How Developmental Studies are Informing Clinical Work with Adults
Written by listed counsellor/psychotherapist: Paul Renn
4th November, 20090 Comments
Using infant observation to inform clinical work brings to life the links between child development and developmental work with adults. This issue is particularly relevant, given the high incidence of unresolved childhood trauma in the form of neglect, loss and abuse in those who seek out therapy. Of particular interest is the way in which mutual or bi-directional patterns of influence on a micro-behavioural level communicate and regulate affect, both in the mother-child dyad and the therapist-client relationship.
The clinical issue of emotion regulation is of central importance, reflecting the problem frequently experienced by clients in regulating their feelings and self-states at moments of intense interpersonal stress. The developmental failure of affect regulation is commonly seen in clients with unresolved trauma. These commonalities may be seen in the personal histories of clients, particularly in those who act out their distress in destructive and self-destructive ways. Before discussing the links between infant research/developmental studies and adult psychotherapy, I outline the theoretical framework that may be used to inform the observation of infants. The common thread running through the approaches under discussion is the theoretical assumption that human development is inherently interactional.
Theoretical Paradigm Informing Observations
Bowlby developed the idea that social as well as intra-psychic behaviour could be instinctive, arguing that the child becomes attached to the person with whom most interactions are carried out. He therefore suggested that human relationships may be the subject of empirical observation. Bowlby’s basic hypothesis, and that underpinning the development of attachment theory, is that the baby has a primary need to form an emotional bond with the mother, or, in the absence of the mother, with the main caregiver (Bowlby, 1958). His clinical experience led him to propose that when deprived of this relationship through separation and loss, the resultant fear, anxiety and distress have deleterious and long-lasting effects on the infant’s overall physical and psychological development. For Bowlby, attachment is a basic biological need and separation anxiety a purely instinctive reaction to an external danger that activates a distinct behavioural system (Bowlby, 1998).
Bowlby (1997) sets out his position by quoting approvingly the philosophical view of mind expounded by Hampshire. The latter asserts that “patterns of behaviour in infancy … must be the original endowment from which the purely mental states develop” (Hampshire, 1962, quoted in Bowlby, 1997, p.6). Moreover, Bowlby (1997) emphasised the fact that Freud’s views on the causes of psychopathology consistently centre on the concept of trauma. The influence of object relations theory is also acknowledged by Bowlby (1997), who states that attachment theory is a derivative of this approach. He was particularly influenced by Fairbairn’s account of the way in which the infant’s actual experiences with people structure his or her internal world of object relations.
For Fairbairn (1996), feelings of security vitally influence the manner by which the infant affectively relates to internalized split off idealized objects and rejecting objects. Furthermore, Fairbairn (1996) views insecurity as stemming primarily from separation anxiety. He argues that this type of anxiety is a causative factor in the development of “schizoid” aspects of personality, engendering a sense of futility and hopelessness. Such a person, he contends, lacks the capacity to differentiate self from other and thus is unable to attain a state of mature dependence.
Relations with objects is also central to Mahler’s theory of the way in which the infant’s inner world is organized. From an ego psychology approach, Mahler and her colleagues (1985) hypothesize that the infant’s initial experience is one of symbiotic attachment to the mother. This is followed by a gradual build up of an integrated inner mental representation of the mother and the self through progressive steps in the development of relations with objects. Mahler et al. (1985) conceptualize this developmental progression in terms of a process of separation-individuation. This process has two distinct but intertwining aspects. Separation refers to the process whereby the infant gradually forms an intra-psychic self-representation distinct and separate from the mental representation of the mother, individuation refers to the infant’s attempts to form a unique individual identity.
On discussing the first sub-phase of the process of separation-individuation, Mahler et al. (1985) describe the way in which the infant gradually disengages from the mother. This aspect of the process is depicted as one of “hatching” or “differentiation”. Mahler and her colleagues (1985) emphasise that successful disengagement is dependent on the quality of mother-child interaction. Their observations show that the process of separation-individuation is forestalled when the mother keeps the infant in a dependent position so as to meet her own symbiotic needs, or, alternatively, pushes the infant precipitously into autonomy.
The second sub-phase of the separation-individuation process is termed “practicing”. By this stage of development the infant has sufficient motility, short of upright independent steps, to explore his or her environment at some physical distance from the mother whilst maintaining an optimal proximity. During this sub-phase, the infant returns to the mother from time to time for “emotional refuelling”. Mahler et al. (1985) found that the unfolding of the infant’s autonomy required the mother’s continuing emotional availability to meet the child’s needs.
The attainment of active free locomotion marks the “practicing sub-phase proper”. As the child explores his or her expanding environment, both human and inanimate, he or she concentrates on practicing and mastering skills and autonomous capacities. In so doing, the child asserts his or her growing individuality. Mahler et al. (1985) view this sub-phase of the separation-individuation process as the first step towards identity formation. The authors stress that the facilitation of this developmental leap requires a demonstration of pleasure by the mother in the child’s increasing autonomy and mastery.
Bowlby (1998), in comparing attachment theory to the process of separation-individuation, points out that his usage of the word separation differs from that employed by Mahler. Whereas Mahler et al. (1985) use the term to refer to a process of differentiation on a psychological level, Bowlby (1998) uses the term to imply that the infant’s primary attachment figure is inaccessible in a physical sense. However, he agrees with Mahler’s (1968) theoretical proposition that self-confidence, self-esteem and pleasure in independence develop out of trust and confidence in others, specifically through the infant’s experience of a mothering person who enables him or her to pass through the developmental phase of separation-individuation.
In describing the child’s early development, Tyson and Tyson (1990) adopt an integrative approach informed by Freud’s early affect-trauma model, infant research, ego psychology, self-psychology and object relations theories. The authors stress the significance of affects in structuring the infant’s inner world. Affects are defined as mental structures that have motivational, somatic, emotional, expressive, and communicative components, as well as having an associated idea or cognitive component. The good enough, attuned caregiver is responsive to the baby’s differentiated affective behavioural patterns and discrete emotional expressions. During the course of such continuous interactions between mother and infant, ideas and memories take on mental representation for the baby, who also constructs wishes and fantasies. The Tysons (1990) argue that affective behavioural responses, and their physiological counterparts, come to be associated with these ideas and fantasies. Through this process, the baby’s behaviour and the response of the caregiver begin to take on meaning for the infant. Thus, the connection between affective behavioural response patterns on the one hand, and memories and ideas, both conscious and unconscious, on the other, develops into an inner psychological experience endowed with individual meaning.
