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Jacques P. Barber, PhD, is associate professor and associate director at the Center for Psychotherapy
Research, Department of Psychiatry and Psychology, University of Pennsylvania School of Medi-
cine in Philadelphia, Pennsylvania. Dr. Barber has published more than 100 articles, chapters, and
books in the area of psychotherapy research.

Helen E. Benedict, PhD, is professor of psychology at Baylor University and a registered play ther-
apist supervisor for Association for Play Therapy. She is a frequent leader of national and interna-
tional workshops on play therapy, especially object-relations play therapy and play therapy for
children with attachment disorders and children who have experienced interpersonal trauma. She
also leads an active research program on play therapy process using childrens play themes.

M. Sue Chenoweth, MS, PsyD, is in private practice in Hartford, Connecticut. She is affiliated
with the Institute of LivingHartford Hospital Mental Health Network in Hartford. She
is a consultant for the Womens Sexual Health ProgramConnecticut Surgical Group, P.C., Urology
Division in Hartford.

John F. Clarkin, PhD, is a professor of clinical psychology in psychiatry at the Joan and Sanford I.
Weill Medical College of Cornell University, the codirector of the Personality Disorders Institute,
and the director of psychology at the Cornell Medical Center. Dr. Clarkin is on the research faculty
and is a lecturer at Columbia Universitys Psychoanalytic Center.

Gerhard W. Dammann, MD, Dipl.-Psych., is attending psychiatrist, clinical psychologist, and psy-
choanalyst (IPA) at the Psychiatric University Hospital in Basel, Switzerland, and Department of Psy-
chosomatic Medicine and Psychotherapy, Technical University Medical School in Munich, Germany.

Ellen A. Dornelas, PhD, is director of Behavioral Health Programs, Preventive Cardiology,

at Hartford Hospital and assistant professor of medicine at the University of Connecticut School of
Medicine. Her research interests are focused on health psychology with special emphasis on psycho-
logical factors related to heart disease.

Scott C. Duncan, PhD, is clinical lecturer, Department of Psychiatry, at the University of Alberta,
Edmonton, Canada. He is a therapist in the Psychiatric Treatment Clinic of the Department and also
maintains a private psychotherapy practice.


Peter Fonagy, PhD, FBA, is Freud Memorial Professor of Psychoanalysis and director of the Sub-
Department of Clinical Health Psychology at University College in London. He is director of the
Clinical Outcomes Research and Effectiveness Centre and the Child and Family Centre, both at the
Menninger Foundation in Kansas. He is also director of research at the Anna Freud Centre, Lon-
don, a clinical psychologist, and a training and supervising analyst in the British Psycho-Analytical
Society in child and adult analysis.

Diana Fosha, PhD, is associate clinical professor of psychology at Adelphi Universitys Derner Insti-
tute of Advanced Psychological Studies. She is the author of The Transforming Power of Affect: A Model
of Accelerated Change (Basic Books, 2000) and of recent articles that integrate emotion theory, affective
neuroscience, and attachment research into the theory and technique of accelerated experiential-
dynamic psychotherapy. She maintains a private practice in New York City.

Cheryl Glickauf-Hughes, PhD, is a licensed psychologist, an adjunct professor at Emory University

Department of Psychiatry, and a private practitioner in Atlanta, Georgia. She has co-authored two
books and numerous book chapters and articles.

Paul A. Grayson, PhD, is director of New York University Counseling Service and clinical assistant
professor of psychiatry at New York University Medical School. Dr. Grayson is coauthor of Beating
the College Blues, a self-help guide for students, and coeditor of College Psychotherapy, a volume for
college psychotherapists.

Stanley I. Greenspan, MD, is clinical professor of psychiatry and pediatrics at George Washington
University Medical School, supervising child psychoanalyst at Washington Psychoanalytic Insti-
tute, and chairman of the Interdisciplinary Council for Developmental and Learning Disorders.

Jos Guimn, MD, PhD, is professor of psychiatry at Geneva University Medical School in Switzer-
land, director of the World Health Organization Collaborative Center for Research and Training in
Mental Health, and author of more than 150 papers and 30 books.

Mary F. Hall, PhD, LICSW, is currently an associate professor at the Smith College School
for Social Work where she teaches the Human Behavior in the Social Environment and Clinical Practice
sequences. Major administrative assignments have included service as director of Continuing Edu-
cation, clinical coordinator of the schools doctoral program, and area coordinator in the Field Work
Department for MSW interns. She has also held prior faculty appointments at the Shirley
Ehrenkrantz New York University School of Social Work and the Boston University School of Social
Work. Her current research interest is the interface between race and gender in pregnant substance

Lara Hastings was trained at Baylor University and is currently completing a postdoctoral at the
Child and Family Guidance Center in Dallas, Texas.

Cecile Rausch Herscovici, Lic, is a full professor of psychology at the Universidad del Salvador and
codirector of the Institute of Systems Therapy in Buenos Aires, Argentina. She is an approved su-
pervisor of the American Association for Marriage and Family Therapy, member of the American
Contributors vii

Family Therapy Academy, of the Academy for Eating Disorders, and of the European Council for
Eating Disorders. She is also editor of the Ediciones Granica Series in Eating Disorders.

Michael D. Kahn, PhD, ABPP, is professor emeritus of clinical psychology at the University of
Hartford in West Hartford, Connecticut, where he recently retired as director of academic affairs
for the Graduate Institute of Psychology. He is a fellow in the American Psychological Associa-
tion, the American Orthopsychiatric Association, and an approved supervisor of the American
Association of Marital and Family Therapy. He is a charter member of the American Family Ther-
apy Academy, member of several editorial boards, and author of more than 40 publications on sib-
ling relations and integrative therapies. Dr. Kahn maintains an active private practice in Hartford,
Connecticut, and is also a professional jazz musician in New England.

Rosemarie LaFleur Bach, PsyD, is a psychologist with The Institute of Living, Hartford Hospitals
Mental Health Network, and school clinician at the Chesire School System, contracted through Hart-
ford Hospital and the Grace Webb School, The Institute of Living. She is also in private practice.

Kenneth N. Levy, PhD, is assistant professor of the Clinical Psychology Doctoral Program, Gradu-
ate School and University Center, and Department of Psychology at Hunter College, City Univer-
sity of New York. He is also adjunct assistant professor, Psychology Section, Department of
Psychiatry, Joan and Sanford I. Weill Medical College of Cornell University. Dr. Levy also has a pri-
vate practice in New York, New York.

Leslie M. Lothstein, PhD, ABPP, is director of psychology at The Institute of Living, Hartford Hos-
pitals Mental Health Network, and has academic appointments at Case Western Reserve University,
University of Hartford, and UCONN Farmington Health Center. Dr. Lothstein serves as consultant
on risk assessment for sex offenders for the Department of Mental Health and Addiction Services,
Connecticut, and as vice chair of the Advisory Board, Whiting Forensic Division, Connecticut Valley

Rita E. Lynn, PsyD, has been a senior member of the Institute of Group Analysis (London) for more
than 30 years. She worked with Dr. Robin Skynner as his cotherapist. She was a teaching fellow at
St. Bartholomews Hospital (London) and held a post at the Medical College of the London Hospi-
tal, where she taught and consulted for 10 years. Until moving to the United States, she supervised
and trained the Institutes trainee analysts. She now lives in Los Angeles, where she is a professor at
the American Behavioral Studies Institute. She has authored numerous articles on the British Ob-
ject Relations approach to treatment.

Jeffrey J. Magnavita, PhD, ABPP, is a fellow of the American Psychological Association and is
both a licensed psychologist and marriage and family therapist. He is the founder of the Connecticut
Center for Short-Term Dynamic Psychotherapy and an adjunct professor of clinical psychology at the
University of Hartfords Graduate Institute of Professional Psychology. He is the author of three
books: Restructuring Personality Disorders, Relational Therapy for Personality Disorders, and Theories of
Personality: Contemporary Approaches to the Science of Personality, as well as numerous professional

J. Christopher Muran, PhD, is chief psychologist and director of the Brief Psychotherapy Research
Program at Beth Israel Medical Center, associate professor of psychiatry at Albert Einstein College
of Medicine, and associate editor for psychotherapy research. He has coedited The Therapeutic Al-
liance in Brief Psychotherapy, coauthored Negotiating the Therapeutic Alliance: A Relational Treatment
Guide, and edited Self-Relations in the Psychotherapy Process.

John S. Ogrodniczuk, PhD, is a clinical assistant professor in the Department of Psychiatry at the
University of British Columbia. His research interests include identifying matches between patient
characteristics and types of short-term, time-limited psychotherapies (group, individual, partial hos-
pitalization). Other interests include the use of psychotherapy for medically ill patients.

Ferruccio Osimo, MD, is a psychiatrist in Milan, Italy. He is adjunct professor of Dynamic Psy-
chotherapy, Universit Statale di Milano; president of IESA (International Experiential STDP Asso-
ciation), New York; a fellow of the American Academy of Psychoanalysis; and treasurer of OPIFER
(Organization of Italian Psychoanalysts-Federation and Roster).

Jeree H. Pawl, PhD, was the director of the Infant-Parent Program at the University of California, San
Francisco, for twenty years following her work with Selma Fraiberg at the Child Development Project
at the University of Michigan. She is also a current member of the board of directors of Zero to Three,
The National Center for Infants, Toddlers and Families, and a past president of that organization.

William E. Piper, PhD, is a professor in the Department of Psychiatry at the University of British
Columbia, Vancouver, Canada. He was president of the Society for Psychotherapy Research and of
the Canadian Group Psychotherapy Association, and is currently editor of the International Journal
of Group Psychotherapy.

Jeremy D. Safran, PhD, is professor of psychology at the New School for Social Research and Senior
Research Scientist at Beth Israel Medical Center. He has authored Widening the Scope of Cognitive
Therapy, coauthored Emotion in Psychotherapy, Interpersonal Process in Cognitive Therapy, and Negotiat-
ing the Therapeutic Alliance: A Relational Treatment Guide. He has also coedited Emotion, Psychotherapy,
and Change and The Therapeutic Alliance in Brief Psychotherapy.

Lynne R. Siqueland, PhD, is currently an adjunct assistant professor at the University of Pennsylva-
nia Medical School in the Center for Psychotherapy Research, where she has been involved in training
and supervision of supportive expressive dynamic therapy. She is also in private practice at the Chil-
drens Center for OCD and Anxiety specializing in the treatment of anxiety disorders.

Marion F. Solomon, PhD, is on the Senior Extension Faculty at UCLA, Department of Humanities,
Sciences and Social Sciences, and a professor at the American Behavioral Studies Institute in Los
Angeles. She is author of two books, Narcissism and Intimacy, and Lean on Me: The Power of Positive
Dependency in Intimate Relationships. She is coauthor of Short Term Therapy for Long Term Change, and
has coedited two books, Countertransference in Couples Therapy, and The Borderline Patient.

Maria St. John, MA, MFT, has been a senior therapist and clinical supervisor at the Infant-Parent
Program at the University of California, San Francisco, for nine years. She is currently a doctoral
Contributors ix

candidate in the Department of Rhetoric at the University of California, Berkeley, studying the
rhetorics of psychoanalysis.

Mary Target, PhD, is a senior lecturer in psychoanalysis at University College London and an asso-
ciate member of the British Psychoanalytic Society. She is deputy director of research at the Anna
Freud Centre, member of the Curriculum and Scientific Committees, chairman of the Research
Committee of the British Psychoanalytic Society, and chairman of the Working Party on Psychoan-
alytic Education of the European Psychoanalytic Federation.

Paul D. Thompson, MD, is director of Preventive Cardiology and director of Cardiovascular Re-
search at Hartford Hospital and professor of medicine at the University of Connecticut School of
Medicine. His research interests include the effects of exercise training in preventing and treating
heart disease and risk of sudden death during exercise.

Manuel Trujillo, MD, is director of psychiatry at Bellevue Hospital and professor of clinical psy-
chiatry and vice chair, Department of Psychiatry, at New York University School of Medicine.
Dr. Trujillo is a distinguished academic clinician, psychiatric administrator, innovator, and re-
searcher. He has been involved extensively in the fields of urban, cross-cultural, and community

Marolyn Wells, PhD, is director, professor, and licensed psychologist at Georgia State University
Counseling Center; joint appointment with the Department of Counseling and Psychological Ser-
vices; and private practitioner in Atlanta, Georgia. Dr. Wells has coauthored two books and nu-
merous book chapters and articles, and is a fellow of the Georgia Psychological Association.

r. Magnavita has collected a broad-ranging group of contributions, providing an open-
minded but critical, enthusiastic yet realistic educational experience. We are in good hands.
As the book illustrates, psychodynamic approaches to psychotherapy have proliferated,
stimulated by the limitations of traditional psychoanalysis and by infusions of existential thought,
with its emphasis on selfhood and being with the other, as in Kohuts self psychology, and of inter-
personal or social concepts, centering on relationship patterns and their reoccurrence in therapy, as in
object relations and intersubjective analysis. There is also the now widely accepted body of evidence
linking change in psychotherapy to the quality of the relationship between patient and therapist.
What is the conscientious reader to do with the many ideas celebrated here? They are a wonderful challenge
to efforts of selection and digestion.
For example, central to much clinical thinking are concepts of development. But what are we to do
with the problem of individual uniqueness, the unpredictable outcome of the myriad factors shap-
ing development? We need concepts of growth, but they must not constrain us. So often, the most re-
markable people emerge from the most difficult circumstances.
How do we select the unit to work with? Is it the traditional one-to-one, couples, or group work,
or even the home-bound therapy eloquently described here?
Bodies and urges have long been central concerns. There is also the brain as the organ of mental
representation, and affects that now rival ideas as the medium of change.
And how much pathological emphasis should we give, perhaps particularly, to the most frightening
presentations? The redemption of a pedophile is described in one of these chapters as partly the result
of his therapists inspired remark, Anyone who loves kids that much cant be all bad. By the pa-
tients own testimony, this changed his life.
Critical in these chapters is a contest between the usual subjects of therapeutic attentionid,
ego, and superego (plus the ego ideal that self psychology has made central)and the intersubjec-
tive field, in which the goal is to create a space where both parties can freely exchange what occurs
to each and where the two can arrive at understanding and change.
Patterns of sexuality are an age-old topic. Today, the ground has partly shifted to concerns with
power, respect, and equality.
And the problems of marriage, without which many of us might well be unemployed, seem in-
creasingly to have become an educational tool for the long-term study of one self in relation to
Here is perhaps as close to a practical answer as we are likely to get: Keep as much as we can put
into the back of our minds for those occasions that may prompt retrieval. Let our intuitive responses


guide us. Or the deeper, perhaps wiser, reflection offered here: Ours is an effort to plumb a depth of
thought untouched by words and a gulf of formless feelings untouched by thought! We work in the
dark. Our doubts should be cherished.
Meanwhile, neuroscience is teaching that the human brain is significantly a creation of each in-
dividuals experience, the individual self being formed by interaction with the world and others,
including our therapeutic selves. Rather than replacing these chapters, neuroscience is confirm-
ing and may someday be extending them.
The challenge of the work is immense, needing the lifetime that, often, we can give it. Let us cel-
ebrate the diversity of our efforts and the opportunities they provide. We have the chance, seldom
matched, to make lives better.

Professor of Psychiatry
Harvard Medical School
and The Cambridge Hospital

he world of psychotherapy theory and practice has changed markedly in the past 30 years.
During this time, many forces have converged, leading to major alterations in the therapeutic
landscape. Therefore, it seemed essential to produce this four-volume Comprehensive Handbook
of Psychotherapy to illuminate the state of the art of the field, and to encompass history, theory, prac-
tice, trends, and research at the beginning of the twenty-first century.
These volumes are envisioned as both comprehensive in terms of the most current extant knowl-
edge and as thought provoking, stimulating in our readers new ways of thinking that should prove
generative of further refinements, elaborations, and the next iteration of new ideas. The volumes are
intended for several audiences, including graduate students and their professors, clinicians, and re-
In these four volumes, we have sought to bring together contributing authors who have achieved
recognition and acclaim in their respective areas of theory construction, research, practice, and/or
teaching. To reflect the globalization of the psychotherapy field and its similarities and differences
between and among countries and cultures, authors are included from such countries as Ar-
gentina, Australia, Belgium, Canada, Italy, Japan, and the United States.
Regardless of the theoretical orientation being elucidated, almost all of the chapters are written
from a biopsychosocial perspective. The vast majority present their theorys perspective on dealing
with patient affects, behaviors or actions, and cognitions. I believe these volumes provide ample evi-
dence that any reasonably complete theory must encompass these three aspects of living.
Many of the chapters also deal with assessment and diagnosis as well as treatment strategies
and interventions. There are frequent discussions of disorders classified under the rubric of Axis
I and Axis II in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders with
frequent concurrence across chapters as to how treatment of these disorders should be ap-
proached. There are other chapters, particularly those that cluster in the narrative, postmodern,
and social constructivist wing of the field, that eschew diagnosis, based on the belief that the only
reality of concern is the one being created in the moment-to-moment current interaction: in this in-
stance, the therapeutic dialogue or conversation. In these therapies, goals and treatment plans are
coconstructed and coevolved and generally are not predicated on any formal assessment through
psychological testing. Whereas most of the other philosophical/theoretical schools have incorpo-
rated the evolving knowledge of the brain-behavior connection and the many exciting and illumi-
nating findings emanating from the field of neuroscience, this is much less true in the postmodern
wing of the field, which places little value on facts objectively verified by consensual validation and


One of the most extraordinary developments in the past few decades has been that barriers be-
tween the theoretical schools have diminished, and leading theoreticians, academicians, re-
searchers, and clinicians have listened to and learned from each other. As a result of this
cross-fertilization, the move toward integration among and between theoretical approaches has been
definitive. Many of the chapters in Volumes 1, 2, and 3 also could fit in Volume 4. Some of the dis-
tance between psychodynamic/object-relations therapies and cognitive-behavioral therapies has de-
creased as practitioners of each have gained more respect for the other and incorporated ideas that
expand their theory base and make it more holistic. This is one of the strongest trends that emerges
from reading these volumes.
A second trend that comes to the fore is the recognition that, at times, it is necessary to combine ju-
dicious psychopharmacological treatment with psychotherapy, and that not doing so makes the heal-
ing process more difficult and slower.
Other important trends evident in these volumes include greater sensitivity to issues surround-
ing gender, ethnicity, race, religion, and socioeconomic status; the controversy over empirically val-
idated treatments versus viewing and treating each patient or patient unit as unique; the
importance of the brain-behavior connection mentioned earlier; the critical role assigned to devel-
opmental history; the foci on outcome and efficacy; and the importance of process and outcome re-
search and the use of research findings to enhance clinical practice. There is a great deal of exciting
ferment going on as our psychotherapeutic horizons continue to expand.
These volumes would not have come to fruition without the outstanding collaboration and team-
work of the fine volume editors, Drs. Jeffrey Magnavita, Terrence Patterson, Robert and Sharon
Massey, and Jay Lebow, and my gratitude to them is boundless. To each of the contributing authors,
our combined thank you is expressed.
We extend huge plaudits and great appreciation to Jennifer Simon, Associate Publisher at John
Wiley & Sons, for her guidance, encouragement, and wisdom. Thanks also to Isabel Pratt, Editorial
Assistant, for all her efforts. It has been a multifaceted and intense enterprise.
We hope the readers, for whom the work is intended, will deem our efforts extremely worth-



