Professional Documents
Culture Documents
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
VOLUME SIXTY
A. Scott Dowling
Introduction 3
Beatrice Beebe
Albert J. Solnit Award paper:
Mother-Infant Research Informs Mother-Infant
Treatment 7
Tessa Baradon
“What Is Genuine Maternal Love?”: Clinical
Considerations and Technique in Psychoanalytic
Parent-Infant Psychotherapy 47
Arietta Slade, Lois Sadler, Cheryl de Dios-Kenn,
Denise Webb, Janice Currier-Ezepchick,
and Linda Mayes
Minding the Baby: A Reflective Parenting Program 74
Judith Arons
“In a Black Hole”: The (Negative) Space Between
Longing and Dread: Home-Based Psychotherapy
with a Traumatized Mother and Her Infant Son 101
Alexandra Murray Harrison
Herding the Animals into the Barn: A Parent
Consultation Model 128
PSYCHOANALYTIC RESEARCH
v
vi Contents
CLINICAL STUDIES
Karen Gilmore
Play in the Psychoanalytic Setting: Ego Capacity,
Ego State, and Vehicle for Intersubjective Exchange 213
Lissa Weinstein and Laurence Saul
Psychoanalysis As Cognitive Remediation: Dynamic
and Vygotskian Perspectives in the Analysis of
an Early Adolescent Dyslexic Girl 239
Silvia M. Bell
A Girl’s Experience of Congenital Trauma: The
Healing Function of Psychoanalysis in the Adolescent Years 263
PSYCHOANALYTIC PERSPECTIVES ON
THE FUTURE AND THE PAST
Harold P. Blum
Psychoanalytic Reconstruction and Reintegration 295
Cornelis Heijn
On Foresight 312
Index 335
INFANT-PARENT RESEARCH
AND INTERVENTION
Introduction
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
3
4 Introduction
BIBLIOGRAPHY
7
8 Beatrice Beebe
Introduction
gaze
We begin by observing gaze. Mothers tend to look at the infant’s face
most 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 they
are about to fight or make love (Chance & Larsen, 1996; Eibl-
Eibesfeldt, 1970). Field (1981) verified that infants organize their
look-look away cycle to regulate degree of arousal. She monitored in-
fant heart rate during face-to-face play and showed that the moment
that the infant looks away is preceded by a burst of arousal in the pre-
vious 5 seconds; following the infant’s gaze aversion, heart rate de-
creases back down to baseline within the next 5 seconds, and then
the 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 the
amount of stimulation according to this gaze cycle, stimulating more
as the infant looks, and decreasing stimulation as the infant looks
away. Although these are typical patterns, we have also noted a pat-
tern of mutual “eye love” (Beebe, 1973; Beebe & Stern, 1977) in
which mothers and infants can sustain prolonged mutual gaze for up
14 Beatrice Beebe
to 100 seconds during periods of positive affect. These are the 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 infants
who present for treatment. If the mother feels that her infant does
not like her or is not interested in her, she may pursue the infant, in-
creasing rather than decreasing the amount of stimulation. In her
pursuit 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’s
head to get the infant to look. Maternal “chase” behavior is counter-
productive; the infant then requires more time to regulate arousal
down sufficiently to return to gazing at mother. Instead, if the
mother can be helped to give the baby a “time-out” to re-regulate,
“cooling it” when the infant looks away, trusting her infant to return
to her, the infant will rapidly re-engage.
head orientation
We next observe infant head orientation to the mother: is the head
oriented vis-à-vis, or displaced in the horizontal plane approximately
30, 60, or 90 degrees away? In the 90-degree aversion, first described
by Stern (1971), the infant’s head is tucked into the chin, which takes
considerable energy. Are head aversion movements in the horizontal
plane complicated by oblique angles of the head down (or up) as
well? These increasing degrees of head aversion are described by
ethologists as degrees of severity of “cut-off” acts (Chance, 1962; Mc-
Grew, 1972). They are “read” by the partner as active initiations of
disengagement. As the infant turns away up to about 60 degrees, he
can still monitor the mother with his peripheral vision (tracking
presence, direction, and intensity of movement); by 90 degrees away,
or arching, however, he may lose peripheral visual monitoring of her
movements. More usual gaze aversions retain head orientation
within an approximately 30-degree angle from the vis-à-vis, retaining
access to rapid visual re-engagement with minimal effort.
In relation to the maternal “chase” behaviors above, the infant may
“dodge” with increasing degrees of head aversion, as well as arching
back, freezing (described by Fraiberg, 1982), or going limp and giv-
ing up tonus. Beebe and Stern (1977) described split-second se-
quences of “chase and dodge” in which maternal chase movements
predicted infant dodges, as the infant monitored her every move-
ment through peripheral vision; but infant dodges also predicted
maternal chase behaviors, a reciprocal, bi-lateral interactive regula-
Mother-Infant Research and Treatment 15
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 center
stage. 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 expression
emerges 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 of
mouth opening are added to a smile, positive affect increases up and
up into the fully opened “gape smile,” hugely exciting for both part-
ners. Mothers intuitively roughly match the infant’s increments, so
that both build to a peak of positive facial excitement. Often both
partners excitedly vocalize at such moments, further increasing the
intensity (see Beebe, 1973; Beebe & Lachmann, 2002; Stern, 1985;
Tronick, 1989). In general, mothers and infants tend to match the di-
rection of the other’s positive-to-negative affective change, increas-
ing and decreasing together (Beebe et al., 2004). Rarely is there an
exact match of expression. Elaboration (Fogel, 1993), echo, or com-
plementing (Trevarthen, 1977) are better metaphors than matching
or imitation (Stern, 1985). Instead of the more romanticized notion
that mothers and infants exactly match, or are in exact “synch,” Tron-
ick and Cohn (1989) have shown that a more flexible process of
match, 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 is
unusual for mothers to display no facial matching at all, particularly
when infants are distressed. Malatesta et al. (1989) showed that un-
usual responses such as maternal joy or surprise to infant anger or
sadness predict toddler preoccupation with attempts to dampen neg-
ative affect (compressed lips, frowning, sadness). We construe these
patterns as “failures of facial empathy.”
16 Beatrice Beebe
vocalization
A key feature of the vocal exchange is a turn-taking structure. Both
partners contribute to turn-taking by matching the brief “switching
pause” as turns are exchanged. Mothers contribute by slowing their
speech rhythms, providing a great deal of repetition, and matching
the intonation of the infant’s sounds. Vocal contours refer to the
“shape” of the sound. Across cultures, a sinusoidal shape indicates
approval and a rightward falling shape disapproval (Fernald, 1993).
Mothers also optimally pause sufficiently to give the infant a turn. On
the one hand, mothers who prattle continuously do not permit this;
on the other hand, mothers who are silent partners can disturb the
development of vocal turn-taking, an essential building block of 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 make
contact with the infant. Because the infant does not have to orient or
to 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.”
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 most
problematic of attachment classifications. We interpreted the high
coordination 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 vocal
rhythm coordination; subsequently, at one year, Clara was classified
as showing disorganized attachment. In the research film, Clara is
crying and flailing as the interaction begins. Mother excitedly re-
peats her name. Clara’s crying rhythm and mother’s rhythmic repeti-
tion of her name synchronize. Mother flashes big smiles at Clara as
she synchronizes with the cry rhythm, as if attempting to “ride” high
negative arousal into a more positive state. Both escalate, Clara
screaming more loudly, mother now frantically vocalizing and mov-
ing Clara’s arms. Although most mothers would back off, this mother
just keeps going, and each partner continues to “top” the other. By
the end Clara has thrown up, sobbing and writhing. In addition to
vigilant vocal rhythm coordination, this interaction illustrates “mutu-
ally escalating over-arousal,” a disturbance of the ability of the dyad
to 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 and
variable. 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 interactive
difficulties and the process of change, in any modality (not just vocal
rhythm), as we do in the first case described below.
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 the
4-month mother-infant face-to-face interaction itself that predicted
infant attachment outcomes. The implication is that, in a community
sample, distressed maternal states of mind at 6 weeks or 4 months do
not necessarily lead to insecure infant attachment outcomes unless
there is also difficulty in the face-to-face interaction. This study pro-
vides a further rationale for therapeutically supporting the quality of
the mother-infant face-to-face interaction when mothers are dis-
tressed, which may then prevent later insecure infant attachment
outcomes. 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 of
arousal, the maintenance of alertness, the ability to dampen positive
or negative arousal in the face of over-stimulation, and the capacity
to inhibit behavior (Beebe & Lachmann, 2002). Neonates differ in
their ability to regulate state (see for example Korner and Grobstein,
1977; Brazelton, 1994). Infant temperament patterns, including
sleep, feeding, arousal difficulties, or special sensitivities to sound,
smell, or touch, are an important area of inquiry in the treatment
(see DeGangi, Di Pietro, Greenspan, & Porges, 1991; Greenspan,
1981; Korner & Grobstein, 1977; van den Boom, 1995). Disturbances
of infant self-regulation can be noted in patterns of autonomic dis-
tress (hiccupping; vomiting) and disorganized visual scanning, as
well as pulling the hair or ear, or a history of head-banging (Tronick,
1989). Although maternal touch is a primary means of soothing a
distressed infant, and extra handling is associated with diminished 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 distinguish
between infant constitutional processing difficulties that may have
existed at birth from problematic interactive patterns. Infant tem-
perament and self-regulation are already intertwined with interactive
regulation difficulties (see also Hofacker & Papousek, 1998). For this
20 Beatrice Beebe
distress regulation
Dyads show important differences in infant ability to manage mo-
ments of heightened distress, and maternal management of infant
distress. Both partners bring capacities to soothe and dampen as op-
posed to escalate distress. Obviously the mother has greater range
and resources in this process. The pattern of “mutually escalating
over-arousal,” where each ups the ante, was illustrated above. In 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). In
this 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 parent “new eyes” to see the infant’s remarkable nonverbal lan-
guage, and the infant’s ability to respond to minute, but nevertheless
identifiable, 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 infant
may be feeling. Very likely I will play this positive portion several
times, at least once in slow-motion.
As we proceed I illustrate how evocative minute infant facial 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 interaction
patterns that I would like the parent to be able to see. Together we
try to observe the effects of each partner’s behaviors on the other in
these difficult moments. I again inquire into what the parent felt,
what the parent thinks the infant felt, and the meaning these mo-
ments have for the parent. It is here that the parent is likely to have a
spontaneous insight into the problem. Being confronted with the im-
plicit “action-dialogue” in the videotape often triggers the parent’s
associations to aspects of his or her history that the parent always
“knew” but could not productively use in the current context with
the infant.
Wherever possible I like to use research findings, illustrating with a
drawing, to help parents understand the infant’s behavior, shifting
attention 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 slow
down, 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 are
identified. At the end of the session the parent is encouraged to trust
what has been learned, and to try not to be too self-conscious. An-
other videotaped assessment is scheduled in another month or two.
24 Beatrice Beebe
The Case of Cecil
play with the infant as she would at home. One camera is focused on
the 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 observed
that the mother continuously gave Cecil toy after toy.
Microanalysis of First Two Minutes of Mother-Infant Interaction
In the opening moments of the interaction, mother shook the toy to-
ward Cecil, with abrupt, rapid movements, each accompanied by a
strong sound, “gheh!” At each maternal movement, Cecil blinked,
with mild startles. Mother then moved into, “What’s that!” showing
the toy, making a series of “ooooh” sounds, and Cecil’s face showed a
hint 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, as
if the stimulation was just a bit too much for him.
After a brief interruption to get the seating and the camera angles
right, Cecil briefly glanced at his mother with a neutral face, and
then looked down. While he was still looking down, mother asked
Cecil to look at the toy, but Cecil stayed with his head down. Then
mother made an interesting noise, “gurooom!” and got 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 a
strong sound. At each Cecil blinked. Cecil then looked down and
away, then shifted his body and hung over the side of the chair, limp.
We have come to view such loss of postural tonus as a coping strategy
in the face of overstimulation.
While Cecil was still hanging over the side of the chair, not looking,
mother found a new toy, and offered it with a “sinusoidal” shaped vocal
contour (the contour of approval and flirtation): “Hello, Cecil; and do
you know what else?” This vocal contour is usually reserved for greet-
ing, once eye contact has already been made. It was successful in getting
Cecil to look at mother, and to pay attention to the new toy, as mother
continued, “Look 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, then
averted, moved his head farther down, and then uttered a fussy
sound. Finally he gave up body tonus and collapsed his head into his
stomach. Simultaneously with the collapsing tonus mother said,
“Hello, Cecil” and gently tapped Cecil on the head with the toy. Ce-
cil’s head collapsed further into his stomach.
26 Beatrice Beebe
stranger-infant interaction
Following the interaction with mother, I played with Cecil for three
minutes, while the mother watched the interaction over a TV moni-
tor from another room. The infant’s ability to engage with a trained
novel partner is a critical aspect of the assessment. Those babies who
Mother-Infant Research and Treatment 27
can “repair” the engagement with a novel partner are generally more
resilient, 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 of
the 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 on
the floor, and this was repeated over and over. In the process, Cecil
was very physically active, turning around in his chair a lot.
Eventually Cecil began to bang his own body gently against the
seat, as if to both self-stimulate and self-soothe. There were then a few
moments of eye contact with me, with midrange positive affect, but
these were very brief. Each brief gaze encounter was followed by a se-
quence of immediate averting, mild negative facial expression, look-
ing down on the floor at an object, and then hanging limp, sideways
over the chair, body tonus collapsed. Each time I waited, and he
came back into the engagement on his own. Once he looked, he 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 the
capacity to re-engage on his own when I waited.
and mother joined Cecil’s vocal distress with similar sounds, and
held him close.
Describing the rest of the session, at a more global level, after a few
minutes mother did a peek-a-boo game, covering Cecil’s face with
her hands and saying, “where is Cecil?” This time the quality was to-
tally different: slower and very successful. Cecil emerged smiling, and
sustained the positive affect. Then Cecil was briefly quiet, and
mother waited. Cecil then heard the noise of the camera again, and
mother joined his line of regard, and waited. Now Cecil wanted to
get out again, and this time I stopped the filming after seven min-
utes. There was nothing the mother did in this second filming that
seemed 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 have
none of it. He cried loudly, angrily, and threw any toys on the floor.
Three different attempts by me to play with Cecil had to be aborted,
since he was crying hard. Finally we organized a set-up in which Cecil
sat in mother’s lap, and mother was instructed to “be the chair,” not
to help or respond.
For the first five minutes of the interaction, Cecil was disengaged.
He was silent, made no eye contact, and every toy that I tried to en-
gage him with was immediately thrown on the floor. However, at
some point he finally made a vocalization, a “spit” sound. Immedi-
ately I matched this sound. And right away he looked at me and
made another, similar one. All of a sudden the whole tenor of the in-
teraction had changed, and we were engaged in a fascinating vocal
dialogue. As we continued to match and elaborate on each other’s
sounds, at some point Cecil began to move his tongue as he made the
sounds, and it came out as “la-ler, la-ler.” He was intensely visually en-
gaged. I tried making the “la-ler” sound, and we both burst into big
smiles, and giggled. Variations on this rich vocal dialogue continued
for the next four minutes. Cecil had been enormously responsive to
my matching his vocalization. Since this form of engagement does
not require the child to be visually engaged, it can potentially pro-
vide a less intrusive or demanding means of making contact. His own
willingness to elaborate on the jointly formed patterns was critical to
the success of the dialogue.
Toward the end of the interaction Cecil began to be tired. Al-
though he had been having a spirited, at times elated, turn taking di-
Mother-Infant Research and Treatment 31
alogue with me (as he sat in his mother’s lap), when he began to get
tired, he arched away into his mother’s body, and avoided me. But
then he was able to keep coming back to me, and to continue the
rhythm of the vocal exchange. These movements away from me were
his own self-regulatory efforts to manage his arousal within a com-
fortable range. The success of his self-regulation efforts could be
seen 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 part
of the therapy. It was a demonstration of a way to make contact with-
out forcing, intruding, or chasing. It also vividly showed the power of
vocal rhythm matching in making contact, since the child does not
have to make eye contact.
This laboratory filming ended with a brief discussion with the
mother that her interaction with Cecil was going extremely well now.
We made a decision not to pursue the attachment test since the visit
had already been too long. Cecil was doing well, and all we needed to
do was to watch to be sure he continued to be fine.
follow-up contacts
September
A telephone conversation: “Things are just great. We were on 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 are
just charmed by him, he is now so social. I had seen this side of him
from time to time, but now it has really come out. He is more bonded
with me too, he wants mommy only. He seems terrific. I’m enjoying
how different he is from his brother.
November
A letter: “You have played an absolutely pivotal role in my life. . . . To
begin with, Cecil; our connection is deep and easy and full of joy. He
is an absolutely delicious, funny, charming, very loving little per-
son. . . . you helped me relax and see him; I stopped focusing on who
he was not and on how he and I were not. . . . So, having discovered
Cecil, I fell in love with Cecil. No surprise. . . . In retrospect, my 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-
32 Beatrice Beebe
sponsive to him anywhere near as much as I can be. Now I am, and let
me tell you, the difference is not minor.”
Similarly, the infant seemed to act like Mrs. C.’s own mother, since
the infant had an “impassive” face, neutral, impossible to read, which
reminded Mrs. C. vividly of her own mother’s face. Mrs. C.’s response
to her own infant’s impassive face was very similar to her response to
her mother’s face when she had been a little girl, that is, to become
anxious and to try harder. Presumably the similarity of this interac-
tion with ones in her childhood interfered with Mrs. C.’s ability to see
that her “trying harder” was just pushing her infant farther away
from her.
These transferences were identified in the process of watching the
videotape. Being presented with the procedural level of action 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 being
asked to make a unique integration of procedural and declarative in-
formation, in an arena that has been out of awareness due to some
kind of unresolved pain. This work allows the mother to shift her rep-
resentation, for example, from the baby rejecting her, to the baby as
over-stimulated and attempting to dampen his arousal.
The optimum midrange model of regulation described above is
useful as a framework for evaluating the progress of the treatment. At
the outset of the treatment, Cecil could be described as preoccupied
with self-regulation (looking away, showing lowered level of arousal,
constricting the range of the face), with lowered levels of contingent
coordination with 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 contingently
responsive to the infant’s every move, with excellent facial-mirroring
and vocal rhythm matching, but interacting with levels of stimulation
that were too high, with patterns that were spatially intrusive, that 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 the
infant’s distress, and give the infant space to initiate play. Moments of
matching 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 both
positive and negative expressions rather than a predominance of
34 Beatrice Beebe
The case of Nicole is a useful counterpoint to the Cecil case, which il-
lustrates mild maternal intrusion coupled with some temperament
and arousal regulation difficulty in the infant. Nicole, on the other
hand, illustrates a maternal “absence of provision.” Because this fam-
ily was from a distant city, and I happened to be traveling nearby, the
mother-infant pair was not evaluated in my lab, but rather in an of-
fice, and they were only seen in person for one extended three-hour
evaluation, 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 videotape
evaluation was luckily not essential. In the Cecil case, I was not able to
detect the problem without the videotape microanalysis. In the case
of Nicole, knowledge of the microanalysis research was nevertheless
essential to the treatment.
Mrs. N. was referred by her therapist, who described her as an 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 daughter
because 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 she
arrived home to see her daughter laughing and giggling with the
Nanny, but Nicole would not even look at her. “I’ve been going 100
miles per hour all day, and Nicole has been with someone laid back
with nothing to do but to be with her. I take Fridays off, and it takes
her quite a while to warm up. My husband does not think it is any-
thing to worry about. But what will it do to her in the long-term? I
feel like she does not love me, that I’m not good as a mother, I’m not
as natural as the Nanny. How much I need her love. I envisioned a
different reaction to me. She smiles more to my husband and the
Nanny than to me.”
“I have never seen myself as a mother. I was little ‘Miss Career.’ My
mother was domestic, but she resented it. We were toys and dolls to
her. Now I want to pick back up the domestic side, but it does not
Mother-Infant Research and Treatment 35
Nicole then needed her diaper changed. She had a large bowel
movement. Mrs. N. was gentle, solicitous, and managed it well. Now
Mother and Nicole were together on the couch, and Mrs. N. showed
me a “pull-to-sit” game that she plays with Nicole, a game that her
friend had taught her. The baby clearly knew the game, anticipating
the moves with her body, but she did not look at her mother, her face
showed no animation, and at the last moment before attaining the
sitting position, her head oriented up and 30 degrees away from the
vis-à-vis. Mrs. N. then held Nicole lying across her lap on the infant’s
back. This was the nicest connection they made, slow, both bodies re-
laxed, both looking at the other, but without smiling. Mrs. N. then
began to talk about how terrible she felt: “Have I hurt her, what will
be the effect, will she know her own mother, should I stop working?”
She cried during most of this discussion.
After about an hour, I suggested that we start to see how we could
help her engage Nicole more. I said that I did not think the issue was
the amount of time that she worked, as much as finding a way to
make a connection with Nicole. I explained that first I needed to play
with her to try to see her range of responsiveness. Nicole chortled,
with high positive affect, sustaining long gazes with me. She was mar-
velously socially engaged. From this interaction it was clear that the
difficulty was not an incapacity on the part of the infant. Evidently,
the social engagements with her Nanny and her father were going
well.
I then set about trying to teach Mrs. N. how to engage Nicole. The
first thing I taught her was vocal rhythm “matching,” making sounds
contingent on the baby’s sounds, both matching and elaborating on
the intonation, pitch, and rhythm. I chose this first because the child
does not have to make eye contact in this mode of relating. Mrs. N.’s
sounds were thin and squeaky. She did not give the sounds a robust
prosody, she could not elaborate on them, and she did not put any
words to the sounds. She did not seem to know how to play. I
coached the sounds from the sidelines. Eventually the sounds she
made were adequate to make some contact with the baby. Nicole ori-
ented to her a bit more, and returned some of Mrs. N.’s sounds with
her own, beginning a rudimentary vocal dialogue. But Nicole did not
look at her mother.
Noting how flat her face was as she interacted with Nicole, I then
tried to teach Mrs. N. facial mirroring, by having her roughly match
some of my faces (gape smile, mock surprise). I tried to get her to
move her face in ways similar to the ways I moved mine (small incre-
ments of open mouth, open a little more, then a little more; moving
Mother-Infant Research and Treatment 37
the upper lip in and out of a purse etc.). She was unable to play with
her face; her face was tight, flat, and unvarying. I then had the idea of
showing her how to unlock her jaw, and how to massage her face. I
asked her if she would be interested in trying this. She agreed. In this
process she had an association to her mother’s angry, tight face, and
she became a little teary. I suggested that her reaction to her
mother’s angry face was expressed in her own facial tightness and
constriction. She was receptive and felt sobered by this idea. The at-
tention to the behavioral details of the procedural level, particularly
the constriction, seemed to trigger her representation, which we
could then address and elaborate at the symbolic level.
We then moved to an attempt at face-to-face interaction between
mother and baby. At first Nicole was very gaze avoidant and her
whole body arched away from her mother. The infant made ab-
solutely no eye contact. Gradually I taught Mrs. N. to slow down and
to 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 surprise
greeting. The instant the infant looked away, I taught her to “cool it.”
Nicole began looking a bit more. We spent quite a while at this.
By the end of the three-hour session Nicole showed some brief par-
tial smiles to her mother. The gazes were not sustained. But Mrs. N.
had a direct, powerful experience of getting some more response
from her baby. She could see that she was getting somewhere. She ex-
pressed relief and gratitude that I had validated that something was
wrong. I reminded her of the many things that were right as well: she
had a very gentle and affectionate capacity to hold Nicole and to
feed her, she did have some games she played with the infant, and
most of all, she wanted more contact with her.
Ten days later we had a telephone session. “Now I make it totally
Nicole’s time when I get home. If I can slow down, we can connect
better. By the end of the week I feel totally disconnected from her.
When the Nanny leaves, she is used to her. I have to be careful: I ex-
pect her to demonstrate affection and attachment. When I don’t get
it, I get worried. Sometimes she does not make any sounds, so I can’t
mimic her.” I asked her if she could start it with occasional sounds of
her own. “My husband can walk in the room and connect with her
right away. He is like the Pied Piper. It is hard for me. I feel bad that I
don’t connect the way he does. If I don’t get a lot of feedback, I feel
unliked.” I asked if there was then a danger that she would feel re-
jected and withdraw. She agreed, yes, very much. She then reported
that Nicole is not as avoidant as she was: “She looks at me, she
38 Beatrice Beebe
watches, though she does not smile. She can concentrate on my face
though, 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 not
smile. “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 was
wonderful that she was trying to engage her child with her face, and
that Nicole was clearly beginning to respond. I congratulated her on
becoming so aware of her own face, and able to notice when she
closes it up.
“When Nicole looks at my husband, she gets this glow; will it always
be this way? In the morning I am terrible with her. I’m trying to get
ready, I’m in a hurry, and I do a dancing conversation in front of her
face, all speeded up.” I commented on Mrs. N.’s increasing ability to
notice what she does and to see if it is disturbing Nicole’s ability to
connect with her. She then asked, “Have I lost my chance? When I
left you, I felt so bad, and angry; I missed my chance. I should have
stayed home and not worked.” Without waiting for me to respond,
she immediately told me that Nicole was looking at her right now,
and Mrs. N. began to make sounds. We practiced the “sinusoidal”-
shaped “hello,” she and I saying it to each other, and she reported
that 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 angry
that no one had been agreeing with her that something was wrong.
She felt that finally I had validated her. “I would be devastated if I do
not have a good relationship with Nicole. She lights up for my hus-
band. She is so responsive to the Nanny. But what you are saying to
me is, it’s not too late for me to connect. I’ve never felt so insecure in
my life.” I empathized with her fear and distress. Then I told her how
terrific it was that she was holding on to her hope to connect with
Nicole, and that she and I could both see progress.
A telephone message two weeks after the initial three-hour session
in person: Mrs. N. was canceling our tentative appointment to see
each other in person because she and Nicole were doing so well: “I
am getting so much feedback from her, I am relaxing a little. She
smiles more, looks more. I don’t feel crazy anymore. All of a sudden
she has started really vocalizing. The biggest thing you said was, focus
on 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
Mother-Infant Research and Treatment 39
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 bad
evening. But I’m more comfortable around her. I may be doing more
of her language. I try to slow it down for her. If I’m rushing, I notice
it. Then I just hand her to the Nanny, because I don’t want her to
sense it. I imitate her sounds, but not all the time. If she initiates, and
I respond, and make it even bigger, then she laughs.” I tell her how
wonderful all this is, how thrilled I am that things are so much better.