The Tysons (1990) make the point that once a feeling has come to be linked with an idea, it has the potential to be verbalized. Feelings or affective states are then more easily recognized, defended against and controlled by the ego. Extending Spitz’s (1959) model of ego formation, the Tysons (1990) argue that given optimal development, affects come to serve a signal function enabling the child to master and regulate his or her own affects, instead of being overwhelmed by their disorganizing effects. According to the Tysons’ (1990) integrated conceptual framework, the use of signal function comes about through the child’s successful internalization of, and identification with, the mother’s organizing and regulating functions. They therefore contend that the achievement of signal function indicates the accomplishment of an important developmental step. However, following Kohut (1971), the Tysons (1990) argue that where there is a failure of parental empathy or traumatic interference of one form or another, this process is disrupted and the development of a coherent sense of self is compromised leading to a fragmentation of experience and, therefore, of personality. From this perspective, psychopathology is viewed in interpersonal terms and traumatic affect as playing a part in organizing mental functioning, in that painful affect may become a significant motivating force in the manifestation of psychopathology (Tyson and Tyson, 1990).
Winnicott (1988) envisages a similar outcome to that proposed by Mahler et al. (1985), though the process of psychological separation expounded by him is characteristically idiosyncratic. He assumes the existence of a transitional space, viewing this as an intermediate area of experience between mother and child in which imagination and reality coincide. Under optimal conditions of good enough mothering within a holding environment the infant is gradually disillusioned of subjective omnipotent phantasies leading to an integration of personality and a sense of continuity within an objective reality. In Winnicott’s (1988) theory of mind, transitional objects, in the form of a favourite teddy bear or blanket, are used by the infant to bridge the space between inner and outer reality. Such phenomena provide a non-compliant solution to the loss of omnipotence and assist the child to separate from the merged state with the mother. A key aspect of the mother’s role is to mirror or reflect back the child’s own being, thereby facilitating the development of an authentic sense of self. For Winnicott (1988), then, the good enough mother provides a facilitating environment for her infant with opportunities for communication and recognition.
In commenting on Winnicott’s theoretical position, Bowlby (1997) construes transitional objects as substitute attachment figures, arguing that the child redirects or displaces his or her attachment behaviour on to such objects because the “natural” object, that is the primary attachment figure, is unavailable.
Bion (1984), for his part, suggests a transformational process whereby the infant’s sense impressions and emotional experiences are transformed into psychic elements that eventually become available for mental work. This process requires the mother to enter a state of calm receptiveness – a state of mind Bion (1984) terms reverie. The mother is thereby amenable to containing the infant’s inchoate state of mind and thus able to give meaning to the anxiety and terror inserted into her by means of projective identification. For Bion (1984), the development of this interactive process indicates the infant’s progressive movement out of an inner world of bodily satisfaction into the world of the mature mind of symbols and symbolic satisfaction.
Clearly influenced by both Winnicott’s and Bion’s thought, Bollas (1994) suggests that during the early stage of development the baby experiences the mother as a transformational object associated with an intersubjective process. The process of intersubjectivity “instructs” the infant into the logic of being and relating. This is achieved by means of the mother’s countless exchanges with the child. Bollas (1994) argues that each exchange is, in itself, a logical paradigm which supports the mother’s conscious and unconscious theory of being and relating. The child is active in this process bringing, in Winnicottian terms, an inherited disposition to meet up with the maternal process. Thus, emotional states and psychic structure are mutually negotiated between mother and infant. Bollas (1994) points out, however, that the mother’s logical paradigm of being and relating will, to varying degrees, act either to facilitate or forestall the development of the infant’s true self or authentic subjective experience.
The work of Bowlby and his collaborators inspired wide interest in infant research, a field of study that continues apace. Main, Kaplan, and Cassidy (1985) emphasise that Bowlby’s theory includes the consideration of representational states, as well as focusing on the role of early trauma and early parent-child interaction patterns in the development of anxiety and defensive processes. Indeed, when conceptualizing the inner world from an attachment theory perspective, Bowlby (1980) looked to cognitive psychology, drawing specifically on the concept of internal working models which he came to view as integral components of the attachment behavioural system. Research findings would seem to confirm both the validity of Bowlby’s theory of attachment and the connection between the child’s interpersonal relations and his or her inner world, namely that a secure attachment tie to the mother functions to integrate the child’s personality (Bowlby, 1958).
Studies utilizing Ainsworth et al.’s (1978) strange situation procedure found that one-year-old infants displayed one of four distinct patterns of attachment behaviour. These patterns have been classified as B (Secure), A (Avoidant), C (Ambivalent-Resistant), and, more recently, D (Disorganized/Disoriented). Research has shown that each of these attachment patterns can be predicted from the quality of interaction observed between the primary caregiver and the infant during the first year of life (Main et al., 1985). These findings indicate that patterns of secure and insecure attachment organization are internalized in the form of particular working models. Working models are thought to mediate the infant’s experience of actual relationships, and to guide and direct feelings, behaviour, attention, memory and cognition. Main et al.’s (1985) findings indicate that once patterns of attachment behaviour are established they tend to become actively self-perpetuating. As a consequence, malignant events relevant to attachment may cause difficulty in integrating information.