Palm Beach Gardens, Florida


Leston Havens, MD

Florence W. Kaslow, PhD, ABPP

Jeffrey J. Magnavita



Stanley I. Greenspan

Helen E. Benedict and Lara Hastings

Jeree H. Pawl and Maria St. John

Peter Fonagy and Mary Target



Cecile Rausch Herscovici


Paul A. Grayson



Lynne R. Siqueland and Jacques P. Barber

Ferruccio Osimo

John F. Clarkin, Kenneth N. Levy, and Gerhard W. Dammann

J. Christopher Muran and Jeremy D. Safran

Cheryl Glickauf-Hughes and Marolyn Wells

Diana Fosha

Manuel Trujillo

M. Sue Chenoweth



Marion F. Solomon and Rita E. Lynn
Contents xvii

Michael D. Kahn

Jeffrey J. Magnavita


William E. Piper, John S. Ogrodniczuk, and Scott C. Duncan

Jos Guimn

Leslie M. Lothstein and Rosemarie LaFleur Bach


Jos Guimn

Ellen A. Dornelas and Paul D. Thompson

Mary F. Hall

Jeffrey J. Magnavita




Psychodynamic Approaches to Psychotherapy:

A Century of Innovations

he first century of modern psychotherapy incorporation of von Bertalanffys (1948) gen-
began with Freuds discovery of the un- eral systems theory has greatly expanded the
conscious and use of free association. We range of psychodynamic conceptualization and
are at an auspicious time at the turn of the cen- treatment. The twentieth century saw various
tury in the field of psychotherapy; much has groundbreaking theoretical innovations.
been achieved over the past century and many Many of the cutting-edge theoretical and tech-
new developments are occurring. Although nical developments in the field today are pre-
some believe that psychoanalysis has outlived its sented in this volume. Schafer (1999), himself
usefulness (Dumont, 1993), the discoveries of an analytic pioneer, comments: In the second
Freud and his followers have continued to spawn half of the 20th century, we have been witness to
remarkable developments that have created an remarkable changes in psychoanalytic theory
ever stronger amalgam of psychodynamic psy- and practice (p. 339). Prior to Freuds discovery
chotherapy. It is true that some aspects of psy- of free association, the use of hypnosis was the
choanalytic theory have not been empirically major technique for exploring and mapping the
supported or clinically validated, most notable, unconscious. With the advent of the technique
the psychosexual theory of development and of free association, a remarkable window into
the view that wishes rather than trauma account the unconscious process was opened. In this
for some forms of psychopathology. However, chapter, I review some of the essential develop-
many constructs remain vital and central to ments and advances that have occurred in psy-
present-day clinical practice (Magnavita, 1993b). choanalysis and psychodynamic psychotherapy
Many of these constructs have evolved and con- during the past century. Now, the beginning
tinue to evolve as other clinicians/theorists have of the twenty-first century, the field of psycho-
expanded, altered, and blended them, and as analysis can be seen to be enormous and
new breakthroughs in other disciplines have its influence on popular culture and lexicon
been made and incorporated. For example, the widespread. This chapter refers to only a small


fraction of the diversity of work that has evolved for the development of behaviorism. Freuds
from Freuds original conceptualization and ap- work stands as one of the intellectual milestones
proach to treatment. of the twentieth century (Schwartz, 1999). His
theory of psychoanalysis is considered by many
to be equivalent to the genius of Einsteins the-
THE OR IGI NS OF THE ory of relativity and Darwins theory of evolu-
T E R M P S YC H O T H E R A PY tion (Bischof, 1970). Freud offered remarkable
new ways of understanding the mind, psycho-
In the first chapter of this four-volume work, a pathology, and methods of ameliorating human
mention of the origins of the word psychother- emotional suffering. It is important to remem-
apy is in order. Long before terms such as psy- ber from a historical perspective that there was
chotherapeutics and psychotherapy were coined, a profound awareness of an unconscious realm
methods were employed for treating or minis- prior to Freuds work and that there is an im-
tering to various forms of sufferingwhether pressive 19th century literature that deals with
those were thought of as diseases, illnesses, unconscious psychic structures (Dumont, 1993,
ailments, disorders, syndromes, or other forms p. 195). Freud and his followers were large sys-
of sicknessthrough the use of psychological tem builders and beneficiaries of a vast litera-
rather than physical measures ( Jackson, 1999, ture that provided them with virtually all the
p. 10). The origins of the term psychotherapy insights bearing on the unconscious (p. 196).
suggest that it appeared toward the end of Psychoanalysis was born when Freud aban-
the 1880s, and had its roots in the Liebeault- doned hypnosis in favor of the technique of free
Bernheim school of suggestive therapeutics at association (Magnavita, 2002). Freud originally
Nancy (pp. 78). According to Jackson, it first was very taken with hypnosis and was influ-
appeared in a work by Hippolyte Bernheim en- enced by Charcot, who pioneered the technique.
titled Hypnotisme, suggestion, psychotherapie in Breuer also stoked his interest in hypnosis, but
1891. Essential to early healer-sufferer rela- S. Freud (1966) became frustrated with it:
tionships were factors such as hope, sympa-
thy/compassion, and the influence of the mind Originally Breuer and I myself carried out psy-
on the body. chotherapy by means of hypnosis; Breuers first
patient was treated throughout under hypnotic
influence, and to begin with I followed him in
this. I admit that at that period the work pro-
ceeded more easily and pleasantly, and in a much
shorter period of time. Results were capricious
and not lasting; and for that reason I finally
The discovery of the unconscious and the devel- dropped hypnosis. And I then understood that
opment of psychoanalytic methods ushered in an insight into the dynamics of these illnesses
a new form of scientific inquiry that may be had not been possible so long as hypnosis was
considered to be the birth of modern scientific employed. (p. 292)
psychology. This is not to minimize the other
paradigmatic shifts that occurred in other areas According to Havens (1973): Breuers method,
of psychology, such as the application of em- however, remained very close to Charcots. It
pirical methods to the study of various psycho- was symptom-centered, hypnotic, and objective
logical topics, for example, Pavlovs (1927) work (p. 90). Freuds method was a radical departure
with classical conditioning, which set the stage from Breuers and Charcots approaches.
Psychodynamic Approaches to Psychotherapy: A Century of Innovations 3

Fundamental to Freuds thinking about the four models all have an important place in psy-
mind was a simple assumption: If there is a chodynamic theory and are reviewed in more
discontinuity in consciousnesssomething the detail throughout this volume.
person is doing but cannot report or explain
then the relevant mental processes necessary to
fill in the gaps must be unconscious (Westen EGO PSYCHOLOGY: THE EMPHASIS
& Gabbard, 1999, p. 59). Freuds technique of free ON ADAPTATION
association allowed him and others who fol-
lowed to explore the dark recesses of the human The ego psychologists were especially inter-
psyche and to provide a map of the unconscious. ested in the functioning of the ego and empha-
He outlined the topographical contours with his sized the importance of adaptation (Hartmann,
delineation of the regions of unconscious, pre- 1958, 1964). Ego psychology set out to elaborate
conscious, and conscious zones. He proposed a the various aspects of healthy functioning or
tripartite model of human psychic functioning ego-adaptive capacity. This aspect of psychody-
with three structural components, now taught in namic theory was expanded by Horner (1994,
every introductory psychology course: the id, the 1995) and is an extremely valuable component
ego, and the superego. He offered an explana- of psychodynamic assessment, especially when
tion of how the instinctual sexual and aggressive conducting brief dynamic therapy.
forces were modulated and channeled either
neurotically into symptom formations or charac-
terologically into personality disturbance. His OBJECT-RELATIONS THEORY: THE EMPHASIS
emphasis on psychosexual development, much ON ATTACHMENT
of which has not been validated, represented one
of the first credible stage theories of human Winnicott viewed aggression as emerging from
development. Key concepts of repression and re- the disruption of attachment rather than ema-
sistance offered psychoanalysts a way to under- nating from an instinctual drive, as Freud sug-
stand how unacceptable impulses and painful gested (Winnicott, Shepherd, & Davis, 1989).
affects are lost to the conscious mind but are ex- This was the beginning of the object-relations
pressed in a variety of symbolic ways. Current- model, advanced by Melaine Klein (1975), W. R.
day psychotherapists of just about every ilk have D. Fairbairn (1954), Margaret Mahler (Mahler,
incorporated the concept of repression into their Pine, & Bergman, 1975), Annie Reich (1960),
theoretical systems. and others (Buckley, 1986). Object relations
recognized the primacy of attachment. Winni-
cott did not believe the infant could be studied
D E R I VA T I V E T H E O R E T I C A L outside the maternal-child dyad; he went so far
SYSTEMS to say There is no such thing as a baby, sug-
gesting that when you describe the baby, you
Psychoanalysis and psychodynamic concepts describe the dyad (Rayner, 1991, p. 60). This
are in constant evolution; they are reinter- theoretical development heralded the move
preted, transformed, and revitalized. A static away from the emphasis on the intrapsychic to a
system never could have provided the field with dyadic model. One of Winnicotts best-known
such a wealth of raw material that could be concepts is the good-enough mother, which
mined for over a century and still continue to implies that although one doesnt need perfect
be vital for each new generation. The following parenting, there must be at least a critical level

of parental function for uncomplicated develop- patients with deficit have not had the necessary
mental progression (Winnicott, Shepherd, & experiences that lead to a solid intrapsychic
Davis, 1989, p. 44). structure, as reflected by adaptive defenses and
a stable sense of oneself. Traditionally, these pre-
oedipal or, in many cases, prelanguage trauma
SELF PSYCHOLOGY: THE STUDY OF NARCISSISM patients have disturbances in primary attach-
ments. This may be the result of injuries that
Kohuts (1971, 1977) groundbreaking work ex- occurred from insufficient mirroring of the pri-
panding Freuds concept of narcissism enabled mary attachment figure or severe attachment in-
clinicians to begin to understand and treat an- sufficiency or disruption (Frank, 1999).
other form of pathological adaptation that was
not effectively treated with standard psycho-
analysis. Stolorow, Atwood, and Orange (1999) INTERPERSONAL PSYCHIATRY:
describe some of the inherent difficulties: THE DYADIC RELATIONSHIP

As useful and pathbreaking as his contextual- Harry Stack Sullivan (1953) developed an inter-
ization of narcissism may have been, Kohuts personal theory of psychoanalysis from his ob-
(1977) subsequent elevation of his psychology of ject-relational perspective. Havens (1973) writes:
narcissism to a metatheory of the total personal- Harry Stack Sullivan is the most original figure
itya psychoanalytic psychology of the self in American psychiatry, the only American to
has created some knotty problems. For one help found a major school (p. 183). Sullivan was
thing, self psychologys unidimensionality, the not so concerned with what transpired inside
exclusive focus on the narcissistic or selfobject people but rather focused on what occurred in
dimension of experience and of transference the relational field. This represented the most
its establishment, disruption, and repairhas
radical departure to that time from Freuds
tended to become reductive, neglecting and
structural drive theory of repressed emotions
failing to contextualize other important dimen-
sions. Even more problematic has been the
and intrapsychic forces. Sullivan believed that
insidious movement from phenomenology to needs were interpersonal and that the therapeu-
ontology, from experience to entitiesa move- tic process was based not on detached observa-
ment reminiscent of Freuds (1923/1961) shift tion but on being a participant-observer. In other
from the centrality of unconscious emotional words, the therapeutic matrix included two peo-
conflict to the trinity of mental institutions pre- ple who mutually contributed to the interp-
sumed to explain it. (p. 384) ersonal experience. He coined the term self-sys-
tem to account for the process of gaining satis-
Kohuts major contribution was in his em- faction and avoiding anxiety in interpersonal
phasis on the development of the self from the relations.
fragile infant state to the cohesive adult person-
ality. He added much to our understanding of Intersubjectiveness
patients who have disorders in their basic sense Many theorists and clinicians challenged
of self-esteem. This branch of psychoanalytic Freuds position that the therapist should be a
theory then began to provide a clearer differen- detached observer of the patients unconscious
tiation between those with emotional distur- process. In their book Faces in a Cloud: Subjectiv-
bances based on intrapsychic conflict who had ity in Personality Theory, Stolorow and Atwood
sufficient attachment experience and those pa- (1979) began to explore the issue of subjectiv-
tients with deficits in their self-structure. The ity and laid the groundwork for the study of
Psychodynamic Approaches to Psychotherapy: A Century of Innovations 5

intersubjectivity (Stolorow et al., 1999). They be quite robust and has continued to demon-
state: To be an experiencing subject is to be po- strate tremendous clinical utility and promi-
sitioned in the intersubjective contexts of past, nence in most current psychodynamic
present, and future (p. 382). This theory of in- conceptual systems. Researchers such as
tersubjectivity emphasizes what many current George Vaillant (1992) and Phebe Cramer (1987,
workers believe is vital: affect. The shift from 1991, 1998, 1999) have empirically documented
drive to affect, one of the hallmarks of our in- the validity of many of these defenses and their
tersubjective perspective, is of great theoretical developmental progression from lower to higher
importance, because unlike drives, which origi- levels. This stage-related fashion has been val-
nate deep within the interior of an isolated idated by Cramers (1991, p. 39) research. For ex-
mental apparatus, affectivity is something that ample, projection, a higher-level defense than
from birth onwards is regulated, or misregu- denial, seems to increasingly predominate dur-
lated, within an ongoing intersubjective sys- ing adolescence. Also, the research shows that
tem (Stolorow et al., 1999, p. 382). Affective anxiety does increase defensive functioning
theory (Ekman & Davidson, 1994) has only (Cramer & Gaul, 1988).
fairly recently been considered a topic worthy
of scientific focus.

In Freuds structural drive model, defensive Freuds metapsychology was a theory both of
functioning was accorded a prominent role in personality and of psychopathology, as well as a
protecting a person against anxiety and contin- method of treatment for emotional disorders.
ues to represent a major conceptual leap in un- Many conceptual elements of Freuds model
derstanding intrapsychic and interpersonal and subsequent developments continue to be
functioning. Freud considered defenses to be useful to current personality theorists and their
used both adaptively and in pathological form, contemporary models of personality (Mag-
and his original conceptualization continues to navita, 2002).
spawn new developments (Holi, Sammallahti, Psychoanalytic theorists/clinicians were very
& Aalberg, 1999). Key concepts in understand- interested in and contributed vast amounts of
ing the function of defenses include repression clinical case material and insight into an under-
and resistance. Defenses allow for repression of standing of character development, which serve
painful conflict in many patients and lead to as the basis for current diagnostic systems. Cur-
patterns of reenactment in others. Defenses rent psychopathologists and personality theo-
also turn into resistance to the therapists effort rists draw from over a century of conceptual
to relieve the suffering. Higher-level defenses developments, many of which are presented
serve to enrich and strengthen the ego organi- in this volume. Psychodynamic constructs have
zation (Schafer, 1968). shown remarkable explanatory power, includ-
Anna Freud (1936; Sandler, 1985) continued ing characteristic ways of coping with and de-
the process her father began of enumerating fending against impulses and affects; perceiving
and cataloguing defenses. Although for a time, the self and others; obtaining satisfaction of
academic psychologists eschewed the construct ones wishes and desires; responding to envi-
of defense as being irrelevant, it has proven to ronmental demands, and finding meaning

in ones activities, values, and relationships active therapy may be useful. If one wants to
(Westen & Gabbard, 1999, p. 82). Contemporary change ones character, it is not simply enough
theorists such as Millon (1999) and Kernberg to become aware of an unconscious schema
(1996) recognize what the early character ana- one also must make an effort not to engage it
lysts such as W. Reich (1949), Horney (1937), (p. 322). Based on their neurodynamic model of
and Fenichel (Fenichel & Rapaport, 1954) came personality, Grigsby and Stevens conclude:
to see as crucial: that personality configuration
should guide treatment. If the therapist repeatedly points out character
Personality disorders are endemic in contem- traits of which the patient is ordinarily unaware,
porary society, most likely the result of the In- their automatic performance is disrupted and
dustrial Revolution and the fragmentation of learning (in other words, a change in the neural
social structure and extended family units due networks subserving the schema) may occur. The
habitual behavior in a sense is unlearned as
to the mobility of members of modern society
one tends to become increasingly aware of the
(Magnavita, 2002). Clinicians are faced with the
behavior during its performance. . . . The process
fact that approximately half of those receiving is not easy, however, and the individual may be
mental health treatment are diagnosed either reluctant to go against the grain of character,
with a primary or comorbid personality disor- since it is uncomfortable and may require great
der (Merikangas & Weissman, 1986; Weissman, effort. (p. 322)
1993). Furthermore, 1 in 10 Americans qualify
for this diagnosis. Personality Disorders (PDs)
are a topic of considerable interest to both clini- T H E F O U N DAT I O N A N D
cians and researchers alike, in part because of A S C E N DA N C E O F
the high prevalence in the general population, AFFECTIVE SCIENCE
and because of the difficulty in treating these
conditions with standard forms of therapy Darwin (1998) demonstrated the importance
(Magnavita, 1999b, p. 1). New applications of and function of affect, and Freud offered a the-
psychodynamic treatment as well as cognitive, ory about the place of affect in human psycho-
cognitive-behavioral, interpersonal, and inte- pathology. The emphasis on repressed affect
grative approaches have been developed ex- as a source of anxiety and symptom formation
pressly for treating personality disorders and laid the foundation for todays affective science.
complex clinical syndromes, a combination of a The importance of affective functioning was em-
number of clinical syndromes and personality phasized by Silvan Tomkins (1962, 1963, 1991)
disturbance (Magnavita, 2000a). Most models of who advanced our understanding of the central-
psychotherapy have integrated or expanded to ity of emotional experience (Ekman & Davidson,
include the construct of unconscious process- 1994). For the most part, however, The topic of
ing. The effective treatment of these personality emotion was downplayed until the 1960s, a
disorders and complex clinical syndromes decade characterized by the advent of neobehav-
requires comprehensive treatment integration iorism and social learning theory, a movement
and, often, multiple models and combinations toward cognitivism, and greater interest in sys-
of treatment (Magnavita, 1999a; Millon, 1999). tems theory (Lazarus, 1991, p. 40). Neuroscien-
It is interesting to note that neuroscientific tists have also recognized the importance of
theory provides some support for the clinical emotion in understanding consciousness and
methods of Ferenczis and Reichs approaches to brain structuralization and organization. Emo-
treating personality pathology (Grigsby & tion primes the neuronal networks and assists in
Stevens, 2000). Here is where Sandor Ferenczis learning. We have come to understand why the
Psychodynamic Approaches to Psychotherapy: A Century of Innovations 7