“I think 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, I
didn’t think so, because things were going so much better. We agreed
that she would call me if she had any more concerns. She thanked
me profusely. I told her that it was so remarkable how quickly she and
Nicole were able to turn things around.
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
BIBLIOGRAPHY
Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of at-
tachment. Hillsdale, N.J.: Lawrence Erlbaum Press.
Bakermans-Kranenburg, M., Juffer, F., van Ijzendoorn, M. (1998). Inter-
ventions with video feedback and attachment discussions: Does type of
42 Beatrice Beebe
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 on
applied psychoanalysis and parent-infant psychotherapy. Member of the Association
of Child Psychotherapists and the Association of Child Psychoanalysis, Inc.
The Parent Infant Project team—Carol Broughton, Jessica James, Angela Joyce,
and Judith Woodhead—have provided valued collegial consultation during the
course of this work and on the paper. I also want to thank Dilys Daws for her interest-
ing comments.
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
47
48 Tessa Baradon
asked about her position on the different heuristic models of
the mind, Anna Freud replied: “I definitely belong to the people who
feel free to fall back on the topographical aspects whenever conve-
nient and to leave them aside and speak purely structurally when that
is convenient” (Sandler with Anna Freud, 1981). Parent-infant psy-
chotherapy is a meeting point for the different disciplines addressing
infant development: psychoanalysis, attachment, and neurobiologi-
cal research. In facilitating our understanding of the ebb and flow of
the therapeutic construction, Anna Freud’s advocacy of conceptual
flexibility 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, attachment
paradigms of “security” and “disorganization,” and neuropsychologi-
cal discussion of relational trauma are useful frames of reference. Yet
there is an additional ingredient to do with love, captured by the pa-
tient in her question: How can we integrate love into scientific and
clinical discussion?
“Genuine maternal love” for the mother who asked the question
was defined by selflessness. My clinical work has convinced me that
the love of a mother for her infant and of a baby for his mother
needs both measure and passion. It contains the 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 the
baby, her adoration of “His Majesty the Baby” (Freud 1914), and her
capacity to tolerate her hatred of her “bondage” to him (Winnicott
1949). Thus, her identification with her baby and yet her ability to
differentiate between herself and her baby and allow individuation
(Mahler et al. 1975) are required. Only then is the baby able to safely
love his mother, in the sense of moving from relating to object-use
(Winnicott 1969) and development of a sense of self as real. At the
same time, “love” is not a static concept. In this paper I attempt to de-
scribe the development of this mother’s love, matched by changes in
her baby’s expressed love for her, and the interventions that may
have 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 of
self (Silverman and Lieberman 1999), failure to protect the infant
from impingements (Winnicott 1962), inability to contain the infant
“What Is Genuine Maternal Love?” 49
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 eating
disorders and self harm, and a number of attempted suicides requir-
ing hospitalizations, the latest one year previously. Consequent upon
the 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 D
reassured her that she is a good mother and that she needed her
fears to be heard and not brushed aside. Although we ask to include
fathers in the therapy where possible, I decided it was important to
enable this mother to indeed be “heard” in her request and to ex-
plore the possibility of including the father after we had established a
therapeutic alliance. In the course of the therapy father did become
involved, but in this paper I will not discuss the work done with the
triad. Mother, baby, and I met once a week for a period of two years.
This paper focuses on the first year of therapy.
She had felt that the fetus was a parasite. She felt very guilty about
this. I asked whether these kinds of thoughts were continuing. At this
question Ms G became distressed, saying that she feels that she is
“forced by him into an artificial position . . . of trying to be a good
mother, who loves her child and takes care of him.” Ms G said she
does not feel like that much of the time. She added that she would
not harm him physically.
Somewhere early in this conversation Ethan fretted a bit. Ms G im-
mediately picked him up with extreme care and held him to her, his
little body slumped against the palm of her hand. She checked with
me whether she could feed him. She snuck him under her shirt, care-
ful to keep her breast hidden. The “feed” was quickly over and Ethan
went on sleeping. Ms G removed him from the breast and covered
herself up.
We spoke about attending parent-infant psychotherapy. I 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 I
would not have been able to tell from her facial expressions and tone
of voice when disturbing thoughts toward Ethan intruded during the
session, and that from this I could tell that she was really trying to
keep a tight grip on her feelings. Ms G reiterated her fear of damag-
ing him through her depression as her mother, too, had been de-
pressed and unavailable. I suggested that we would attend to both
the good things that happen between her and Ethan, such as her
gentle stroking of him that I had observed even when she was upset,
and to her bad feelings and thoughts. Ms G hugged Ethan to her.
I felt that the central verbal and affective communication to me in
this session was Ms G’s sense of being damaged herself and, through
her very being with her baby, of damaging him. Her state of primary
maternal preoccupation had a particular quality to it: hypersensitive
to the baby via herself, it seemed that projection did not aid her to
“feel herself into her infant’s place” (Winnicott 1956, p. 304) but that
the infant was equated with her, as a disturbed extension of herself
(King 1978). Moreover, his critical early hospitalization, in which her
dread of damaging a child was actualized and exposed, seemed to
have been a trauma which confirmed a psychic equation between
her inner and external worlds (Fonagy and Target 1996; Target and
Fonagy 1996).
In turn, I experienced Ms G and Ethan, separately and as a dyad, as
extremely fragile and needing both to be reached out to and to be
handled with care. On the one hand, I struggled with my own need
to establish some contact with her averted face, as I strained to hear
her whispers. I felt responsible for her very life, as I imagine rescue
workers feel in response to the sounds of life after disaster. In this
54 Tessa Baradon
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, we
adults do the same. Yah . . . Take a little break in a conversation, ah,
otherwise it gets too much, doesn’t it?”
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 use
of my validation of Ethan’s desire for her to express her conun-
drum—can she allow personalization: “Should he be smiling at me
more?” This offered an opportunity to explore what Ethan might be
avoiding. I learned that Ms G habitually scanned the object for their
affective communications/demands and that, since Ethan’s needs
and wants evoked her hatred, it felt dangerous for him to look into
her face/mind as he may see those emotions in it.
I was aware that she had not related to Ethan for some length of time
and asked whether she was feeling ambivalent about Ethan there and
then in the session? Ms G said she was not sure . . . perhaps her in-
stinct was to touch him but she did not want him to feel smothered
by her. She wondered if she is not perhaps too disengaged with him. I
suggested that, on the contrary, I thought she was very engaged with
him but that she is protecting him from the toxicity that she felt was
passed to her by her mother and which she fears she may pass to
Ethan. Ms G nodded. She said she wanted to make it clear that her
mother did the best she could at the time and added that of course
she feels that it wasn’t good enough. I rushed in too quickly at this
point, saying that perhaps in her attempts to protect Ethan she was
keeping a distance between them that prevented them from sponta-
neous exchanges, such as laughing and playing together. Ms G
replied that Ethan may in years to come experience her as in a state
of severe depression or absent from him. Almost under her breath
she murmured that if she were to leave through dying she would not
come back. Ms G was quite tearful and picked Ethan up, caressing
him. Then she said that she is not sure whether she’s holding Ethan
because he is a soft, comforting thing . . . and she put him down on
the floor, on his side facing away from her, and at a distance. He
sucked hard on his hand and just lay there, looking into space.
The whole interaction was extremely painful as baby and mother
seemed quite unable to come together. The essential elements of
adoration and appetite for the baby were missing from Ms G’s love. It
seemed that his dependency, need, and desire for her resonated with
the representation of him as parasitic during pregnancy—depleting
her of self-hood. The transference to Ethan was thus of a consuming
object like the mother of her childhood. This dilemma is likely to
have been accentuated by her feelings of abandonment by me 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
58 Tessa Baradon
she suffered. In this way, distancing him was an act of love as well as
cruelty. Ethan, to my concern, veered between disintegration and
precocious defense.
I felt caught in the middle and responsible for the devastation, as
though during the break the therapy had replicated the hollow 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 his
mother. Certainly my “too quick” response contained a veiled criti-
cism (also reversing the attack on me): in protecting Ethan from
damage you are in fact killing off a live relationship. Obviously, I may
have responded from the countertransferential reserves of my own
tetchy narcissism. We also know from clinical experience that past re-
lational trauma can be reproduced in the present therapeutic situa-
tion, in the transference-countertransference transactions. Yet I
think 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 of
course my) possible future loss of herself. The habitual solution to
overwhelming 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 away
from us. As he lay rigidly on his side looking into space, I felt I was
witnessing his emergent identification with the dead mother (Bollas
1999)—a kind of dying in situ.
sent, in which she felt “used” by her mother for her own narcissistic
needs. Moreover, she held her parents responsible for her damaged
mental state and, even as an adult, had no real sense of volition to
modify the childhood feelings of helplessness.
Yet, despite the relentless grip of the past, I observed her handling
of Ethan extend to more animated exchanges. Ethan responded to
these tentative “protoconversations” with widened eyes, excited 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 looking
at her and cooing. When I pointed this out, Ms G said that friends vis-
iting had commented that Ethan’s eyes followed her wherever she
is—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 less
ambivalent parenting and Ethan aspects of “good enough” related-
ness, and thus also development. Indeed, during this period in the
therapy, 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. I
noted that sometimes Ms G reached out to Ethan, and he, in the pro-
cess of being attended to, became distressed. His tiny body became
rigid and he clawed at his mother’s body. At such times Ms G moved
through 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 so
hard to soothe Ethan? Was he damaged at birth, would another
mother get it right? I tried to explore with her what happens to her
when he cries. Ms G confirmed that she gets very upset. I suggested
that sometimes Ethan’s cries feel like her own. Ms G became tearful
and then reprimanded herself for not always acting the adult with
him. I said that when they are both crying she no longer feels the
mother. I also spoke about the rage that she feels when he triggers
her pain. Ms G whispered that she feels so guilty and ashamed.
Thus, it was becoming clearer the extent to which Ethan was the
barometer of her own emotional state. When his needs did not res-
onate with her own conflicts, Ms G was able to respond. Unpre-
dictably, however, his ordinary infantile needs could trigger or link in
with her own volatility. This is another aspect of relational trauma—
where the quality of affective communication with the baby imparts
trauma from the mother’s internal world to that of the baby.
60 Tessa Baradon
separation-individuation
In the course of a longer-term therapy the infant naturally moves
from a state of total dependency on the mother toward the begin-
ning of separation-individuation. This offers opportunity to work
with 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 risk
for this dyad was that separation-individuation would plunge mother
into narcissistic despair and rage.
Sleeping and feeding were ubiquitous arenas for expression of
conflicts over separation in Ms 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 woke
her up. She moved Ethan to his Moses basket at her side, but kept
vigil through the night. She recalled childhood fears of the dark and
of sleeping alone and felt unable to tolerate Ethan’s cries when put
into a cot. At the same she felt driven to madness and despair by lack
of sleep. D, with his own difficulties in this area, was unable to offer
support, and soon Ethan was restored to the parental bed. Ms G’s
chronic insomnia was thereafter channeled into nightime rumina-
62 Tessa Baradon
tions as she waited for dawn so as to escape from the bed to a strong
coffee and cigarette.
With Ethan waking hourly, sleep disturbances became woven into
the conflicts around feeding and weaning. Ms G repeatedly ex-
pressed her feelings that feeding was the sole good thing she could
give him and admitted her gratification that only she could provide
this. However, these feelings also came into conflict with her experi-
ence of his dependency as depleting. In the sessions I observed feed-
ing encompass many regulatory functions, so that Ethan was put to
the breast when he cried, when he was tired, when they were both at
a loss as to play. With feeding used to meet such a variety of 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 opinion
moved 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 internal
split was thus effectively externalized, with the medical network and
her partner now carrying for her the thrust for forced separation,
while she maintained the ubiquitous place of breast-feeding. It
seemed important that at that point I did not ‘know’ what would be
best, and held neither a wish for Ms G to wean nor for her to 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 to
let him cry. She said that before Ethan was born she spent much of
the time alone. I wondered if that was her way of keeping her emo-
tions on an even keel and she confirmed this. I suggested that having
Ethan with her all the time meant that she has no means of regaining
her “emotional balance” (her words). Thus the closeness was experi-
enced as loss of self, provoking rage. Getting away was a relief at that
level, but it also brought with it the fear that she could disappear
from their lives and it would not matter.
As Ethan became more mobile he could initiate movement toward
and away from his mother.
7 months into treatment. I noted how Ethan seemed to want to be
close to her today. Ms G said she did not know if she wanted him
close or not. She said her guilt at not really wanting his “relentless”
“What Is Genuine Maternal Love?” 63
Anticipating this loss Ms G thought she and Ethan would miss their
sessions 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 and
wan, while Ethan seemed to have gained bulk and weight. My first
thought was “he’s feeding off her!” He also looked strikingly like his
father, 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 a
distance and looking worried. After a while he gave me a smile and I
smiled back and asked whether he was beginning to forgive me for
the summer break. Ms G told me that on their holiday everyone had
adored Ethan and that he had gone easily to the men but not to the
women who wanted to pick him up. I wondered whether she was link-
ing Ethan’s reserve with me to this. She shrugged. I asked her what
she made of her observation. She said, “It’s like being run over by a
red car and then not liking red cars afterwards.” I said it seems to
have reinforced her fear that she was not a good mother and as a re-
sult all women were like red cars to Ethan. Again she shrugged, this
time seemingly in agreement. Ethan was crawling about—initially
energetically but then looking lost. A number of times he headed to-
ward his mother and then veered away. When he absolutely ran out
of resources he crawled to her and tried to clamber onto her lap. Ms
G held him loosely, pulling away a bit and getting her hair out of his
clasp. She then abruptly stood up muttering that he needs a climbing
frame, carried him over to one of the chairs and stood him there.
Ethan looked tiny and forlorn across the room. I felt shocked. She
came back to her place on the cushion. I said she was equating 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 was
about to say, I asked whether she wanted him to be independent of
her so that she could do away with herself if she felt she needed to.
Ms G looked pale. She whispered that this was very selfish. I said per-
haps she thought that in order to continue living she needed to feel
that she could kill herself. Ms G said everybody had their escape
routes.
Ethan had crawled back to our vicinity and was searching Ms G’s
bag. He pulled out a plastic container with food. We watched as he
struggled to get an apple out. I accompanied him with words: is he
wanting the apple, can he get to it? He managed to extract the apple
“What Is Genuine Maternal Love?” 65
and tried to bite into it. I asked him if he can eat it, is it too big? I said
maybe Ms G thought I was fussing too much. She moved closer to
him and asked him if he needed her to cut it for him, but Ethan had
in the meantime made indentations with his teeth. He chewed on
the apple for a while and then tried to get the bottle of baby food
out. Ms G watched him closely and I found it agonizing that she did
not capitalize on his interest. When she finally, tentatively offered
him some food, he spat it out. She immediately put the bottle of food
away. Shortly after this he began to cry.
Ms G told me that at D’s insistence she had taken Ethan to a nurs-
ery that morning. I asked how they had felt about it. She said Ethan
had choked on a brick during his visit. She conveyed immense sad-
ness. I said she seemed torn between loving Ethan and wanting his
love for her, and her fear that this dependency in both of them
would take away her escape route. I suggested that the long break
had probably also brought up these feelings in relation to me. Ethan
was getting more upset and when picked up by Ms G he clung to her
strongly. I said to him that he was showing his mummy how much he
needed her and how frightened he gets when she thinks about leav-
ing him. Ms G carried him over to the windowsill and sat him on it so
he could look out. Ethan calmed, and soon after this it was time to
end. Ms G fled the room clutching Ethan in her arms.
The story of the holiday could have been taken entirely as a trans-
ference communication: I had “run over” her dependence on me
and 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 a
retaliatory attack on me. Her rage with me was communicated in the
narrative of the red car and enacted in substitution of climbing
frame/chair for self, that is, in her refusal to embrace 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 initial
attempt 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 displacements
that perhaps could have been taken up for it is there that the experi-
ence of cruelty lay. Addressing her rage with me may have relieved
Ethan from the burden of carrying it.
With the rupture (break) with me unsufficiently reflected upon,
what followed was Ethan’s performing a transference enactment of
66 Tessa Baradon
monitored his endeavors and encouraged him. Ethan then ate his
fruit, swallowing some and spitting some out. Gradually eating and
playing/exploring became somewhat more integrated, and he
moved between the activities and us.
He approached his 1st birthday and this preoccupied Ms G.
She said she still had not found the perfect present. She mentioned a
cloth she’d had as a comforter which had worn away—she wished
she still had it to give to Ethan. I said it sounded that she was wanting
to protect and comfort him for the years to come. She replied that
she had a lot to make up. I said this made me think of the perfect
present as representing a wish to make good their very difficult early
beginning. Ms G spoke of reparation and I thought she was also re-
pairing something for herself. Her emphasis was on her wish to pro-
tect Ethan’s trust and expectations that people will respond to him
kindly. I suggested she may have felt unprotected and that cruelty hit
her abruptly as a child. Ms G spoke about her mother doing her best,
but that it was not good enough. She added that her mother does a
lot of charitable work but she wishes she could have given the same
to her children. I said that perhaps she feels that sometimes both her
parents 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 G
struggled with this, though she did not deny it.
Ethan had finished eating and messing and was exploring under
the table where he discovered the telephone wire and plug. Ms G ini-
tially asked him not to play with the cord and then went over and
picked him up. Ethan gleefully crawled back to the table and Ms G
became firmer in her tone of voice. I spoke about what was happen-
ing between them, reflecting that he really enjoyed being gathered
up by his mother and had found a hide and seek game which he
could play with her.
This session was characterized by a sense of calmness and re-
flection between Ms G and myself, the adults, and playful exploration
on 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 baby
and 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 celebrate
their coming together through the love she had discovered within
herself for her child. In wishing to extend the “comforter” from her
childhood to him, she also had begun to mourn the lonely child-
hood she had, and to relinquish some of the envy of her child for the
maternal comfort he could still have in his. Ethan’s play with the tele-
68 Tessa Baradon
Discussion
Ethan’s first birthday also heralded the end of our first year of work
together—a good time to take stock. The wish, and failure as yet, to
find a “perfect present” seemed symbolic of what had been achieved
and of that which still needed to be addressed.
Ms G had approached parent-infant psychotherapy with the wish
for a “filter” to protect her baby from the transmission of damage she
felt had been done to her by the parenting she had received. In equal
measure, although more hidden, was the fear of being damaged by
her baby. This mutual threat was created through their very exis-
tences in relation to each other. As Ms G said, “Can one damage
one’s baby just by being available?” In the transference I was also of-
ten a source of danger, most spectacularly around breaks when my
unavailability confronted Ms G with her the extent of her depen-
dency on me and my maternal failure to hold it. Ethan’s post-natal
vulnerability—his smallness, sensitivity to lights and noise, seemingly
low threshold to “unpleasurable” experiences and the difficulties in
comforting him—intensified the sense of fragility and risk. My coun-
tertransference fantasy that we were constructing the therapeutic
space within a sea of shards highlighted the power of the emotions,
projections and enactments.
In the course of the first year of the therapy there were some
changes in the quality of the relationship between Ms G and Ethan.
The most significant was the expanding sense of maternal love for
Ethan. In the early months Ms G’s fear of, and guilty hatred for, her
baby’s dependency overrode her ability to accept more benign feel-
ings in herself. She defensively adopted an ideal of altruism that
negated not only her passions but also his. Ethan was forced into pre-
cocious inhibition of attachment behaviors toward his mother. His
turning from her, and her failure to meet her ascetic standards, com-
pounded her depression. In the course of the first year of therapy
there 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 acknowledge
and 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?
“What Is Genuine Maternal Love?” 69
Perhaps “falling in love” could start to take root only after there
was some measure of surviving the destruction and despair brought
from her past primary relationships into her present ones. By the
third quarter of the year Ethan, although delayed, was making up the
early impingements and developmental tests confirmed he was on
track. Thus Ms G’s psychic reality of the inevitability of damage
could, sometimes, be challenged by a different, external voice.
Ethan, for his part, seemed to capitalize on the openings in their re-
lationship and became more forward in expressing his desire for her.
This, too, was a positive reinforcement which Ms G could at times
perceive.
In the transference relationship with me I, too, was surviving her
destructiveness and was not retaliating with narcissistic demands of
my own. Thus Ms G was meeting with a different “motherhood con-
stellation” (Stern 1995) from the persecutory internal one, one in
which 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—using
words 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, the
misattuned emotional “dance” between mother and baby was re-
peated in the interactions between the three of us. In time, I became
better at matching and repair of the spontaneous gestures and af-
fects that constitute “authentic person-to-person connection” (Stern
et al. 1998, p. 904) and this then framed the developing relationships
between mother and baby and myself.
Because so much in the earliest transactions between Ms G and
Ethan was driven by her negative transference to him, offering myself
as someone who could simply be with mother and baby and could re-
flect on them in relation to each other without fear of damage, seems
to have been important. For quite some time it seemed that only in
my mind could their survival as a dyad be contemplated. This raised
the question of which patient should be privileged from moment to
moment—Ethan, mother, father (present or absent), the relation-
ships? At times I left a session feeling that more work should have
been 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 Ms
G, to address her depression and the defenses and distortions that
constituted her zone of safety but also derailed the relationship with
Ethan. Despite the compelling nature of Ms G’s narrative, it was cru-
70 Tessa Baradon
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 the
more urgent given Ethan’s young age and the chronicity of Ms G’s
difficulties, spanning critical periods in his development.
Alongside the changes that marked the achievements of our first
year together there remained areas of great vulnerability in their re-
lationship. It seemed that the quality of love Ms G was able to offer
Ethan was contingent on her emotional state at any given time and
the extent of preoccupation with herself. Often Ethan had to make
do with the crumbs of emotional availability that penetrated her 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 threat
and 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, subject
to 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 in
occasional veering away in the midst of approach or a momentary
freezing when mother seemed annoyed.
These thoughts about clinical process are relevant to the question
of whether “genuine maternal love” exists.
It seems to me that what Ms G captured in this term was the affec-
tive quality of her love for her baby as described above. In presenting
the question she was disclosing her knowledge that something was
going very wrong for them. At the same time, bringing the question
into the therapy also underlined Ms G’s commitment to do better by
her baby: whatever her state of mind, however conflicted she was
about the therapy, Ms G and Ethan attended their sessions without
fail. In using the therapeutic space to risk intimacy, Ms G and Ethan
were constructing their particular version of “genuine” love—some-
what more measured and a little more vibrant at the end of the year
than 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 to
hold in mind in the course of the therapy with mothers and babies.
In the face of conscientious maternal care, it provides a framework
for understanding a particular quality of “maternal failure” and ensu-
ing relational trauma for the baby. It also suggests an outline of the
“What Is Genuine Maternal Love?” 71
BIBLIOGRAPHY
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, the
Yale 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 to
thank Jean Adnopoz, the Director of Family Support Services at the Yale Child Study
Center, as well as Sean Truman, both of whom were instrumental in getting the pro-
gram off the ground. Finally, we wish to thank the administration and staff at Fair
Haven Community Health Center, particularly Katrina Clark, Kate Mitcheom, Karen
Klein, and Laurel Shader, who along with many other members of the pediatric and
obstetric services gave Minding the Baby a home.
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
74
Minding the Baby 75
that is, we work with mothers and babies in a variety of ways to de-
velop mothers’ reflective capacities. This approach—which is an
adaptation of both nurse home visiting and infant-parent psychother-
apy models—seems particularly well suited to highly traumatized
mothers and their families, as it is aimed at addressing the particular
relationship disruptions that stem from mothers’ early trauma and de-
railed attachment history. We discuss the history of psychoanalytically
oriented and attachment based mother-infant intervention, the theo-
retical assumptions of mentalization theory, and provide an overview
of the Minding the Baby program. The treatments of two teenage moth-
ers and their infants are described.
these young mothers are struggling to find words for the in-
ner life—their baby’s and their own; tentatively, poignantly, they
glimpse the other, and themselves. They look for ways to describe
what is inside, what can be known, what can be held in mind, and
what can be contained. They hold the past next to the present, the
76 Arietta Slade and others
self next to the other. And as they discover their babies, they are 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 of
pregnancy. Both had been in different ways abandoned and betrayed
by their own mothers when they were but babies themselves. They
had lived their whole lives against the backdrop of trauma, within
their own families and within the culture of their violent, impover-
ished, and chaotic communities. Knowing others and their minds
had been fraught with terror, disappointment, and rage. And now
they were faced with the enormous challenge of holding their own
children in mind, children who had been born at a time when they
were still children themselves.
The crucial human capacity to understand the mind of the other,
to make meaning of behavior—one’s own and others—in light of un-
derlying mental states and intentions, is essential to the development of
social relationships, and most particularly intimate relationships
(Fonagy, Gergely, Jurist, & Target, 2002). Fonagy and his colleagues
have referred to this interpersonal and intrapersonal capacity as the
reflective function, and they suggest that it is essential to affect mod-
ulation and regulation; experiences that can be known and under-
stood, held in mind without defensive distortion, can be integrated
and contained.
