also appears in Ledwith(1960).1

Clinical Interview: Each child was administered a semi-structured clin-ical interview, developed for this research to gather informationabout the following: 1) self-esteem, 2) ego ideal, 3) body image, 4)quality of interpersonal relatedness, 5) narcissism, 6) conscious andunconscious feelings and their discharge, and 7) coping mechanismsand their functioning. The principal investigator administered theclinical interview. Each interview was tape recorded and transcribed.The clinical interviews were not scored for this research paper; thechildren’s responses were used to confirm and deepen the under-standing of the test data.Parent Questionnaire: Every four to six months the parents of eachchild were asked to complete a 16-page parent questionnaire devel-oped for this research. The questionnaire elicited information aboutthe child’s ongoing feelings and attitudes about him/herself, fantasyand dream material, general mood, relationships with family andfriends, behavior and performance in school, parents’ feelings andbehavior toward the child, and information about the parents’ feel-ings about themselves. The child’s mother was asked to fill out theentire questionnaire. The child’s father was encouraged to con-tribute information for this questionnaire, and he was required to fillout the part of the questionnaire that concerned his feelings and atti-tudes about the child and himself. Responses from the questionnairehave not been scored as yet but were used anecdotally to further ourunderstanding of the test data.Observation of Child in Play with Peers: Each child was observed annu-ally and videotaped for 1–2 hours in free play with a friend in thechild’s house. This information was not used in the present study.Teacher Questionnaire: Two thirds of the way through the school year,each child’s teacher was asked to complete a questionnaire about the


1. Bibring (1959) also found a dramatic difference between the disturbed Ror-schach responses of pregnant women and their everyday good functioning in the realworld.

child. The teacher questionnaire elicited the teacher’s evaluation ofthe child’s general mood, school performance and behavior, and re-latedness to peers, using a five-point rating scale, which was primarilyused in this paper to see how well the children were functioning inschool.Procedure: The above measures were administered each year to eachchild and their parents and teachers for the six-year period that eachchild was studied.

Results

early latency: ages six to eight years

This clinical study delineates the processes of attachment and auton-omy that occurred during the latency age period in these ten chil-dren. 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 sepa-rate from their parents in a way that they had not experienced previ-ously. This sense of separation was related to the denouement of theoedipal period and their feeling pushed out into the world outsidetheir home. Along with this new sense of separateness came feelingsof disconnection, sadness, and anger. Although both sexes experi-enced this development, they had different timetables—the boys en-tered 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 Rorschachtesting at age five and were judged as not yet feeling separated andhad no fragmentation responses. However, between ages six to eightall the boys were judged to be feeling separated from their objects.All four boys had fragmentation responses on the Rorschach at agesix, which were less intense at age seven and were completely gone byage eight. Typical of the advent and waning of a feeling of fragmenta-tion was one boy’s responses to Card III on the Rorschach: at age fivehe saw two whole people; at age six he saw two heads, two chins, legsor knees, and shoes; at age seven he saw two ladies smashing pump-kins together; and at age eight he saw two people. Table III shows theprocess of fragmentation and separation responses in the six- toeight-year-old boys and girls.

At age six the boys had feelings of being alone, abandoned, andnot nurtured in the big world. TAT stories about feeling lost andwithout parents were typical. Feeling little and damaged, they hadconcerns about whether they could make it on their own, feeling in-

186 Rona Knight

sufficiently supported by their parents. These responses were presenton the TAT and were also expressed in the conscious fears anddreams these boys reported in the clinical interview. One boy wor-ried about getting hit by a car while walking to school without a par-ent, 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 aloneto fend for themselves. They associated separation with the death oftheir parents. In the clinical interview they expressed fears aboutpeople in their families getting hurt and killed and reported dreamsabout their parents dying. One boy’s story to a TAT picture of a girlleaving for school expresses these feelings: “Somebody got killed inher family. The grandfather. Then the father died and everyone elsein the family died, and so she’s gonna get adopted. They just all diedcause they were real old, like 100 years old. (How old is the girl?)She’s 19.” These boys also experienced guilt about their underlyingfantasy that separation will lead to the death of their parents, which


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

often increased their worries. One boy’s dream at age six illustratesthis 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 fromthe house.”

Oedipal defeat and the resulting narcissistic injury added to thesix-year-old boys’ feeling rejected by their mother and not nurturedby her. Mothers were often pictured as dead or hurt. The boys weresad and angry about their loss and unconsciously expressed their de-pression in explosive discharge. The main defenses they used to copewith all these affects were intellectual and obsessive-compulsive de-fenses. Their ego control, judging from their teacher’s high ratingsof their concentration and behavior, was good enough to hold thesefeelings at bay during school hours; however, parents reported thatthe boys’ behavior at home was often aggressive and difficult to man-age.

At age seven, the boys sense of oedipal defeat and their concommi-tant oedipal feelings continued. Most of the boys still made the con-nection between separation and the death of their parents. The boysfelt a push to be independent but were scared about being lost or indanger on their own. They found two ways to cope with their anxietyabout still feeling little and being able to manage on their own in theworld. The boys started to see their fathers as very human, capable ofmaking mistakes, but also able to help and/or protect their sonsfrom danger. They also began to use the defense of magic to helpthem cope with their fears of getting lost in this new, larger, moredangerous world. One boy’s TAT story at age seven describes his faithin his father: “A boy is sitting there with nothing to do. . . . He goesbird watching and gets lost. Then his father was coming home and hefound him and brang him home. The boy felt scared when he waslost and good when his father found him.” His story to a TAT cardwith no picture on it shows his use of magic: “There’s a boy right hereand he’s lost in the woods so the forest animals lead him home. Hefeels relieved that the forest animals know where his home is. Themother and father thank the forest animals.”

The boys’ developmental push for independence at age seven ledto their feeling much more independent at age eight. The boys expe-rienced a conflict over feeling more independent because they stillhad the same worries and needs they felt the year before. Separationwas still experienced as getting lost in a big world and still includedthe total loss of parental objects. One boy showed some regressionback to more typical six-year-old responses on the Rorschach afterthe death of his uncle, which increased his anxiety over parental loss.

188 Rona Knight

Girls: While the six-year-old girls were all beginning to feel pushedout into the big world by both their parents and their own drive to-ward separation, they were not yet as separated as the boys were atthis age. Their Rorschach protocols included responses like animalsand monsters with two heads, and a wall that split open but is still at-tached at the ground. Separating was associated with parents’ dying.The following TAT story told at age six is representative of their sepa-ration concerns: “The girl is going to school and she’s staring at someIndians coming. So she’s going to run back to her family and tell herfamily to run. She’s worried about the Indians killing her. Her par-ents are going to run but they get killed and she survives.” None ofthe girls had any fragmentation responses on a Rorschach at age six.They were all still in the throes of the Oedipus complex, with the at-tendant concerns about body damage and death related to the oedi-pal struggle.

By age seven, five girls were feeling a lack of cohesion, with manyfragmentation responses in their Rorschach protocols. Five of theseven-year-old girls showed evidence of having made a separationbased on their Rorschach responses and their TAT stories. They hadfantasies about going out into the world alone and having their ownhouses. Their dreams and their conscious worries were about beingforcibly taken away from their homes by ghosts, monsters, and kid-nappers, and separation often was associated with parental death.The following TAT story told at age seven illustrates the girls’ feelingsof loss, sadness, and conflict around separating: “This is a person cry-ing ’cause her parents just died. And she came back to the house andshe dropped the keys on the floor and she started crying. She feelssad, and she’s thinking she wished she never moved away from herparents’ home. At the end she finds out that this is a time that peoplehave to die.” One girl had not achieved a sense of separation and alsohad no fragmentation responses on the Rorschach. The absence ofunconscious feelings of a lack of integration and separation was para-doxical; for this girl separation meant total abandonment that led toher own death, making her too anxious to tolerate a complete sepa-ration. While she was able to achieve appropriate separation in herday-to-day life (based on teacher and parent questionnaires and clini-cal interviews), her responses on the projective testing indicated per-sistent unconscious difficulty in this area.

The seven-year-old girls were frequently preoccupied with perva-sive loss, deprivation, and a need for nurturance. Like the boys, theyfelt little in a big world. Oedipal defeat added to the girls’ sense ofloss. Stories in which men were perceived as dead, hurt, or deni-


grated were frequent. The anger that the girls felt about their losstook the forms of oppositional behavior and aggression turnedagainst the self and siblings. The girls defended against these feelingsby denying and avoiding strong aggressive and libidinal feelings.Some girls used repression and/or intellectual and obsessive-com-pulsive defenses to close off or constrict their feelings and impulses.Their increased anxiety around aggressive impulses led them to aconflict over good and bad behavior, exemplified by the followingTAT story told at this age: “The girl is sad. Her mother sent her to herroom because she had been bad. ‘I have been a nasty little girl,’ shethought. And she went to her room and fell asleep on the bed. (Whathad she done?) She hurt her little brother. She hit him.” Despitestrong aggressive feelings, they do not have the sense of these im-pulses getting as out of control that the eight-year-old boys experi-ence.

By age eight, the girls who had separated felt psychically impover-ished and felt they had to work hard to perform, leaving all of themfeeling tired but hopeful of becoming more competent as they gotolder. Like the boys at seven, the eight-year-old girls use benevolentmagic to manage their anxiety about their separation and scary inde-pendence in the big world. Nurturance needs continued to increaseat age eight, which added to their conflict between wanting to stay lit-tle and wanting to grow up. One girl’s TAT story nicely describes theneed and the conflict: “This is a little boy, and he’s sitting on the stepof a barn door sucking his fingers watching his father feed the ani-mals. And he’s thinking that he doesn’t want to grow up. He wants tostay little ’cause his mother just read him Peter Pan. . . .”

Table IV outlines the findings for the six- to eight-year-old girls andboys.

middle latency—age nine years

By age nine, the latency separation process converges for both theboys and the girls. They felt both an external push to grow up fromtheir parents and an internal push to grow up. Both the boys and thegirls were made extremely anxious by their newfound separateness.Projective tests at this age showed a breakdown of defenses. Contami-nation and anthropomorphic responses appear frequently on theRorschach as well as a reporting of visual and/or auditory responsesnot actually present on the Rorschach or TAT cards. For example,one girl saw “talking and hearing vibrations” on the Rorschach. Thehigh degree of anxiety and emotional disturbance seen on the

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TABLE IV

Summary of Findings for Ages Six to Eight Years

BOYS GIRLS

AGE 6 1. Feeling separate and fragmented 1. Not separated2. Feeling pushed out into the world 2. Feeling pushed out into

the world3. Separation equated with the death 3. Separation equated with

of both parents the death of both parents4. Feeling alone and abandoned 4. Concern about body dam-

age and death5. Sad about being alone and mad 5. Strong Oedipus Complex

about being kicked out6. 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 damaged10. Oedipal defeat; mothers seen as

dead or hurt11. Feeling not nurtured

AGE 7 1. Push to be independent 1. Feeling separate and frag-mented

2. Concern about danger or getting 2. Feeling rejected andlost in the big world pushed out into the world

3. Separation equated with the death 3. Separation equated withof both parents the death of both parents

4. Sense of damage 4. Sad about the loss; sense of deprivation

5. Oedipal defeat; mother experi- 5. Oedipal defeat; Men seenenced as dead as hurt, denigrated or

dead6. Sad and mad about loss of mother 6. Feeling little and damaged7. Fear of explosive discharge; 7. Nurturance needs

oppositional behavior at home8. Nurturance needs 8. Oppositional behavior at

home; aggression turnedon the self and siblings

continued

Rorschach is not manifested in the children’s typical conscious stateand functioning as described by teachers and in the clinical inter-view. Mothers of the boys, however, did describe more fighting withtheir siblings during this age.Girls: The nine-year-old girls became much more concerned with

moving away from their parents and toward their peers, exemplifiedin the following TAT story: “This girl is crying ’cause her family is go-ing away on a trip, and she wants to go to her friend’s birthday party.She’s gonna get to go to the sleepover party, and her parents andbrother will go away for the weekend, and she will get to sleep at herfriend’s house an extra day.” The girls responded to the anxiety theyfelt around their newfound separateness and autonomy with an in-creased need for nurturance and a yearning for an idealized child-hood. While they all had a desire to grow up, they were very con-flicted about it and had an intense wish to be taken care of like a

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TABLE IV

Summary of Findings for Ages Six to Eight Years

BOYS GIRLS

9. Magic used as defense 9. Aggressive feelings de-fended against with denial,avoidance, repression, in-tellectual and obsessive-compulsive defenses

10. Fathers seen as helping sons 10. Conflict over good and in world bad behavior

AGE 8 1. Conflict over independence 1. Conflict over growing up2. Feeling small and damaged 2. Feeling small and dam-

aged3. Nurturance needs strong 3. Nurturance needs con-

tinue to increase4. Concerns about getting lost in 4. Feeling psychically impov-

the big world erished; having to workhard to perform

5. Separation equated with the death 5. Oedipal concerns; deni-of both parents grating men

6. Concern that aggression leads 6. Fear of parental lossto death

7. Oedipal concerns very present 7. Magic used as a defense

much younger child. The external pressure to grow up that they ex-perienced made them very angry and anxious about their ability tofunction on their own and resulted in lowered self-esteem. One girl’sdream illustrates the anxiety at this age: “I am on a bridge with myfriends. I have just left my mother on one side, and me and myfriends are going to the other side. As I am crossing the bridge it be-gins to unsnap, and I am terrified me and my friends will fall. Myfriend’s parents are on the other side, and they snap the bridge backtogether again, and we can safely get across.” Their concern aboutnot getting enough nurturance and their yearning for it can be seenin the following TAT story: “This boy is sitting here waiting ’cause hismother is out shopping, and he’s really hungry. They’re poor. Hefeels really hungry ’cause his mother is taking so long. (What is goingto 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 sep-

arate, alone quality. They made a point of noting that the people theysaw on the Rorschach were separating or separate. This more devel-oped sense of separation and autonomy often made them feel asense of isolation and disconnection from people. This TAT story ex-emplifies the cold, isolating quality of the boys’ sense of separateness:“One day there was a blizzard. And a man got locked out of his housein 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 fathercame and tried to wake him up, but he couldn’t. The next day hecame out of his coma and lived happily ever after. (How did he get tobe so alone outside?) He was locked out in the wilderness and hedidn’t live near anyone. Someone going down a road saw him.”While they expressed an unconscious sense of separateness and isola-tion, they were able to maintain very caring relationships with theirpeers.

The boys at age nine responded to their sense of separateness witheither a constriction that held their affects at bay but kept them iso-lated, or maintained a connection at the expense of feeling anxious.Two boys were able to stay connected while feeling separate, al-though they were both disturbed sufficiently to see and hear thingsthat weren’t there during times when they were experiencing separa-tion. This could be seen in the flow of associations through severalTAT cards. For example, one boy’s response to TAT Card 4 was astory about a wife and husband who separate and divorce. When thenext card (TAT Card 3BM) was presented to him, he told a storyabout a boy who has amnesia and a case of seeing things that aren’t


there. The boy is scared by what is happening to him. His story to thenext card presented (TAT Card 7BM) was about a boy who is separat-ing from his father to go off to college. Responses on the Rorschachalso show the boys’ disturbance around separating: “It looks like twoChinese dancers or people of some kind. They are separate. Maybetwo big dogs playing patty cake with their back feet and their frontfeet. Maybe two big Chinese dog dancers. They just finished clappingand are about to separate and then it looks like they are about to col-lide. They are slapping so hard the red stuff is the noise. The red andthe sharpness look like noise.” Concurrent with the boys’ feelings ofseparation, projective testing showed that their aggressive and sexualfeelings can feel intense and out of control because their au-tonomous defenses do not hold as well as before. At times these feel-ings actually got out of control. Parents reported an increase in theboys’ fighting with their siblings at this age.

Table V shows the findings for the nine-year-old girls and boys.

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TABLE V

Summary of Findings for Age Nine Years

BOYS1. Intense feelings of separation2. Sense of aloneness and isolation in the separateness3. Weakened defenses3. Anxiety about separation4. Constriction of affect in aloneness—two boys

Anxiety in connectedness—two boys5. Aggressive and sexual feelings that can feel out of control; increased fighting

with siblings6. Caring relationships with friends

GIRLS1. Intense feelings of separation2. Push toward peers3. Weakened defenses4. Anger about being pushed to grow up5. Anxiety about being able to function independently6. Lowered self esteem7. Increased nurturance needs8. Conflict over growing up

late latency—preadolescence

At ages ten and eleven another phase of separation and autonomybegins to develop. This sense of separation is related to the hor-monal/biological and cognitive changes occurring in preadoles-cence as well as attributable to the continued development of thechildren’s feelings and experiences of attachment and separation ex-perienced with their family and their peers. In this next phase, theboys and girls diverge significantly, with the girls taking the lead inthe developmental process this time.Girls Ages 10 and 11: The early latency phase of attachment and au-

tonomy was revived and incorporated into this next phase of separa-tion. At ages ten through eleven, concerns about connection andseparation re-occurred as the now late latency/preadolescent girlsbegan to experience the beginning of the adolescent separation-indi-viduation phase described by Blos (1967). Typical responses on theRorschach were: two horseshoe crabs stuck together, two boys as thesame person going out on Halloween, and two animals back to backabout 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 asfrequently as they did at age seven. This sense of a lack of integrationappeared 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 whohad no fragmentation responses at age seven, once again did nothave any. The variation of timing in this next separation phase sug-gests that this is a process that may occur over a longer period forsome children, and one that depends on the psychological, cogni-tive, hormonal, and physiological development of the individualchild. Based on mothers’ reports, five of the six girls were at StageTwo of Tanner’s pubertal staging (1962) by age eleven, and one girlhad reached menarche at age ten years.

For the ten-and eleven-year-old girls, attachment and autonomymeant a moving away from home base to create a life and world oftheir own, with a knowledge that they could still return when theywanted to or were needed at home. This is a very different scenariofrom that of the seven-year-old’s picture of separation, which entailsparental death. The following TAT story is an example of the differ-ent tone of this next phase: “The lady’s just thinking about herfriends and family, ’cause she just moved here, and she misses them.She needs to find a job, but she doesn’t know what kind of job she isgood at. Finally she decides she’s going to be a shopkeeper. She


thought she was old enough to move away so she moved. She willstart her own store and it will be okay.” Frequently teachers were seenas helping the girls achieve their goals, replacing parents, and friendsalso filled in for family. The importance of the peer group for thegirls is demonstrated by the following story to the blank TAT card:“Gabrielle, age eleven, was starting to go to a new camp this year. Shewas nervous. As she rode in the bus, she almost cried. But then shethought of all her friends from school and cheered up. As it turnedout, it was the best summer of her life—for friends, creativity, andhappiness. It was one of the best summers of her life, and shecouldn’t wait ’til next summer.”

This next phase of separation was not entirely free of fears andconflicts. Three of the six girls had very real concerns about death,which they applied to themselves and their loved ones. One girl hadthe following dream about the possibility of death following separa-tion: “A week or two after we got our kitten, I had this dream that shedrowned. My friend dropped Lizzy [in the water] and we cried,‘She’s drowned!’ I started diving underneath the water, and she wasat 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 bet-ter ’cause she was missing her mother.”

Conflicts fused with anxiety about growing up were exceptionallystrong at ages ten and eleven. Contamination and anthropomorphicresponses were present in all of the girls’ Rorschach protocols, whileat the same time they were telling TAT stories about going off to col-lege and being on their own. While change and separation were ex-perienced as scary, these girls had a sense that they would survive itand even fare well in the world. They didn’t defend against thesefeelings but tolerated the anxiety and sadness that comes with theseparation, bolstering themselves with a hope for a wonderful out-come. The one girl whose concern about separation was problematicwhen she was seven was still concerned that she would not fare welland described visions of homelessness, drudgery, and neglect, whichmay be why she did not experience the more intense disconnectionthat the other girls showed.

Along with this newfound sense of autonomy and its concomitantfeelings, oedipal concerns were more present again, and the girls ex-perienced a surge of aggressive and sexual feelings that at timeswould break through their defenses and overwhelm them. The girls’conflict about growing up at this point was also a response to theiranxiety 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 themin the following arenas: 1) out in the world, 2) with their very strongand conflictual instinctual feelings, and 3) with their feelings abouttheir changing bodies.Boys Ages 10 and 11: Three of the ten-year-old boys showed no evi-

dence of entering another phase of separation and autonomy. Theseboys had no fragmentation responses and there was no commontheme concerning separation. Based on their mothers’ reports, theseboys were predominantly in Tanner’s Stage I. Only one ten-year-oldboy had entered a new phase of separation. While he had fragmenta-tion responses on the Rorschach, he did not have the connected re-sponses that were characteristic of the girls who had fragmentationresponses at this age. At ten, this boy was clearly in Tanner’s Stage IIof early puberty, suggesting that this next phase and process of at-tachment and separation may also have a biological clock that is laterin boys than in girls.

At age eleven, images of both connection and separation appearedin all the boy’s Rorschach responses, despite their still early Tannerstaging. The boys once again felt that the only way to separate was ei-ther to kill their parents or never see them again. Their early latencyfeelings and fantasies about separation were revived and incorpo-rated into this phase of separation. These feelings were mixed withaggression, an intensification of oedipal wishes, and a longing to re-main connected. The following TAT story demonstrates their long-ing to remain connected during complete separation: “There was ason [who] left his house when he was eighteen and didn’t talk to ei-ther of his parents for around twenty years. And then he came backand was thinking what to say to his mom so that she would believe itwas him. And after a while he still couldn’t think of anything. He justleft. He wrote a letter to her explaining everything, and she was stillmad at him. He was sad because he really wanted to come back to hisfamily. He never did, and he wrote a lot of letters all the time.” Theboys’ resurgence of oedipal feelings is evident in one boy’s TAT story:“There is this girl in high school. And she likes this guy here. And shewants to marry him, and he wants to marry her. But this lady—thisguy is a slave to her, and she won’t let them get married. So the girl isthinking, ‘What can I do to get rid of this lady?’ So then one day shetakes a knife and kills her, and they live happily ever after. (Who wasthe lady?) His owner.”

Their mounting sexual and aggressive feelings worried all fourboys. Three of the four boys had concerns about the death of them-selves and their loved ones in their Rorschach and TAT responses at


this age. While this appears related to their sexual and aggressivefeelings, there is also a quality of a wish to return to lost oedipal ob-jects. The following TAT story expresses this wish: “This lady was thewife of the guy who got in the car accident. He died and so did herkid and then she lost her job. So she got really depressed and shecommitted suicide ’cause that’s a gun right there.”

Table VI summarizes the findings for the ten- and eleven-year-oldboys and girls.

Discussion

Analysis of the responses of these ten children outlines a process ofattachment and autonomy that occurred in two waves, one duringearly latency and another in preadolescence. In both waves there isevidence of a change in the antecedent mode of object connectionand the concomitant breakdown of self-coherence. The develop-mental task of negotiating dyadic and triadic relationships—attach-ment as well as separation and autonomy—is an ongoing processthat starts in infancy and continues throughout the life cycle. It is em-phasized in latency when children must negotiate another level of in-ternal separation and independence from their family as they jointhe world of their peers.

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TABLE VI

Summary of findings for Ages Ten and Eleven Years

GIRLS BOYS

Feeling fragmented—five out of six Not feeling fragmented—three out girls of four boys

Images of connection and breaking 11-year-olds: images of connection apart and breaking apart

Separation means moving away from Separation means killing parents or home never seeing them again

Suicidal ideation and concerns Suicidal ideation and concerns aboutabout death death

Teachers and friends replace familyConflict over growing upNurturance needsStrong aggressive and sexual feelings; Strong aggressive and sexual feelings;

oedipal concerns oedipal concerns

their early latency children for after-school activities like scouts,sports, dance, karate, after school programs, etc., keeping them awayfrom the home many afternoons until dinner time and requiringthem to enter into a world of peers for most of their day.

This new sense of separation leads to feeling a lack of integrationand disconnection that is experienced unconsciously. A sense of anunconscious, internal lack of integration may be a necessary part ofthe separation process. The one girl who did not have any fragmenta-tion responses had difficulties managing separation in her adoles-cence. One might hypothesize that each successive phase of separa-tion along this developmental line has a period of wishing to mergeand a breaking apart that marks its inception. This corroborates theanalytic assumption that the development of an autonomous self re-quires a repeated process of identification and de-identification withsignificant objects, as well as object removal and deidealization, all ofwhich can feel destabilizing.

This normal latency state of experiencing a lack of self-cohesionmay be a more advanced state similar to the one Stern (1985) de-scribed when he discusses the lack of organization the infant first ex-periences in the emergent sense of self, and Sander (1980) describedat the beginning of the mother-infant regulatory system that gets es-tablished in the neonatal period. Kohut (1971) also theorized a re-gression to a state of feeling fragmented when the child experiencesan absence of the narcissistically invested lost object, along with at-tempts to re-establish the union through visual fusion and other ar-chaic forms of identification.

Feeling a lack of self-cohesion may also be a response to the con-flict of independence. Experiencing a lack of integration is con-sciously expressed during normal developmental periods of separa-tion. One mother reported that her seven-year-old daughter, duringa crying episode, screamed, “I feel all in pieces!” I have heard severalthirteen-year-olds, another developmental period of growing auton-omy, describe their mothers as “the tape that holds me togetherwhen I feel in pieces (or unglued).” When working with childrenand adolescents in analysis, their expression of feeling a lack of self-coherence may indicate that they are entering a period of transfor-mation in development.

While these latency separation concerns are clearly tinged withoedipal wishes, as they similarly are in early adolescence, they arealso about a yearning to merge, a desire to be attached and con-nected 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 forceserving the individual’s attempt to close the open space that is inher-ent in relationships throughout the lifespan, starting with the em-bryo and continuing, transformed, at birth.”

For both the boys and the girls in this study, separating in early la-tency had connected to it an idea of both parents being dead. Thetheme of parents who have either died or abandoned the latency-agechild has frequently been expressed in literature read by latency agechildren, most notably in the fictional lives of characters such asPippi Longstocking, Peter Pan, Superman, Luke Skywalker, andHarry Potter. This theme is the fantasized expression of the internalobject loss that the children are unconsciously experiencing in thisphase of separation and a necessary step in the development of a sep-arate sense of self. Loewald (1979) has described the separation pro-cess at the end of the oedipal period as one in which the child mustmurder and mourn the “incestuous ties” in order to achieve a moreseparate sense of self. Modell (1984) has described the guilt that en-sues as a result of the underlying fantasies that separation will lead tothe death or damage of a parent. Because of this underlying fantasyand the guilt that it produces, an actual death of a parent during thisperiod can severely impede the process of separation, which oftenbecomes clinically noticeable during adolescence and early adult-hood.

When working with latency children in analysis, it is helpful tospecifically delineate the content and context of their attachmentand separation wishes and fears in order to more appropriately inter-pret them and provide empathy to our analysand’s inner experienceof attachment and separation at each moment in time within the an-alytic process and relationship.

the management of anger in latency

The boys and girls experienced their anger in different ways, al-though the resulting fantasy of parental death may be the same. Bothgenders exhibited oppositional behavior at home, as reported by theparents. But on the projective testing, the girls consistently turnedtheir anger against themselves and their siblings while the boysmostly directed it outward toward people and objects. This is consis-tent with Olesker’s (1984) findings of gender differences in the ex-pression of aggression in the first phase of separation-individuation.Both her findings and mine suggest that through the process of iden-


tification and cultural handling, boys and girls develop differentstyles of processing and expressing aggression at a very early age. Theneed to defend against anger by turning it on the self may accountfor the drop in self-esteem the girls showed beginning at age nine.These findings may also be an additional reason for the drop in self-esteem that Gilligan (1982) found in her study of preadolescent girls.

Both the boys and the girls used the defense of aggression turnedagainst the self as they began to enter their early preadolescent sepa-ration phase; however, it sometimes had a quality of being a fanta-sized way to return or reunite with a lost object. This feeling wasclearly expressed in analysis by a young man with separation difficul-ties: “Suicide and my mother are like the same thing; it’s a way out.It’s a moment when it seems like all of your problems are removedfrom you and you don’t have to grow up. I feel like I can get it anytime. I feel like there is an easier way.” A further elaboration of thesuicide theme expressed by the girls at times was the feeling that tolose your mother could mean the loss of one’s own self, suggestingthe strong internal ties the girls have with their mothers. This studysuggests that suicidal ideation—very real thoughts and concernsabout death applied to oneself during the preadolescent phase ofseparation-individuation—is part of a normative process that is notpathological or pathognomonic.

The responses of the children in this study suggest that the latencyand pre-pubertal phases of attachment and separation are filled withintense experiences and feelings that can lead to significant disrup-tion in self-coherence and ego functioning and to suicidal ideation—all derivatives of a normative process. Evaluating children in this agegroup requires an understanding of the complexity of their normaldevelopment in order to then determine pathology in a latency orpreadolescent child.

coping with separation

The children’s feeling of separation leading to more autonomousfunctioning at the beginning of latency is enhanced by the develop-ment of concrete operational thinking, a higher level of cognition(Piaget, 1967). This cognitive maturation allows the child to decen-ter and measure himself/herself against others and experience theworld as bigger and more challenging, leading to anxiety about go-ing out into the world of school and peers, where they really are thesmallest, least knowledgeable children in that larger world.

All the children used fantasy and magic to help them cope with

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fears of managing on their own as they felt more separated and alonein the larger, challenging world. This supports Anna Freud’s (1936)and Sarnoff’s (1976) finding that fantasy is used as a major defensein the latency period, and the use of magic within that defense is sig-nificant. The boys in this study also felt they could rely on their fa-thers to help them manage difficulties in the world outside the fam-ily. One interesting finding was that the girls in the study did not feelthey could rely on their parents in the same way as the boys, anddemonstrated an oral neediness that grows in intensity throughoutthe latency period as well as a sense of being tired at times by the taskof growing up. These findings are illustrated in the “Harry Potter”stories (Rowling, 1998–2003). Harry has his god-father, his friendRon’s father and brothers, and several male teachers to help himavoid dangers as he grows up in the magical world of Hogwarts.Hermione, by contrast, has parents that are of no help to her, andshe has to study magic very hard (sometimes taking two classes at thesame 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 seetheir fathers as helping figures while girls cannot use their mothers(or fathers) in a similar way during this phase of identification withthe same sex parent must be considered. All of the girls’ mothersworked part-time in professional positions, yet the girls could notimagine their mothers as helping figures in the world outside of thehome in their fantasy.

One possible explanation for the different reactions of the boysand girls has to do with gender identification processes in early la-tency. Mahler (1981) addressed the gender difference in the firstseparation phase, noting that the boy has his father to support andmaintain his personal and gender identity, while the girl, in her sepa-ration from the post-infancy mother, has a much more difficult andcomplicated task to attain and maintain her sense of self because herrelationship with her mother “carries the burden of threatening re-gressions.”

In latency, boys identify with their fathers and their sense of theirfathers’ more competent position in the outside world. The girls’TAT stories often expressed a sense of tiredness related to indepen-dent functioning in the world. The girls in this study may have identi-fied with their mothers’ tiredness from having to maintain two jobs—work and family care, and/or their mothers’ overriding maternalfunction of being the main caretaker of the basic needs of the homeand children. Stephen King (1983) nicely expressed this male-female


role dichotomy: “What your mother leaves you is mostly good hard-headed practical advice—if you cut your toenails twice a month youwon’t get so many holes in your socks; put that down you don’t knowwhere it’s been . . . but it’s from your father that you get the magic,the talismans, the words of power” (p. 36). This component of thegirls’ identification with their mothers, when combined with theirlowered self-esteem, may sometimes leave them feeling that they arenot competent enough to be completely out in the world.

Another explanation for this gender difference may be found inthe remains of the late oedipal phase conflict. In this study, the earlylatency boys unconsciously experienced their mothers as dead tothem, while the girls unconsciously experienced their fathers in thissame way. In their effort to break their oedipal tie to their fathers, thegirls need to distance themselves internally from their fathers, andtherefore do not have them as available as the boys do to help themin their fantasy working through of the present stage of separation.This might make the girls feel they have to bank on their own re-sources, which would increase nurturance needs in the face of mov-ing out in the world without the internal reliance on their fathers.Their increased need to rely more on their own resources may add totheir feelings of lowered self-esteem by the age of nine.

Two of the boys felt an intense sense of disconnection at age ninethat the girls didn’t have. It is interesting to note that the two boyswho retained a sense of connection at age nine both had mild learn-ing difficulties, requiring them to remain more dependent on theirmothers for help with their school work and the structuralization oftheir environment. Chodorow (1989) suggested that the masculinepersonality is founded on the denial of relational needs out of thedifference in social attachments that evolve out of the oedipal config-uration, requiring the boy to more fully repress his primary relation-ship and, consequently, the degree of dependency attached to it.While this finding supports her theoretical position, the relationalpicture is more complicated.

The nine- to eleven-year-old boys in this study, while feeling inter-nally disconnected and isolated, maintained caring peer relation-ships. Their unconscious feelings of disconnection seemed to be a re-sponse to their internal experience of separation, but did notnecessarily lead to a denial of relational needs in their peer relation-ships. Their attachment and loyalty to a primary, close male friendwas much more constant than the girls’ friendships were duringthese 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 werestudied in depth, this study can only generate hypotheses about thedevelopmental process for all children in this age group; however,the convergence of data from a variety of sources makes the resultscompelling and ring true with our analytic observations. While thereis value in small N studies (Jones, 1993), additional studies on largenumbers of children from different cultural, racial, and socioeco-nomic groups are necessary to validate the ideas proposed in this pa-per. Therefore, these findings can only be applied cautiously to amore varied cultural, cognitive, or socioeconomic group.