intense emotional activation that occurs from about the prevalence of child sexual abuse by fa-
trauma, particularly when the trauma occurs thers and others, which has held up in current
early in development, has a significant impact time as a factor for Dissociative Identity Disor-
on personality formation. The universality of der and Borderline Personality Disorder, may
emotion seems to be a cross-cultural phenome- have been too much for Freud to accept. Some
non, although there is still some debate be- believe that he experienced a personal crisis
tween the cultural relativists and Darwinians. and worried about the impact that publishing
Nevertheless, it is fairly well established that these findings might have on his career. He has
there are six primary emotionsanger, fear, been harshly criticized and condemned by
sadness, disgust, happiness/joy, and surprise some modern-day writers (Masson, 1984, 1990).
and secondary emotions, which include guilt, According to Masson, the field of psychoanaly-
shame, and pride. Emotion is considered by sis suppressed the truth and did not take seri-
many contemporary theorists and clinicians to ously patient reports of incest and abuse.
be the lifeblood of the therapeutic process. For Rachman (1997) writes:
example, rage and its mobilization can be a
powerful transformative experience. Cum- Psychoanalysis has had a love/hate relationship
mings and Sayama (1995) write about a require- with the seduction theory and the treatment of
ment they believe is important: the incest trauma. In point of fact, the origins of
psychoanalysis are based upon Freuds discovery
Just as one would not trust a surgeon who fears that neurosis (hysteria) was caused by the sexual
the sight of blood, why trust a therapist who can- seduction of mostly female patients by their
not stand the sight of psychic blood when an fathers (and secondarily by surrogated father fig-
intervention that might be termed psychological ures). This was a remarkable discovery and es-
surgery is in the best interest of the patient. Mo- tablished psychoanalysis on a phenomenological
bilization of rage in the interest of health is a basisthat is to say, the data for the analysis
powerful technique in the hands of a compas- were generated from the subjective report of the
sionate therapist. It is deadly in the hands of a patient. (p. 317)
noncompassionate therapist. Similarly, the sur-
geons scalpel in the wrong hands would be inap- Freuds abandonment of this seduction/
propriate, sadistic, or fatal. (p. 54) trauma theory was a major setback for him and
the field of psychoanalysis. His replacement,
Affective science, like cognitive science, is be- wish fulfillment, had the aura of blaming the
coming a component part of understanding per- victim. Even though Freud abandoned trauma
sonality, psychopathology, and psychotherapy theory as the cause of many forms of psycho-
(Magnavita, 2002). pathology when he replaced the seduction the-
ory with an Oedipal one, others, most notably
Ferenczi (1933), continued to work along the
T H E DEV ELOPMEN T OF original line. Rachman (1997) suggests that
SUPPRESSION AND Ferenczis early findings and model of trauma
R E DI S C OV E RY O F are remarkably consistent with contemporary
T R AU M A T H E O RY trauma models (Herman, 1992): On the basis of
his work with difficult cases, Ferenczi verified
Freud believed that hysteria derived from child Freuds original seduction theory and empha-
sexual abuse. In fact, he believed that he had sized a return to the original findings (p. 317).
discovered the causative agent in all the major The suppression of Ferenczis findings is a dark
neuroses (Schwartz, 1999, p. 73). This finding spot in the history of psychoanalysis.

LONG-TERM major innovator and father of short-term dy-

P S YC H OA N A LY T I C namic psychotherapy, Ferenczi, was rejected for
P S YC H O T H E R A PY A N D his challenge to orthodox psychoanalysis (see
P S YC H OA N A LY S I S Osimo, this volume). Ferenczi (Ferenczi &
Rank, 1925) and generations of clinician-theo-
As Freuds psychoanalytic technique began to rists after him developed innovative technical
crystallize, his original experimentation and interventions. The analytic community tended
interest in brief treatment waned. The develop- to discredit them and reject their pioneering
ment of his technique of free association and efforts, though others, such as Alexander and
the emphasis on the development of the trans- French (1946), rediscovered them later (Mag-
ference neurosis lengthened the course of psy- navita, 1993a). The field of short-term dynamic
choanalysis. Psychoanalytic treatment provided psychotherapy is one example of how psychody-
Freud with the method he needed to probe fur- namic metapsychology continues to revitalize
ther the unconscious and begin the process of and shape the field of psychotherapy. In the past
organizing his observations and mapping the 20 years there has been a major resurgence of
intrapsychic terrain. This led to the develop- interest in this evolutionary branch of psychody-
ment of metapsychology. namic therapy. Many of the cutting-edge theo-
Traditional psychoanalysis, consisting of rists/clinicians are included in this volume. As
three to five psychotherapy sessions per week cost-effectiveness has become a major concern in
over the course of many years, has greatly re- the delivery of mental health treatment, contem-
ceded as a form of treatment due to the cost and porary clinicians increasingly revisit the works
time required. However, for those who are in- of the pioneering figures in short-term therapy
terested in becoming psychoanalysts, a training (Cummings & Sayama, 1995).
analysis is still required by some psychoana-
lytic institutes (Havens, 2001). This can be ex-
tremely beneficial for those who want to pursue A P P L I C AT I O N O F
a career as a depth therapist or to conduct P S YC H OA N A LY S I S A N D
psychoanalysis. At the turn of this century, most P S YC H O DY NA M I C T H E R A PY
practitioners who conduct long-term therapy are TO CH ILDR EN
highly influenced by the psychodynamic model,
with its emphasis on unconscious processes, The twentieth century witnessed another major
transference/countertransference, and establish- phenomenon when psychotherapeutic tech-
ing conditions where the patient can freely niques were modified for the treatment of child-
speak what comes to mind. This model of treat- hood disorders. Although Freud treated a few
ment offered a compendium of technical ad- children, it was not until his daughter Annas pi-
vances that have been well articulated in major oneering work at the Hamptead Child-Therapy
works, such as The Technique of Psychoanalytic Clinic was disseminated that the field of child
Psychotherapy (Langs, 1989). therapy emerged. Melanie Klein (1975), another
pioneering figure in theories and techniques of
child therapy, also contributed much to the field
EFFORTS TO ACCELERATE and modified analytic techniques in the treat-
PSYCHODYNAMIC TREATMENT ment of psychotic disorders (Sayers, 1991). Many
techniques of current-day play therapy have
From the very beginning, efforts were made their origins in the works of these two pioneer-
to accelerate the course of psychoanalysis. The ing women of psychoanalysis.
Psychodynamic Approaches to Psychotherapy: A Century of Innovations 9

A T R E N D T O WA R D new integrative theory of personality and

I N T E G R AT I V E T H E O RY A N D psychotherapy (Magnavita, 2002). The domain
A M U LT I PE R S PE C T I V E and scope of psychodynamic psychotherapy has
A P PROAC H T O been broadened even further with the incorpora-
P S YC H O T H E R A PY tion of triadic theory (Bowen, 1978) and a rela-
tional-systemic component (Magnavita, 2000b).
Many theorists have recognized the need for
integration in the field of personality theory
and psychotherapy (Magnavita, 2002). In fact, CRITICISM AND
William James (1890), the father of modern psy- CON TROV ER SY
chology, was one of the original proponents of
integrating seemingly disparate systems. He Numerous criticisms have been leveled against
believed that human nature was far too complex the field of psychoanalysis, some justified and
to be reduced to a theoretical, consistent sys- others less so. One of the major problems of the
tem. His clarion call did herald a movement, past century has been the isolation of psycho-
which gained credibility in the last quarter of analysis from other disciplines although there
the twentieth century. However, before integra- have been exceptions such as the interdiscipli-
tion could occur, a variety of models had to be nary work of Erik Erikson (Coles, 2000). This is
developed and tested over time. beginning to shift, although much potential
Gordon Allport (1968) also called for system- was lost for interdisciplinary cross-fertilization,
atic eclecticism. He realized that eclectic was a which would have strengthened and further
word of ill-repute (p. 3), but he believed that evolved the field. Another problem for which
theoretical assimilation offered promise. Theo- the field has been justly criticized is the relative
rists and clinicians had to wait until there were lack of interest in providing empirical support
sufficiently developed discrete theories or mod- for treatment effectiveness. Admittedly, this
els that could be integrated. The topic of psy- is an onerous task, but nevertheless a vital one.
chotherapy integration is covered extensively in Popular notions about psychodynamic treat-
volume 4 of the Comprehensive Handbook of Psy- ment have been difficult to dislodge. One im-
chotherapy and will not be recapitulated here. It portant assumption made by many regards
is important to note, however, that modern psy- the sanctity of the therapeutic relationship.
chodynamic theory and practice have been This has been reified to the point of not allow-
shaped by integration within psychodynamic ing the process to be studied, except third-
schools. hand. With the advent of low-cost audiovisual
Pine (1985) and Mann and Goldman (1982) equipment, the process of psychotherapy is now
have suggested a multiperspective approach capable of being readily studied by clinicians.
using the main theoretical perspectives as Inspired by the trendsetting and courageous
lenses, each offering a different view of a clinical work of pioneering practitioners who video-
phenomenon. Theoretical blending occurs as taped their treatment sessions, a new genera-
well when other theoretical constructs outside tion of clinicians is using this technology to
psychoanalysis, such as systems theory, have advance the field and provide more intensive
been assimilated (Messer, 1992). Dollard and training for psychotherapists. Clearly, there are
Miller (1950) presented a major effort in the clas- potential pitfalls and a possible downside to
sic volume Personality and Psychotherapy: An using videotape for research and training, but
Analysis in Terms of Learning, Thinking, and Cul- the advances in knowledge seem to outweigh
ture. This groundbreaking volume represented a potential difficulties.

S U M M A RY Cramer, P. (1998). Freshman to senior year: A follow-

up study of identity, narcissism, and defense
Psychoanalytic concepts, theories, and tech- mechanisms. Journal of Research in Personality, 32,
niques continue to have a strong influence on 156 172.
current psychodynamic psychotherapy, as well Cramer, P. (1999). Personality, personality disor-
as many other schools presented throughout ders, and defense mechanisms. Journal of Person-
ality, 67(3), 535 554.
this Comprehensive Handbook of Psychotherapy.
Cramer, P., & Gaul, R. (1988). The effect of success
Psychoanalysis offered the first comprehensive
and failure on childrens use of defense mecha-
metapsychology of personality function, psycho- nisms. Journal of Personality, 56, 729741.
pathology, and methods of psychological heal- Cummings, N., & Sayama, M. (1995). Focused psy-
ing. Many of the main evolutionary theoretical chotherapy: A casebook of brief, intermittent psy-
models of psychoanalysis continue to offer mul- chotherapy throughout the life cycle. New York:
tiple perspectives for understanding the vast Brunner/Mazel.
variations in human suffering confronted in Darwin, C. (1998). The expression of the emotions in
clinical practice by mental health clinicians. Use- man and animal (3rd ed.). New York: Oxford Uni-
ful methods and techniques of treatment have versity Press.
derived from these theoretical systems and offer Dollard, J., & Miller, N. E. (1950). Personality and psy-
the clinician at the start of the second century of chotherapy: An analysis in terms of learning, think-
modern psychotherapy an array of approaches ing, and culture. New York: McGraw-Hill.
Dumont, F. (1993). The forum: Ritualistic evocation
with which to assist those who come with the
of antiquated paradigms. Professional Psychology:
hope of being healed.
Research and Practice, 25(3), 195 197.
Ekman, P., & Davidson, R. J. (Eds.). (1994). The na-
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215 232. ington, DC: American Psychiatric Press.
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psychoanalysis. New York: Viking/Penguin.


Chapter 2 The Developmental Basis of Psychotherapeutic Processes

Chapter 3 Object-Relations Play Therapy
Chapter 4 Infant Mental Health
Chapter 5 Psychodynamic Approaches to Child Therapy

The Developmental Basis of

Psychotherapeutic Processes

hrough clinical work and observations The DIR model is based on relatively recent
with infants and young children, we have insights about three interrelated processes that
been able to more fully identify and de- contribute to a childs development. The first
scribe the early stages of ego development. We process involves early stages in a childs presym-
have also been able to describe stage-specific bolic functional emotional development (the build-
affective interactions and relationship patterns ing blocks of ego functioning and intelligence).
and individual motor and sensory processing These capacities include regulation and shared
differences that influence these early ca- attention; relating with intimacy; gestural, affec-
pacities. Taken together, these elements consti- tive reciprocal and social interactions; and creat-
tute the Developmental, Individual-Difference, ing and connecting symbols. The second process
Relationship-Based (DIR) model (Greenspan, involves each childs individually different underly-
1997a, 1997b). This model provides a develop- ing processing capacities, such as sensory modula-
mental framework for conceptualizing the psy- tion, auditory and visual-spatial processing, and
chotherapeutic process. The DIR framework, motor planning. Infants and young children dif-
which can be applied to both children and fer significantly in their sensory reactivity, au-
adults, includes an individualized developmen- ditory and visual-spatial processing, and motor
tal approach to assessment and diagnosis and planning and sequencing, and these differences
the practice of psychotherapy and psychoanaly- are important contributors to ego structure, char-
sis. It also includes developmental insights into acter, and symptom formation. The third process
a range of disorders (e.g., anxiety, depression, involves the role of relationships and affective inter-
character, and personality disorders, autism, actions in facilitating a childs intellectual and
mental retardation, learning disorders) and in- emotional growth. For example, the earliest cog-
forms a comprehensive intervention program nitive structures and sense of causality do not, as
for children with autistic spectrum disorders Piaget believed, first arise from early sensorimo-
and other special needs. tor (cognitive) explorations. They arise from even


earlier affective interactions between a baby and presymbolic levels often involve basic structure-
his or her caregiver (e.g., a smile begetting a building, affective interactions. In considering
smile). At each stage of early cognitive develop- different types of problems and personalities,
ment, emotional interactions lead the way. The one is often tempted to go where the action is,
meaning of words, early quantity concepts (a getting caught up in the conflict of the moment
lot to a 21 2 -year-old is more than he expects; a (the family drama or, understandably, the pa-
little is less than he wants), logical and abstract tients anguish). However, a full developmental
thinking, and even important components of profile includes early presymbolic structures as
grammar depend on specific types of emotional well as dynamic contents (i.e., a full profile in-
interactions (Greenspan, 1997b; Greenspan & cludes the drama and the stage on which
Wieder, 1999). Similarly, early ego development the drama takes place).
can now be traced to specific types of early The profile begins with a description of indi-
emotional interactions. For example, complex viduals regulatory capacities: the ability to re-
reciprocal affective interactions in the second main calm, attentive, and process and respond
year of life enable children to begin integrating in an organized way to the variety of sensations
affective polarities and form a more integrated around them. Next is a rich description of their
sense of self. style and capacity for engaging, followed by
their capacity to enter into reciprocal affective
gesturing in a full range of emotional and the-
T H E DI R MODEL AN D matic realms. Then comes their ability to orga-
CONSTRUC T I NG T H E nize their behavior and affects into purposeful
DE V E L O P M E N TA L P R O F I L E patterns that constitute a presymbolic sense of
self and take into account the expectations of
In the DIR model of development, there are three their environment. These presymbolic capaci-
dynamically related influences on development. ties are followed by the ability to represent
Biological, including genetic, influences affect wishes, affects, and ideas, use them imagina-
what the child brings into his or her interactive tively, and then create bridges between differ-
patterns. They do not act directly on behavior, ent represented experiences as a basis for a
but on part of the child-caregiver interactive pro- representational sense of self and other, a dif-
cess. Cultural, environmental, and family factors ferentiated sense of time and space, and affect
influence what the caregiver or interactive part- proclivities, the capacity to construct a sense of
ner brings into the interactions. The resultant reality and to move toward abstract and reflec-
child-caregiver interactions then determine the tive thinking.
relative mastery of six core developmental In each area of the profile, one looks for com-
processes (e.g., regulation, relating, preverbal petencies as well as deficits (where the ability is
affective reciprocity). Symptoms or adaptive be- not attained at all). One also looks for constric-
haviors are the result of these stage-specific af- tions (where the ability is there but not at its full,
fective interactions. robust, and stable form). Constrictions may in-
The DIR model enables the clinician to con- volve a narrowing of the thematic or affective
struct a detailed developmental profile based on range (only pleasure, no anger), a lack of stability
these dynamic processes. A special feature of (the child can engage, but loses this capacity and
the profile is its focus on early presymbolic becomes self-absorbed whenever anxious), or a
levels of ego functioning. Higher levels of ego lack of motor, sensory, cognitive, or language
functioning are explored through an elabora- support for that capacity (e.g., the child can be as-
tion of the content of the patients mental life; sertive with words, but not with motor patterns).
The Developmental Basis of Psychotherapeutic Processes 17