The capacity to mentalize, or envision mental states in the self and
other, emerges out of early interpersonal experience, particularly the
experience of being known and understood by one’s caregivers. The
child 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 discovery
of 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 also
regulating and containing for his caregiver. Parenting is a fraught
and 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 who
have been traumatized find their children’s needs and fears over-
Minding the Baby 77
other Western countries since World War II, and in the tenements of
New York in the early 1900s by public health nurses (Wald, 1915)—
has become one of the most common approaches to improving psy-
chological and developmental outcomes in high-risk mothers and
babies across most of the United States. Certainly David Olds and his
colleagues’ Nurse Home Visitation program is the most effective and
valid of the many home visiting programs described in the literature
(Kitzman, Olds, Henderson, et al., 1997; Kitzman, Olds, Sidora, et
al., 2000; Olds, 2002; Olds, Hill, Robinson, Song, & Little, 2000). In
Olds’ model, experienced public health nurses conduct frequent
home visits to first-time high-risk mothers and their infants 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 relationship
with the home visitor is key to a number of positive mother and child
outcomes. Olds chose to use nurses rather than mental health pro-
fessionals for a variety of reasons, the most central being his belief
that they are perceived by families as highly informed and helpful,
and are free of the stigma of mental health service providers. When
Olds first began his work, nurse home visitors did not receive any
training specific to mental health concerns; however, as the program
has evolved over the past twenty years, and the mental health needs
of families have emerged with great clarity, nurses have received
increasingly specific training regarding what might be called “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 relationship
through a transforming relationship with a clinician is key to improving
outcomes for child and mother. In addition, both approaches pro-
vide a range of ego supports for the mother, so as to improve the
chances 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 urban
poverty, and she will be able to serve as a secure base and facilitating
environment for her child. What the NHV program adds to the psy-
choanalytic model of parent-infant work, however, is the emphasis on
the body and on physical care; despite the fact that the issues of the
body played a central role in classical psychoanalytic theory, this is an
Minding the Baby 81
mia
We first met Mia at age seventeen when she was seven and a half
months pregnant. Mia and her boyfriend Jay—who was eight years
her senior—were living with his family in a situation that was both
chaotic and overwhelming. Mia had been forced to move out of her
home when her mother discovered Mia was pregnant. Mia had been
the great hope of her family; she had done extremely well in high
school, and was hoping to be the first member of her extended fam-
ily’s generation to go to college. But Mia’s hopes for the future had
been dashed by the conception of her unplanned baby. She dropped
out just months before her graduation from high school. The baby
solidified Mia’s already estranged status from her single mother, who
had disapproved of her boyfriend, whom she saw as certain to derail
her hopes and dreams for her daughter; as she put it: “You’re just an-
other teen mother statistic.” Mia recalled, “This never was supposed
to 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. She
was doing everything she could NOT to think about her baby, and
was awkward, distracted, and almost dissociated when asked about
the baby. “Oh . . . That.” While there were small glimmers of 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 the
same time, Mia showed a number of indices of what we might call la-
tent capacities for reflective functioning. While these were scarcely
manifest in relation to her thinking about the baby, she was able to
reflect upon her initial denial of her pregnancy, and in so doing to
suggest a shift in her capacity to hold her complex emotions in mind:
“I was in denial even up to my fifth month. I couldn’t sleep, saying, ‘I
know I’m not pregnant.’ . . . I didn’t know what to do.” More striking
was her ability to describe her own complex fears and worries about
becoming a mother, and—in particular—her feelings of being lost
86 Arietta Slade and others
and overwhelmed. The depth and quality of her language, and her
capacity to vividly describe her pain led us to feel that as little as she
was able to imagine the baby, and keep any kind of a representation
of a relationship in mind as she prepared for motherhood, she was
able to give voice to her own anxieties and sense of confusion. This
proved to be a resource that was of great value to her once the baby
was born.
Both of our home visitors worked hard during the third trimester
to help the mother “make room” for the baby (Mayes & Cohen,
2001): preparing the room, planning for childcare, thinking through
labor and delivery. Mia had little conception of the child’s concrete,
physical needs, and when encouraged, for instance, to wash a baby
doll 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 gave
birth—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 dirty
and crowded with multiple relatives. The adults in the home were in-
trusive and often inappropriate; Mia had to guard her and the baby’s
food 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 her
fears—began to slip away, as Jay became disinterested in being with
the new mother and baby.
Her baby appeared well-cared for but Mia did not touch her 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, and
not bothering to get dressed unless she had to go out. Mia was often
pale, her eyes puffy from crying. She spoke with eyes downcast, dis-
gusted with her isolation and feeling of uselessness. Within one
month post-partum, the team felt that her depression had reached a
critical level (likely as a function of biological as well as other fac-
tors). As is very typical of the mothers we are working with, Mia was
averse to seeking psychiatric treatment, leaving us with little choice
but to address her severe depression in a way that respected her pace,
needs, and expressed wishes, but at the same time kept clearly in fo-
cus the very real possible risks to the baby. We decided that the social
worker should see Mia weekly, so as to provide the level of mental
Minding the Baby 87
did not push, but instead remained gently present, watching for
Mia’s glazing over, the sign that she had remembered and described
all that she could.
At four months of age, Noni was an attractive and communicative
baby, who in many ways managed to ignite 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 the
routine care, if not the emotional care, of the infant, were high-
lighted and validated. “There’s no one else that can comfort her like
you. Look how she’s gazing right at you as if to say ‘thanks.’” This
kind of comment, repeated multiple times over multiple home visits,
fed Mia on many levels, and acknowledged her importance to the
baby in ways that she herself could not yet recognize. Despite being
unable to recognize her baby’s experience, she was, however, able to
express complex feelings about her: “I don’t regret the baby, but I
wish 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 with
her. She had at this point no capacity to recognize or tolerate fear or
distress in her baby (having not yet been able to articulate her own
fears and need for comfort), especially fear and distress that she her-
self generated. Mia’s game of choice was to startle her infant, which
she would do in a variety of ways. She would loom into the baby’s face
quickly, smiling in a threatening way as she approached menacingly,
or she would shove a shrill squeaking toy intrusively in her face. Mia
delighted in this game, oblivious to Noni’s startled grimace and
frozen expression. Noni would attempt a false, scared smile, as if she
needed to placate Mia and keep her at bay. Repeatedly, Mia raised
the threshold for tension, but did little to soothe the frightened baby,
re-enacting her own helplessness as a child. This scary experience
was repeated again and again, with the other adults’ finding similar
pleasure in startling and overwhelming Noni.
Equally disturbing was the fact that not only did Mia fail to recog-
nize Noni’s fear, but that she viewed Noni’s response as false and ma-
nipulative. Whenever Noni would become distressed—not only with
the startle game, but at times when she took a tumble or hurt
herself—Mia would respond indignantly with some version of the
following: “Faker! Big fake-crier! You don’t fool anyone.” Thus,
Noni’s self-experience was both disavowed and distorted within the
context of her mother’s response; it is these kinds of early relational
experiences that Fonagy and his colleagues (2002) so richly describe
as fundamental to a child’s developing an abiding feeling of alien-
Minding the Baby 89
ation and emptiness. Even in these early months we could see Noni
dissociated and frightened in interaction with her mother.
The next task was clearly to help Mia recognize her baby’s fear and
distress, feelings that were at this juncture too threatening for Mia to
see, even in her own history. We began by trying to elicit curiosity
about the baby’s intent, “Why is she fake-crying? What could she
want by calling out to you?” Focusing on the baby’s intentions helped
Mia 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 own
experience of the crying. “How does it feel when you think Noni is
trying to trick you into paying attention to her?” Her responses
opened up a discussion about the “street’s” code of emanating fear-
lessness, denying needs, and feeling excited by fear. After revisiting
these themes many times over, Mia began to explore the times in
which she felt afraid, alone and/or felt like no one was taking her
needs seriously. Mia admitted that indeed her own obvious cries for
help in dealing with the overwhelming demands of straddling 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 began
by using the therapeutic relationship with the home visitors to give
voice to her own experiences of fear and distress. These therapeutic
relationships then became the platform from which she could view
the baby’s experience—her intentions and affects—with increasing
accuracy and clarity, without needing to distort or misinterpret as a
means of protecting her own fragile sense of self. Mia’s willingness to
hold the baby in mind was quite tenuous and fleeting at first, and
had to be nurtured in a variety of ways at all times, because her 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 observe
her 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 her
mother’s home. She made the choice to move away from the father
of the baby because she believed it was a better environment for a
baby. When asked, “Why now?” she replied, “She’s much happier. In the
other home, she’d hold her hands over her ears, it was too much for her . . . I
wanted to for her. It was an easy decision.” Mia was making links 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 more
regulating and containing environment.
Minding the Baby 91
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 suffered
a range of traumas in her short life. And yet, over the course of home
visits, we see the effects of these traumas diminishing in her day-to-
day interactions with Noni. She finds pleasure in her, she plays with
her, she inhibits her own instincts to frighten and overwhelm. She
comforts her child and tolerates her distress. For the most part, Mia
can hold Noni in mind.
Despite 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 Mia
keep Noni in mind has been successful, and we can feel somewhat
confident that there are protective factors in place for both Mia and
Noni that will make a big difference in both of their developments.
This in sharp contrast to Iliana, whose case we turn to next.
iliana
We met Iliana, 19 years old, at a group prenatal class in the second
trimester of her pregnancy. She was accompanied by the father of
her baby, a 20-year-old man with a previous history of substance
abuse and incarceration. During the two-hour class Iliana remained
attentive but maintained a skeptical distance from others in the
group. Indeed, distance and anger were to characterize Iliana’s cen-
tral struggles, both as they were manifested internally and in relation
to the team. In contrast to Mia, who from the beginning had some ca-
pacity to hold complex mental states in mind, Iliana was overtly more
angry, more defended, and much less able to tolerate and describe
her internal world. She had survived a childhood deeply marred by
chaos, poverty, and violence. Her mother had left the family when 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 her
mother—of whom she spoke with bitterness and rage—was a defin-
ing moment for Iliana, a scar that would not heal. Iliana’s defense
against pain was to threaten and push away anyone who got close to
her. She was proud of her toughness, her readiness to fight and estab-
lish her dominance on the street. She readily described herself as the
kind of person who would act before she thought, and was clearly
pleased at her capacity to frighten and intimidate people. At the
same time, though, impending motherhood had stimulated—as it so
92 Arietta Slade and others
tle baby. They are so small they look like they can break. And when
the baby cries—I might get mad or nervous and just walk away!” Em-
bedded in these comments were signs of another set of difficulties
that 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 feel
out of control and angry. She was terrified of labor, and particularly
frightened of the feelings of powerlessness and vulnerability that it
would engender; these feelings can be especially poignant in women
who have been sexually abused and who find labor retraumatizing.
As might be expected, Iliana’s feelings about her own body were to
later 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 choices
ahead of time about medication, restraint, and other aspects of the
delivery (Simkins, 2002). The labor was difficult, but the labor
plan—which was supported fully by the midwifery team—allowed Il-
iana to feel in control of her experience. She was extremely proud of
herself, and her daughter was easy to feed and console. The new
mother held the baby—a girl named Lucia—closely, gazing warmly
into her eyes and imitating her facial expressions. We pointed out
how she was able to make the baby feel safe by holding her close and
how she was learning to read the infant’s cues to comfort her. Iliana
was enormously pleased that she could regulate the baby’s states to
reduce 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 auspicious
beginning. 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 to
move toward reflective understanding in relation to her baby—Iliana
and 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. On
the one hand, there were moments when she could be tender toward
her daughter. At these times, however, Iliana was also reminded of
her own loss, of not having been nurtured and protected by her own
mother. Iliana said she longed to “be a little girl all over again. Not to
have the childhood I did have, but to have someone take care of me.”
As a consequence, she often could not tolerate the baby’s need for
94 Arietta Slade and others
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 through
her body, and through her concrete needs. She could not work at a
metaphoric or abstract level. When we tried to talk to her about her
feelings about her life experience, she would become enormously
sleepy and actually appear to doze off. Mentalization could only take
place at a very concrete, protosymbolic level (Werner & Kaplan,
1963). But as we did this, she began to involve us more directly in
helping her. It turned out that Lucia’s father had been abusing Iliana
throughout the pregnancy, and he was now continuing to physically
threaten 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 us
to help her obtain an order of protection, and to support her desire
to protect her baby. At this time she became more overtly dependent
upon the home visitors, and in particular needed a great deal of so-
cial service help to obtain a place to live as well as a variety of social
service benefits. Her extreme neediness was experienced by the
home visitors as a continuing volley of demands, within the context
of which they had to continuously work to keep the baby in mind
for Iliana. These demands only increased when we decreased the
number of regular home visits when Lucia turned one (a standard
transition in the Minding the Baby protocol). She responded with
overt indifference and appeared to pull sharply away, but she began
to call us nearly daily with minor and major crises. Iliana the tough
and defended young woman who needed no one could not get
enough of us.
Over time Iliana has slowly become more aware of her 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 do
what I am doing. It makes me crazy!” The nurse practitioner brought
over a small plastic tub and a few containers for the little girl to play
in, and asked the mother to follow the baby’s lead while she herself
washed the dishes. Imitating her child’s actions, Iliana suddenly
“saw” what the child was doing. In imitating her daughter’s splashes
and play with soap bubbles, she laughed and exclaimed, “Oh! This is
fun!” She had a sense of the child’s internal experience at that mo-
ment and recognized that the sharing of the experience brought
them closer together. She was able to express this feeling to her child
by having a short conversation about what they were doing. This real-
ization has sometimes spilled over into other parts of their life to-
gether. Recently Iliana laughingly described her daughter as “being
96 Arietta Slade and others
her own little self.” Iliana had been outside watering the flowers in
the garden, and—anticipating her child’s desire to be included—
had dressed her in a swimsuit. She had understood and accepted her
baby’s desire to be nearby and involved with her, as well as to explore
her 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 the
ER. She has a relationship with her primary care providers, facili-
tated by the nurse practitioner, who has served as a bridge between
clinic and mother in an ongoing way. For Iliana, who has in the past
tried to control her body and that of her baby’s as a means of regulat-
ing her fragile sense of self, the willingness to allow others to care for
her 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 a
number of domains. While significantly less widespread and deeply
held than Mia’s capacity to understand and hold her baby in mind,
there were signs that she had begun to understand that there was a
baby to be known. She tentatively acknowledged that she had begun
to allow the home visitors to get to know her, and to witness her expe-
rience. She has acknowledged the power of her mother’s abandon-
ment and her own unrequited longings for love and simple care. She
began to talk about her child’s needs and understanding as being dif-
ferent from her own. Thus, even though these reflective capacities
can easily disappear in an instant when she becomes angry or threat-
ened, it is nevertheless becoming more natural to her to think about
the baby in this way.
At the same time, it is important to acknowledge that there are
profound limitations to Iliana’s reflective capacities, even after nearly
two years of treatment. Unlike Mia, Iliana has not been able to de-
velop and rely upon a narrative—a story of herself—that helps her
to 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 described
by 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. She
can still be openly neglectful of Lucia, and very harsh with her, al-
though now she yells instead of slaps. Nevertheless, we worry that we
will have to get child protective services involved, as there continue
Minding the Baby 97
Discussion
services, again needing this kind of very concrete help to support any
reflective capacity whatsoever.
We think that the progress made by the mothers and babies in our
program has come—finally—from our home visitors’ capacity to
hold their bodies and feelings in mind, to witness their pain and
their anger without dysregulation and retribution, and to keep the
baby alive for the mother in the face of relentless chaos and uncer-
tainty. As we hope we have been able to convey in our description of a
mentalization based, multidisciplinary mother-infant intervention
program, this is complex work indeed.
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90 Arietta Slade and others
When Noni was 14 months old, 17 months after Mia’s entry into
the program, the social worker reviewed a videotape that had been
made of Noni and Mia interacting when Noni was 4 months old. Mia
was obviously troubled in watching the tape, and noted readily how
insensitive she had been to Noni’s cues—“I had no idea what she
wanted, I couldn’t read her . . . I see now that her crying was to tell
me she’d had enough . . . here I can see her face sad telling me what
I 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 deflect
some of the guilt she felt in recognizing her failure to hold Noni in
mind, she was nevertheless fully cognizant of the fact that she was ig-
noring signs of distress that she was readily able to identify in retrospect. This
reaction signified crucial progress to the treatment team.
The central focus of the work of both home visitors was to make
Noni and her internal world real to Mia, slowly and in a way she
could tolerate. At the same time, it is important to highlight the fact
that the work was taking place on many other levels as well. Mia was
overwhelmed by her living situation, and we worked in a variety of
ways to help her make Jay’s family home safer for the baby. This
meant she first had to recognize that the baby required safety and
that she could participate in providing that. Filters were provided
that protected the baby from the smoke in an environment where
everyone smoked cigarettes. She needed help with travel to and from
school, with birth control, with obtaining food for the baby, and with
basic caretaking skills. We brought toys and baby books, and taught
her how to play with the baby. She had several frightening blow ups
with Jay (who had a history of violence), which required our help in
sorting out. All reflective work took place against this backdrop of
concrete support and education: help in stress reduction, vocational
planning, safety procedures, medical care, and the like. Without
these levels of support, the therapeutic work would have been utterly
impossible.
Noni is now 20 months old, and Mia is living in her mother’s clean
and orderly home. Jay is still firmly in the picture; indeed, he is often
present at home visits, and is proud of his understanding of develop-
ment, as well as the mutual feelings of love and attachment that he
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ment status, Noni was not classified as disorganized in relation to at-
100 Arietta Slade and others
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“In a Black Hole”: The (Negative)
Space Between Longing
and Dread
Home-Based Psychotherapy with a
Traumatized Mother and Her Infant Son
JUDITH ARONS, LICSW
This paper offers fragments from the first year of a home-based mother-
baby psychotherapy, in which I attempted to help a traumatized and
dissociated mother to emotionally engage with her infant son. The
treatment was organized in part around certain developmental objec-
tives common to both attachment and psychoanalytic theory. These in-
clude: The ability to name and metabolize feelings, to evoke a soothing
maternal 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 of
containing 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 and
Children’s Service of Waltham, Massachusetts, and a lecturer at Simmons Graduate
School 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 and
editorial input, George Ganick Fishman, M.D., for his untiring support, Sarah Birss,
M.D., and Ann Epstein, M.D., for teaching me so well, the Center for Early 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.
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
101
102 Judith Arons
Mothers who struggle with unresolved trauma and loss are at high
risk 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” state
of 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 is
a correlation between mother’s unresolved state and her ability to
104 Judith Arons
fends herself against the threat of her baby’s fearful expressions and
his need for comfort by restricting her awareness of his state (Lyons-
Ruth, and Jacobvitz et al., 1999a). She is hindered in providing the
adequately attuned affective envelope that would instill an experi-
ence of “felt security” in her baby. Mother also shows impairment in
self-reflective functioning and in her ability to reflect upon her child
as a separate individual with a unique inner life. Self-reflective capac-
ities are thought to be among the key mediators in the transmission
of 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 the
development 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), excessively
caretaking, controling, or frankly aggressive behaviors (Lyons-Ruth
and Jacobvitz, 1999a, Lyons-Ruth, Bronfman and Atwood, 1999b,
Lyons-Ruth, Alpern and Rapacholi, 1993, Jacobvitz and Hazen, 1999,
Solomon, George, and DeJong, 1995), chaotic internal 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 cognitive
functioning (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 fear
on brain development and functioning, stress arousal systems, and
physical 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, and
living with sickening dread or unremitting sorrow (Terr, 1991).
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’t
call myself his mother, I don’t deserve him. Sometimes I think he
hates me and would be better off with someone else.” Mary had been
sober for only twenty-eight days.
My visits to the home revealed Mary to be a sweet and tentative
mother who was struggling to stay sober and to care for her child.
John was a beautiful twelve-month-old with a shock of curly blond
hair and ice-blue eyes. He was cheerful, curious, and engaging. He
approached his mother for help and to share his toys, and they would
laugh or be silly together at his prompting. I observed Mary and
John sharing moments of pleasure, joy, and hilarity. Mary responded
well to the structure afforded by particular aspects of John’s daily
care. 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 wait
patiently for John to signal the next spoonful or when it was time to
continue diapering or dressing him. These interactions included
much mutual gazing, turn-taking, and playful physical contact. Mary
could also be attentive and natural in her responses to John’s ebul-
lient expressions, and he regularly looked at her and reached for her
to help him. As John interjected himself into the adults’ conversation
Mary would encourage him proudly and speak of what a good and
beautiful boy he was.
But coupled with these positive behaviors were more ominous in-
teractions. John often crawled around the house with the pet dog,
dangerously unsupervised. He had difficulty focusing in on toys or
play, but could spend an hour amusing himself alone in his crib. In
these early home visits John would sometimes cry from the other
room in the middle of some mishap, as Mary, in a world of her own,
spoke to me of her terrible childhood experiences, her guilt, and her
urge to drink. Mary asked, “Is it o.k. for him to play alone so much? I
don’t want him to grow up with a black hole in the middle of him like
I have.” Mary’s eyes spoke volumes of her fearful inner world, but her
narrative tone was one of disorienting cheer. In our first interview
she revealed the depth of her alienation, “I wake up in the morning
and I wonder, whose baby is this, whose house is this, whose life is
this?”
Throughout our initial meetings Mary revealed her painful story.
Her narrative was filled with contradictions, lapses in reasoning, and
affective incongruence. Sequencing of events was so confused that I
was unclear exactly what had happened to her and when.
Mary’s intense self-absorption and dissociated states initially placed
110 Judith Arons
John on the periphery of our conjoint work. I observed that she did
not seek John out as an emotional companion; it was he who 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 this
possible. Mary could not consistently help John transform his nega-
tive states to positive or neutral ones. When he was distressed she
would pick him up, but then put him down before he was sufficiently
calmed. Toys were often offered as comfort instead of her body or
voice. Mary often allowed John to get into highly charged emotional
states that were on the verge of decompensation. She was unable to
play with him; there were few spontaneous gestures of affection, and
she often asked if he would like to go up to bed.
I was uncomfortable with how little we included John in our initial
sessions. He was continuing to do all the reaching out for contact,
and I was caught between the imperative need to include him and
my concern that doing so would cause Mary to feel ashamed or over-
whelmed.
History
Fraiberg, S. (1980). Clinical studies in infant mental health. New York: Basic
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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-
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“In a Black Hole” 111
twice daily AA meetings. At that time Mary was frantic and depressed
about John’s behavior toward her. Until he was eleven months, John
rejected his mother’s attempts to connect. He screamed when she
held him, would not gaze into her eyes, and would not smile at or
reach for her. One month into Mary’s sobriety John began to reach
out to her for comfort and to track her visually, but at thirteen
months he developed a strange rolling eye movement in her pres-
ence. John had been followed neurologically since birth and there
had been no sequelae from his early seizures or hematoma. The
strange eye movement was determined to be non-organic in nature.
Mary’s own childhood had been devastating. When she was a one
year old her schizophrenic mother attempted to drown her in the
bath and she required resuscitation. Mother then abandoned the
family and was in and out of young Mary’s life. For a time Mary was
passed among relatives so that her father could work. When father
remarried three years later (Mary was four) she lived through cruel
and degrading neglect at the hands of her stepmother, who locked
her in her room each day, refusing to feed her or allow her to use the
toilet. She was often locked outside of the house while her stepsib-
lings had after-school snack. In winter the kindness of an elderly
neighbor sheltered Mary from the cold.
Mary began to drink at age fourteen. But despite the depth of her
difficulties, during adolescence Mary felt she had the love of her pa-
ternal grandparents and recently sober father. She lost her fear of
her “evil stepmother” and became provocative and oppositional. She
successfully completed high school and college and went on to have
several interesting and responsible jobs. She fell in love with a gentle
if troubled young man, and married into a large family.
Process Vignette
I arrive for a session in the home. John has just returned from daycare and seems
tired and cranky. He is standing in front of the refrigerator yelling “more
cheese!” over and over. He is spinning out of control. He reaches up for his
mother.
Mother: (stepping away from him and speaking sweetly.) “You’ve had enough
cheese, soon its dinnertime, let’s go in the living room.” (She turns to
walk into the living room. She appears tuned out, unable to hear or notice
him.)
John starts to scream, and throws himself on the floor sobbing. “Cheese, mama,
more cheese!” (His eyes are glassy, his face red and puffy with exertion, it’s
all I can do not to pick him up.)
Mother: (with false sympathy) “No more cheese, sorry.” (angrily) “You have
to learn not to get so upset. I’m getting frustrated.”
John is up off the floor and asking to be held by mother. She picks him up but puts
him down before he can settle. He asks again to be held and then strikes her in
the face as she reaches for him. She puts him down again, more forcefully. John
staggers away while pitifully crying for his mother. He begins to wander aim-
lessly around the house, stumbling over his toys. He suddenly lies down on the
rug and becomes very quiet. Mother looks at me, frightened.
Therapist: “O.K., lets try to figure out what’s going on and what each one
of you is feeling right now.” (I sit by John, as he lies exhausted on the rug.)
Mother: “I feel frustrated and helpless to make him feel better. I’m not a
good mother. I don’t know how to handle this stuff. He confuses me, I
try one thing and another but nothing helps.”
“In a Black Hole” 115
Mother: “Maybe I can help him . . . Maybe I don’t have to dread being
with him if there are things that I can do to help him to be happy and
grow.”
to comfort John in his distress, but I believe that this would have
shamed his mother.
Feeling for Mary’s and John’s affective states and developmental
capacities 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 procedural
domain, and it provides an interactive format in which to modify
compulsive role assignments and to model containment. It is en-
hanced by the baby’s natural dynamism. It makes use of mother’s
open 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 know
how to let me comfort him. I don’t know how to do it . . .) signaled her
readiness to let me into her confusion around how to interact with
John. I began to wonder if something new could happen between us.
I believe that it was the lending of my physical presence (moving
back and forth between them) that offered the following unspoken
response to Mary: “I can empathize with and hold both of your emo-
tional states. I am free to move within your compulsive and confused
enactment. You can use me to bridge the gap between your current
level of interacting and something that will be more complex and
new.” As I sat close to Mary and John on the couch, Mary continued
to relax her defended stance. Tentatively she mused, “I don’t know if
I should say something to him.” At this point in the interaction a new
developmental level of relating was about to emerge.
Mary’s suicidal crisis lent great urgency to our top priority: To estab-
lish a therapeutic relationship that would offer open and responsive
emotional contact and modulation of fear. Mary’s suicidal gesture
had delivered into our relationship all the uncontained emotions of
her childhood. I believed that we were going to have to feel our way
through the therapy and live through the unnamed terrors, giving
narrative voice to the process when we could. In the words of
Phillips, sometimes, “stories are lived before they are told” (quoted
in Holmes, 1996, p. 167).
giving voice
Mary struggled to put words to feelings and experiences. In the
mother-baby sessions at home I had began to gently draw her into my
“In a Black Hole” 119
metabolizing fear
Mary was afraid of everything. Her terrors had derailed her efforts af-
ter mastery and psychic wholeness. Toxic levels of fear occluded her
ability to create and to synthesize (inter)personal meaning. Fear had
interrupted her ability to attend or even to maintain a consistent
state of consciousness. Abuse and neglect had taught Mary to expect
that her feelings would be forgotten or obliterated. Frequently slip-
ping into dissociated or empty states, Mary often did not know what
she felt.