At the beginning of latency, the children in this study began to de-velop an unconscious sense of being separate from their parents in away that they had not experienced previously. Although both sexesexperienced this development, they had different timetables—theboys entering this phase one year earlier than the girls. Several possi-bilities could account for the gender difference in the latency pro-cess of the development of attachment and autonomy. Olesker(1990), studying separating toddlers, reported that mothers weremore likely to push boys toward independent behavior and keep girlscloser longer. She suggested that this might lead the girls to enter theoedipal period less well separated from their mothers than the boys.In addition, boys may enter the latency separation period with a his-tory of a more established separation than the girls may because theyhave had to establish a predominantly male gender identity that isdifferent from that of their mother. This forces them into a differ-entiation pattern earlier than the girls and may promote earlier development of separation and independence. Buxbaum (1980)suggested another factor that may influence this developmental dif-ference. She proposed that the girl’s oedipal phase might not be as“violent” as the boy’s, in that girls don’t have to give up their originallove object. This may explain why the girls may have a differenttimetable, 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 whatfelt like an instinctual desire to push their children out into theworld. One mother characterized her feelings of pushing her daugh-ter into activities outside the home: “I feel like a mother bird pushingher out of the nest.” The biological clock (Shapiro and Perry, 1976)that gives latency its start may also be present in the parents’ respon-sive need to push their children out into the world of peers. Al-though both parents and children were ambivalent about this newphase of separation and autonomy, all of these parents registered


ferent—the girls talked to each other more and shared fantasies inplay; 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 re-structuralization of the ego as the latency child develops new levels ofcognition, physical abilities, socialization, and the autonomous use ofdefense functioning. By age nine all of the children had consolidatedthe latency phase of separation and autonomy. Their higher levels ofautonomous and internalized defense functioning and their newlydeveloped cognitive functions were not yet sufficiently established toprotect them from their strong feelings, which were in greater powerthan their defenses at this point, resulting in the breakdown of de-fense functioning and the considerable distress that can be seen ontheir Rorschach protocols. Ames et al. (1974) noted that the nine-year-olds on the Rorschach protocol look “neurotic or disturbed.”She and her co-workers also found a large number of responses re-ported by their ten-year-old subjects but not actually present on theRorschach card, similar to the talking and hearing vibrations one girlin this study reported. The age difference between her subjects andthese children may be due to the fact that the children in the presentstudy were more intellectually advanced and so experienced thisbreakdown in ego functioning somewhat earlier than the averagechild might. That such a breakdown of defenses at age nine occursafter consolidation of separation and a more autonomous self andego structure at age eight is consistent with the idea that the most re-cently developed functions are the first to show vulnerability during amaturational change that also includes a surge of strong feelings (A.Freud, 1966; Piaget, 1967). It is also compatible with Blos’s (1967)description of adolescent separation in which ego impoverishmentfollows the sense of internal object loss.

late latency/preadolescent attachment and autonomy

At age ten there starts to be another clear distinction between theboys’ and girls’ development. Between the ages of ten and eleven, allthe girls’ Rorschach protocols once again had fragmentation re-sponses along with concerns about merging and breaking apart, verysimilar to their seven-year-old protocols. Ames et al. (1974) also re-ported a similarity between the ten- and seven-year-old Rorschachprotocols. This return to the seven-year-old subjects’ feelings was


nicely expressed by one ten-year-old girl’s response to the blank TATcard; she told a story about a seven-year-old-girl having a birthdayparty during which the children played pin the tail on the donkey(note the disconnected donkey). The disturbance in defense func-tioning seen at age nine continued, as the girls’ newly establishedego functions were further bombarded by their drives and the addi-tional stress of a new phase of separation. Mahler (1972) has re-ported the defensive use of rageful, distancing behaviors in girls to-ward their mother during separation. This time parents reportedthat their girls “had become very difficult,” were easily angered, eas-ily had hurt feelings and became upset, had frequent mood swings,and mothers reported a significant increase in mother-daughter con-frontations. The girls did manage to maintain their high functioningin school, as teachers continued to praise their abilities and behavior.

This preadolescent phase of separation is certainly related to a bio-logical clock driven by a major change in hormonal functioning,which starts earlier for girls than for boys. While only one boy wasclearly in early puberty and showed fragmentation responses at agesten and eleven, all of the boys were internally preoccupied with con-nection and separation, just as the girls were. Because data collectionin the present study stopped after age eleven, it is not possible toknow when the other three boys would have felt the same breakdownin self-coherence that the girls did at ages ten and eleven. One mayassume that this next phase of separation is biologically driven, sincethe one boy who did feel fragmented was in early puberty, while theothers still looked like latency boys at age eleven. This finding sug-gests that boys tend to remain in a late latency/prepubertal stage ofdevelopment longer than girls do. The biological time-table that con-tributes to these two waves suggests a discontinuous process of attach-ment and autonomy separate from underlying dynamic conflicts, al-beit not unaffected by them.

stages and phases of latency

The stages and phases of latency have been described in the litera-ture in many different ways, as discussed in the introduction to thispaper. The results of this study suggest another theoretical additionto the phases of latency related to the development of attachmentand autonomy. In the proposed model, the early latency phase wouldbe between six and eight years in boys and seven to eight years ingirls, when the latency child begins a new phase of separation and au-tonomy from his/her primary objects. Middle latency would occur at

206 Rona Knight

age nine, when both boys and girls consolidate their more indepen-dent and autonomous functioning. Late latency/preadolescencewould begin at age ten in girls and ten/twelve� years in boys, whenanother phase of separation and autonomy begins. If this theoreticalhypothesis holds true, then girls have a much shorter period of la-tency development than most boys do, and consequently don’t haveas much time to consolidate their growth during this developmentalphase before they have to cope with another major developmentalshift to preadolescence.

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CLINICAL STUDIES

Play in the Psychoanalytic Setting

Ego Capacity, Ego State, and Vehiclefor Intersubjective Exchange

KAREN GILMORE, M.D.

The psychoanalysis of an 8-year-old boy who does not play is presentedto illustrate the centrality of the “state of playing” for meaning-makingand communication in treatment. Developmental research links affectregulation, narcissistic balance, and the capacity for make-believe tothe early intersubjective exchange between mother and infant. The in-tersubjective dialogue between patient and analyst in the “state ofplaying” is a crucial component of child analysis and its absence bothreflects and compounds ego vulnerability in the child and presents adaunting technical challenge to the analyst.

So—here I am in the dark alone,There’s 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 UniversityCenter for Psychoanalytic Training and Research.Presented as the Robert Kabcenell Memorial Lecture, New York Psychoanalytic In-

stitute, March 9 2004.The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,


213

I can laugh whatever I like to laugh,There’s nobody here but me.

—From “In the Dark,” by A. A. Milne

in this communication, i describe my efforts to understand alatency age boy, Andy, whose analysis has been remarkable in my ex-perience because of its absence of thematic content and emergent“intersubjective exchange” in the form of play (Birch 1997). Throughdiscussion of one boy’s particular difficulties, I hope to demonstratehow analytic work with prepubertal children is facilitated by thechild’s capacity to achieve a shared “state of play” where meaningmaking, affect modulation, and mental representation of intolerablepsychic experience becomes bearable and achieves therapeutic ef-fect. The absence of play creates formidable obstacles to therapeuticprogress and indicates serious ego-impairment in the child.

Play in Psychoanalysis

In child work, the evaluation of child’s capacity to play and the pro-cess of playing typically yield an invaluable trove of informationabout the individual’s psychological and cognitive development, dy-namics, diagnosis, and interpersonal relatedness. The child clinicianexpects that, despite possible inhibitions and constrictions, pseudo-maturity or chaotic impulsivity which may deform the playing func-tion, the child patient will usually produce some form of play thatcan serve as a shared “intermediate region,” (a term borrowed fromFreud’s 1914 metaphor of the “transference as playground”) wherethe action of the analysis can safely unfold. Play has been addressedextensively in the analytic literature even before Freud’s immortaldescription of the “Fort-da” game (1920); with the advent of ego psy-chology and observational studies of infants and children, it hasbeen increasingly privileged as serving a central role in child devel-opment. No longer reduced to merely a discharge or wish-gratifyingphenomenon, it is conceptualized as a complex normative growth-promoting capacity that evolves with cognitive and psychological de-velopment (Marans et al. 1993, Solnit 1987). Its crucial position inthe analytic treatment of children has also been described exten-sively in the clinical literature where it has been analogized to thetransference (Battin 1993), termed a “creative workshop for action”(Mahon 1993), and yet distinguished from the enactments that di-rectly draw the analyst into a dramatization of unconscious fantasy,which, of course, are also prevalent in child analysis (Chused 1991).

214 Karen Gilmore

Child analysts are very well acquainted with the “coercive” as well asthe “generative” effects (Ogden 2004) that accompany playing out achild patient’s narrative. Like enactments, i.e. “symbolic interactionsbetween analyst and patient which have unconscious meaning toboth” (Chused 1991), play typically reveals that the analyst is both“playing a role in, and serving as author of, someone else’s uncon-scious fantasy” (Ogden 2004) that inevitably reverberates with herown.However, play differs from enactments in that it is, either implicitly

or explicitly, “make-believe.” Playing in the analytic setting estab-lishes a space “without real consequences” (Freud 1917) where com-munication between the child and analyst can occur at the develop-mental level of the child in a state that is demarcated as meaningfuland yet not real. While both action and verbalization are involved,what is optimally achieved is an intersubjective exchange in the mu-tual state of playing where transformation of the child’s anxieties anddefenses can be accomplished by the analyst’s clarifications, recipro-cal engagement, and interpretive work. This phenomenon is compa-rable to “the analytic third” as conceptualized by Ogden (2003) or byBromberg as “space for thinking between and about the patient andthe analyst” (1999) in adult work. In child analysis, this state is con-cretely anchored to favored play objects endowed with layers ofmeaning, both explicit and unconscious (Abrams 1988), and it isrepresented in the idiosyncratic play themes that emerge and evolveas a product of the child and the analyst’s conscious and unconsciouscommunication in the course of an analysis.But more fundamental than these tangible artifacts is the intersub-

jective “mutual state of playing” that characterizes each patient/ana-lyst relationship and that sustains and is in turn transformed throughthe metaphors of the evolving play narratives and props. Because theplaying analyst, to be truly effective, must fully engage in playing(Birch 1997, Yanof 1996, Cohen and Cohen 1993), the play is in-evitably co-created and contains elements from the unconscious ofboth patient and analyst, although the patient’s contribution is privi-leged by the nature of the endeavor. Beyond mastering the typicalcountertransference anxieties around regression and instinctual dis-charge, child analysts ideally have remastered the capacity to playwithout condescension or self-consciousness and to maintain a con-sciousness divided between the analytic and the playing functionwherein the analyst is tuned into that particular child’s inner life.In child work where playing is prominent, there are layers of diag-

nostic, dynamic, and transference meanings within the play, as well as

Play in the Psychoanalytic Setting 215

in the freedom with which the child reveals his personal “state ofplaying” and in the manner with which the child draws the analystinto the play and allows the emergence of an intimate dialogue. I be-lieve that the child analyst, more than any other professional whoworks with children, most consistently attempts to enter the child’sinner world and go beyond the typical array of self-protective barri-ers that children present to grown-ups. Both child patient and analystmust be willing to engage wholeheartedly (Birch 1999, Yanof 1996)in the “conceptual world” (Cohen and Cohen 1993) that the child-with-the-analyst creates. Over time, the analyst readily launches her-self into the singular world of her patient’s “state of playing,” a worldwhose rhythms, rules, and rituals as well as opportunities for thera-peutic work are unique and to some extent idiosyncratic to the par-ticular individual and the dyad; among these are the pathologicaladaptations that can be addressed best by being in that world withthe child. This state includes unconscious communication and intu-itive leaps that can result in dramatic shifts in the child’s tolerancefor 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 fromplaying alone or even with another child or adult. Playing with theanalyst is all at once revealing the self, drawing the other into a pri-vate world, and tolerating an openness to a dialogue which now sub-jects his psychic experience to modification and “mentalization”here used to mean the establishment of links between drive-affectand mental representation that are gradually identified and elabo-rated verbally (Lecours and Bouchard 1997). Of course, children dif-fer a great deal in their guardedness around this threshold, butbridging it is a crucial moment in the treatment. This is the momentwhere the child admits the analyst into his private world, by nomeans without its own resistances and defensive organizations, butthe 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 discussionagainst a backdrop of a selective review of some pertinent formula-tions of how early experience within the mother-baby relationshipserves as the birthplace for shared intersubjectivity which in turnstimulates the interrelated set of ego-capacities that are at questionhere, allowing a more informed speculation about how Andy’s par-

216 Karen Gilmore

ticular history and endowment disadvantaged him. While much ofAndy’s relevant personal early history was indistinct due to his par-ents’ relative lack of awareness, the absence of imaginary play andeven typical infantile play (such as peek-a-boo) with either parent wasnoteworthy.Findings from allied disciplines underscore the importance of the

earliest relationship for many facets of future development. The vastresearch and theoretical literature that has sprung up around infantobservation and the developmental sciences underscore the impor-tance of the mother-infant relationship and intersubjectivity for theestablishment of very fundamental ego capacities, such as affect reg-ulation, symbolic capacity, self-experience, and implicit proceduresthat characterize object-relatedness. Infant observers and cognitive-developmental scientists have been able to illuminate the steps in theemergence of affect recognition, mutual regulation, self-reflectiveand symbolic capacity in the context of the earliest interaction withthe caretaker, demonstrating the significant contribution of the envi-ronmental surround (Stern 1985). Given the nature of our contem-porary child patient population, which, like Andy, is distinguished bya variety of disorders alternately called “developmental,” “regula-tory” and the like, these findings provide fascinating corroborativedata and suggest new ways of thinking about and addressing thesefundamental deformations that clearly predate the Oedipus and pro-foundly affect its unfolding.A number of seminal papers written by psychoanalysts and psycho-

analytically informed baby watchers from previous decades, such asAnna Freud, Winnicott, Weil, Mahler, Sander, Emde, Pine, andShapiro, adumbrate these contemporary conceptualizations and fa-cilitate their contextualization within our psychoanalytic metapsy-chology. All of these writers observed and privileged “the interactionbetween the infant’s equipment and early experiential factors—aninteraction that aggravates or attenuates initial tendencies” (Weil1970). Weil termed this the “basic core” which establishes the earliest“regulatory stability;” this regulatory stability—or relative lack of sta-bility—contains directional trends for all later functioning” (p. 242–43, my italics). Neurotic conflict is ubiquitous but rests on a substruc-ture that predates its appearance and does not originate in conflictbut rather represents a transactional adaptation.This idea and its variants rephrase in concrete ego psychological

terms Winnicott’s principle: “there is no such thing as an infant,”that is, “the infant and the maternal care together form a unit”(1960). Winnicott’s work elaborates the notion that the “inherited


potential of the infant cannot become an infant” without the mater-nal care, which in infancy is guided predominantly by “maternal em-pathy.” This maternal matrix facilitates the tolerance of anxiety,structured integration of the personality, the “dawn of intelligenceand the beginning of the mind” (p. 45). Winnicott’s ideas also under-score the fact that neurotic conflict as it emerges in childhood occursin a mind already stamped by its interaction with its particular envi-ronment, the product of a complex transaction that begins withinthe 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 in-creasingly occupied infant observers and researchers (Mahler andMcDevitt 1982, Stern and Sander 1980, Emde 1983, Pine 1982). In1985, Stern drew upon his infant observational studies to posit that avery early existential sense of self, or rather a number of “senses ofself,” predate language development and self-reflective capacitiesand are both revealed by subsequent development and transformedby it. Among the senses he identified are the “senses of agency, ofphysical cohesion, of continuity in time, of having intentions inmind . . . the sense of a subjective self that can achieve intersubjectiv-ity with another, the senses of creating organization and the sense oftransmitting meaning” (pp. 6–7). The presence of the other is cru-cial for self-regulation of affect and somatic experience and indeedhas a central role in defining the infant’s primary self-state. Betweenseven and nine months, the human infant discovers that the otherhas a mind of her own and that that mind can be engaged in sharingsubjective experience. Indeed, infancy research offers a series of ele-gantly simple paradigms, such as Tronick’s still face, the visual cliff,and theory of mind studies, that underscore the parallel strands ofthe infant’s and young child’s expectation of mutuality and engage-ment with the significant other even as he is increasingly able to real-ize the fundamental separateness of the other’s mental state, rangingfrom beliefs and desires to available mental contents that inform himabout the world.The notion that the same interpersonal process that produces

emotional recognition and regulation, reflective function, and selfand object constancy also is central for the birth of symbolic capacityand imaginary play began with Anna Freud’s Normality and Pathologyin Childhood (1965). The very young infant “neither distinguishes selffrom object nor is able to manipulate symbols and . . . the emergenceof each process is importantly interrelated with that of the other”(Drucker 1979). For example, social referencing referred to above,

218 Karen Gilmore

i.e. looking at the mother’s face for affective guidance, is a develop-mental milestone that highlights the presence of self-other differ-entiation. Moreover, it shows that the infant is available to receive theattribution of meanings to objects and circumstances from themother, an essential step in the development of symbolic capacityand imagination. “The infant relates not only to the world as percep-tually specified, but also to someone else’s psychological relation tothat same world . . . [More important than mere information aboutthe world], this configuration of experience affords an infant the op-portunity to learn that given objects and events can have multiple,person-related meanings. The meaning-for-me is not necessarily themeaning-for-her” (Hobson 1993). This remarkably rich developmen-tal moment captures as in a freeze-frame the complex processwhereby the infant learns to use the mother’s affective signal toguide both his own affect and his actions, a process which, when in-ternalized, provides a key component of future self-regulation of af-fect. In addition, this same moment illuminates the infant’s recogni-tion of separateness, the intersubjectivity of his mental state as heobtains the required affective guidance from his mother’s expres-sion, and the process through which meanings of things are con-ferred by minds. With these developments comes the possibility thatobjects and their meaning can be assigned and transformed by cre-ative invention on a personal, interpersonal, or cultural level. Thus,the child achieves the developmental level required for symbolicplay.Another tradition within infant observational studies underscores

the crucial role of contingency detection, an infant capacity that isdemonstrable within the first months of life. Interestingly, this capac-ity has also been shown to figure as a key component in the develop-ment of narcissistic integrity and the capacity for make-believe.Broucek, reviewing the relevant research prior to 1979, observes thatthe infant’s discovery that a contingency exists between his own activ-ity and the occurrence of external events is a fundamental buildingblock in the infant’s development of “self-feeling” and narcissistic in-tegrity; violations of contingency expectation early in life can insti-gate withdrawal and avoidance, infantile defenses against traumatichelplessness and impotence. This is beautifully demonstrated inTronick’s still-face experiment where violation of the infant’s expec-tations that his mother’s facial expression will vary in response to hisown communicative expressiveness results in disorganization andwithdrawal (Gergely and Watson 1996).In more recent studies, Gergely (1996) calls upon the infant’s sen-


sitivity to the contingency structure of face-to-face interaction andthe “species-specific propensity for the facial and vocal reflection ofthe infant’s emotion-expressive displays during affect-regulative in-teractions” to explicate how the infant develops awareness of his ownaffects, recognizes the nature of his mother’s affects, learns to self-regulate his emotional state based on parental mirroring, and comesto distinguish real affect from pretend (i.e. “marked”) affect. Thisvery detailed study suggests that the interaction with the parentaround emotional displays is midwife to both the infant’s self-regula-tory capacities and the infant’s entry into the world of make-believe.Even as the infant is distinguishing between his mother’s face “re-flecting what she sees” (Winnicott 1965) in his own face and hismother’s face expressing her own affect, he achieves the associateddevelopmental milestone of distinguishing, by their markedness,mock displays of emotion, those playful exaggerated expressions ofsurprise, fear, delight, and so on, from real ones. With these miracu-lous achievements, the infant engages in the excited interplay ofemotional expression with the parent, correctly interpreting mocksurprise, anger, and sadness and ultimate re-creating these “play” af-fects. This, of course, constitutes a vital step toward symbolizationand the world of make-believe.In tandem with the increasing emphasis on the crucial interper-

sonal context of the infant’s developing capacities—to recognizeand regulate his own affective states (Gergely and Watson 1996), toappreciate and distinguish the mind of his caretaker from his own, toidentify his unique intentionality and agency (Fonagy and Target1998), and to freely access the developmentally crucial world ofmake-believe where mentalization can occur—there is a growing ac-cumulation of data to suggest biological and genetically basedsources of psychopathology. Many of the children we see today havebeen examined systematically in terms of their ego equipment andtheir genetic pedigrees, and we often face the conundrum of under-standing their psychopathology in the context of contributions frommarkedly uneven ego functioning which is developing in a complextransaction with conflict. While the stability of findings from neu-ropsychiatric testing is variable depending on the age of the child, aswell as on dynamic and educational factors, there is no doubt thatthese variations feed into, as well as reflect, psychopathology andcolor the interchange with the environment throughout life. I be-lieve that the impact of these features are far more powerful in pre-sentations in childhood than in adulthood for a number of reasons,including the obvious one that adults have developed more stable

220 Karen Gilmore

ego organization and adaptations and are rarely called upon to per-form in as many diverse arenas as the average school child. The adultwill presumably manifest less distress and symptomatology aroundchronic exposure to impossible environmental demands and canavoid confrontation with areas of relative weakness by his choice ofprofession and pastimes. The child analyst thus faces a diagnosticand clinical challenge where the multiple transactions among na-ture, nurture, history, on-going development, and environmental ex-pectations and demands are all intermingled and clearly contributeto the child’s 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 usualcontemporary 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 ana-lytic practice. The degree to which his psychology was influenced bya documented developmental strain due to markedly uneven cogni-tive and physical maturation is, I believe, both considerable and com-monplace. Elsewhere, I and others (Gilmore 2000, Greenspan 1989,Cohen 1991) have suggested that our current thinking, enhanced byour greatly improved assessment techniques, allows us to take into ac-count the impact of developmental idiosyncrasy on the evolvingstructure of the mind; that is, we are able to identify and consider theway that the unique individual developmental profile shapes and or-ganizes the evolving personality and defines its potential. I wouldspeculate that Andy’s extraordinary degree of uneven ego endow-ment, with marked delays in coordination, visuo-spatial integration,and sustained alert attentiveness, and his low thresholds for frustra-tion and stimulation tolerance impacted his sense of efficacy and hisavailability for easy interpersonal exchange from the outset. His vul-nerabilities diminished his opportunities for the early repeated expe-rience of joy, self-satisfaction, and parental admiration in the routinefine and gross motor accomplishments of early childhood. Theseconsiderations, plus the report of maternal depression in the firstyear of life and his parents’ orientation toward emotionality in gen-eral, support hypotheses about the complex bio-psycho-social under-pinnings of this boy’s particular difficulties when he presented inearly latency, which included the absence of unstructured play, intol-erance of affect, impulsivity, and a markedly constricted inner life.The working hypotheses which thus guided Andy’s treatment accu-

mulated over the course of my work with him. I offer them here inadvance to show the interweaving of the developmental, diagnostic,


and dynamic issues as they served to light the way in what sometimesseemed a discouraging darkness. To my way of thinking, they repre-sent 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, especiallyhis limited capacity to sustain quiet alertness and focus (ADHD) andhis reduced proclivity toward object relatedness (non-verbal learningdisability), diminished his availability for early engagement with hismother, where affect regulation and imaginary play find their ori-gins.2. Andy did not play because his mother was depressed during the cru-cial 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 hispleasure in his own productions were compromised by his motor andvisuo-motor deficits.4. Andy did not play because ego weaknesses, interference in mater-nal attunement, and, possibly, constitutional factors, heightened hisfear of his affects and his difficulty developing signal function.5. Andy did not play because his narcissistic fragility and sense of in-ternal impoverishment inhibited the development of fantasy and theexpression of creativity.6. Andy did not play because affective expression was devalued in hisfamily and precocious intellectuality was strongly prized. Obsessionaldefenses against his constitutionally determined impulsivity were re-inforced by his intellectual, “workaholic” parents; coupled with hisperfectionism and his fear of his own affects, these defenses furthersquelched his freedom to play creatively.

Over the course of the two years of treatment to date, I came toconceptualize the core of Andy’s pathology as a complex disturbancein his ego organization, one that remained as an on-going (althoughalso evolving and transforming) limitation in his development. Hisclinical presentation, corroborated by his history, showed that hehad on-going difficulty establishing and maintaining an intersubjec-tive state where self-discovery, emotional exploration, and creativityare engendered, where his inner world can be made manifest with-out crippling self-consciousness, a state that we rely on as child ana-lysts and that we usually get to experience directly or sometimes onlyindirectly, as with highly oppositional children. His analysis has in-deed been marked by fierce resistance, behind which lay anguishedloneliness, narcissistic fragility, and mistrust of adults—all attribut-able to the factors outlined above. Furthermore, Andy used his con-stitutionally based tendency to “tune out” as a powerfully opaque

222 Karen Gilmore

ego-state of pseudo-autonomy, resistance, and disengagement; thesefactors conspired against Andy’s experiencing an open exchangewith me.

Andy

When Andy’s parents first sought consultation, he was just short of 8years 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 schoolhad urged his parents to seek an evaluation for his hyperactivity, dis-tractibility, and fine and gross motor delays, his parents consulted apediatric neurologist. Neuropsychiatric test results corroborated anextraordinary degree of developmental unevenness with a 41 pointdifference in his superior verbal and low average performance IQ;most significantly depressed were the scores on tasks that required vi-suo-motor integration and visual memory. His attentional lapses anddifficulties with organization were felt to impair his capacities acrossthe board, but with most damaging effect on his weak performancescores. Attention deficit disorder, grapho-motor delays, and visuo-motor learning disability were diagnosed; his affect dysregulationand low frustration tolerance were attributed primarily to the com-bined impact of these disorders. Andy’s distractibility and hyper-motility were viewed as serious impediments to his learning and med-ication was recommended and begun.However, despite his teacher’s report of significant improvements

in his learning, Andy’s overall state worsened over the year to thepoint that there was now an urgent need for psychiatric input. Onstimulants, Andy was more impulsive, rather than less, and his emo-tional instability was becoming unmanageable. New and peculiar be-haviors included his refusal to swallow his saliva, which he retained inhis mouth and spat out at intervals. His behavior at recess was in-creasingly reclusive; he removed himself from contact with otherchildren, paced, and twirled about, seemingly lost in fantasy. Hismeltdowns and impulsivity spilled over to the classroom, to the pointwhere his teachers felt that they needed extra help dealing with himin class. His nighttime enuresis, typically occurring once or twice perweek, had increased and he also began wetting and soiling at school.At home his “oversensitivity” to slights and misunderstandings, hisfrustration 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


one night and ran several blocks, across busy intersections, before be-ing apprehended by a policeman.What was most striking in my conversation with his concerned par-

ents was their lack of awareness of Andy’s mental life or, for that mat-ter, of subjective or interpersonal experience in general. Well edu-cated, well intentioned, and exceedingly busy professionals, theyconveyed bewildered sympathy for their son’s situation, reacting withdismay tinged with a kind of abashed perplexity and frustration, butat the same time suggesting that everyone was exaggerating the seri-ousness of his disturbance. They complied with the school’s insis-tence on a “shadow teacher” but viewed it as alarmist. This posturepreviewed their reaction to the recommendation for analysis. Laterin the first year of treatment, Andy’s mother, who was herself in anon-going treatment, acknowledged her own significant depressionduring Andy’s first year of life precipitated by her father’s death. Shealso articulated a tension between herself and her husband and in-deed his entire extended family. She had come to recognize that asshe increasingly gave voice to her feelings, she felt peripheralized asan excessive worrier, a “mother hen,” in a culture characterized by acasual but somewhat implacable denial of danger and distress and ahumorous disregard for anyone who was frightened or who visiblyemoted. The mother seemed unable to sustain her position in theface of this attitude, lapsing into a kind of hapless posture, as if,Woody Allen-like, she was just being “neurotic.”This quality in Andy’s parents highlighted to me how much we as

analysts rely on parents to provide a context for our growing under-standing of their child. The idiosyncrasies of their own dynamics andthe dynamics of their relationship as it emerges willy-nilly in the con-sulting room, their reflections on their own psychologies and theirpersonal histories, their complaints about each other or their child,their blind spots, kindnesses, and cruelties accrue in our experienceof the parents and facilitate our capacity to understand our patient’sexperience. In meeting with parents, I am often aware of a process ofidentification with my child patient, which emerges as a reverie aboutwhat it feels like to be both the present-day child and the very younginfant of these people: what are the rituals of interaction, the sharedassumptions, the unspoken expectations about engagement, the“ease and continuity” of on-going experience (Pine 1982)?Parents’ transparency in terms of their representation of them-

selves, their relationship, and the portrait of their child that developsin the course of the work reflects their willingness to openly engagewith the analyst in helping their child; to some extent this corre-

224 Karen Gilmore

sponds to their own self-reflective capacity, as well as to the particu-larities of their individual dynamics and psychopathology. As sug-gested above, the parents’ own “reflective function” has been ro-bustly linked to secure attachment (Main and Hesse 2000) and to thechild’s capacity to experience his drives and affects as mental con-tents (Lecours and Brouchard 1997) and to maintain a “theory ofmind.” Andy’s parents’ opacity adumbrated the powerful interfer-ence within the analysis, that is, the absence of the medium of play.Work with the parents over the course of Andy’s treatment involved aprocess of establishing an arena of communication which capitalizedon their considerable intellect and investment in his cognitive devel-opment. For example, at one point, his mother observed that she wasable to reinvigorate his father’s commitment to the treatment by re-minding him of how much Andy’s fine motor skills had improved,presumably because we drew together.Early in our relationship, Andy announced: “I’m an oxymoron,”

proof of which, he suggested, was his “wish to die, while everyonewanted just the opposite” for him. He then proceeded to demon-strate his global determination to “do the opposite”; for example, heinsisted that any activity he agreed to participate in must be done left-handed and claimed to be left-handed, which he is not. He did notplay and he seemed most emphatically unwilling to talk, even aboutthe mundane facts of his life. When I tried to explore any topic, espe-cially one that bore on him and his mind, he would silence me by say-ing, “Stop talking, I’m trying to think . . .” and then, after multiplefalse starts that seemed to lack specific content, he insisted that hecouldn’t explain what he was thinking and besides, “you wouldn’t un-derstand.” He spat surreptitiously into the garbage can. He at-tempted some drawing and coloring, but in such microscopic dimen-sions that he became agitated and inconsolable as his attemptsproved unsatisfactory. On other occasions he would simply standstock-still and stare at the clock. Even after Andy settled into the rou-tine of treatment, he consistently began our sessions by flopping him-self upside down on a chair or floor cushion with his buttocks in theair facing me, a posture I have suggested is his “opposite” way of de-claring that I’m the “butt-face.” While this behavior ultimately yieldedto interpretation, there is no doubt that Andy relied on oppositional-ity as a defense against the variety of encroachments that beset himwhen he first presented and which continued to threaten his tenuousnarcissistic balance, among which I include myself. But as his opposi-tionality alternated with a worrisome potential for compliance, alsoexpressed in presenting his butt submissively to me, I recognized the


polar manifestations of his oppositional defense against exposure ofa poorly developed sense of self, a threatened sense of agency and apersonal agenda that is organized primarily around maintaining hisfragile narcissistic balance. Andy relied on the other as a form to sub-mit to, to mold to, or to repulse, but he could not seem to use theother for mutuality and progressive development. He repeatedly re-treated from the establishment of mutual engagement and, despitehis considerable intelligence and verbal agility, he shrank from theopportunity to establish better internal regulation through bringinghis experiences under the modulating influence of metaphoricaland/or verbal symbolization in playing, an activity that is, of course,the sine qua non of child analysis.Andy’s resistance during this introductory phase reached a peak of

anguish and despondency when he spent a session wedged into thesmall entry hall of the office, refusing to go farther and bellowing forhis mother who was sitting in the waiting room 10 feet away. His non-stop screaming brought the neighbors to my door in alarm! Whenhis mother repeated, “Andy, just come in here, I’m here waiting foryou,” he finally replied, “Something in me wants to do that, but an-other part says I can’t after all this; I won’t let me.” What more vividdemonstration of his sense of aloneness and his inability to make useof his mother in his struggle with affects! This episode came to epito-mize for me the great divide between Andy and his mother aroundthe communication and translation of overwhelming emotion intomanageable experience. It also illuminated how his oppositionalityhad hardened within the breach into a monument of stony isolation.The assessment period did not auger well for analytic work: in-

deed, it seemed to me as if he had come to experience everythingcoming from a supposedly helpful person as a poisonous, murder-ous, or disintegrating intrusion; understandably, he was desperate torefuse and resist. One issue seemed obvious: Andy deeply resentedand was determined to expel the hated medication and the implica-tion of severe disturbance that he read into it and that it seemed tohave the power to create. In this initial phase of the treatment then,my goal was to “listen” to Andy’s action and find a better solution tohis medication problem. While not perfect, a marked improvementwas achieved by changing his stimulant and adding an SSRI, since hisagitation seemed driven by anxiety and despondency, although it re-mained unclear whether I was medicating an iatrogenic or endoge-nous 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

226 Karen Gilmore

inner life. When he told me in response to a question, that hecouldn’t talk about certain things with me “yet” because he didn’tknow me well, I felt more optimistic, because such a statement im-plied a less rigid and guarded stance and supported the hope that hemight be able to feel safe with me. But he remained aimless and pro-foundly impaired in his capacity to play. It was not that his play wasprimitive, perseverative, stereotypic, chaotic, or lacked key features,such as characterizations and narratives, upon which the dynamicchild clinician typically depends in order to diagnose, explore con-flict, and analyze. It was not that he relied on the typical rote play ofthe well-defended latency child. He only very rarely resorted to theuse of prepackaged games, board games or cards, and mostly at myinstigation; those moments were, with Andy, treasured opportunitiesto view his management of competitive feelings. But they were fewand far between. In most sessions, Andy just seemed stymied, unableto 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 offmedication as the summer approached so that we could reassessAndy without the distorting effect of both the stimulant and theSSRI. After the medications were removed and with an increased fre-quency of sessions that I proposed as a trial, my experience of Andycontinued to be curiously blank, as if I were in the company of ahighly mobile, courteous spinning top. The Andy that graduallyemerged was manifestly far less disturbed, dysphoric, and remote butremained unable to generate any play. Andy seemed to acquiesce toour sessions and his self-described “oxymoronic” behavior, with its re-flexive oppositional stance, abated; the only hint of oppositional feel-ing remaining was in his momentary hesitation in putting down hisbook in the waiting room when I beckoned him into the playroom.When I addressed this whisper of resentment, he seemed eager tospare my feelings and to attribute his reluctance to his absorption inreading. 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 youaren’t so happy to be here” worried him.It was as if both of us had to be affect-neutral to maintain Andy’s

equilibrium. In general, despite his earlier presentation, Andyseemed exceedingly careful and polite, quickly undoing the rare andminimal expressions of anger or hostility by his characteristic phrase,“I’m only kidding.” Whereas the Andy of the past seemed to definehimself by anger, refusal, and resistance, the Andy of the present, ap-parently divested of oppositionality, seemed shapeless and aimless,


with little or no affective expression. Once in the playroom, he wouldrock on the rocking chair, wheel about on the wheeled chair, or jumpfree-form about the room, often colliding into various projects ofother children but without a discernable intent to destroy, usuallyquite apparent in the palpable rivalries of our child patients. Thecontent of the hours was almost impossible to recount; there was con-versation but the evolution of themes that could knit our work to-gether was curiously absent. Moreover, the atmosphere in the ses-sions, formerly distinguished by passionate refusal, frustration, anddespondency, was now curiously flat. The dramatic opening presen-tation of desperate expulsion of poisonous intrusions gave way to animplicit demand for me to fill him up and enliven him. He said withsome resentment that since I did not “give him ideas,” I was of novalue as a playmate. My presence did not even promise the simple ad-vantage of a compliant other “at his service,” i.e. with no play agendabut Andy’s own. Indeed by not providing a play agenda, I denied himthe necessary borrowed scaffolding (or content) for what Andycalled “playing” to take place.While I did not minimize the potentially inhibiting impact of my