After an individuals profile is constructed, connected to the affect (which might be a smile
two contributions to the challenges or strengths as she banged the doll aggressively). She was
of that profile are explored. These are the biolog- purposeful and organized in her interactions
ically based regulatory contributions (i.e., motor and play, but during times of transitions, going
and sensory processing differences) and the from one activity to another, she would seem to
family, cultural, and interactive contributions. get lost in her own world again, and the thera-
pist would have to work to regain a sense of or-
ganized interaction. She used lots of ideas and
CASE EXAMPLE OF THE DIR was able to build bridges between her ideas (an-
DE V E L O P M E N TA L P R O F I L E swering what and why questions), but her
imaginative play was focused on only a few
To illustrate the importance of constructing themes in a very intense, repetitive manner. She
such a profile, consider the following example. had dolls undressing and had one doll doing ag-
A 6-year-old girl presented with an inability gressive things to the genital areas of the other
to talk in school and an ability to talk only to dolls. In one scene, she had monsters blocking
her mother. She had always been a dependent, some of the dolls from getting their clothes
clingy, quiet, and passive little girl, had a lot of back, with sadistic fights ensuing. In this profile,
separation anxiety in going to school, and al- then, we see a child who has marked constric-
ways had difficulty interacting with other chil- tions at the presymbolic areas of development
dren. However, her difficulties were getting around attention, engagement, and reciprocal
worse over the prior two years. It will be in- affective gesturing and cuing, as well as a preoc-
structive now to look at the profile that was con- cupation and constriction at the symbolic or rep-
structed for this little girl from numerous play resentational level.
sessions. She took a long time to connect with In cases like this, with a little child who can
the therapist doing the evaluation. She would elaborate themes, I found that many therapists
initially fiddle with toys or other objects in a would focus predominantly on the content of
seemingly self-absorbed way and only with the childs themes (in this case, her preoccupa-
many vocal overtures would she enter into a tion with sexual and aggressive themes) and
state of shared attention, where she was pay- obviously want to explore the family dynamics
ing attention to the therapist. The therapist that were contributing, including questions of
had to maintain a fairly high level of activity to sexual abuse, sexual play with other children or
keep this state of shared attention. Similarly, babysitters, or overstimulation due to exposure
although she had some warmth and the thera- to sexual materials or witnessing sexual scenes.
pist found herself looking forward to seeing But our profile, in addition to alerting us to
the child, the therapist kept feeling she had to these factors, also alerts us to the fact that there
work hard to maintain the sense of engage- is a lack of mastery of critical early phases of de-
ment. There was some emotional expressive- velopment, including an ability for consistent
ness and some back-and-forth smiling and attention, engagement, and the earliest types of
smirking, suggesting some capacity for emo- affective reciprocity. When, for example, chil-
tional reciprocity, but often, the emotional re- dren cannot match the content of their interests
sponses were either very inhibited (lacking) or to their affects, it often suggests that early in
global, with seemingly inappropriate giggling life, a caregiver was unable to enter into recip-
or repetitive, tense, discharge-oriented play rocal gesturing around certain affective incli-
(such as banging a doll). Often, the content of nations. For example, the way children learn to
the play, such as banging the doll, was not match content with affect is by demonstrating

different affects as an infant in association with prerepresentational capacities, the therapist

different kinds of behavior, perhaps knocking needed to work with the parents interactions
the food off the table with a look of defiance or with their daughter to foster mastery of these
surprise. In return, they get a reciprocal affect basic interactive capacities around attention,
or gesture back from Mommy or Daddy. If the engagement, and reciprocal affective inter-
parent freezes or withdraws at that moment, change. She also began working on the issues
however, there is no return affective gesture directly in therapy, paying more attention to af-
and the childs content (i.e., throwing the food fects and gestures, the tone of the relationship
on the floor) now has no reciprocal affects as- itself, and the understanding of verbal content.
sociated with it. As a consequence, the child A developmental profile systematically done
doesnt develop the rich connections between will help the therapist look in a balanced way at
interactive affects and content. Obviously, var- the whole individual and, most important, will
ious types of processing problems can also help the therapist raise hypotheses about where
contribute. the challenges may lie and even some potential
In terms of regulatory patterns in this case, reasons for the challenges. The profile enables
the child did have some overreactivity to touch the therapist to develop a therapeutic strategy
and sound and some mild motor planning to further explore the initial hypothesis. With-
problems, but was quite competent in her au- out such a systematic profile, its easy for the
ditory and visual-spatial processing abilities. therapist to get lost in the content or symptoms
There were both physical and interactive differ- of the moment without a full appreciation of all
ences contributing to her profile. the areas of challenge and the likely experi-
As we looked at her developmental profile, we ences that might be associated with them.
were therefore alerted to the fact that there were In some respects, by focusing on the patients
a number of prerepresentational issues that need fundamental capacities, the developmental pro-
to be worked on in therapy as well as issues in- file may reveal aspects of the patients develop-
volved in her emerging symbolic world. As we mental history that the patients memories
were speculating from her profile, we wondered are unable to reveal. The processes that the de-
whether there were some profound difficulties velopmental perspective helps us observe reveal
ongoing in the early relationship between this where the patient has been and, even more im-
child and her caregivers as well as some current portant, where he or she needs to go.
experiences that were leading to her preoccupa-
tion with sex and aggression. We also wondered
about current trauma severe enough to disrupt T H E D E V E L O P M E N TA L LY
basic presymbolic abilities (if, for example, they BA S E D P S YC H O T H E R A P E U T I C
were formerly attained). PROCE SS W I TH CH ILDR EN
As a result of this profile, the therapist who A N D A DU LT S
had started with twice-a-week sessions to work
on the content of the childs play and once-a- The individualized profile and the DIR model
month sessions with the parents shifted her ap- can inform the practice of psychotherapy and
proach. It was decided that it was important to psychoanalysis. Most therapists use a develop-
develop a deeper alliance with this family to mental framework in their clinical work. Many
explore the nature of this little girls preoccu- recent developmental discoveries, however, have
pation with sexual and aggressive content and, not yet found their way into this evolving frame
therefore, they needed to be seen at least once a of reference. See Developmentally Based Psycho-
week. It was also determined that because therapy (Greenspan, 1997a) for a detailed de-
there were a number of constrictions of the scription of this approach.
The Developmental Basis of Psychotherapeutic Processes 19

OBSERVING AND WORKING WITH FUNDAMENTAL capacities when they act to maintain a calm,
DEVELOPMENTAL PROCESSES alert, focused state and organize behavior, af-
fect, and thoughts.
The overarching principle of a developmen- We have observed individual differences in
tally based approach to psychotherapy is mo- constitutional-maturational characteristics that
bilization of the developmental processes contribute to ones regulating capacities. They
associated with an adaptive progression of the begin in infancy and then can be observed in
personality throughout childhood and adult- older children and adults. These maturational
hood. The therapeutic relationship is the vehi- patterns may change as one develops, however.
cle for mobilizing developmental processes in The following list may prove helpful in observ-
the therapy sessions and for helping the pa- ing regulatory differences:
tient create developmentally facilitating ex-
periences outside the therapy situation. The 1. Sensory reactivity, including hypo- and hy-
critical difference between the developmen- perreactivity in each sensory modality (tac-
tally based approach to the psychotherapeutic tile, auditory, visual, vestibular, olfactory).
process and other approaches is the degree to 2. Sensory processing in each sensory modal-
which early stages in development are ob- ity (e.g., the capacity to decode sequences,
served and worked with. Typically, most ther- configurations, or abstract patterns).
apists work with verbal material with adults 3. Sensory affective reactivity and process-
and verbal and play themes with children. If ing in each modality (e.g., the ability to
earlier levels are worked with (e.g., separation- process and react to degrees of affective
individuation), they are worked with in terms intensity in a stable manner).
of verbal or symbolic elaborations. Early stages 4. Motor tone.
can be worked with more directly in terms of 5. Motor planning.
critical structural features. These involve the
capacity to self-regulate; relate to others; pro- Sensory reactivity (hypo or hyper) and sen-
cess, comprehend, and use preverbal affective sory processing can be observed clinically: Is
gestures to define a sense of intent and form a the child or adult hyper- or hyposensitive to
preverbal sense of self and integrate basic touch or sound? Do sounds of motors or of a
emotional polarities; and learn to represent af- noisy party overwhelm the individual? Is a gen-
fects and experiences and broaden and differ- tle touch on the hand or face reacted to by a
entiate ones inner affective, symbolic life. startled withdrawal? The same questions must
To mobilize these fundamental developmental be asked in terms of vision and movement in
processes, however, we must be able to identify space. In addition, in each sensory modality,
them in children and adults. Brief descriptions processing of sensations occurs. Does the 4-
of these processes appear below. (For more com- month-old process a complicated pattern of
plete discussion, including clinical observations information input or only a simple one? Does
and developmental studies, see Greenspan, 1989, the 412 -year-old have a receptive language prob-
1992 , 1997a, 1997b.) lem and therefore is unable to sequence words
together or follow complex directions? Is the
Level 1 young adult prone to get lost in his own fan-
The first level of development involves regulation tasies because he has to work extra hard to de-
and shared attention, that is, self-regulation and code the complex verbal productions of others?
emerging interest in the world through sight, Is the 3-year-old an early comprehender and
sound, smell, touch, and taste. Children and talker, but slower in visual-spatial processing?
adults build on this early developing set of If spatial patterns are poorly comprehended, a

child may be facile with words, sensitive to attributed to lack of motivation or emotional
every emotional nuance, but have no context, conflicts. Observing carefully and obtaining a
never see the forest; such children get lost in history of regulatory patterns will make it pos-
the trees. In the clinicians office, they may sible to separate maturational variations from
forget where the door is or have a hard time pic- other factors and also determine how many
turing that mother is only a few feet away in the factors often operate together.
waiting room. Similarly, adults may find it dif- In addition, there are feelings and themes that
ficult to follow instructions or easily get lost in emanate from the processes of self-regulation,
new settings. They may also have difficulty see- attention, and interest in the world. Children
ing the emotional big picture. If the mother is and adults get a sense of confidence in their abil-
angry, the child may think the earth is opening ity to be calm, regulated, and interested in the
up and he is falling in; he cannot comprehend world. They also may have a feeling of basic se-
that she was nice before and will probably curity in the way their body works, especially
be nice again. Similarly, adults may be over- their perceptual and motor equipment. A sense
whelmed by the emotion of the moment, losing of control often goes along. When difficulties
sight of the past or future. during this stage arise, we not infrequently see
It is also necessary to look at the motor sys- themes concerned with being overwhelmed and
tem, including motor tone, motor planning (fine falling apart and, at times, attempts at omnipo-
and gross), and postural control. A picture of the tent overcontrol to create order and manipulate
motor system will be provided by observing how select sensory or motor experiences.
a person sits or runs, maintains posture, holds a We are finding that when certain processing
crayon or pen, hops or draws, and makes rapid patterns are coupled with certain environmental
alternating movements. Security in regulating patterns, they can intensify each other. We can
and controlling ones body plays an important observe, therefore, what Freud had anticipated:
role in how one uses gestures to communicate. the ways in which the biological influences on
Motor planning and sequencing (i.e., the ability character structure and the selection of defenses
to initiate and carry out a series of actions to operate (Greenspan, 1989). For example:
solve problems) is an especially important com-
ponent of initiative, problem-solving, executive Individuals who are overreactive to touch
functions (planning, judgment, etc.) and many or sound and have stronger auditory pro-
ego functions. Motor planning influences the cessing abilities and relatively weaker
ability to regulate dependency (being close or visual-spatial ones tend toward the hys-
far away), the confidence in regulating aggres- terical, depressive, and anxiety disorders.
sion (Can I control my hand that wants to hit?), Those who have difficulty with movement
and the ability to comprehend social sequences in space tend toward phobic disorders.
and follow through on tasks. Individuals who are underreactive to sen-
The constitutional and maturational vari- sations and have low motor tone tend
ables may be thought of as regulatory factors. toward more withdrawn behavior. They
When they contribute to difficulties with at- tend to escape into fantasy and, in the ex-
tending, remaining calm and organized, or treme, evidence more schizoid and autistic
modulating affect or behavior and therefore patterns.
are a prominent feature of a disorder of behav- Individuals with hyporeactivity to sensa-
ior, affect, or thought, such a disorder may be tions along with stimulus-craving patterns,
considered a regulatory disorder (Greenspan, coupled with high activity levels and or-
1992). Regulatory differences sometimes are ganized gross motor patterns, tend toward
The Developmental Basis of Psychotherapeutic Processes 21

risk taking and, if there is emotional depri- optimism. In contrast, difficulties with this
vation, antisocial patterns. stage and its processes can be associated with
Individuals with relatively stronger visual- feelings and themes of isolation, emptiness,
spatial processing and overreactivity to greed, preoccupation with inanimate objects,
certain sensations tend toward patterns and overreaction to expectable relationship
characterized by negativism, stubborn- challenges, such as temporary losses or disap-
ness, and compulsiveness. pointments. At times, one also sees compensa-
Individuals with marked motor planning tory themes centered around grandiosity and
and sequencing challenges tend toward at- the need for unconditional love.
tentional problems.
Level 3
When environmental conditions enhance flex- The third level involves purposeful communication:
ibility rather than pathology, we tend to see intentional, preverbal affective communications
healthy character formation, but with a tendency or gestures. These gestures include facial ex-
toward one or another of these characteristics. pressions, arm and leg movements, vocaliza-
For example, instead of panic or anxiety or de- tions, and spinal posture. From the middle of
pression, we see a sensitive person who is reac- the first year of life onward, individuals rely on
tive and alert to others moods and behaviors. gestures to communicate. Initially, during the
stage of purposeful communication, simple re-
Level 2 ciprocal gestures such as head nods, smiles, and
The second level of development involves forming re- movement patterns serve a boundary-defining
lationships. Relationship patterns, once formed, role. The me communicates a wish or intention
continue and further develop throughout the and the other or you communicates back
course of life. Most clinicians have a great deal some confirmation, acknowledgment, or elabora-
of experience in monitoring the quality of relat- tion on that wish or intention.
edness. But sometimes, the clinician ignores the When there have been distortions in the
quality of engagement while working on spe- emotional communication process, as occurs
cific ideas or thoughts, so that indifference, when a mother responds in a mechanical, re-
negative feelings, or impersonal or aloof pat- mote manner or projects some of her own de-
terns continue longer than necessary. pendent feelings onto her infant, the infant and,
For example, the child who walks in and goes later, the child and adult may not learn to appre-
right for the toys, ignoring the clinician, is dif- ciate causal relationships between people at the
ferent from the child who looks at the clinician level of compassionate and intimate feelings.
with a twinkle in his eye and points to the toys, This situation can occur even though causality
waiting for a warm accepting smile. The adult seems to be developing in terms of the inanimate
who strides in the office and makes a beeline for world and the impersonal human world.
the new painting on the wall with nary a wave During an interview, a child or adult demon-
or a nod in the therapists direction may be es- strates mastery of this stage by using purpose-
chewing any initial sense of engagement to ce- ful gestures, such as facial expressions, motor
ment a relationship. One observes if there is a gestures (showing you something), or vocaliza-
range of affects used to try to establish a sense of tion. Aimless behavior, misreading of the other
connectedness and relatedness: warmth, pleas- persons cues, or fragmented islands of pur-
ure, intimacy, and trust. poseful interaction together with aimless or
In addition, with this stage, there are often self-absorbed behavior indicate challenges at
feelings and themes of positive nurturance and this level. The ability to be purposeful around

some affects but not others (e.g., around love sense of warmth, and compassion to the devel-
but not assertiveness) also indicates limitations. opmentally advanced emotion of empathy. Af-
Themes that characterize this level can in- fects can be combined with verbal themes,
clude a can do sense of mastery. Difficulties showing a pattern during a session.
with this stage may be associated with the sense How does the person begin the session? What
that interactions can be chaotic and fragmented, happens as he or she moves through the first
helplessness about ones ability to have impact third to the middle of the session, and then from
on others, passivity, fears of unpredictability, the last third to saying good-bye? Follow the
and lack of an emerging differentiation of differ- change in affect. For example, an individual
ent feeling states, wishes, and intentions. may come in showing apprehension and tenta-
This stage of two-way, causal, intentional tiveness, become warm and then competitive;
communication (or somatopsychologic differen- show concern with issues of sibling or spousal
tiation) indicates processes occurring at the so- jealousy and rivalry; and then express concern
matic (sensorimotor), affective, and emerging about separating from the therapist toward the
psychological levels. It is a foundation for self end of the interview. Another patient may
and other boundaries and, therefore, for basic show only one or two affects during the entire
ego functioning and reality testing. interview.
The basic emotional messages of lifesafety
Level 4 and security versus danger, acceptance versus
The fourth stage, behavioral organization or a com- rejection, approval versus disapprovalcan all
plex sense of self, involves more complex affective and be communicated through facial expressions,
social patterns involving many circles of inten- body posture, movement patterns, and vocal
tional communication with the aim of solving tones and rhythm. Words enhance these more
problems (e.g., a child taking an adult to the basic communications, but most of us form split-
shelf to get help in getting a book or toy). Pat- second judgments regarding a new persons
terns that began with these early capacities can dangerousness or approachability from his or
be seen in many behaviors in older children and her gestures before the conversation even gets
adults, including comprehending simple ges- started. In fact, if a person looks threatening
tural cues, such as eye contact, finger pointing, and says You know, Im your friend, we tend
interjections or vocalizations, facial expressions, to believe the gestures and discount the words.
motor gestures, and different subtle affect ex- At a more subtle level, gestural communica-
pressions. The therapist should note whether pa- tion also relays to us what aspects of our own
tients initiate such gestures and in turn respond emotions are being accepted, ignored, or re-
to the clinicians countergesturing with a fur- jected. The raised eyebrows and head nods we
ther gesture of their own. perceive quickly tell us whether the person hear-
The different emotions patients reveal sug- ing our message is reacting with excitement,
gest the range and type of affect gestures they anger, curiosity, or detachment. More important,
can communicate. The range and degrees of spe- our ever emerging definition of the uniqueness
cific affects can be very broad. In the aggressive of our very self is dependent on how others react
domain, for instance, there are gradations that to our own special tendencies with preverbal
run from assertive, competitive, and mildly ag- gestures. Differential responses stir different af-
gressive behavior to explosive and uncontrolled fects and are part of the process that refines and
rage. The same is true for the affectionate and defines our maturing behavior and sense of self.
caring domain, which ranges from promiscuous How is our mischievous behavior and devilish
emotional hunger, to mild affection, a sincere grin responded to: with an accepting smile or a
The Developmental Basis of Psychotherapeutic Processes 23

head-shaking frown? Our natural inclinations Feelings and themes emanating from this
toward mischievousness, laziness, and a whole stage include assertiveness, exploration and cu-
host of other personality traits are in part riosity, pleasure and excitement, anger and ag-
accepted and supported or refined or squelched gression, a beginning sense of gender (in an
as a result of the impact of this nonverbal com- infant or child), and an initial capacity for self-
munication system. The nonverbal, gestural limit setting. In contrast, if there are challenges
communication system is therefore a part of at this level, the child or adult may experience
every dialogue contributing to our sense of who patterns such as narcissistic self-absorption or
we are and what we perceive. preoccupation with polarized feeling states and
In fact, it is through this system that we first themes such as grandiosity, suspiciousness, so-
integrate different affective polarities such as matic concerns, and global self-deprecation. One
love and hate. One may observe whether a per- may also see preoccupation with fragmented
son can integrate, as part of one long interactive partial needs and wishes, for example, certain
pattern, different affective states or if each state types of limited pleasures.
is a separate island.
The clinician who focuses only on a persons Level 5
words may miss an underlying, critical lack of The fifth level involves the elaboration and sharing of
organized gestural communication ability. The ideas and meanings. The individuals ability to
spacey child who floats in and out of the room, represent or symbolize experience is illustrated
or misreads the implied social rules of the play- in the pretend play of a child or the verbal ex-
room and hides toys, ignoring the therapists pression of the adults worries and anxieties.
facial expressions and sounds; the adult who Building on the capacities of this level, chil-
misreads the intentions of others, seeing, for ex- dren and adults use ideas to indicate their
ample, assertiveness as anger or dependence as wishes, intentions, and expectations. For exam-
rejectionboth betray an inability to fully pro- ple, children may indicate a certain degree of
cess organized gestural communications. trust or cautiousness about trying to define what
Complex, self-defining gestures (such as is going to happen in the clinical interview. They
opening and closing 30 or 40 circles of communi- may stage pretend play sequences, featuring
cation in a row) emerge in the second year of life hurricanes and disasters or children getting in-
and are further developed and seen in increas- jections. They may be indicating their expecta-
ingly complex, nonverbal interactions, where tions of this new relationship. Children whose
patterns are communicated and comprehended. play focuses on dolls being fed and everyone
As one observes gestures expressing a complex being happy may be indicating a different set of
sense of self, one should take note not only of expectations about the emerging relationship
the range of affects but the richness and depth with the clinician. The adult who talks about re-
of affects observed. Are they superficial, as if lationships in the past that have led to disap-
the person is simply playacting or imitating pointment is giving different messages than the
someone? Or do they convey a sense of personal patient who talks of satisfying relationships.
depth? In other words, is one able to empathize This level in relating not only involves using
with the way the patient is feeling? One also representations or symbols in play and/or ver-
observes the complexity and organization of bal communication, but sometimes is evidenced
gestures. Are there many gestures that work by the use of subtle spatial communications,
together to convey an emotional theme such as such as building complicated towers or houses
competitiveness or a wish for closeness and de- with passages in them. Older children and adults
pendency or both? sometimes use a picture to convey a feeling or