In terms of the mechanisms involved in this process, the authors suggest that when an established attachment behavioural system receives potentially disruptive signals it counters these by actively deploying perceptual and behavioural control mechanisms. Main et al. (1985) conclude, albeit tentatively, that internal working models deriving from insecure patterns of attachment behaviour are resistant to modification and updating because error-correcting information is being defensively and selectively excluded from consciousness. They suggest that this difficulty may affect maternal sensitivity, as the need to exclude, restrict or reorganize attachment relevant information may result in an inability on the part of the mother to perceive and interpret accurately the infant’s attachment behaviour signals. Indeed, Main et al. (1985) propose that the mother, because of issues stemming from her own attachment history, may experience an active need to alter or inhibit the signals being expressed by the infant. This is not to say that other more specific socio-cultural factors may have a maladaptive effect on maternal sensitivity in the early months of life. Such variables include post-natal depression, marital conflict and the degree of loving support available from the infant’s father, particularly in families with older children in need of care-giving.
Main, Kaplan and Cassidy (1985) emphasise that a parent’s sensitive responsiveness has consistently been found to be the best predictor of security of attachment at one year of age. By contrast, parental rejection is predictive of infant avoidance, and a parent’s inconsistent response predicts ambivalent-resistant infant behaviour. The great majority of parentally maltreated children fit the disorganized/disoriented category (Main, et al., 1985; Main, 1991). In line with these findings, Schore (1994) argues that all early psychopathology constitutes disorders of attachment and is manifested as failures of interactive regulation and/or self-regulation of non-verbal, pre-symbolic affect.
More generally, developmental studies indicate that from the very start of life the infant is involved in numerous interactions with others, both responding to their initiatives and actively initiating interaction themselves. Stern’s (1985) synthesis of research findings indicates that all the perceptual systems of the infant are functional at birth. For example, the infant is compelled and stimulated by the sound of the human voice and the sight of the human face. From this data, Stern (1985) concludes that the infant’s states of consciousness are socially negotiated during the course of differing kinds of relationships.
This proposal mirrors Tronick et al.’s (1978) aphorism, “I interact, therefore I am”. The authors’ statement reflects the findings of the so-called “still face” situation in which the mother, after a period of normal interaction, adopts an immobile posture and mask-like expression when sat en face to her baby. The effect on the infant is dramatic and distressing, in that after repeated unsuccessful attempts to elicit the expected interactional response from the mother, the baby collapses into a detached, self-protective state (Brazelton and Cramer, 1991). Tronick et al. (1978) conclude that the micro-repair of the breakdown of attunement or misaligned interaction is probably at the heart of the establishment of a viable human relationship.
This premise is supported by research using the time series regression model which films the split-second world of interaction between the mother and the infant not visible to the naked eye (Gottman, 1981). Micro-analysis of research using this technique has demonstrated the bi-directional influence in communicative processes between the mother-infant dyad in terms of the timing, tracking and matching of vocal exchanges (Jaffe et al., 1991), and the duration of “movements” and “holds” in the changes of facial expression and direction of gaze (Beebe, Jaffe and Lachmann, 1992). Beebe, Jaffe and Lachmann (1992) cite research findings, including those of Main et al. (1985) and Trevarthan (1979), demonstrating that variations in early social interactions are predictive of cognitive development and patterns of attachment at one year and two years of age.
Measures used in these various research projects include mutual gazing, mutual smiling and social play in the first four months of life, and the mother’s capacity to respond contingently to the infant’s signals in the first six months of life. For example, maternal sensitivity during feeding at four weeks, in terms of rhythmic holding and the facilitation of infant activity, was found to predict secure attachment at one year of age. The authors argue that a dyadic symmetry is in operation, with each partner’s behaviour being predictable from that of the other and employed for the specific purpose of regulating the exchange. Moreover, they suggest that interaction structures are represented internally over the early months of life and play a major role in the emerging symbolic forms of self- and object representations. From an attachment theory perspective, the dyadic communicative process is conceptualized in terms of mutual responsiveness to attachment behaviour signals.
Beebe, Jaffe and Lachmann (1992) conceptualize misattunement as the loss of mutual influence or contingent responsivity. Research indicates that the infant may come to associate lack of contingency with negative affects and escalating arousal. This, in turn, may interfere with the infant’s optimal regulation of his or her arousal. The authors suggest that prolonged and severe states of withdrawal to accomplish re-regulation of arousal in the face of misattuned care-giving may compromise the infant’s attention and information processing capacities. They argue that an infant who typically uses inhibition of responsivity alters his or her capacity to stay alert and be fully attentive and responsive to the environment.
On theorizing about the development of self, Stern (1985) places the focus firmly on the infant’s inner subjective experience and his or her interpersonal context. He adopts and operationalizes Trevarthan and Hubley’s (1978) definition of intersubjectivity, viz “a deliberately sought sharing of experiences about events and things”. Stern (1985) proposes four senses of the self and suggests that each emergent sense of self defines a new domain, that is, a sphere of influence or activity of social relatedness. He views the initial formation of a domain as constituting a sensitive period of development, arguing that each domain will hold predominance during that time. However, he points out that once all domains of relatedness are available to the infant no one domain will necessarily claim preponderance during any particular age period.
The four senses of self are a sense of emergent self (birth to two months); a sense of a core self (two to six months); a sense of a subjective self (beginning seven to nine months); and a sense of a verbal self (beginning around 15 to 18 months). Alongside the emergent self is a domain of emergent relatedness; alongside the core self is a domain of core relatedness; a domain of intersubjective relatedness parallels the sense of a subjective self; and a domain of verbal relatedness parallels a sense of a verbal self. Stern (1998) suggests that the infant’s newly developed senses of self provide the arena within which clinical issues are played out. Such issues include autonomy, orality, symbiosis, mastery, control, trust, dependence, independence, and separation. However, Stern (1998) argues that clinical issues are not merely age- or phase-specific, but life-course issues. He therefore contends that though these issues may take different forms during different developmental epochs they are continually being worked on, negotiated and reorganized in dyadic interaction.
For Stern (1985), then, each sense of self and each domain of social relatedness is a form of self-experience and social interaction. He therefore proposes that a “sense of self with other” grows along with a sense of self and a sense of the other. Along similar lines to Winnicott (1988), Stern (1985) suggests that the mother’s task is to maintain an internal “line of continuity”, as this provides the child with a coherent sense of self and, thereby, the capacity to cope with temporary separations without recourse to maladaptive defences. He argues that such coherence is achieved through a process of “affect attunement”, a subtle process of interaction during which the mother mirrors and marks her infant’s moods and behaviour, either directly or by using different sensory modalities to match the shape, intensity and timing of her infant’s activity. This form of attuned, cross-modal responsiveness by the mother is thought to resonate with the child’s experience, thereby creating a matching of affective inner states between the mother and the infant.