We set out to explore the “black hole” left by Mary’s trauma, and
the overwhelming feelings and contradictory inner representations
it had spawned. With each frightening memory or state delivered
into the treatment we entered a new interpersonal negotiation. We
asked, how could Mary contain her upset around John? What feel-
120 Judith Arons
ings did he arouse in her? How could she use her relationships (with
me, 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 mother
and son. Her initial requests to connect were subtle, often overrid-
den by an expectation that she did not matter and could not be
known or contained by another. Mary had covered her childhood
devastation with an avoidant style and disorienting cheer, punctuated
by states of panic and emptiness. Her affective cues were as confusing
to me as they must have been to John. But eventually we were able to
frame our miscommunications within the context of Mary’s longing
to have her attachment needs met and her dread that I would rebuff
her. Gianino and Tronick, (1988) link the ability to repair affective
mismatches in infancy to the establishment of the attachment figure
as reliable and trustworthy. Experiences of disruption and repair also
contribute to the infant’s sense of mastery and control and to the de-
velopment of a positive emotional core. I believe that within the
transference Mary’s increasingly secure attachment to me offered
her similar gains. Her diminishing fear led to an increased sense of
agency and inner cohesion and to a budding capacity to make 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 during
powerful emotional eruptions around John, her confusing responses
to his need for comfort, and his disorganization in response. Consis-
tent inquiry into Mary’s inner states introduced the notion that I
could know and remember her. At the same time we observed the
ways in which Mary’s intense and confusing experiences impeded
her ability to keep John in mind and to represent him as a separate
being. As her affect tolerance and self-reflective abilities increased,
Mary and I could more deeply explore the relational context in
which powerful feelings or defenses against them emerged. She
struggled to share her private terror, anger, and emptiness with me,
while valiantly attempting to make loving contact with her son.
Our conversations signaled to Mary that she could use our rela-
tionship to hold and metabolize her confusion and fear and to
gather 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
“In a Black Hole” 121
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 that
scared her. These messages I saved for her until she felt safe enough
to address them in person. We then began to anticipate the emer-
gence of the “evil stepmother’s” cruel and degrading voice within
Mary. We called this frightening figure out of the shadows, stared her
down, and told her that her days as a saboteur were numbered.
Mary’s need to defend against the feelings John aroused coupled
with her cognitive dysregulation (dissociation and transient thought
disorder) had rendered her unable to consistently attend to their re-
lationship. In mother-baby sessions we worked to enhance responsive
relating by containing the fear and anger aroused by John’s need for
comfort. In individual sessions we explored how Mary’s attachment
needs within the transference paralleled those of her son. Mary was
the mother of a child she could not comfort and a child herself in
need of comfort.
Over time, as we co-constructed the scope and pace of what
emerged between us, Mary’s inner representations (terrifying mother
and terrified/enraged child, idealized rescuer and cruel saboteur)
existed side by side with a budding new way of our being together:
We became a collaborative therapeutic team. Less constricted by her
own defensive exclusion of painful affects, Mary developed freer 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 and
her need to control the fear he aroused, he emerged as a positive
force of nature, a baby to be loved and understood.
Conclusion
chic space that encircles attachment and separation. With the help of
psychotherapy, pharmacotherapy, and AA, she has not had a drink in
fourteen months.
Mary continues to use our relationship to hold her fear and her
rage. The frightening inner representations and emotions that in-
habit her psychic landscape have emerged in full force. She has ad-
dressed violent fantasies of throwing her son out the window or
slashing his face with a knife. She has been able to use me as a secure
base around disorienting and psychotic flashbacks. Having partly
freed the mother-child relationship from the toxic intrusion of in-
tolerable affects, we continue to address the need to name and to
metabolize such feelings in all areas of Mary’s life. We continue to
explore the emotional impact of mother and son upon one another
and their patterns of communication. Sometimes I am rocked by
Mary’s vacillating experiences of flooding and deadness. I continue
to worry and wonder about the impact of John’s early life upon his
future development. But the projections, dissociation, and affective
misattunements, 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 for
care and protection are not conflicted; they are the expressions of a
child who anticipates that comfort and aid will be forthcoming. Mary
feels more connected to herself and to her son. She takes great pride
in how John is developing as an individual, and the important role
she has played in this.
While an in-depth analysis of the multiple transferences of trauma
survivors is extremely relevant to this case, it exceeds the scope of my
discussion. Several authors have written about the fluid and 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 to
analyze her murderous maternal transference toward me, or if this is
even advisable. It may be that in cases of severe early loss and trauma,
rage in the transference represents too great a threat to the thera-
peutic relationship and requires metabolizing and repair in displace-
ment. To date, Mary has very much needed to keep me as a “good
enough mother.”
The difficulties in depicting mother-infant psychotherapy are simi-
lar to those one faces in describing human relating and development
“In a Black Hole” 123
Post Script
Recently, Mary and I were reviewing the progress that she and John
have made (John is now two and a half). She related that while pack-
ing up some of his infant clothes she had been overwhelmed with
how vulnerable John had been as a small baby, how he had needed
her, and she wasn’t there. She remembered with great sorrow and re-
morse leaving him for long spells alone in his crib. Then she related
this story:
After school yesterday John and I were playing together in his room,
like I am trying to do more with him these days. He began a new
game: he put me in his big boy bed, covered me with his favorite
blanket, kissed me goodnight and went out of the room, closing the
door. Without thinking about it I began to cry, “Mama! Mama, I am
scared, Mama!” He rushed into the room, snuggled me with the
blanket, and kissed me softy, whispering, “o.k. baby, don’t cry baby,
don’t cry,” and went out. We repeated this game several times; each
time he came in and comforted me. Then it was his turn. He wanted
to be in his bed with the covers. I kissed him, said goodnight, and left
the room. He pretended to cry, “Mama, come, Mama!” I rushed in as
he had done, kissed him, and cozied him up with the blankets,
telling him that everything was all right. After doing this several
times he became quite relaxed and quiet. He looked so peaceful ly-
ing snugly in his blankets. And then, as I sat there on the edge of his
bed, I experienced a moment of grace. I realized that I can comfort
my child!
The child who no longer arouses intolerable feelings resides more
securely in his mother’s heart and mind.
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126 Judith Arons
Introduction
128
Herding the Animals into the Barn 129
She explains that her 4-year-old son is disruptive at school and does
not follow directions. At home he is fearful, demanding of her 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 the
problem as a prelude to seeing the child in individual sessions—first
in a diagnostic session and then, if therapy appeared warranted, as a
patient in psychotherapy or psychoanalysis. I would of course discuss
my initial observations and recommendations with the parents, and
get information from them about major constitutional and environ-
mental factors that affect their son; but the tools I had to obtain that
important information would be limited to my own observations of
the child and parents in the initial sessions and the parents’ own 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 I
have changed my approach to the initial evaluation of children with
psychological 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 I
use 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 interactions
that simply could not be discovered without the benefit of detailed
ex post analysis. Developmental theories provide a means of organiz-
ing these detailed observations into coherent patterns. Colleagues
and I have recently discussed the ways in which these techniques can
be useful in psychotherapy and psychoanalysis (Harrison 2003, Har-
rison and Tronick, forthcoming). This paper discusses the ways in
which these same tools of videotape micro-analysis and developmen-
tal theory can be used in the initial assessment and discussions with
parents regarding therapeutic interventions. Indeed, I refer to this
method as a Parent Consultation Model (PCM), to emphasize the
importance of providing critical information to the parents as well as
to the clinician in this key initial stage. Moreover, this collaborative
or interactive model can usefully be continued beyond the initial di-
agnostic stage and become part of the ongoing process of engaging
parents 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-
130 Alexandra Murray Harrison
1. I now use the PCM for all my child evaluations, regardless of age or presenting
problem of the child. In evaluations of older children I use a family discussion instead
of play format.
134 Alexandra Murray Harrison
hard for him (Sean) to have his problems discussed in front of his
brother. He is easily shamed.” I tell her that the play session is in-
tended to be a pleasant experience. Usually I would not discuss
Sean’s problems directly. The information I need to answer Mr. and
Mrs. R’s questions will show up in the play. I say that I will direct the
session and take care not to let anyone be put on the spot. At the be-
ginning of the session, I will explain that we are going to “play in
partners,” that Sean will begin as Dad’s partner, and his brother as
Mom’s partner. After five to ten minutes, I will tell everybody to
switch partners. Then after a similar time period, I will tell everybody
to play altogether. After another ten minutes of playing together, I
will tell everybody that Mom and Dad are going to sit in the two
chairs and have a conversation with each other while Sean and his
brother continue to play. This section is the last part of the play ses-
sion. After this, I announce the end of the playtime, and we all pick
up the toys and say goodbye. The entire family play session takes
about 45 minutes.
Mrs. R says that she thinks this approach is just what she and her
husband are looking for. She then notes that she and her husband
are also concerned about the toll the family situation is taking on
Sean’s little brother, Mattie, and considering the whole family will
give 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 move
forward with the consultation. If they choose to carry on, we will
schedule the meetings. In suggesting that Mrs. and Mr. R talk about
the consultation together, I am putting the emphasis of the decision-
making back on the parental couple. I am also giving them a chance
to reflect on the approach. The next day, Mrs. R calls and says that
she and her husband have decided they would like the consultation.
We schedule the first meeting.
conceptual framework
I have found it to be critical to have some conceptual framework for
evaluating the wealth of information available in the videotaped ses-
sions used in the evaluation. Indeed, without some framework, the
material tends to be overwhelming. I have found conceptual frame-
works developed by two developmental psychologists particularly
helpful—Elisabeth Fivaz-Depeursinge and George Downing—both
of whom I have studied for some time. Although these conceptual
Herding the Animals into the Barn 135
ing the child or by moving the child’s play objects without an invita-
tion? Do the family members respect the play space presented to
them, or does the child stray into the part of the room where the
computer and the video equipment is? Does the parent make a clear
boundary between playtime and time to stop and pick up the toys?
(5) Apropos language, how is language used in the play session—to
promote the play, to comfort, to criticize, or to control? What kind of
language does the parent use—primarily descriptive language such as,
“Oh, you are putting that there” or prescriptive language such as, “Put
that there.”
Downing’s model is based on developmental theory but is de-
signed primarily as a clinical theory. In that sense, particularly, it has
been an important influence on my work on the PCM. I also owe
much of my skill in making observations about families and 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 created
by the order of the partner play, in which the identified problem
child plays with the father first. This order offers the opportunity to
observe a “mini reunion” of the child with the mother. The PCM
does not, of course, replicate the experimental conditions related to
the “strange situation” of Attachment Theory. Nonetheless, my expe-
rience suggests that this design can elicit interesting observations
about the mother-child relationship corresponding in some way to
the findings of the strange situation test (Lyons-Ruth, 1991). Finally,
because it is a play session designed for preschool and early school
age children, the PCM also offers the opportunity to evaluate the
quality of the child’s play and uses psychoanalytic theory to identify
and make sense of symbolic representations in the play. Psychoana-
lytic theory and developmental theory are thus both instrumental in
informing the observations obtained from the PCM.
In sum, the PCM draws primarily from developmental theory—
particularly the observational research of Fivaz and colleagues and
the clinical model of 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 of
the 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-
138 Alexandra Murray Harrison
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.
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 with
his negative effect on the family—he wears his mother down.” Mrs. R
adds, “How do I get this kid motivated to do the things he needs to
do, like get himself dressed in the morning or go to the bathroom by
himself?” Mr. R concludes, “How do we help him with his confi-
dence, self-esteem?” Although sometimes I find I am able to answer
some of the parents’ questions immediately, in this case I think that a
family meeting is essential, and I tell the Rs that a family meeting will
help me answer their questions.
We discuss the family meeting. I repeat the description of the fam-
ily meeting to Mr. and Mrs. R, concluding with a discussion of what to
tell the children about the meeting. After hearing Mr. and Mrs. R’s
ideas about how to best present the idea to their children, I suggest
that they refer to me by my first name rather than as “doctor,” so as
not to unnecessarily alarm the children, and suggest that they refer
to me as “a lady who knows a lot about children and families and who
gives families ideas about how they can get along better together.”
Then I suggest adding, “And the way she does that is to have families
come and play at her house, and then go home again. She also uses a
camera to take a film so that she can remember what happened after
the meeting.” We schedule a meeting time.
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 establish
themselves in front of the barn. Sean says to Mr. R, “Let’s herd them
into the barn, because there is a big storm coming!” Mr. R asks,
“Which ones? Which ones?” and starts to pick up the animals. The
two of them are smiling and obviously happy to be together. They are
picking up the animals and talking about them. Interestingly, the 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 to
Mrs. 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 again
about herding the animals. Sean and Mrs. R also play together well,
though they both look somewhat uncomfortable and constrained.
Mrs. R does not look as if she is enjoying herself and is sitting back
with her hands folded most of the time. Again, in this seven-minute
play sequence, despite much talking about it, the animals do not get
herded into the barn.
When I call for the family to play together, the family makes an-
other smooth transition, with Mrs. R making suggestions about how
they might combine the two types of play. They begin to play with the
garage and some of the farm animals. Mattie, Mr. R, and Mrs. R clus-
ter around the garage and play with it for the entire period. Sean
plays on the periphery, connecting vehicles with their trailers, peri-
odically joining the others and then removing himself again from the
central family play.
Finally, I ask for the family to make the transition of Mr. and Mrs. R
to the two chairs, so that they might have a conversation with each
other. Mr. and Mrs. R move to the chairs, and the boys continue their
play. Mattie goes to play with the barn, and Sean continues playing
with the cars and trailers. The parents are able to have a conversation
with each other, though now and then they are distracted and turn
their attention to the boys. They seem to anticipate a problem that
they must be ready to manage.
Then Mattie says, “We have to herd the animals into the barn.
There’s a big storm coming.” He begins to put the animals into the
barn. Sean comes over to the barn and starts to help him, but he is
Herding the Animals into the Barn 141
more erratic in his attention and his movements than his little
brother. Numerous times he grabs a toy away from Mattie; sometimes
Mattie objects, sometimes he does not. At one point, Sean declares,
“The storm is over now,” but Mattie responds, “No, it’s not,” and con-
tinues his work of herding. Sean moves back and forth from the
barn, to the activity of hooking up the cars and trailers. Finally, Mat-
tie declares, “Now they’re all inside—safe and sound.” In a dramatic
conclusion to the course of events, Sean’s little brother is able to im-
plement Sean’s stated agenda more effectively than either parent is
able to do alone with Sean.
How can we understand this interesting eventuality? As I consider
this question, I am thinking of the powerful metaphor of herding the
animals into the barn to find protection from the impending storm,
which I take to signify Sean’s dysregulated behavior and its effect on
the family. The whole family seems to resonate with this symbolic
theme. The conclusion of the family play is to find a safe place for all
the animals inside the barn, yet this is accomplished in an unex-
pected way. It is only when the constraining behavior patterns Sean
and his parents have created together are relegated to the back-
ground, and the parents allow the children to exercise their own
agency, that Sean’s agenda can be constructively engaged.3 Yet, a full
answer to the question must wait until later, since we must first return
to the model as a practical way of answering the parents’ questions.
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 as
emerging 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).
142 Alexandra Murray Harrison
of Sean’s intrusive behavior toward him, and Sean, because of his dif-
ficulty maintaining a focus of joint attention and other regulatory
difficulties and because of the family’s response to his controlling be-
havior.
The transition to the parents sitting together to have a conversation
also goes smoothly. Mrs. R notifies the boys of what they are going to
do. Neither boy objects. Mr. and Mrs. R sit in the chairs and begin to
talk. This part of the session in particular demonstrates important
strengths of the family—the parents’ capacity to constitute a well-
functioning relationship of their own, and the siblings’ ability to play
together 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 and
which he has not played with before. He says, using Sean’s exact
words and tone of voice, “We have to herd the animals into the barn,
because a big storm is coming!”4 He is oriented away from Sean, and
he speaks apparently to himself. Sean, however, approaches him and
attempts to join his play. Without looking at Sean, Mattie continues
to put animals into the barn. His attention is more focused and his
actions smoother and better coordinated than Sean’s. In ignoring
Sean, it is as if he recognizes that Sean could introduce a significant
disruption in his plan. When about half the animals have been put
back in the barn, Sean pronounces, “The storm is over now.” With-
out looking up or changing his position, Mattie responds, “No, it’s
not,” and continues putting animals into the barn. Sean, after a hesi-
tation, leaves the cars and joins him. Finally, the animals are in the
barn. Leaning back, Mattie surveys the barn and says, “Now they are
all in the barn, safe and sound.” It is remarkable to me observing the
tape, as it was when I was observing the meeting itself, how Mattie is
able to accomplish Sean’s agenda by the end of the meeting. In fact,
it is now clear that although initially articulated by Sean, it is a family
agenda and all the family members—Mr. and Mrs. R also, by allowing
the boys to play uninterrupted—cooperate in its accomplishment.
4. This observation gives evidence for the influence all family members have on
one another while playing in the same room at the same time, whether they are play-
ing in “dyads” or all together.
Herding the Animals into the Barn 147
Concluding Remarks
BIBLIOGRAPHY
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Tavistock Autism Workshop. London: Routledge Press.
Beebe, B., & Lachmann, F. (1994). Co-constructing inner and relational
processes: Self and mutual regulation in infant research and adult treat-
ment. Psychoanalytic Psychology 11(2), 127–265.
Beebe, B. & Lachmann, F. (2002). Infant Research and Adult Treatment: Co-
Constructing Interactions. Hillsdale, N.J.: Analytic Press.
Beebe, B., Lachmann, F., & Jaffe, J. (1997). Mother-infant interaction struc-
tures and presymbolic self- and object representations. Psychoanalytic Dia-
logues 7(2), 133–182.
Bernstein, I. (1995). The importance of characteristics of the parents in de-
ciding on child analysis. J. Amer. Psychoanal. 6, 71–78.
Burlingham, D. (1951). Present trends in handling the mother-child rela-
tionship during the therapeutic process. Psychoanal. Study of the Child, 6,
31– 37.
Downing, G. (2000). Emotion theory reconsidered. In Wrathall, M., and
Malpas, J., eds. Heidegger, Coping and Cognitive Science. Cambridge, Mass.:
MIT Press, pp. 245 –270.
Downing, G. (2005a, [in press]). A different way to help: Position paper for
the council on human development.
Downing, G. (2005b). Emotion, body, and parent-infant interaction. In
Nadel, J., and Muir, D., eds., Emotional Development: Recent Research Ad-
vances. Oxford: Oxford University Press.
Fivaz-Depeursinge, E., & Corboz-Warnery, A. (1999). The Primary Trian-
gle. A Developmental Systems View of Mothers, Fathers, and Infants. New York:
Basic Books.
Fivaz-Depeursinge, E., Stern, D., Corboz-Warnery, A., Lamour, M., &
Lebovici, S. (1994). The dynamics of interfaces: Seven authors in search
of encounters across levels of description of an event involving a mother,
father, and baby. Infant Mental Health Journal 15(1), 69 – 89.
Fogel, Al. (1993). Two principles of communication: Co-regulation and
framing. In Nadel, J., and Camaioni, L., eds., New Perspectives in Early Com-
municative Development. London: Routledge.
Herding the Animals into the Barn 153
To date there has been very little research looking at how former child
analytic patients have made sense of the experience of being in psycho-
analytic treatment as children. Based on semi-structured interviews
with twenty-seven people who, as children, had been in intensive psy-
choanalysis at the Anna Freud Centre, London, between 1952 and
1980, this study uses a qualitative methodology to explore two central
themes: “attitudes toward being in therapy” and “memories of therapy
and the therapist.” This report presents the findings of the study in
narrative form, and argues that the recollections of former child ana-
lytic patients are an important, but under-used, source of knowledge
for an understanding of the psychoanalytic process.
Nick Midgley, Anna Freud Centre, London, and Mary Target, Anna Freud Centre
and 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 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
157
158 Nick Midgley and Mary Target
man also reports his memory of an incident when his analyst “told
him it was unacceptable to put his feet or chocolate-smeared hands
on [the therapist’s] desk” (117).
Although she gives no other examples, Beiser observes that many
of the memories of therapy that these former patients retain were re-
lated to experiences of limit-setting by the analyst, and she wonders
whether the experience of gratification and frustration, inherent to
the analytic experience itself, encourages the process of internaliza-
tion. She also notes that several of her former patients had entered
professions 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 of
former child patients who have returned to analysis as adults (e.g.
Adatto 1966, Ritvo 1966, Ritvo and Rosenbaum 1983, Ostow 1993,
Babatzanis 1997, McDevitt 1995, Colarusso 2000, Parsons 2000,
Rosenbaum 2000). Most of these studies have been attempts to show
how “core aspects of character seem to be continuous from 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 place
the child analyst appears to have retained in the former patient’s
mind. In a review of several cases, Ritvo suggests that many of these
adults have maintained an internal representation of the child ana-
lyst as a “source of self-awareness and self-understanding to which
they 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 knows
how to help them” (2000:344).
While the focus of much of this follow-up literature is elsewhere,
the few glimpses we are given of the former patients’ memories of
their analyses are tantalizing: Ms B, who “recalled many aspects of
her first analysis, especially in connection with her 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 an
adolescent in analysis, she had been able to “get better because [the
analyst] was kind like her father,” and who recalled particularly a
painting on the wall of the analyst’s office (Adatto 1966:500); and
“Evelyne,” who, in a follow-up interview at the age of thirty-four, re-
160 Nick Midgley and Mary Target
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 written
by a former child patient her or himself is Peter Heller’s A Child
Analysis with Anna Freud (1990). The book includes a reproduction of
the 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 her
own death. Heller chose to publish these, together with an account
of 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 and
his childhood, Heller expresses with great force his deep but ambiva-
lent feelings toward Anna Freud and his analysis with her, which was
carried out in quite unusual circumstances. (Heller also attended a
special school run by Anna Freud and his later life was closely tied
up with that of Anna Freud and her circle). He describes his memo-
ries of Anna Freud’s “kindly severity” (xxii) as she sat behind the
couch on which he lay (between the ages of nine and twelve), knit-
ting or crocheting. He remembers that his analysis focused on the
loss of his mother and his “problematic” relationship to his father
(xlvi), and he describes how as a child he “loved and revered [Anna
Freud] above all other humans” (xxvii). Yet Heller is deeply ambiva-
lent about the experience: he explains how, “in analysis I wanted to
be loved . . . and like so many patients, I did not think I was loved
enough” (xxvii).
Heller’s account of his child analysis hints at the depth of feeling
he still retains about this period in his early life, and suggests that for-
mer child analytic patients can provide us with another point of view
on the psychoanalytic process, one which would complement the
many accounts of child treatments from the 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 was
what led us to carry out the current study.
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). These
interviews were extremely wide-ranging and in-depth, exploring all
aspects 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 one
small part—the interviews which focused specifically on memories of
being in child analysis (Barth 1999). The approach chosen to analyze
these interviews was broadly-speaking “qualitative.” The relatively
small sample (twenty-seven participants), the nature of the data (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 probably
more appropriate than a hypothesis-testing one) are all features that
have been widely recognized as appropriate for qualitative studies
(McLeod 1999).
Inevitably the detail and depth of memory retained by the 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 the
period of time since the analysis had ended varied a great deal—
from eighteen years to forty-two years, with the average length of
time being twenty-seven years. Some people refer to specific, but
quite major gaps in their memory, like being unable to remember
anything about starting or ending therapy, or whether they saw one
or two different therapists, or how often or for how long a period
they came. Only two people (aged four and a half and five at the time
of their respective referrals) claimed to have no memory at all of the
experience. Perhaps unsurprisingly, those whose memories were less
clear tended to be the ones who had been referred for therapy when
they were six or under, although this was not always the case. For ex-
ample, one person who had been in therapy at the age of three and a
half for about two years, had quite clear memories of his therapy and
his therapist.
Results
among those who had been in therapy as adolescents, the fact that
they did not feel they understood why they were coming to the Anna
Freud Centre was a more serious obstacle, and made it harder for
them to make use of the therapy itself. In one woman’s case, her diffi-
culty in understanding why she had been referred for therapy led to
a more negative attitude toward being in therapy:
I think that it would have been very helpful if it had been all ex-
plained to me if everything, the whole treatment was explained to
me . . . why I was there, the necessity of her to react to me in the way
she did . . . as I say at eleven I didn’t have any choice about going. I
didn’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 was
felt 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 got
on 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 they
had come to therapy, a number expressed a wish that they had been
consulted more, that there was “a negotiating kind of process, about
what’s going to happen” (Daniella, 13.9), or that they had been given
more 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 feeling
that “we never sort of assessed as we went along how it might have be
helping [. . .] and it might have been helpful for her to say ‘Let’s see
how you progress, let’s see what value has been in it, let’s see perhaps
let’s talk to your parents together’” (Tamsin, 12.6). Without such a
process, 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 the
greatest differences between child and adult psychoanalysis was the
164 Nick Midgley and Mary Target
and Urie 1975) and that helping adolescents to understand why they
are 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 as
an on-going process—is perhaps one of the most important findings
of this study, given the degree to which these former child analytic
patients report a lack of understanding in this respect.
I think, initially, I think I liked the fact that it was one to one and
the—I could do things here like art and craft that I couldn’t do at
home or at school, and that seemingly you could do anything you
wanted. So it was like fun, it was brilliant, it was so, you know, 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 do
and to say whatever she wanted, but for others (again, mostly those
who were slightly older children when they came to therapy) it is
more specifically the opportunity to talk that characterizes their 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 the
same as the “talking” that might go on elsewhere; not only was the
content sometimes different, but so too the way in which the talking
evolved:
And sometimes I would just sit there [laughs] and not say anything
for about ten minutes and then, he would just say “well,” you know,
and then I’d start talking about anything that came to my mind, you
know, it’s very, very difficult, it’s really difficult. (Mark, 16)
While recognizing the difficulty of this process, this interviewee
and others acknowledged that it enabled them to talk in a way that
was quite different to other situations with other people. A number
of people refer specifically to the fact that they were able to talk
about “secret” thoughts and feelings, and emphasize that they would
not be able to speak like this elsewhere, or that they would not be lis-
tened to in the same way:
Yeah, it was like a chance to go through things which, which I
couldn’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 my
mind so, to be able to do that was a privilege, it was something very
special. (Phil, 9.3)
While the quotation above describes the 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 we
might understand as “making an interpretation.” In some cases, this
is 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,
Recollections of Being in Child Psychoanalysis 167
10.10). One man talks about the way his therapist would “mould”
things and “talks about things I’d been talking about, like dreams or
whatever” (Mark, 16) and goes on to describe what this felt like:
Sometimes, sometimes he came out with, I’m pretty sure he would
come out with some very interesting sort of links, you know with what
I 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 used
to make, and remarks on how, “20, 30 years later I can remember lit-
tle comments [the therapist] made to something I said that she may
not have even thought was important,” describing this as a “power-
ful” experience (Heather, 17.5).