complex meaning. Adults often use descrip- knowing what is real and unreal, regulating im-
tions of visual imagery from dreams or free as- pulse and mood, and the capacity to focus at-
sociations. One can observe the depth and tention and concentrate to learn and interact.
range of themes developed at the representa- The capacity for differentiating internal repre-
tional level. Are there only shallow, repetitive sentations becomes consolidated as object con-
dramas or rich, deep ones with a range of stancy is established (Mahler, Pine, & Bergman,
emotions? 1975). As the capacity for a differentiated inter-
From this fifth stage, we often observe the nal symbolic world is consolidated, children
construction of a rich pattern of imagery con- become capable of progressing into higher lev-
cerning inner wishes, ideas, and feelings. Fan- els of ego development. Briefly, as children
tasies emerge that are part of an elaborate move into latency and become more concerned
imaginative capacity. Fantasies can embrace with peers, they begin to appreciate emotional
most of the major themes of life, from depen- complexity such as gray area feelings.
dency and separation anxiety to curiosity, as- At the sixth level, children can make connec-
sertiveness, and aggression. In short, a rich, tions between different ideas and feelings (I
intrapsychic symbolic life is created. In con- am mad because you took my toy) and balance
trast, challenges at this level can be associated fantasy and reality. Adults similarly can hold
with a paucity of emotionally rich ideation, logical conversations about wishes and feelings
fears of separation, concerns with danger, and and make connections (I feel lonely and needy,
a tendency to experience and rely on action and I get helpless when I feel that way. Some-
patterns or somatization, rather than ideas or times I get mad because I cant stand being so
symbols. vulnerable).
Shared differentiated meanings involve the
Level 6 communication of ideas to another person and
The sixth level involves creating logical bridges be- building on the other persons responses, not
tween representations or ideas. Shared meanings just having ideas. Some people communicate
are used both to elaborate wishes and feelings only their own ideas, never building on the re-
and to categorize meanings and solve problems. sponses of the other person. In both childhood
As logical bridges between ideas are established, dramas and adult conversations, they talk but
various types of reasoning and appreciation of do not easily absorb or reply to someone elses
reality emerge, including dealing with conflicts ideas and comments. For example, when a 4-
and distinguishing what is pretend from what is year-old girl came home from preschool, she
believed to be real. As children become capable played out scene after scene of being a princess,
of emotional thinking, they begin to under- letting her mother hold her imaginary ermine
stand relationships between their own and oth- robe, while her mothers casual questions, such
ers experiences and feelings. They begin to as What does the princess want me to do
elaborate and eventually differentiate those next? and Who did you play with today?
feelings, thoughts, and events that emanate were ignored. Similarly, a 40-year-old business-
from within and those that emanate from oth- man seen in therapy could elaborate about how
ers, and they begin to differentiate the actions No one satisfies me. He was unable to wrench
of others from their own. This process gradu- his thoughts away from this theme and would
ally forms the basis for the differentiation of obsessively return to it, regardless of the thera-
self representations from the external world, pists comments or questions. Without the abil-
animate and inanimate. It also provides the ity to form bridges between various feelings
basis for such crucial personality functions as states, including his own and someone elses,
The Developmental Basis of Psychotherapeutic Processes 25

that patient was incapable of exploring a fuller age, and the organization of themes must be
range of feelings. Other individuals are just the weighed against the age-appropriate standard.
opposite, diligently following instructions, lis- Here, too, themes may cover the broad range
tening to every word, but rarely elaborating of human dramas, from dependency to aggres-
their own feelings about or understanding of sion. We also may see a more integrated sense
events. of gender emerging along with interests in dif-
Children operating at the level of creating log- ferent aspects of sexuality and pleasure. Often
ical bridges between different islands of sym- emanating from this stage are themes of power,
bolic or representational communication do not being admired, and being respected. Some de-
negotiate only via pretend dramas. They also gree of concern with shame, humiliation, loss of
begin to negotiate the terms of their relationship love, and fear of injury to self and others is also
with the clinician in a more reality-based way. expected. When there are challenges, one may
Can I do this? or Can I do that? the child see symbolic somatic expressions (preoccupa-
may say. What will you do if I kick the ball tion with ones own body functioning), symbols
into the wall? the child may inquire. Children used in the service of action rather than reflec-
may also want to know if they and the clinician tion, and polarized rather than integrated
can play after the session is over because they themes (preoccupation with things being all
enjoy the playroom so much (and seem to yearn bad or all good). We may see massive preoccu-
for a little extra contact with other people). A pation with order, control, or limited types of
childs negotiations about bringing parents into pleasure or sexuality. In addition, we may see
the playroom, wanting either to continue or to paralyzing preoccupations with shame, humil-
end the session early, or curiosity about where iation, loss of love, and injury or harm to self or
the clinician lives and what his or her family others.
is like, clearly indicate a use of symbols or There are also advanced stages of represen-
words in a logical, interactive way. These logi- tational differentiation. The sixth functional
cal bridges between one thought and another developmental capacity keeps growing and in-
suggest that this more advanced level of negoti- cludes a number of substages reflecting the
ating relationships has been mastered. The progress of development as it advances. These
adult who shifts between free associations and include expanding perception and reasoning
logical reflection, or who wonders about how capacities to include triadic and then multiple
two feelings are connected, or who makes such social groups. It also includes the internaliza-
connections, also reveals this level. tion of a sense of self as a reference for a stable
The fifth and sixth stages of representational sense of reality and the capacity to broaden
elaboration and differentiation can be observed ones sense of reality into an integrated picture
and further assessed as one looks at the way of past and present, as well as future possibili-
individuals organize the content of their com- ties in the context of expanding interpersonal,
munications and deal with anxiety. Thematic family, and group experiences. These substages
development (i.e., the content of the communica- can be observed to see what level of advanced
tion) helps one assess the individuals re- ego development an individual has attained. It
presentational level. Look first at the overall is important to note that if the basic stage of
organization in terms of the presence or absence representational differentiation is not stable
of logical links connecting the thematic ele- and broad, there invariably will be difficulties
ments. A certain minimum capacity to organize at these higher levels. These basic levels of rep-
thinking can be expected with adults. With a resentation and the advanced levels or sub-
child, however, the standards vary according to stages are outlined in Table 2.1.

Table 2.1 Developmental levels of representation.

Basic Levels
Representational elaboration and differentiation
Action level: Person uses ideas to convey action and discharge rather than as a true symbol (e.g., I hit him).
Somatic level: Person uses ideas to describe body sensations (e.g., My stomach hurts or is exploding).
Global level: Person uses ideas to describe global affect states (e.g., feel good feel bad).
Polarized level: Person uses ideas to polarize affects into all-or-nothing states.
Differentiated, Abstracted, Affective Representational level: Person uses ideas to describe specific affects
and elaborate them and reasons about them.
Advanced Levels
Triangular thinking: Triadic interactions among feeling states (I feel left out when Susie likes Janet better than
Relativistic thinking (playground politics): Shades and gradations among differentiated feeling states (ability to
describe degrees of feelings around anger, love, excitement, disappointment; I feel a little annoyed).
Internalized sense of self (the world inside me): Reflecting on feelings in relationship to an internalized sense of self
(Its not like me to feel so angry; I shouldnt feel this jealous).
Extending representational capacity to new realms of biological, psychological, and social experience: Expanding reflective
feeling descriptors into sexuality, romance, closer and more intimate peer relationships, school, community, and
culture, and emerging sense of identity (I have such an intense crush on that new boy that I know its silly. I
dont even know him).
Extending representational capacities in time and space: Using feelings to anticipate and judge future possibilities in
light of current and past experience (I dont think I would be able to really fall in love with him because he likes
to flirt with everyone and that has always made me feel neglected and sad). Broadening reflective capacities to
include the larger community and culture.
Extending representational capacities into the stages of adulthood, middle age, and the aging process: Expanding feeling
states to include reflections and anticipatory judgment with regard to new levels and types of feelings associated
with the stages of adulthood, middle age, and the aging process, including:
Ability to function independently from and yet remain close to and internalize many of the capacities initially
provided by ones nuclear family.
Inner sense of security.
Judgment and self-limitation of behavior and impulse.
Regulation of mind.
Reality-based organized thinking.
Intimacy (serious long-term relationships).
The ability to nurture and empathize with ones children without overidentifying with them.
The ability to broaden ones nurturing and empathetic capacities beyond ones family and into the larger
The ability to experience and reflect on the new feelings of intimacy, mastery, pride, competition,
disappointment, and loss associated with family, career, and intrapersonal changes of midlife and the aging
process. (See Greenspan, 1989, 1997b for further discussion and review of the research related to these stages.)

SUMMARY OF DEVELOPMENTAL LEVELS or emotional relatedness that soon develops be-

tween therapist and child. As soon as the thera-
The organizational levels discussed above are pist opens the door and the child makes eye
not difficult to observe, and are often taken for contact or perhaps follows a few facial or arm
granted. When a child comes into the playroom gestures indicating where the toys are kept, we
ready to play or talk, there is often some rapport have an intentional, preverbal communication
The Developmental Basis of Psychotherapeutic Processes 27

system going. Therapist and child are engaged descriptions rather than put them into acting-
and intentional with each other. out behaviors,* they further look to see if the
As the child begins complex play, staging person can represent global, somatically based
mock battles with appropriate sound effects or affects and can represent simple, general af-
making noises and pointing to indicate Get me fects or more differentiated, abstracted affects.
that!, more complex intentional communica- Clinicians also look for the ability to make con-
tion is occurring. When the child puts feelings nections between different affective domains
into words and elaborates pretend play themes, and categories of feelings and behaviors, and
the level of shared meanings or representational the ability for self-observation and reasoning
elaboration is reached. The next level is reached about ones emotional inclinations and tenden-
when the child not only elaborates themes, but cies. One can further look at this last category
constructs bridges between domains of experi- in terms of the ability to observe oneself and
ence: Im scared when Im mad. The ability reason in different dimensions: in the here-and-
to categorize experience indicates emotional now, which is the easiest in a historical sense; to
thinking (i.e., representational differentiation). anticipate the future; and to do all of the above
A symbolic me and a symbolic you are now as part of an active exploration, and finally, to
in evidence: I always get so scared of every- integrate them.
thing. Most important, the capacity for catego- As clients are capable of more differentiated
rizing experience helps an individual elaborate self-observing capacities, they can apply this to
feelings and build on anothers communica- different types of relationship patterns. There-
tions. The patient can have a logical two-way fore, in terms of comprehending relationships,
dialogue and tell the difference between fan- various levels of representational differentia-
tasy and reality. tion can also be noted. At an early level, one is
Individuals may have clear compromises in able to explore feelings that occur in dyadic re-
their attainment of these organizational levels, lationship patterns; at a later level, one is able
such as patients who come to therapy and can to test triangular relationship patterns. A still
only partially engage. When anxious or fright- later level involves group patterns that have
ened, they typically disengage and become many different dyads and triads as well as the
aloof or withdrawn. Not infrequently, they also relationship between members of the group
get disorganized and cannot even gesture pur- and the group as a whole. Finally, signposts of
posefully and intentionally. Their gestures and higher levels of organization can be seen in the
speech become disjointed. Their capacity for ability to move into explorations of feelings
representational elaboration is limited to either having to do with stable internal values and
disorganized emotional communications or or- principles and being able to look at an emerg-
ganized descriptions of impersonal events. ing sense of self against these aspirations and
There is little capacity for balancing subjective principles.
elaborations and an appreciation of reality.
They use words in a fragmented way, tend to be
concrete and impersonal in their descriptions of
the world, gesturally signal in a disorganized
and chaotic way, and, although capable of en-
gaging with others, easily disengage and be- *Acting-out behaviors are usually characteristic of the
person who hasnt yet mastered the complex interchange
come aloof.
of behavioral intentions and expectations and who is
As clinicians look at the tendency to use ver- somewhat arrested between the simple gestural and
bal descriptions of behavior, and organize these complex gestural stages.

PR I NCIPLES OF make the mistake of communicating with the

D E V E L O P M E N TA L LY patient in a manner that is inappropriately ab-
BA S E D P S YC H O T H E R A PY stract or basic. For example, some individuals
do not have the capacity for verbal expression of
The developmental approach to the psychother- emotions. They may operate on a more basic,
apeutic process builds on an understanding earlier level where affect spills over immedi-
of and ability to work with all the critical devel- ately into behavior. They stomp and yell and
opmental levels at the same time. A number of scream when they are angry; they cling when
principles summarize this approach. they are needy. They commonly dont say, I
feel angry or I miss you so much that I think
about you all the time. We often put those
PRINCIPLE 1 words in a patients mouth, yet they really may
not be able to abstract affect in that way. If such
Build on the patient s natural inclinations and inter- patients begin to act out aggressively or with-
ests to try to harness all the core developmental draw after the therapists vacation, for example,
processes the patient is capable of at the same time. offering them an interpretation like Gee, you
These core processes have to do with self- must have missed me and are showing me your
regulation, forming intimate relationships, en- anger by stubbing out your cigarettes on my
gaging in simple boundary-defining gestures, couch will go right over their heads. Patients
and complex preverbal, self-defining communi- may nod, but if they are operating at a more
cation. They also have to do with representing primitive level, they simply wont get it. It wont
internal experience, including representing and be a meaningful intervention because the pa-
abstracting wishes, intentions, and affects, and tient is not at the level to process that kind of
becoming able to differentiate these internal interpretation. For such an intervention to be
representations and build bridges between effective, patients need to be able to represent
them. Where the patient has not reached a cer- affect, to see connections between different af-
tain level, the therapist engages him or her at fects (I missed you, and therefore Im mad),
the levels that have been mastered, and begins and to self-observe while seeing this connection.
the process of working toward experiences that
will facilitate reaching the new levels.
In many psychoanalytic and psychodynamic PRINCIPLE 3
therapies, it is mistakenly assumed that many
patients can use a highly differentiated repre- Engage the patient in the context of his or her indi-
sentational system to perceive, interpret, and vidual processing differences (regulatory profile).
work through earlier experiences and conflicts. For example, the sensory-hypersensitive in-
Most patients, however, evidence either deficits dividual requires soothing; the underreactive,
or constrictions at prerepresentational as well self-absorbed individual requires animated dy-
as representational levels, and these levels need namic interaction. (See discussion of Develop-
to be worked with directly. mental Level 1, above, for more examples.)


The therapist should work with the patient at the pa- Therapists should aim to effect change by helping pa-
tient s developmental level. It is essential not to tients negotiate the developmental levels they have
The Developmental Basis of Psychotherapeutic Processes 29

not mastered and strengthen vulnerable or limited might be very patient and comment once or
processing capacities. These levels may have been twice about the patients aloofness or tendency
bypassed earlier in life, which at present is to withdraw, but not do anything to alter that
in evidence as a deficit or constriction. In facili- state of withdrawal directly other than comment
tating the negotiation of a developmental level on it intellectually. Months, even years, may go
or processing limitation, the therapist is not by with a relatively mechanical therapist and an
simply a commentator or insight giver, but a equally mechanical patient, with little or no af-
collaborator in the construction of experience. The fect exchange taking place. If the patient were at
therapist does this within the traditional an advanced representationally differentiated
boundaries of the therapeutic relationship, and level and could abstract affect and see connec-
not by role-playing or reenacting real rela- tions, the therapist might be able to effect change
tionships. Collaborating in the construction of by this approach. For example, the therapist
experience should not be confused with histori- might muse Every time you seem mad at me,
cal tactics, such as a corrective emotional expe- you tend to withdraw. Such a comment may
rience, where the therapist may deliberately help open up the patients associations.
take an extra vacation to stimulate certain feel- But with the patient who is not representa-
ings in the patient. Such contrived strategies can tionally differentiated, who is instead primi-
undermine the naturally occurring affects that tively organized and tends to withdraw when
will characterize the therapeutic relationship. he feels intensity of affect of any kind, the ther-
Rather, therapists use the tools of communica- apist must pay attention to and focus on sub-
tion available within the confines of the thera- tleties in the patients nonverbal behavior and
peutic role of following and dealing with the affective tone. Let us postulate, for example,
patients spontaneous communications, verbal that this persons mother was intrusive and
and nonverbal. As collaborative constructors of his father was emotionally removed. Neither
experience, therapists are aware of the different parent successfully found a way to woo this
developmental levels of the therapeutic relation- sensory-sensitive person into a more intimate
ship. They do not limit themselves to exploring pattern of relating. The therapist pays careful
only the more representational levels. They also attention to his mood and physical sensations
are aware of the importance of the interactive ex- while the patient is in various states of attention
perience, guided by the patients natural inclina- and relatedness. Rather than using the tone he
tions and communications. Therapists must be uses with other patients, the therapist needs to
especially aware of their own countertransfer- find a particular tone and rhythm (e.g., using
ence tendencies so that the therapeutic explo- voice tone and rhythm and facial gestures to
rations reflect the patients natural, spontaneous maintain a sense of relatedness) that will work
inclinations and communications at multiple de- with this particular patient. The establishment
velopmental levels. Therapists listen, empathize, of this pattern may be a critical first therapeu-
and offer developmentally useful communica- tic step. Rather than comment that the patient
tions, while patients explore their experiences as is afraid of his direct gaze, the therapist main-
best they can. In maintaining the integrity of the tains the rhythms that increase relatedness
therapeutic relationship, therapists allow for fu- and wonders what voice tone or look the pa-
ture transference configurations. tient finds most comforting. For example, the
A brief illustration may help illuminate this therapist notes that when he talks assertively
point. Consider a patient who tends to withdraw and looks directly at the patient, the patient
during the sessions and become aloof and me- becomes more aloof; when he talks softly and
chanical in his affect. Traditionally, the therapist looks slightly to the side of the patient, only