Stern’s (1998) theoretical concepts are informed by infant research which, as noted above, demonstrates that interactional patterns between parent and child consist of mutual micro-regulations. Stern (1998) argues that these repeated patterns of interaction constitute the basic building blocks of psychic formation which structure the infant’s representational world. These patterns, in turn, build the perceptual, affective and cognitive schemas used to organize and construct subsequent life experience (Fosshage, 1992).
A schema is said to consist of a procedural memory. The latter consists of non-conscious, non-reflective emotional and impressionistic information derived from, and arising out of, a dynamic series of micro-events. Micro-events refer to processes of mutual influence between the mother and the infant and constitute what Stern (1998) calls the relational mode, that is “a-way-of-being-with” or “a style of relating”. As we have seen, mutual influence takes the form of the timing, tracking and matching of vocal exchanges and the duration of “movements” and “holds” in the changes of facial expression and direction of gaze. These interactive behaviours are employed for the specific purpose of regulating the exchange (Jaffe et al., 1991; Beebe, Jaffe and Lachmann, 1992).
Stern (1985), then, argues that procedural memories are internalized and represented as patterns of interactive behaviours that become generalized. He terms this process Representations of Interactions that have been Generalized (RIGs), seeing this process as preceding the development of internal working models (Bowlby, 1980; Main et al., 1985). Infancy research indicates that such interactive patterns are the means by which affect is communicated and, moreover, provide a behavioural basis for the mother and infant to perceive and enter into the temporal and feeling state of the other (Beebe, Jaffe and Lachmann, 1992).
Schore (1994), too, emphasises the non-verbal, emotion-transacting mechanisms inherent in the caregiver-infant relationship. He argues that this process takes place at pre-conscious/unconscious levels and is represented by communications between the dyad’s respective right brain hemispheres that are tuned in to receive such communications. Schore (1994) contends that this communicative process facilitates a dyadic matching of psychobiological states of mind and thence an interactive regulation of affect. In line with this hypothesis, he suggests that empathy may best be understood as non-verbal psychobiological attunement.
While the bi-directional model of influence points up the importance of the dyad in the organization of individual behaviour, Beebe, Jaffe and Lachmann (1992) emphasise that this model incorporates and integrates the crucial contribution of the individual’s own self-regulatory capacities, a point also made by Schore (1994). Stern (1985; 1998) construes the mother-infant relationship as a subtle process of intersubjectivity during which states of consciousness, in terms of affect, attention, and intention come to be shared. The self is viewed as developing through this intersubjective process and as composed of relational configurations that are developed in the context of interaction with others. Psychopathology is seen as arising out of an accumulation of maladaptive interactive patterns that result in character and personality types and disorders.
Stern (1985) acknowledges that his concepts are, in part, derived from Bowlby’s theorizing and the infant research to which this has given rise. Here, as we have seen, it is postulated that patterns of interaction gradually structure and organize the child’s inner world of experience, being internalized in the form of working models. These models consist of the relations the child has with primary attachment figures, as well as of the child’s own sense of self and of him/herself in interaction with these significant others. It is assumed that repeated failure by the mother to respond in a contingent and congruent way to the infant’s attachment cues and signals leads to the breakdown of secure affectional bonds and to the organization of insecure patterns of attachment with concomitant difficulty in integrating attachment relevant information (Main et al, 1985). Although internal working models tend to reinforce a basic sense of continuity to the infant’s personality or sense of self, it is thought that they remain open to elaboration, modification and change, thereby shaping the developing infant’s new experience (Main et al., 1985; Sroufe, 1988).
From Stern’s (1985) perspective, the effect on the infant of the mother who characteristically inhibits or defensively excludes from consciousness attachment behaviour signals (Main et al., 1985) is a lack of attunement and a resultant mismatch in their affective states. Mahler et al. (1985) would construe such parent-child interaction as meeting the mother’s symbiotic needs instead of the infant’s needs for phase-appropriate autonomy. Winnicott (1988) might well have described the situation as representing a failure of the facilitating maternal process which, if characteristic of the relationship, would impinge on the child’s inherited disposition and lead to the development of a conformistic, over-adapted false self. Bion (1984), for his part, may have viewed the mother as lacking the capacity to enter a state of reverie and contain and modify her infant’s inchoate experience and projected terror. Bollas (1994) is likely to perceive the mother’s idiomatic logical paradigm of intersubjective being and relating as acting to forestall the infant from attaining a sense of authentic experience. Beebe, Jaffe and Lachmann (1992), Tyson and Tyson (1990) and Schore (1994), would, respectively, tend to view such misaligned interaction as compromising the infant’s capacity to self-regulate non-verbal pre-symbolic affect during heightened states of emotional arousal.
In summarizing the foregoing it may be seen that adult theorists tend to develop theory about the infant’s state of mind retrospectively via phenomena gleaned from clinical work with their clients. By contrast, infant research/developmental studies seek to understand the inner world of subjective experience prospectively via empirical observation of mother-infant interactions (Ainsworth, 1982). Here, the data consist not only of patterns of attachment organization but also of the numerous and varied exchanges which occur between the mother and the child. These patterns of interaction are thought to play a significant role in structuring and organizing the infant’s internal experience.
Initially, the inner world is conceptualized in terms of non-verbal pre-symbolic representations of interactions that have been generalized (Beebe, Jaffe and Lachmann, 1992; Stern, 1985), and later in terms of internal working models of self in relation to a hierarchy of attachment figures (Bowlby, 1980; Main et al., 1985). Working models are described in motivational terms, in that they are assumed to guide and direct affect, cognition, behaviour, memory, and attention. With regard to insecure patterns of attachment organization, internal working models are thought to mediate and perceptually distort actual experience of others and of events by means of selective attention and defensive exclusion (Main et al., 1985).