“other” agenda, that of knowing him, developing a relationship withhim, and in this way, gaining understanding for both of us, I came tofeel that the apparent paucity of internal resources was pervasive inAndy’s experience. It often found expression in his lament that myplayroom (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 Andymanifested had colonized my mind. I had the demoralizing impres-sion that I had no ideas about him dynamically, I had no insights orhunches; I began to feel that I complained about his not playing withme 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 antidepressantmedication, he did not appear grossly inhibited in any obvious way,he did not appear chaotic, he was no longer adamantly oppositionaland resistant, and he was able to play with peers when they provideddirection. For example, he reported great enjoyment of role-playing-games (RPG’s) but said he was a poor “dungeon master” (i.e. hecould not direct the play) and was therefore unable to import suchplay into our sessions. At home, his “play” consisted almost exclu-sively of video and computer games whose complex story lines hewould “borrow” on rare occasions, in order to attempt an RPG withme. 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 daywas taken up the next; there was none of the often preemptory driv-enness of the child patient who is playing out important thematicconflicts in displacement, who comes in knowing just where the playleft off and easily reestablishes continuity.Andy returned to school without any medication and when 4

months later, Strattera, a new non-stimulant ADHD medication, wasfinally introduced, his parents and I agreed to try it. I hoped thatAndy would accept this medicine because it had an initial sedativeeffect and could provide relief for his chronic sleep onset insom-nia. Overall, on a relatively low dose of Strattera, Andy’s insomnia,marked hyperkinesis, and restlessness improved; moreover, the Strat-tera seemed to have little effect on Andy’s conscious experience, andtherefore did not generate the same resistant response that he wasable to mount to the stimulants. Nonetheless he told me some timelater that while he appreciated the improved sleep, he didn’t like theidea of medicine, whether he actually noticed it or not.Andy’s progress in the past two years of treatment has been consid-

erable, with a dramatic cessation of disruptive meltdowns, improve-ment in frustration tolerance and in overall functioning. But the ana-lytic relationship continues to feel to him like a judgment of“abnormality” and a deprivation because I do not provide “ideas” forplay and do not assert my personal agenda beyond the attempt toknow him.I began to think about Andy’s quality of relatedness, his transfer-

ence in the broad sense, and to consider how rarely I experienced in-tersubjectivity (Birch 1997) or even a sense of his desire for joint vi-sual attention (Scaife and Bruner 1975), that typical developmentalmarker of the infant who is just beginning to appreciate the idea thatmother’s mind differs from his own and must be actively engaged. Inthe assessment period, he frequently responded to my interest inwhat was on his mind as if I were, like the intrusive medication, tryingto disrupt his control of his thoughts. While this seemed to improveto the extent that he did not forcibly attempt to silence me, he wasunable to generate any activity where we engaged in mutual discov-ery and elaboration of meaning. Often, when he engaged in somemotor task like tracing a picture, I would realize that he had gradu-ally turned his back to me. Other activities he proposed, often in re-sponse to my observation of his disengagement, were attempts totrick me, by definition an avoidance of a shared mental state. With-out my intervention, Andy most readily lapsed into his default posi-tion, his “tuning out” state of mind, a state as closed to introspection


as it was to my inspection, but which protected him from any experi-ence of interpersonal desire or vulnerability. I regularly observedAndy’s use of this “tuning out” to slip into an ego-state unavailablefor communication and intersubjectivity; at times this appeared as avisible shift in his attention which in some children marks the intru-sion of inner fantasy or preoccupation. While I initially approachedthese “disappearances” with the confidence that he was internally oc-cupied, I came to realize that Andy’s access to his inner life was alsocompromised; he described a frustrated, stymied feeling, a sense ofpressure, and an absence of specific content. Andy certainly was noteager to engage in an open communication with me, but this was atleast in part because he simply did not have the tools to do so. In or-der to even establish contact I had to break through his self-absorbedinwardness with my increasingly plaintive refrain, “Play with me!”Over time, I was able to show Andy how he made me the left-out littleone in this passive to active enactment where I was yearning to makecontact with someone so withdrawn or preoccupied that I was quiteunnoticed. I could also sample the frustration and anger that this ne-glect engendered. While Andy concurred with the “fact” of this con-nection by saying, “My parents never play with me; that’s why I don’tknow 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 ear-lier, he interpreted any sign of intensity in me with alarm and did hisbest to neutralize his own emotions. Only unmodulated disruptive af-fects (Lecours and Bouchard 1997) could force themselves into fullexpression, as in his so-called “melt-downs,” those inarticulate cha-otic tantrums, which at this point were rare events and hardly ever oc-curred in my view. Affects that were better contained and potentiallyverbalizable were apparently experienced as intolerably demeaning,and were vigorously disavowed. I was struck over and over again byAndy’s effort to be objective and to eschew the range of emotion thatmost people experience. In fact, in the treatment relationship, hismirroring my neutrality was far more successful than my capacity tomaintain it! In one session, I recalled his apparent willingness to bewildly 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 havetwo ‘big emotions’: frustration and embarrassment.”Andy’s 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 rangeof affect and it exacerbated Andy’s constitutional difficulties with af-fect-regulation and the integration of affect into his self-representa-tion. Certainly Andy experienced many other feelings, some of themquite obvious to me, such as anxiety, pride, jealousy, hurt, and loneli-ness, to name a few, but he vigorously and elaborately denied thesefeelings, as if they diminished him. For example, he struggled to dis-guise his visible deflation upon losing a game and with somewhat lessdetermination, tried to subdue his joy upon winning. He insistedthat his brother shared everything with him and therefore nevermade him feel envious or excluded in the blatantly contradictorycontext of a reported meltdown on his brother’s birthday. Despitemy first-hand knowledge of his rages, he undid even the mildest hos-tility by the “I’m only kidding” mantra, and denied his anger in mo-ments when he was clearly angry; he far preferred a victimized pos-ture which he seemed to willingly embrace. He even denied curiosityabout sex, certainly not atypical of his age group, but increasinglynoteworthy as his peers showed more excited interest from which heanxiously retreated.It became apparent that Andy’s urgent need to be “an oxymoron,”

that is, an original, also contributed to this disavowal of feelings, andfurther impeded his capacity to name them and understand them;his ideal was a caricature of his father who was so remarkably unflap-pable. The same narcissistic pressure impeded verbalization andthought in other arenas. Its impact in regard to his academic perfor-mance was onerous, because he was unable to rest until he was sureof producing work that was extraordinary. His parents reported thatany time something “special” was called for at school, even some-thing as banal as an “interesting sentence” using a new spelling word,Andy would fall into an anxious and paralyzed state that extendedthe activity for hours. While he demanded his parent’s presence inthese struggles, he could not use them to “brainstorm,” since any in-put from others immediately threatened his originality. The fragilityof his ideas and of his sense of ownership of them was so great thatAndy could not use an adult’s mind as scaffolding for his own inven-tion.Over the course of the work, the global disavowal of ordinary emo-

tions in his transaction with the world outside the office gradually re-mitted as I strenuously addressed his defense and linked his alteredstate to his denial and fear of emotion. Andy’s capacity for sophisti-cated humor was a great asset here, as he could tolerate my musingsabout his extraordinary absence of feelings and what I, a mere mor-


tal, might feel in his shoes. As I examined the responses he tried toelicit in me by his remarkable “absence in my presence,” he was ableto identify and admit to more feelings and more nuance of feelings.The intensity of his competitive dynamic, wherein his aggressive wishto triumph and lord it over his opponent was in perpetual strugglewith his anxiety about maintaining the relationship and consequentsubmissiveness, was clearly present in this struggle with me over af-fect expression, and we were gradually able to recognize it in relationto a range of narcissistic and oedipal conflicts. I was also able to sug-gest my dynamic hypothesis about the premium placed on affect-neutrality as representing Andy’s identification with his father and aposition 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; in-stead, he would transpose his feelings of loss and/or anxiety into a di-atribe about treatment, my lack of forthrightness about myself, andthe implicit accusation of “abnormality” that the treatment com-prised. It was almost as if Andy intuited that a transference com-plaint, no matter how stereotypic, would lure me away from seeingthe hot spot where he was acutely suffering at that moment; he thussubstituted friction with me to indirectly achieve his shameful wishfor closeness, a pattern demonstrated outside of the treatment in hisrelationships with his mother and brother. For example, on one oc-casion, I addressed his palpable suffering while his brother was atcamp and his parents were traveling for work. It was clear to me thatAndy was enduring even greater loneliness than usual. He adamantlydenied my observation and attributed his tears to his frustration athaving to see me so often. This was all the more striking because ourschedule had been disrupted by his day camp and we had met onlyonce that week. On another occasion, when he was bereft at thepainful yearly change of au pair, he shifted way from acknowledginghis loss and resumed his litany of reproaches to me. In one fascinat-ing hour when Andy (I fear accurately) read my attempts to connectas a critical complaint, he said with considerable bitterness, that infact, he was with me just like I was with him: “You don’t give yourideas, so I won’t give mine. You see as much of me as I see of you. Ifyou don’t tell me anything about you and if you don’t start anything,if you don’t show your feelings, why should I?” Here again his opposi-tionality seemed pronounced, taking the form of an imitativepseudo-analytic stance; but I sensed behind that a painful sense ofdeficiency and a deep narcissistic wound created by our differing sta-tus in the treatment and his conflicted wish that I love him and pur-

232 Karen Gilmore

sue him. The transference meanings of his complaint, i.e. its historyin his relationship to his father, was less available than its defensivefunction in the here and now. I had ample opportunity to see thatthis posture protected him against the frightening feeling that hecouldn’t think of anything, that his thoughts and intentions seemedto drift out of his mind, that his attempts at creativity were strainedand empty, and that he was just an ordinary sad and lonely kid, andtherefore unlovable. Not unexpectedly, these rare moments of openlyexpressed resentment toward me, which of course were at once dis-placements of painful states experienced in relation to others, ex-pressions of on-going transference themes, and a way to engage withme and keep me at a distance all at once, were typically followed by arapprochement which was certainly motivated in part by guilt andanxiety. When I observed once more how difficult it was for him totalk about feelings with me and to feel comfortable having feelingsabout me, he said with great poignancy,

One is the loneliest number that you’ll ever do(But) Two can be as bad as one,It’s the loneliest number since the number one.

(From “One,” by Three Dog Night)

Without the precious medium of the playing state, it is a challengeindeed to represent these many layered issues to such a child in a waythat usefully examines his oedipal and sibling rivalries, narcissistic in-jury, and shameful sense of inadequacy, while recognizing his realdisabilities arising from his maturational unevenness as well as theirrole in his developmental lag in tolerance of intersubjectivity and af-fective expression.

Discussion

While the psychoanalytic view of play acknowledges its importance inthe elucidation of the child’s inner world and mental conflicts in thetreatment, 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 prac-tice gender roles, to master developmental challenges and personaltrauma, to overcome helplessness, to modulate drive derivatives, andso on. A child who does not play is not only manifesting a symptom,he is suffering from an on-going developmental handicap that haswidespread reverberations. The ability to play is a developmentally


determined capacity with strong biological foundations serving arange of social, interpersonal, and intrapsychic functions, and ob-servable in the young of all human cultures, mammals, and birds(Friedman and Downey 2000). Although my intention here is not toiterate the mental building blocks of this complex function, I drawyour 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 toirrational fantasy content, the displacement in the service of the ego,the willing suspension of a number of ego and superego functionssuch as reality testing, critical self-consciousness and censorship, theassociated tolerance of otherwise unacceptable impulses and affects,and, of course, the array of cognitive and motor capacities requiredto enact the roles or manipulate the props of the play. These featuresdiffer in prominence and amplitude depending on the developmen-tal phase and the psychology of the individual child.In emphasizing the crucial and ubiquitous development-promot-

ing features of the capacity to play, I believe that the many excellentpsychoanalytic contributions on the subject have underemphasizedthe unique nature of play in the psychoanalytic setting. Just as Lewin(1955) observed that there are several types of free association de-pending on the context and intention, so there are differences inplay from one setting to another; the play with a peer, the play with aparent, and the play of the child alone all share many features butdiffer from playing with the analyst, in that the latter is a communica-tion and an invitation into the child’s subjective experience ad-dressed to a person whose declared goal is to learn about that worldfor the purpose of understanding and helping the child to under-stand himself. While this circumstance may bear complex relation-ships to transference and resistance, it exists as fundamental premisein any session in which the child is playing. As child clinicians wellknow, there are some children who play in life but refuse, for brief orsustained periods, to play in our playrooms, and some children whoplay nowhere but with the analyst. These variations reflect the child’sposture toward the threshold of engagement with the analyst, vari-ously understood to be affected by disturbances in attachment his-tory, oppositionality and overt resistance, profound narcissistic vul-nerability, shame, or superego severity. But the child’s capacity toplay with the analyst also reflects his freedom to achieve, in the pres-ence of his particular analyst, a state of playing that is intrinsic tosome of its components but is more than the sum of those parts; it isan altered state of consciousness (Birch 1997) with a much closer re-lationship to unconscious mentation, more like the secondary elabo-

234 Karen Gilmore

ration of a dream with a less exacting requirement for logic and real-ity, even in latency-age children fully capable of concrete operationalthought. Moreover, this state is more or less porous to the analyst’splaying participation, as the child dictates how much input the ana-lyst is permitted, and the analyst assumes a playing state informed byher growing knowledge of the patient and her appreciation of theboundaries of play in its interface with direct expression of drive de-rivatives and consequential action. Inevitably, the analyst’s play stateis also informed by her own unconscious mentation and her counter-transference toward the particular patient. The resilience and stabil-ity of the playing state are unique to the individual child and his rela-tionship to the specific analyst, because once the state of playing isproduced in the treatment it becomes an intersubjective mediumwith its own conventions and its objects, whose historical meaningsare gradually transformed as they become incorporated into the his-tory of this new relationship, just as transference paradigms and his-torical memories show plasticity and evolution in the course of adultanalysis (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), thetransformation that child analysis facilitates and which the child pa-tient anticipates, is achieved primarily through verbalization while in thestate of playing. Child analytic literature certainly abounds with clini-cal reports where a significant therapeutic benefit is gained by the fa-cilitation of previously inhibited or chaotic playing without explicitinterpretation of conflict (Birch 1997, Mayes and Cohen 1993, Slade1994). Nonetheless, in all such instances, the analyst’s verbalizationsare a central, transforming element, much like the mother’s transfor-mation of the infant’s chaotic experience into discrete affects, recog-nizable self-states, and familiar interpersonal exchange by her nam-ing and dialogical prosody. As Rizzuto (2003) declared in a recentpaper on the transformation of self-experience in adult treatment,“Analysis is the second instance in life in which another person tries per-sistently to ascertain the internal experiences and needs of the sub-ject by naming, describing and interpreting them with his or her ownspeech.” (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 co-herent, disavowed self-representations are clarified and modified topermit reintegration, nameless and disorganizing anxieties are namedand organized, and dissociated self-states are open to contact both


intrapsychically and interpersonally through the analyst’s participa-tion and verbalizations within the state of playing.

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238 Karen Gilmore

Psychoanalysis AsCognitive Remediation

Dynamic and Vygotskian Perspectivesin the Analysis of an

Early Adolescent Dyslexic Girl

LISSA WEINSTEIN, Ph.D., andLAURENCE SAUL, M.D.

The interface of neurocognitive problems and dynamic concerns areexamined in the treatment of an early adolescent dyslexic girl. Despiteprevious intensive remediation, she had been unable to master readingand spelling, but made remarkable progress after a relatively brief pe-riod of psychoanalysis. Psychoanalytic and Vygotskian perspectives areintegrated to provide a model of how play, within the analytic context,is mutative for learning disabled children. Through the process of re-exteriorization in the transference, play allows for the interpretationand resolution of traumatic situations which have become associated

Dr. Weinstein is an Assistant Professor in the Clinical Psychology doctoral programof the City University of New York, lecturer on the faculty of the Columbia Center forPsychoanalytic Research and Training, and a graduate of the New York Psychoana-lytic Institute. Dr. Saul is a Clinical Instructor in Psychiatry at the Weill Medical Col-lege of Cornell University and an Attending Psychiatrist at New York PresbyterianHospital. He is a faculty member of the Columbia Center for Psychoanalytic Researchand 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 Develop-ment,” sponsored by the Association for Psychoanalytic Medicine.


239

with learning. As the act of learning becomes separate from the per-sonal and affective context in which it took place, the child gains ac-cess to other, more normative, functions of play. These functions in-clude the development of the capacity to separate meaning from actionand the ability to understand words as generalized categories whichrepresent objects, rather than being part of the specific object named.These two capacities, fundamental to the development of abstractthought, will support reflective awareness and help modulate affectivestates. The abilities furthered in play also act to remediate one compo-nent of dyslexia—the difficulty separating context from more abstractbits of knowledge. Finally, the child learns to “play at reality,” oftentrying on the new role of “student.” As Vygotsky notes, play is essentialin allowing the child to become aware of what she knows. For a dyslexicchild, for whom reading may never become completely a part of proce-dural memory, becoming conscious of what he knows may also en-hance mastery of the skills of phonological processing, albeit moreslowly than normally developing readers. The pleasure in play and therepetition it generates aids the internalization of the task and the de-velopment of automaticity.

Introduction

the emotional problems of learning disabled children oftenbring them to psychoanalytic treatment, and in recent years the viewthat analysis is not the treatment of choice for children with neu-rocognitive 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 na-ture of the neurocogntive problems, eventuating in a hodgepodge ofdiagnoses lumped under the rubric of learning disabilities, eventhough the factors that make analysis helpful to children with lan-guage based learning problems may be quite different from themechanisms that are mutative for children whose problems in pro-cessing perceptual stimuli form the core of their difficulties (Rourke,1985). Lacking a clear rationale for why analysis might be helpful, itbecomes impossible to evaluate the necessity for any changes in tech-nique. With few exceptions (e.g. Cohen & Solnit, 1993), papers focuson the affective difficulties rather than the manner in which analysisalters or enhances ego functions which support learning.The current paper examines the interface of neurocognitive prob-

lems and dynamic concerns in the analysis of an early adolescentdyslexic girl and tries to specify those aspects in the analytic context

240 Lissa Weinstein and Laurence Saul

which were mutative. Developmental dyslexia, the most commonneurobehavioral disorder affecting children, seems an ideal startingpoint for a discussion of the interactions of neurocognition, dynam-ics and development, because its organic basis is clearly demon-strated by significant differences in the temporo-parieto-occiptal brainregions between people with dyslexia and those who are not readingimpaired (McCandless & Noble, 2003; Shaywitz, 2003).Natalie was 12¹⁄₂ years old when she was referred for psychoanalysis

to address long standing disturbances in her sense of self and otherswhich stemmed from her learning difficulties and traumatic history.No effort will be made to examine the entire complex of dynamicfactors in her analysis; nor is it our intention to present an “ideal” an-alytic treatment, as a rocky course may be inevitable in the treatmentof learning disabled children (Rothstein & Glenn, 1998). Instead,the focus of examination will be one curious fact—despite intensivecognitive remediation prior to beginning analysis, Natalie continuedto have difficulties with spelling, reading, and school performance.After a relatively brief period of analytic treatment, she was increas-ingly able to access reading and spelling skills that everyone had as-sumed she did not possess. Natalie made this remarkable progressdespite 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 documentthe nature of Natalie’s early speech and language delays and herlearning problems in order to support the diagnosis of specific read-ing disability before attempting to articulate Natalie’s unconscious as-sociations to her dyslexia as they emerged in the transference. In thediscussion, a multifactor model is proposed to explain how psycho-analysis, a treatment not directed at cognitive change, can enhancethe capacity to learn even in cases of clearly documented neurologi-cally based deficits. The necessity for the interpretation of uncon-scious conflict is integrated with the work of Lev Vygotsky, a Russianconstructivist thinker and early member of the Russian Psychoanalyticsociety, who noted play’s dual role in helping the child to restructurecognition and embrace the constraints of reality.

Review of the Literature

The psychoanalytic theory of play has focused heavily on content andwhy only certain events (often unpleasant ones) are chosen for re-production. Relying on Freud’s (1918) notion of the repetition com-pulsion as a way to bind traumatic overstimulation, Waelder (1933),defining trauma operationally as “an onslaught of more events in a

Psychoanalysis As Cognitive Remediation 241

relatively brief period of time than the immature ego can handle,”suggested that children, being passive, must suffer experiences thatthey cannot absorb and which they attempt to master through repeti-tion. In addition to the disappointments of reality, play also helps thechild cope with trauma generated internally, either by the upsurgesof the drives or via the heightened pressures of the superego. Playaids mastery by turning passive to active. It allows the child to alterthe outcome of the experience or to change his role. Rather than asuffering victim or an anxious onlooker, the child can instead be aworld creator. In addition, the reenactment of an experience in itselfconstitutes a switch from passive to active. The observed repetitionsin play allow for the fact that the child’s weak ego can master realityonly a little bit at a time and are necessitated by the child’s limited ca-pacity for verbalization and his inability to link thoughts togetherthrough cognitive work. The actual play is a compromise formation.By offering the most satisfying solution between the desire for plea-sure, the demands of reality, and the conscience, play strives to makeup for anxieties and deficiencies at a minimum risk of danger. Al-though 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 shapingplay. Winnicott’s (1974) notion of transitional space also suggests arole for play in the structuring of external and internal reality in ad-dition to the interpretation of play which focuses on meaning. Morerecently, theorists have noted the contribution of play in the creationof new representations, suggesting that play in itself acts as a force ingetting development back on track (Mayes & Cohen, 1993; Neu-bauer, 1993; Scott, 1998; Slade, 1994). Although this structuring roleof play has been noted particularly in children with ego deficits (Co-hen & Solnit, 1993), cognition and its relationship to play has beenlargely ignored in the psychoanalytic literature with only a few excep-tions (e.g. Santstefano, 1978)

Case Presentation

presenting problem

Natalie’s mother sought psychological testing at age 12 years and twomonths because of Natalie’s worsening irritable, withdrawn, and ag-gressive behavior both at home and at school. Natalie frequentlyscreamed, cried, hit, and kicked. She directed these outbursts mainlyat her sister, who was 3 years her junior, but also at her parents and


peers. Shortly prior to the start of treatment, Natalie threw a butcherknife toward her sister, missing her. Natalie’s interactions with herpeers at school, although far less dramatic, provoked them into an-tagonizing and ostracizing her. Testing resulted in a recommenda-tion for psychoanalysis. Natalie was highly opposed to psychophar-macological intervention.

developmental history

Natalie was the product of a planned, uncomplicated pregnancy withan induced delivery at 41 weeks that required forceps. Fine and grossmotor milestones were within normal limits, but there was a notabledelay in language. Natalie did not speak her first words until 18months or speak in full sentences until 4 years of age. Speech therapywas begun at 4 years and continued until she was 11. From early inchildhood, Natalie struggled with articulating her thoughts and feel-ings and she was described as a highly anxious child who was needyof her mother’s attention. Psychological testing at age 8 years, initi-ated because of her distress over not reading, led to transfer to a spe-cialized school for learning disabled youngsters. Medical history wassignificant only for seasonal environmental allergies. Menarche wasat age 11 years and 10 months.Two weeks after Natalie’s birth, Natalie’s mother returned to her

career full time. Natalie’s paternal grandmother moved from East-ern Europe to become Natalie’s primary caretaker, as her mother of-ten did not arrive home until 10:00 p.m. This non-English speakingwoman was stern and cold but reliable.Natalie’s father was also a constant presence. Although highly in-

telligent, he was an alcoholic who was unable to keep a job. Particu-larly close with Natalie, her father read her Greek mythology andstudied American Civil War tactics and strategy with her. Natalie fre-quently witnessed her father vomiting and passing out in a drunkenstupor. She also regularly witnessed verbally and physically violent al-tercations between her parents. Once, when Natalie was 7 years old,her father lay down in front of his family, held a steak knife to histhroat, and threatened to kill himself. Natalie saw her mother sus-tain a fractured arm and, at another point, a subdural hemorrhagefrom father’s beatings. Father also frequently exhibited bruises hiswife had inflicted on him. Natalie’s sister attempted to break up thebattles by getting physically between her parents while Natalie, insharp contrast, would run to her room and remain under her bedcovers.


When Natalie was 11 years old, her mother had the police removeNatalie’s intoxicated father and placed an order of protectionagainst him because of verbal threats. Natalie never asked to see him.Visitations were started 6 months later because Natalie’s sister re-quested to see him, and visitations continued sporadically. A fewmonths after Natalie’s father was removed from the home, Natalie’spaternal grandmother died. Therefore, she suffered two major lossessimultaneously. These apparent precipitants closely preceded Na-talie’s increasingly withdrawn, intermittently violent, and hypersensi-tive behavior which led to her mother seeking help.

psychological testing

Several evaluations provided ample evidence for the diagnosis of de-velopmental dyslexia. An educational evaluation completed at age 8demonstrated receptive and expressive linguistic difficulties ratherthan oromotor problems. Natalie failed to initiate a lot of language,had trouble sequencing her thoughts, and had difficulty with wordretrieval and naming. Phonological processing was impaired. Thisskill (the ability to hear and sequence the sounds within words) is thecentral deficit found in reading disorders (Morris et al., 1998; Shay-witz, 2003). Natalie had poor auditory discrimination, could notidentify medial vowel sounds, and had poor memory for phonemes.While she needed the scaffolding provided by a listener in order toorganize her thoughts, the more object related and para-verbal as-pects of communicative language (prosody, eye contact, and turntaking) were intact. In sum, Natalie met the criteria for double deficitdyslexia (Wolfe, 1999), a term used to identify children who showproblems in both rapid automatized naming and phonological pro-cessing, 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 adyslexic child of average to high average intelligence, with a fairly fo-calized language disorder. The WISC III yielded a Full Scale IQ of103, with a Verbal IQ of 106, and a Performance IQ of 99.The subtest scores were as follows:

Verbal Scale Performance ScaleInformation 11 Picture Completion 10Similarities 10 Picture Arrangement 14Arithmetic 12 Block Design 11Vocabulary 12 Object Assembly 9Comprehension 10 Coding 5Digit Span 7


Despite the apparent evenness of the major subscale scores, therewas considerable variability amongst her abilities. While verbal skillsranged from the average to high average, visual perceptual and visualspatial performance skills varied from a defective performance on atask of cross modal integration to a very superior performance on atask where she has to sequence cartoon pictures of interpersonal in-teractions. Thus, Natalie’s ability to understand the motivationalstates of others, as well as to process complex perceptual material wasintact.In structured settings, Natalie’s oral language was not impaired.

Voice quality, pitch rate, volume, and fluency were within normal lim-its. Natalie’s ability to follow complex multipart directions werewithin the average range and her lexicon, as measured by her abilityto form word classes, was average. She had no trouble processing se-mantic relationships and was able to answer questions about para-graphs that had been read to her. Tests of reasoning and problemsolving were in the superior range. Informal assessments of oral ex-pression were deemed normal for her age.Reading/decoding skills were several grade levels below average,

as was mathematical computation, a finding compatible with a diag-nosis of dyslexia as computations (unlike mathematical concepts) of-ten tap semantic/linguistic abilities rather than the visual-spatialskills. Reading comprehension was above grade level, suggesting thatthe act of decoding was what barred the way to comprehension intimed settings. The qualitative nature of Natalie’s performance, hertendency to misread or skip small function words (such as the, was, orbut) which are not directly representational, also spoke to the pres-ence of a developmental reading disorder. A writing sample showed adifficulty using vowel sounds, poor punctuation, poor sequencing ofsounds within words (“breath day” for birth day), and omission ofsounds (“presten” for present). In short, the testing provided strongevidence of classic dyslexia with problems in decoding, spelling, andwritten expression.Natalie’s functioning was more compromised in ambiguous situa-

tions than in structured ones and her sparse, ten response Rorschachshowed her difficulty in mobilizing her cognitive equipment in newsituations. None of her responses involved a sophisticated integra-tion of the components. The lack of human movement responsessuggested that it was difficult for Natalie to utilize internalized im-ages of others which might serve as templates for behavior or sup-port her ability to delay her impulses. Instead, Natalie’s Rorschachresembled that of a much younger child with few content categories,


little ability to integrate her emotional responses to a situation with amore cognitive viewpoint, and a tendency to become emotionallyoverwhelmed and cognitively impaired in situations of stress.

course of treatment

Natalie began treatment at age 12¹⁄₂. Literally within the first few min-utes of treatment with her male analyst, Natalie introduced a trans-ference theme that would be continually elaborated throughout heranalysis: her need to maintain distance (particularly from men) inorder to feel safe. The early manifestation of this theme took placeprimarily in the behavioral realm: Natalie kept her coat on duringthe first session, claiming she didn’t want to see a psychoanalyst be-cause she had “other things [she] wanted to do . . . like kick boxing.”In a dramatic demonstration of her wish to be the aggressor, ratherthan a victim, Natalie punched her sister in the mouth on the wayhome from her second analytic session. Shifting identifications be-tween victim and victimizer reverberated in her fantasy life as well, asNatalie described a music video where men on strings were manipu-lated by a woman puppeteer and another video where a woman whotries to leave her boyfriend is beaten to death. The analyst tied thesetwo videos together, noting that “women better maintain control ofmen or they’ll end up dead.”Continuing her posture of “not getting involved” Natalie kept her

coat on for the first weeks of treatment, refusing to discuss “personalstuff.” Similarly, she isolated herself with peers, voicing a desire to beunique and different from the “boring popular crowd.” When speak-ing of her family, Natalie expressed both despair and a wish to re-main distant. For example, she claimed July fourth as a favorite holi-day because “the fireworks are like paint in the sky bursting, and youdon’t know what it’s going to look like.” This contrasted to all thefamily based holidays she hated like Thanksgiving, where “you justget a big stomach ache,” Christmas “where there’s so much pressureto get the right gift,” or the absolute worst holiday, Valentine’s Day,with its associated themes of love and kisses. Natalie then decidedthat she would write an article for the school newspaper entitled, “XValentine’s Day.” She added that she wanted to “X” dating, marriage,and having babies as well. Natalie agreed with the offered interpreta-tion 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. Inresponse to an observation that she didn’t like showing off, she


agreed that she preferred to blend into a crowd and did not like tobe closely observed, alluding to her fears of being seen in the analyticencounter. During sessions, turning passive to active, she would pullher hat over her head, turn away from the analyst, or even sleep. Na-talie alternated between attempts at contact and a need to lessen theamount of experienced stimulation through physical distance. Shechose to sit in the analyst’s swivel chair which allowed her to sit veryclose by him and quickly turn away when necessary. She alternatedbetween talking engagingly and playing catch or being by herself, re-maining silent for entire sessions during which she would refuse torespond, even to direct questions. Often, “silent” sessions followedones in which she had been particularly talkative. The analyst’s coun-tertransference responses illuminated the nature of the conflictsaroused. He felt relieved when Natalie talked and careful not to con-front her or her anger, as well as worried that he had caused her peri-ods of retreat by being too aggressive with his interpretations.That the highly charged feelings emerging in the treatment con-

tained sexual fantasies of seduction and pursuit was made clear whenafter 6 months in treatment, an analogous situation surfaced in Na-talie’s school life. She excitedly reported being “stalked” by two boysin her class. When the analyst wondered out loud whether the inci-dent might be flattering as well as scary, Natalie threw a ball harderand harder toward the analyst until it was impossible to catch. Theanalyst’s premature interpretation of Natalie’s underlying sexualwishes led to the fortification of her defensive strategies and a regres-sion to action where violent, castrating wishes were expressed di-rectly. In the following session, Natalie found a spare tie in the ana-lyst’s closet and put it around her own neck. Gleaming with pleasure,Natalie threatened to “cut the tie” in a highly condensed metaphori-cal statement which included elements of castration as well as her ef-forts to defend against her dependency. It is also noteworthy that inmoments of high affective intensity, words did not “hold” her and shequickly moved to highly symbolic and expressive actions to regulateher feelings. In addition to action, Natalie would also remove herselffrom the more passionate arena of verbal interaction and seek solacein 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 ex-

press an interest in acting. She performed Shakespeare soliloquiesfor her analyst and simultaneously blushed and smiled with pride atthe applause he would give. At this point, Natalie’s exhibitionistic de-sires were not interpreted. Rather, the analyst allowed Natalie to ex-


perience that wishes could be expressed and contained in the ana-lytic situation without dire consequences. This stance seemed to sup-port Natalie’s ability to tolerate previously disavowed affects.Several months later, at her beach club, Natalie began taking pho-

tographs of a 15-year-old boy she had a “crush” on. She then sold theprints for $5 each to girls at the art school where she was takingclasses during the week. The analyst, exclaimed, “Now, you’re doingthe stalking!” She brought in prints of this boy, drooled over them,and drew portrait after portrait of him. She was frustrated with thisboy’s lack of enthusiasm with her but was determined not to let thisfact get in the way of her talking and thinking about him incessantly.The analyst pointed out that it appeared as if it didn’t matter whatthis boy thought of Natalie. “You are the stalker. You are in control.”Natalie replied jokingly, “Hey, don’t spoil my fun.” While Natalie feltfreer to express her sexual and voyeuristic interest in a peer, she re-mained defended against recognition of any excitement about heranalyst.The reasons for this became obvious as Natalie’s experience of her-

self in relation to her father in particular and men in general contin-ued to be further elaborated in the analysis in the transference.Upon returning from a vacation, the analyst was asked by Natalie togo back to Iraq where she imagined he had been playing pool anddrinking beers with “your good friend Haddam Hussein . . . You’rebuddies.” The analyst said, “I guess you want to keep a safe distancefrom a dangerous, beer guzzling, take over the world kind of guy likeme.” In later sessions, she imagined the analyst was plotting with Hus-sein to blow up some countries. The analyst noted how untrustwor-thy and dangerous he seemed to her. Natalie responded. “You’re notHussein, you’re Barney,” referring to the goofy pre-school TV charac-ter who teaches the letters of the alphabet. He was too adorable andclearly inept: “Do you see purple dinosaurs on Wall Street or at adesk getting a fax?” Natalie quipped. It was at this juncture thatNatalie’s conflict around men being either dangerously abusive andexciting, or harmlessly castrated and ineffective crystallized in thetransference.In another variation upon this same theme, over a year into the

analysis, Natalie complained of being “stuck with ‘Mr. Tingle,’” amale version of a comedy movie character, Mrs. Tingle, a sadistichigh school teacher. Natalie went on to say that she felt “You’re pok-ing at me. Looking at me under a microscope.” The analyst said, “SoI’m the teacher from hell. Forcing you to talk about things you don’twant to.” Natalie retorted, “Yeah, Mr. Tingle, and I don’t want to!”