periodically looking directly at him, the patient we assume that the patients nod or compliant
is more engaged. free associations along the lines we suggest is
Therapist and patient then observe and expe- proof of the value of our insight.
rience different states of relatedness together; Part of individuals self-sufficiency is rooted
they explore at the same time. Initially, they do in their ability to create growth-producing ex-
not explore historical or even current complex periences in other relationships in addition to
patterns of wishes and feelings. They explore, the therapeutic one. As a particular issue is
in a supportive manner, aspects of their inter- being mastered, the therapist needs to actively
action (e.g., the patient may be helped to see explore factors that might be interfering with
that he finds the therapists voice soothing or ir- the patient taking this step.
ritating). The therapist uses the boundaries of
the therapeutic relationship in a new way, but
still maintains those boundaries. PRINCIPLE 6
In general, the therapist attempts to first
broaden the range of experiences dealt with at The representational system, including unconscious
the patients developmental level. For example, symbols, are only the tip of the iceberg. Of special
if the patient avoids assertion or aggression or importance to better understanding the devel-
intimacy, the therapists initial goal is to facili- opmental basis of psychotherapy is the fact that
tate a full range of feelings at his or her current the representational system, so central to most
level. The next goal is to help the patient move dynamic therapies, deals only with the most
up to the next level. surface aspects of ego functioning. The ability
to represent experience and elaborate represen-
tations, and the ability to differentiate among
PRINCIPLE 5 representations, are the two levels of ego func-
tioning acquired in later stages of ego develop-
Therapists should always promote the patient s ment (i.e., when children are already verbal and
self-sufficiency and assertiveness. This principle, symbolic). There are four earlier levels that
though generally accepted in most dynamic must also be dealt with, which deal with the
therapies, is often ignored. Learning occurs in way experience is organized prerepresentation-
life, and particularly in the psychotherapeutic ally. They include how regulation (sensory re-
process, through a persons own active discov- activity and processing) occurs; the way early
ery in the context of the relationship he or she engagements and relationships are formed and
develops with the therapist. For example, it is elaborated; and how early simple and complex,
often not helpful to make comments on the per- intentional, gestural communication becomes a
sons behavior or affects, while the person nods part of a prerepresentational pattern of mental
acceptingly and then goes on free associating. It organization.
is the active learning done by patients them- By being aware of early stages of ego develop-
selves, as opposed to the passive nodding accep- ment, therapists have greater empathetic range.
tance of what the therapist says and does, that They can go beyond empathy to be an actual fa-
proves to be more helpful. Always promote pa- cilitator of new ego development. While intuitive
tients own assertiveness, self-sufficiency, and therapists have always been able to empathize
active construction of their experiences, as op- with early affective states, most therapists will
posed to the more passive, compliant accep- be aided by a theoretical road map indicating the
tance of what we may have to offer them. Not sensory, regulatory, gestural, behavioral, and af-
infrequently, in the enthusiasm of the moment, fective signposts to look out for. Limitations due
The Developmental Basis of Psychotherapeutic Processes 31

to countertransference phenomena and the ther- feeling when seeing a familiar, friendly face,
apists own experiences naturally limit ones which, without even thinking, leads to the
empathetic range to some degree. smile, the hello, and an extended hand. If its
the latter, we would promote it by creating op-
portunities for interactions where the child
PRINCIPLE 7 could link his affects, thoughts, and behaviors.
Intellectual activity requires two components:
Affect and interaction are the basis for ego develop- the affectively mediated creation of personal ex-
ment and, more generally, intelligence. The thera- perience and the logical analysis of that experi-
pists role is based on the critical notion that ence. Almost every intellectual experience an
development occurs from affective interactions. infant, young child, or adult has involves these
This notion emerged from our observation that two components: an affective as well as a more
both emotional and intellectual growth depend purely cognitive one. This process begins early
on affective interactions and that these interac- in development. The earliest experiences are
tions can be harnessed in various contexts. In double-coded according to both their physical
this model, interactions are, in a sense, the fuel and affective properties. The affects, in fact, ap-
that mobilizes the minds various functions. pear to work like a sensory organ, providing
These interactions create opportunities for af- critical information. For example, the ball is
fective interchange, and these affects are then red, but looking at it also feels nice, scary, or in-
vital to the way the mind organizes itself and teresting. The food is yellow and firm and af-
functions. fectively is delightful or annoying. As a child
Each interaction gives rise to affects such as learns about size, shape, and quantity, each of
pleasure, annoyance, surprise, sadness, anger, these experiences are also both emotional and
and curiosity. Variations in the quality and in- cognitive. For example, a lot is more than you
tensity of these and other affects make for an expected; a long time is the rest of your life.
almost infinite variety of affect patterns. The The ability to count or formalize these quanti-
affects, in many respects, operate as the orches- ties is simply the formal classification of what
tra leader, organizing and differentiating the you already affectively know.
minds many functions. Affects stemming from The earliest sense of causality and ego dif-
interactions become the foundation for both ego ferentiation emerges not from sensorimotor ex-
growth and differentiation and, more broadly, plorations, as Piaget (1962) thought, but from
for intelligence (Greenspan, 1979a, 1997b). earlier affective interactions (e.g., a smile caus-
Ego growth is not a surprising concomitant of ing a smile back; Greenspan, 1997b). At each
affective interchanges, but cognitive or intellec- stage of cognition, affects lead the way. Com-
tual abilities are not usually thought of as stem- plex abstract concepts, such as love, honor, and
ming from interactive and affective patterns. To justice, are also the products of these same
see why they do, consider the following. A child processes. The concepts have a formal, cognitive
is learning to say hello, a seemingly simple definition, but to comprehend or create this def-
cognitive task. Does the child learn to say hello inition requires a range of personal affective ex-
only to close friends, relatives, and those who perience. Love, for example, is pleasure and
live within a quarter-mile of his house? When excitement, but it is also commitment and loy-
he meets a stranger, does he think to himself, alty, as well as the ability to forgive and recover
Where does this person live in relationship to from anger. Taken together, these affective ex-
me? Or is the decision of when to say hello periences associated with the word give it its
mediated by an affective cue, such as a warm full abstract meaning. We have observed that

children and adults who remain concrete have ego functions and capacities. When we are try-
difficulty integrating multiple affective experi- ing to remember something quickly or figure
ences into a word or concept. out which cognitive operation to use, we dont
Affects are also, as indicated earlier, at the logically explore all the various alternatives; we
foundation of our most basic ego functions. Our quickly come to the strategy or memory through
sense of self and other differentiates out of an our emotional orchestra leader. Similarly, when
infinite number of subtle affective interchanges we automatically use a particular defense cop-
at each of the stages of ego development. In ing strategy or regressive route, these same af-
addition, the selection of defenses or coping fects determine the selected operations.
strategies is often mediated by affects. When a Another important dimension of reciprocal,
child avoids an angry encounter and becomes affective interactions is that they lead to the ca-
compliant and sweet, often the affect of fear pacity for an individual to use affect as a signal,
mediates this change in the childs behavior, which fosters anticipation and consideration of
feeling tone, and ideas. When an adult avoids in- alternatives rather than direct discharge, shut-
timacy or competition, there are sometimes un- down, or withdrawal. The regulation made pos-
pleasant affects associated with these types of sible by back-and-forth affective exchanges
interactions mediating the avoidance. There is a leads to symbolization, and the symbolization
hierarchy of ways in which the ego copes with of affect makes it possible to use affect as a
underlying affects. These include disorganized signal.
behavioral patterns, states of self-absorption, in-
tentional impulsive patterns, somatically expe-
rienced affects, polarized, global emotions and CASE EXAMPLE OF A
beliefs, and represented, symbolized feelings L AT E N C Y- AG E C H I L D
and experiences (from fragmented to cohesive
integrated forms). This is a case of a latency-age child, Andy, who
In our developmental model, therefore, inter- tended to be either agitated or depressed. The
actions and their associated affects mobilize all goals of his psychotherapy were to help him
aspects of development, emotional as well as progress to higher levels in his functional emo-
cognitive. A wise person is both intellectually tional capacities (i.e., ego development). Specif-
and emotionally wise; the two cannot be sep- ically, one of the goals was to enable him to
arated. There are, of course, individuals who engage in longer chains of regulated, reciprocal
have isolated areas of cognitive skill (perhaps in affective exchanges. During longer and longer
science, math, or the arts), and there are indi- exchanges, the therapist would help Andy bet-
viduals who have highly differentiated ego ter regulate his affective and behavioral ex-
structures who lack some of these areas of skill. pressions through critical preverbal as well as
But overall intelligence, wisdom, and emotional verbal responses. For example, when Andy
maturity are part of one and the same process. would begin to evidence more agitation in his
An integrated and differentiated human being voice and body movements, the therapist would
is one who can negotiate all the areas of age- deliberately move toward a more soothing,
expected functioning: emotional, social, and comforting tone to attempt to down-regulate
intellectual. the intensity of affect. When Andy became
The affects, as they come into place and as more apathetic and self-absorbed, the therapist
therapeutic experiences harness them, not only would deliberately move toward a more ener-
differentiate and develop our personalities, they gized rhythm of preverbal and verbal exchange
also serve as the orchestra leader for our many (e.g., more animated facial expressions and
The Developmental Basis of Psychotherapeutic Processes 33

faster tempo) to up-regulate. At the same time Therapeutic interactions, which generate af-
that the therapist was working at the preverbal fects, are at the foundation of developmentally
level, he would also periodically explore how based psychotherapy. Each component of ego
Andy felt during these shifts of affective rhythm development requires certain types of interac-
and intensity. He was attempting to help Andy tions and affective experience. The challenge of
symbolize and reflect on the subtle feeling the therapeutic process is to figure out ways to
states he was experiencing when either agitated harness these as part of the therapeutic relation-
or apathetic. ship. Therapists must always remember, how-
Over a period of six months, Andy was able ever, that the therapeutic relationship is only a
to make progress toward both of these goals. component of patients overall set of relation-
He gradually responded to the therapists ships and, therefore, one needs to help patients
soothing, comforting tone of voice and interac- create opportunities for interactive and affec-
tive rhythm by becoming more regulated (less tive experiences in other sectors of their life.
agitated) when talking, for example, about his The therapeutic relationship that attempts to
father being unfair or kids at school picking on provide the critical experiences in the patients
him. He was also able to begin verbalizing more life, rather than assist the patient in orchestrat-
abstracted feeling states, shifting from somatic ing such life experiences, many limit necessary
descriptions and descriptions of actions he was and healthy age-expected interactions.
going to carry out to true descriptions and re-
flections on inner feelings. For example, instead
of talking about his exploding insides or how he A CASE EXAMPLE
was going to punch so-and-so, he began describ- OF DEPR E S SION
ing feeling like my insides were shouting . . .
like I was so mad. Consider another example to illustrate the de-
Interestingly, as Andy was able to symbolize velopmental approach to the psychotherapeutic
affect, he began to use affect as a signal (i.e., to process. A middle-aged depressed woman had
both unconsciously and consciously anticipate grown up with an extremely intrusive, control-
next steps). For example, when his brother came ling mother and a very available but passive fa-
into his room uninvited, Andy became aware of ther who deferred to mother. As near as can be
feeling angry and then considered alternative ac- reconstructed (some of it intellectually from
tions. It is important to note that his capacity to mothers behavior), even as an infant and tod-
use affect as a signal was based on his first learn- dler, this womans every reach for any sort of
ing to regulate reciprocal affective exchanges dependency gratification or for closeness was
and then describe his affective states symboli- met by her mothers intrusive, controlling, and
cally. Both steps appear to be important. With- sometimes rejecting responses. The patient later
out the regulation, affective states tend to be came to feel that her mothers behavior was
intense and, therefore, are often experienced in aimed at humiliating her. Much of her latency,
an overwhelming or catastrophic manner, and adolescence, and now adulthood were geared to
there is a tendency toward discharge, somatiza- never showing weakness, vulnerability, or needi-
tion, or interpersonal withdrawal. The regula- ness in regard to her mother.
tion of the affective interchanges enables shifts In addition, this patient had a history from her
toward symbolization (i.e., greater awareness own recollection, as well as from her parents de-
and description of subtle affective states); in scriptions of her, of overreactivity to basic sensa-
turn, the symbolization enables the affects to tions, such as touch and sound. She was gifted in
serve as intrapsychic signals. her use of language but had relatively weaker

visual-spatial processing capacities. These pat- manner because they werent occurring at the
terns continued into adulthood, leaving her behavioral interaction level.
prone to feeling overloaded, fragmented, Contributing to this womans depression in
or falling apart. She would experience over- adulthood was an inability to represent longing
load when in a noisy room or in a group of peo- feelings for anyone in her life, including her
ple brushing up against her. She was much child, the therapist, or her husband, who was
better at recalling details than seeing the big thoughtful and very devoted to her. During the
picture; her loud, forceful, top sergeant therapists vacation times, the patient would
mother, for example, made her cringe when get agitated and uncomfortable, but could never
she would surprise her and walk into her picture the therapist away on vacation or expe-
room. rience longing or angry feelings. All she experi-
The patients tendency to become overloaded enced was a vague sense of anxiety, tension in
and fragmented and her difficulty in visual- my muscles, and a feeling like Im going to fall
spatial abstracting, in terms of regulating pat- down. Intellectually, being a sophisticated in-
terns, would have made it hard, under any dividual, she said, Im probably missing you,
circumstances, for her to engage as a toddler in but Ill be honest, I dont feel a shred of it, al-
the full range of organized behavioral and emo- though I feel physically lousy when youre
tional patterns. Fragmented, piecemeal patterns away. Interestingly, she felt similarly when she
would be more likely to occur. Likewise, it would had an urgent work project and needed to talk
have been difficult for her to conduct organized with her husband when he was away on a busi-
and integrated mental representations as a pre- ness trip. During the day, she would get agi-
schooler. Again, fragmented patterns would be tated, headachy, and dizzy and experience
more likely from the combination of overreactiv- patterns of disorganized thinking. When she
ity and relatively weak integrating capacities. was having a big meeting with her bosses, she
With an intrusive, overwhelming mother, how- could never imagine being soothed by her hus-
ever, what might have been difficult to master band or calling him up for a pep talk before-
became almost an impossibility. The relation- hand: The image just never occurred to me.
ship with the mother, therefore, accentuated her This person, like many who are prone to de-
constitutional and maturational weaknesses. A pression, may lack the ability to represent, in
soothing, comforting mother might have helped the most fundamental sense, wishes and affects
her overcome her vulnerabilities. At the same having to do with longing feelings. They are, in
time, the dynamics of her relationship with her fact, better at representing anger or aggression
mother were intensified by her regulatory pat- than longing. They have conflicts with aggres-
terns. A child with excellent self-calming and sion, but an even more fundamental issue is the
self-soothing abilities and strong integrating ca- very lack of ability to represent critical affects.
pacity might have been able to deal with an in- This type of difficulty has been observed in pa-
trusive mother by becoming a little stubborn or tients with psychosomatic and substance abuse
negative or, simply, strong-willed. This patients difficulties (Nemiah, 1977).
degree of rage and humiliation and sense of frag- The ability to represent certain longing feel-
mentation were all quite intense, in part because ings can be viewed metaphorically as each in-
of the regulatory pattern. dividuals ability to create a personal internal
As she progressed into her representational Linus-type security blanket. Early in develop-
phase, she was, therefore, unable to fully repre- ment, children initially are at a level where their
sent nurturing, caring interactions in a stable own real behavior and the behavior of their
The Developmental Basis of Psychotherapeutic Processes 35

caregivers as well as the presence of specific and reassurance, is not present. It is not the loss
concrete objects serve security and communica- of the real object but the internal representation
tive purposes. Around 18 to 24 months, however, that may be a critical aspect of certain types of
under optimal circumstances, they develop the depression. Interestingly, the biological compo-
ability to create internal images, as Mahler and nents of depression may be mediated through
others (1975) described so well. These internal the regulatory patterns (hyperreactivity and/or
images become invested with certain wishes and visual-spatial integration), rather than as a di-
feelings. Once children can create images, these rect effect on mood. Therefore, there is an inter-
can obviously be used for self-soothing as well as action between experience and biology.
for fantasizing about anger. Once individuals These considerations play out in the treatment
have the flexibility to create representational of this patient. Simply clarifying and interpret-
images, they can create a temporary sense of se- ing these patterns would not be sufficient, and
curity and experiment with anger while em- might be counterproductive. First, the therapist
braced in the safety of real relationships. Many must always meet patients at the developmental
individuals, for a variety of reasons, cannot level of their ego structure. For this patient, it
create aspects of mental representations, often meant dealing directly with her regulatory pat-
because of early conflicts in their prerepresen- terns, not only by helping her describe them, but
tational stage and/or certain regulatory pat- creating in the office a regulatory environment
terns. I believe this scenario holds true for the (e.g., not talking too fast or intrusively and find-
woman discussed here, where the seeking of ing soothing vocal rhythms and tones). Second,
dependency and support was involved in be- attention should be paid to behavioral expecta-
havioral-level conflicts with her mother. Such tions. In this case, the patient expected intrusion
people cannot chance creating the representa- and her countertendencies were to withdraw or
tional image of these wishes. This patient may become fragmented in speech or behavior. It was
have given up those types of seeking behaviors insufficient to simply point out that whenever
before she was even 2 years of age. Her only she felt needy, she expected the analyst to in-
memories were those told to her, for example, trude and overwhelm her, as she felt her mother
that she either ran around without purpose or had done in the past. Because this was a behav-
withdrew and was sometimes defiant. She never ioral rather than representational expectation,
sought out her mother to cuddle or hug; she al- it was experienced not as I feel as though you
ways treated her mother as a person who could will control me, but as You are going to control
give her things. She was more warm and nurtur- me and, with regard to her withdrawn or frag-
ing with her father, and could seek support from mented behavior, You are overloading me.
him, albeit in concrete ways. The therapist was verbally interactive to main-
In our developmental model, an important tain a sense of relatedness when the patient was
aspect of certain types of depression is not nec- withdrawing. His counterbehavior was geared
essarily the loss of the real object, but the loss of, to increase the patients behavioral and affective
or never having the ability to create, the internal range. He attempted to help the patient organize
representation of the object, particularly in its communications when she became fragmented
soothing and dependency-oriented patterns. (e.g., I lost your last idea). When she became
This leaves the person at the mercy of direct, very fragmented, he increased visual and be-
concrete behavioral patterns. A sense of internal havioral interchange through gestures to main-
self-esteem, based on representations of the ob- tain organization. When there were gestural
ject, in terms of soothing, admiration, respect, indications in terms of tone of voice, motor

gestures, or affect cues of dependency feelings, different developmental levels that are not al-
the therapist would attempt to maintain and ways intuitive.
further elaborate these through the interactive
dialogue, which provided an experience of non-
intrusive comfort. As the patient withdrew or S C H E M AT I C O U T L I N E
became hostile in anticipation of intrusiveness, OF THE F UNC TIONAL
initially the therapist did not clarify or interpret DE V E L O P M E N TA L L E V E L S
underlying feelings or wishes. Such comments
would have been at a different developmental To assist in visualizing the developmental
level than the patients level at that point. In- approach to mental health and illness, the
stead, the therapist maintained the dialogue schematic outline in Table 2.2 may be useful. For
with the behavioral descriptions: You see me as each fundamental capacity, there are a range of
doing this to you, rather than being comforting. possibilities, from very adaptive and healthy to
As the patient became more flexible, the ther- maladaptive and disordered. This type of ap-
apist helped her identify those affects that led proach may prove more useful than narrow-
to withdrawal or fragmentation, which were based, symptom-oriented approaches and could
initially at a somatic, physical level: My mus- even be used for research applications. Clini-
cles are tense; My heart is beating fast. De- cally, each capacity can be rated on a 20-point
tailed somatic descriptions led to abstracted scale, for example, and the totals summed for a
affect descriptions and representational-type more global picture. Reliability studies based on
patterns: I feel like Im falling apart; I feel rating videotapes of children and validity stud-
empty; I feel lonely and isolated. Eventually, ies as well as a manual are available (Greenspan,
states of longing and need could be communi- DeGangi, & Wieder, 2001).
cated in terms of missing feelings, and the
capacity to represent dependency and longing
emerged, perhaps for the first time in the pa- A P P L I C AT I O N O F D I R
tients experience. MODEL TO CH I LDR EN
Once she could represent experience, it was W I T H AU T I S T I C
possible to use clarifying and interpretive com- SPEC TRUM DI S ORDER S
ments to help her deal with pathologic defenses
and work through her conflicts. She could then Although a number of intervention and educa-
further develop her capacities for representa- tional strategies have been developed for chil-
tional differentiation and self-observation. There dren with autistic spectrum disorders (Bristol
are a number representational levels (from con- et al., 1996; Rogers, 1996), there has not been suf-
crete to more abstract and reflective) that are de- ficient emphasis on working with individual
scribed elsewhere in this text. processing patterns and different functional de-
Some of these strategies are no different from velopmental capacities.
approaches that many intuitive therapies have In contrast to limited educational models that
been following for years. But often they are focus on isolated cognitive skills and behavioral
viewed as intuitive and not systematic or cen- models that isolate and work with selective
tral to therapeutic growth. The developmental discrete behaviors, the DIR model focuses on
perspective can help systematize them and underlying developmental processes and struc-
open up new areas for inclusion, such as consti- tures. It extends traditionally helpful relation-
tutional and maturational differences and the ship approaches (Carew, 1980; Feuerstein, Rand,
The Developmental Basis of Psychotherapeutic Processes 37

Table 2.2 Functional developmental levels.