The next section discusses the ways in which data derived from empirical observations of caregiver-child patterns of interaction are influencing the construction of models of adult psychotherapy.
The Links between Infant Research/Developmental Studies and Adult Psychotherapy
In recent years, the Boston Process of Change Study Group (Stern et al., 1998a, 1998b) have attempted to synthesize attachment theory, cognitive science and psychoanalysis into a new integrative model of adult psychotherapy. Fonagy (1998) summarizes these ideas with particular reference to therapeutic technique and the role of the adult therapist as a new developmental object. He points out that non-conscious schemata are thought to define how interpersonal behaviour is conducted. This view is based on the premise that memory consists of two relatively independent systems, namely autobiographical or declarative memory, which is partly accessible to awareness, and implicit or procedural memory. Research in this area has demonstrated that procedural memory is principally perceptual, non-declarative and non-reflective, being more dominated by emotional and impressionistic information than autobiographical memory. Fonagy (1998) considers it likely that “the schematic representations postulated by attachment and object relations theorists are most usefully construed as procedural memories, the function of which is to adapt social behaviour to specific interpersonal contexts” (p.348). Given this, Fonagy (1998) suggests that patterns of attachment are stored as procedural memories which themselves are organized as mental models. He argues that knowledge of these procedures is accessible only through behavioural performance, that is, by direct observation of the individual’s manner or style of relating. Previously it was assumed that such knowledge was accessed through the verbal description of ideas or memories.
Fonagy (1998) contends that the therapeutic model proposed by Stern and his colleagues (1998a, 1998b) adds relevance to the strange situation procedure as a method of assessing the way in which an infant’s attachment behaviour is developed with a specific caregiver. This is because the classification of patterns of attachment (Ainsworth et al., 1978) taps into procedural memory (Crittenden, 1990). Further, he points out that in the case of adults, attachment security is evaluated by reference to “the procedures used by the individual to create an attachment related narrative” (p.348).
Fonagy (1998) draws attention to Main’s (1991) research which indicates that the quality of the person’s narrative and the manner in which it is related is of more clinical significance than its historical content. Main developed the Adult Attachment Interview (AAI) from which she devised four classifications of parental states of mind with respect to attachment: Secure/Autonomous, Dismissing, Preoccupied and Unresolved. In a follow-up study, she found that the classifications observed in the AAI five years previously matched the infant’s behaviour towards the parent (Main, 1991). As noted above, parents judged to have a secure state of mind with respect to attachment (secure/autonomous) had a matching secure child, whereas those who were dismissing of attachment-related experiences had matching avoidant children. Preoccupied parents had matching ambivalent/resistant children, and parents whose state of mind was unresolved in respect of trauma had matching disorganized/disoriented children.
Furthermore, Main (1991) found that whereas secure/autonomous subjects possessed the capacity both to reflect on their experience and interpret their own and others’ mental states (meta-cognitive monitoring), parents of D children manifested signs of mental disorganization and disorientation during discussions of traumatic events such as loss or abuse. Disorientation took the form of lapses in the monitoring of reasoning and discourse. For example, the parent would leave illogical statements hanging in the air unelaborated. Main (1991) suggests that such lapses may indicate the existence of parallel, incompatible belief and memory systems regarding a traumatic event which may have become dissociated. Lapses in the monitoring of discourse also suggest the possibility of “state shifts”. Here, the individual may enter a peculiar, compartmentalized state of mind involving a particular traumatic experience. Shifts of state of this kind may result in frightened and/or frightening behaviour on the part of the parent (Main and Hesse, 1990). The authors conclude that parental behaviour of this kind results in disorganized/disoriented behaviour by the child.
We see then that the findings of Main et al. (1985), Main and Hesse (1990) and Main (1991) demonstrate that each pattern of attachment organization has as its precursor a specific pattern of infant-mother interaction and its own behavioural sequelae. Using the AAI, the authors found that the language used by the subject to describe attachment-related experiences was predictive of the unborn infant’s attachment status. Fonagy (1998) refers to van Ijzendoorn’s (1995) meta-analysis of the predictive validity of the AAI, concluding that the success of this heuristic instrument “speaks volumes for the promise of a procedure-oriented psychodynamic approach” (p.348).
Fonagy (1998) suggests that clinicians are accustomed to working with procedural memory and that such work requires an astute awareness of the multiple meanings encoded into a single verbal message by the use of stress, speech pauses and intonation, etc. Beebe et al. (1985) cite evidence showing that the adult communicative process, in terms of turn-taking and intrapersonal/interpersonal pauses, operates in a similar way to that of the mother-infant dyad outlined in the previous section. In line with such research, Fonagy (1998) describes the new therapeutic model as one that emphasises interpersonal factors in the generation of procedural aspects of personality functioning based on the concept of what Stern et al. (1998a, 1998b) call “now moments”. These are thought to occur when two consciousnesses succeed in encountering one another. Following such “moments of meeting”, disengagement takes place. The new model postulates that successful disengagement is dependent on the subject being sufficiently confident of the availability of the other. Further, disengagement creates what Stern et al. (1998a) term an “open space”. During such moments, both participants are able to restructure their relational systems in the light of the experience of the other’s mental organization.
Fonagy (1998) sees the theoretical assumptions of the new model as linked to Winnicott’s (1958) description of the capacity to be alone, which he (Fonagy) views as central to the process of change. Winnicott (1958) argues that being alone in the presence of someone is based on the assumption that the other “is available and continues to be available when remembered after being forgotten” (p. 55). For Winnicott (1958), this capacity is gradually built up within a “good enough” environment. It becomes part of the child’s personality through a process of introjection and, thereby, is equated unconsciously with the comforting presence of the mother. The concepts of “holding” (Winnicott, 1988) and “containing” (Bion, 1984), as well as that of meta-cognitive monitoring (Main, 1991), are of relevance here. These concepts seem to have influenced Fonagy et al.’s (1997) concept of mentalization, that is, the capacity to reflect on, organize and integrate mental experience. Following Main (1991), Fonagy and his colleagues (1997) conclude that the child’s capacity to explore the mind of the other and develop as a thinking and feeling being with insight into the representational basis of human interaction and intentionality arises within the matrix of a secure attachment relationship.