Natalie’s excitement became intolerable to her and she swiftly emas-culated 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 hisreputation as strict and demanding. The analyst noted that when hethought of a scary man for Natalie, her father came to mind. Natalieremarked, “I hate my father! But he’s not scary. He’s just a mo-ron . . .” The analyst replied, “In the same way that you call your fa-ther names, you’ve called me a few.” Natalie said, “Yea, Mr. Tingleand yea, Barney.” The analyst remarked, “There seems to be twosides to me for you, this scary teacher or this wimpy dinosaur.” Na-talie retorted, “You’re not scary, you’re just chubby. You’re a chubby,chubby man.” The analyst became acutely aware of feeling emascu-lated and pointed out, “So now you’re having more fun—at my ex-pense, of course—with me being chubby—the wimpy Barney side ofme.” Natalie laughed. The analyst further mused, “Perhaps you feelsafer around my possible scary side by turning me into a chubby andbumbling 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 hermother degraded her father. For example, while mother and daugh-ters went to a beach spot during summer weekends, mother had fa-ther do menial jobs for her like walk the dogs and clean the bathtubto earn money so that he could take out his daughters with themoney. Natalie got worked up thinking about how her “jackass fathercan’t even work at Barnes and Noble to help us out.” He’s a “good-for-nothing drunk.”As the historical roots of her bivalent attitudes toward her father

were becoming more conscious, Natalie’s mother reported that Na-talie was expressing a new desire for physical contact, affection, andcomfort. This contrasted sharply with her lifelong pattern of physicalavoidance, withdrawal, and difficulty being soothed. In school aswell, Natalie’s teacher reported that she was “blossoming,” with de-creasing moodiness and impulsivity, and a lessening tendency to pro-voke attacks from peers. Even more curious was her teacher’s reportthat Natalie was beginning to absorb academic material in a new way,given that scholastic performance had not been a focus of treatmentto date.As her fear and excitement about being with a man continued to

be evoked, tolerated, and addressed in the relatively calm context ofthe therapeutic relationship, a new aspect of Natalie’s relationship to


her father began to manifest in the transference. She started to usethe analyst as a teacher, albeit this time one who remained more sep-arate from the frightening aspects of her teacher/father. Shebrought schoolwork into the sessions, using the analyst as a home-work helper or stayed after sessions to complete her assignments inhis presence. She increasingly viewed the analyst as the nurturing fa-ther who read to her and acted as a comforting, organizing, andsoothing physical presence who would sit with her quietly observingwhile she worked. She asked to be quizzed on vocabulary words orgeographical locations. The studying was, of course, used to regulatethe comfortable space between her and the analyst, helping her todefend against awareness of sexual excitement by taking an activestance. However, it was a far more productive compromise formationthan merely keeping her coat on, as it incorporated elements of sub-limation and identification rather than just turning passive to active.It is equally important that the studying served the adaptive purposesof 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 be-gan actively examining being the “teacher” as well as the student. Shewould test her analyst, taking particular sadistic pleasure if he didn’tknow 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 otherchildren asked to be in her group, because she was the best speller.She was chosen to represent her class at 8th grade graduation by giv-ing the senior speech. At this point, (1¹⁄₂ years into treatment),Natalie did not hold back the excitement of her triumph at beingchosen and not only practiced the speech before her analyst, butwent into a blow by blow account of the audience responses. Nataliehad also gradually became quite comfortable in the transferencewith her desires to do the “looking.” Toward the end of treatment,over 2 years into the analysis, Natalie began to avidly use the analystas a model (primarily his hands) for her drafting class assignments.She acknowledged that this was a way of remembering her analyst. Inthis example, it is interesting that Natalie’s mode of internalizing theanalyst still involved a concrete representation, rather than the ana-lyst’s words or the function of reflection.However, Natalie also became increasingly able to symbolize and

take a reflective stance about her learning problems. In describingGeorge Orwell’s novel, Animal Farm, Natalie focused on Clover thehorse, “who had strong feelings but couldn’t figure out how to put


those feelings into words.” When her analyst made the analogy be-tween herself and Clover, she was able to say that problems learning“really suck.” While Natalie was able to voice these feelings after hav-ing some academic success, clearly her analysis had been instrumen-tal in making her educational interventions increasingly assessable.Natalie was accepted to several mainstream private schools and ul-

timately attended a competitive public school specialized for the arts.Natalie was very proud that she was one of the few students withlearning disabilities admitted. Because of financial difficulty, Na-talie’s mother requested that treatment be terminated after 2¹⁄₂

years. Natalie was thriving at school both academically and withpeers. Although there was certainly more analytic work to be donearound her conflicts with her mother and father, Natalie was devel-opmentally back on track. In the final weeks of analysis, Natalie re-quested that the analyst teach her how to play poker. This was plea-surable 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 sessionNatalie was an expert.At 12¹⁄₂ years of age, Natalie presented as a young adolescent with

affective symptomatology, an oppositional defiant disorder, learningproblems and a history of traumatic overstimulation. Her symptomsresulted from three interweaving factors: a biologically based learn-ing disorder and alterations in the timing of the maturation of herspeech and language, her chronically traumatic home life, and herentrance into adolescence. Exposed to a greater than normal degreeof aggressive stimulation, these traumatic experiences shaped theway she perceived herself and interacted in relationships, for exam-ple via identification with the aggressor, and placed considerablestrain on defenses already compromised by processing difficulties. Fi-nally adolescence, with its heightened drive pressure further in-creased the demands on her stressed ego resources.Natalie’s language difficulties affected her not only in school, but

throughout her development, making it harder for her to accesswords as a mediating force during critical periods (Migden, 1998).Offering new gratifications and connections, speech usually helpsthe child to master the waning symbiotic ties and the loss of the ac-companying feelings of omnipotence and safety. Conceptualizedthus, language is a central aspect of the separation process. For Na-talie, early separation from her mother resulted both in object loss aswell as the loss of an optimal linguistic environment because her En-glish exposure was curtailed when she was cared for by a non-English


speaking grandmother. In addition, without language, Natalie had amore limited array of impulse control mechanisms. Because shecould not interpolate words as a form of trial action, it was harder forher to distance from the immediacy of a situation (Lewis, 1977).Finally, Natalie’s 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 necessityfor an intimate relationship, slowed efforts at separation, and madethe repression of oedipal impulses more difficult. All these factorsmade it more likely that the autonomous functions (Hartmann,1954), in her case language and to a lesser degree perception, wouldbe drawn into conflict. Given these complicating factors in Natalie’sdevelopment, how are we to understand the helpfulness of psychoan-alytic intervention, particularly as it relates to her school perfor-mance?

Discussion

While developmental dyslexia can be conceptualized as a deficit(Winner, 2001), some children are able to make use of compen-satory strategies and others are not. Psychoanalysis, with its uniqueobservational vantage point on the question of motivation, poten-tially offers some answers that predictions based on the severity ofneurocognitive deficits alone cannot. As analysts, we learn the spe-cific connotations of the disability for the child by accessing the per-sonal landscape and its presuppositions—how events, whether exter-nal ones such as the behavior of caretakers or internal ones such asthe perception of bodily or intellectual processes, are woven into aweb of meaning, which then become: the starting point for furthercausalities. Analysis is a science of subjective experience, and howone interprets neurophysiological events is imperfectly correlatedwith the events themselves. Like A. R. Luria (1979), who chose to hu-manize and make whole the most puzzling of neuropsychological en-tities, psychoanalysts are engaged in a “romantic science” that seeksnot only to abstract general laws but to describe human ordinarinessin all its glory and detail. To base an understanding of a dyslexicchild solely on the delineation of the neural pathways that mediatethe reading process falls prey to the same misconceptions as thinkingthat internal representations are isomorphic copies of real externalevents. Events in the outer world and those in the internal environ-ment meld, with neurophysiology and the transactions around thedevelopmental crises of childhood mutually influencing each other


in a manner that is truly individual and not easily subject to regularlaws. While it is possible to argue that Natalie’s improvement in read-ing was due to an increased ability to use contextual cues that accom-panies adolescence, it is not usual for spelling skills to improve.Along with slow reading speed, spelling difficulties remain one of theindicators of compensated dyslexia. It is our argument that the analy-sis allowed Natalie to access skills that had been acquired during pre-vious remediation efforts, but had remained dormant or blocked byconflict.The literature offers numerous general statements about the psy-

chological functioning of dyslexic children. For example: they aremore vulnerable to states of overstimulation which generates troublewith 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 moreprimitive defensive structures (Rothstein & Glenn, 1998). All of theabove general statements are to some degree true about Natalie, butwhat is more salient is that her inability to learn, or to retrieve whatshe knew, was also a way of warding off an affective awareness of thetraumatic overstimulation of events with her father.

the association of learning with conflict and theregulation of affective intensity

While defending against sexual excitement with aggression is typicalof early adolescence, in Natalie’s case, this defense was also sup-ported by experiences with her father which had left her feeling thatmen were violent and untrustworthy and should be responded to inkind. For Natalie “knowing” became drawn into conflict when shesaw her father (her teacher) act violently toward her mother. Learn-ing became connected with sadomasochistic fantasies about sexual-ity. Additionally, his threatening to kill himself right around the timeshe was learning to read may have functioned as a specific traumawhich further interfered with the development of automaticity inreading. Given the mind’s tendency to associate like-valenced affects,Natalie was unable to learn because of the disruptive effects of whatshe experienced as her father’s seductiveness, her own excitement,and her aggressive responses. As learning became libidinized, therewas an inhibition of function, which led to her trouble with lookingas well as with its opposite—exhibiting.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,


about which she wished to remain blind. The defensive efforts thatinterfered with retrieving memories of her father’s frightening vio-lence and the painful affects they would arouse also interfered withother information that for associative reasons shared the same “ad-dress” (Westen & Gabbard, 2002). Although unconscious, the mem-ories remained in a state of activation that accounted for their con-tinuing effects. In Natalie’s case these events, associated with theprocess of learning, affected her motivation to learn. Natalie’s dys-lexia came to function as an anlage, a model based on constitutionaround which the defenses can crystallize. Not knowing became a de-fense; 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, functionsas a powerful anamnestic tool. In the analysis, Natalie was thrilledand repulsed by sexuality and furious at being reminded of her inter-est. The Janus faces of Mr. Tingle and Barney explicate Natalie’s re-peated experience of intense excited attachment coupled withfears/desires of being attacked/attacking. Natalie experienced plea-sure both as the terrorized girl and as the emasculating female. Ofsignificance is that both Barney and Mr. Tingle were teachers, onesadistically drilling facts into her, the other an emasculated and use-less wimp. Becoming a “student” and learning was either danger-ously exciting or doomed to devastating disappointment. Natalie’sfusion of sexuality and aggression is determined by her age, but alsoby her history. “I don’t love you,” she says, as she kicks her male ana-lyst. “I don’t love you,” she says to her father as she fails to learn toread.It was harder for Natalie to use language as a tool to abstract and

distance herself from her experience. She alternated between excite-ment, talkativeness, and silence. When she could not talk, she with-drew into a world of art work. Natalie’s neurophysiological weaknessleft her with a tendency to focus on the non-linguistic aspects of theenvironment; she had a strong reaction to tone and prosody in lan-guage and maintained a strong attachment to the visual world whereshe could retreat when her affective stability was disrupted. She alsoregressed 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, previ-ously unconscious memories into cognitive structures. When herconflicts with the father were repeated in the transference and inter-preted, Natalie was able to “look” and to learn, to spell and to re-member. She was helped, through the mechanism of the transfer-


ence to work through the exhibitionistic and voyeuristic wishes thatwere tied into reading and learning. What was implicit memory be-came explicit. While part of the explanation is that she no longerneeded to use so much of her available energy for defense, her im-provement can be understood in other terms than as a transfer of en-ergy 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 Na-talie’s cognitive functioning has relied on an understanding of con-flict and the use of interpretation to understand her play. Vygotsky(1933/1978) offers an additional perspective, suggesting that playaids structuralization by allowing a child to become less tied to situa-tional constraints and to act independently of what he sees. To ayoung child, perception cannot be separated from meaning, motoractivity, or motivation. Thus, an object is what it is used for, or eventhe context in which it has been used. One prosaic example: a 2¹⁄₂

year old child hears his mother curse when she accidentally dents hercar by backing into a mail truck. The next day the child, sitting on hisride-on toy, curses as he pedals backward. Very matter of fact, he ex-plains to his shocked nanny, “I’m backing up. I say ‘Fucking damnit’” as if the curse were simply part of going in reverse, rather thanrepresenting an angry feeling.This connection between an object and its context was more poeti-

cally articulated by Ruth Krauss and Maurice Sendak, when they tellus “A Hole is to Dig,” in their classic children’s book: A First Book ofFirst Definitions. In play, however, objects will inevitably have noveluses and the same object will have multiple uses. Krauss and Sendakunderstood this developmental point as well. Over the course oftheir book a hole changes from something that is “to dig” to “some-thing you could hide things in,” or “sit in” and “a place for a mouse tolive in,” a thing “to look through,” and “when you step in it, you godown.” As multiple connections, varied perspectives, and experi-ences with objects accrue, they form new grids of meaning separatefrom any one action and there is a consequent shift from action to se-mantics. Vygotsky’s conception is virtually identical to Rappaport’s(1951) description of the shift from the drive-organization to theconceptual 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 thesounds. In play, however, a dust mop can be “Black Beauty”; using the


old object in a new way acts as a pivot to disentangle perceptual quali-ties or action done on the object from the meaning of the object. Atfirst, the play object must share some similarities with the repre-sented object (i.e. the mop is “Black Beauty” because you can ride itbetween your legs), but gradually, semantic qualities come to over-ride perceptual ones and the word “horse,” which bears no similarityat all, even to the “Black Beauty” mop, can be used to represent horsein the creation of stories about horses. These shifts can be describedat any one time as the product of a ratio between object/ meaningand action/ meaning. As the meaning of the object and its place inthe play narrative becomes central and the perceptual qualities ofthe object become subordinate, the child becomes able to existabove the field for a moment, capable of stepping back. Vygotsky par-allels this shift to the change in the child’s ability to observe his orallanguage after acquiring grammatical forms and written language.

A vital transitional stage toward operating with meanings occurswhen a child first acts with meanings as with objects (as when he actswith the stick as though it was a horse). Later, he carries out theseacts consciously. This change is seen too, in the fact that before achild has acquired grammatical and written language, he knows howto do things, but does not know that he knows. . . . Thus, throughplay the child achieves a functional definition of concepts or objectsand words become parts of a thing. (Vygotsky, 1978, p. 99)

In this way, play allows the meaning of a situation (both consciousand unconscious) to emerge more fully and then, translated into ac-tion, to become amenable to thought and self reflection. In theirusual prescient manner, Krauss and Sendak end their book of firstdefinitions with “A book is to look at,” thus intuiting the parallel thatVygotsky makes consciously between play and the acquisition of skillswhich allow for the extraction of meaning from text.In Natalie’s case, the process of learning is associated with the con-

text 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 doesto all men/teachers and is unable to take anything in from the ana-lyst. She responds to his verbal interpretations in action; she cuts histie, turns away from him, or hits out at others. The fact that the ana-lyst does not respond to her provocations or collude with the under-lying unconscious fantasies (i.e. that men will frighten and violate)allows the original context of her fears to emerge. She is helped bythe relatively calm affective climate that develops as the analyst allows


Natalie to titrate the level of stimulation so it remains tolerable toher. As Natalie begins to separate her image of the analyst from thatof her father and gradually to separate the act of learning from thecontext in which it originally took place, she becomes able to use theanalyst’s words in a new way. As language gains ascendancy over ac-tion, she is able to make increasing use of his interpretations.Natalie’s ability to use the analyst develops in tandem with a

change in her play. Early on, Natalie is unable to symbolize. Emotionis expressed in action and there is no “as if” quality to her involve-ment in the transference. Her defensive strategies consist mostly ofinstinctual vicissitudes such as turning active to passive and reversal.Over time, her responses become increasingly sublimated and dis-tanced from her physical body, eventuating in her story about Clover,with whom she shares a partial identification as being unable to puthis feelings into words.A second central point in Vygotsky’s work is that play is intimately

tied to reality and the development of self regulation. Vygotksy wouldagree that symbolic play includes an aspect of wish fulfillment as playdevelops at the time that the child becomes aware of desires that canneither be immediately gratified nor forgotten. However, he was notfocused on motivation in the psychoanalytic sense of hidden desirenor the need to deny reality through imagination. For Vygotsky, mo-tivation is the bridge between a nascent developmental achievementand its final form. Because imaginative play evolves into play withrules, Vygotsky started his investigation searching for the origin ofthis trajectory, noting that in all play the child invokes rules—therules of role based behaviors as the child has observed them. Thechild is literally “playing with reality” (Vygotsky, 1978), by trying onthe actions that define important others, such as mother, dentist,teacher, or student. Only actions that fit these roles will be acceptableto the play. During the act of play, rules of behavior which are ob-served and imitated but not necessarily conscious or available to re-flection are made conscious and explicit. They can then be internal-ized and used for self regulation and delay.Thus, play is instrumental in the acceptance of the demands of re-

ality. In analytic terms, it promotes the development of the superegoby furthering the creation of an internal agency which guides thechild’s behavior so that prohibitions are no longer imposed onlyfrom the outside. While the child would not participate in play if itdid not involve pleasure, now the child willingly subordinates himselfto the rules of reality and renounces immediate gratification as a newform of desire develops—to act in accordance with the rules. Now


the child’s desire centers on her role, on a fictitious “I” that relates tothe rules of external reality and takes them in, making them her own.In Natalie’s analysis, this development is seen most clearly in her

teacher play. As Ross (1965) notes, the teacher game allows both ob-ject cathexis (of the teacher by the student) and identification (withthe teacher’s role) and employs these psychic mechanisms inter-changeably. In this way the process of learning can be separated fromfixed roles and internalized. In play, the child acts ahead of her aver-age age. Thus, play exists in the child’s zone of proximal develop-ment, offering a measure of the difference between the child’s actualdevelopmental level and her potential. In this zone, functions such asabstract thinking and the child’s relation to reality are in the processof maturing. The areas where play is essential, namely in the develop-ment of abstract, semantically dominant, and more emotionally dis-tant attitudes, are also those which analytic writers have noted to beimpaired in dyslexic children.

Conclusion

It is our contention that play in analysis functions in essentially twoways for language based learning disabled children. First, learningdisabled children, with their increased need for external cognitivesupport and structure, find it more difficult to separate from figuresthat are associated with learning, and learning is more likely to be-come entwined with conflict. Undoubtedly, even in the absence of anaggressive father, learning is an everyday trauma inflicted by parentsand teachers on a daily basis. Therefore, play in analysis must initiallyfunction in the transference to externalize and interpret conflicts as-sociated with learning. If this task of working through in the transfer-ence is successful, then the child is able to make use of play for pur-poses of learning and for the development of cognitive structureswhere meaning is super ordinate to the immediate perceptual situa-tion. This offers the opportunity to separate objects from the actionsdone upon them and ultimately to distinguish meaning from action,thus allowing the child to take an abstract attitude. This develop-ment, in itself, provides remediation for one aspect of the dyslexia,the difficulty separating context from more abstract bits of knowl-edge.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. Sev-eral authors have noted this common type of play in learning dis-


abled children, a play very close in nature to reality (Cohen & Solnit,1993). It has been suggested that in addition to functioning as an ob-ject in the service of transference repetition, the analyst also func-tions in a role as a new object which has some overlap with teaching(Freud, 1974; Wilson & Weinstein, 1996; Weinstein, 2002). Thisteaching role allows for the internalization of insight. Both aspects ofthe analytic role are heightened and intertwined for the dyslexicchild. As the analyst functions as an object in the service of repeti-tion, conflicts around learning will be re-evoked as the traumatic situ-ations accompanying learning come closer to consciousness. Oncethese conflicts are interpreted, as they were with Natalie, then thechild can begin to use the analyst as a partner (new object) inplay/learning. During this phase, interpretation is probably less re-quired, as the child is finally able to make use of play for cognitivestructuring and for developing a decontextualized abstract attitude.These skills are notably essential for learning to read as well as othermodes of symbolization.Beyond the mutative aspects of interpretation, by allowing Natalie

to titrate the level of stimulation, the analytic context also supportedher ability to access knowledge she already possessed. Thus the ana-lyst acted neither exclusively as a developmental new/real object noras transference object, but as both depending on the context of thetreatment at any one point.Although it is beyond the scope of this paper to offer technical pre-

scriptions, some differences in the way play and the analytic contextmay function for learning disabled children should be highlighted.First, learning disabled children may need to play beyond the usualage than that of other children, both inside and outside of the ana-lytic context. In the context of the analysis, play that might tradition-ally be considered resistance (i.e. doing homework in the sessions)may, in fact, be a sign of progress in the treatment and essential inthe remediation of the learning problems. Third, although it wouldbe impossible to judge whether the nonverbal aspects of the interac-tion are more salient than the interpretive ones, a possibility sug-gested by the Boston Change Process Study Group (2002), it is clearthat the regulation of a tolerable state of affective stimulation be-comes necessary before the analytic work can take place. Finally, in-terpretation is most successful if geared to the child’s cognitive abili-ties, either by adjusting one’s use of syntax, using shorter words, oreven allowing for an enhanced role for action in the treatment. Thenecessity for factoring in the child’s level of cognitive development inthe formulation of interpretations as well as the interrelationship be-


tween language development and the child’s ability to reflect on herown actions and feelings has earlier been discussed by Lewis (1977),although he did not apply his findings directly to learning disabledchildren.Combining the analytic and the Vygotskian notions of play poten-

tially offers a more comprehensive picture of the nature and utility ofplay for the learning disabled child. First: play is pleasurable. It allaysanxiety by turning passive to active or by changing the outcome oftraumatic situations through the transference. Second: play allows thelearning disabled child the space to take in the reality of the outsideworld—to play the “student,” to learn the difficult spellings and pho-nemes. As part of the fictitious “I” in play, she can work hard at some-thing without humiliation, she can begin to learn the part of “the student” “I” who can fight against great odds, by “borrowing” thestrength of the characters in play. Through play, the transference setsup a new possibility for separating action from meaning. The tie be-tween perception and meaning is ineluctable to a young child, andprobably even in an older child under situations of stress or high af-fective tone, which engender regressions. Learning as an act can nowbe separated from its situational constraints. The child can begin tothink about learning, to think about thinking. As the implicit mean-ing is analyzed, play can move from the pathological to the normative.

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Freud, A. (1974). The Writings of Anna Freud, Vol. I. Introduction to Psycho-analysis. Lectures for Child Analysts and Teachers. New York: IUP.

Freud, S. (1918/1955). Beyond the Pleasure Principle. S.E. 17.Garber, B. (1988). The emotional implications of learning disabilities: Atheoretical integration. Annual of Psychoanalysis, 16:111–128.

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A Girl’s Experience ofCongenital Trauma

The Healing Function of Psychoanalysisin the Adolescent Years

SILVIA M. BELL, Ph.D.

This paper addresses the centrality of conflict in psychic trauma, as ev-idenced in the psychoanalytic treatment of an adolescent girl with acongenital life-threatening and disfiguring condition that necessitatedmultiple surgical procedures in early childhood. The focus is twofold:to elucidate certain characteristics of analysis in the adolescent phasethat promote the integration of early trauma; and to shed light on themodes of therapeutic action of psychoanalysis. Case material is pre-sented indicative of the psychic consequences of early medical trau-mata, including the impairment of the ego’s capacity to utilize anxietyas a signal function that mobilizes defense, the failure of repetition toeffect mastery of the trauma, the predominant use of aggression in theinterest of defense, and distortions in self and object representations.The author offers evidence to show that conflicts over aggression andoedipal desires, characteristic of adolescent girls who have not beensubject to trauma, were involved in the defensive function of her pa-

Training and Supervising Analyst, and Associate Supervisor in Child and Adoles-cent Analysis, Baltimore-Washington Institute for Psychoanalysis; Clinical AssistantProfessor 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 thispatient. I thank also Drs. Boyd Burris and Charles Brenner for their thoughtful cri-tique of an earlier version of this manuscript.


263

tient’s pervasive sense of defectiveness. She postulates that the interpre-tation of conflict and defense is the analyst’s attuned response to themind of the patient, and points to the resulting increase in the capac-ity to observe and to exercise volitional control over heretofore uncon-scious, automatic mental processes as evidence of the mutative func-tion of dynamic interpretation.

in a recent publication, harold blum (2003c) reminds us thatpsychoanalysis began with the concept of psychic trauma. The classicdefinition (Freud, 1926) emphasizes a psychic state that results whenthe ego has been flooded and overwhelmed by stimulation emanat-ing from danger, be it internal or external. Psychic trauma, then,refers to the experience of the ego which is helpless to cope with astate of excitation that has annihilating power. Trauma can be causedby an exceptional event, taking place at a particular point in time, orit can be an ongoing life circumstance. In either case, it has an orga-nizing effect. Memory of the trauma is registered both consciouslyand unconsciously. Blum states that it “has both verbal and non-ver-bal elements, the latter reflected in sensory, affective, motor, acting-out, and somatic phenomena” (p. 418). When the trauma is imposedby congenital conditions, it inherently marks the development of theego and of object relations. “It is important,” cautions Blum, “to dif-ferentiate the traumatic event, the internal traumatic situation, andposttraumatic sequelae” (p. 416). This speaks to the central role ofthe child’s internal experience of the trauma, which is representedin unconscious fantasy, as it marks subsequent development and af-fects adaptation.

While the benefit of psychoanalytic treatment for patients with ahistory of trauma is unquestionable, the nature of therapeutic actionin psychoanalysis has been the focus of active controversy. One as-pect of disagreement that surfaced in a recent publication (IJP,2003), centers around whether the mutative function is inherent inthe analysis of transference and in “genetic interpretation and recon-struction of the unconscious conflicts and trauma of childhood”(Blum, 2003a, p. 500), or whether change results from the experi-ence of “self with other,” where “the crucial component is the provi-sion of a perspective or a frame for interpreting subjectivity” (Fonagy,2003, p. 506). In the first, or traditional conceptualization, interpre-tation and reconstruction, though inexact, play a crucial role in theprocess of addressing “the best possible approximation to the pa-tient’s unconscious fantasies and the traumatic realities of life”(Blum, 2003a, p. 512). While not excluding the therapeutic effect of

264 Silvia M. Bell

the patient’s experience of safety as the trauma is revisited in thepresence of the nonjudgmental figure of the analyst, the emphasis ison “the analysis of unconscious retarding and inhibiting forces” thatare inherent consequences of trauma (ibid.). The second view, ex-pounded by Fonagy (2003), emphasizes instead the “deep explo-ration of subjectivity from alternative perspectives” that the patienthas heretofore not had “ready conscious access to apart from the an-alytic encounter” (p. 506). This view privileges the importance of im-plicit, that is, non-declarative, memory representations from past re-lationships. Dynamic (i.e., intrapsychic) conflict is not consideredpathognomonic, and reconstruction of past trauma is significantonly to the extent that it leads to generating a coherent historicalself-narrative. The “curative” aspect of psychoanalytic treatment is as-cribed to “the process of reworking current experiences in the contextof 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 inimplicit relational structures that represent “non-conscious” influ-ences of the past on the present. It is the analyst’s “attention to thepatient’s currently repudiated feelings in the analysis” (Fonagy, 2003,p. 507), rather than the interpretation of their unconscious deriva-tives, that promotes intrapsychic reorganization.

This paper discusses the psychoanalytic treatment of an adolescentgirl born with a life-threatening, disfiguring congenital conditionthat necessitated multiple surgical interventions in childhood. Thefocus is twofold: to elucidate certain characteristics of analysis in theadolescent phase that promote the integration of early trauma; andto shed light on the mutative aspects of a psychoanalytic interventionthat focuses on the interpretation of conflict/compromise.

Clinical Presentation

I first met Beccah when she was 14. She came to our scheduled ap-pointment dressed in Spandex running shorts and a sports bra. Sheapproached me quickly with a broad smile when I greeted her in thewaiting room, and made a point to bring her face very close to mineas she went past me to enter the consultation room. Before sittingdown, she faced me and asked, “Can you tell?” “Tell?” I asked. “Yes,can you tell that I’ve had something wrong with my face?” In re-sponse, I said that that seemed to be very much on her mind. “Yes,”she said, “I’ve had surgery on my lip and my face many times, and alot of work on my skin.” This launched her into a description of her

Healing Function of Psychoanalysis 265

history of many surgical interventions aimed at repairing and recon-structing her features as a result of disfiguring birth defects. Her ini-tial, rather provocative “take charge” attitude, clearly a reaction todefend against the anxiety that our meeting stirred up in her, turnedinto a description of experiences of early trauma, that impressed mefor its balance and forthrightness. She reflected on her fear of painand hospitalizations (“I’ve had to weather it for my own good.”); onher endurance of rejection (“It’s amazing how much I’ve changed,and I still remember how it feels being looked at funny.”); and on thedifficult relationship with her parents (“My parents don’t know howto work things out. My mother cries about me, and all I want is forher to feel proud of me”). She spoke, with embarrassment, about herconcern that she “does not know how to handle boys,” and describedher conflict about an intense neediness for attention that renderedher vulnerable (“I know that I need to please, especially boys, be-cause it’s so important that they like me. So maybe if someone wereto force himself on me, I might not be able to stop him.”)

This rather dramatic first meeting, revealed key elements of Bec-cah’s adaptation that remained central considerations for the dura-tion of our work. Beccah presented as an attractively built, vivaciousadolescent whose pretty eyes and bright expression diverted atten-tion away from the minor remnants of her previous deformities, nowconfined to relatively unobtrusive facial scarring and skin discol-oration that she ameliorated with the skillful application of make-up.She behaved as an action-oriented young lady, who took charge ofthe session; in particular, of the impact she wanted her appearance tomake on me. While there were no obvious physical signs of what hadbeen, for much of her childhood, a salient appearance, now it washer manner and style that cut a striking figure.

In this session, she gave a coherent autobiographical account thatincluded the consciously stored aspects of her painful childhood,and she was self-reflecting enough to include observations about herfeeling states and motivation—she had experienced fear and pain“for her own good.” She expressed a wish to confide in, even seeknurturing from me, as she spoke of her compromised sense of confi-dence in light of her early experiences of rejection. As feelings of de-fectiveness and hopelessness surfaced, she turned to chastisingthoughts about her mother, who was not able to express a sense ofpride in her, in a defensive maneuver that helped to regulate affect.In these respects, she was responding like a well-functioning adoles-cent. However, the exposure in her manner of dress and her con-frontational style evinced a deeper struggle marked by self-conscious-

266 Silvia M. Bell

ness, insecurity, and vulnerability to deep narcissistic hurt, that wasrevealed in her question, Can you tell? In fact, her actions upon firstmeeting me were an attempt to master anxiety that also expressedher conflict—she was exposing herself actively to avoid the pain sheexpected in the form of rejection from me, and masking her sadnessand anger in a casual, yet “tough” demeanor. There was a ready-made transference to me as “judge”—the female who, like themother, would scrutinize her with a critical eye. She reacted by as-suming a provocative, almost oppositional posture—she camedressed as she wished, not as she might be expected to look, rushingtoward me, yet ready to run away.

As we would discover together, there was a deeper meaning to herquestion about whether I could tell. Her question revealed her ownconfusion around internal representations, which rendered her vul-nerable in relationships with others: she couldn’t tell. Beccah wasaware that she couldn’t get away from “remembering how it feels be-ing looked at funny.” Despite the cosmetic success that had changedher external appearance, unconscious aspects of her internal experi-ence prevented her from integrating a healthier image of herself.She exposed her new female body, but she spoke of her sense of de-fectiveness and of her fear of sexuality. Her presentation communi-cated an almost desperate need to figure out what others thought ofher now, as she sought to make sense of the confusing images of her-self, past and present. In a shift expectable in adolescence, she madeclear that her longing search for mother’s admiring gaze had nowturned to seeking acceptance in the eyes of a boy.

history

Beccah was born in an Eastern European country, with facial defor-mities and serious birth defects, including complete cleft lip andpalate, and multiple benign soft tissue tumors which involved theface, the vascular system, and obstructed the airways and bowel. Herparents, both professionals who had been educated in the UnitedStates and counted many friends and relatives here, recognized thather medical needs would be extensive, and took immediate action torelocate. Indeed, Beccah required multiple surgical interventions inthe first four years of life, and her condition was considered lifethreatening. Her medical status stabilized after age five, and she wasessentially healthy thereafter. However, she underwent staged peri-odic facial cosmetic surgery between the ages of five and twelve toapproximate a normal appearance. These interventions became less


invasive as she grew older but represented, nevertheless, an inescap-able specter in her childhood experience.

Infancy was a highly stressful period for mother and infant; Beccahhad projectile vomiting, cried excessively and had poorly regulatedsleep-wake cycles. As her rhythms stabilized in her second year, therelative respite from anxious concern over her status was periodicallybroken by emergency hospitalizations for various complications in vi-tal organ systems. Despite Beccah’s medical history, the parents re-ported an otherwise normal accomplishment of developmental mile-stones. Beccah was a charming, active little girl in early childhood—astoic patient who seemed to find the strength to maintain a sense ofrelatedness toward others, and the resilience to tolerate her hospital-izations. Periodically, however, she had angry outbursts, was demand-ing, and not easily soothed. A maternal aunt, who lived in close prox-imity, provided daytime care for her since infancy, given the mother’sdecision to pursue her career. Beccah turned to her aunt for com-fort, and experienced her as a refuge when she felt embattled withher parents. Beccah’s developmental history would have been con-sidered unremarkable, were it not for the enormous achievement itrepresented 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 herjunior, was described as healthy, aggressive, and irreverent like his fa-ther. Beccah took pride in being “the smart one,” whose academic ac-complishments far surpassed his. The children shared an interest insports, in identification with the father, and there were no obviousconflicts between them. The father was a self-acknowledged “no-non-sense person,” who wanted his children to be strong and active.Threatened by Beccah’s history of damage and suffering, he focusedon his daughter’s present status and denied the psychological impactof her early appearance and medical vulnerability. His affirmationthat there was “nothing the matter with Beccah now,” obviated whatcomfort this conflicted girl might have garnered from his seeminglysupportive comment, since it was delivered by way of a complaint:“What is her problem? She looks fine!” He railed at his wife for “mak-ing too many excuses for her,” and it was clear that Beccah was at thecenter of marital conflict.