In some cases, the therapist’s “interpretation” seems less about
what the therapist said, and more related to what the therapist did, a
particular action or response which had significance. One man re-
members how he used to make things in his sessions, and that his
therapist used to “dutifully walk down stairs” and get whatever he
needed:
And then on some occasions I’ll forget to ask her for something and
I’ll say “could you go and get me this” and she had to go all the way
back down again [laughs]. I’m sure I used to deliberately kind of just
see, you know, boundary again, just kind of see how far I could push
her and you know, she always used to go until there came a point
where she said “I’m not going to do that” and I was like “oh, why
not?,” 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 of
boundaries, and that his experience of the therapist setting limits was
an important one, and leads directly into his comment about his
“fond” feelings for the therapist.
When asked explicitly, about two thirds of those interviewed de-
scribed some kind of positive feelings toward their therapist, and this
was especially true of those who came into therapy as young children.
A large number said simply that they “liked” their therapist, without
elaborating greatly on this. Others spoke about their therapist being
“warm and friendly” (Elaine, 6.4), or being “a sympathetic person”
(Jason, 7.1) and of themselves having “real feelings of warmth” to-
ward the therapist (Neil, 10.4).
Among those who spoke about their therapist in these positive
terms, a few people expressed a more specific sense that they felt ac-
cepted, looked after, and listened to by their therapist. One man
168 Nick Midgley and Mary Target
I didn’t like him at first, or I was scared of a man, [the therapist] was
strict and wouldn’t do what I asked [. . .] And later I was very fond of
him, I remember later saying to him “I think I might, I think I might
want do what you do for a living,” some real feeling of warmth toward
him toward the end. (Neil, 10.4)
For two others, one of whom will be described further in the next
section, 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 something
like—“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)
170 Nick Midgley and Mary Target
For this woman, as for some others, her negative feelings about the
therapy eventually led her to end her treatment prematurely.
172 Nick Midgley and Mary Target
Commentary
It appears from this study that those who remembered their child
analyses in the most positive way were often in analysis as quite young
children, although they may have had only a vague idea of what the
analysis was about. In The Technique of Child Psychoanalysis, Sandler et
al. acknowledge that “for the young child the positive tie to the 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 opportunity
to play with an interested adult figure seems to confirm this. The
view of Sandler et al. seems to be confirmed by the findings of this
study:
To a child, analysis probably seems simply to be another one of those
strange activities that grown-ups enter into with children, responding
to whatever is put to them. The child’s experience in treatment grad-
ually enables him to sort out the meaningful differences [. . .] even if
he speaks of treatment as “play.” (1980:156)
But this study also tells us something more specific about what as-
pects of the experience of being in analysis as children were felt to be
important. For some participants in this research, there is a powerful
sense that the experience of being able to talk about whatever they
wanted to, in the presence of a sympathetic, non-judgmental listener,
was the essence of the therapeutic experience. The emphasis on the
experience of being accepted, listened to, and looked after by a ther-
apist who is “warm” and “non-judgmental” appears to confirm once
again what Sandler et al. have written:
The child in analysis has a novel experience in that the therapist is an
adult who takes his feelings and expressions seriously over a signifi-
cant period of time. This has the result that the therapist raises the
self-esteem of the child by saying, in effect, “I regard you as someone
to be considered important, and I am not going to dismiss you out of
hand. I will listen to what you have to say.” (1980:112/13)
This emphasis on being listened to and understood echoes much
of the research into patients’ views of adult psychotherapy, in which
the interpersonal qualities of the relationship are seen as consider-
ably more important than any particular thing that the therapist said
or did (e.g. Llewelyn and Hume 1979). However the current study
also suggests that former child analytic patients remembered, and
valued, some of the particular “comments” or “links” that their ana-
lyst had said, indicating that a “significant interpretation” (Sandler et
Recollections of Being in Child Psychoanalysis 173
Concluding Comments
AGE AT LENGTH OF
REFERRAL ANALYSIS AGE AT
NAME (Years, months) (Years, months) FOLLOW-UP
BIBLIOGRAPHY
Child, Adolescent, and Adult Psychoanalyst; Founding Member and Senior Faculty
at 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 this
study. 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 for
her thoughtful contributions to this paper. I would like to thank Dr. Anna Wolff for
her many thoughtful readings of this paper, the IPA Research Program (1998) for
their advice and encouragement, and Drs. A. Scott Dowling, Anton Kris, Samuel
Abrams, Peter Neubauer, and Paul Brinich for their helpful suggestions.
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
178
Attachment and Autonomy in Latency 179
Method
Subjects: Four boys and six girls participated in this study. Each child
was followed from age six through age eleven, for a total of six years
for each child. Only children who fell within the normal range of psy-
chological functioning at age six were chosen. A determination of
normal 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 clinical
interview 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 in
the middle to upper-middle, white socioeconomic class. To be in the
study a child must have had an intact family unit at age six, no history
of severe or moderate psychological problems requiring professional
help, no physical abnormalities, chronic illness, or significant learn-
ing disability. Only children whose families could be expected to stay
in the Boston area and whose parents had no chronic illness, physical
disabilities, or moderate to severe psychological problems were se-
lected. All the families remained intact throughout the study.
The children who participated in the study were extremely bright
and very verbally expressive. Their average I.Q. was 134 at age six. A
182 Rona Knight
lytic researchers who have documented reliability and validity for the
systematic 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 clinical
measure (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 the
Rorschach, the level of object relatedness was based on the subject’s
ability to differentiate boundaries between objects, ranging from
merged to separate (Table I). Rating is based on the degree to which
an object’s boundaries are described as distinct or separate from
one another. Merged responses indicate that the subject does not
feel himself as separate from “the other,” or yearns for an undif-
ferentiated closeness. Separated responses indicate that the subject
experiences 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
TABLE II
Psychoanalytic Rorschach Profile
Example of One
Boy’s Sequence:
Age 5—People
Age 6—Two shoes, two knees, two chins
Age 7—Two ladies smashing pumpkins
Age 8—People
THOUGHT
PROCESSES Contamination Chinese dancers. Dogs playing patty-cake.
Chinese dog dancers.
1. Bibring (1959) also found a dramatic difference between the disturbed Ror-
schach responses of pregnant women and their everyday good functioning in the real
world.
186 Rona Knight
Results
TABLE III
Rorschach Fragmentation and Separation Responses
For Five- to Eight-Year-Old Children
BOYS
GIRLS
often increased their worries. One boy’s dream at age six illustrates
this conflict: “There is a monster coming to the house and I run out.
I worry about what will happen to the family when I run away from
the house.”
Oedipal defeat and the resulting narcissistic injury added to the
six-year-old boys’ feeling rejected by their mother and not nurtured
by her. Mothers were often pictured as dead or hurt. The boys were
sad and angry about their loss and unconsciously expressed their de-
pression in explosive discharge. The main defenses they used to cope
with all these affects were intellectual and obsessive-compulsive de-
fenses. Their ego control, judging from their teacher’s high ratings
of their concentration and behavior, was good enough to hold these
feelings at bay during school hours; however, parents reported that
the boys’ behavior at home was often aggressive and difficult to 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 boys
felt a push to be independent but were scared about being lost or in
danger on their own. They found two ways to cope with their anxiety
about still feeling little and being able to manage on their own in the
world. The boys started to see their fathers as very human, capable of
making mistakes, but also able to help and/or protect their sons
from danger. They also began to use the defense of magic to help
them cope with their fears of getting lost in this new, larger, more
dangerous world. One boy’s TAT story at age seven describes his faith
in his father: “A boy is sitting there with nothing to do. . . . He goes
bird watching and gets lost. Then his father was coming home and he
found him and brang him home. The boy felt scared when he was
lost and good when his father found him.” His story to a TAT card
with no picture on it shows his use of magic: “There’s a boy right here
and he’s lost in the woods so the forest animals lead him home. He
feels relieved that the forest animals know where his home is. The
mother and father thank the forest animals.”
The boys’ developmental push for independence at age seven led
to their feeling much more independent at age eight. The boys expe-
rienced a conflict over feeling more independent because they still
had the same worries and needs they felt the year before. Separation
was still experienced as getting lost in a big world and still included
the total loss of parental objects. One boy showed some regression
back to more typical six-year-old responses on the Rorschach after
the death of his uncle, which increased his anxiety over parental loss.
Attachment and Autonomy in Latency 189
Girls: While the six-year-old girls were all beginning to feel pushed
out into the big world by both their parents and their own drive to-
ward separation, they were not yet as separated as the boys were at
this age. Their Rorschach protocols included responses like animals
and monsters with two heads, and a wall that split open but is still 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 some
Indians coming. So she’s going to run back to her family and tell her
family 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 of
the girls had any fragmentation responses on a Rorschach at age six.
They were all still in the throes of the Oedipus complex, with the 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 many
fragmentation responses in their Rorschach protocols. Five of the
seven-year-old girls showed evidence of having made a separation
based on their Rorschach responses and their TAT stories. They had
fantasies about going out into the world alone and having their own
houses. Their dreams and their conscious worries were about being
forcibly taken away from their homes by ghosts, monsters, and kid-
nappers, and separation often was associated with parental death.
The following TAT story told at age seven illustrates the girls’ feelings
of loss, sadness, and conflict around separating: “This is a person cry-
ing ’cause her parents just died. And she came back to the house and
she dropped the keys on the floor and she started crying. She feels
sad, and she’s thinking she wished she never moved away from her
parents’ home. At the end she finds out that this is a time that people
have to die.” One girl had not achieved a sense of separation and also
had no fragmentation responses on the Rorschach. The absence of
unconscious feelings of a lack of integration and separation was para-
doxical; for this girl separation meant total abandonment that led to
her own death, making her too anxious to tolerate a complete sepa-
ration. While she was able to achieve appropriate separation in her
day-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, they
felt little in a big world. Oedipal defeat added to the girls’ sense of
loss. Stories in which men were perceived as dead, hurt, or deni-
190 Rona Knight
grated were frequent. The anger that the girls felt about their loss
took the forms of oppositional behavior and aggression turned
against the self and siblings. The girls defended against these feelings
by denying and avoiding strong aggressive and libidinal feelings.
Some girls used repression and/or intellectual and obsessive-com-
pulsive defenses to close off or constrict their feelings and impulses.
Their increased anxiety around aggressive impulses led them to a
conflict over good and bad behavior, exemplified by the following
TAT story told at this age: “The girl is sad. Her mother sent her to her
room because she had been bad. ‘I have been a nasty little girl,’ she
thought. And she went to her room and fell asleep on the bed. (What
had she done?) She hurt her little brother. She hit him.” Despite
strong aggressive feelings, they do not have the sense of these 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 them
feeling tired but hopeful of becoming more competent as they got
older. Like the boys at seven, the eight-year-old girls use benevolent
magic to manage their anxiety about their separation and scary inde-
pendence in the big world. Nurturance needs continued to increase
at 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 the
need and the conflict: “This is a little boy, and he’s sitting on the step
of 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 to
stay little ’cause his mother just read him Peter Pan. . . .”
Table IV outlines the findings for the six- to eight-year-old girls and
boys.
BOYS GIRLS
continued
192 Rona Knight
TABLE IV
Summary of Findings for Ages Six to Eight Years
BOYS GIRLS
much younger child. The external pressure to grow up that they ex-
perienced made them very angry and anxious about their ability to
function on their own and resulted in lowered self-esteem. One girl’s
dream illustrates the anxiety at this age: “I am on a bridge with my
friends. I have just left my mother on one side, and me and my
friends are going to the other side. As I am crossing the bridge it be-
gins to unsnap, and I am terrified me and my friends will fall. My
friend’s parents are on the other side, and they snap the bridge back
together again, and we can safely get across.” Their concern about
not getting enough nurturance and their yearning for it can be seen
in the following TAT story: “This boy is sitting here waiting ’cause his
mother is out shopping, and he’s really hungry. They’re poor. He
feels really hungry ’cause his mother is taking so long. (What is going
to happen?) His mother is going to come home with a lot of food,
and he is going to eat lots.”
Boys: The nine-year-old boys’ responses tended to have a more sep-
arate, alone quality. They made a point of noting that the people they
saw on the Rorschach were separating or separate. This more devel-
oped sense of separation and autonomy often made them feel a
sense 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 house
in the blizzard. By the time someone found him he was in a coma.
The person that found him took him to the hospital. Then his father
came and tried to wake him up, but he couldn’t. The next day he
came out of his coma and lived happily ever after. (How did he get to
be so alone outside?) He was locked out in the wilderness and he
didn’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 their
peers.
The boys at age nine responded to their sense of separateness with
either a constriction that held their affects at bay but kept them 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 things
that weren’t there during times when they were experiencing separa-
tion. This could be seen in the flow of associations through several
TAT cards. For example, one boy’s response to TAT Card 4 was a
story about a wife and husband who separate and divorce. When the
next card (TAT Card 3BM) was presented to him, he told a story
about a boy who has amnesia and a case of seeing things that aren’t
194 Rona Knight
there. The boy is scared by what is happening to him. His story to the
next card presented (TAT Card 7BM) was about a boy who is separat-
ing from his father to go off to college. Responses on the Rorschach
also show the boys’ disturbance around separating: “It looks like two
Chinese dancers or people of some kind. They are separate. Maybe
two big dogs playing patty cake with their back feet and their front
feet. Maybe two big Chinese dog dancers. They just finished clapping
and are about to separate and then it looks like they are about to col-
lide. They are slapping so hard the red stuff is the noise. The red and
the sharpness look like noise.” Concurrent with the boys’ feelings of
separation, projective testing showed that their aggressive and sexual
feelings can feel intense and out of control because their 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 the
boys’ fighting with their siblings at this age.
Table V shows the findings for the nine-year-old girls and boys.
TABLE V
Summary of Findings for Age Nine Years
BOYS
1. Intense feelings of separation
2. Sense of aloneness and isolation in the separateness
3. Weakened defenses
3. Anxiety about separation
4. Constriction of affect in aloneness—two boys
Anxiety in connectedness—two boys
5. Aggressive and sexual feelings that can feel out of control; increased fighting
with siblings
6. Caring relationships with friends
GIRLS
1. Intense feelings of separation
2. Push toward peers
3. Weakened defenses
4. Anger about being pushed to grow up
5. Anxiety about being able to function independently
6. Lowered self esteem
7. Increased nurturance needs
8. Conflict over growing up
Attachment and Autonomy in Latency 195
late latency—preadolescence
At ages ten and eleven another phase of separation and autonomy
begins 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 the
children’s feelings and experiences of attachment and separation ex-
perienced with their family and their peers. In this next phase, the
boys and girls diverge significantly, with the girls taking the lead in
the developmental process this time.
Girls Ages 10 and 11: The early latency phase of attachment and au-
tonomy was revived and incorporated into this next phase of separa-
tion. At ages ten through eleven, concerns about connection and
separation re-occurred as the now late latency/preadolescent girls
began to experience the beginning of the adolescent separation-indi-
viduation phase described by Blos (1967). Typical responses on the
Rorschach were: two horseshoe crabs stuck together, two boys as the
same person going out on Halloween, and two animals back to back
about to go away from each other. This is a response that Ames et al.
(1974) also reported with their population of normal ten-year-olds.
Once again, fragmentation responses on the Rorschach appeared as
frequently as they did at age seven. This sense of a lack of integration
appeared in four out of the six girls’ Rorschach protocols at age ten,
and in five of the six girls’ protocols at age eleven. The one girl who
had no fragmentation responses at age seven, once again did not
have any. The variation of timing in this next separation phase sug-
gests that this is a process that may occur over a longer period for
some children, and one that depends on the psychological, cogni-
tive, hormonal, and physiological development of the individual
child. Based on mothers’ reports, five of the six girls were at Stage
Two of Tanner’s pubertal staging (1962) by age eleven, and one girl
had reached menarche at age ten years.
For the ten-and eleven-year-old girls, attachment and autonomy
meant a moving away from home base to create a life and world of
their own, with a knowledge that they could still return when they
wanted to or were needed at home. This is a very different scenario
from that of the seven-year-old’s picture of separation, which entails
parental death. The following TAT story is an example of the differ-
ent tone of this next phase: “The lady’s just thinking about her
friends 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 is
good at. Finally she decides she’s going to be a shopkeeper. She
196 Rona Knight
thought she was old enough to move away so she moved. She will
start her own store and it will be okay.” Frequently teachers were seen
as helping the girls achieve their goals, replacing parents, and friends
also filled in for family. The importance of the peer group for the
girls is demonstrated by the following story to the blank TAT card:
“Gabrielle, age eleven, was starting to go to a new camp this year. She
was nervous. As she rode in the bus, she almost cried. But then she
thought of all her friends from school and cheered up. As it turned
out, it was the best summer of her life—for friends, creativity, and
happiness. It was one of the best summers of her life, and she
couldn’t wait ’til next summer.”
This next phase of separation was not entirely free of fears and
conflicts. Three of the six girls had very real concerns about death,
which they applied to themselves and their loved ones. One girl had
the following dream about the possibility of death following separa-
tion: “A week or two after we got our kitten, I had this dream that she
drowned. My friend dropped Lizzy [in the water] and we cried,
‘She’s drowned!’ I started diving underneath the water, and she was
at the bottom. I brought it up and started squeezing all the water out.
My friend appeared with the mother cat, and that made her feel bet-
ter ’cause she was missing her mother.”
Conflicts fused with anxiety about growing up were exceptionally
strong at ages ten and eleven. Contamination and anthropomorphic
responses were present in all of the girls’ Rorschach protocols, while
at the same time they were telling TAT stories about going off to 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 it
and even fare well in the world. They didn’t defend against these
feelings but tolerated the anxiety and sadness that comes with the
separation, bolstering themselves with a hope for a wonderful out-
come. The one girl whose concern about separation was problematic
when she was seven was still concerned that she would not fare well
and described visions of homelessness, drudgery, and neglect, which
may be why she did not experience the more intense disconnection
that the other girls showed.
Along with this newfound sense of autonomy and its concomitant
feelings, oedipal concerns were more present again, and the girls ex-
perienced a surge of aggressive and sexual feelings that at times
would break through their defenses and overwhelm them. The girls’
conflict about growing up at this point was also a response to their
anxiety about their intense sexual and aggressive feelings at this age.
They felt a need to be taken care of and nurtured by their mothers,
Attachment and Autonomy in Latency 197
GIRLS BOYS
this age. While this appears related to their sexual and aggressive
feelings, there is also a quality of a wish to return to lost oedipal ob-
jects. The following TAT story expresses this wish: “This lady was the
wife of the guy who got in the car accident. He died and so did her
kid and then she lost her job. So she got really depressed and she
committed suicide ’cause that’s a gun right there.”
Table VI summarizes the findings for the ten- and eleven-year-old
boys and girls.
Discussion
fears of managing on their own as they felt more separated and alone
in the larger, challenging world. This supports Anna Freud’s (1936)
and Sarnoff’s (1976) finding that fantasy is used as a major defense
in 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 feel
they could rely on their parents in the same way as the boys, and
demonstrated an oral neediness that grows in intensity throughout
the latency period as well as a sense of being tired at times by the task
of growing up. These findings are illustrated in the “Harry Potter”
stories (Rowling, 1998–2003). Harry has his god-father, his friend
Ron’s father and brothers, and several male teachers to help him
avoid dangers as he grows up in the magical world of Hogwarts.
Hermione, by contrast, has parents that are of no help to her, and
she has to study magic very hard (sometimes taking two classes at the
same time), relying on her wits to help her and Harry along the way
(Harry relies on her ).
The cultural and psychological implications that allow boys to see
their fathers as helping figures while girls cannot use their mothers
(or fathers) in a similar way during this phase of identification with
the same sex parent must be considered. All of the girls’ mothers
worked part-time in professional positions, yet the girls could not
imagine their mothers as helping figures in the world outside of the
home in their fantasy.
One possible explanation for the different reactions of the boys
and girls has to do with gender identification processes in early la-
tency. Mahler (1981) addressed the gender difference in the first
separation phase, noting that the boy has his father to support and
maintain his personal and gender identity, while the girl, in her sepa-
ration from the post-infancy mother, has a much more difficult and
complicated task to attain and maintain her sense of self because her
relationship with her mother “carries the burden of threatening re-
gressions.”
In latency, boys identify with their fathers and their sense of their
fathers’ more competent position in the outside world. The girls’
TAT stories often expressed a sense of tiredness related to 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 maternal
function of being the main caretaker of the basic needs of the home
and children. Stephen King (1983) nicely expressed this male-female
204 Rona Knight
role dichotomy: “What your mother leaves you is mostly good hard-
headed practical advice—if you cut your toenails twice a month you
won’t get so many holes in your socks; put that down you don’t know
where 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 the
girls’ identification with their mothers, when combined with their
lowered self-esteem, may sometimes leave them feeling that they are
not competent enough to be completely out in the world.
Another explanation for this gender difference may be found in
the remains of the late oedipal phase conflict. In this study, the early
latency boys unconsciously experienced their mothers as dead to
them, while the girls unconsciously experienced their fathers in this
same way. In their effort to break their oedipal tie to their fathers, the
girls need to distance themselves internally from their fathers, and
therefore do not have them as available as the boys do to help them
in their fantasy working through of the present stage of separation.
This might make the girls feel they have to bank on their own 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 to
their feelings of lowered self-esteem by the age of nine.
Two of the boys felt an intense sense of disconnection at age nine
that the girls didn’t have. It is interesting to note that the two boys
who retained a sense of connection at age nine both had mild learn-
ing difficulties, requiring them to remain more dependent on their
mothers for help with their school work and the structuralization of
their environment. Chodorow (1989) suggested that the masculine
personality is founded on the denial of relational needs out of the
difference in social attachments that evolve out of the oedipal 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 relational
picture 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 not
necessarily lead to a denial of relational needs in their peer relation-
ships. Their attachment and loyalty to a primary, close male friend
was much more constant than the girls’ friendships were during
these years. However, the quality of the connection did seem to be dif-
Attachment and Autonomy in Latency 199
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 of
cognition, physical abilities, socialization, and the autonomous use of
defense functioning. By age nine all of the children had consolidated
the latency phase of separation and autonomy. Their higher levels of
autonomous and internalized defense functioning and their newly
developed cognitive functions were not yet sufficiently established to
protect them from their strong feelings, which were in greater power
than their defenses at this point, resulting in the breakdown of de-
fense functioning and the considerable distress that can be seen on
their 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 the
Rorschach card, similar to the talking and hearing vibrations one girl
in this study reported. The age difference between her subjects and
these children may be due to the fact that the children in the present
study were more intellectually advanced and so experienced this
breakdown in ego functioning somewhat earlier than the average
child might. That such a breakdown of defenses at age nine occurs
after consolidation of separation and a more autonomous self and
ego structure at age eight is consistent with the idea that the most re-
cently developed functions are the first to show vulnerability during a
maturational change that also includes a surge of strong feelings (A.
Freud, 1966; Piaget, 1967). It is also compatible with Blos’s (1967)
description of adolescent separation in which ego impoverishment
follows the sense of internal object loss.
age nine, when both boys and girls consolidate their more indepen-
dent and autonomous functioning. Late latency/preadolescence
would begin at age ten in girls and ten/twelve⫹ years in boys, when
another phase of separation and autonomy begins. If this theoretical
hypothesis holds true, then girls have a much shorter period of la-
tency development than most boys do, and consequently don’t have
as much time to consolidate their growth during this developmental
phase before they have to cope with another major developmental
shift to preadolescence.
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213
214 Karen Gilmore
I can laugh whatever I like to laugh,
There’s nobody here but me.
—From “In the Dark,” by A. A. Milne
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 information
about the individual’s psychological and cognitive development, dy-
namics, diagnosis, and interpersonal relatedness. The child clinician
expects 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 that
can serve as a shared “intermediate region,” (a term borrowed from
Freud’s 1914 metaphor of the “transference as playground”) where
the action of the analysis can safely unfold. Play has been addressed
extensively in the analytic literature even before Freud’s immortal
description of the “Fort-da” game (1920); with the advent of ego psy-
chology and observational studies of infants and children, it has
been increasingly privileged as serving a central role in child devel-
opment. No longer reduced to merely a discharge or wish-gratifying
phenomenon, 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 in
the analytic treatment of children has also been described exten-
sively in the clinical literature where it has been analogized to the
transference (Battin 1993), termed a “creative workshop for action”
(Mahon 1993), and yet distinguished from the enactments that di-
rectly draw the analyst into a dramatization of unconscious fantasy,
which, of course, are also prevalent in child analysis (Chused 1991).
Play in the Psychoanalytic Setting 215
Child analysts are very well acquainted with the “coercive” as well as
the “generative” effects (Ogden 2004) that accompany playing out a
child patient’s narrative. Like enactments, i.e. “symbolic interactions
between analyst and patient which have unconscious meaning to
both” (Chused 1991), play typically reveals that the analyst is both
“playing a role in, and serving as author of, someone else’s uncon-
scious fantasy” (Ogden 2004) that inevitably reverberates with her
own.
However, play differs from enactments in that it is, either implicitly
or explicitly, “make-believe.” Playing in the analytic setting 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 meaningful
and 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 and
defenses 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 by
Bromberg as “space for thinking between and about the patient and
the analyst” (1999) in adult work. In child analysis, this state is con-
cretely anchored to favored play objects endowed with layers of
meaning, both explicit and unconscious (Abrams 1988), and it is
represented in the idiosyncratic play themes that emerge and evolve
as a product of the child and the analyst’s conscious and unconscious
communication 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 through
the metaphors of the evolving play narratives and props. Because the
playing analyst, to be truly effective, must fully engage in playing
(Birch 1997, Yanof 1996, Cohen and Cohen 1993), the play is in-
evitably co-created and contains elements from the unconscious of
both patient and analyst, although the patient’s contribution is privi-
leged by the nature of the endeavor. Beyond mastering the typical
countertransference anxieties around regression and instinctual dis-
charge, child analysts ideally have remastered the capacity to play
without condescension or self-consciousness and to maintain a con-
sciousness divided between the analytic and the playing function
wherein 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
216 Karen Gilmore
in the freedom with which the child reveals his personal “state of
playing” and in the manner with which the child draws the analyst
into the play and allows the emergence of an intimate dialogue. I be-
lieve that the child analyst, more than any other professional who
works with children, most consistently attempts to enter the child’s
inner world and go beyond the typical array of self-protective barri-
ers that children present to grown-ups. Both child patient and analyst
must be willing to engage wholeheartedly (Birch 1999, Yanof 1996)
in the “conceptual world” (Cohen and Cohen 1993) that the 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 world
whose 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 pathological
adaptations that can be addressed best by being in that world with
the child. This state includes unconscious communication and intu-
itive leaps that can result in dramatic shifts in the child’s tolerance
for affects and rejected self-representations.