In the light of empirical findings from infant research, and in line with Stern et al. (1998a, 1998b), Fonagy (1998) posits that the new integrative model offers a clear psychological paradigm of intersubjectivity, complete with developmental roots and technical implications. With regard to the latter, these focus on the micro-processes that take place in the here-and-now of the analytic situation. Indeed, Fonagy (1998) views the interactional aspect of the therapeutic relationship as providing the key to understanding psychic change. He concludes that the effective ingredient of therapy must be contained within the relationship component because this is the only feature that the different techniques of talking cure have in common.
In a meta-analysis of successful outcomes, Roth and Fonagy (1996) found that research evidence supports “moments theory”, in that it suggests that the extent to which ruptures to the therapeutic alliance are adequately addressed is predictive of the outcome of therapy. Fonagy (1998) argues that in using a similar model of relating or interacting, the therapist may become a new developmental object whose involvement with the client permits a departure from past experience with other people. Indeed, Fonagy and Target (1998) suggest that in many instances the goal of therapy is “the observation of patterns of interaction, the identification of maladaptive models, and the correction of such models, principally through strengthening an overarching mental capacity to selectively activate alternative models of interaction”(p. 4). The mental capacity to which the authors refer is, as mentioned previously, what Fonagy and his colleagues (1997) label mentalization or reflective functioning, and what Main (1991) terms meta-cognitive monitoring.
More generally, Fonagy (1998) suggests that moments of meeting involve the intersubjective recognition of a shared subjective reality during which each partner contributes something to the interaction that is both unique and authentic. Benjamin (1995) emphasises that the intersubjective therapist views personal growth and change as occurring not in moments of empathy but in moments of empathic failure. In line with Winnicott (1988), she suggests that at times of misalliance, the analyst’s task is to survive omnipotent destructive fantasies without collapsing or retaliating. Benjamin (1995) argues that the significance of this form of “holding” response is that it helps the client to recognize the analyst’s existence as a separate person available to be used and related to intersubjectively.
Along similar lines, Anne Hurry (1998) suggests that an interactional perspective may help clinicians to understand both developmental and therapeutic processes. As with Fonagy (1998) and Stern et al. (1998a, 1998b), she argues that findings from developmental psychology support the interpersonal basis of development and of therapy. Indeed, she suggests that developmental factors play a role in all analyses, alongside the analysis of neurosis and conflict, and that developmental interaction is, therefore, an important aspect of the therapeutic process. She cites Emde (1980), who conceives of this process as acting to re-open the pathway to benign environmental influences. To this extent, the client experiences the therapist as a new object with developmental potential. Tähkä (1993), elaborating on Emde’s (1980) theory, sees structural (intra-psychic) change as stemming specifically from the client’s use of the analyst as a new developmental object. This view accords with Benjamin’s (1995) contention that intersubjectivity consists of a subtle intertwining of both interpersonal and intra-psychic processes.
Similarly, Lachmann and Beebe (1990) propose a model of transference informed by a dyadic systems view of communication, as outlined above. This model integrates the simultaneous contributions of the client-analyst interactions with the enduring psychic structures from the client’s past. Thus this model of transference integrates a two-person psychology perspective with a one-person psychology perspective. In line with Benjamin (1995), Lachmann and Beebe (1990) argue that both interpersonal and intra-psychic sources operate interactively and concurrently throughout treatment, regardless of the origin of the pathology. Tähkä (1993) contends that in terms of the transference-countertransference process, the therapist becomes a new developmental object by acting differently from the original developmental object being sought in transferential re-enactment. According to Tähkä (1993), the difference in the client’s experience between old and new developmental object provides a “corrective emotional experience” based on the therapist’s “empathic … recognition of the patient’s frustrated and arrested developmental needs and potentials” (p.231).
The concept of a corrective emotional experience was introduced by Alexander and Frank (1946), and arose out of their concern with clinical effectiveness and expediency (Mitchell, 1997). The authors suggest that analysis is effective precisely because the client finds in the analytic situation a different sort of experience than he or she encountered in childhood. They therefore recommend that the analyst actively addresses the client’s need for an emotional experience with a different sort of object than the original pathogenic parent (Mitchell, 1997).
Hurry (1998) points out that when a client has experienced pain, neglect or disappointment he or she may have difficulty in trusting a more benign relationship and, instead, defensively rely upon old, malign but familiar internal working models. However, she suggests that concomitant to the need defensively to repeat such negative patterns the transference will carry an unconscious wish for change and the hope that the therapist will act as developmental rather than transference object. Again, this view emphasises the interaction between interpersonal and intra-psychic processes. Hurry (1998) therefore argues that in unconsciously asking the therapist to contradict transference expectations, the client is seeking an appropriate developmental object. Indeed, she contends that this search may be the client’s real agenda and the basis for a genuine, though predominantly unconscious, therapeutic alliance.
Hurry (1998) acknowledges that the interaction between client and therapist is often compared to parenting. Indeed, Phillips (1988) points out that Winnicott increasingly drew direct equivalents on a developmental continuum between the mother-infant relationship and the psychotherapeutic situation. Hurry (1998) believes that while many therapists accept such comparisons, they see themselves as providing a different kind of holding or containing to that of the parent, even though both parent and therapist aim to facilitate psychological growth. She suggests that in addition to Winnicott’s (1988) emphasis on the analyst as a maternal developmental object, the analyst may serve in the role of the father more often than is realized. Thus, she posits that the client is seeking to find or re-find in the analyst both maternal and paternal developmental objects. Such experiences in the therapeutic process are used to forge new relationships outside of the analytic situation. Indeed, Tähkä (1993) argues that “In a successful analysis, [the analyst’s] fate as the patient’s developmental object may have a course analogous to what the patient’s interactions with his original developmental objects should have been: that is, a gradual, relative abandonment of the analyst, both as the patient’s self ideal and as an ideal love object” (p.248). In looking at the analytic process, Hurry (1998) stresses that underlying models of insecure attachment inevitably arise in the therapeutic situation, thereby allowing for their recognition within the analytic relationship. Aspects of the transference will, therefore, emerge and coalesce around actual aspects of the setting, as well as in response to the analytic work itself. Hurry (1998) argues that concomitant to these processes the developmental relationship will need to be grounded within reasonable limits as this helps the client to confront the reality of separateness and separation. She suggests that developmental work is rooted in the individual personalities of the client and analyst and in their spontaneous interaction. Citing research by Kantrowitz (1995), she points to the importance of the fit or match between the client and the analyst.