The mother, more attuned to her daughter’s emotional distress,was the one seeking psychological help for her. She had the compe-tent demeanor of one experienced in the handling of emergencies,but she could verbalize her awareness of underlying anxiety and con-flicted feelings about this child who had “brought so much trauma”

268 Silvia M. Bell

into their lives. She was undergoing psychotherapeutic treatment toaddress “a pervasive sense of guilt” that interfered with her relation-ship with her daughter. She felt close to Beccah, able to understand,nurture and comfort her, but also felt overwhelmed and entrappedby the requirements of her care. She acknowledged that she had re-turned to work as a respite from trauma; yet she had been availableto support Beccah as she endured the uncertainties, repetitive inva-sive interventions, and frustrations of her medical condition. Themother was deeply pained by the undercurrent of anger which sur-faced in periodic outbursts between them, and she expressed a wishto soothe and promote her daughter, whom she experienced as“masking pain with anger.”

With the onset of prepubertal changes at age ten, Beccah’s behav-ior deteriorated. She became defiant at home, caused fights with andbetween her parents, and resisted doing her school work. After evalu-ation by the school psychologist, she underwent once-a-week psy-chotherapy for one year, with noticeable improvement in her moodand conduct. Since menarche at age 12, Beccah had once again be-come unmanageable. She was neglectful of her academic work, gotinto 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 herselfto her passion—horseback riding. In fact, she had demonstrated sub-stantial 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 recogni-tion that lent urgency to their request for help once more.

treatment

An extended evaluation was undertaken, to explore Beccah’s capac-ity to tolerate anxiety and regression prior to the recommendationfor analysis. As is characteristic of individuals who have suffered earlytrauma, Beccah experienced anxiety as a sudden and intense onrushof affect, which felt disorganizing. She defended against this feelingby taking counterphobic measures—that is, she exposed herself tothe very situation she dreaded so she would not be surprised by it.The affect would be further moderated through primitive denial, orisolation—she would purport not to feel anything at all. I noted withconcern, a pervasive tendency to repeat trauma by creating sado-masochistic relationships wherein she identified with the aggressor,but also experienced the victimization of being the object of abuse.


She seemed to need to relieve a pervasive sense of defectivenessthrough impulsive action that imperiled her safety. It became clearthat the nature of her conflicts required a more intensive interven-tion that would promote the development of her capacities for intro-spection, and provide her with the opportunity to integrate herchaotic early experience. Beccah had established a therapeutic al-liance 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 be-coming more conversational and less introspective in a defensive ma-neuver to maintain distance from affect. My indication that we wouldmeet four times per week felt like an increased interest in her—anapproach that triggered anxiety at an unconscious level. In a dis-placement of the conflict, she developed a fascination with a boy. Shehad picked him up at the beach after he made “an obscene remarkabout her body.” In her sessions, she recounted the details of their in-teraction, which took place primarily over the phone. This behaviorwas a compromise that allowed her to counter the regressive pullgenerated by the analytic experience, as she talked excitedly to me,about him. She phoned him repeatedly, hounding him with de-mands for attention, and stimulating him with seductive storiesabout her provocative behavior. His tough manner and provocativesexual comebacks fascinated and terrified her, and triggered a defen-sive identification with the aggressor. She developed a verbally abu-sive stance towards him, demeaning his socioeconomic status and hisacademic ability. He became “a good-for-nothing, with no cultureand no morals.”

This relationship was an enactment of her experience of past rela-tionships, which she expected would be repeated with me. Whereasshe had often felt victim to surprise and hurt in response to the reac-tion of others, now she created a sadomasochistic entanglement inwhich she exacted and suffered pain and humiliation. The excite-ment generated in the interaction defended against her belief that“no nice boy” (or “nice doctor”) could genuinely like her, andagainst the dread that the wished-for closeness was inevitably linkedto abuse. A relationship with a boy she regarded as more defectivethan she was, ameliorated the sense of being damaged and “bad” thatwas exacerbated by my recommendation to increase the frequency ofour sessions. In fact, whilst she consciously regarded me as a trustwor-thy confidante, her relationship with this boy expressed in displace-ment her unconscious fear of what would happen between us—wewould hurt and disappoint each other.

270 Silvia M. Bell

These complex dynamics needed to be addressed gradually. Myearly interventions aimed to help her to observe her affect in rela-tion to her actions, and to begin to consider her use of defense toregulate her internal state (turning passive into active, and identifica-tion with the aggressor). “When a boy notices you, something hap-pens inside and you feel that you need to find out what he thinks ofyou. Maybe you rush to find out, to stop yourself from worrying.” Shereplied insightfully, “When I get attention, I don’t know what I feel; Ican’t figure it out; I can’t make sense of myself or what is going on.”

In this early period, rather than explore directly the nature of herfantasies and self- and other-representations, the interventionsaimed to help her to consider her sense of confusion. We noted notonly the disorganizing quality of her anxiety but also its genetic as-pect: “Not knowing how you feel now may be showing us what it waslike for you when you were little, and you couldn’t figure out whatkind of attention you were getting.” Thinking about her experiencein the past created a respite from the intense anxiety generated inthe moment, and thus it facilitated her capacity to observe her inter-nal state. Mindful of her observation in our first session that she hadhad to weather fear and pain for “her own good,” a statement refer-ring to elective but “necessary” painful cosmetic surgery, I recon-structed that sometimes it was hard for her to distinguish whetherthe attention she gets is helpful or destructive, because in the pasteven good attention was tied up with so much bad feeling. She re-flected, “I’ve had to put up with so much pain, I never know whetherthe pain is for my own good or not. Maybe I don’t want to thinkabout it.” The internal confusion she experienced when she was thefocus of attention was an automatic reaction based on past experi-ences that were encoded in implicit, non-verbal memory. However,Beccah was also inhibited by unconscious conflict pertaining to com-plex feelings about the need to subject her self to medical proce-dures and cosmetic changes in order to be “normal.”

Beccah was caught up in impulsive externalization that defendedagainst new and old reactions to her body that were exacerbated byadolescence—the painful sense of defectiveness of her childhoodbody and the frightening wishes related to her new female body. Wenoticed that focusing on what a boy thought of her, kept her from let-ting herself know more about what she was feeling. This led her toobserve that “something happens inside when a boy is interested. Ican’t let it go.” She reflected on not being able to tell me that herboyfriend had made a vulgar comment about her breasts, which shefound pleasing and scary. Rushing at him with excitement, as she had


done with me on our first appointment, she defended against feel-ings of vulnerability and helplessness that surfaced with his attention.She recognized that she felt attractive some times, but then doubtedthat anyone could find her attractive. With sadness, she added, “I’vehad such bad luck, born with all these birth defects I have to live withthe rest of my life. I have this need to get attention from guys andthen I let them abuse me. I’m so angry inside.” I noted to myself thatshe had turned to thoughts of pain and damage after she had al-lowed herself to acknowledge her new, attractive body, and her excit-ing, seductive behavior.

Beccah’s traumatic history predisposed her to repetition, in an at-tempt at mastery where she had felt the helpless victim. When con-fronted with a situation that called up a sense of defectiveness, as inmeeting someone new, she called attention to herself. She projectedher sense of defectiveness and became provocative and aggressive todefend against the disappointment of not being lovable. She invitedhurt through teasing, thus enacting her sadistic wishes, and then iso-lated the affective content of the interaction. Often, her behaviorelicited the rejecting response she had dreaded in response to herappearance. Our work gradually elucidated the complex meaning ofher feelings of defectiveness. On the one hand, the implicit record ofpainful experiences in face-to-face interaction now mobilized anxietyand depressive affect around looking at her self and being looked at.We learned, however, that feelings of defectiveness also surfaced as adefensive turning against the self in the service of maintaining equi-librium 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 de-spair, affects kept in abeyance by her aggressive stance, surfaced. Shecommented: “Only dirtballs are interested in me; I’m the one theyabuse, but they choose somebody else for a girlfriend.” She told meof her recent encounter with her first grade teacher who, not havingseen her in the intervening years, asked unfelicitously, “What hap-pened to you?” In the safety of the analytic work, we explored Bec-cah’s painful experience of looking and being looked at. We recon-structed that she had learned from the look of others that herappearance could inflict an emotional response that elicited a reac-tion that was incongruous with what she was feeling, and caused herpain. While her provocative actions seemed to cry out “look at me!,”her manner was a defensive maneuver that startled and interferedwith close scrutiny. Her salient behavior deflected the onlooker’s

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gaze away from her face. Looking and being looked at were highlycharged affective moments, which mobilized fantasy and conflict.She began to recognize that her own looking was compromised—shelooked to others as mirrors of herself, because she could not see theyoung woman in the mirror as herself. As our work progressed, weconsidered the meaning of her searching in my eyes, as she had doneon our first meeting; a search that repeated her experience with hermother’s eyes.

Beccah had enrolled in a course to make porcelain dolls, and shebrought them to her sessions. She was critical of her work, andshowed me that she could not get the face “quite right.” The connec-tion with her wish to have the perfect face with a flawless complexionwas unconscious. She did not recognize that her newfound interestrepresented her experience of remaking her own face. After sharingin her interest in porcelain dolls—that is, keeping our work in thedisplacement—I noted the unremitting quality of her concern aboutnot getting the doll’s face “quite right,” and I asked her whether shewas curious about it. She asked my opinion, what did I think aboutthe face? I replied that her checking now how I felt about the doll’sface reminded me of her question, “can you tell?” We addressed herexternalization; her checking what others felt kept her confusingfeelings about herself temporarily out of mind. She connected withher anxiety upon meeting people, “I have this constant knot in thepit of my stomach; so much, that I don’t even know it’s there.” At ournext appointment, she brought a porcelain baby doll. Now awarethat her behavior had meaning beyond an interest in the hobby, shesaid, “I like babies. I worry about having babies in the future.” We ex-plored her worry that she could not have a normal baby—a worrywhich, although connected to her pervasive sense of being damaged,was also an expression of normal conflicts about the dangers of grow-ing up and being female. This work was also a harbinger of conflictedfeelings about her mother, who had not passed on a normal body toher.

The transference deepened, and Beccah’s response to the treat-ment setting gave us an added, unexpected opportunity to recon-struct the genetic aspects of her pervasive feelings of vulnerability.My office was located at the end of a U-shaped corridor in a suitewith four other offices. After several months of treatment, I still oftenfound her roaming the hallway. She seemed momentarily surprised,even startled at my presence, and then responded by assuming a ca-sual, distracted demeanor that resolved into a broad smile denyingdeeper feeling. As I wondered with her whether she experienced a


discomfort in the waiting room that compelled her to move around,she recognized a mounting feeling of anxiety as she waited for mepassively, that compelled her to “check out the place.” Beccah be-came aware of an internal state of alarm, and she recognized that, de-spite her frequent checking, she felt confused and could not makesense of the office space. I considered that, in the regressive statepromoted by the analytic process, Beccah was enacting an earlier,non-verbal memory. I interpreted that her experience in the officewith me gave us further clues about what it might have been like forher as a little girl, when she repeatedly found herself in strange,frightening doctor’s spaces waiting for something to be done to her.Her anxiety, which must have felt intolerable then, now impelled herto take charge but still impaired her effective mastery of the situa-tion. She recognized that waiting brought up fears that I would notcome for her, and that a stranger with harmful intent might appearinstead. She was abandoned and helpless. She responded to this in-sight by making a map of the office. She also started setting an alarmto signal the end of our appointments before the time was up. “I liketo know when you’re going to tell me it’s time to go,” she stated. AsBeccah understood that fantasies of rejection and abandonmentwere mobilized in the treatment, she felt increasingly able to takecharge and this, in turn, furthered our exploration of her internalexperience.

As the transference deepened, she “remembered” an episodewhen her incision “opened up” after abdominal surgery when shewas a toddler. She described, as if telling an exciting, funny story, heraunt’s panic and ensuing confusion, as she was alone to handle thisemergency. Her account had the quality of bringing me into the fam-ily lore; it revealed how humor had been used to cope with trauma. Ifelt the importance of respecting the affective tenor of her communi-cation, which defended against the traumatic impact of that mo-ment. I commented, after acknowledging the humorous quality ofher story, that remembering how her aunt had experienced this mo-ment helped her to put aside what it had been like for her. She re-sponded by disclosing her worry that someone could come throughthe window and attack us. As we explored this fear, she revealed herchronic 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 andisolation of affect, this behavior was automatic and she was not awareof the feelings that necessitated her avoiding her bed. She recalledthat, as a child, she needed to hear that there were people aroundher who could rescue her if she stopped breathing. She realized that

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she lived with a pervasive fear that she might die. We noted that shewas worried about whether I would or could protect her from harm.Gradually, the fantasy that I might assault her, which was emerging inthe transference, became amenable to interpretation.

Beccah spoke of the comforting feeling of hearing the sound ofvoices from the TV at night; they helped her to feel safe. I had regis-tered that her memories, which depicted her mother’s unavailabilityand her aunt’s helplessness, had triggered a fantasy of assault thatelaborated on her feelings in the waiting room. I said: “Perhaps thesound of voices from the TV may even feel safer than a voice upclose.” I interpreted that fearing that someone might come throughthe window to attack us had something to do with a fear about beingalone with me. She reflected thoughtfully: “I tell you so much. Youcould do something that would hurt me.” In the months that fol-lowed, Beccah explored her confusion about her mother, whoseemed to be in charge of her well-being and yet so helpless to pro-tect her, and whose interventions she experienced both as life-savingand as murderous assaults. Her awareness of feeling vulnerable withme gave us an entry to explore her aggressive feelings. The fantasy ofthe intruder who would attack us, was a compromise that includedthe projected aspects of her rage at me, the powerful doctor-motherwho, by providing treatment, exacerbated her feelings of being dam-aged. It was also a harbinger of the deepening paternal transference.

As the treatment progressed, Beccah focused more actively insports, and she brought evidence of her success, indeed her stellarperformance, as recognized in newspaper clippings, ribbons, and ci-tations. We noted, however, that she felt a great pressure to maintainan “unblemished” record. Every event was a new challenge, as if herprevious success did not serve to ameliorate her blemished self-con-cept. She reported a worry that “people out there” wanted her tolose, a projection of her enviousness that also reflected her expecta-tion of punishment. Winning was of paramount importance, yetfraught with conflict. Noting her anxiety prior to a particular eques-trian competition, I wondered if these events recalled her experienceof her cosmetic surgeries, so fraught with promise and risk. The ex-ploration of her exaggerated sense that so much was riding on theoutcome, led Beccah to recognize that she dreaded failure as evi-dence “that it was all her fault.” This insight allowed her to connectwith her sadness about needing reconstructive surgery, and to recog-nize that, although her body had undergone a process of change, herold feelings of being faulty and at fault remained unchanged. She ex-pressed anger at her mother who, in contrast to her athletic, aggres-


sive father who “did not see anything wrong with her,” was felt as themirror reflecting her defectiveness.

Beccah accessed her conflicted feelings about her father beforeshe could fully address the complexity of her reactions to hermother. Her bisexual conflict was openly manifest in this period inher analysis, as she focused on sports in an effort to identify with herfather and disavow her dangerous, defective femininity. The identifi-cation with him did not offer lasting comfort, however. She reported“shouting matches” between them; he was insensitive and didn’t careabout her feelings. “He is an angry person ready for a fight.” Bec-cah’s wishes for closeness with her father stimulated oedipal conflictand called forth the dual threats of rejection from father and aban-donment from mother. We recognized that anger maintained close-ness between them, and defended against intimacy and disappoint-ment. She added, “I’m afraid that I’m just like him, and nobody willbe able to set limits on me.” The identification with his intact imageseemed to bolster a sense of hope about her own strength, also expe-rienced in her horseback riding, and was a relief from the complexfeelings in relation to her mother. However, it also promoted fan-tasies of unbridled impulse, which increased her sense of vulnera-bility.

The intensification of Beccah’s feelings towards her father led toan increase in her nighttime fears. She revealed that she had askedher mother to sleep with her, as when she was a little girl. In thecourse of our exploration of her regressive response to oedipal pres-sures, she painfully uncovered her confusing feelings toward hermother. Sometimes she felt reassured of the much-needed mother’slove 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 mother’s health and well-being.Her sense of defectiveness seemed to intensify with her fear of herdestructive wishes toward her mother. “How can I be so angry withmy mother when I have been the cause of so much pain?” sheprotested, and proceeded to turn against herself as the defective one.Being the damaged one also defended against the frightening wishesto surpass her mother by becoming the young woman with the beau-tiful body who would bear the healthy, porcelain-skin child.

As our work progressed, Beccah’s appearance and demeanorchanged. She began wearing age-appropriate, stylish outfits andjoined the “preppy” crowd. There was a shift in the transference, andwishes for me as the oedipal father surfaced. She talked about beingglad 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 aboutthings that happened in the movies kept her from considering herthoughts about me, right here. Her fantasy of my sexual feelings to-ward her, manifested in sadomasochistic wishes, condensed oedipalcomponents and a developmentally expectable erotic interest in me.I interpreted that the excitement of thinking about an abusive rela-tionship between us distracted her from considering other feelingsthat surfaced as we worked together. I spoke to her excitement as adefense against her worry about feeling unloved, if I did not recipro-cate her interest and longing for me.

In conjunction with the process of object removal, which had beendelayed by conflict, Beccah developed an idealized view of me thatpromoted her capacity to relinquish her mother. She became curiousabout my interests, my salary, my education, and admired that I hadbecome my own boss. She imitated me in her manner of dress, iden-tified with me in considering career choices; she felt that I was smart,reliable, and interested in her: “You never forget anything I say.” At atime when development required that she relinquish mother in or-der to attain a separate and independent sense of herself as female, Iprovided the necessary unblemished female substitute.

Noticing an adult female patient who had left the office, Beccahpondered whether she used the couch, and asked “to try it.” Thecouch was “weird” but, as if it were a test of her readiness to face hergrowing up, she was determined to use it. She reacted against the rel-ative restraining quality of it, as adolescents are prone to do, but I wasaware of her unconscious association to a sick bed, and to her fears ofdying, that led her mostly to sit in the middle of the couch with herback leaning against the wall. She told me about having set appropri-ate limits on a boy: “You’ll be proud of me when I tell you this!” I re-sponded to the identification (“you are very pleased too, thinkingthat we share in that feeling”), while mindful of the defensive aspectsof her remark. She came to one of her appointments dressed like ahippie and asked whether I had been one, thus revealing her bur-geoning interest in my body and my sexuality as she tried to recon-struct and imitate me in my adolescence. She replied to herself,“Nah, you’re too conservative. I don’t think so. You go too much bythe rules.” I wondered with her whether she thought of me in thatway to feel safe from a worry that I might do something surprisingand scary. She said: “It’s a relief.” She mentioned getting a learner’spermit, and jokingly added that we could go driving together. I com-mented that she was thinking about things we might do together out-side of the office. She mused that it was good that it was just the two


of us in the office—then she didn’t need to decide what to call me,whether by my title or by my first name. I said that by not calling meanything she wasn’t letting us know more about what made thechoice difficult. We noted a sense of risk that prevented her fromspeaking freely about her wishes for a special closeness with me.

She came to our next appointment wearing very high heels, andtold me that her mother borrows them. “But she does not fit into myclothes. Do you like them?” she asked in a challenging tone. Theerotic wishes from the previous session had given way to the lesserrisk of the defiant stance. I replied that she wonders whether I likewhat she has and whether, like her mother, I might also want whatshe has. She exposed herself as she flipped over on the couch, sat up,and pranced around the room. Then she took off her shoes andpicked her toenails, first littering and then cleaning up the debrisfrom her body. She had brought greasy food that she spilled/con-tained/cleaned up; all the while as if she were oblivious to me. I feltthis provocative behavior as action language that expressed the mul-tiple 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 inmy envy. Her messy, regressive behavior defended against the risks in-herent in the wish to be the woman who might incur my retaliation; arisk fueled by her projected envy. She needed to remain the little girlwho would incur my wrath for her messiness, so as to avoid my retalia-tion against her femaleness.

In a subsequent session, Beccah reported that she had gotten goodgrades; then she pointed to a run in her brand new stockings. “I hateruns. I am so bothered by little things!” She showed me that it lookedjust like the hyperplastic scar on her abdomen, from one of her pro-cedures. She told me she has many others like it. “I can’t wear a two-piece bathing suit; I will have to have more plastic surgery.” Shestarted picking on a scab and said, “I’m lengthening the healing pro-cess. I know that. I’m attacking my skin.” I noted to myself that, as shewas more in touch with her wishes to be like me and liked by me, herconflicted feelings about her self-representation were coming to thefore with an increase in depressive affect. While I was mindful of thedefensive aspects of this behavior, I felt that, in light of her past his-tory, the fantasies and realistic concerns about her “vulnerable fe-maleness” were surfacing in the image of the fragility of her stock-ings. Beccah was now aware of her feelings, and she was able toexplore 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 herfear of dying in sexual intercourse, or in childbirth. Her past historyof defectiveness accentuated the developmentally expectable con-cerns about her changing body, and stimulated the certainty of fu-ture trauma. As a little girl she had relied on her mother or hergrandmother to take over her body in order to feel safe; becoming awoman meant giving up that tie to them, and taking charge of herown body—a body that had felt unreliable as a child, and was under-going a risky process of change.

Beccah’s behavior toward me became more erratic. She reportedthat her mother had commented on her progress—“we don’t fightany more”—but now she was angry with me. I was “weird” and out oftouch with kids her age. She told me that she spoke on the phonewith her boyfriend’s mother every day; “I’ve never met her. I don’tcare what she thinks.” I pointed to the worry about letting her selftell me more because she might care too much about what I think.She became more resistant. “I don’t have the maturity for this analy-sis. You’re trying to connect things up. I don’t want to do that. I don’twant to remember.” Then she told me that there are pictures of her“back then” all over the house, and upsetting stories from hermother about how people used to react to her. Letting herself experi-ence with me her wishes and worries about her femaleness had mobi-lized in the transference the manifestation of a fantasy that I, like hermother, wished to ensnare her in the past in order to keep her frommoving forward.

The work in this period gave us further access to the defensivefunction of the defective view of her self. Beccah was aware of stilllooking at other people’s reactions to her in order to get a clearersense of her self, as if what she saw in the mirror was not convincing.She expressed despair about whether she would ever feel “goodenough.” I ventured that she seemed aware that, no matter what im-age was reflected back, something was interfering with letting herselfchange the old picture in her mind. Maybe being her new, grown upself felt scary and she kept herself looking back. She brought an al-bum of photographs of a recent family event and used each photo-graph to evaluate herself—her 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 facethere,” clearly taking pleasure and pride in her image. I clarified herambivalent feelings: “Sometimes you can’t stand looking at yourself,and sometimes you like what you see.” As if my words had touched onsomething that brought up discomfort, she dismissed her pleasure


and remarked: “There’s only one good one.” We were thus able toobserve that expressing to me the feeling that she liked what she sawhad mobilized a need to take the good feeling away.

Beccah developed a relationship with a boy. Her boyfriend was “anice guy, but he is adopted.” His adopted status fascinated her; shesaw it as his secret defectiveness. In that sense, he was more defectivethan she—her parents had not given her up, she was valuable tothem.

The threat of abandonment and loss, so prominent in her thoughtsabout her boyfriend’s history, was also a central aspect in her conflictabout growing up. Her relationship with this boy stimulated hetero-sexual feelings that signaled the potential disruption of her child-hood tie to her mother, and resulted in an exacerbation of her anxi-ety. The impulse to call him repeatedly resurfaced; she felt miserableand sought his constant reassurance. One day she broke out in greatanger at me: “Despite all this work, I still feel so insecure! What goodis this analysis anyway? And how can I trust that you really like mewhen you didn’t know me back then?” I said, “You worry that some-thing about my seeing you back then would change what I feel aboutyou now.”

Beccah came to her next session carrying the framed pictures ofherself as a child that her mother displayed in the home. Shepropped them in front of me, all the while scrutinizing my face. “Canyou understand,” she asked, “why it’s hard for me to make sense ofhow I look now? It’s like, to me, I’m the same, I’m me then and now.”I felt the poignancy of this moment. She had brought the childhoodpictures to the office as if reclaiming ownership of her experience. Iunderstood intuitively at that moment the importance of my role astrusted observer of her struggle, a struggle she was proclaiming andwas determined to work through, albeit in the context of the analyticexperience that granted me a vital role. She pointed to the many de-fects of old, and commented on the few vestiges that remained, sym-bols of past and present. I said, “You wonder whether I see an old youthat’s not right, or a changed you that makes you acceptable, andhow that makes me feel about you, the 16-year-old girl in front ofme.” “I still don’t believe anyone could find me attractive,” she said.

This session was powerful for both of us. Beccah exposed her vul-nerability in the wish that she would feel undamaged as she displayedher defects, a gesture no longer masked and distorted by the defen-sive provocative stance she had displayed in our first meeting. I wasmoved by her presence, aware of feeling sorrow and pain for the lit-tle 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 theyoung person before me. I do not doubt that Beccah was impacted bythe affective tenor of that session, in which I served as witness to herincreasing appreciation and acceptance of her struggle (Poland,2000). Beccah was now “telling herself.” However, in order to under-stand the psychic meaning of her action, it is necessary to place itin the rich context within which it manifested, and consider whatcompelled Beccah to bring the pictures to me at this point in hertreatment.

Beccah had been expressing openly her experience of being lov-able in the context of the growing relationship with a boy. As thosefeelings, harbingers of her developing femininity, deepened, thethreat of the loss of the childhood experience with mother mobilizedintense conflict. Testing my response to her as a child at this time, amove which could be regarded to serve in the interest of acquiring anew way of “seeing herself with me,” was in effect a maneuver thatput a halt, albeit temporarily, to dangerous developmental wishes toexperience herself as a young woman in my presence. A stormy pe-riod ensued during which Beccah enacted the sadomasochistic fan-tasies pertaining to her early relationship with her mother. Fearsabout her vulnerability to illness became prominent. She worriedthat her immune system “was down,” and that her body could notfight infection. A simple cold triggered fears that she would not beable to breathe. She put down our work; talking was not doing any-thing. I was helpless and ineffectual. Her agitation switched to coolwithdrawal. She came to the office barefoot. “My mother made acomment, Do you think it’s dangerous to walk around barefoot? Ican decide what to do.” I said that maybe she wanted for me to worryabout the danger, and then she wouldn’t have to worry about her de-cision. She reported that she had eaten her lunch during her biologylab. “We were dissecting a rat. The teacher said there was a possibilityof bacterial contamination. If I get sick, I could pass it along.” Likethe rat on the dissecting table, Beccah felt dangerous to herself andto others. While, on the one hand, she felt that her mother was re-sponsible for her defectiveness, she also struggled with the fantasythat she was the one at fault, who hurt her mother with her defective-ness. 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 ownsense of vulnerability; she was thus enacting with me in the transfer-ence the sadomasochistic symbiotic fantasy that kept her locked in asense of defectiveness.


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 anxietyabout separation intensified. “What good is this doing? So now I havea lot of fears!” she yelled at me. I interpreted that now that she wasnot doing so many exciting, scary things, she was more aware ofother feelings. I added that maybe her fears had intensified as shewas experiencing upset feelings towards me who, like her mother,seemed helpless to make things right for her. She said, “That’s right!And just as I get worse, I am going to have to stop with you!” I spokeabout how scary it must feel to make plans to go away as she was feel-ing worse. Maybe she was looking for me to say we needed to con-tinue our work because that would stop her from leaving, and wouldrelieve her of her worry about making the decision to go. Beccah re-vealed a fantasy that her mother would not be there for her unlessshe needed her in sickness; it seemed inevitable that letting go, a sig-nal of her health, would have destructive consequences. The regres-sion ensured their closeness, but it engendered hostility in responseto what felt like a requirement to succumb to mother. Fighting withme, as she had done with her mother, was an attempt to regulate theinterpersonal distance between us, given the dependent longingsand aggressive reaction that were stimulated in the transference.

Her history of risk-taking behavior had come under close scrutinyin the analytic work. Creating a state of excitement and worry washer way not to know about complex difficult feelings about “being onher own” in light of her overwhelming experience of vulnerability asan infant and young child. Her behavior was a compromise that rep-resented her wish to experience herself as invulnerable so she mightdare let go of the mother, while it heightened her real susceptibilityto damage, thus safeguarding her closeness to her mother. Leavingmother and me was a loss associated with death and harm. As Beccahconnected with the affectively charged fantasies that pervaded herinternal experience and observed her conflicts, she was able to ad-dress her present fears about going to college—feeling small and atrisk, being subject to the old dread of meeting people that would in-hibit her, being alone to meet life in its many challenges. She beganactively to make plans to attend college away from home; she metwith her college counselor, and she brought books to her sessions todiscuss her college search. “My only requirement,” she said whenconsidering schools, “is that it be a very big school, with all kinds ofpeople and pretty buildings.” We both understood that this was anexpression of her wish to feel “main stream,” and one among many

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people who displayed differences that made them uniquely pretty. Iinterpreted that thinking about “many people” was a way not to thinkabout the worry about being all alone, now that our work wouldcome to an end.

The final weeks of the termination phase were stressful. Shestarted to miss her sessions. She had taken a job and “was going tothe lounge to talk with her friends.” I interpreted that she was leavingme before we terminated, because of the worry about what feelingsmight come up on our final good-bye. During her last sessions, shereflected thoughtfully on her reaction to ending: “It really did sink inthat I’m going away to college. I was missing appointments here totry it out on my own, but I didn’t want to know about it.” As weworked through old and new feelings about being on her own, shereflected on her gains. “I’m proud of myself now; I told this guy offwho was after me. I don’t chase guys any more, and I don’t have tohave people prove they like me. I feel calmer all around. I have moreesteem for myself.” While Beccah could have profited from furtheranalytic work, she left for college rooted in a sense of being a youngwoman with much to offer, a view of her self that would stand her ingood stead to meet the challenges ahead.

Discussion

This presentation details the analytic treatment in adolescence of agirl who suffered pervasive trauma, originating from a congenitalcondition that persisted for many years and necessitated multiple in-vasive medical interventions. Beccah’s history involved all of the ele-ments common to trauma—repeated assaults of intolerable magni-tude that inflicted pain, helplessness, and chaos on an ego incapableof mobilizing adequate defensive action. At the inception of theanalysis, she functioned like a highly traumatized youngster. Shetended to enact in order to defend against sudden, disorganizinganxiety, while sadness and rage locked her in a fixed view of herself asdefective. She projected her hostile view of herself onto others, andher relationships became battlegrounds that expressed her inner tur-moil. She went through a period of “action-filled adolescence,”where she acted outrageously to counteract worries about the dan-gers of adolescence.

Blos (1962) describes the central role of regression in adolescence.The adolescent reworks the tie to the parents in the interest of indi-viduation and disengagement from infantile dependency, a processthat involves the need to solidify the image of one’s own personality


as the parental figures are relinquished. Both Blos (1962) and Winni-cott (1971) state that, because of the centrality of regression, adoles-cence is a phase that facilitates the opportunity to undo developmen-tal arrests and promotes restructuralization. Earlier conflicts andfantasies that interfere with successful individuation, and can be-come further structuralized in pathological outcomes, now areuniquely available for observation. The data from Beccah’s analysisattests to the importance of the adolescent period as one that pro-vides a propitious opportunity for psychoanalytic intervention. Expe-riences involving her new female body, and the intensification of dri-ves that safeguard individuation, provided a context that promotedour exploration of the crippling conflicts that were interfering withthe process of psychic differentiation. Given the mental capacities ofadolescence—the ability to think beyond the concrete aspects of thepresent, to consider past, future, and the possible—Beccah was ableto rework the governing childhood adaptations, and effectively uti-lize the forces that promote development.

Accounts of female adolescent development (Dahl, 1995; Ritvo,1984, 1989) attest to the vicissitudes of this phase, which were muchexacerbated for Beccah given her past conflicts. The girl’s entry intoadolescence is characterized by a resurgence of the preoedipal ob-ject tie to the mother; she responds to the major shifts in physical,and mental, functioning, as well as to the intensification of drive im-pulses, by seeking emotional closeness with the protective mother ofearly childhood. With the onset of menarche, there is a heighteningof anxiety over the inability to control the body that intensifies thegirl’s neediness of mother’s help with bodily care. These longingsstimulate fears of passive submission to the mother, and reactivateearlier conflicts about merger with/engulfment by her. Beccah’s ex-perience of life-death dependency on mother’s ministrations andprotection was reactivated in this phase of development, and itthreatened to keep her locked in a pervasive posture of defectivenessthat defended against separateness. The immediacy of these feelingsin the context of the concomitant drive toward separateness madethe reworking of separation-individuation issues more accessible toanalytic intervention

The girl’s awareness that she is beginning to possess a body like themother’s may further stimulate fantasies of merging with her (Ritvo,1989). A replay of the struggles of the anal period can ensue, and op-positional feelings, aversion, and estrangement from the mothertake over. When the resurgence of sadism is too powerful, the girlmay defensively externalize the sadism onto her mother. Rather than

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fearing her own murderous impulses, she then feels endangered bythe mother’s rage (Dahl, 1995). Competitive feelings may surface de-fensively to establish a more comfortable distance, but this can leadthe girl to experience her development as a destructive surpassing ofthe mother (Dahl, 1995; Laufer, 1986). Moreover, the regressive pullto the mother who took care of the body is a harbinger of an eroticentanglement with her. The girl may ward off the homosexual dan-ger by turning to precocious heterosexuality (Ritvo, 1984). However,the mother may remain fixed unconsciously as the erotically longed-for object the girl is inadequate to satisfy. In a projection, she expe-riences her mother as a “jealously possessive, envious, malignantlydestructive witch-mother” who fascinates and imprisons her (Dahl,1995, p. 196). In order to mask and protect her heterosexual long-ings, the girl regresses to a messy, disorganized presentation that safe-guards her from a fantasized attack.

Beccah’s focus on her body, and the nature of the conflicts arounddevelopmental progression that emerged in the analytic exploration,are in keeping with these expectable characteristics of adolescent de-velopment, albeit marked in specific ways by her history of earlytrauma. The analytic work with Beccah attests to the pervasive, on-going power of annihilation fears and traumatic anxiety, as they in-fluenced her internal experience. Fears of “being overwhelmed,merged, penetrated, fragmented and destroyed” (Hurvich, 2003,p. 579), characteristic in individuals who have experienced an insuf-ficiency of safety (Sandler, 1960), were intrinsic to Beccah’s affectivestate. Laub and Lee (2003), referring primarily to the psychic conse-quence of acts of cruelty, state that trauma “creates a strong impulseto repeat destruction” (p. 460). Beccah understood on a consciouslevel that the trauma befalling her was not a premeditated act of cru-elty. Nevertheless, she experienced it unconsciously as damaging ac-tions against her body and self that had resulted because of hermother, and because of herself. In the state of total dependency ofinfancy and early childhood, her mother was the defective/intactmirror of her damaged self, a rescuing lifeline unable to provide ahaven of safety, or to help her with the regulation of suffering. Nowin adolescence, she experienced sadomasochistic fantasies about sur-passing her mother, which interfered with the development of a viewof herself as an attractive young woman.