05 Points 613 Points 1419 Points 20 Points

Attention is fleeting (a few When very interested or Focused, organized, and Focused, organized, and
seconds here or there) motivated or captivated, calm except when calm most of the time, even
and/or very active or can attend and be calm for overstimulated or under stress.
agitated or mostly self- short periods (e.g., 30 to 60 understimulated (e.g.,
absorbed and/or lethargic seconds). noisy, active, or very dull
or passive. setting); challenged to use
a vulnerable skill (e.g., a
child with weak fine
motor skills asked to
write rapidly), or ill,
anxious, or under stress.

Aloof, withdrawn, and/or Superficial and need- Intimacy and caring are Deep, emotionally rich
indifferent to others. oriented, lacking intimacy. present but disrupted by capacity for intimacy,
strong emotions, like anger caring, and empathy, even
or separation (e.g., person when feelings are strong or
withdraws or acts out). under stress.

Mostly aimless, Some need-oriented, Often purposeful and Most of the time
fragmented, unpurposeful purposeful islands of organized, but not with a purposeful and organized
behavior and emotional behavior and emotional full range of emotional behavior and a wide range
expressions (e.g., no expressions. No cohesive expressions (e.g., seeks out of subtle emotions, even
purposeful grins or smiles larger social goals. others for closeness and when there are strong
or reaching out with body warmth with appropriate feelings and stress.
posture for warmth or flirtatious glances, body
closeness). posture, and the like, but
becomes chaotic,
fragmented or aimless
when very angry).
The Preverbal Sense of Self: Comprehending Intentions and Expectations

Distorts the intents of In selected relationships Often accurately reads and Reads and responds to
others (e.g., misreads cues can read basic intentions of responds to a range of most emotional signals
and, therefore, feels others (such as acceptance emotional signals, except flexibly and accurately
suspicious, mistreated, or rejection) but unable to in certain circumstances even when under stress
unloved, angry, etc.). read subtle cues (like involving selected (e.g., comprehends safety
respect or pride or partial emotions, very strong vs. danger, approval vs.
anger). emotions, or stress or due disapproval, acceptance vs.
to a difficulty with rejection, respect vs.
processing sensations, humiliation, partial anger,
such as sights or sounds etc.).
(e.g., certain signals are


Table 2.2 (Continued)

05 Points 613 Points 1419 Points 20 Points

Creating and Elaborating Emotional Ideas

Puts wishes and feelings Uses ideas in a concrete Often uses ideas to be Uses ideas to express full
into action or into somatic way to convey desire for imaginative and creative range of emotions. Is
states (My tummy action or to get basic needs and express range of imaginative and creative
hurts). Unable to use met. Does not elaborate emotions, except when most of the time, even
ideas to elaborate wishes idea of feeling in its own experiencing selected under stress.
and feelings (e.g., hits right (e.g., I want to hit conflicted or difficult
when mad, hugs or but cant because someone emotions or when under
demands physical is watching rather than I stress (e.g., cannot put
intimacy when needy, feel mad). anger into words or
rather than experiencing pretend).
idea of anger or expressing
wish for closeness).
Emotional Thinking

Ideas are experienced in a Thinking is polarized, Thinking is constricted Thinking is logical,

piecemeal or fragmented ideas are used in an all-or- (i.e., tends to focus mostly abstract, and flexible
manner (e.g., one phrase is nothing manner (e.g., on certain themes like across the full range of
followed by another with things are all good or all anger and competition). age-expected emotions
no logical bridges). bad. There are no shades of Often thinking is logical, and interactions. Thinking
gray.). but strong emotions, is also relatively reflective
selected emotions, or at age-expected levels and
stress can lead to in relationship to age-
polarized or fragmented expected endeavors (e.g.,
thinking. peer, spouse, or family
relationship). Thinking
supports movement into
the next stages in the
course of life.
Additional Functional Developmental Stages

Throughout the life cycle, these stages build on emotional thinking.

Triangular thinking. Triadic interactions among feeling states (I feel left out when Susie likes Janet better than
Relativistic thinking (playground politics). Shades and gradations among differentiated feeling states (ability to
describe degrees of feelings around anger, love, excitement, love, disappointmentI feel a little annoyed).
Internalized sense of self (the world inside me). Reflecting on feelings in relationship to an internalized sense of self
(Its not like me to feel so angry or I shouldnt feel this jealous).
Extending representational capacity to new realms of biological, psychological, and social experience. Expanding
reflective feeling descriptors into new realms, including sexuality, romance, closer and more intimate peer
relationships, school, community, culture, and emerging sense of identity (I have such an intense crush on that
new boy that I know its silly; I dont even know him).
Extending representational capacities in time and space. Using feelings to anticipate and judge future possibilities in
light of current and past experience (I dont think I would be able to really fall in love with him because he likes
to flirt with everyone and that has always made me feel neglected and sad). Broadening reflective capacities to
include larger community and culture.
The Developmental Basis of Psychotherapeutic Processes 39

Table 2.2 (Continued)

Extending representational capacities into the stages of adulthood, middle age, and the aging process. Expanding feeling
states to include reflections and anticipatory judgment with regard to new levels and types of feelings associated
with the stages of adulthood, including:
Ability to function independently from, and yet remain close to and internalize many of the capacities
initially provided by ones nuclear family.
Inner sense of security.
Judgment and self monitoring of behavior and impulses.
Regulation of mood.
Reality-based, organized thinking.
Intimacy (serious long-term relationships).
The ability to nurture and empathize with ones children without over-identifying with them.
The ability to broaden ones nurturing and empathetic capacities beyond ones family and into the larger
The ability to experience and reflect on the new feelings of intimacy, mastery, pride, competition,
disappointment, and loss associated with the family, career, and intrapersonal changes of mid-life and the
aging process.

Hoffman, & Miller, 1979; Feuerstein et al., 1981; opposite direction to get reciprocal, affective
Greenspan, 1979a, 1979b, 1989, 1997b; Klein, interactions going. These affective interactions,
Wieder, & Greenspan, 1987; Rogers & Lewis, however, are tailored to the childs individual
1989). It does this through an understanding of differences; soothing or energetic interactions,
three unique features: childrens functional de- visual or auditory patterns, complex or simple
velopmental level, their individual processing motor patterns may be emphasized, depending
differences, and the affective interactions likely on the childs profile. Consider the following
to broaden their functional developmental ca- examples of individual developmental profiles
pacities and enable them to move to higher de- guiding the interaction.
velopmental levels. The first child, a 312 -year-old, was fleetingly
In this approach, childrens affect or intent is engaged, capable only occasionally of purpose-
harnessed by following their lead or natural in- ful gestures. He had very weak motor planning
terests. However, they are not followed into and sequencing capacities and was underreac-
aimless or perseverative behavior. Their affec- tive to sensation. He required an intervention
tive interests are used as a guide to mobilize at- program that provided a great deal of sensory
tention, engagement, purposeful interactions, input (because of his sensory underreactivity),
and preverbal problem solving and, eventually, animated affective interaction (to woo him into
to create ideas and build bridges between them. engagement), and highly motivating yet simple
Focusing on these fundamental functional de- challenges (a favorite perseverative toy was put
velopmental processes rather than specific be- on the caregivers head) to draw him into more
haviors or skills (which are often part of these engagement and purposeful interactions (e.g.,
broader processes) helps to reestablish the de- reaching for the toy). He was working at mas-
velopmental sequence that went awry. For ex- tering the early functional developmental ca-
ample, rather than trying to teach a child who pacities of engagement and simple purposeful
is perseveratively spinning the wheels on a car gestures.
to play with something else or to play with the A very different approach was required for a
car appropriately, the caregiver uses the childs second case. This 4-year-old child could engage
interest and gently spins the wheel in the and be purposeful some of the time, but became

easily overloaded because of sensory hypersen- expressive language, and relatively stronger
sitivity to touch and sound. As a consequence, visual-spatial capacities. Therefore, instead of
he would become self-absorbed and persevera- soothing, the interactions needed to be very ani-
tive. At other times, he could use purposeful mated. Pictures were used to augment symbolic
gestures to problem-solve (take a caregiver to communication, not simply to convey needs or
the door to try to go outside), and imitate sim- choices, but to enable characters in pretend play
ple gestures, including sounds, and, on occa- to amplify their action dramas with dialogue
sion, use a word meaningfully (e.g., Open) and elaborate a sequence of back-and-forth com-
and feed a doll. He was, however, significantly munication. Interestingly, this child learned to
delayed in social skills and functional language read and write faster than she learned to speak.
(and most of the time would memorize scripts Therefore, we used reading and writing to
and randomly repeat phrases). In contrast to maintain both pretend and reality-based dia-
the first case, this child, because of his sensory logues while she was improving her speaking.
hypersensitivities, required extra soothing, not Interactions using her strengths increased two-
animation or sensory play. He also needed op- way gestural and symbolic communication and
portunities to turn perseveration into interac- enabled her to develop the capacity to build
tions and problem-solving activities (e.g., bridges between ideas and think.
instead of letting him simply open and close
the play garage door when the toy car made too
much noise, we challenged him to put the car COMPONENTS OF A COMPREHENSIVE PROGRAM
inside the garage and tell it to stop by having
a gesturing and talking car driver insist on A comprehensive program often includes inter-
parking the car). Functional language was fur- active speech therapy (three to five times per
ther encouraged by challenging him to connect week), occupational therapy (two to five times
words like open and stop to intent or emo- per week), appropriate biomedical approaches,
tional interests by setting up situations where a developmentally appropriate education pro-
he would want to imitate open to open a door gram, and a home-based program of devel-
to get his favorite toy. Similarly, scripted or opmentally appropriate interactions, which
echolalic language was turned into purposeful includes consultations working on caregiver-
problem-solving interactions by challenging him child interactions and, if needed, direct thera-
with highly motivating, meaningful choices, peutic work with the child. It also includes
such as choosing between two objects he might regular family consultations and team meet-
be labeling in a rote manner. He was wooed into ings for reviewing the overall therapeutic and
a continuous flow of problem-solving interac- educational program and coordination of rele-
tions even when overloaded (with soothing but vant biomedical interventions.
compelling interactions). Based on his unique The home-based program of developmen-
profile, this child worked at a different func- tally appropriate interactions is especially im-
tional developmental level than the first child portant. It is related to the National
the level of complex, purposeful, social problem Association for the Education of Young Chil-
solving and the early use of ideasand required dren recommendation of developmentally ap-
a more soothing approach. propriate practices for all children (Bredekamp
Case 3 was similar to Case 2 except that this & Copple, 1997). Such practices, however, are
child was underreactive to touch and sound, difficult for a child with severe processing
had slightly weaker auditory processing, signifi- problems who may spend hours perseverating
cantly weaker articulation (oral-motor) and and self-stimulating, including repetitively
The Developmental Basis of Psychotherapeutic Processes 41

watching the same videotapes. To help such a the therapeutic program to begin as soon as
child become involved in developmentally ap- possible.
propriate interactions requires tailoring the in- The DIR intervention approach, which fo-
teractions to the childs natural interests (mood cuses on the delayed childs developmental level
and mental state), functional developmental and individual differences, is different from
level, and individual processing differences. psychotherapy or play therapy. What often oc-
This often includes three types of interactions: curs in traditional play therapy with children
(1) spontaneous, follow-the-childs-lead interac- with autism is a type of parallel play, rather
tions geared to enable the child to work on the than true developmentally based interactions.
six functional developmental levels; (2) semi-
structured problem-solving interactions to work
on specific cognitive, language, and social skills STEPS IN THE DIR INTERVENTION PROCESS
as determined by the team of parents and educa-
tors (e.g., helping the child to say open when a For children with autistic spectrum patterns,
toy is put outside the door); and (3) motor, sen- initial therapeutic goals often need to focus on
sory, and spatial activities geared to improve four essential presymbolic capacities. The first
these typically vulnerable processing capacities. is to foster regulation, focus, and concentration
These developmentally appropriate types of in- (shared attention) through gearing interactive
teractions are needed during the childs waking experiences to the childs processing profile
hours to mobilize growth. What children do (e.g., very energetic and challenging for the
most of the time determines their pattern of underreactive child and soothing and gradual
progress; without these interactions, they often for the oversensitive child). The second is to
will shift into perseverative, self-stimulatory, or promote engagement with the human world
aimless patterns. through following the childs lead and working
When a child develops some capacity for re- with his or her pleasurable interests. The third
lating, gesturing, and imitating, including imi- is creating opportunities for two-way intentional
tating words, an important component of the communication through enticing the child to
overall program during the preschool years is take initiative and use gestures purposefully,
an integrated preschool (i.e., 25% children with such as taking a desired toy from the top of dads
special needs and 75% children without special head.
needs). Here, teachers are especially gifted When children are perseverative, aimless,
in interacting with challenging children and avoidant, or negative, we treat every behavior as
working with them on interactive gesturing, though it is purposeful. We might get stuck in
affective cuing, and early symbolic communica- a door they are opening and closing (a kind of
tion. The preschool enables children with spe- cat-and-mouse game). As they try to get us out
cial needs to interact with children who are of the way, gestural interactions occur and be-
interactive and communicative (e.g., as a child havior becomes purposeful. For children who
reaches out for relationships and communica- are aimless or wandering, a clinician might fol-
tion, there are peers who reach back). Four or low them to a corner of the room and try to
more play sessions with a peer who is interac- interest them in what we are looking at or
tive and verbal are also essential at this point, playfully obstruct their path, pretending to be a
so that the child can practice emerging abilities horse. It is important to soothe and comfort
with a friend. To minimize self-absorption and when being playfully obstructive, though after
perseveration and to enable children and their a few minutes, children often find these types
parents to be reengaged, it is important for of interactions amusing.

As children become more interactive and pur- CASE EXAMPLE OF A CHILD WITH AN
poseful, they are ready to work on the fourth AUTISTIC SPECTRUM DISORDER
presymbolic capacity: to interact continuously
(i.e., open and close many circles of communica- Alex, a 21 2 -year-old, was seen because of
tion in a row) to solve problems, such as taking parental concerns of extreme self-absorption,
dad to the toy area to get the horse. Many chil- perseveration, and self-stimulation. There was
dren, even as they become verbal, lack mastery no language and only intermittent ability to re-
of continuous social problem-solving interaction, late to parents around concrete needs, such as
leaving them vulnerable to intermittent self- getting juice or a cookie. History revealed de-
absorption and perseveration and the limited layed motor milestones (e.g., walking at 16
use of ideas. months) and a pattern of some moderate ability
With sufficient practice on continuous prob- to engage in the first year, but a gradual move-
lem-solving interactions, children learn to in- ment toward self-absorption and repetition from
corporate imitation into their social dialogue the middle of the second year on. A diagnosis of
and may copy feeding a doll, or repeating autism had been made by a developmental pedi-
mine or open to get the door open or get atrician; a biomedical and neurological workup
her doll back. Through copycat games, they was negative.
may gradually learn to use ideas creatively and We conducted a comprehensive evaluation,
begin to pretend, for example, feeding the which includes detailed history, observations of
dolly. child-caregiver interactions, and exploration of
With lots of interactive pretend play and family patterns, as well as assessments of all
pulling for words when the childs affects or in- areas of development. In observing Alex, we
terests are high, the child gradually may be- saw that there was some fleeting eye contact
come symbolic. However, it is often much easier and a quick turn away toward perseverative
for children to pay attention to their own ideas play with a toy.
rather than the ideas of others because of audi- This child was preoccupied with wheels on
tory processing difficulties. The caregiver or cars and would spin them around and around.
therapist enters the childs symbolic world with His father, who took the lead in playing with
back-and-forth exchanges of emotionally mean- him, quickly got impatient and tried to hold his
ingful ideas, including debates and opinions sons hand and direct him to other toys, which
rather than facts (in both pretend play and logi- resulted in tantrumming and more intense self-
cal conversations). These symbolic exchanges stimulatory activity. Mother tended to talk to
encourage emotional differentiation, reality Alex about what he was doing and try to be sup-
testing, and higher levels of abstract and logical portive, but was unable to get any engagement
thinking. going as he was unable to understand what she
The common practice of teaching thinking was saying.
through scripting dialogue for the child does Our systematic developmental profile re-
not work. Children learn to think and abstract vealed that Alex had only fleeting capacity
and generalize by connecting more and more for shared attention and engagement and was
affectively meaningful experiences to the con- purposeful only with objects, although he could
cepts, words, and behavior they are using. Over purposefully turn away from and avoid his care-
time, imaginative play and emotionally mean- givers. He was unable to engage in complex prob-
ingful negotiations, not memorized scripts, be- lem solving or multicircle interactions using
come the foundations for higher-level social and gestures, and there were no indications of sym-
cognitive abilities. bolic capacities in terms of either elaboration or
The Developmental Basis of Psychotherapeutic Processes 43