Indeed, Kantrowitz (1995), in her long-term follow-up study, found that client-analyst match was the main factor relevant to successful outcome. Hurry (1998) argues that such matching is most important with regard to the spontaneous developmental aspects of the therapeutic process. In elaborating on this issue, she notes Tähkä’s (1993) recognition of the analyst’s legitimate experience of parent-like feelings of pleasure and pain as part of a stage-appropriate developmental relationship with the client. However, Tähkä (1993) acknowledges that there is a heightened countertransferential risk in developmental work of the analyst using the client variously as a source of narcissistic gratification, to relieve guilt, to overcome feelings of helplessness or to gratify his or her own infantile needs. Hurry (1998) emphasises that these risks demand ongoing self-reflective monitoring of the countertransference.
In a similar way to Stern et al. (1998a, 1998b) and Hurry (1998), Schore (1994) argues that developmental studies are of direct relevance to the psychotherapeutic process with adults. He cites the commonality of interactive emotion-transacting mechanisms in the caregiver-infant relationship and the therapist-client relationship. With regard to parent-child interactive mechanisms, it may be accepted that these have been amply demonstrated in the various findings discussed above (Ainsworth et al., 1978; Beebe, Jaffe and Lachmann, 1992; Gottman, 1981; Jaffe et al., 1991; Mahler et al., 1985; Main et al., 1985; Main and Hesse, 1990; Main, 1991; Sroufe, 1988; Stern, 1985, 1998; Trevarthan and Hubley, 1978; Trevarthan, 1979; Tronick et al., 1978). In formulating a model to treat emotional dysregulation resulting from a failure of affective development, Schore (1994) emphasises the need to match the client’s developmental level, arguing that non-verbal internal working models of insecure attachment should be a central focus of treatment. Schore (1994) contends that interactive regulation of affect is a fundamental mechanism of both psychobiological development and psychotherapeutic treatment. He therefore suggests that transference phenomena should be interpreted from a developmental perspective. In line with findings from infancy research, Schore (1994) conceptualizes the therapeutic alliance in terms of mutually reciprocal influences, arguing that the client’s capacity for attachment combines with the therapist’s facilitating behaviours to permit the development of the working relationship. For this process to be successful, the client must experience the therapist as being in a state of “vitalizing attunement”.
In Schore’s (1994) model, defence mechanisms are conceptualized as forms of “emotional regulation strategies”. These are deployed to avoid or minimize affects that are experienced as too painful to tolerate and to prevent entry into “dreaded states” charged with intense negative affect. Schore’s (1994) perspective lays stress on primitive affects such as shame, disgust, elation, excitement, terror, and rage, rather than on guilt and anxiety. The overarching therapeutic goal in his model is the recognition and identification of unconscious affects that have never been subject to developmental interactive regulation nor represented internally, rather than the uncovering of unconscious resistances and disavowed repressed affects. An inherent aspect of this approach is the identification of discrete, automatic, facially and prosodically expressed affects and attention to the intensity, duration and lability of emotional states. This process requires a moment-to-moment tracking of subtle and dramatic affect and of shifts in mood-state associated with the client’s narratives. Schore (1994) argues that this level of psychobiological attunement requires the therapist to use his or her “contertransference visceral-somatic responses to the client’s internal state”. In a similar way to Hurry (1998), he stresses that developmental work of this kind requires the therapist to bring his or her own emotions and personality more explicitly into the therapeutic frame.
As in the AAI (Main, 1991), the identification of significant cognitions that trigger “phenomenological discontinuities” (dissociation) is an important aspect of Schore’s (1994) model. Infancy research suggests that affect and cognition develop into an interactive process during the course of the child’s development. From a social constructivist perspective, D. B. Stern (1997) views cognition as an amalgam of thought and feeling and an integral aspect of a continuous phenomenological process operating within the interpersonal field. He suggests that under optimal conditions, the function of this process is to organize, structure and unify subjective experience, thereby providing the individual with a sense of coherence and meaning. However, Stern (1997) argues that experience may be split for defensive reasons in reaction to trauma and result in the isolation of emotion from mentation.
Stern’s (1997) contention accords with the findings of van der Kolk and Fisler (1995). On discussing their research into dissociation and the fragmentary nature of traumatic memories they, too, stress the existence of declarative or explicit memories and non-declarative or implicit memories. The authors argue that the explicit memory system may fail during conditions of high arousal. Their findings suggest that traumatic memories are dissociated, being encoded and stored as sensory fragments without a coherent semantic/linguistic component. As a consequence, the traumatized individual is left in a state of “speechless terror”, lacking the words to describe what has happened. The traumatic incident is, instead, initially “remembered” in the form of fragmented somatosensory experiences that have been encoded and stored in the implicit memory system (van der Kolk, 1994). Flashbacks of the traumatic event occur in a variety of discrete sensory modalities: visual, olfactory, affective, auditory and kinaesthetic (van der Kolk and Fisler, 1995).
In comparing childhood trauma with adult trauma, van der Kolk and Fisler (1995) conclude that the former results in more pervasive biological dysregulation. Significantly, they found that clients who had a history of childhood trauma experience greater difficulty in regulating internal states than those first traumatized in adulthood. The findings in respect of both groups in their sample population indicate that the enhancement and intensification of discrete sensory modalities stemming from the dissociated traumatic experience helps to bring these fragmented modalities into consciousness in unified form. This integrative process assists in the construction of a coherent personal narrative. This, in turn, allows the intrusive somatosensory elements (procedural memories) to be transcribed into explicit or declarative memories.