As for the child patient, even young children know, within a short
time, that playing with an analyst is a very different business from
playing alone or even with another child or adult. Playing with the
analyst is all at once revealing the self, drawing the other into a 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-affect
and 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, but
bridging it is a crucial moment in the treatment. This is the moment
where the child admits the analyst into his private world, by no
means without its own resistances and defensive organizations, but
the juncture marks a point where the treatment relationship reaches,
to borrow a favorite video game metaphor, the next level.
Before describing the work with Andy, I will frame the discussion
against a backdrop of a selective review of some pertinent formula-
tions of how early experience within the mother-baby relationship
serves as the birthplace for shared intersubjectivity which in turn
stimulates the interrelated set of ego-capacities that are at question
here, allowing a more informed speculation about how Andy’s par-
Play in the Psychoanalytic Setting 217
ego organization and adaptations and are rarely called upon to per-
form in as many diverse arenas as the average school child. The adult
will presumably manifest less distress and symptomatology around
chronic exposure to impossible environmental demands and can
avoid confrontation with areas of relative weakness by his choice of
profession and pastimes. The child analyst thus faces a diagnostic
and clinical challenge where the multiple transactions among na-
ture, nurture, history, on-going development, and environmental ex-
pectations and demands are all intermingled and clearly contribute
to 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 usual
contemporary range of analyzable childhood psychopathology, i.e.
he fell within the spectrum of neurotic/developmentally uneven/
dysregulated patients who are the staple of contemporary child ana-
lytic practice. The degree to which his psychology was influenced by
a 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 by
our greatly improved assessment techniques, allows us to take into ac-
count the impact of developmental idiosyncrasy on the evolving
structure of the mind; that is, we are able to identify and consider the
way that the unique individual developmental profile shapes and or-
ganizes the evolving personality and defines its potential. I would
speculate 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 his
availability 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 routine
fine and gross motor accomplishments of early childhood. These
considerations, plus the report of maternal depression in the first
year of life and his parents’ orientation toward emotionality in gen-
eral, support hypotheses about the complex bio-psycho-social under-
pinnings of this boy’s particular difficulties when he presented in
early 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 in
advance to show the interweaving of the developmental, diagnostic,
222 Karen Gilmore
and dynamic issues as they served to light the way in what sometimes
seemed a discouraging darkness. To my way of thinking, they 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, especially
his limited capacity to sustain quiet alertness and focus (ADHD) and
his reduced proclivity toward object relatedness (non-verbal learning
disability), diminished his availability for early engagement with his
mother, where affect regulation and imaginary play find their 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 his
pleasure in his own productions were compromised by his motor and
visuo-motor deficits.
4. Andy did not play because ego weaknesses, interference in mater-
nal attunement, and, possibly, constitutional factors, heightened his
fear of his affects and his difficulty developing signal function.
5. Andy did not play because his narcissistic fragility and sense of in-
ternal impoverishment inhibited the development of fantasy and the
expression of creativity.
6. Andy did not play because affective expression was devalued in his
family and precocious intellectuality was strongly prized. Obsessional
defenses against his constitutionally determined impulsivity were re-
inforced by his intellectual, “workaholic” parents; coupled with his
perfectionism and his fear of his own affects, these defenses further
squelched his freedom to play creatively.
Over the course of the two years of treatment to date, I came to
conceptualize the core of Andy’s pathology as a complex disturbance
in his ego organization, one that remained as an on-going (although
also evolving and transforming) limitation in his development. His
clinical presentation, corroborated by his history, showed that he
had on-going difficulty establishing and maintaining an intersubjec-
tive state where self-discovery, emotional exploration, and creativity
are 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 only
indirectly, as with highly oppositional children. His analysis has in-
deed been marked by fierce resistance, behind which lay anguished
loneliness, 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
Play in the Psychoanalytic Setting 223
Andy
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, they
conveyed bewildered sympathy for their son’s situation, reacting with
dismay tinged with a kind of abashed perplexity and frustration, but
at 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 posture
previewed their reaction to the recommendation for analysis. Later
in the first year of treatment, Andy’s mother, who was herself in an
on-going treatment, acknowledged her own significant depression
during Andy’s first year of life precipitated by her father’s death. She
also articulated a tension between herself and her husband and in-
deed his entire extended family. She had come to recognize that as
she increasingly gave voice to her feelings, she felt peripheralized as
an excessive worrier, a “mother hen,” in a culture characterized by a
casual but somewhat implacable denial of danger and distress and a
humorous disregard for anyone who was frightened or who visibly
emoted. The mother seemed unable to sustain her position in the
face of this attitude, lapsing into a kind of hapless posture, as if,
Woody Allen-like, she was just being “neurotic.”
This quality in 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 and
the dynamics of their relationship as it emerges willy-nilly in the con-
sulting room, their reflections on their own psychologies and their
personal histories, their complaints about each other or their child,
their blind spots, kindnesses, and cruelties accrue in our experience
of the parents and facilitate our capacity to understand our patient’s
experience. In meeting with parents, I am often aware of a process of
identification with my child patient, which emerges as a reverie about
what it feels like to be both the present-day child and the very young
infant of these people: what are the rituals of interaction, the shared
assumptions, the unspoken expectations about engagement, the
“ease and continuity” of on-going experience (Pine 1982)?
Parents’ transparency in terms of their representation of them-
selves, their relationship, and the portrait of their child that develops
in the course of the work reflects their willingness to openly engage
with the analyst in helping their child; to some extent this corre-
Play in the Psychoanalytic Setting 225
day. In fact it was the rare exception that a motif generated one day
was taken up the next; there was none of the often preemptory driv-
enness of the child patient who is playing out important thematic
conflicts in displacement, who comes in knowing just where the play
left off and easily reestablishes continuity.
Andy returned to school without any medication and when 4
months later, Strattera, a new non-stimulant ADHD medication, was
finally introduced, his parents and I agreed to try it. I hoped that
Andy would accept this medicine because it had an initial sedative
effect and could provide relief for his chronic sleep onset 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, and
therefore did not generate the same resistant response that he was
able to mount to the stimulants. Nonetheless he told me some time
later that while he appreciated the improved sleep, he didn’t like the
idea 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” for
play and do not assert my personal agenda beyond the attempt to
know 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 developmental
marker of the infant who is just beginning to appreciate the idea that
mother’s mind differs from his own and must be actively engaged. In
the assessment period, he frequently responded to my interest in
what was on his mind as if I were, like the intrusive medication, trying
to disrupt his control of his thoughts. While this seemed to improve
to the extent that he did not forcibly attempt to silence me, he was
unable to generate any activity where we engaged in mutual discov-
ery and elaboration of meaning. Often, when he engaged in some
motor 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 to
trick 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
230 Karen Gilmore
sue him. The transference meanings of his complaint, i.e. its history
in his relationship to his father, was less available than its defensive
function in the here and now. I had ample opportunity to see that
this posture protected him against the frightening feeling that he
couldn’t think of anything, that his thoughts and intentions seemed
to drift out of his mind, that his attempts at creativity were strained
and empty, and that he was just an ordinary sad and lonely kid, and
therefore unlovable. Not unexpectedly, these rare moments of openly
expressed resentment toward me, which of course were at once dis-
placements of painful states experienced in relation to others, ex-
pressions of on-going transference themes, and a way to engage with
me and keep me at a distance all at once, were typically followed by a
rapprochement which was certainly motivated in part by guilt and
anxiety. When I observed once more how difficult it was for him to
talk about feelings with me and to feel comfortable having feelings
about me, he said with great poignancy,
One is the loneliest number that 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 challenge
indeed to represent these many layered issues to such a child in a way
that usefully examines his oedipal and sibling rivalries, narcissistic in-
jury, and shameful sense of inadequacy, while recognizing his real
disabilities arising from his maturational unevenness as well as their
role in his developmental lag in tolerance of intersubjectivity and af-
fective expression.
Discussion
ration of a dream with a less exacting requirement for logic and real-
ity, even in latency-age children fully capable of concrete operational
thought. Moreover, this state is more or less porous to the analyst’s
playing participation, as the child dictates how much input the ana-
lyst is permitted, and the analyst assumes a playing state informed by
her growing knowledge of the patient and her appreciation of the
boundaries of play in its interface with direct expression of drive de-
rivatives and consequential action. Inevitably, the analyst’s play state
is 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 is
produced in the treatment it becomes an intersubjective medium
with its own conventions and its objects, whose historical meanings
are gradually transformed as they become incorporated into the his-
tory of this new relationship, just as transference paradigms and his-
torical memories show plasticity and evolution in the course of adult
analysis (Rizzuto 2003).
In regard to this evolution, I believe that despite the considerable
controversy about the therapeutic value of playing in and of itself
(Mayes and Cohen 1993, Scott 1998, Cohen and Solnit 1993), the
transformation that child analysis facilitates and which the child pa-
tient anticipates, is achieved primarily through verbalization while in the
state 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 explicit
interpretation of conflict (Birch 1997, Mayes and Cohen 1993, Slade
1994). Nonetheless, in all such instances, the analyst’s verbalizations
are 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 recent
paper 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 own
speech.” (p. 293)
I believe that the same process occurs in the play dialogue of child
analysis; in a comparable way, narratives about the self are made co-
herent, disavowed self-representations are clarified and modified to
permit reintegration, nameless and disorganizing anxieties are named
and organized, and dissociated self-states are open to contact both
236 Karen Gilmore
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Psychoanalysis As
Cognitive Remediation
Dynamic and Vygotskian Perspectives
in the Analysis of an
Early Adolescent Dyslexic Girl
LISSA WEINSTEIN, Ph.D., and
LAURENCE SAUL, M.D.
239
240 Lissa Weinstein and Laurence Saul
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 action
and the ability to understand words as generalized categories which
represent objects, rather than being part of the specific object named.
These two capacities, fundamental to the development of abstract
thought, will support reflective awareness and help modulate affective
states. The abilities furthered in play also act to remediate one compo-
nent of dyslexia—the difficulty separating context from more abstract
bits of knowledge. Finally, the child learns to “play at reality,” often
trying on the new role of “student.” As Vygotsky notes, play is essential
in allowing the child to become aware of what she knows. For a dyslexic
child, for whom reading may never become completely a part of proce-
dural memory, becoming conscious of what he knows may also en-
hance mastery of the skills of phonological processing, albeit more
slowly than normally developing readers. The pleasure in play and the
repetition it generates aids the internalization of the task and the de-
velopment of automaticity.
Introduction
relatively brief period of time than the immature ego can handle,”
suggested that children, being passive, must suffer experiences that
they cannot absorb and which they attempt to master through repeti-
tion. In addition to the disappointments of reality, play also helps the
child cope with trauma generated internally, either by the upsurges
of the drives or via the heightened pressures of the superego. Play
aids mastery by turning passive to active. It allows the child to alter
the outcome of the experience or to change his role. Rather than a
suffering victim or an anxious onlooker, the child can instead be a
world creator. In addition, the reenactment of an experience in itself
constitutes a switch from passive to active. The observed repetitions
in play allow for the fact that the child’s weak ego can master reality
only a little bit at a time and are necessitated by the child’s limited ca-
pacity for verbalization and his inability to link thoughts together
through cognitive work. The actual play is a compromise formation.
By offering the most satisfying solution between the desire for plea-
sure, the demands of reality, and the conscience, play strives to make
up 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 shaping
play. Winnicott’s (1974) notion of transitional space also suggests a
role for play in the structuring of external and internal reality in ad-
dition to the interpretation of play which focuses on meaning. More
recently, theorists have noted the contribution of play in the creation
of new representations, suggesting that play in itself acts as a force in
getting development back on track (Mayes & Cohen, 1993; Neu-
bauer, 1993; Scott, 1998; Slade, 1994). Although this structuring role
of play has been noted particularly in children with ego deficits (Co-
hen & Solnit, 1993), cognition and its relationship to play has been
largely 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 two
months because of Natalie’s worsening irritable, withdrawn, and ag-
gressive behavior both at home and at school. Natalie frequently
screamed, cried, hit, and kicked. She directed these outbursts mainly
at her sister, who was 3 years her junior, but also at her parents and
Psychoanalysis As Cognitive Remediation 243
developmental history
Natalie was the product of a planned, uncomplicated pregnancy with
an induced delivery at 41 weeks that required forceps. Fine and gross
motor milestones were within normal limits, but there was a notable
delay in language. Natalie did not speak her first words until 18
months or speak in full sentences until 4 years of age. Speech therapy
was begun at 4 years and continued until she was 11. From early in
childhood, Natalie struggled with articulating her thoughts and feel-
ings and she was described as a highly anxious child who was needy
of 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 was
significant only for seasonal environmental allergies. Menarche was
at 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 speaking
woman 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 and
studied American Civil War tactics and strategy with her. Natalie fre-
quently witnessed her father vomiting and passing out in a drunken
stupor. 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 his
throat, and threatened to kill himself. Natalie saw her mother sus-
tain a fractured arm and, at another point, a subdural hemorrhage
from father’s beatings. Father also frequently exhibited bruises his
wife had inflicted on him. Natalie’s sister attempted to break up the
battles by getting physically between her parents while Natalie, in
sharp contrast, would run to her room and remain under her bed
covers.
244 Lissa Weinstein and Laurence Saul
When Natalie was 11 years old, her mother had the police remove
Natalie’s intoxicated father and placed an order of protection
against him because of verbal threats. Natalie never asked to see him.
Visitations were started 6 months later because Natalie’s sister re-
quested to see him, and visitations continued sporadically. A few
months after Natalie’s father was removed from the home, Natalie’s
paternal grandmother died. Therefore, she suffered two major losses
simultaneously. 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 8
demonstrated receptive and expressive linguistic difficulties rather
than oromotor problems. Natalie failed to initiate a lot of language,
had trouble sequencing her thoughts, and had difficulty with word
retrieval and naming. Phonological processing was impaired. This
skill (the ability to hear and sequence the sounds within words) is the
central deficit found in reading disorders (Morris et al., 1998; Shay-
witz, 2003). Natalie had poor auditory discrimination, could not
identify medial vowel sounds, and had poor memory for phonemes.
While she needed the scaffolding provided by a listener in order to
organize her thoughts, the more object related and para-verbal as-
pects of communicative language (prosody, eye contact, and turn
taking) were intact. In sum, Natalie met the criteria for double deficit
dyslexia (Wolfe, 1999), a term used to identify children who show
problems in both rapid automatized naming and phonological 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 a
dyslexic child of average to high average intelligence, with a fairly fo-
calized language disorder. The WISC III yielded a Full Scale IQ of
103, with a Verbal IQ of 106, and a Performance IQ of 99.
The subtest scores were as follows:
Verbal Scale Performance Scale
Information 11 Picture Completion 10
Similarities 10 Picture Arrangement 14
Arithmetic 12 Block Design 11
Vocabulary 12 Object Assembly 9
Comprehension 10 Coding 5
Digit Span 7
Psychoanalysis As Cognitive Remediation 245
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 her
analysis: her need to maintain distance (particularly from men) in
order to feel safe. The early manifestation of this theme took place
primarily in the behavioral realm: Natalie kept her coat on during
the first session, claiming she 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, rather
than a victim, Natalie punched her sister in the mouth on the way
home from her second analytic session. Shifting identifications be-
tween victim and victimizer reverberated in her fantasy life as well, as
Natalie described a music video where men on strings were manipu-
lated by a woman puppeteer and another video where a woman who
tries to leave her boyfriend is beaten to death. The analyst tied these
two videos together, noting that “women better maintain control of
men or 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 “personal
stuff.” Similarly, she isolated herself with peers, voicing a desire to be
unique 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 you
don’t know what it’s going to look like.” This contrasted to all the
family based holidays she hated like Thanksgiving, where “you just
get a big stomach ache,” Christmas “where there’s so much pressure
to get the right gift,” or the absolute worst holiday, Valentine’s Day,
with its associated themes of love and kisses. Natalie then decided
that she would write an article for the school newspaper entitled, “X
Valentine’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. In
response to an observation that she didn’t like showing off, she
Psychoanalysis As Cognitive Remediation 247
agreed that she preferred to blend into a crowd and did not like to
be closely observed, alluding to her fears of being seen in the analytic
encounter. During sessions, turning passive to active, she would pull
her hat over her head, turn away from the analyst, or even sleep. Na-
talie alternated between attempts at contact and a need to lessen the
amount of experienced stimulation through physical distance. She
chose to sit in the analyst’s swivel chair which allowed her to sit very
close by him and quickly turn away when necessary. She alternated
between talking engagingly and playing catch or being by herself, re-
maining silent for entire sessions during which she would refuse to
respond, even to direct questions. Often, “silent” sessions followed
ones in which she had been particularly talkative. The analyst’s coun-
tertransference responses illuminated the nature of the conflicts
aroused. 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 when
after 6 months in treatment, an analogous situation surfaced in Na-
talie’s school life. She excitedly reported being “stalked” by two boys
in her class. When the analyst wondered out loud whether the inci-
dent might be flattering as well as scary, Natalie threw a ball harder
and harder toward the analyst until it was impossible to catch. The
analyst’s premature interpretation of Natalie’s underlying sexual
wishes 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 in
moments of high affective intensity, words did not “hold” her and she
quickly moved to highly symbolic and expressive actions to regulate
her feelings. In addition to action, Natalie would also remove herself
from the more passionate arena of verbal interaction and seek solace
in a calmer visual perceptual world, painting vivid scenes of serene,
inanimate content.
Usually ill at ease with her desires to be seen, Natalie began to ex-
press an interest in acting. She performed Shakespeare soliloquies
for her analyst and simultaneously blushed and smiled with pride at
the applause he would give. At this point, Natalie’s exhibitionistic de-
sires were not interpreted. Rather, the analyst allowed Natalie to ex-
248 Lissa Weinstein and Laurence Saul
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 with
learning 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 with
peers. Although there was certainly more analytic work to be done
around 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 session
Natalie was an expert.
At 12¹⁄₂ years of age, Natalie presented as a young adolescent with
affective symptomatology, an oppositional defiant disorder, learning
problems and a history of traumatic overstimulation. Her symptoms
resulted from three interweaving factors: a biologically based learn-
ing disorder and alterations in the timing of the maturation of her
speech and language, her chronically traumatic home life, and her
entrance into adolescence. Exposed to a greater than normal degree
of aggressive stimulation, these traumatic experiences shaped the
way she perceived herself and interacted in relationships, for exam-
ple via identification with the aggressor, and placed considerable
strain 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 access
words as a mediating force during critical periods (Migden, 1998).
Offering new gratifications and connections, speech usually helps
the child to master the waning symbiotic ties and the loss of the ac-
companying feelings of omnipotence and safety. Conceptualized
thus, language is a central aspect of the separation process. For Na-
talie, early separation from her mother resulted both in object loss as
well as the loss of an optimal linguistic environment because her En-
glish exposure was curtailed when she was cared for by a non-English
252 Lissa Weinstein and Laurence Saul
Discussion
about which she wished to remain blind. The defensive efforts that
interfered with retrieving memories of her father’s frightening vio-
lence and the painful affects they would arouse also interfered with
other 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 the
process of learning, affected her motivation to learn. Natalie’s dys-
lexia came to function as an anlage, a model based on constitution
around 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, functions
as a powerful anamnestic tool. In the analysis, Natalie was thrilled
and 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 with
fears/desires of being attacked/attacking. Natalie experienced plea-
sure both as the terrorized girl and as the emasculating female. Of
significance is that both Barney and Mr. Tingle were teachers, one
sadistically drilling facts into her, the other an emasculated and use-
less wimp. Becoming a “student” and learning was either danger-
ously exciting or doomed to devastating disappointment. Natalie’s
fusion of sexuality and aggression is determined by her age, but also
by 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 to
read.
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 weakness
left her with a tendency to focus on the non-linguistic aspects of the
environment; she had a strong reaction to tone and prosody in lan-
guage and maintained a strong attachment to the visual world where
she could retreat when her affective stability was disrupted. She also
regressed to action as a mode of expression.
The analysis allowed Natalie to access language for what had been
inchoate and in so doing to connect a variety of associated, previ-
ously unconscious memories into cognitive structures. When her
conflicts 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-
Psychoanalysis As Cognitive Remediation 255
the child’s desire centers on her role, on a fictitious “I” that relates to
the rules of external reality and takes them in, making them her own.
In 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 (with
the teacher’s role) and employs these psychic mechanisms inter-
changeably. In this way the process of learning can be separated from
fixed 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 actual
developmental level and her potential. In this zone, functions such as
abstract thinking and the child’s relation to reality are in the process
of 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 be
impaired in dyslexic children.
Conclusion
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). This
teaching role allows for the internalization of insight. Both aspects of
the analytic role are heightened and intertwined for the dyslexic
child. As the analyst functions as an object in the service of repeti-
tion, conflicts around learning will be re-evoked as the traumatic situ-
ations accompanying learning come closer to consciousness. Once
these conflicts are interpreted, as they were with Natalie, then the
child can begin to use the analyst as a partner (new object) in
play/learning. During this phase, interpretation is probably less re-
quired, as the child is finally able to make use of play for cognitive
structuring and for developing a decontextualized abstract attitude.
These skills are notably essential for learning to read as well as other
modes of symbolization.
Beyond the mutative aspects of interpretation, by allowing Natalie
to titrate the level of stimulation, the analytic context also supported
her ability to access knowledge she already possessed. Thus the ana-
lyst acted neither exclusively as a developmental new/real object nor
as transference object, but as both depending on the context of the
treatment at any one point.
Although it is beyond the scope of this paper to offer technical pre-
scriptions, some differences in the way play and the analytic context
may function for learning disabled children should be highlighted.
First, learning disabled children may need to play beyond the usual
age than that of other children, both inside and outside of the 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 in
the remediation of the learning problems. Third, although it would
be 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 clear
that 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, or
even allowing for an enhanced role for action in the treatment. The
necessity for factoring in the child’s level of cognitive development in
the formulation of interpretations as well as the interrelationship be-
260 Lissa Weinstein and Laurence Saul
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262 Lissa Weinstein and Laurence Saul
Training and Supervising Analyst, and Associate Supervisor in Child and Adoles-
cent Analysis, Baltimore-Washington Institute for Psychoanalysis; Clinical Assistant
Professor of Psychiatry, University of Maryland School of Medicine.
I gratefully acknowledge the invaluable contribution of my discussions with Dr.
Alan B. Zients, whose insight and support were instrumental in my treatment of this
patient. I thank also Drs. Boyd Burris and Charles Brenner for their thoughtful cri-
tique of an earlier version of this manuscript.
The Psychoanalytic Study of the Child 60, ed. Robert A. King, Peter B. Neubauer,
Samuel Abrams, and A. Scott Dowling (Yale University Press, copyright © 2005 by
Robert A. King, Peter B. Neubauer, Samuel Abrams, and A. Scott Dowling).
263
264 Silvia M. Bell
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. She
approached me quickly with a broad smile when I greeted her in the
waiting room, and made a point to bring her face very close to mine
as she went past me to enter the consultation room. Before sitting
down, she faced me and asked, “Can you tell?” “Tell?” I asked. “Yes,
can you tell that 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 a
lot of work on my skin.” This launched her into a description of her
266 Silvia M. Bell
history
Beccah was born in an Eastern European country, with facial defor-
mities and serious birth defects, including complete cleft lip and
palate, and multiple benign soft tissue tumors which involved the
face, the vascular system, and obstructed the airways and bowel. Her
parents, both professionals who had been educated in the United
States and counted many friends and relatives here, recognized that
her medical needs would be extensive, and took immediate action to
relocate. Indeed, Beccah required multiple surgical interventions in
the first four years of life, and her condition was considered life
threatening. Her medical status stabilized after age five, and she was
essentially healthy thereafter. However, she underwent staged peri-
odic facial cosmetic surgery between the ages of five and twelve to
approximate a normal appearance. These interventions became less
268 Silvia M. Bell
treatment
An extended evaluation was undertaken, to explore Beccah’s capac-
ity to tolerate anxiety and regression prior to the recommendation
for analysis. As is characteristic of individuals who have suffered early
trauma, Beccah experienced anxiety as a sudden and intense onrush
of affect, which felt disorganizing. She defended against this feeling
by taking counterphobic measures—that is, she exposed herself to
the very situation she dreaded so she would not be surprised by it.
The affect would be further moderated through primitive denial, or
isolation—she would purport not to feel anything at all. I noted with
concern, 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.
270 Silvia M. Bell
gaze away from her face. Looking and being looked at were highly
charged affective moments, which mobilized fantasy and conflict.
She began to recognize that her own looking was compromised—she
looked to others as mirrors of herself, because she could not see the
young woman in the mirror as herself. As our work progressed, we
considered the meaning of her searching in my eyes, as she had done
on our first meeting; a search that repeated her experience with her
mother’s eyes.
Beccah had enrolled in a course to make porcelain dolls, and she
brought them to her sessions. She was critical of her work, and
showed me that she could not get the face “quite right.” The connec-
tion with her wish to have the perfect face with a flawless complexion
was unconscious. She did not recognize that her newfound interest
represented her experience of remaking her own face. After sharing
in her interest in porcelain dolls—that is, keeping our work in the
displacement—I noted the unremitting quality of her concern about
not getting the doll’s face “quite right,” and I asked her whether she
was curious about it. She asked my opinion, what did I think about
the face? I replied that her checking now how I felt about the doll’s
face reminded me of her question, “can you tell?” We addressed her
externalization; her checking what others felt kept her confusing
feelings about herself temporarily out of mind. She connected with
her anxiety upon meeting people, “I have this constant knot in the
pit of my stomach; so much, that I don’t even know it’s there.” At our
next appointment, she brought a porcelain baby doll. Now aware
that her behavior had meaning beyond an interest in the hobby, she
said, “I like babies. I worry about having babies in the future.” We ex-
plored her worry that she could not have a normal baby—a worry
which, 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 conflicted
feelings about her mother, who had not passed on a normal body to
her.
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 suite
with four other offices. After several months of treatment, I still often
found her roaming the hallway. She seemed momentarily surprised,
even startled at my presence, and then responded by assuming a ca-
sual, distracted demeanor that resolved into a broad smile denying
deeper feeling. As I wondered with her whether she experienced a
274 Silvia M. Bell
she lived with a pervasive fear that she might die. We noted that she
was worried about whether I would or could protect her from harm.
Gradually, the fantasy that I might assault her, which was emerging in
the transference, became amenable to interpretation.