Several authors have demonstrated that self and object representa-tions are crystallized around experiences of early medical traumathat lock mother and child in a sadomasochistic relationship. Ken-nedy (1986), describing the analysis of an adolescent boy who suf-


fered from phimosis requiring surgery at age two, detailed how theperception of the mother as “a vicious attacker, whose longed-for at-tention and concern could be attained only by suffering and painand by relinquishing his penis, absorbed, restructured and organizeda whole range of earlier experiences and conflicts” (p. 217–218).Beccah’s “affect storms,” which she enacted in her relationships withothers, can be conceptualized as expressions of her internal repre-sentation of self and objects—a “systematic repetition of the relation-ship between a persecutory, scolding, and derogatory object, and arejected, depressed, and impotent self” (Kernberg, 2003, p. 520).However, as Goldberger (1995) points out in her account of theanalysis of a five-year-old-girl who suffered medical trauma, the pic-ture is more complex. The child who, out of medical necessity, hasexperienced painful maternal ministrations, develops an attachmentto being handled in painful ways; in fact, the gratification obtainedfrom such relationships is “something which is feared, but also lookedto have repeated” (p. 268) so as to prevent object-loss. The analyticwork with Beccah revealed that sadistic fantasies around her early ex-perience (that her mother caused/wished her trauma; that she dam-aged her mother through her defectiveness), and conflict (rooted inoedipal and pre-oedipal wishes wishes that mandated punishment)interfered with the appropriate restructuring of her internal repre-sentations, and kept her locked in a regressive posture of being thedefective child. The excitement of her sadomasochistic entangle-ments, as well as the unconscious connections between health—lossof mother—abandonment/death, that interfered with the develop-ment of an adequate view of herself, required careful interpretationand working through.

Hoffman (2003) comments on the prominent role of aggression inenactment and defense in the traumatized person, in particular thepredominant use of “identification with the aggressor” and “turningpassive into active.” A posture of “nonchalant bravado” is a charac-terologic defense in traumatized youngsters, serving to obscure in-tense object hunger, and passive libidinal object longings, as well asto ward off expectations of repeated rejection and loss (StevenMarans, as reported in Mazza, 2003). Goldberger (1995) commentsthat the incessant need to repeat the traumatic experience is a hall-mark behavior of the victimized child. The data from Beccah’s analy-sis gives evidence of the pervasive nature, and complex function, ofrepetition.

Repetition, which is a function we observe in play, provides nor-mally a much-needed opportunity to re-experience a situation, this

286 Silvia M. Bell

time as the active agent rather than helpless victim. This experiencepromotes the gradual assimilation and mastery of anxiety. Whentrauma is involved, however, the capacity to utilize anxiety as signalfunction is impaired. The ego is, once again, overwhelmed and can-not mobilize defense in response to the affect generated in the pro-cess of repetition. Loewald (1971) regards the revival of the experi-ence in the analysis as “an active recreation on a higher organizinglevel which makes resolution of conflict possible” (Moore and Fine,1990). Hence, one of the functions of the analytic intervention is therestoration of the ego’s capacity to utilize anxiety for adaptation(Yorke, 1986). Beccah’s treatment created an opportunity for con-tained repetition, where she was able to “take an affective sample ofthese basic danger situations, to experience them in miniature” (Yorke,1986). Blum (2003c), underscoring the importance of genetic recon-struction, states that re-experiencing a trauma in the context of thesafety of the analytic situation effects changes in adaptive capacitythat are more congruous with present reality. As the record of Bec-cah’s treatment elucidates, reconstruction did not refer to the accu-rate recall of past events, nor to a simplistic ascription of causationbetween early factors and later pathology, but to the recovery of af-fective experiences which, when understood in light of what wasknown of “the relevant dimensions” of her childhood (i.e., within agenetic context), facilitated the capacity to distinguish between “real-ity 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 om-nipotence, prevents the establishment of self-soothing and self-regu-lating capacities, and disrupts the capacity to recognize mental statesand to find meaning in one’s own and others’ behavior. Referring toFonagy’s concept of “mentalization” (Fonagy et al., 2002), many as-sert that the major goal of treatment is to facilitate the developmentof the capacity to conceptualize and make sense of situations, affectand behavior. The clinical material elucidates that Beccah’s capacityfor affect regulation was seriously compromised, and it had a disorga-nizing impact on her ability to comprehend her internal and exter-nal experience. In the early phase of our work, she experienced aresurgence of the traumatizing childhood feelings that accompaniedher many overwhelming experiences pertaining to her medicalneeds. The affective impact of these experiences, which were re-corded at a procedural (i.e., non-verbal) level, were actualized in thetransference as she felt disoriented in my physical space, and she ex-


perienced me as a dangerous intruder. My interventions aimed tohelp her to make sense of herself in the present, by promoting con-nections between relevant information that was known or inferredfrom her history, and her internal experience then and now, thusmeaningfully integrating past and present at a conscious level. Bec-cah became less impulsive as she became more cognizant of her in-ternal state, and she could begin to identify, and label her affects,and connect them with her thoughts and her behavior. This worktook place in a context of safety, what Fonagy refers to as a therapeu-tic “secure base” (2003), and it promoted the development of a senseof containment, which facilitated the use of affect as signal function.

While these interventions promoted mentalization, and providedher with a new experience of “self with other,” which Fonagy (2003)asserts are the mutative factors in psychoanalysis, the unfolding ofthe clinical material provides evidence of the persistence of the dy-namic unconscious as manifested in the pathologic compromise for-mations that continued to inhibit the developmental process. Un-conscious fantasy and conflict that were integral to her experienceof childhood became increasingly highlighted as the central aspects ofher misery.

As the interpretive work addressed dynamic conflict, Beccah’s ca-pacity to regress and access earlier fantasies and their related affects,deepened. Interpretations that focused her attention on the sense ofdanger attached to her excitement about her new female body, reac-tivated fantasies that ensnared her and her mother in irreparable de-fectiveness. Dahl (2002) states that conflicts over aggression andoedipal desires are defensively concealed by disguising oneself as lit-tle and devalued in relation to the hated, beloved, and feared archaicmother. Beccah began a complex enactment of the experience of be-ing the defective child with mother by bringing her childhood imagefor me to see. This defensive reaction to the intensification of separa-tion wishes and drive derivatives, brought her in contact with her inner-most feelings and earliest childhood fantasies. The immediateresponse to seeing the pictures with me was the resurgence of de-pressive affect. (“I still don’t believe anyone could find me attrac-tive.”) Despite the fact that our work provided an opportunity for acorrective experience (implicit and explicit) to being looked at inchildhood, Beccah would be unable to integrate a new image of her-self until we had addressed the conflicts that surfaced more poi-gnantly in subsequent sessions. Beccah enacted her sense of the utterunreliability of her body, of the helplessness and destructiveness ofher mother, of her fantasy of herself as dangerous and damaging,

288 Silvia M. Bell

which represented the affective experience of her early years and heradaptation to it.

In the course of the analysis, Beccah came to appreciate that sheexperienced her developmentally appropriate wishes in a context ofdanger that reflected her earlier adaptation to her painful past. Weuncovered that she adhered to a devalued view of herself for com-plex reasons intended to restrict her functioning. Because the mean-ing of this experience became accessible to interpretation in the con-text of our work, she was able to achieve a new integration thatreworked the heretofore sadomasochistic aspects of her relationshipwith her mother, and relinquished the defensive use of defectivenessthat interfered with adolescent development. As a result, her affect,her behavior, and the quality of her thought processes increasinglyreflected changes indicative of a modification in the constellation ofintrapsychic factors that determines adaptation. By the time treat-ment discontinued, she gave eloquent testimony about the differ-ences she experienced in herself.

The interpretive work functioned to promote insight, and permit-ted her to achieve “conscious solutions to those conflicts that, whenthey were unconscious, threatened to mobilize anxiety” (Gray, 1988,p. 44). Specifically, Beccah’s attention was directed to the defensivefunction of her sense of defectiveness, which could be observed byher as we noted her tendency to turn to disparaging images of herselfin order to inhibit strivings that felt dangerous. While, as Gray em-phasizes, profound unconscious changes take place as a result of theinfluence of the experience of the analyst-patient dyad, the therapeu-tic aim of a focus on the analysis of resistance, to quote Gray, is “to re-duce the patient’s potential for anxiety, as differentiated from an aimthat merely seeks to reduce the patient’s anxiety” (Gray, 1988, p. 41).In Beccah’s case, depressive affect was also a target, as it became in-volved in compromise formations that relied on turning aggressionagainst her self in a depressive response intended to relieve anxiety(Brenner, 1982).

Each instance when the patient can confirm the connection be-tween their sense of danger and the activities of the mind intendedto relieve that feeling strengthens the capacity to exercise volitionalcontrol over internal forces (Busch, 1999). For example, when Bec-cah recognized that her aggressiveness protected her from the worryabout being overwhelmed by fear, she was better able to evaluate heranxiety and could establish more satisfying relationships with others;when she realized that she experienced being healthy as a harbingerof loss, and understood that thoughts of “defectiveness” kept her safe


from strivings she experienced as dangerous, she was free to pursueher goals and wishes. Given that fantasy and conflict were pervasiveand persistent at the inception of treatment, the significant changesin the patient’s psychic function subsequent to interpretations aimedat the pathologic aspects of compromise can be considered eviden-tial criteria that validate the mutative action of dynamic interpreta-tion in psychoanalysis (Boesky, 1988).

The psychoanalytic method engages complex verbal and non-ver-bal processes of the mind. Analysis is an experience where thepatient increasingly exposes these processes, about which he/she re-mains unaware pending intervention from the analyst. The psycho-analytic intervention requires a specific kind of matching betweenthe mind of the analyst at work, as it facilitates the elaboration of thepatient’s mental processes and elucidates them, and the mind of thepatient at work, engaged in an “effort at self-healing” (Jacobs, 1988,p.66). The congruence of these processes creates a context that en-hances the patient’s capacity for self observation, promotes the affec-tive reliving of inner experience, and stimulates the integration ofpresent in light of past experience that lends meaning to mentalfunctioning. Beccah was able to look forward to leaving home to at-tend college, because she had gained insight into her inner reality,and a sense of her capacity for conscious management of internal im-pulses.

BIBLIOGRAPHY

Blos, P. (1962) On Adolescence: A Psychoanalytic Interpretation. New York: FreePress.

Blum, H. (2003a) Psychoanalytic controversies: Repression, transferenceand reconstruction. In Int. J. Psychoanal., 84:497–503.

——— (2003b) Response to Peter Fonagy. In Int. J. Psychoanal., 84:509–513.——— (2003c) Psychic trauma and traumatic object loss. In JAPA, 51/2:

415–432.Boesky, D. (1988) A discussion of evidential criteria for therapeutic change.

In How Does Treatment Help?, A. Rothstein, ed. Madison, Conn.: Int. Univ.Press, pp. 171–180.

Brenner, C. The Mind in Conflict. Madison, Conn.: Int. Univ. Press.Busch, F. (1999) Rethinking Clinical Technique. Northvale: Aronson.Dahl, E. K. (1995) Daughters and mothers: Aspects of the representational

world during adolescence. In Psychoanal. Study Child, 50:187–204.——— (2002) In her mother’s voice: Reflections on “femininity” and the

superego. In Psychoanal. Study Child, 57:3–26.

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Fonagy, P. (2003) Rejoinder to Harold Blum. In Int. J. Psychoanal., 84:503–509.

Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002) Affect Regulation,Mentalization, and the Development of the Self. New York: Other Press.

Freud, S. (1926) Inhibitions, symptoms and anxiety. SE, XX: 87–174.Goldberger, M. (1995) Enactment and play following medical trauma: An

analytic case study. In Psychoanal. Study Child, 50:252–271.Gray, P. (1988) On the significance of influence and insight in the spectrum

of psychoanalytic psychotherapies. In How Does Treatment Help?, A. Roth-stein, ed. Madison, Conn.: Int. Univ. Press, pp. 41–50.

Hoffman, L. (2003) Vicissitudes of aggression: Theoretical and technicalapproaches to psychic trauma. In JAPA, 51/2:375–380.

Hurvich, M. (2003) The place of annihilation anxieties in psychoanalytictheory. In JAPA, 51/2:579–616.

Int. J. Psychoanal. (2003) 84: part 3.Jacobs, T. (1988) Notes on the therapeutic process: Working with the young

adult. In How Does Treatment Help?, A. Rothstein, ed. Madison, Conn.: Int.Univ. Press, pp. 61–80.

Kennedy, H. (1986) Trauma in childhood: Signs and sequelae as seen in theanalysis of an adolescent. In Psychoanal. Study Child, 41:209–219.

Kernberg, O. (2003) The management of affect storms in the psychoana-lytic psychotherapy of borderline patients. In JAPA, 51/2:517–545.

Laub, D. & Lee, S. (2003) Thanatos and massive psychic trauma: The impactof death instinct on knowing, remembering, and forgetting. In JAPA, 51/2:433–464.

Laufer, M. E. (1986) The female oedipus complex and the relationship tothe body. In Psychoanal. Study Child, 41:259–276.

Mazza, D. (2003) Dangerous behavior in children and adolescents. In JAPA,51/2:651–666.

Poland, W. (2000) The analyst’s witnessing and otherness. In JAPA, 48/1:17–35.

Ritvo, S. (1984). The image and uses of the body in psychic conflict. In Psy-choanal. Study Child, 39:449–468.

——— (1989). Mothers, daughters and eating disorders. In Fantasy, Mythand Reality: Essays in Honor of Jacob A. Arlow, Blum, Kramer, Richards, &Richards, eds. Madison, Conn.: Int. Univ. Press, pp. 371–380.

Sandler, J. (1960) The background of safety. In Internal. J. Psychoanal.,41:352–365.

Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books.Winnicott, D. (1971) Playing and Reality. New York: Basic Books.Yorke, C. (1986) Reflections on the problem of psychic trauma. In Psycho-

anal. Study Child, 41:221–236.


PSYCHOANALYTIC

PERSPECTIVES ON THE

FUTURE AND THE PAST

Psychoanalytic Reconstructionand Reintegration

HAROLD P. BLUM, M.D.

Psychoanalytic reconstruction has declined in theoretical and clinicalinterest as greater attention has been directed to the here and now of thetransference—counter-transference field and inter-subjectivity. Trans-ference, however, is based upon childhood fantasy, and is a new edi-tion of unconscious intra-psychic representation and relationships. Inthis paper transference is viewed as a guide to reconstruction, buttransference itself is also an object of reconstruction. Reconstruction isa complementary agent of change, which integrates genetic interpreta-tions and restores the continuity of the self. The patient’s childishtraits, features, fixations, and irrational childish fantasies and behav-ior point to the necessity for reconstruction. Reconstruction organizesdissociated, fragmented memories, potentiating the further retrieval ofrepressed memories. Reconstruction is essential to the working throughand attenuation of early traumatic experience. Recapture of the past isnecessary to demonstrate and diminish the persistent influence of thepast in the present, and to meaningfully connect past and present. Acase is presented in which reconstruction had a central, vital role inthe analytic process.

Clinical Professor of Psychiatry, New York University School of Medicine, Trainingand 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 PsychoanalyticTheory and Practice” 2/2003 (XVIII) © 2003 Stroemfeld Verlag, Frankfurt am Main/Basel, published here in English with the permission of Stroemfeld Verlag.


295

in its second century, psychoanalysis has moved in many newdirections, often with increasing distance from its origins and coreformulations. Psychoanalytic reconstruction has been treated eitherwith neglect or declining interest as attention has turned to otherpsychoanalytic issues and agents of change. Psychoanalysis itself isnot regarded as particularly popular in many parts of the world to-day, and reconstruction has particularly fallen out of favor as therehas been more immediate attention and emphasis on the here andnow, inside and outside psychoanalysis. Actually, analysts and pa-tients have pondered the question of where the patient was comingfrom, and how he or she got there. It is not only the adopted childwho is curious about his/her origins, but all persons and peoples.Nations have legends about their origins, which are constructionscompounded of fact and fantasy. Freud (1919, p. 83) asserted: “ana-lytic work deserves to be recognized as genuine psychoanalysis onlywhen it has succeeded in removing the amnesia which conceals fromthe adult his knowledge of his childhood . . . This cannot be saidamong analysts too emphatically or repeated too often . . . anyonewho neglects childhood analysis is bound to fall into the most disas-trous errors. The emphasis which is laid here upon the importanceof the earliest experiences does not imply any under-estimation ofthe influence of later ones.” Extending my previous work on the the-oretical and therapeutic value of reconstruction (Blum, 1980, 1994,2000), this paper supports reconstruction as inherent to the psycho-analytic point of view and virtually all clinical work. In my view, recon-struction is not only reciprocal to transference interpretation in thepresent, but it is a complementary agent which guides and integratesinterpretations and reorganizes and restores the continuity of thepersonality.Reconstruction for Freud was both a technique, a means toward

the goal, and a goal of psychoanalysis. Experience such as the birthor death of a sibling had an impact on the patient’s life, permanentlyinfluencing the personality. Freud (1937, p. 26) illustrated such aprototypical reconstruction, “Up to your nth year you regarded your-self as the sole and unlimited possessor of your mother; then cameanother baby and brought you grave disillusionment. Your motherleft you for some time; and even after her reappearance she wasnever devoted to you exclusively. Your feelings toward your motherbecame 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

296 Harold P. Blum

specific and focal, and it traces, for example adult obesity, to child-hood conflicts concerning feeding and object loss. Genetic interpre-tations are fostered by the regressive character of free associationand transference. Reconstruction would encompass broader consid-erations, e.g. of dependent relationships, concurrent parental re-gression, inability to mourn and accept loss, identification with thelost object, etc.Reduction of the transference to its childhood roots and the accu-

mulated analytic data converge in a reconstruction, which in turnfurthers the analytic process. Contrary to the current position insome analytic quarters, that such genetic data are co-determined bythe analyst’s suggestion or countertransference, the childish charac-ter of the transference, the patient’s childish traits, features, fixa-tions, and irrational childish fantasies point to the childhood locus ofpathogenesis and the patient’s psychopathology. Although analyticwork requires the reconstruction of childhood (Freud, 1937), thisdoes not mean that any two reconstructions by two different analystswill be identical. Each analyst will select, organize, and interpret thedata with some degree of theoretical and personal preference. Theanalyst’s countertransference may make it difficult to analyze thetransference, or from another point of view, it may provide furtherinsight into the patient’s conflicts, the transference, and the patient’sresistance in the analytic process. The analyst’s analytic attitude, selfanalysis, education, and experience should contain and limit the an-alyst’s 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 longbeen complemented by infant observational research and childanalysis. The reconstruction of childhood takes into account affec-tive, cognitive, and moral development. Reconstruction considersthe overlap and sequence of developmental phases, and the uniquequality of individual endowment and experience. Because of the the-oretical implications of reconstruction, it has been used from the be-ginnings of psychoanalysis to propose, confirm, or challenge a theo-retical or developmental hypothesis.As analysis proceeds, the wealth of associations, memories, trans-

ference reactions, etc. provide a foundation for the process of recon-struction. Usually there are a number and variety of reconstructionsrather than one grand encompassing reconstruction. Like interpre-tation, reconstruction is neither arbitrary nor capricious nor dog-matic. All too often what is depicted as analysis in popular distortionsand misconceptions is a parody of the psychoanalytic process. A cari-

Psychoanalytic Reconstruction and Reintegration 297

cature of the psychoanalyst as insensitive, insistent, robotic, and self-serving is deployed to defend against the authentic yet disturbingnature of analytic insights. Self-protection is preferred to self-knowl-edge. When a reconstruction is offered to the patient, it is a productof prior analytic work, tentative and always an approximation. Psy-choanalysis and the process of reconstruction are not based on faith,dogma, or conjecture, but on evidence, inference, and further con-firmation or alteration with new data. Fragmented, dissociated, andrepressed memories emerge and have to be differentiated fromscreen memories and pseudo-memories. Screen memories are oftensimilar to the patient’s constructions.Our knowledge of memory has significantly advanced in the re-

cent decade. Bridges are under construction between psychoanalysisand neuroscience, and both disciplines should benefit. Several mem-ory systems are now recognized. These systems appear to have theirrespective modes of registration, storage, and retrieval with interre-lated functions and controls. Autobiographical memory is closelyconnected to declarative, explicit, usually conscious verbal memoryfor persons and places and general knowledge. Procedural, implicitmemory for skills, e.g. riding a bicycle, playing the piano, is not con-scious, though not repressed, and is not modified as a consequenceof psychoanalysis. At this time the dynamic unconscious has not beendefinitely delineated within any specific memory system or configu-ration. Traumatic memory is an exception, however, and appears tobe processed differently from other memory. Severe trauma altersthe structure and the memory function of the hippocampus. Uncon-scious traumatic memory is essentially formed in the amygdala (LeDoux, 2002), which appears to instigate automatic fight-flight reac-tions to stress. These findings illuminate the complexity of memoryand the necessity of reconstruction superseding the limitations ofdiscrete memory.Patients sometimes offer reconstructions before the analyst. In any

case, reconstruction will be invoked in analysis unless the past contin-ues to be resisted and avoided. If the past and present have not beenmeaningfully interconnected, then the patient’s defenses have notbeen sufficiently diminished. The past will continue to influence thepresent, but the past may also defend against the present. A patient,for example, preferred to reconstruct her childhood strife with hermother, rather than scrutinize her derivative overprotection andover-indulgence of her daughter. Any confrontation with her daugh-ter was to be strenuously avoided. The present as well as the child-hood past may be viewed through a glass darkly.Before the reconstruction is verbalized and offered to the patient,

298 Harold P. Blum

the psychoanalyst has been building a mental construction of the pa-tient’s childhood. Based on the patient’s presenting symptoms andcharacter, the life history described by the patient, and the initialtransference reactions of the patient along with the analyst’s counter-transference responses, construction evolves. Construction is an ini-tial preliminary formulation, which goes on silently in the analyst’smind, particularly concerning the nature of the patient’s psycho-pathology and its relationship to pathogenesis. Construction is thusan initial set of hypotheses about the patient’s unconscious conflictsand character structure which is not shared with the patient andwhich develops during the opening phase of psychoanalysis (Green-acre, 1975; Blum, 1994). Differentiated here from construction, re-construction is generally formulated after the opening phase of anal-ysis and is shared and shaped with the patient.In the material that follows I shall focus primarily on reconstruc-

tion. This will allow a deeper understanding of the significance of thechild that lives on within the adult, the persistence of childish fea-tures and fixations within the adult personality, and the revival ofchildhood in the patient’s regressive responses. This is not to say thatthe child in the adult is ever revived as he/she actually existed inchildhood. Childish reactions in the adult may or may not serve theiroriginal defensive and adaptive functions, and there may have beendevelopmental transformation of meaning and function. The adult’spresent personality and life situation influences the form and con-tent of childhood revivals. Reconstruction of the patient’s past is nec-essary to demonstrate the persistent influence of the childhood pastin the present, but contemporary reconstruction also demonstratesthe influence of the present in the way the past is revived, re-experi-enced, and understood. The archeological metaphor which Freudoriginally used in his description of reconstruction as reclaiming theburied past is still apt in many respects. “His work of construction, orif it is preferred, of reconstruction, resembles to a great extent anarcheologist’s excavation of some dwelling-place that has been de-stroyed and buried or of some ancient edifice. . . . except that the an-alyst works under better conditions and has more material at hiscommand to assist him, since what he is dealing with is not some-thing destroyed but something that is still alive . . .” (Freud, 1937,p. 259). Patient and analyst develop rational conviction about a re-construction based upon analytic knowledge, observations, infer-ences and their cohesive integration. Reconstructions have transfer-ence and counter-transference meaning, however, so a patient’sreaction to reconstruction becomes part of the analytic process.Some of the main features of clinical reconstruction will be illus-


trated in the following clinical material. The primary case report isthat of the analysis of a white male in his thirties who held an aca-demic position. He was gaining increasing recognition and was devel-oping a consulting practice, which made private psychoanalysis possi-ble. He sought treatment because he suffered from intermittentdepression with feelings of poor self-esteem. He was quite conflictedand indecisive with respect to their relationship. He felt that theanalysis was necessary, and he anticipated it would be painful to ex-pose his vulnerabilities. He hoped to develop a more positive confi-dent self-image, and greater self-esteem and to become more success-ful in his life goals. He was completely naïve about analysis and at thesame time, seemed to have an intuitive grasp of what was expected ofhim. He was fascinated with the idea of “everything means some-thing.”During the first half year the patient remained interested, enthusi-

astic, and motivated. He was very intelligent and seemed very cooper-ative. This honeymoon period did not last and what then emergedwas a person who expressed himself in two different ways, almost as ifhe were two different people. Frequently his language was crude,with poor grammar and frequent curses and obscenities. On theother hand, he would make frequent literary allusions, quotingShakespeare, Proust, Joyce, and other authors. He was capable of us-ing a very large excellent vocabulary and subtle expressions, just ashe was capable of using crude language riddled with profanity. He al-ternated between curiosity and indifference regarding his two con-trasting language styles. He also had two different ways of relating tothe analyst, and similar expectations of how the analyst would relateto him. He expected his analyst to be in either a crude and uncon-trolled dangerous closeness, or to be more distant and cultivated. Heindicated that he was afraid he would become too dependent on theanalyst and analytic process. The analysis had become one of themost 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 weretwo women in his life. While living with his girlfriend, presumably ex-clusively, he actually saw other women, primarily his ex-fiancee. Hislover had resumed sexual relations with the patient during the timethat he was living with his present girlfriend. He actually becamecloser to his former fiancee whom he began to visit regularly. He wasafraid to reveal this to his girlfriend for fear that she would rejecthim. He was divided between his two conscious loves, his present andformer girlfriend. This had now become intolerable. His divided love

300 Harold P. Blum

and loyalties, and his guilt toward these women, were major reasonsfor his seeking psychoanalysis.When his girlfriend learned about his “affair” with his former fi-

ancee, she repeatedly told the patient that had hurt her deeply, andthen she broke off all contact with him. Separation reactions acti-vated in the transference. He was reluctant to leave sessions, and onFriday 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 mur-der in the waiting room. Although he was afraid of getting caught, hehad somehow left the magazine open to that page. He then recalledthat in adolescence he had found his father’s pornographic pictures.Disgusted, but excited, he masturbated with these pictures. He was soafraid of being discovered that he replaced them exactly as he foundthem. He thought his parents were shameful hypocrites. When hehad asked for the analyst’s card, he was unconsciously referring to hisfather’s pornography, wondering if the analyst were trustworthy or alascivious hypocrite.This led to feelings about morality and specifically religion. He

wondered if the analyst were Jewish. He had grown up in an anti-Semitic milieu with contempt of Jews. In a Catholic college he hadtold a fellow that he had no use for any Jews and this person de-clared, “I’m Jewish.” The patient was stunned and mortified. In hisview, though weaklings, Jews could be ruthless and they did the dirtywork (like servants). Later he began to examine the many stereo-types of his childhood. He was unconsciously afraid that the possiblyJewish psychoanalyst would encourage immoral thoughts and acts.On the couch he was vulnerable; he felt feminine and was homopho-bic. The patient was dimly aware of his fear of all women and pre-ferred to think of them as asexual Madonnas. As a child he had won-dered about sounds coming from the thin partition of his parents’bedroom, and as an adolescent he audited their sexual relations andwas sexually aroused. His adolescence was burdened by guilt andfears of punishment.At this point the analyst could reconstruct the patient’s reactivated

primal scene fantasy and sibling experience during his childhoodand adolescence, which reflected in all his current relationships. Hehad slept in the same room as a sister until puberty, undressing to-gether. His removal from their bedroom at puberty convinced him ofhis sinfulness and motivated his urge to confession in church andlater in analysis. His masturbation while looking at the parentalpornography was unconsciously incestuous, and he was fearful of the


incestuous voyeurism, exhibitionism, and sibling sex play. He wasguilty and anticipated punishment for his incestuous fantasies. Thesecret of his affair was tied to the secrecy of the primal scene, his sib-ling experience, and his unconscious fantasy of impregnating sisterand mother. After this reconstruction he could understand his fearof intimacy. The patient spoke again of the hypocrisy of his parents,their own crude behavior, their not setting limits, and their implicitcondoning of inappropriate sibling intimacy. His attention turned tohis irrational fear of the analyst’s cruel and dirty impulses and thento recollections of parochial school. The priests and nuns were sup-posed to be kindly but they were frequently cruel. They too were un-reliable hypocrites. He then described physical abuse, endless repeti-tions of prayers, and penance for minor infractions. He had despisedthe Jews in part as a defense against his ambivalence toward theChristian 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 difficultyin paying the analyst, ostensibly because he did not have an envelopein which to enclose the check. The bare check would be nude, notproper, but pornographic. Payment led to associations about dirtymoney, greed, and the analyst becoming enriched through the pa-tient’s efforts and expense. A very important childhood theme thenaffectively emerged in the center of analytic work. The patient hadgrown up in New England, mostly on large estates in which his par-ents worked as servants. He was the son of servants, within a socio-economic class system. The analyst reconstructed the influence ofthe servant experience on his fear of being compliant and depen-dent, his fragile self-esteem and compensatory striving for social sta-tus and affluence. His father was a tyrant at home but deferential andsubservient toward his rich employers. The patient too had to knowhis place. He recalled with humiliation and rage how his father madehim walk to the back door, the servant’s entrance, and how he hatedbeing a caddy, carrying golf clubs for affluent adults to earn extramoney. The patient had played with a Jewish employer’s son, but theywere not allowed to eat together in the main dining room, nor did heknow proper etiquette. The primary house of his childhood was actu-ally a cottage on an estate, servant’s quarters. He realized this ac-counted for the lack of boundaries and privacy since the few smallrooms had flimsy walls. The two different styles of language and man-ners, which had appeared in the transference, could now be recon-structed as related to his early experience, that of observing twoclasses, his parents and the estate owners with different styles of lan-

302 Harold P. Blum

guage and dress. He identified with his parents of the servant classand also with the aristocratic parents. He had not been aware of hisdual identifications, languages, and ambivalent attachments. He hadlived in two worlds which were dissociated; ego integration was possi-ble 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” at-tempted to devalue what they did not have. He should have beenrich, and what a better life he would have if he were the son oradopted son of the nobility. Yet his identification with the cultivated,educated, refined aristocrats proved to be a very important factor inthe patient seeking higher education and developing many culturalinterests. He displayed the superficial accoutrements of affluence,and elegance but he knew that deep inside he had a servant mental-ity. Secrecy had also referred to the social devaluation of servants,which he regarded with shame and humiliation. Moreover, servantsknew some of their employers’ secrets, and could know too much.Acting servile and submissive was unconsciously associated with be-

ing feminine, with being Jewish. Anything that reminded him, or wassuggestive of being submissive or subjugated, enraged and fright-ened the patient. He transiently thought of quitting analysis ratherthan lying compliantly on the couch. He needed to be clean andneat, not only because of his guilt, but because of the dirty work ofhis parents. His father had done manual labor, and his mother prob-ably served as a maid. He felt compassion and pity, but also con-tempt, for manual laborers and for the lower class. He identified notonly with the values of the aristocracy but also with their condescend-ing, haughty superiority toward their servants. He admired and ideal-ized their prestige and power. He wanted to realize grandiose om-nipotent fantasies and to never again be subjected to being humbleand humiliated.A flood of painful memories returned, integrated in the recon-

struction of the patient’s childhood as the son of servants. Thewealthy estate owners had referred to his parents by their first namesor without a name. The patient saw this as a lack of respect, treatinghis belittled parents as if they were children. He thought that one ofthe reasons they worked on different estates was that his parents hadbeen summarily dismissed from some of their jobs. Apparently someof the estates were owned by descendents of the “Robber Barons,” in-fluential individuals who inherited great wealth from the financialmanipulations of their forebears. The estate owners, partially throughprojection, feared that their servants would engage in theft. The pa-


tient had fantasies of acquiring great wealth by defrauding the rich.In the analysis he wondered about concealing his still rising incomeso that he would not have to raise the fee. In fantasy he was thegreedy thief, the Robber Baron, a role formerly assigned to his ana-lyst and Jews. He realized that he, his parents, and the aristocrats allhad a common religion—they 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, andhumiliation. The analyst pointed out that the patient’s view of his ser-vant parents was that they had to swallow their pride. As servants theyhad been fed and swallowed a steady diet of denigration. The patienthad a fleeting coprophagic fantasy; he identified with his degradedparents, but also was hungry for money and its power. On one levelhe regarded his parents as shameless, but he identified with theirsilent compliant acceptance of shame and humiliation. The patientwanted to erase, reverse, and revenge the humiliations. The analystreconstructed the patient’s organizing his life around overcomingany narcissistic injury, obtaining narcissistic supplies, and becomingan aggrandized aristocrat. As a consequence of the reconstruction,many of his disconnected thoughts, memories, and feelings were or-ganized into a cohesive, coherent, meaningful constellation. Hecould reflect on the family life of servants. He had fantasized that hewas not the child of the servants, but the masters. He was of, or des-tined to be, the nobility. The reconstruction unified what had been adouble identity, prince and pauper, servant and master. He had twolanguages, two sets of parents, two women, and two polarized sets ofattitudes toward people and society. His self and object world hadbeen split between idealized and denigrated childish representa-tions. In a parallel reconstruction, he had taken upon himself or hadbeen delegated by his parents to redress their narcissistic mortifica-tion, to overcome the family shame, and turn humiliation into prideand glory. He rebelled against any idea of being subservient towardhis analyst. He would not be treated with contempt by his analyst orany authority, but would rise to the superior status to which he wasentitled, like the landed aristocracy.The patient could see that some memories defended against much

more disturbing memories of his adolescence and childhood. Thesecrecy of his ex-wife’s illegitimate child, the secrecy of sibling sexplay, the secrecy of the primal scene were associated with the child’ssecrecy and confusion concerning his parents’ denigrated status.Why their job dismissals and moves? Servants had no job security and

304 Harold P. Blum

no status. Were they actually fired because they committed rob-beries? Frequently paid in cash, they avoided income tax. Did theydeserve punishment? Were they without self-respect, and/or secretlyenjoying humiliation? What had led to their becoming servants? Didhis parents also idealize and identify with the aristocracy, basking intheir reflected glory, while denying their own devaluation? Did theywish to be adopted as he did by the estate owners and analyst in a fa-milial family romance just as he had, now manifest in wishes to beadopted by the analyst (Freud, 1909; Frosch, 1959)? The reconstruc-tion gave him insight into his thoughts and feelings about the pastand his plans for the future. It allowed greater access to the negativefeelings of guilt, shame, and humiliation, his low self-esteem, his fearof failure, and his drive for success.The reconstruction elucidated to the patient’s intrapsychic fan-

tasies and responses to his pre-adult experiences. He was less con-fused by his pendulum-like swings between his feeling affluent andindigent, aristocrat and servant, master and slave. The reconstruc-tion did not compete with nor defend against transference interpre-tation, but advanced understanding of both transference and geneticinterpretation. The recovery of dissociated, forgotten, and repressedmemories reciprocally facilitated reconstruction.Although Freud noted that reconstruction may serve as a convinc-

ing surrogate for a memory that could not be retrieved from repres-sion, his basic premise was developmental and dealt with a forgottenpiece of childhood. Freud reconstructed a part of the analysand’s de-velopment, with pathogenic or progressive ramifications. Freud’s(1937) formulation went far beyond a single memory or element:“What we are in search of is a picture of the patient’s forgotten yearsthat shall be alike trustworthy and in all essential respects complete”(p. 258). Freud added that the task of the analyst “is to make out whathas been forgotten from the traces which it has left behind, or morecorrectly, to construct it.” Freud (1920) anticipated the contempo-rary developmental issues in reconstruction, and early differentiatedbetween genetic and developmental perspectives.