Genetic variables notwithstanding, infant research may help to elucidate the question as to why individuals respond differently to the same, or qualitatively similar, traumatic incident. As detailed above, researchers have demonstrated that children with a secure pattern of attachment organization develop the capacity to stay attentive and responsive to the environment and use error-correcting information to construct a coherent narrative (Main et al., 1985; Main, 1991). Secure/autonomous individuals may, therefore, possess the mental resources to process information more readily in the aftermath of a traumatic event without developing full-blown post-traumatic stress disorder than the insecure subject whose ability to regulate states of arousal was compromised during early development. As we have seen, children subjected to misattuned, insensitive and over-arousing caregiving may typically inhibit responsivity and enter prolonged and severe states of withdrawal (Beebe, Jaffe and Lachmann, 1992) as an “emotional regulation strategy” (Schore, 1994). It would seem reasonable, therefore, to hypothesize that an individual with an insecure/unresolved adult attachment style, and concomitant incapacity to regulate states of arousal at moments of stress, may be more susceptible to subsequent trauma and its sequelae than an individual with a secure/autonomous pattern of attachment organization.
Schore’s (1994) perspective would appear to have much in common with studies into the nature of traumatic memories. His model is, moreover, informed by neurobiological research. This area of study indicates that a primitive splitting occurs between the right and left hemispheres of the brain. With such findings in mind, Schore (1994) argues that self-and-object images are encoded in implicit/procedural memories stored as right hemispheric non-verbal internal working models (internalized object relations). It therefore follows that the therapeutic process requires an uncovering of these images.
Schore (1994) suggests that dynamic states of consciousness are observable as “heightened affective moments” and most readily seen at times of enactment. He contends that the interactive regulation of the client’s state during such moments enables him or her to link non-verbal and verbal representational domains and thence to transfer implicit information in the right hemisphere of the brain to explicit or declarative systems in the left. He avers that this developmental advance facilitates the “evolution of affects from their early form in which they are experienced as bodily sensations, into subjective states that can gradually be verbally articulated”. It may be seen that, in essence, this is Bion’s (1984) theoretical position. Moreover, the mechanisms described by Schore (1994) are remarkably similar to those thought to occur in the recovery from dissociated traumatic experience (van der Kolk and Fisler, 1995; van der Kolk, 1994).
In addition to these similarities, we see that Schore’s (1994) model has much in common with that proposed by the Boston Process of Change Study Group (Stern et al., 1998a, 1998b). Both models apply a developmental perspective to adult clinical material and both hold that interaction structures or patterns of attachment are encoded in procedural or implicit memories that are observable through expressive behavioural display, particularly during heightened moments of interaction.
From Schore’s (1994) perspective, internalized relations expressed in the transference take the form of “motivational expectations of misattunement-induced dysregulation”. He contends that expectations of misattuned regulation constitute the client’s “theory of mind”. Such expectations are encoded in enactments of unconscious interactive representations (procedural memories) and manifested at times of transference-countertransference ruptures. Given this, Schore (1994) argues that the therapist needs to appreciate the centrality of interactive repair as a dyadic mechanism. The reparative aspect of the therapeutic relationship disconfirms the client’s pathogenic transferential expectations and allows for the emergence of a psychic structural system that more effectively regulates negative affect. Again, the similarities between Shore’s (1994) model of adult psychotherapy, the assumptions of object relations theoreticians and the findings of infant and trauma researchers are striking.
Schore (1994) emphasises that the therapist’s own tolerance of affects critically determines the range and types of emotion that may be explored or disavowed in the transference-countertransference relationship. As with Bion (1984), Schore (1994) argues that the therapist needs to direct therapeutic technique towards the “elevation of emotion from a primitive, pre-symbolic sensorimotor level of experience to a mature symbolic representational level”.
The technical consideration of intensifying affect is consistent with the findings of van der Kolk and Fisler (1995), as outlined above. In a similar way to Main (1991) and Fonagy et al. (1997), Schore (1994) suggests that this aspect of the treatment requires the creation of a self-reflective position from which the client may appraise the significance and meaning of his or her affect. Schore (1994) draws attention to the need of a safe interpersonal environment to accomplish self-organization of this kind. He asserts that if successful this process “generates an internal structural system capable of modulating emotional states and utilizing affects as signals”, a view also expounded by Tyson and Tyson (1990).
From Schore’s (1994) perspective, then, a goal of long term treatment is “structural alterations in the client’s right hemispheric orbito-frontal system”, a region of the brain thought to require attuned social interaction for optimal development of affect regulation. Schore (1994) contends that successful outcome leads to the “imprinting of an internalized representation of the therapist’s comforting function”. Optimally, the therapeutic process produces a self-system capable of tolerating a broader range and intensity of positive and negative affect allowing for “adaptive options of intrapsychic and interpersonal functions”.
From the foregoing, it may be seen that in many respects the “good enough” caregiver-infant relationship constitutes the prototype of a therapeutic model in work with adult clients and that the analytic process is redolent of the subtle intersubjective, communicative and regulatory processes that take place between mother and child. From a relational perspective, the inner world is viewed as developing through these mutually reciprocal influences and the mind as composed of relational configurations developed in the context of interaction with others. In consequence, the therapeutic process is perceived as being inherently interactive and thus as requiring the active participation of both therapist and client (Mitchell, 1993).
Aspects of the various ideas, concepts, processes and research findings discussed above reflect theoretical and philosophical assumptions derived from systems theory, interactionism, phenomenology and social constructivism. Systems theory holds that the observer ineluctably becomes an interrelated and interconnected element of the system as a whole, both influencing and being influenced by the mutual interactions of the system and its environment. Interactionism, phenomenology and social constructivism emphasise, in their respective ways, the sociability of subjective experience and behaviour, the situated, context-bound nature of human existence and the socially constructed nature of knowledge and the self.
It will readily be appreciated that such theoretical and philosophical assumptions inform both developmental studies and new models of adult psychotherapy. It would, therefore, seem particularly pertinent that those observing an infant adopt a method of observation that is consonant with the research findings and therapeutic models discussed above.
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