Beccah spoke of the comforting feeling of hearing the sound of
voices from the TV at night; they helped her to feel safe. I had regis-
tered that her memories, which depicted her mother’s unavailability
and her aunt’s helplessness, had triggered a fantasy of assault that
elaborated on her feelings in the waiting room. I said: “Perhaps the
sound of voices from the TV may even feel safer than a voice up
close.” I interpreted that fearing that someone might come through
the window to attack us had something to do with a fear about being
alone with me. She reflected thoughtfully: “I tell you so much. You
could do something that would hurt me.” In the months that fol-
lowed, Beccah explored her confusion about her mother, who
seemed to be in charge of her well-being and yet so helpless to pro-
tect her, and whose interventions she experienced both as life-saving
and as murderous assaults. Her awareness of feeling vulnerable with
me gave us an entry to explore her aggressive feelings. The fantasy of
the intruder who would attack us, was a compromise that included
the projected aspects of her rage at me, the powerful doctor-mother
who, by providing treatment, exacerbated her feelings of being dam-
aged. It was also a harbinger of the deepening paternal transference.
As the treatment progressed, Beccah focused more actively in
sports, and she brought evidence of her success, indeed her stellar
performance, as recognized in newspaper clippings, ribbons, and ci-
tations. We noted, however, that she felt a great pressure to maintain
an “unblemished” record. Every event was a new challenge, as if her
previous success did not serve to ameliorate her blemished self-con-
cept. She reported a worry that “people out there” wanted her to
lose, a projection of her enviousness that also reflected her expecta-
tion of punishment. Winning was of paramount importance, yet
fraught with conflict. Noting her anxiety prior to a particular eques-
trian competition, I wondered if these events recalled her experience
of her cosmetic surgeries, so fraught with promise and risk. The ex-
ploration of her exaggerated sense that so much was riding on the
outcome, led Beccah to recognize that she dreaded failure as evi-
dence “that it was all her fault.” This insight allowed her to connect
with her sadness about needing reconstructive surgery, and to recog-
nize that, although her body had undergone a process of change, her
old feelings of being faulty and at fault remained unchanged. She ex-
pressed anger at her mother who, in contrast to her athletic, aggres-
276 Silvia M. Bell
sive father who “did not see anything wrong with her,” was felt as the
mirror reflecting her defectiveness.
Beccah accessed her conflicted feelings about her father before
she could fully address the complexity of her reactions to her
mother. Her bisexual conflict was openly manifest in this period in
her analysis, as she focused on sports in an effort to identify with her
father and disavow her dangerous, defective femininity. The identifi-
cation with him did not offer lasting comfort, however. She reported
“shouting matches” between them; he was insensitive and didn’t care
about her feelings. “He is an angry person ready for a fight.” Bec-
cah’s wishes for closeness with her father stimulated oedipal conflict
and 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 will
be able to set limits on me.” The identification with his intact image
seemed to bolster a sense of hope about her own strength, also expe-
rienced in her horseback riding, and was a relief from the complex
feelings 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 to
an increase in her nighttime fears. She revealed that she had asked
her mother to sleep with her, as when she was a little girl. In the
course of our exploration of her regressive response to oedipal pres-
sures, she painfully uncovered her confusing feelings toward her
mother. Sometimes she felt reassured of the much-needed mother’s
love and approval. Often, she experienced mother as abandoning,
helpless to create a haven of safety where she would feel protected.
She developed a concern about her mother’s health and well-being.
Her sense of defectiveness seemed to intensify with her fear of her
destructive wishes toward her mother. “How can I be so angry with
my mother when I have been the cause of so much pain?” she
protested, and proceeded to turn against herself as the defective one.
Being the damaged one also defended against the frightening wishes
to surpass her mother by becoming the young woman with the beau-
tiful body who would bear the healthy, porcelain-skin child.
As our work progressed, Beccah’s appearance and demeanor
changed. She began wearing age-appropriate, stylish outfits and
joined the “preppy” crowd. There was a shift in the transference, and
wishes for me as the oedipal father surfaced. She talked about being
glad that I was not a male doctor. “I would worry what he might do to
Healing Function of Psychoanalysis 277
me; there are movies about this.” I commented that thinking about
things that happened in the movies kept her from considering her
thoughts about me, right here. Her fantasy of my sexual feelings to-
ward her, manifested in sadomasochistic wishes, condensed oedipal
components and a developmentally expectable erotic interest in me.
I interpreted that the excitement of thinking about an abusive rela-
tionship between us distracted her from considering other feelings
that surfaced as we worked together. I spoke to her excitement as a
defense against her worry about feeling unloved, if I did not recipro-
cate her interest and longing for me.
In conjunction with the process of object removal, which had been
delayed by conflict, Beccah developed an idealized view of me that
promoted her capacity to relinquish her mother. She became curious
about my interests, my salary, my education, and admired that I had
become my own boss. She imitated me in her manner of dress, 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 a
time when development required that she relinquish mother in or-
der to attain a separate and independent sense of herself as female, I
provided the necessary unblemished female substitute.
Noticing an adult female patient who had left the office, Beccah
pondered whether she used the couch, and asked “to try it.” The
couch was “weird” but, as if it were a test of her readiness to face her
growing up, she was determined to use it. She reacted against the rel-
ative restraining quality of it, as adolescents are prone to do, but I was
aware of her unconscious association to a sick bed, and to her fears of
dying, that led her mostly to sit in the middle of the couch with her
back leaning against the wall. She told me about having set 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, thinking
that we share in that feeling”), while mindful of the defensive aspects
of her remark. She came to one of her appointments dressed like a
hippie and asked whether I had been one, thus revealing her 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 by
the rules.” I wondered with her whether she thought of me in that
way to feel safe from a worry that I might do something surprising
and scary. She said: “It’s a relief.” She mentioned getting a learner’s
permit, 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
278 Silvia M. Bell
about the worry that her menstrual flow would not stop, and of her
fear of dying in sexual intercourse, or in childbirth. Her past history
of defectiveness accentuated the developmentally expectable 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 her
grandmother to take over her body in order to feel safe; becoming a
woman meant giving up that tie to them, and taking charge of her
own 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 reported
that her mother had commented on her progress—“we don’t fight
any more”—but now she was angry with me. I was “weird” and out of
touch with kids her age. She told me that she spoke on the phone
with her boyfriend’s mother every day; “I’ve never met her. I don’t
care what she thinks.” I pointed to the worry about letting her self
tell me more because she might care too much about what I think.
She became more resistant. “I 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’t
want to remember.” Then she told me that there are pictures of her
“back then” all over the house, and upsetting stories from her
mother about how people used to react to her. Letting herself 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 her
mother, wished to ensnare her in the past in order to keep her from
moving forward.
The work in this period gave us further access to the defensive
function of the defective view of her self. Beccah was aware of still
looking at other people’s reactions to her in order to get a clearer
sense of her self, as if what she saw in the mirror was not convincing.
She expressed despair about whether she would ever feel “good
enough.” I ventured that she seemed aware that, no matter what im-
age was reflected back, something was interfering with letting herself
change the old picture in her mind. Maybe being her new, grown up
self felt scary and she kept herself looking back. She brought an 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 face
there,” clearly taking pleasure and pride in her image. I clarified her
ambivalent feelings: “Sometimes you can’t stand looking at yourself,
and sometimes you like what you see.” As if my words had touched on
something that brought up discomfort, she dismissed her pleasure
280 Silvia M. Bell
and remarked: “There’s only one good one.” We were thus able to
observe that expressing to me the feeling that she liked what she saw
had mobilized a need to take the good feeling away.
Beccah developed a relationship with a boy. Her boyfriend was “a
nice guy, but he is adopted.” His adopted status fascinated her; she
saw it as his secret defectiveness. In that sense, he was more defective
than she—her parents had not given her up, she was valuable to
them.
The threat of abandonment and loss, so prominent in her thoughts
about her boyfriend’s history, was also a central aspect in her conflict
about 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 miserable
and sought his constant reassurance. One day she broke out in great
anger at me: “Despite all this work, I still feel so insecure! What good
is this analysis anyway? And how can I trust that you really like me
when you didn’t know me back then?” I said, “You worry that some-
thing about my seeing you back then would change what I feel about
you now.”
Beccah came to her next session carrying the framed pictures of
herself as a child that her mother displayed in the home. She
propped them in front of me, all the while scrutinizing my face. “Can
you understand,” she asked, “why it’s hard for me to make sense of
how 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 childhood
pictures to the office as if reclaiming ownership of her experience. I
understood intuitively at that moment the importance of my role as
trusted observer of her struggle, a struggle she was proclaiming and
was determined to work through, albeit in the context of the analytic
experience that granted me a vital role. She pointed to the many 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 you
that’s not right, or a changed you that makes you acceptable, and
how that makes me feel about you, the 16-year-old girl in front of
me.” “I still 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 displayed
her defects, a gesture no longer masked and distorted by the defen-
sive provocative stance she had displayed in our first meeting. I was
moved 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-
Healing Function of Psychoanalysis 281
tures. But, I was also responding to the strength and courage of the
young person before me. I do not doubt that Beccah was impacted by
the affective tenor of that session, in which I served as witness to her
increasing appreciation and acceptance of her struggle (Poland,
2000). Beccah was now “telling herself.” However, in order to under-
stand the psychic meaning of her action, it is necessary to place it
in the rich context within which it manifested, and consider what
compelled Beccah to bring the pictures to me at this point in her
treatment.
Beccah had been expressing openly her experience of being lov-
able in the context of the growing relationship with a boy. As those
feelings, harbingers of her developing femininity, deepened, the
threat of the loss of the childhood experience with mother mobilized
intense conflict. Testing my response to her as a child at this time, a
move which could be regarded to serve in the interest of acquiring a
new way of “seeing herself with me,” was in effect a maneuver that
put a halt, albeit temporarily, to dangerous developmental wishes to
experience herself as a young woman in my presence. A stormy pe-
riod ensued during which Beccah enacted the sadomasochistic fan-
tasies pertaining to her early relationship with her mother. Fears
about her vulnerability to illness became prominent. She worried
that her immune system “was down,” and that her body could not
fight infection. A simple cold triggered fears that she would not be
able to breathe. She put down our work; talking was not doing any-
thing. I was helpless and ineffectual. Her agitation switched to cool
withdrawal. She came to the office barefoot. “My mother made a
comment, Do you think it’s dangerous to walk around barefoot? I
can decide what to do.” I said that maybe she wanted for me to worry
about the danger, and then she wouldn’t have to worry about her de-
cision. She reported that she had eaten her lunch during her biology
lab. “We were dissecting a rat. The teacher said there was a possibility
of bacterial contamination. If I get sick, I could pass it along.” Like
the rat on the dissecting table, Beccah felt dangerous to herself and
to others. While, on the one hand, she felt that her mother was re-
sponsible for her defectiveness, she also struggled with the fantasy
that 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 own
sense of vulnerability; she was thus enacting with me in the transfer-
ence the sadomasochistic symbiotic fantasy that kept her locked in a
sense of defectiveness.
282 Silvia M. Bell
Discussion
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 and
fantasies that interfere with successful individuation, and can be-
come further structuralized in pathological outcomes, now are
uniquely available for observation. The data from Beccah’s analysis
attests 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 promoted
our exploration of the crippling conflicts that were interfering with
the process of psychic differentiation. Given the mental capacities of
adolescence—the ability to think beyond the concrete aspects of the
present, to consider past, future, and the possible—Beccah was able
to 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 much
exacerbated for Beccah given her past conflicts. The girl’s entry into
adolescence 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 of
early childhood. With the onset of menarche, there is a heightening
of anxiety over the inability to control the body that intensifies the
girl’s neediness of mother’s help with bodily care. These longings
stimulate fears of passive submission to the mother, and reactivate
earlier conflicts about merger with/engulfment by her. Beccah’s ex-
perience of life-death dependency on mother’s ministrations and
protection was reactivated in this phase of development, and it
threatened to keep her locked in a pervasive posture of defectiveness
that defended against separateness. The immediacy of these feelings
in the context of the concomitant drive toward separateness made
the reworking of separation-individuation issues more accessible to
analytic intervention
The girl’s awareness that she is beginning to possess a body like the
mother’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 mother
take over. When the resurgence of sadism is too powerful, the girl
may defensively externalize the sadism onto her mother. Rather than
Healing Function of Psychoanalysis 285
fered from phimosis requiring surgery at age two, detailed how the
perception of the mother as “a vicious attacker, whose longed-for at-
tention and concern could be attained only by suffering and pain
and by relinquishing his penis, absorbed, restructured and organized
a whole range of earlier experiences and conflicts” (p. 217–218).
Beccah’s “affect storms,” which she enacted in her relationships with
others, 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 a
rejected, depressed, and impotent self ” (Kernberg, 2003, p. 520).
However, as Goldberger (1995) points out in her account of the
analysis of a five-year-old-girl who suffered medical trauma, the pic-
ture is more complex. The child who, out of medical necessity, has
experienced painful maternal ministrations, develops an attachment
to being handled in painful ways; in fact, the gratification obtained
from such relationships is “something which is feared, but also looked
to have repeated” (p. 268) so as to prevent object-loss. The analytic
work with Beccah revealed that sadistic fantasies around her early ex-
perience (that her mother caused/wished her trauma; that she dam-
aged her mother through her defectiveness), and conflict (rooted in
oedipal and pre-oedipal wishes wishes that mandated punishment)
interfered with the appropriate restructuring of her internal repre-
sentations, and kept her locked in a regressive posture of being the
defective child. The excitement of her sadomasochistic entangle-
ments, as well as the unconscious connections between health—loss
of mother—abandonment/death, that interfered with the develop-
ment of an adequate view of herself, required careful interpretation
and working through.
Hoffman (2003) comments on the prominent role of aggression in
enactment and defense in the traumatized person, in particular the
predominant use of “identification with the aggressor” and “turning
passive into active.” A posture of “nonchalant bravado” is a charac-
terologic defense in traumatized youngsters, serving to obscure in-
tense object hunger, and passive libidinal object longings, as well as
to ward off expectations of repeated rejection and loss (Steven
Marans, as reported in Mazza, 2003). Goldberger (1995) comments
that the incessant need to repeat the traumatic experience is a hall-
mark behavior of the victimized child. The data from Beccah’s analy-
sis gives evidence of the pervasive nature, and complex function, of
repetition.
Repetition, which is a function we observe in play, provides nor-
mally a much-needed opportunity to re-experience a situation, this
Healing Function of Psychoanalysis 287
time as the active agent rather than helpless victim. This experience
promotes the gradual assimilation and mastery of anxiety. When
trauma is involved, however, the capacity to utilize anxiety as signal
function is impaired. The ego is, once again, overwhelmed and 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 organizing
level which makes resolution of conflict possible” (Moore and Fine,
1990). Hence, one of the functions of the analytic intervention is the
restoration of the 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 of
these 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 the
safety of the analytic situation effects changes in adaptive capacity
that 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 causation
between early factors and later pathology, but to the recovery of af-
fective experiences which, when understood in light of what was
known of “the relevant dimensions” of her childhood (i.e., within a
genetic context), facilitated the capacity to distinguish between “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 states
and to find meaning in one’s own and others’ behavior. Referring to
Fonagy’s concept of “mentalization” (Fonagy et al., 2002), many as-
sert that the major goal of treatment is to facilitate the development
of the capacity to conceptualize and make sense of situations, affect
and behavior. The clinical material elucidates that Beccah’s capacity
for 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 a
resurgence of the traumatizing childhood feelings that accompanied
her many overwhelming experiences pertaining to her medical
needs. The affective impact of these experiences, which were re-
corded at a procedural (i.e., non-verbal) level, were actualized in the
transference as she felt disoriented in my physical space, and she ex-
288 Silvia M. Bell
which represented the affective experience of her early years and her
adaptation to it.
In the course of the analysis, Beccah came to appreciate that she
experienced her developmentally appropriate wishes in a context of
danger that reflected her earlier adaptation to her painful past. We
uncovered that she adhered to a devalued view of herself for 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 that
reworked the heretofore sadomasochistic aspects of her relationship
with her mother, and relinquished the defensive use of defectiveness
that interfered with adolescent development. As a result, her affect,
her behavior, and the quality of her thought processes increasingly
reflected changes indicative of a modification in the constellation of
intrapsychic factors that determines adaptation. By the time 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, when
they were unconscious, threatened to mobilize anxiety” (Gray, 1988,
p. 44). Specifically, Beccah’s attention was directed to the defensive
function of her sense of defectiveness, which could be observed by
her as we noted her tendency to turn to disparaging images of herself
in order to inhibit strivings that felt dangerous. While, as Gray em-
phasizes, profound unconscious changes take place as a result of the
influence 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 aim
that 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 aggression
against 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 intended
to relieve that feeling strengthens the capacity to exercise volitional
control over internal forces (Busch, 1999). For example, when Bec-
cah recognized that her aggressiveness protected her from the worry
about being overwhelmed by fear, she was better able to evaluate her
anxiety and could establish more satisfying relationships with others;
when she realized that she experienced being healthy as a harbinger
of loss, and understood that thoughts of “defectiveness” kept her safe
290 Silvia M. Bell
BIBLIOGRAPHY
295
296 Harold P. Blum
in its second century, psychoanalysis has moved in many new
directions, often with increasing distance from its origins and core
formulations. Psychoanalytic reconstruction has been treated either
with neglect or declining interest as attention has turned to other
psychoanalytic issues and agents of change. Psychoanalysis itself is
not regarded as particularly popular in many parts of the world to-
day, and reconstruction has particularly fallen out of favor as there
has been more immediate attention and emphasis on the here and
now, inside and outside psychoanalysis. Actually, analysts and pa-
tients have pondered the question of where the patient was coming
from, and how he or she got there. It is not only the adopted child
who is curious about his/her origins, but all persons and peoples.
Nations have legends about their origins, which are constructions
compounded of fact and fantasy. Freud (1919, p. 83) asserted: “ana-
lytic work deserves to be recognized as genuine psychoanalysis only
when it has succeeded in removing the amnesia which conceals from
the adult his knowledge of his childhood . . . This cannot be said
among analysts too emphatically or repeated too often . . . anyone
who neglects childhood analysis is bound to fall into the most disas-
trous errors. The emphasis which is laid here upon the importance
of the earliest experiences does not imply any under-estimation of
the influence of later ones.” Extending my previous work on the 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 the
present, but it is a complementary agent which guides and integrates
interpretations and reorganizes and restores the continuity of the
personality.
Reconstruction for Freud was both a technique, a means toward
the goal, and a goal of psychoanalysis. Experience such as the birth
or death of a sibling had an impact on the patient’s life, permanently
influencing the personality. Freud (1937, p. 26) illustrated such a
prototypical reconstruction, “Up to your nth year you regarded your-
self as the sole and unlimited possessor of your mother; then came
another baby and brought you grave disillusionment. Your mother
left you for some time; and even after her reappearance she was
never devoted to you exclusively. Your feelings toward your mother
became ambivalent, your father gained a new importance for you . . .
and so on.”
A genetic interpretation shows that a current symptom, behavior,
thought, feeling, or trait is derived in some way from childhood. It is
Psychoanalytic Reconstruction and Reintegration 297
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 association
and transference. Reconstruction would encompass broader consid-
erations, e.g. of dependent relationships, concurrent parental re-
gression, inability to mourn and accept loss, identification with the
lost object, etc.
Reduction of the transference to its childhood roots and the accu-
mulated analytic data converge in a reconstruction, which in turn
furthers the analytic process. Contrary to the current position in
some analytic quarters, that such genetic data are co-determined by
the 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 of
pathogenesis and the patient’s psychopathology. Although analytic
work requires the reconstruction of childhood (Freud, 1937), this
does not mean that any two reconstructions by two different analysts
will be identical. Each analyst will select, organize, and interpret the
data with some degree of theoretical and personal preference. The
analyst’s countertransference may make it difficult to analyze the
transference, or from another point of view, it may provide further
insight into the patient’s conflicts, the transference, and the patient’s
resistance in the analytic process. The analyst’s analytic attitude, self
analysis, 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 long
been complemented by infant observational research and child
analysis. The reconstruction of childhood takes into account affec-
tive, cognitive, and moral development. Reconstruction considers
the overlap and sequence of developmental phases, and the unique
quality of individual endowment and experience. Because of the 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 reconstructions
rather 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 distortions
and misconceptions is a parody of the psychoanalytic process. A cari-
298 Harold P. Blum
and loyalties, and his guilt toward these women, were major reasons
for his seeking psychoanalysis.
When his girlfriend learned about his “affair” with his former fi-
ancee, she repeatedly told the patient that had hurt her deeply, and
then she broke off all contact with him. Separation reactions acti-
vated in the transference. He was reluctant to leave sessions, and on
Friday would cheerfully state, “have a nice weekend.”
The intrigues in his personal life entered the analytic situation. He
confessed guilt about reading a magazine report about a mass mur-
der in the waiting room. Although he was afraid of getting caught, he
had somehow left the magazine open to that page. He then recalled
that in adolescence he had found his father’s pornographic pictures.
Disgusted, but excited, he masturbated with these pictures. He was so
afraid of being discovered that he replaced them exactly as he found
them. He thought his parents were shameful hypocrites. When he
had asked for the analyst’s card, he was unconsciously referring to his
father’s pornography, wondering if the analyst were trustworthy or a
lascivious hypocrite.
This led to feelings about morality and specifically religion. He
wondered if the analyst were Jewish. He had grown up in an anti-
Semitic milieu with contempt of Jews. In a Catholic college he had
told a fellow that he had no use for any Jews and this person de-
clared, “I’m Jewish.” The patient was stunned and mortified. In his
view, though weaklings, Jews could be ruthless and they did the dirty
work (like servants). Later he began to examine the many stereo-
types of his childhood. He was unconsciously afraid that the possibly
Jewish psychoanalyst would encourage immoral thoughts and acts.
On the couch he was vulnerable; he felt feminine and was 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 and
was sexually aroused. His adolescence was burdened by guilt and
fears of punishment.
At this point the analyst could reconstruct the patient’s reactivated
primal scene fantasy and sibling experience during his childhood
and adolescence, which reflected in all his current relationships. He
had slept in the same room as a sister until puberty, undressing to-
gether. His removal from their bedroom at puberty convinced him of
his sinfulness and motivated his urge to confession in church and
later in analysis. His masturbation while looking at the parental
pornography was unconsciously incestuous, and he was fearful of the
302 Harold P. Blum
guage and dress. He identified with his parents of the servant class
and also with the aristocratic parents. He had not been aware of his
dual identifications, languages, and ambivalent attachments. He had
lived in two worlds which were dissociated; ego integration was 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 been
rich, and what a better life he would have if he were the son or
adopted son of the nobility. Yet his identification with the cultivated,
educated, refined aristocrats proved to be a very important factor in
the patient seeking higher education and developing many cultural
interests. He displayed the superficial accoutrements of affluence,
and elegance but he knew that deep inside he had a servant mental-
ity. Secrecy had also referred to the social devaluation of servants,
which he regarded with shame and humiliation. Moreover, servants
knew some of their employers’ secrets, and could know too much.
Acting servile and submissive was unconsciously associated with be-
ing feminine, with being Jewish. Anything that reminded him, or was
suggestive of being submissive or subjugated, enraged and fright-
ened the patient. He transiently thought of quitting analysis rather
than lying compliantly on the couch. He needed to be clean and
neat, not only because of his guilt, but because of the dirty work of
his parents. His father had done manual labor, and his mother 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 not
only 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 humble
and humiliated.
A flood of painful memories returned, integrated in the recon-
struction of the patient’s childhood as the son of servants. The
wealthy estate owners had referred to his parents by their first names
or without a name. The patient saw this as a lack of respect, treating
his belittled parents as if they were children. He thought that one of
the reasons they worked on different estates was that his parents had
been summarily dismissed from some of their jobs. Apparently some
of the estates were owned by descendents of the “Robber Barons,” in-
fluential individuals who inherited great wealth from the financial
manipulations of their forebears. The estate owners, partially through
projection, feared that their servants would engage in theft. The pa-
304 Harold P. Blum
have been just as well able to understand and explain the latter. The
synthesis is thus not so satisfactory as the analysis. (p. 167)
educators. There were few if any parties in his childhood, and holi-
days were not celebrated. He had never had a birthday party, though
the patient was aware that the aristocrat’s children on the estate had
such 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 little
interested in their children’s feelings. If he did not like the food he
was offered, he was expected to eat it without complaint, so that his
preferences were largely ignored. In later childhood he was painfully
ashamed of his parents and strenuously defended against feelings of
shame. His parents conveyed their feelings of denigration to their
son, but they and the aristocrats encouraged both his later achieve-
ment and entitlement.
Transference analysis and reconstruction were synergistic rather
than competitive or adversarial. The reconstruction was regarded as
mutative, “making a decisive difference in clinical analysis . . . the
past within the present is transformed forging a new vision of reality”
(Blum, 1994, p. 150). In the process of reconstruction, self-represen-
tations as well as object representations from various phases of life
are 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 affective
processes. What the patient cannot remember and articulate has to
be laboriously reconstructed. Somatization reactions and non-verbal
communication may be at least initially of great importance. 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 the
feelings of helplessness, and of the void of protecting or rescuing ob-
jects (Grubrich-Simitis, 1981; Krystal, 1991; Blum, 1994). An attempt
is made to clarify the details of the traumatic situations, and when
necessary, to uncover the intergenerational transmission of trauma,
with analytic awareness of inevitable unknowns and ambiguities.
Only then can traumatic reality and its fantasy elaboration be 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-
308 Harold P. Blum
constructed, to belong to the past rather than the ever present. Fur-
ther analytic reconstruction may encompass prior and subsequent
traumatic experience, telescoped into the maelstrom of massive
trauma.
I shall now turn to the early facilitating value and integrative
effects of reconstruction psychoanalysis and in insight oriented psy-
choanalytic psychotherapy. While it is true that reconstruction is not
necessarily a part of psychotherapy as it is in psychoanalysis, recon-
struction is often utilized to help the patient become aware of the
power and persistence of childhood fantasy and experience into
their adult lives. Transference and current reality may take prece-
dence, but at the same time, reconstruction may be necessary to illu-
minate the transference and the current reality situation, which the
patient 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 are
irrational and unjustified. The psychoanalyst regards the patient’s
criticism as part of transference fantasy, whereas the patient believes
that the analyst truly merits criticism. The analyst has a negative
counter-transference, about which he is inwardly conflicted. The 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 to
the patient. This is a departure from the general use of reconstruc-
tion after the initial phase of therapy. The exception here is not
meant to detract from Freud’s (1940) counsel, “we never fail to make
a distinction between our knowledge and his knowledge. We avoid
telling him at once things we have often discovered at an early stage,
and we avoid telling him the whole of what we think we have discov-
ered. We reflect carefully over when we shall impart the knowledge
of 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 of
mistreatment derived not from the present, but predominantly from
the past with his parent. The patient has identified with the aggressor
and was treating the therapist to the same disparagement to which he
was subjected. The patient had become the critical parent and the
Psychoanalytic Reconstruction and Reintegration 309
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 reconstruction
or interpretation. Psychoanalysis requires tolerance and evaluation
of alternative considerations. Ambiguity and perplexity are part of
psychoanalytic work and the quest for greater insight. In addition to
Freud’s (1911) two principles of mental function, the pleasure and
reality principles, we live and work with the uncertainty principle
(Heisenberg, 1958).