So long as we trace the development from its final outcome back-wards, the chain of events appears continuous and we feel we havegained in insight, which is completely satisfactory or even exhaustive.But if we proceed the reverse way, if we start from the premises in-ferred from the analysis and try to follow these up to the final result,then we no longer get the impression of an inevitable sequence ofevents, which could not have been otherwise determined. We noticeat once that there might have been another result, and that we might


have been just as well able to understand and explain the latter. Thesynthesis is thus not so satisfactory as the analysis. (p. 167)

The problem of reconstructing developmental steps and se-quences, of tracing the over-determined numerous factors of patho-genesis both evokes and challenges reconstruction. The issues of ge-netic fallacy and adultomorphic myth are further complicated by thepossible confusion of pathological regression, normal development,and deviant development; by the number of factors and variedstrength of forces involved; and by the discontinuities which have tobe bridged. Reconstruction is made possible by the wealth of infor-mation provided by the analysis. But it is never a singular, veridical“red thread” of connections. The reconstructive inferences dependupon the totality of analytic data, and not just the transference alone,on the elaboration and remodeling of the reconstruction in the cru-cible of the analytic process. How could this patient understand hismaster-slave fantasies, his feelings of emasculation and inferiority, hisoverall preoccupation with narcissistic injury and self-aggrandize-ment without the affective reconstruction of his childhood?Some of the unresolved analytic issues in this case are of great in-

terest. The genetic interpretations, and the reconstruction to whichthey were attached, did not fully explain the patient’s psychopathol-ogy. So far the classical explanation of the patient’s disorder was interms of oedipal conflict. Were there not also primary narcissisticand pre-oedipal issues, which were important antecedents of laterconflict? Of course the further back into the pre-oedipal period a re-construction is attempted, the more speculative it inevitably be-comes. The earlier the level of reconstruction, the greater the levelof conjecture. What was his early experience with his mother? Shewas stoic in her menial work of cleaning and laundering. Some of theambivalence toward his father may have been transferred and dis-placed from his mother. She was not described in warm terms andwas regarded as rigid and unempathic. She was quite possibly de-pressed during his early childhood, hardly playful. It is likely that hisfeeding, sleeping, and toilet training were rigidly controlled. Was hismother the prototype of the rigid, insensitive, callous nun? Mothercould be a Madonna-like figure who protected him from his own im-pulses, but also an exciting and emasculating prostitute. He stated,“I’m uncomfortable with cracks in the edifice I have created.”Women were cracked, tempting, and dangerous; they were split intodegraded pairs of prostitutes and nuns. Only after more analysiscould he admit that some of the clergy were dedicated and effective

306 Harold P. Blum

educators. There were few if any parties in his childhood, and holi-days were not celebrated. He had never had a birthday party, thoughthe patient was aware that the aristocrat’s children on the estate hadsuch parties. His father was not sure about his son’s birthday.The atmosphere of home was somber. His parents’ relationship

was not marked by overt affection and friendship, and they were littleinterested in their children’s feelings. If he did not like the food hewas offered, he was expected to eat it without complaint, so that hispreferences were largely ignored. In later childhood he was painfullyashamed of his parents and strenuously defended against feelings ofshame. His parents conveyed their feelings of denigration to theirson, but they and the aristocrats encouraged both his later achieve-ment and entitlement.Transference analysis and reconstruction were synergistic rather

than competitive or adversarial. The reconstruction was regarded asmutative, “making a decisive difference in clinical analysis . . . thepast within the present is transformed forging a new vision of reality”(Blum, 1994, p. 150). In the process of reconstruction, self-represen-tations as well as object representations from various phases of lifeare re-evaluated and reintegrated into new and more realistic repre-sentations. Not only were the defenses modified, but also the pa-tient’s 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 affectiveprocesses. What the patient cannot remember and articulate has tobe laboriously reconstructed. Somatization reactions and non-verbalcommunication may be at least initially of great importance. Recon-struction may contribute to the retrieval and reorganization of frag-mented, distorted, memories, as well as filling in memory gaps. Without the reconstruction of memory what is indescribable and in-effable may be somatized, enacted, or acted-out through the chil-dren, the next generation. To avoid a collusion of silent avoidance,reconstruction is required of the trauma, terror, and panic, of thefeelings of helplessness, and of the void of protecting or rescuing ob-jects (Grubrich-Simitis, 1981; Krystal, 1991; Blum, 1994). An attemptis made to clarify the details of the traumatic situations, and whennecessary, 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 in-tegrated into the relatively intact personality. The verbal reconstruc-tion coalesces with step-by-step working-through of trauma and terror. This permits the massive trauma of the past, recalled and re-


constructed, to belong to the past rather than the ever present. Fur-ther analytic reconstruction may encompass prior and subsequenttraumatic experience, telescoped into the maelstrom of massivetrauma.I shall now turn to the early facilitating value and integrative

effects of reconstruction psychoanalysis and in insight oriented psy-choanalytic psychotherapy. While it is true that reconstruction is notnecessarily a part of psychotherapy as it is in psychoanalysis, recon-struction is often utilized to help the patient become aware of thepower and persistence of childhood fantasy and experience intotheir adult lives. Transference and current reality may take prece-dence, but at the same time, reconstruction may be necessary to illu-minate the transference and the current reality situation, which thepatient has helped to create. A borderline patient, who is bitterly crit-ical and contemptuous of the analyst, may not respond to the ana-lyst’s attempts to show the patient that the attacks on the analyst areirrational and unjustified. The psychoanalyst regards the patient’scriticism as part of transference fantasy, whereas the patient believesthat the analyst truly merits criticism. The analyst has a negativecounter-transference, about which he is inwardly conflicted. The pa-tient has succeeded in eliciting the psychotherapist’s hostility, justify-ing in his mind his criticism of the analyst. A transference-counter-transference stalemate might ensue.There are different approaches to such thorny problems, but early

reconstruction can be very helpful, to the psychoanalyst as well as tothe patient. This is a departure from the general use of reconstruc-tion after the initial phase of therapy. The exception here is notmeant to detract from Freud’s (1940) counsel, “we never fail to makea distinction between our knowledge and his knowledge. We avoidtelling 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 discov-ered. We reflect carefully over when we shall impart the knowledgeof one of our constructions to him . . . which is not always easy to de-cide” (p. 178).Where the patient has experienced a pathogenic relationship with

a parent involving regular overdoses of criticism, contempt, and dis-paragement, the therapist could point out that the patient had expe-rienced withering criticism long before his treatment. His feelings ofmistreatment derived not from the present, but predominantly fromthe past with his parent. The patient has identified with the aggressorand was treating the therapist to the same disparagement to which hewas subjected. The patient had become the critical parent and the

308 Harold P. Blum

analyst is treated as the child whom the parent holds in contempt ofcourt. Without this reconstruction of a piece of the patient’s child-hood, it may not be possible for an ego impaired patient to distancehimself from the transference as well as to understand and accepttransference interpretation. Furthermore, the reality of a patient be-ing contemptuous and insulting toward others in his life situation,may still be readily subjected to projection and rationalization thatthe others deserved his animosity.The adult woman who is seductive and exhibitionistic in an erotic

transference may have similar dynamics. Seduced by an older brotherinto sibling sex play, she is now the active seducer. This would be aspecific genetic interpretation. She gains control over the analyst infantasy and unconsciously seeks not so much his falling in love withher, but his downfall. In this case the erotic transference recapitu-lates the sibling relationship, and defends against an underlying hos-tile fantasy of emasculating the analyst and destroying his reputation.The reconstruction integrates and explains her seductive behavior asrepetition 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 reconstruc-tions presented here were essential to the analytic and the therapeu-tic process and progress. It is difficult to understand how analytic ex-perience without the insights enriched by reconstruction wouldsignificantly alter unconscious, unrealistic self and object representa-tions, as proposed by inter-subjective theorists. An emphasis on themutative effect of the here and now analytic experience takes ac-count of the influence and effect of the analyst’s counter-transfer-ence and subjectivity, but with loss of balanced focus on childhood,and patient’s infantile neurotic fantasies and features. The analystalso engages in reciprocal self-examination and counter-transferenceanalysis. The value of reconstruction is exemplified in the clinicalmaterial in which the past so prominently influences the present and impinges on the future. Without reconstruction, psychoanalysistends to become a-historic, dissociated from the infantile uncon-scious, and the context and shaping of life experience. Reconstruc-tion restores the continuity and cohesion of personal history, correct-ing personal myths while simultaneously fostering greater and morerealistic self-awareness, knowledge, and insight. Spanning life experi-ence, 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 patient’s response to the


reconstruction. Individual fantasy and experience may coalesce withuniversal fantasies and the universals of life experience, but there arealways individual variations. This is exemplified in the family ro-mance of the son of servants. A reconstruction should be internallyconsistent and cohesive, logical and lucid, and closely linked to theprevailing unconscious conflicts and analytic issues. While it may re-place gaps in memory, reconstruction has a different contemporaryposition in the theory of technique, deriving from and applying thegenetic and developmental points of view in clinical psychoanalysis.In contemporary psychoanalysis, reconstruction has largely sup-planted reliance on the recovery of repressed memory. Patterns aremore important in general than are single memories, with the majorexception of shock trauma. Reconstruction also has an importantcurrent research dimension, testing and potentially integrating ana-lytic data with the findings of infant developmental studies.Validation and conviction are not necessarily achieved. Either ana-

lyst, analysand, or researcher may be much more convinced of the va-lidity of a reconstruction than the other persons. While Freud attimes shifted positions concerning the relative importance of fantasyand real experience, he never relinquished the importance oftrauma. Freud (1926) referred to the sometimes “irrefutable evi-dence that these occurrences which we inferred really did takeplace” and he then stated, “The correct reconstruction, you mustknow, of such forgotten experiences of childhood always has a greattherapeutic effect, whether they permit of objective confirmation ornot” (p. 216). Unlike the past when non-analytic data tended to bedismissed or scorned as impediments or contaminants in the analyticprocess, such concerns are no longer regarded as entirely appropri-ate. External confirmation can be analytically useful and contributeto rational validation and conviction of correct reconstruction(Good, 1998). Patients are stimulated to check and correct recon-structions whenever possible through objective evidence, e.g. of doc-uments and the reports of relatives and witnesses. It is remarkablehow often psychoanalytic reconstructions are confirmed and ex-panded with extra-analytic evidence. However, no source or selectionof data is inherently free of distortion. The legal system has painfullylearned that eyewitness reports may not be reliable.The past is not only rediscovered but is recreated in clinical psy-

choanalysis. Memory is remodeled. The past has taken on elaboratenew meanings, which did not exist in childhood. Moreover, develop-mental transformations may not be retrievable in their pristine form.The “second look” (Novey, 1968) at childhood is through analytic

310 Harold P. Blum

eyes with the refraction of an adult lens. Though the analytic autobi-ography is further illuminated and integrated by a particular recon-struction, there are no guarantees in analysis of valid reconstructionor interpretation. Psychoanalysis requires tolerance and evaluationof alternative considerations. Ambiguity and perplexity are part ofpsychoanalytic work and the quest for greater insight. In addition toFreud’s (1911) two principles of mental function, the pleasure andreality principles, we live and work with the uncertainty principle(Heisenberg, 1958).

BIBLIOGRAPHY

Blum, H. (1980). The value of reconstruction in adult psychoanalysis. Inter-nat. Psychoanal., 61:39–54.

——— (1994). Reconstruction in Psychoanalysis. Childhood Revisited and Recre-ated. 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 experi-ences 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: Aten year retrospective. Amer. Imago, 48:93–118.

Laub, D. (1998). The empty circle: Children of survivors and the limits of re-construction. J. Amer. Psychoanal. Assn., 46:508–529.

LeDoux, J. (2002). Synaptic Self: How Our Brains Become Who We Are. NewYork: Viking.

Novey, S. (1968). The Second Look. Baltimore: Johns Hopkins UniversityPress.


If a man carefully examines his thoughts he will be sur-prised to find how much he lives in the future. His wellbeing is always ahead.

—Ralph Waldo Emerson

it seems that only man imagines the “winter of his discon-tent,” or the “glorious summer.” No other living being can hold animagined future before the mind, and has the responsibility of its op-portunities and dangers. But we who have this comforting and tor-menting companion of inner thought extending beyond the mo-ment 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 oftendiscover we’ve been quietly including the future anyway. The psy-chology 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 andanticipation, and although attention to the future is implicit in muchanalytic writing, I found no papers on the specific concept of fore-sight 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 fu-ture. In addition, reconstruction of the past, and recovery of re-pressed, has been so useful a focus of clinical work. The neurotic partof us is in the grip of the past. In fact, one way to view neurosis is as atruncation of realistic foresight, as the past is repeated over and overagain, 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 fromattention to the subject.This paper is an introductory effort to explore our concern about

the future and to consider what might be reasonable possibilities andlimitations of our attempts at foresight. It is not about knowingevents in advance, about prediction of specifics, about foreknowl-edge. It is about forms of anticipation that do not transcend oursenses, experience, and judgment. A mature imagination has muchto contribute when its limitations are recognized.

On Foresight 313

1. Emde (1995) notes, “It is only very recently that our contemporary behavioralsciences have become aware that a future orientation in our psychology has beengrossly neglected in the twentieth century. A multitude of studies have been doneconcerning the influence of present and past events on behavior, but we have ne-glected the influence of the future.”

Freud observes the difficulties of prediction during the flow of an-alytic work:

So long as we trace the development from its final outcome back-wards, the chain of events appears continuous, and we feel we havegained insight which is completely satisfactory and even exhaustive.But if we proceed to reverse the way, if we start from the premises in-ferred from the analysis and try to follow these up to the final result,then we no longer have the impression of an inevitable sequence ofevents which could not have been otherwise determined . . . thechain of events can always be recognized with certainty if we followthe line of analysis, whereas to predict along the lines of synthesis isimpossible. (Freud 1920)

However, in analysis we do often sense a direction, envision a hori-zon, and feel that some possibilities exist more than others. Thesedelicate impressions, however, don’t elbow their way in to focused at-tention, often don’t come in verbal language, and are easily over-looked. They are more like a quiet breath, or a passing fantasy orfleeting image, but may be of surprising value when noted. Some-times we have a fantasy or image, on the “edge of awareness”2 thatlater appears in the patient’s associations.3

Often, however, we pay little attention to such impressions. We feelthat conscious, secondary process, deliberate thought is the locus ofhigher mental functions such as insight. The characteristics of con-scious, secondary process thought work toward differentiating, sepa-rating, categorizing, analyzing, and focus, all processes that restrictthe breadth of gaze while also removing us from full involvement.They objectify and detach us from what we study. Primary processthought blends and synthesizes, makes ideas collide, spill over, inter-mingle, come together, and influence each other over a wide field ina manner in which we remain immersed. One isolates, the otherunites, one narrows, the other broadens. In one we step back and ob-serve, in the other we find ourselves involved.Primary process, however, is in practice still viewed with more skep-

ticism among us, and also is not as easily studied since it goes on in asilent realm, revealing its manifestations more than its workings. Sec-ondary process, on the other hand, makes greater use of the lan-

314 Cornelis Heijn

2. Robert Gardner’s phrase suggests psychic events that one may easily attend to ornot. This often depends on delicate circumstances of the moment, such as the state ofthe therapeutic alliance or the tactfulness of the analyst’s wonderings.3. Bennett Simon, M.D., has made such an event the subject of an interesting arti-

cle in Psychoanalytic Inquiry. See Bibliography.

guage and symbols familiar in the logic and reasoning of consciouslife and can be studied, criticized, evaluated, and its products thenembraced or cast aside.These reflections begin with some examples from general medi-

cine, psychoanalysis, poetry, and life that suggest the pervasive im-portance 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 prosperedin Germany for many generations, but he had foreseen the comingpersecution of the Jews very early in the Nazi era, and moved herewith his wife and children soon after Hitler came to power, leavingbehind a considerable fortune. Unable to practice his professionhere, he started a farm, did well, and was soon on to other ventures.Although we talked only once, his story left a lasting impression. Hisrealism when most anguished, his foresight and ability to act upon itwith the sureness of faith in his own judgment, his resilience and ca-pacity for adaptive renunciation, and his gentleness, modesty and es-sential 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 initialmeeting and the beginning of analysis some time later. The patient isnot aware that he or she is reacting to an unconscious assessment ofwhat may happen in analysis, but the awful relationship he first com-plained about is happy now, the problems at work have been re-solved. We learn that the patient has been anticipating, without con-sciously knowing it, an analytic experience of lost freedom, ofinsensitive control by an unempathic analyst, and we can expectsome form of long negative, or false positive, transference. The pa-tient is in the grip of the past and can hardly believe that today or to-morrow could be different. Much of the work of analysis is to free thefuture from such influences of the past, or in Loewald’s words, help“ghosts” become “ancestors,” and thus make possible realistic fore-sight.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, asnoted earlier, an image on the “edge of awareness,” the surface feel-ings of deeper happenings.One of the great organizers of our lives is the certainty of time pass-

ing and of our own eventual death. We are often eager to modify thiscertainty, and much of the power of religion has come from promisesof some kind of eternal life, or at least measures of consolation forlife reaching its end. However, perhaps especially in a scientific age in

On Foresight 315

which we doubt ideas of immortality, and religion has more troublefinding a relevant message, many of us have that event hovering inmind, and this influences how we view the future. Religion and po-etry each aim at trying to make our present and future more mean-ingful and the inevitable end more tolerable. Love and death are of-ten the subjects of poetry, and when talking of love the theme of timeand perishing is close by, as in these few lines from the famous poemby Andrew Marvell “To His Coy Mistress.”

But at my back I always hearTime’s winged chariot hurrying near:And yonder all before us lieDeserts of vast eternity.Thy beauty shall no more be found;Nor, in thy marble vault, shall soundMy echoing song: then worms shall tryThat long preserved virginity,And your quaint honor turned to dust,And into ashes all my lust.The grave’s a fine and private place,But none, I think, do there embrace.Now therefore, while the youthful hueSits 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 daymight say something like “hey, let’s get with it babe,” but the arrest-ing images of the poem bring a power and depth of meaning to theargument. Here words are used to evoke images, and the images sideby side build a complex new meaning that neither image has alone.Poetry brings together what is usually unrelated, in this case love anddeath, beauty and perishing, and this synthetic act seems typical ofmechanisms we think of as primary process. MacLeish writes, “Oneimage is established by words which make it sensuous and vivid to theeyes or ears or touch—to any of the senses. Another image is put be-side it. And a meaning appears which is neither the meaning of oneimage nor the meaning of the other nor even the sum of both but aconsequence of both—a consequence of both in their conjunction,in their relation to each other.” And later, regarding the effect of cou-pled images, “To carry experience itself alive into the heart is anextraordinary achievement, an achievement neither science nor phi-losophy has accomplished” (MacLeish 1960, pp. 65, 67). This seemsto be brought about by a process akin to condensation, but here it isused in the creation of new meaning rather than for disguise. Poetry

316 Cornelis Heijn

seems a good example of our concerns about the future as well as theuse of tools we would think of as belonging to the primary process:images, symbolization, condensation, displacement. Images carry af-fect in a way that other symbols cannot do.4

You will probably have imagined by now that I have been trying tosuggest some of the ways that images and primary process modes ofthought may be important in how we process information con-sciously and unconsciously. The emergence of images and primaryprocess in regression of thought and for purposes of disguise hasbeen emphasized and well developed in analytic thought, but thismay be only an aspect of their importance. Perhaps a way to welcomeprimary process mechanisms that is more comprehensive and lesstentative than “regression in the service of the ego” would extendour reach as analysts.In Keats, Frost, Emily Dickinson, Shakespeare we repeatedly feel

the search for the eternal moment, the timelessness of the primaryprocess, in the continually perishing beauty of the world. Paul Ri-coeur writes:

because history is tied to the contingent it misses the essential,whereas poetry, not being the slave of the real event, can address it-self directly to the universal, ie: to what a certain kind of personwould likely or necessarily say or do. (Ricoeur 1995)

Poetry has a truth arising from its ability to reach beyond the wel-ter of daily events into the essence of things and the timelessness ofthe truth it finds seems to include some concern to help us bear theunbearable aspect of the future. As poetry leaps into what is timelessit includes essences of past, present, and future. “The Wasteland,” byT. S. Eliot had a profound impact not only as a statement of the pre-sent day but of ominous trends leading into the future.

A Brief Diversion into History

While the “contingent” events of history in themselves may miss theessential, or draw us away into details, we also do infer from theseevents some important truths. Machiavelli, in The Prince, discussesthe disadvantages of using auxiliaries and mercenaries in warfare,and writes:

On Foresight 317

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 themoment of real experience.

But man’s little foresight will initiate a project which at the startseems good, but it does not notice the poison that is underlyingit: . . .And so whoever does not recognize evils when they arise in a prin-

cipality is not truly wise, and this ability is given to few.[He goes on to describe causes leading to the overthrow of the Ro-man Empire—a principal one being the employment of Gothic mer-cenaries.] (Machiavelli, p. 177)

History provides many examples of the success and failure of fore-sight. We owe much to James Madison in the design of our Constitu-tion. His profound knowledge of good and evil in human affairs, andhis awareness that greed and power would be avidly sought unlesscontained, along with intensive study of the various structures of gov-ernment that attempt to channel such motives, enabled him morethan anyone to see the long-range implications of the various plansput 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 de-stroyed and only 10,000 half-frozen and starving men escaped, we seemany examples of the deterioration of this faculty, of valuable fore-sight ignored or rejected, and of foresight used to ultimate victory bythe opposing General Kutuzov. This is described in the remarkablejournal of General Caulaincourt, one of Napoleon’s closest aides.

Once he had an idea implanted in his head, the Emperor was carriedaway by his own illusion. He cherished it, caressed it, became ob-sessed with it, one might say he exuded it from all his pores. . . .Never have a man’s reason and judgment been more misguided,more led astray, more the victim of his imagination and passion, thanthe reasoned judgment of the Emperor on certain questions. (Cau-laincourt 1935, p. 28)

Caulaincourt anticipated the probable course of the campaign. Heknew the vast area into which the Russians could withdraw, the fiercecold of the Russian winter, and the terrible revenge peasants wouldinflict on any stragglers. He describes the disastrous result of failingto provide for such small necessities as horseshoes with spikes, suit-able for travel on ice. Horses were unable to haul wagons up frozeninclines and many supplies had to be abandoned.The Russian campaign was after Napoleon’s great successes but

while he was still a relatively young man. He had been famous for hisability to visualize how a battle was likely to evolve the next day. Butforesight is a fragile process, easily lost or perhaps disrupted by the

318 Cornelis Heijn

hubris that may flower with success. Its loss was revealed in many waysin 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 un-damaged if we had made the necessary sacrifices in time. But to twoor three unfortunate horses we allotted guns and waggons thatneeded six, and by not abandoning one or two guns and waggons atthe proper time, we lost four or five a few days later. We planned forthe day only; and because we refused, as the saying is, to give the devilhis 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 fore-sight, Napoleon’s campaigns suggest another subject of importance,that of the factors that influence its adaptational use. In one of herlast books, The March of Folly, Barbara Tuchman describes how greatevents are often determined by people who cling, through vanity orwhat she calls “wooden-headedness,” to plans seen by others at thetime to be unworkable. Britain’s loss of the American Colonies, theintransigence and corruption of the Renaissance Popes that led tothe Reformation, the Vietnam war, the Japanese attack on Pearl Har-bor, which someone described as “destined only to awaken a sleepinggiant,” all took place when those in power would not listen to reason-able foresight. Her meticulous gathering of evidence is compelling,and one senses that she was doing what she could to awaken a worldmoving mindlessly toward great dangers.5

Toynbee emphasizes the need for a currently felt challenge toevoke creative response. Apparently he feels our imagination mostlyslumbers when long-range adaptation is concerned, and this con-tributes to the rise and fall of civilizations.

On Foresight 319

5. Such problems envelop us today, as science and technology grow in power, con-trolled by an economic system that feeds on the demand for constant growth andever increasing private profit, with little consideration of long range consequences toa finite and fragile world. So we see the problems of global warming, environmentaldestruction, genetic engineering, rapid transmission of world diseases, enormous in-equality of wealth, loss of species, changes in family structure brought on by eco-nomic 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 limita-

tions, some of which lie particularly in the difficulty of applying the scientific methodto highly complex interdependent systems in which small changes may have massivebut often slowly developing effects. Yet in idealizing science we have also given upmuch of our reliance upon expert experience, and upon the foresight of wisdom.Thus we run great dangers with calmness.

Lack of foresight makes us more merry. (Oxford English Dictionary)

In warm climates, nature being bountiful, there is no need of fore-sight. (Oxford English Dictionary)

On a more optimistic note we have in the recent past the exampleof George Kennan. An article in the New York Review of Books, April 26,2001, entitled “A Memorandum for the Minister” describes how in1932 Kennan, then a 28-year-old member of the delegation at Riga,Latvia, analyzed the deficiencies of the radical Soviet policies thenbeing implemented in Russia. It showed how destruction of the exist-ing tradition and ideals that ground a coherence of life, on the onehand, and how the failure to provide new sources of psychologicaland moral elements necessary for a healthy society were likely tocause the eventual failure and collapse of the Russian-Communistsystem. 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 architectof the Marshall Plan. It is hard to think of another person whose fore-sight and wisdom has had such a vast and benevolent effect on eventsof 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 humil-ity in this regard with a beautiful passage from her last novel, Persua-sion. Advised by a well-meaning aunt, Lady Russell, Anne had sacri-ficed a deep love when she was young. As the years went by, as thebloom of youth faded, but confidence in her own judgment grew,Anne felt she had made the most unfortunate mistake of her life. It isan all too common story. She would not give such advice in a similarsituation.“How eloquent would Anne Eliot have been, how eloquent, at

least, were her wishes on the side of early warm attachment, and acheerful confidence in futurity, against the over-anxious cautionwhich 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 an-alyst’s appreciation of the unknown, undeveloped potential, on theanalyst’s vision of the patient’s future.

The parent ideally is in an empathic relationship of understandingthe child’s particular stage in development, yet ahead in his vision of

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the child’s future and mediating this vision to the child in his deal-ings with him . . .The child, by internalizing aspects of the parent, also internalizes

the parent’s 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, inter-actions of a comparable nature (comparable to parent-child interac-tions) have to take place . . . the analyst relates . . . always from theviewpoint of potential growth, that is, from the viewpoint of the fu-ture. (Loewald 1960, p. 21)

What a lovely project it would be to explore how we develop andcommunicate this vision of the patient’s future, how we come to seethe potentials of character, of intellect and feeling, and nourish themwhile respecting their freedom, and how we responsibly imagine asmall kernel of talent blossoming with maturity.6 It would take con-siderable artistry to provide examples because such interactions aresubtle and complex.These examples are presented to suggest that we are deeply con-

cerned about the future and that much of life is influenced in thelight 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. Itmay be useful to consider more deeply the role of the primary pro-cess in addition to that of disguise and defensive regression. It seemslikely that these three issues, the future, the function of the image inthought, 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 fu-ture? The future is all tendency and possibility, but these are at least

On Foresight 321

6. James Engell, in a beautiful scholarly book The Creative Imagination, writes: “Cole-ridge deals with one of the most curious and fascinating properties of the imagina-tion: it is even more powerful as an idea when described in its own terms.” If theimagination is a higher power than reason (as the Romantics said), and every higherpower includes the lower power, then reason cannot express its comprehension ofthe imaginative power. He quotes Coleridge, “They and they only can acquire thephilosophic imagination, the sacred power of self-intuition, who within themselvescan interpret and understand the symbol, that the wings of the air-sylph are formingwithin the skin of the caterpillar: those only who feel in their own spirits the same in-stinct which impel the chrysalis of the horned-fly to leave room in its involucrum forantennae yet to come. They know and feel, that the potential works in them, even asthe actual works on them.” (Engell 1981, pp. 346–47)

in part expressions of what we know from the past and what we see to-day. To approach a vision of the future is to embrace in thought andfeeling many variables that differ in weight and quality, to have easyaccess to different contexts, and to weigh facts that are constantlychanging. What form may this take? As with so many human issues,Shakespeare provides a rich example. In Richard II, the King has nei-ther consolidated his power nor gained the confidence of his sub-jects. His decisions vacillate. He has just banished a powerful Lord,and then gone to quell a rebellion in Ireland. The Queen feels disas-ter approaching, without being able to specify why, or what form itmight take.Lord Bushy urges her to “lay aside life-harming heaviness.”

Queen: “I cannot do it, yet I know no causeWhy I should welcome such a guest as grief, . . .”Some unborn sorrow, ripe in fortune’s womb,Is coming towards me; and my inward soulWith nothing trembles; at something it grieves.”

After some time news comes that the exiled Lord Bolingbroke haslanded with an army and the other Lords are flocking to him. TheKing’s 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 join’d.’Lord Bushy: “Despair not, Madam.’Queen: “Who shall hinder me?I will despair, and be at enmityWith 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 namespecific causes or outcome. Her realism, refusal to accept false hope,her trust in her own feelings without elaborating them into specificfantasied disasters as a paranoid person would do so exuberantly, allseem noteworthy. Her character seems comparable to that of Oedi-pus or Hamlet in its requirement that she see the world without illu-sions. She is sensing tendencies, directions that are probably in theiressence if not predictable in their particulars, in a complex situation,at some level of thinking that is not logical in a way we could describebut that has validity even as it is nourished in unknown ways. Some

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7. The Yale Shakespeare Edition of The Tragedy of King Richard the Second, edited byRobert T. Petersson, explains that prodigy as used here means “monster.”

people would call it intuition but that tells us little about the pro-cesses involved. “Inward soul” suggests its central place, one that con-cerns us deeply.How can one approach thinking of this kind, and learn how it op-

erates in our “inward soul”? It is elusive, and emerges from and re-cedes into silence. We often seem in awe of it, cautious, fascinated attimes, aware of its power, skeptical of its reliability. We are sometimesglad in our uncertainty to defer to someone else, and astrologers, or-acles, psychics, pundits, ‘authorities’ of all stripe abound and playupon the irreducible doubt that is realistically part of such an assess-ment.8 We also yearn to dismiss such ominous intimations as theQueen describes, or to welcome hopes unreasonably when they arepleasant, and are helped in both directions by well-meaning friends.Perhaps we trust such ‘thinking’ less in our scientific age, when con-scious reasoning is valued most highly, and some incline to believethat everything should either be certain and scientifically proven ornot 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 realitysense and judgment. We can never remove all doubt, however, sincewe are often led astray by hopes and fears, hubris or timidity, andsince contingencies that impinge on future events can never be elim-inated.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 wilder-ness 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 un-usual quiet, or the nervousness of other animals, but through an ab-sorption of multiple perceptions he has knowledge worth taking seri-ously. In analysis we sometimes have a similar sense of what mayemerge. Perhaps our level of comfort is changing, or we becomeaware that a determined clock-watcher hasn’t mentioned time forseveral weeks, and realize that the middle phase is upon us with all itsincreased trust and greater terrors, or we notice that a patient occa-sionally talks about how things were earlier in analysis, using the pasttense, and sense that the sadness and rebuke of termination is soonto come. These changes in analysis, small in all but significance, arelike the snow-drop, the first tiny flower of late winter, coming up of-

On Foresight 323

8. American analysis has a long history of concern with what is referred to as “wildanalysis,” and the ready association of “foresight” with unscientific modes of thoughtmay 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 offoresight is taken as a focus for questions regarding the relative inat-tention to a psychology of the future in psychoanalytic thought. Thisinquiry leads to consideration of the varying constraints and poten-tials that are determined by the formal properties of verbal languageand mental images, which are briefly compared and contrasted in re-gard to their usefulness in understanding complex dynamic systemssuch as psychoanalysis. The paper concludes with questions regardingthe qualities of conscious and unconscious, and secondary and pri-mary process thought, and with comments on technique.

I stopped short in the woods today to admire how thetrees grow up without forethought, regardless of thetime and circumstances. They do not wait, as men do.Now is the golden age of the sapling: earth, air, sun, andrain are occasion enough.They were no better in primeval centuries. “The win-

ter of their discontent” never comes. Witness the budsof the native poplar, standing gaily out to the frost, onthe sides of its bare switches. They express a native con-fidence.

—Thoreau’s Journal, January 2, 1841

Clinical Professor Emeritus, Tufts University School of Medicine.An earlier version of this paper was presented at the Western New England Insti-

tute and Society in November 2000. I have greatly benefited from the superb discus-sion there by Dr. David Carlson.The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,


312

ten unnoticed through the snow itself, the harbinger of spring longbefore the great explosion of life in May. I find that I noticed thesesubtle changes more explicitly when hearing about a case in supervi-sion than when involved as analyst, but I must have been potentiallyaware of them then as well, and were there time again would want tocultivate this delicate function of the “analyzing instrument.”9

These intimations may be compared with creative activity in otherfields such as painting, poetry, or scientific discovery. All involve thearrival of new meaning before it is obvious and forced upon us. Ger-man Expressionist painting, for example, seems to embody forcesand directions at work between the wars. Its dark and brooding qual-ity, the inexorable sense of brutality and violence close at hand,seems to foreshadow the cruelty to come. Or Van Gogh’s late paint-ing of crows over the wheatfields, with the road leading into empti-ness, conveys, to this viewer at least, an aloneness beyond lonelinessthat makes his suicide seem understandable if not predictable.10

A few scientists have recognized the limitations of the scientificmethod, which at least apparently is dominated by the secondaryprocess, for the study of complex dynamic living systems.

convenient characteristics of physical nature bring it about that vastranges of phenomena can be satisfactorily handled by linear alge-braic or differential equations, often involving only one or two de-pendent variables; they also make the handling safe in the sense thatsmall errors are unlikely to propagate, go wild and prove disastrous.Animate nature, on the other hand, presents highly complex andhighly coupled systems—these are, in fact, dominant characteristicsof 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 variablestwo at a time. Animate nature also exhibits very confusing instabili-ties, as students of history or the stock market, or genetics are wellaware. (Weaver 1955, p. 1256)

(He might have included psychoanalysis as an example of highlycomplex, highly coupled systems.)

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9. Often the conscious insight comes as the patient is leaving. How often have Iwished to call a patient back when the meaning of an hour suddenly crystallizes. I sawthis as a failure of my listening, now I see it more as a change in the state of the “ana-lyzing instrument.” There is much evidence to suggest that creative insights oftencome during a transitional state between involvement and detachment. We analystshave “wax in the third ear” much of the time.10. A friend has observed that the roads in Van Gogh’s painting, which I saw as

leading nowhere, could also be seen as leading anywhere and everywhere. We needalways to weigh the subjectivity of our judgments in such matters.

Mathematics has begun to approach elucidation of dynamic sys-tems through the development of catastrophe theory, and chaos andcomplexity theory, and may be coming closer to providing methodscongenial to the study of psychoanalysis. It is interesting that each ofthese new theories makes extensive use of images to convey theessence of their concepts.11

Abstract Symbols and Images

What might be some differences between the functional possibilitiesof various symbolic forms? For instance, if we compare and contrastmathematical symbols, words, and images, what tasks are best ap-proached with which medium?Mathematical symbols have beautiful clarity and precision, and pu-

rity of form and meaning. A number, or a constant such as pi, or afunction seem to mean precisely one thing and nothing else. It there-fore has a universal, lifeless, and timeless meaning that seems to ap-proach Plato’s ideal forms. It is, however, detached from the uniquething it is used to describe, and is impersonal. It deals with the rela-tions between things rather than with the things themselves. Wherewhat is being studied moves around and won’t sit still to be mea-sured, mathematics has developed probability theory and statistics,so that without giving up the exactness of its tools it recognizes thatunique things may differ, and so provides us with levels of confi-dence. While mathematics can help us predict and control many as-pects of our surroundings and thus seems most closely allied with sci-ence as it has developed so far, it loses touch with the teeming activityof life. For most of us it resides in an ethereal world, and we cannotswear or make love mathematically, and rarely communicate with ourfriends 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 arelatively consensual meaning, although even dictionaries differsome, but their meaning can often change gradually, so a word oncerich with meaning can become empty over time. The meaning ofwords is often highly dependent on context. Words also mean some-thing different to each of us as our individual experiences get at-

On Foresight 325

11. If one considers the essence of science not only as it is embodies in the scientificmethod, but in the scientific conscience, with the ideal of putting aside wishes, fears,and pride in the search for truth, psychoanalysts systematically cultivate this scientificideal, with more or less effect, in the analysis of counter-transference.

tached to them, and their usefulness depends upon the degree ofshared 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 de-gree of precision and universality. When a word does evoke a feelingit 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 differ-ent 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 describedin words and mathematical symbols, although this exercise would belengthy and not very interesting, and its beauty and significance as aloving memorial would vanish. The image of the Taj Mahal has aneconomy, 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 ofmathematical symbols, but also partakes directly of the thing itself. Itis not as severe an abstraction, removed, but a depiction, involved;analog not digital. It is capable of infinite degrees of change andmolding without loss of precision. However, we have whole disci-plines of linguistics and mathematics but as yet little theory of the im-age. 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 psychologyof the image as a revivication of a perceptual trace resists the psycho-analytic discovery of the constructed character of the fantasm,”“. . . the universe of discourse appropriate to the analytic experienceis not that of language but that of the image. Unfortunately, however,we do not yet possess a theory of the image and the imagination” (Ri-coeur 1978).

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12. A valuable study of the limitations of words in grasping reality, in reflecting ourinner thought processes, and in communicating with others, is found in the book byBen-Ami Scharfstein (1993).

The Study of Mental Imagery

David Hume asserted in the eighteenth century that a mental imagewas only the trace of a perception, not modified by processes of anactive mind. The subject evoked little interest until William Jamesridiculed this view, and devoted several chapters in his great text onpsychology to the functions of mental imagery in thinking and cre-ativity. Later, however, Watson declared that only observable behav-ior was deserving of serious study, and such “airy nothings” as mentalimages were again neglected by psychology until the poverty of thestrict 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 processingwithin the brain. One group, including many who were interested inthe computer as a model, argued that there were no depictive, or im-age-like representations in the brain, and that images we experienceare an epiphenomenon of information processing that is at the basiclevel propositional. Another group felt that images are not epiphe-nomena but are actively involved in memory and thought. A conver-gence of findings from many studies, and conclusively from PositronEmission Tomography, have shown that visual images are anatomi-cally localized in the visual cortex, and similarly in other areas wherevision is broken down and processed, in a pattern similar to their lo-cation on the retina, and these areas are used in reverse in the cre-ation of mental images.13 So it seems that there are at least twoanatomical systems for processing information, one involving thesymbols, signs, and rules of language and the other, a more privateand 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 endur-ing discoveries. His focus was on their role in the service of disguiseof the conflicted and repressed, as these were believed to induce a re-gression to the visual. Analytic interest has subsequently beenweighted toward the recovery of the repressed and interpretation of

On Foresight 327

13. This debate and its resolution are admirably described in Image and Brain, S.Kosslyn.It no longer seems beyond possibility that some day an external observer will be

able to view another’s dreams.

the latent content, which the manifest content was, according to thistheory, structured to conceal. The value of these mechanisms forother 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 waswrestling with the same issues in the manifest as in the latent contentwithout recognizing that fact himself. They conclude that the “dis-tinction between manifest and latent in the formation of dreamsshould be reconsidered” and “the concepts of dream censor and ofdrive discharge no longer seem necessary to our understanding ofdream formation.” An implication seems to be that the image is a dif-ferent way of placing our concerns before the mind but that thefunction 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 betweenforesight and insight, an aspect of foresight being insight into hypo-thetical situations cast into the future.) Freud writes:

It is misleading to say that dreams are concerned with the tasks of lifebefore us or seek to find a solution for the problems of our dailywork. Useful work of this sort is as remote from dreams as is any in-tention of conveying information to another person. When a dreamdeals with a problem of actual life, it solves it in the manner of an ir-rational 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 completelydifferent from it qualitatively and for that reason not comparablewith it. It does not think, calculate or judge in anyway at all; it re-stricts itself to giving things a new form. (Freud 1931)

Many still accept this sharp parceling out of our mental functions asin this statement by Edward Joseph in his Presidential Plenary ad-dress at the American Psychoanalytic Association. “becoming con-scious of a particular mental product is always a prerequisite to in-sight. The unanimity of psychoanalytic writers on this score wasimpressive” (Joseph 1987). Other authors: Rangell, Dorpat, Weiss ex-press 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 sec-ondary process functioning in the unconscious, I am astonished andperplexed as to how a practicing psychoanalyst can do without it”(p. 197). And “Insight does not always, or promptly, or even eventu-ally become conscious” (p. 198). He would extend our understand-ing of the workings of the unconscious to include evaluating, plan-ning, problem solving, and executing action.

328 Cornelis Heijn

Dorpat states that “most often reception, registration, and re-sponse to stimulation occur outside conscious awareness.” His “cog-nitive arrest theory” postulates arrest of perceptual and cognitiveprocesses before the stage of conscious awareness but “the earlierphases of the transformations of the sensory information remain in-tact and unaffected by the action of denial,” and contradicts Freud’sidea that the denier first forms a normal, conscious percept and laterdisavows and distorts the percept. Evaluation, judgment, develop-ment of implications are going on in a pre-verbal mode of thinkingout of consciousness (Dorpat 1985, p. 28).Joseph Weiss (1993) finds the “unconscious control hypothesis”

most consistent with clinical experience. This assumes that a personis unconsciously able to use his higher mental functions and bringsrepressed contents to consciousness when he unconsciously decideshe may safely experience them. This points away from emphasis ofcorrect interpretation to emphasis on unconscious judgments ofsafety for release of repressed and clinical progress. These authors allseem convinced that higher mental functions operate in the uncon-scious.Although our age considers the scientist as the highest form of ra-

tional man, and the scientific method as the surest way to truth, sci-entific discovery, as distinct from method, appears often to rely onprocesses that are not conscious and deliberate, and that involvethinking with images. There are many anecdotes about this in biogra-phies of scientists, sometimes told with embarrassment becausedreaming is not always recognized by a serious scientist as an honor-able 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 nottell from the percept alone whether the man was falling or the housewas rising, an image including the concept of relativity. In responseto an inquiry about his thought processes, he said, “The words of thelanguage, as they are written or spoken, do not seem to play any rolein my mechanism of thought. The physical entities which seem toserve as elements in thought are certain signs and more or less clearimages which can be ‘voluntarily’ reproduced and combined. . . .Conventional words or other signs have to be sought for laboriouslyonly in a secondary stage” (1974, pp. 25–26).Edison, ever the inventor, invented a way to capture his hypna-

gogic hallucinations because he found they often contained the solu-tion to a problem he had been pondering. He took frequent cat-napsin his chair, holding steel balls in his hands over metal plates on thefloor. At the moment of sleep onset, when all the muscles relax, they

On Foresight 329

would make a great clatter and wake him up while the hallucinationwas still vivid.Our thought when expressed in words is more open to our exami-

nation than is our thinking in images. How often do we inquireabout the formal qualities of dreams, their skill and accuracy? Per-haps some of us dream with the fidelity of Vermeer, others with theskill of a Sunday painter.Books by Arthur Koestler and Harold Rugg outline steps in the cre-

ative process. This usually begins with intense study and conscious ef-forts to solve a problem, then follows a continuing sense of puzzle-ment, a feeling that things do not fit. Eventually there is a turningaway from the problem, and at an unpredictable point what Ruggcalls a “flash of insight” and Koestler the “Eureka phenomenon” en-sues, usually during some not fully alert focused state, one that Ruggcalls “trans-liminal.” 14While there are many descriptions of the phe-nomenon, 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 accompanyawareness of time. When our experience is connected to primaryprocess we feel no past or future in the same reflective sense, andpeople long gone may appear as they were. We dwell then outside oftime or, as Loewald says, in eternity, the absence of time. Remote as-pects from the full granary of related past experience may enter thepresent.The potentials of having at our aid all the related experience of

our lives, fresh and vital in the immediate moment, to be felt andworked with in a plastic medium capable of an infinite variety ofshades, forms, and intensities, all with deep involvement but withoutthe distraction of troubling feelings of loss, disappointment, ambi-tion, or the limitations of time, such as we feel when awake, wouldseem a great advantage for some issues, allowing integration of re-lated experience, help from past experience. Perhaps wisdom, be-yond intelligence and knowledge, depends upon such thinking in-volving 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 experi-ence seem to be effortlessly before us, drawn together as by a mag-net, in a fluid medium capable of infinite variation and great preci-

330 Cornelis Heijn

14. This immediacy of insight may have contributed to the belief that some peopleof genius seem to work effortlessly. In fact, while talent is needed, hard work andmuch preparation are essential preparation for creative work.

sion. We have no sense of authorship even as we are the director,painter, and only audience of our dream. Awareness of today’s realityis in suspension, and we can’t step back from the dream reflectivelyand ask if our thinking partakes of our usual standards of logic, hon-esty, balance, and earnestness. That sort of detached critical thinkingseems absent from the dream state. One man did remark on the ex-quisite beauty and realism of the women in his dreams, and on theblends of deep color that seemed to reflect mood as truly as in aBergman film. The rational part of us, however, tends to dismiss thedream upon awakening. Why we would be so grasped and take so se-riously something that we then may dismiss as “just a dream” is notentirely 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. Ashe became more introspective he wondered if they were trying towarn him about something worth attending to. Eventually hethought they were wiser than he was. They seemed repeatedly to betrying to alert him to the possibility that he might continue to fritteraway his precious time, indeed his life. They returned at moments ofimportant choice to the theme of the undone thesis, the first majorinstance of avoidance due to anxiety, an avoidance that had resultedin a half-hearted and failed effort and lifelong regret. At times of po-tential achievement in later life his dreams might offer him a secondchance at courses he had neglected, but then would show him forget-ting to go to class or sleeping through the exams. He felt that hisdreams kept him in touch with both the opportunities and danger inhis current situation, the danger that he might again avoid a chal-lenge.Finally, we might renew an inquiry into what standards of honesty,

realism, and judgment can guide our thoughts when we think in im-ages. It is true that the logical forms and structures of verbal lan-guage are lacking but this is inherent in the formal qualities of im-ages, 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 in-sight, which never seems complete and is always subject to revision.In this arduous quest, however, the relevant facts are at least poten-tially available to the resourceful and determined inquirer since theyall lie within the present or the past. Even so, with our varying per-

On Foresight 331

ceptions, imperfect judgment, revision of memory, skill at self-decep-tion, 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 amystery. We know this well in analytic work but it is equally true ofhuman behavior on the larger scale. Historical events are not onlydifficult to foresee but explanations after the fact often seem simplis-tic and inadequate, often following the personal predilections of thehistorian.Imagine then the added difficulty achieving reliable foresight,

where the problem is still developing in a constantly changing worldand some relevant facts have yet to be born. Here we sense the needfor abilities and qualities of character in a new dimension of realismand imagination.I have gradually come to feel that some of the distinctions between

consciousness and the unconscious, and between primary and sec-ondary process lie more in the nature of the medium of thoughtthan in the quality and validity of thought. It has been more usefulclinically to work as if we can be as sane, honest, and integrated inour imagery as in our wordiness. The idea of the dream as a “normalpsychosis” or as lacking in judgment leads us away from the positivevalue of the dream and other mental images. I think I worked betterwhen I saw us all struggling to find meaning, and to reveal and con-ceal 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 suspi-

cion” but as a science of discovery. To view the patient as split intosuch different portions as to require a science of suspicion leads tosuch 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, whilestill with ample difficulty, leads to notions of acceptance rather thanhard earned neutrality, to mutuality in the process of inquiry, to cu-riosity and wonder, and to the analyst as good traveling companion,gardener, wilderness guide, or assistant analyst to the patient who isthe true analyst.15 One of my last patients said that her analysis hadbeen like a “treasure hunt.” While pain, sorrow, and chance oftragedy cannot be eliminated, analysis can also be a joyous adven-ture.

332 Cornelis Heijn

15. The concept of analyst as assistant-analyst to the patient originated with RobertGardner.

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Engell, J. (1981). The Creative Imagination.Harvard University Press.Freud, S. (1920). A Case of Homosexuality in a Woman. S.E. 15:182.——— (1933). The Interpretation of Dreams. Third English Revision, BasicBooks, Avon Edition 1963.

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——— (1995). Figuring the Sacred. Fortress Press.Rugg, H. (1963). Imagination.Harper and Row.Scharfstein, B. (1993). Ineffability: The Failure of Words in Philosophy and Reli-gion. State University of New York Press.

Selye, H. (1964). From Dream to Discovery: On Being a Scientist.McGraw Hill.Shakespeare, W. (1921). The Tragedy of King Richard the Second. Yale Univer-sity 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 BooksEdition. Originally published by Alfred A. Knopf, Inc., 1954.

Tuchman, B. (1984). The March of Folly. Knopf.Waelder, R. (1960). Basic Theory of Psychoanalysis. International UniversitiesPress.

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Weaver, W. (1955). Science and People. Science. 122:1256. Charles Scrib-ner’s Sons.

Weiss, J. (1988). Testing Hypotheses about Unconscious Mental Function-ing. Int. J. Psa. 69:87–95.

——— (1993). Empirical Studies of the Psychoanalytic Process. J.A.P.A.41:7–30.

West, T. (1997). In the Mind’s Eye: Visual Thinkers, Gifted People with Dyslexiaand Other Learning Difficulties. Prometheus Books.

334 Cornelis Heijn

Abandonment, 266, 269, 274–276, 280–282, 286

Abusive behavior, 269–270, 272, 302Adolescents. See also Latency development:attitudes toward therapy, 164–165, 169–171, 173; cognitive remediation, 239–260; latency development, 179–180; neurocognitive problems, 239–241; psy-chic trauma, 263–290; relational trauma,251

Adult Attachment Interview, 104Adult narratives, 119Aggressiveness: 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., 16Alcoholism, 110–111Ames, L., 183, 195, 205Analytic third, 215Anger management, 201–202, 227, 231–232, 267–269. See also Aggressiveness

Animal Farm (Orwell), 250–251Anna Freud Centre, 50, 161Anthropomorphism, 184, 190, 195–196Anxiety. See also Death anxiety: Andy (casestudy), 232; as defense mechanism, 263,266–267, 269–275, 287–290; latency de-velopment, 188–194, 196; maternal dis-tress, 8, 18; relational trauma, 49–50;Sean (case study), 138–139; separation-individuation, 282–284

Attachment theory: frightened/disorga-nized attachment, 102–108, 120–124; la-tency development, 178–207; maternallove, 48–49; parent-infant interactions,16–20; Strange Situation attachmenttest, 16, 90–91, 103–104, 137

Attention deficit hyperactivity disorder(ADHD), 222, 223

Austen, J., 320Autobiographical memory, 298Autonomy: consolidation process, 205; la-tency development, 178–207; play ses-

sions, 136, 142, 144, 145–146; Sean (casestudy), 148–149

Aversion movements, 14–15, 135, 284

Balint, E., 60Bateman, A. W., 77Beebe, B., 14, 17Behavior observations. See also Facial ex-pressions: body orientation, 135–136;gaze, 13–14, 135; head orientation, 14–15; video microanalysis, 13–23, 40–41,135–137, 142–152; vocalizations, 16–18,23, 26, 30–31, 36, 39

Beiser, H., 158–159Bender-Gestalt, 182Bergman, A., 9Bi-directional regulation, 11Birth defects, effect of, 266–268, 272–273,278–280, 289–290

Black holes, 107, 119Blatt, S., 182Blos, P., 180, 195, 205, 283–284Blum, H., 264, 287Body awareness, 93–97, 267, 271–272,278–279, 284–285

Body orientation, 135–136Bornstein, B., 180Boston Change Process Study Group, 259Boundaries, 136–137, 142, 143, 145Brazelton, T. B., 13Bromberg, P., 215Broucek, F., 219Burke, W., 182Buxbaum, E., 199

Case studies: Andy, 221–233; Beccah, 265–290; Cecil, 24–34; Ethan, 52–70; Iliana,91–97; Little Hans, 157–158; Mary andJohn, 108–124; Mia, 85–91; Natalie,242–258; Nicole, 34–40; Sean, 138–152

Caulaincourt, A., 318–319Center for Early Relationship Support, 108Chase and dodge behavior, 14, 26, 33, 40Chess, S., 3Child Analysis with Anna Freud, A (Heller),160

335

Index

Childhood analysis, 296–311Chodorow, N. J., 204Closeness versus distance, 62–63Cognitive development, 179–180, 214,258–260

Coherence, 151, 185–186, 198–200, 206Cohn, J., 15Conceptual frameworks, 134–138Conflict/compromise interpretations,264–267, 270–273, 275, 281–282, 284,288–289

Conflicts in learning, 258–260Congenital trauma, 263–290Conscious insight, 324, 328–332Construction, 299Contamination, 184, 190, 196Contingency detection, 219–220Coping mechanisms, 179, 188, 202–205,225–226

Countertransference: Ethan (case study),58, 68; Mary and John (case study), 113;Natalie (case study), 247; parent-infantinteractions, 51; reconstruction process,295–311; state of playing, 215, 235; ther-apist’s role, 107

Creative Imagination, The (Engell), 321Creativity, 324, 330Crown, C., 17Culver, C. SeeMalatesta, C.

Dahl, E. K., 288Dead baby complex, 49–50Death anxiety, 187–192, 195–198, 201–202Dependency, 55–66Depression, 8, 18, 49–54, 86–87, 221–222,300

Developmental theories, 129, 137Disconnection, 34, 37, 145, 193, 200, 204Disorganized attachment, 48–49, 52–54,60, 102–108, 113–117

Dissociation. See Frightened caregivingDissolution of the Oedipus Complex, The(Freud), 179

Distress: infant distress, 60–61, 89–91, 94,107; maternal distress, 8–9, 18–19, 60–61, 88; regulation patterns, 89–90

Distress regulation, 20Dorpat, T., 329Downing, G., 12, 134, 136–137Dreams, 328–332Dyadic systems. See Parent-infant interac-tions

Dynamic systems theory, 132, 151–152Dyslexia, 239–241, 244–245, 252–254,258–259

Edison, T. A., 329–330Ego: Andy (case study), 230–231; capaci-ties, 263–264, 287; ego capacities, 216–217, 220–223; and Freud, S., 78; latencydevelopment, 179–180; reconstructionprocess, 303, 307; regression, 234; stateof playing, 214, 216–217, 242; unevenfunctioning, 220–223, 230–231

Einstein, A., 329Eliot, T. S., 317Emde, R., 217, 313Emerson, R. W., 313Emotional issues, 62, 68–70, 116–123,220–221, 230–233

Empathic attunement, 5Enactments, 214–215. See also Fantasy for-mation

Engell, J., 321Erikson, E., 180

Facial expressions: mirroring, 15, 26, 36–37, 39; parent-infant interactions, 15, 23,27–28, 135; separation-individuation,218–220; stranger-infant interactions,26–27

Faith, 323Family interaction patterns, 131–152Fantasy formation: Andy (case study), 222;Beccah (case study), 271–273; conflictinterpretations, 288; incestuous fan-tasies, 301–302; latency development,179, 187–189, 192–198, 201–203; Nata-lie (case study), 246–247, 253; psychictrauma, 264; reconstruction process,296–297, 307, 309–310; separation-indi-viduation, 282, 284, 288; sexuality, 276–281, 285–286, 288; social status, 303–305; state of playing, 214–215

Fear, 88–89, 92–93, 119–121. See also Dis-organized attachment; Frightened care-giving

Feldstein, S., 17Ferenczi, S., 326Field, T., 13First Book of First Definitions, A (Krauss andSendak), 255–256

Fivaz-Depeursinge, E., 134–135, 137Flexibility, 148, 151Fonagy, P., 76, 77, 83, 265, 287–288Foresight, 312–332Former child patients: attitudes towardtherapy, 162–165; feelings about thera-pist, 166–173; memories of therapy,158–162, 165–174; non-engagement,169, 173; participants, 175

336 Index

Fragmentation, 184–187, 189, 191–192,195, 200, 205–206

Fraiberg, S., 4, 50, 78–80Freedman, S., 180Freud, A.: attitudes toward therapy, 163–164; fantasy formation, 203; and Heller,P., 160; infant psychoanalysis, 3, 9, 48; la-tency development, 179, 180, 203; par-ent-infant interactions, 217, 218

Freud, S.: ego, 78; imagery symbolism,327–328; latency development, 178–179; prediction difficulties, 314; recon-struction process, 296–297, 299, 305–306, 308–311; repetitive activities, 241;repression barrier, 157–158, 305; state ofplaying, 214–215, 242

Friedman, G., 182Frightened caregiving, 102–108, 113–117.

See also FearFuture, influence of, 312–332

Gaze, 13–14, 135Genuine maternal love, 47–71Gergely, G., 219–220. See also Fonagy, P.Gianino, A., 120Gilligan, C., 202Goldberger, M., 286Gorlitz, P., 182Green, A., 49Greenberg, R., 328Greenspan, S., 181

“Harry Potter” stories (Rowling), 203Head orientation, 14–15Heller, P., 160Helpless caregiving. See Frightened care-giving

Hesse, E., 104Hoffman, L., 286“Hole Is to Dig, A” (Krauss and Sendak), 255Home-based mother-infant psychotherapy,101–124

Homer, T., 201Home visits, 79–82House-Tree-Person Drawings, 182Hume, D., 327Hypersensitivity, 53–54

Images, impact of, 316–317, 326–331Imaginary play. See Fantasy formation;Make-believe; Play

Improvisation, 117–118Interactive regulation, 11, 19, 56Internalization, 159, 267, 274, 285, 287–288

Interpersonal connections, 136, 142, 143,144–145

Intersubjective exchanges, 215–219, 229–230, 235

Intuition, 322–323Irma dream, 328Isolation, 193–194, 204, 226, 232, 246, 269

Jaffe, J., 17James, W., 327Jasnow, M., 17Jewish Family and Children’s Service, 108Joseph, E., 328Jurist, E. See Fonagy, P.

Kantrowitz, J. L., 182Kennan, G., 320Kennedy, H., 285–286. See also Sandler, J.Kernberg, P., 9King, S., 203–204Klein, M., 9, 159Klopfer, B., 182Koch, E., 158Koestler, A., 330Kohlberg, L., 179–180Kohut, H., 180, 200Kozlowski, B., 13Krauss, R., 255–256Kutuzov, M., 318

Language usage: dyslexia, 244–245, 252–254; learning disabled children, 239–241; play sessions, 137, 142, 144, 145; re-lational trauma, 251–254

Latency development, 178–207Laub, D., 285Laufer, M., 173Lausanne Triadic Play Model, 135–136Learning disabled children, 239–260Ledwith, N., 183, 185Lee, S., 285Lewin, B., 234Lewis, M., 260Little Hans, 157–158Loewald, H. W., 201, 287, 313, 320–321,330

Longitudinal study of latency develop-ment: analytical discussion, 198–201;anger management, 201–202; back-ground information, 178–181; early la-tency, 186–190; gender differences,186–207; late latency, 195–198, 205–206; methodology, 181–186; middle la-tency, 190–194; results, 186–198; time-line, 206–207

Index 337

Long-term follow-up project of child analy-ses, 157–175

Loss, 186–192, 232Luria, A. R., 252Lyons-Ruth, K., 104

Machiavelli, N., 317–318MacLeish, A., 316Magic, use of, 188, 190, 192, 202–204Mahler, M., 9, 203, 206, 217Main, M., 13, 104Make-believe, 215, 218–220Malatesta, C., 15March of Folly, The (Tuchman), 319Marshall, G. C., 320Marvell, A., 316Maternal failure, 48–49Maternal love, 47–71Mathematics, 325–326Memories of therapy, 158–162, 165–174Memory, reconstruction process, 295–311Mental imagery, 327–331Mentalization theory: fantasy formation,220; Iliana (case study), 95–98; Mia(case study), 87–90; Minding the Babyprogram, 81–85; parent-infant interac-tions, 76–77; psychic trauma, 287–288;state of playing, 216

Metabolizing feelings, 112, 119–122Metraux, R. See Ames, L.Midrange regulation model, 33Milne, A. A., 213–214Minding the Baby program, 74–98Mini-reunion experience, 137Modell, A. H., 201Motherhood Constellation, The (Stern), 112Mutuality, 11, 218, 226

Napoleon I, Emperor of the French, 318–319

Narcissistic balance: Andy (case study),222, 225–226, 230–233; contingency de-tection, 219; psychic trauma, 267; recon-struction process, 304, 306

National Center for Infants, Toddlers, andFamilies, The, 79

Neubauer, P., 4Neurocognitive problems, 239–241Neurotic conflict, 217–218Non-engagement, 169, 173, 222–223, 228–230

Nonverbal language, 12–13, 21–34, 106,135, 247

Normality and Pathology in Childhood(Freud), 218

Noy, P., 317Nurse Home Visitation program, 80Nurturance, 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., 215Olds, D., 80Olesker, W., 199, 201Oppositionality, 225–227, 232, 267, 284Orwell, G., 250–251Overstimulation, 19, 25–28, 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 (casestudy), 91; Mary and John (case study),110–114; Mia (case study), 87; Natalie(case study), 243–244, 253–254; recon-struction process, 301–304, 306–307;video microanalysis, 40

Parent Consultation Model (PCM), 128–152

Parent-infant interactions. See alsoMindingthe Baby program: behavior observa-tions, 13–41, 135–137, 142–152; Cecil(case study), 24–34; ego capacities, 216–217, 220–223; face-to-face interactions,10–12, 18–20; frightened/disorganizedattachment, 102–124; Iliana (casestudy), 91–97; intersubjectivity ex-changes, 217–220; intervention tech-niques, 3–5; Mary and John (case study),108–124; maternal love, 47–71; Mia(case study), 85–91; mind-body aware-ness, 78–81, 83; Nicole (case study), 34–40; Parent Consultation Model (PCM),128–152; perception, 11; psychotherapyinterventions, 48–71, 79–98, 101–124;regulation patterns, 11–12, 19–20, 24–34, 55–56, 217–220; temperament, 3, 5, 19; treatment methodology, 21–23;video microanalysis, 7–13, 40–41, 129–138

Pearlman, C., 328Pearson correlation coefficient, 182Peer relationships, 180, 204–205Perry, R., 180Persuasion (Austen), 320Phonological processing, 244Piaget, J., 179–180Pine, F., 9, 217

338 Index

Play: lack of play, 221–233; learning dis-abled children, 239–241, 258–260; ob-ject relationships, 255–256; regulationpatterns, 257–258; state of playing, 213–236; therapeutic value, 233–236, 241–242, 258–260

Play sessions, 133–137, 139–141Poetry, 315, 316–317Preadolescence, 195–198, 202, 205–206Primary process thought, 314, 316–317,330, 332

Prince, The (Machiavelli), 317–318Provence, S., 4Psychic trauma, 76–77, 263–290, 298–311Psychological testing, 181, 182–185, 244–246

Puberty, 195, 197, 206

Rangell, L., 328Rappaport, D., 255Reconstruction process, 295–311Reflective awareness function: frightened/disorganized attachment, 105; Iliana(case study), 95–98; Mary and John(case study), 119; Mia (case study), 87–90; Minding the Baby program, 81–85;parent-infant interactions, 76–77; psy-chic trauma, 76–77; state of playing, 216,218, 225

Regression, 179, 215, 254, 269, 282, 283–286

Rejection, 266–267, 274. See also Abandon-ment

Relational trauma: Beccah (case study),270; Ethan (case study), 59–60; Iliana(case study), 91–97; Mary and John(case study), 110–123; Natalie (casestudy), 242–244, 249, 251, 253–254; parent-infant interactions, 48–49, 51,76–81, 104–105

Reparation, 66–68, 120Repetitive behavior, 269, 272, 286–287Representational/behavioral domains, 112Repressed memories. See Reconstructionprocess

Repression barrier, 158Richard II (Shakespeare), 322Ricoeur, P., 317, 326Ritvo, S., 159Rizzuto, A., 235Rodell, J. See Ames, L.Rorschach tests, 182–190, 192–197, 205,245–246

Rowling, J. K., 203Rugg, H., 330

Sadomasochism, 269–270, 277, 281, 284–286, 289

Safety issues, 274–275, 285Sander, L., 200, 217Sandler, J., 172–173Sarnoff, C., 180, 203Schafer, R., 183Scientific method, 324–325, 329Scoring systems, 182–183Secondary process thought, 314–315, 324,329–330, 332

Self-esteem: dyslexia, 253; latency develop-ment, 193, 194, 202, 204; parents, 40; re-construction process, 300

Selflessness, 48Self-other differentiation, 218–220, 263–265, 271, 285–286, 288

Self-regulation: aggressiveness, 266, 271;Cecil (case study), 24–34; challengingbehaviors, 145–147; frightened/disorga-nized attachment, 105; importance, 11–12; Mia (case study), 89–90; parent-in-fant interactions, 19–20, 24–34, 55–56,135–136; psychic trauma, 287; self-otherdifferentiation, 217–220; state of play-ing, 257–258; traditional evaluation pro-cess, 132

Sendak, M., 255–256Separation-individuation: adolescence,277; aggressiveness, 282–284, 288; Ethan(case study), 61–64, 70; gender differ-ences, 186–207; latency development,180–183, 186–207; parent-infant inter-actions, 218–220

Sexuality: Beccah (case study), 267, 269–270, 272, 276–279, 284–285; as defensemechanism, 269–270; fantasy formation,284–285, 288; latency development, 179,194, 196–198; Natalie (case study), 247–250, 253–254

Shakespeare, W., 322Shapiro, T., 180, 217Shepard, B. SeeMalatesta, C.Solnit, A., 4Space/time organization, 136, 142, 143,145

Stern, D., 14, 112, 200, 218Stevens, W., 326Stranger-infant interactions, 20–21, 26–27,30–31

Strange Situation attachment test, 16, 90–91, 103–104, 137

Study of Images, The (Stevens), 326Suicide. See Death anxietySullivan, H., 180

Index 339

Symbolism. See Images, impact of; Mathe-matics; Poetry

Tanner, J. M., 195, 197Target, M. See Fonagy, P.Teacher game, 250, 258Technique of Child Psychoanalysis, The (Sand-ler et al.), 172–173

Teen parents, 82Tesman, J. SeeMalatesta, C.Testing, psychological, 181, 182–185, 244–246

Thematic Apperception Test (TAT), 182–183, 186–190, 192–198, 203, 206

Therapist’s role: Ethan (case study), 53–71; Minding the Baby program, 82–84;state of playing, 214–216, 234–236, 258–260; traditional evaluation process, 130–133; transferences, 51, 79–80, 106–107

Thomas, A., 3Thoreau, H., 312“Three Essays, The” (Freud), 179“To His Coy Mistress” (Marvell), 316Toynbee, A., 319–320Traditional evaluation process, 130–133Transferences: Cecil (case study), 32–33;distance theme, 246–250; erotic inter-pretations, 309; Ethan (case study), 57–58, 64–70; 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, 273–275,287–288; reconstruction process, 295–311, 315; relationship issues, 246–250,254–257; state of playing, 214–216, 235,258–260; therapist’s role, 50–51, 79,106–107; transference complaints, 232–233

Traumatic memory. See Psychic traumaTriangular frameworks, 135–136Tronick, E., 9, 15, 120, 218, 219Tronick’s still face experiment, 218, 219Tuchman, B., 319

Turn-taking structure, 16, 23Tutors, E., 12Tyson, R. See Sandler, J.

Unconscious communication, 60Unconscious foresight, 314, 315, 329, 332

Verbalizations, 231, 235, 242Video feedback techniques: behavior ob-servations, 13–34, 40–41, 135–137,142–152; family interaction patterns,131–152; microanalysis, 5, 40–41, 129–138; nonverbal language, 12–13; parent-infant interactions, 7–12; treatmentmethodology, 21–23

Vision. See ForesightVocal rhythm coordination, 16–18, 23, 26,30–31, 36, 39

Vulnerability, 266–267, 268, 272–283Vygotsky, L., 241, 255–257

Waelder, R., 241–242Walker, R. See Ames, L.“Wasteland, The” (Eliot), 317Watson, J., 327Wechsler Intelligence Scale for Children(WISC), 244

Wechsler Intelligence Scale for Children—Revised Edition (WISC-R), 182

Weil, A., 217Weinberg, K., 9Weiss, J., 329Williams, M., 180Winnicott, D. W., 78, 217–218, 242, 284Wolff, P., 3Words, impact of, 325–326World Association of Infant Mental Health,79

Yale Child Study Center, 77Yale University School of Nursing, 77Yeats, W. B., 3

Zero to Three, 4, 79

340 Index

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The Psychoanalytic Study of the Child

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