BIBLIOGRAPHY
1. Emde (1995) notes, “It is only very recently that our contemporary behavioral
sciences have become aware that a future orientation in our psychology has been
grossly neglected in the twentieth century. A multitude of studies have been done
concerning the influence of present and past events on behavior, but we have ne-
glected the influence of the future.”
314 Cornelis Heijn
2. Robert Gardner’s phrase suggests psychic events that one may easily attend to or
not. This often depends on delicate circumstances of the moment, such as the state of
the therapeutic alliance or the tactfulness of the 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.
On Foresight 315
seems a good example of our concerns about the future as well as the
use of tools we would think of as belonging to the primary process:
images, symbolization, condensation, displacement. Images carry af-
fect in a way that other symbols cannot do.4
You will probably have imagined by now that I have been trying to
suggest some of the ways that images and primary process modes of
thought may be important in how we process information con-
sciously and unconsciously. The emergence of images and primary
process in regression of thought and for purposes of disguise has
been emphasized and well developed in analytic thought, but this
may be only an aspect of their importance. Perhaps a way to welcome
primary process mechanisms that is more comprehensive and less
tentative than “regression in the service of the ego” would extend
our reach as analysts.
In Keats, Frost, Emily Dickinson, Shakespeare we repeatedly feel
the search for the eternal moment, the timelessness of the primary
process, in the continually perishing beauty of the world. Paul 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 person
would 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 of
the truth it finds seems to include some concern to help us bear the
unbearable aspect of the future. As poetry leaps into what is timeless
it includes essences of past, present, and future. “The Wasteland,” by
T. S. Eliot had a profound impact not only as a statement of the pre-
sent day but of ominous trends leading into the future.
4. Pinchas Noy has written about the need to concretize in order to carry affect.
The intellectualization of the obsessional bores us because of its distance from the
moment of real experience.
318 Cornelis Heijn
But man’s little foresight will initiate a project which at the start
seems good, but it does not notice the poison that is underlying
it: . . .
And so whoever does not recognize evils when they arise in a 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, and
his awareness that greed and power would be avidly sought unless
contained, along with intensive study of the various structures of gov-
ernment that attempt to channel such motives, enabled him more
than anyone to see the long-range implications of the various plans
put forward at the Convention.
Early in his career Napoleon had shown a high degree of foresight.
Later, in the Russian campaign, when his army of 433,000 was de-
stroyed and only 10,000 half-frozen and starving men escaped, we see
many examples of the deterioration of this faculty, of valuable fore-
sight ignored or rejected, and of foresight used to ultimate victory by
the opposing General Kutuzov. This is described in the remarkable
journal of General Caulaincourt, one of Napoleon’s closest aides.
Once he had an idea implanted in his head, the Emperor was carried
away by his own illusion. He cherished it, caressed it, became 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, than
the reasoned judgment of the Emperor on certain questions. (Cau-
laincourt 1935, p. 28)
hubris that may flower with success. Its loss was revealed in many ways
in the months to come.
. . . the Emperor could not or would not show a trace of foresight.
There is no doubt that we should have preserved much more un-
damaged if we had made the necessary sacrifices in time. But to two
or three unfortunate horses we allotted guns and waggons that
needed six, and by not abandoning one or two guns and waggons at
the proper time, we lost four or five a few days later. We planned for
the day only; and because we refused, as the saying is, to give the devil
his due, we paid heavily in the end to the enemy. (Caulaincourt,
p. 208)
Although the focus of this paper is the concept and process of fore-
sight, Napoleon’s campaigns suggest another subject of importance,
that of the factors that influence its adaptational use. In one of her
last books, The March of Folly, Barbara Tuchman describes how great
events are often determined by people who cling, through vanity or
what she calls “wooden-headedness,” to plans seen by others at the
time to be unworkable. Britain’s loss of the American Colonies, the
intransigence and corruption of the Renaissance Popes that led to
the Reformation, the Vietnam war, the Japanese attack on Pearl Har-
bor, which someone described as “destined only to awaken a sleeping
giant,” 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 world
moving mindlessly toward great dangers.5
Toynbee emphasizes the need for a currently felt challenge to
evoke creative response. Apparently he feels our imagination mostly
slumbers when long-range adaptation is concerned, and this con-
tributes to the rise and fall of civilizations.
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 and
ever increasing private profit, with little consideration of long range consequences to
a finite and fragile world. So we see the problems of global warming, environmental
destruction, genetic engineering, rapid transmission of world diseases, enormous 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 method
to highly complex interdependent systems in which small changes may have massive
but often slowly developing effects. Yet in idealizing science we have also given up
much of our reliance upon expert experience, and upon the foresight of wisdom.
Thus we run great dangers with calmness.
320 Cornelis Heijn
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 the
viewpoint 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 and
communicate this vision of the patient’s future, how we come to see
the potentials of character, of intellect and feeling, and nourish them
while respecting their freedom, and how we responsibly imagine a
small kernel of talent blossoming with maturity.6 It would take con-
siderable artistry to provide examples because such interactions are
subtle 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 the
light of our assessment of that great unknown.
In addition, much remains to be learned about the functional
properties of the image, the major medium of the primary process. It
may be useful to consider more deeply the role of the primary pro-
cess in addition to that of disguise and defensive regression. It seems
likely that these three issues, the future, the function of the image in
thought, and the primary process, are all related.
The Form That Foresight Takes in Conscious Life
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 the
imagination is a higher power than reason (as the Romantics said), and every higher
power includes the lower power, then reason cannot express its comprehension of
the imaginative power. He quotes Coleridge, “They and they only can acquire the
philosophic imagination, the sacred power of self-intuition, who within themselves
can interpret and understand the symbol, that the wings of the air-sylph are forming
within the skin of the caterpillar: those only who feel in their own spirits the same in-
stinct which impel the chrysalis of the horned-fly to leave room in its involucrum for
antennae yet to come. They know and feel, that the potential works in them, even as
the actual works on them.” (Engell 1981, pp. 346 – 47)
322 Cornelis Heijn
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 and
feeling many variables that differ in weight and quality, to have easy
access to different contexts, and to weigh facts that are constantly
changing. What form may this take? As with so many human issues,
Shakespeare provides a rich example. In Richard II, the King has 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 it
might take.
Lord Bushy urges her to “lay aside life-harming heaviness.”
Queen: “I cannot do it, yet I know no cause
Why I should welcome such a guest as grief, . . .”
Some unborn sorrow, ripe in fortune’s womb,
Is coming towards me; and my inward soul
With nothing trembles; at something it grieves.”
After some time news comes that the exiled Lord Bolingbroke has
landed with an army and the other Lords are flocking to him. The
King’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 enmity
With cozening hope, he is a flatterer,
A parasite, a keeper back of death.” (Shakespeare, p. 44)
The Queen is feeling disaster ahead without being able to name
specific causes or outcome. Her realism, refusal to accept false hope,
her trust in her own feelings without elaborating them into specific
fantasied disasters as a paranoid person would do so exuberantly, all
seem noteworthy. Her character seems comparable to that of Oedi-
pus or Hamlet in its requirement that she see the world without illu-
sions. She is sensing tendencies, directions that are probably in their
essence if not predictable in their particulars, in a complex situation,
at some level of thinking that is not logical in a way we could describe
but that has validity even as it is nourished in unknown ways. Some
7. The Yale Shakespeare Edition of The Tragedy of King Richard the Second, edited by
Robert T. Petersson, explains that prodigy as used here means “monster.”
On Foresight 323
people would call it intuition but that tells us little about the 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 at
times, aware of its power, skeptical of its reliability. We are sometimes
glad in our uncertainty to defer to someone else, and astrologers, or-
acles, psychics, pundits, ‘authorities’ of all stripe abound and play
upon the irreducible doubt that is realistically part of such an assess-
ment.8 We also yearn to dismiss such ominous intimations as the
Queen describes, or to welcome hopes unreasonably when they are
pleasant, and are helped in both directions by well-meaning friends.
Perhaps we trust such ‘thinking’ less in our scientific age, when con-
scious reasoning is valued most highly, and some incline to believe
that everything should either be certain and scientifically proven or
not entertained at all.
Serious consideration of such thinking must ultimately involve
some wager of faith, yet it is not blind faith, but faith in our reality
sense and judgment. We can never remove all doubt, however, since
we are often led astray by hopes and fears, hubris or timidity, and
since contingencies that impinge on future events can never be 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 may
emerge. Perhaps our level of comfort is changing, or we become
aware that a determined clock-watcher hasn’t mentioned time for
several weeks, and realize that the middle phase is upon us with all its
increased trust and greater terrors, or we notice that a patient occa-
sionally talks about how things were earlier in analysis, using the past
tense, and sense that the sadness and rebuke of termination is soon
to come. These changes in analysis, small in all but significance, are
like the snow-drop, the first tiny flower of late winter, coming up of-
8. American analysis has a long history of concern with what is referred to as “wild
analysis,” and the ready association of “foresight” with unscientific modes of thought
may have contributed to the lack of attention to this subject.
On Foresight
CORNELIS HEIJN, M.D.
Examples of our interest in the future are drawn from poetry, religion,
general medicine, and from the aims of psychoanalysis. The concept of
foresight is taken as a focus for questions regarding the relative inat-
tention to a psychology of the future in psychoanalytic thought. This
inquiry leads to consideration of the varying constraints and poten-
tials that are determined by the formal properties of verbal language
and mental images, which are briefly compared and contrasted in re-
gard to their usefulness in understanding complex dynamic systems
such as psychoanalysis. The paper concludes with questions regarding
the qualities of conscious and unconscious, and secondary and pri-
mary process thought, and with comments on technique.
312
324 Cornelis Heijn
ten unnoticed through the snow itself, the harbinger of spring long
before the great explosion of life in May. I find that I noticed these
subtle changes more explicitly when hearing about a case in supervi-
sion than when involved as analyst, but I must have been potentially
aware of them then as well, and were there time again would want to
cultivate this delicate function of the “analyzing instrument.”9
These intimations may be compared with creative activity in other
fields such as painting, poetry, or scientific discovery. All involve the
arrival of new meaning before it is obvious and forced upon us. Ger-
man Expressionist painting, for example, seems to embody forces
and 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 loneliness
that makes his suicide seem understandable if not predictable.10
A few scientists have recognized the limitations of the scientific
method, which at least apparently is dominated by the secondary
process, for the study of complex dynamic living systems.
convenient characteristics of physical nature bring it about that vast
ranges of phenomena can be satisfactorily handled by linear alge-
braic or differential equations, often involving only one or two de-
pendent variables; they also make the handling safe in the sense that
small errors are unlikely to propagate, go wild and prove disastrous.
Animate nature, on the other hand, presents highly complex and
highly coupled systems—these are, in fact, dominant characteristics
of what we call organisms. It takes a lot of variables to describe a man,
or, for that matter, a virus; and you cannot often study these variables
two at a time. Animate nature also exhibits very confusing instabili-
ties, as students of history or the stock market, or genetics are well
aware. (Weaver 1955, p. 1256)
(He might have included psychoanalysis as an example of highly
complex, highly coupled systems.)
9. Often the conscious insight comes as the patient is leaving. How often have I
wished to call a patient back when the meaning of an hour suddenly crystallizes. I saw
this as a failure of my listening, now I see it more as a change in the state of the “ana-
lyzing instrument.” There is much evidence to suggest that creative insights often
come during a transitional state between involvement and detachment. We analysts
have “wax in the third ear” much of the time.
10. A friend has observed that the roads in Van Gogh’s painting, which I saw as
leading nowhere, could also be seen as leading anywhere and everywhere. We need
always to weigh the subjectivity of our judgments in such matters.
On Foresight 325
11. If one considers the essence of science not only as it is embodies in the scientific
method, but in the scientific conscience, with the ideal of putting aside wishes, fears,
and pride in the search for truth, psychoanalysts systematically cultivate this scientific
ideal, with more or less effect, in the analysis of counter-transference.
326 Cornelis Heijn
12. A valuable study of the limitations of words in grasping reality, in reflecting our
inner thought processes, and in communicating with others, is found in the book by
Ben-Ami Scharfstein (1993).
On Foresight 327
The Study of Mental Imagery
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.
328 Cornelis Heijn
the latent content, which the manifest content was, according to this
theory, structured to conceal. The value of these mechanisms for
other purposes has rarely been explored, and sometimes disavowed.
Greenberg and Pearlman, using as an example information from
the Freud-Fleiss letters about the Irma dream, show that Freud was
wrestling with the same issues in the manifest as in the latent content
without recognizing that fact himself. They conclude that the “dis-
tinction between manifest and latent in the formation of dreams
should be reconsidered” and “the concepts of dream censor and of
drive discharge no longer seem necessary to our understanding of
dream formation.” An implication seems to be that the image is a dif-
ferent way of placing our concerns before the mind but that the
function of disguise is overdrawn (Greenberg and Pearlman 1978).
The analytic literature emphasizes the primacy of conscious thought
as a prerequisite to insight. (I am assuming a relationship between
foresight and insight, an aspect of foresight being insight into hypo-
thetical situations cast into the future.) Freud writes:
It is misleading to say that dreams are concerned with the tasks of life
before us or seek to find a solution for the problems of our daily
work. Useful work of this sort is as remote from dreams as is any in-
tention of conveying information to another person. When a dream
deals 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 completely
different from it qualitatively and for that reason not comparable
with it. It does not think, calculate or judge in anyway at all; it re-
stricts itself to giving things a new form. (Freud 1931)
Many still accept this sharp parceling out of our mental functions as
in this statement by Edward Joseph in his Presidential Plenary 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 was
impressive” (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 and
perplexed 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.
On Foresight 329
would make a great clatter and wake him up while the hallucination
was still vivid.
Our thought when expressed in words is more open to our exami-
nation than is our thinking in images. How often do we inquire
about the formal qualities of dreams, their skill and accuracy? Per-
haps some of us dream with the fidelity of Vermeer, others with the
skill of a Sunday painter.
Books by Arthur Koestler and Harold Rugg outline steps in the 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 turning
away from the problem, and at an unpredictable point what Rugg
calls a “flash of insight” and Koestler the “Eureka phenomenon” en-
sues, usually during some not fully alert focused state, one that Rugg
calls “trans-liminal.” 14 While 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 accompany
awareness of time. When our experience is connected to primary
process we feel no past or future in the same reflective sense, and
people long gone may appear as they were. We dwell then outside of
time or, as Loewald says, in eternity, the absence of time. Remote as-
pects from the full granary of related past experience may enter the
present.
The potentials of having at our aid all the related experience of
our lives, fresh and vital in the immediate moment, to be felt and
worked with in a plastic medium capable of an infinite variety of
shades, forms, and intensities, all with deep involvement but without
the distraction of troubling feelings of loss, disappointment, ambi-
tion, or the limitations of time, such as we feel when awake, would
seem 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-
14. This immediacy of insight may have contributed to the belief that some people
of genius seem to work effortlessly. In fact, while talent is needed, hard work and
much preparation are essential preparation for creative work.
On Foresight 331
15. The concept of analyst as assistant-analyst to the patient originated with Robert
Gardner.
On Foresight 333
BIBLIOGRAPHY
Abandonment, 266, 269, 274 –276, 280 – sions, 136, 142, 144, 145 –146; Sean (case
282, 286 study), 148 –149
Abusive behavior, 269 –270, 272, 302 Aversion movements, 14–15, 135, 284
Adolescents. See also Latency development:
attitudes toward therapy, 164 –165, 169 – Balint, E., 60
171, 173; cognitive remediation, 239 – Bateman, A. W., 77
260; latency development, 179 –180; Beebe, B., 14, 17
neurocognitive problems, 239 –241; psy- Behavior observations. See also Facial ex-
chic trauma, 263 –290; relational trauma, pressions: body orientation, 135 –136;
251 gaze, 13–14, 135; head orientation, 14–
Adult Attachment Interview, 104 15; video microanalysis, 13–23, 40–41,
Adult narratives, 119 135 –137, 142–152; vocalizations, 16–18,
Aggressiveness: as defense mechanism, 23, 26, 30–31, 36, 39
263, 266 –267, 269 –272, 275 –276, 281– Beiser, H., 158 –159
283, 286, 288 –290; latency development, Bender-Gestalt, 182
179, 188, 190 –192, 194, 196 –198, 201– Bergman, A., 9
202; Natalie (case study), 246 –250, 253 – Bi-directional regulation, 11
254 Birth defects, effect of, 266 –268, 272–273,
Ainsworth, M., 16 278 –280, 289 –290
Alcoholism, 110 –111 Black holes, 107, 119
Ames, L., 183, 195, 205 Blatt, S., 182
Analytic third, 215 Blos, P., 180, 195, 205, 283 –284
Anger management, 201–202, 227, 231– Blum, H., 264, 287
232, 267–269. See also Aggressiveness Body awareness, 93–97, 267, 271–272,
Animal Farm (Orwell), 250 –251 278 –279, 284 –285
Anna Freud Centre, 50, 161 Body orientation, 135 –136
Anthropomorphism, 184, 190, 195–196 Bornstein, B., 180
Anxiety. See also Death anxiety: Andy (case Boston Change Process Study Group, 259
study), 232; as defense mechanism, 263, Boundaries, 136 –137, 142, 143, 145
266 –267, 269 –275, 287–290; latency de- Brazelton, T. B., 13
velopment, 188 –194, 196; maternal dis- Bromberg, P., 215
tress, 8, 18; relational trauma, 49 – 50; Broucek, F., 219
Sean (case study), 138 –139; separation- Burke, W., 182
individuation, 282–284 Buxbaum, E., 199
Attachment theory: frightened/disorga-
nized attachment, 102–108, 120 –124; la- Case studies: Andy, 221–233; Beccah, 265 –
tency development, 178 –207; maternal 290; Cecil, 24– 34; Ethan, 52–70; Iliana,
love, 48–49; parent-infant interactions, 91– 97; Little Hans, 157–158; Mary and
16–20; Strange Situation attachment John, 108 –124; Mia, 85– 91; Natalie,
test, 16, 90– 91, 103 –104, 137 242–258; Nicole, 34– 40; Sean, 138 –152
Attention deficit hyperactivity disorder Caulaincourt, A., 318 – 319
(ADHD), 222, 223 Center for Early Relationship Support, 108
Austen, J., 320 Chase and dodge behavior, 14, 26, 33, 40
Autobiographical memory, 298 Chess, S., 3
Autonomy: consolidation process, 205; la- Child Analysis with Anna Freud, A (Heller),
tency development, 178 –207; play ses- 160
335
336 Index
Fragmentation, 184 –187, 189, 191–192, Interpersonal connections, 136, 142, 143,
195, 200, 205 –206 144 –145
Fraiberg, S., 4, 50, 78–80 Intersubjective exchanges, 215 –219, 229 –
Freedman, S., 180 230, 235
Freud, A.: attitudes toward therapy, 163– Intuition, 322– 323
164; fantasy formation, 203; and Heller, Irma dream, 328
P., 160; infant psychoanalysis, 3, 9, 48; la- Isolation, 193 –194, 204, 226, 232, 246, 269
tency development, 179, 180, 203; par-
ent-infant interactions, 217, 218 Jaffe, J., 17
Freud, S.: ego, 78; imagery symbolism, James, W., 327
327–328; latency development, 178 – Jasnow, M., 17
179; prediction difficulties, 314; recon- Jewish Family and Children’s Service, 108
struction process, 296 –297, 299, 305 – Joseph, E., 328
306, 308 – 311; repetitive activities, 241; Jurist, E. See Fonagy, P.
repression barrier, 157–158, 305; state of
playing, 214 –215, 242 Kantrowitz, J. L., 182
Friedman, G., 182 Kennan, G., 320
Frightened caregiving, 102–108, 113 –117. Kennedy, H., 285 –286. See also Sandler, J.
See also Fear Kernberg, P., 9
Future, influence of, 312– 332 King, S., 203 –204
Klein, M., 9, 159
Gaze, 13–14, 135 Klopfer, B., 182
Genuine maternal love, 47–71 Koch, E., 158
Gergely, G., 219 –220. See also Fonagy, P. Koestler, A., 330
Gianino, A., 120 Kohlberg, L., 179 –180
Gilligan, C., 202 Kohut, H., 180, 200
Goldberger, M., 286 Kozlowski, B., 13
Gorlitz, P., 182 Krauss, R., 255 –256
Green, A., 49 Kutuzov, M., 318
Greenberg, R., 328
Greenspan, S., 181 Language usage: dyslexia, 244 –245, 252–
254; learning disabled children, 239 –
“Harry Potter” stories (Rowling), 203 241; play sessions, 137, 142, 144, 145; re-
Head orientation, 14–15 lational trauma, 251–254
Heller, P., 160 Latency development, 178 –207
Helpless caregiving. See Frightened care- Laub, D., 285
giving Laufer, M., 173
Hesse, E., 104 Lausanne Triadic Play Model, 135 –136
Hoffman, L., 286 Learning disabled children, 239 –260
“Hole Is to Dig, A” (Krauss and Sendak), 255 Ledwith, N., 183, 185
Home-based mother-infant psychotherapy, Lee, S., 285
101–124 Lewin, B., 234
Homer, T., 201 Lewis, M., 260
Home visits, 79–82 Little Hans, 157–158
House-Tree-Person Drawings, 182 Loewald, H. W., 201, 287, 313, 320 – 321,
Hume, D., 327 330
Hypersensitivity, 53– 54 Longitudinal study of latency develop-
ment: analytical discussion, 198 –201;
Images, impact of, 316 –317, 326 – 331 anger management, 201–202; back-
Imaginary play. See Fantasy formation; ground information, 178 –181; early la-
Make-believe; Play tency, 186 –190; gender differences,
Improvisation, 117–118 186 –207; late latency, 195 –198, 205 –
Interactive regulation, 11, 19, 56 206; methodology, 181–186; middle la-
Internalization, 159, 267, 274, 285, 287– tency, 190 –194; results, 186 –198; time-
288 line, 206 –207
338 Index
Play: lack of play, 221–233; learning dis- Sadomasochism, 269 –270, 277, 281, 284 –
abled children, 239 –241, 258 –260; ob- 286, 289
ject relationships, 255 –256; regulation Safety issues, 274 –275, 285
patterns, 257–258; state of playing, 213 – Sander, L., 200, 217
236; therapeutic value, 233 –236, 241– Sandler, J., 172–173
242, 258 –260 Sarnoff, C., 180, 203
Play sessions, 133 –137, 139 –141 Schafer, R., 183
Poetry, 315, 316 – 317 Scientific method, 324 – 325, 329
Preadolescence, 195 –198, 202, 205 –206 Scoring systems, 182–183
Primary process thought, 314, 316 – 317, Secondary process thought, 314 –315, 324,
330, 332 329 –330, 332
Prince, The (Machiavelli), 317– 318 Self-esteem: dyslexia, 253; latency develop-
Provence, S., 4 ment, 193, 194, 202, 204; parents, 40; re-
Psychic trauma, 76 –77, 263 –290, 298 – 311 construction process, 300
Psychological testing, 181, 182–185, 244 – Selflessness, 48
246 Self-other differentiation, 218 –220, 263 –
Puberty, 195, 197, 206 265, 271, 285 –286, 288
Self-regulation: aggressiveness, 266, 271;
Rangell, L., 328 Cecil (case study), 24– 34; challenging
Rappaport, D., 255 behaviors, 145 –147; frightened/disorga-
Reconstruction process, 295 – 311 nized attachment, 105; importance, 11–
Reflective awareness function: frightened/ 12; Mia (case study), 89–90; parent-in-
disorganized attachment, 105; Iliana fant interactions, 19–20, 24– 34, 55– 56,
(case study), 95–98; Mary and John 135 –136; psychic trauma, 287; self-other
(case study), 119; Mia (case study), 87– differentiation, 217–220; state of play-
90; Minding the Baby program, 81– 85; ing, 257–258; traditional evaluation pro-
parent-infant interactions, 76 –77; psy- cess, 132
chic trauma, 76–77; state of playing, 216, Sendak, M., 255 –256
218, 225 Separation-individuation: adolescence,
Regression, 179, 215, 254, 269, 282, 283 – 277; aggressiveness, 282–284, 288; Ethan
286 (case study), 61– 64, 70; gender differ-
Rejection, 266 –267, 274. See also Abandon- ences, 186 –207; latency development,
ment 180 –183, 186 –207; parent-infant inter-
Relational trauma: Beccah (case study), actions, 218 –220
270; Ethan (case study), 59– 60; Iliana Sexuality: Beccah (case study), 267, 269 –
(case study), 91–97; Mary and John 270, 272, 276 –279, 284 –285; as defense
(case study), 110 –123; Natalie (case mechanism, 269 –270; fantasy formation,
study), 242–244, 249, 251, 253 –254; 284 –285, 288; latency development, 179,
parent-infant interactions, 48 – 49, 51, 194, 196 –198; Natalie (case study), 247–
76–81, 104 –105 250, 253 –254
Reparation, 66–68, 120 Shakespeare, W., 322
Repetitive behavior, 269, 272, 286 –287 Shapiro, T., 180, 217
Representational/behavioral domains, 112 Shepard, B. See Malatesta, C.
Repressed memories. See Reconstruction Solnit, A., 4
process Space/time organization, 136, 142, 143,
Repression barrier, 158 145
Richard II (Shakespeare), 322 Stern, D., 14, 112, 200, 218
Ricoeur, P., 317, 326 Stevens, W., 326
Ritvo, S., 159 Stranger-infant interactions, 20–21, 26–27,
Rizzuto, A., 235 30 – 31
Rodell, J. See Ames, L. Strange Situation attachment test, 16, 90–
Rorschach tests, 182–190, 192–197, 205, 91, 103 –104, 137
245 –246 Study of Images, The (Stevens), 326
Rowling, J. K., 203 Suicide. See Death anxiety
Rugg, H., 330 Sullivan, H., 180
340 Index