building logical bridges. In other words, he stuck again. Their first interactions occurred
seemed to have some very limited capacities at around these types of playful obstructions.
the first three levels, with no evidence of capac- We also coached the parents to be very ener-
ities at the fourth, fifth, and sixth levels. getic to compensate for Alexs underreactivity.
Alexs processing profile revealed severe He needed highly energized caregivers for him
deficits in auditory processing and language, as to even notice them, let alone interact. Ani-
well as marked deficits in motor planning and mated voices, exaggerated facial expressions,
sequencing; even with his interest in toys, he and gentle but clear gestures were the rule of
could carry out only one-step actions, such as the day. Lots of visual support to take advan-
spinning a wheel, banging a toy, or pressing tage of relatively stronger visual-spatial pro-
against something. His visual-spatial process- cessing was provided through brightly colored
ing looked like it might hold some relative toys, well-lit rooms, and interesting visual de-
strengths for him, but would require further signs and visual challenges in the play (e.g.,
observation. For example, he seemed to flit hiding things).
around to multiple objects in the room; once, Mother was helped to combine her verbal di-
when his father took away something he was alogue with gestures and actions. Alex tended
playing with, he appeared to begin to walk be- to accept another car with better wheels from
hind his father to try to find it. He quickly be- her, in comparison to his father. She could move
came self-stimulatory, and it wasnt possible to the car with big fancy wheels away from him and
be sure he was embarking on a search (when he would come after her to get it. Over time,
motor planning is impaired, it can be hard to these beginnings led to more engagement and
assess visual-spatial processing). He was very more purposeful interaction.
sensory underreactive and also evidenced low Space precludes describing the next steps in
muscle tone. this case in detail. Over time, Alex was able to
With this profile in hand, we were able to string together many purposeful interactions in
begin a comprehensive intervention program. a row and eventually problem-solve and imi-
It included three individual speech therapy tate. After about a year of intensive work, he
sessions per week and three individual oc- was able to imitate sufficiently to start copying
cupational therapy sessions a week. It also in- words and, eventually, phrases.
cluded an intensive home program involving Once Alex became more related and able to
the three types of interactions described ear- use many gestures in a row as part of a long
lier. In the home program, we took advantage chain of reciprocal interactions, to problem-
of Alexs interest in objects to help him be- solve, and to use a few words, we recommended
come more engaged, purposeful, and inten- a regular preschool program with an aide so
tional. For example, instead of trying to change that he could practice his new skills with peers.
his activity, we coached father to join him in Over the next few years, progress sped up be-
spinning wheels and try to entice Alex into cause Alex was now engaged and interactive
spinning fathers bigger and faster car wheel. with his environment and, therefore, learning
Alex generally ignored this enticing overture, all the time; there was only occasional self-
so we coached father to get his hand stuck stimulatory and perseverative activities and he
on Alexs wheel (playful obstruction). This could easily be drawn into patterns of engage-
worked better. Alex would look at his father ment when he became self-absorbed.
and push his wheel a little harder or try to pull The key to his program was the compre-
it away. Dad was helped to supportively let hensiveness and intensity of the intervention,
Alex win for a second and then get his hand which enabled him to practice his new skills in

a nurturing and joyful manner, rather than presented the developmental structuralist
spend lots of time in states of self-absorption. framework and its associated DIR model. We
At present (Alex is now 10 years old), he is a showed how this developmental model can
bright, verbal child with a sense of humor and deepen and broaden psychotherapeutic work
some close friends. Hes doing well in his fam- with children and adults with a range of chal-
ily and in a regular grade school. He still has lenges. We also showed how it could be used as
challenges in motor planning and sequencing the basis for constructing individualized com-
(penmanship and writing), but is rather gifted prehensive programs for children with special
in his verbal insights about the world. Most im- needs.
portant, hes a very warm and loving child.
Alex is one of a subgroup of children who
have done very well and exceeded our expecta-
tions. There appears to be a subgroup of chil-
dren with autistic spectrum diagnoses who can Bredekamp, S., & Copple, C. (Eds.). (1997). Develop-
do exceedingly well. Other subgroups weve mentally appropriate practices in early childhood pro-
identified make much slower progress (Green- grams. Washington, DC: National Association for
span & Wieder, 1997, 1999). Children who make the Education of Young Children.
rapid progress have the ability to become en- Bristol, M., Cohen, D., Costello, J., Denckla, M., Eck-
gaged and purposeful and to problem-solve in berg, T., Kallen, R., et al. (1996). State of the sci-
the early phases of intervention and quickly ence in autism: Report to the National Institutes
move on to imitative capacities and the begin- of Health. Journal of Autism and Developmental Dis-
nings of symbolic communication. Even though orders, 26, 121154.
Alexs initial profile showed many more chal- Carew, J. V. (1980). Experience and the development
lenges than most of the children in this of intelligence in young children at home and in
day care. Monographs of the Society for Research in
subgroup who do well, he was able to make
Child Development, 45(607), 1115.
consistent progress in the critical areas of
Feuerstein, R., Miller, R., Hoffman, M., Rand, Y.,
engagement, reciprocal interactions, problem Mintsker, Y., Morgens, R., et al. (1981). Cognitive
solving, and imitation early in his program. He modifiability in adolescence: Cognitive structure
may have presented looking more challenging and the effects of intervention. Journal of Special
in part because his parents werent able to in- Education, 150(2), 269287.
tuitively figure out how to work with his bio- Feuerstein, R., Rand, Y., Hoffman, M., & Miller, R.
logically based processing challenges and, as (1979). Cognitive modifiability in retarded adoles-
indicated earlier, they tended to accentuate his cents: Effects of instrumental enrichment. Ameri-
difficulties. Their capacity to learn quickly as can Journal of Mental Deficiency, 83(6), 539550.
well as his and their ability together to partici- Greenspan, S. I. (1979a). Intelligence and adapta-
pate in an intensive, comprehensive program tion: An integration of psychoanalytic and Pi-
were significant factors. agetian developmental psychology. Psychological
Issues, Monograph 47/68. New York: International
Universities Press.
Greenspan, S. I. (1979b). Psychopathology and
S U M M A RY adaptation in infancy and early childhood: Prin-
ciples of clinical diagnosis and preventive inter-
New insights into the early stages of the de- vention. Clinical Infant Reports, No. 1. New York:
velopment of the mind have the potential to International Universities Press.
advance our understanding of the psycho- Greenspan, S. I. (1989). The development of the ego: Im-
therapeutic process. In this chapter, we have plications for personality theory, psychopathology, and
The Developmental Basis of Psychotherapeutic Processes 45

the psychotherapeutic process. Madison, CT: Inter- disorders. Journal of the Association for Persons
national Universities Press. with Severe Handicaps, 24(3), 147161.
Greenspan, S. I. (1992). Infancy and early childhood: Klein, P. S., Wieder, S., & Greenspan, S. I. (1987). A
The practice of clinical assessment and intervention theoretical overview and empirical study of medi-
with emotional and developmental challenges. Madi- ated learning experience: Prediction of preschool
son, CT: International Universities Press. performance from mother-infant interaction pat-
Greenspan, S. I. (1997a). Developmentally based psy- terns. Infant Mental Health Journal, 89(2), 110129.
chotherapy. New York: International Universities Mahler, M. S., Pine, F., & Bergman, A. (1975). The
Press. psychological birth of the human infant. New York:
Greenspan, S. I. (1997b). The growth of the mind and Basic Books.
the endangered origins of intelligence. Reading, MA: Nemiah, J. C. (1977). Alexithymia: Theories and models.
Addison-Wesley Longman. Proceedings of the eleventh European conference
Greenspan, S. I., DeGangi, G., & Wieder, S. (2001). on psychosomatic research. Basel, Switzerland:
The Functional Emotional Assessment Scale (FEAS) Karger.
for infancy and early childhood: Clinical and research Piaget, J. (1962). The stages of intellectual develop-
applications. Bethesda, MD: Interdisciplinary ment of the child. In S. Harrison & J. McDermott
Council on Developmental and Learning (Eds.), Childhood psychopathology (pp. 157166).
Disorders. New York: International Universities Press.
Greenspan, S. I., & Wieder, S. (1997). Developmental Rogers, S. (1996). Brief report: Early intervention in
patterns and outcomes in infants and children autism. Journal of Autism and Developmental Disor-
with disorders in relating and communicating: A ders, 26, 243 246.
chart review of 200 cases of children with autistic Rogers, S. J., & Lewis, H. (1989). An effective day
spectrum diagnoses. Journal of Developmental and treatment model for young children with perva-
Learning Disorders, 1, 87141. sive developmental disorders. Journal of the Amer-
Greenspan, S. I., & Wieder, S. (1999). A functional ican Academy of Child and Adolescent Psychiatry, 28,
developmental approach to autism spectrum 207214.

Object-Relations Play Therapy


H I S T ORY O F Play therapy first began to be a significant

T H E R A PE U T I C A P PROAC H factor in psychotherapy with children during
the 1930s in the parallel development of the
The model of object-relations play therapy to be three psychoanalytically based but quite differ-
presented in this chapter developed out of three ent play therapy approaches of Anna Freud
major traditions: object-relations therapy with (1936), Melanie Klein (1932), and Margaret
adults, play therapy, and developmental psycho- Lowenfield (1939). All three approaches contin-
pathology. Whereas the first two traditions have ued to develop, although Freuds work was ulti-
often intersected to some degree, a fully elabo- mately more influential for play therapy than
rated play therapy approach has been lacking. either Kleins or Lowenfields. Another thread
The first application of the emerging object- in the emergence of play therapy as it is prac-
relations theories to children is found in the ticed today is the structured therapy of Levy
work of Melanie Klein (1932). However, both (1939) and Solomon (1938) that also first ap-
play therapy and object-relations therapy, peared in the 1930s. The structured approach
though building on some of Kleins revolution- has continued to develop through the work of
ary concepts, moved away from each other. Hambridge (1955), Gardner (1971), Jernberg
Both departed from the therapy model of Klein, (1979), and, more recently, Brody (1993).
with each tradition developing independently. Increasingly, two other major traditions have
Only recently have there been significant at- influenced the practice of play therapy. The first
tempts to integrate play therapy methods and of these to develop, nondirective play therapy,
current object-relations theories (Prior, 1996). grew out of relationship therapies, the work of
Integrating an object-relations play therapy ap- Allen (1942) and applications of Carl Rogerss
proach with current research findings from (1951) ideas by Virginia Axline (1947). Directive
developmental psychopathology provides a pow- play therapies, representing a diversity of theo-
erful frame of reference for approaching rela- retical stances, emerged as a strong contrast to
tionally based child assessment and treatment. the Rogerian approach. These include Gestalt


play therapy (Oaklander, 1988), filial therapy Many theorists have developed models that
(Guerney, 1964), cognitive-behavior play ther- have contributed to the understanding of how
apy (Knell, 1993), Adlerian play therapy an individuals mental representations of self
(Kottman, 1993), and ecosystemic play therapy and others become enduring psychic struc-
(OConnor, 1991). tures (Glickauf-Hughes & Wells, 1997, p. 18).
By the early 1990s, there existed a rich tradi- These models started from a basic psych-
tion of play therapies, ranging from psycho- oanalytic viewpoint but often have been in-
analytic to structured to nondirective and formed by the ego psychologists emphasis on
directive approaches. However, no single ap- coping resources and experiential influences on
proach has emerged. Object-relations play ther- psychological development, in contrast to tradi-
apy, while drawing its theoretical base from tional drive theory (Blanck & Blanck, 1986). The
object-relations therapy with adults, has incor- approach to object-relations play therapy pre-
porated many techniques from various play sented here places particular emphasis on the
therapy approaches including those from the works of Mahler and associates (Mahler, 1968;
psychoanalytic tradition (Prior, 1996) but also Mahler, Pine, & Bergman, 1975) and on con-
several from Axline (1964), Brody (1993), and cepts derived from the British object-relations
OConnor (1991). school (Bowlby, 1988; Fairbairn, 1952; Winni-
cott, 1965, 1971a, 1971b), as well as Prior (1996),
whose model integrates the trauma literature
T H EOR E T ICAL CONSTRUC T S with concepts drawn from Kernberg (1966). Re-
cent work in both neuroscience and developmen-
Object-relations theories center on two funda- tal psychology, especially the works of Stern
mental assumptions: First, the core of psycholog- (1985), Schore (1994), and empirical studies of
ical functioning is believed to be the relationship early attachment (Kraemer, 1992), have also con-
between the self and significant others (Glick- tributed to the model presented.
auf-Hughes & Wells, 1997); second, as develop- Mahler, who based her model on detailed ob-
ment proceeds, interactions between the infant servations of young children in therapy and on
and significant others and the infants emerging mother-child pairs followed longitudinally
perception of those interactions become inter- over the first three years of life, proposed that
nalized as concepts or templates of the self, the early development of object relations pro-
other, and self in relation to other. These inter- ceeded through three stages, culminating in
nal working models, which are essentially the emergence of emotional object constancy
cognitive-affective structures, filter perceptions around 3 years of age (Mahler, 1968; Mahler
and shape the attitudes and reactions of the et al., 1975). These three stages, modified by the
developing childs and eventually the adults in- empirical work of Stern and others, provide the
terpersonal relationships (Bowlby, 1988; Siegel, basic framework for conceptualization of the ob-
1999). Internal working models thus first emerge ject-relations play therapy presented here.
in the context of experience of the earliest rela- Mahlers first stage, normal autism, occurs over
tionships in life, and interrelate as object rela- the first month of life. Whereas Mahler assumed
tions that animate a persons understanding of the infant was objectless, Stern (1985) found evi-
and functioning in relationships. Throughout dence that infants are born with rudimentary
the life span, internal object relations not only object-relatedness. We want to avoid confusion
influence but also are influenced by experience with infantile autism as a disorder and ade-
in relationships. quately capture this rudimentary relatedness,
Object-Relations Play Therapy 49

and replace autism with the term presymbiosis when the object is experienced as separate but
here. The second stage is normal symbiosis, in not yet constant, is often consciously introduced
which the infant functions as if the caregiver in object-relations play therapy to facilitate
and infant form a dual unity, occurring from constancy in the therapeutic relationship or to
about 2 to 4 months of age. The third stage, promote progress in separation-individuation.
separation-individuation, has been divided by His notions of good-enough mothering and
Mahler into subphases: differentiation (about 4 holding environment both emphasize the childs
to 11 months), in which the infant shifts from an need, developmentally and within therapy, to be
inward-directed focus to outward-directed ten- protected from impingement while also experi-
sion and alertness; practicing (about 11 to 17 encing acceptance and having needs me (Abram,
months), in which the newly mobile infant moves 1996). Winnicotts concept of attunement, where
away from the symbiotic orbit to explore the the caregiver is sensitive to the infants needs
world, returning to the mother periodically and meets those needs accurately, describes an
for refueling; rapprochement (about 18 to 24 essential feature of the therapeutic relationship
months), in which the toddler becomes increas- in this approach (Glickauf-Hughes & Wells,
ingly aware of his or her vulnerability and thus 1997). Finally, Winnicott (1965) describes a
seeks closeness with the mother, yet simultane- false self, where the childs compliance in an at-
ously has a strong need for separateness and tempt to gain approval leads the child to lose
autonomy; and on the way to object constancy ready access to the true self, which we propose
(about 24 to 36 months), in which the toddler is a key feature of arrested development at the
increasingly separates from the mother while in- time the child emerges from the rapproche-
tegrating the good and bad parts of both the self ment crisis. Fairbairn (1952) contributed the
and the object. concept of obstinate attachment, which helps
In the model presented here, we argue that explain the paradox of young children remain-
when progress through Mahlers stages and ing intensely attached to an abusive or nonat-
substages is arrested or distorted, it results in tuned caregiver.
characteristic patterns of relating and behaving Bowlby (1988) articulated the concept of at-
depending on when the problem arises. Each tachment as a neurologically based innate drive
point of arrest has a pattern of psychopathologi- to seek security in relationships. Schore (1994)
cal functioning with unique dynamics that war- elaborates on the interface of neurological de-
rant particular therapeutic goals and techniques. velopment in the attachment process and the
Moreover, these behavioral patterns differ in im- evolution of object relations during the first
portant ways from presentations of pathology at three years of life. Increasingly, evidence is
the adult end of the developmental trajectory, mounting that the mother-child relationship
presumed to have originated in unsuccessful ne- influences and is influenced by neurological de-
gotiation of Mahlers stages. velopment (Stern, 1985; Siegel, 1999). For exam-
Several representatives of the British object- ple, the absence of what Schore calls the
relations school, notably Winnicott, Bowlby, and mother-infant dance has profound ramifica-
Fairbairn, have contributed concepts that we tions for neurological development as well as
have incorporated in our model to clarify either the development of attachment, particularly in
the dynamics of object-relations development or the orbitofrontal cortex.
therapeutic goals and techniques. Winnicotts Another concept from Bowlby (1988), which
(1971a) concept of the transitional object, a phe- has been empirically demonstrated in the work
nomenon that can be experienced or employed of Ainsworth and her students (Cicchetti, Toth,

& Lynch, 1995), is that of a secure base. In the more rigid with ongoing development and can
presence of a secure base, the caregiver is per- ultimately result in adult personality disorders
ceived as safe, stable, and caring, enabling the that are resistant to treatment. The object-
infant to feel free to move away from the care- relations play therapy model thus argues that
giver and explore the environment. As will be interventions based on developmentally sensi-
seen in the presentation of the actual therapy, tive understanding of object-relations dynamics
establishing a secure base relationship is central and needs should be conducted in childhood,
to effective therapy. when the potential for change is greatest.
Prior (1996) contributed to this approach in
three ways. First, he applied Kernbergs (1966)
concept of unmetabolized object parts to ex- METHODS OF ASSESSMENT
plain mechanisms of splitting in relationally AN D I N TERV EN T ION
traumatized children and account for episodes
of rage in his object-relations model of child ASSESSMENT
therapy for sexual abuse victims. His notion of
relational trauma has significantly influenced Effective object-relations play therapy requires
our view of the types of psychopathology most careful assessment of the child and the childs
appropriate for treatment using our approach. world. This assessment needs to focus on four
Prior also elaborates on Fairbairns concept of major areas: developmental assessment, dy-
obstinate attachment when he argues that namic and object-relations evaluation, clinical
through splitting, the child comes to attach all diagnosis, and systems assessment. Only by un-
of the bad feelings and emerging object rep- derstanding the childs developmental level for
resentations to the self to maintain the good each of the ego functions, the dynamics of the
parent representation needed for psychological childs emerging object relations, the childs
survival in an abusive environment. clinical presentation, and the types of experi-
Thus, this model of object-relations play ther- ences the child has within the family and, when
apy integrates Mahlers stages of development applicable, the school system can the therapist
of emotional object constancy with recent be- determine appropriate therapeutic goals for the
havioral and neuropsychological research on child and broader systems.
early relationship development. This approach Determining developmental level for a child
places central importance on the biological requires observation and data gathering for each
pathways for attachment and relationship de- of the ego functions: language, cognition, percep-
velopment as they interface with the caregiving tion, emotional, social, psychosexual, play, and
environment to direct neurological develop- motor development. Several sources of informa-
ment of cognitive-affective structures called in- tion can be used for this assessment, including
ternal working models. These internal working observation, interviews with parents and teach-
models emerge early in life and continually ers, and standardized instruments such as tests
evolve over the lifetime and serve to guide per- of adaptive, intelligence, achievement, neuro-
ceptions of and interactions with others. Al- psychological or language functioning. (For
though object relations theoretically can be an overview of developmental assessment, see
modified throughout life, their plasticity is OConnor, 2001.) In this part of the assessment,
greatest in the first years of life. In experiences it is crucial to be constantly aware of uneven de-
of relational trauma, internal working models velopment, as many children appropriate for ob-
and the neural networks they reflect become ject-relations play therapy may have cognitive
Object-Relations Play Therapy 51

and intellectual development far in advance of the Diagnostic Interview Scale for Children
their social and emotional development or some (Costello, Edelbrock, Duncan, Kalas, & Klaric,
other pattern of vastly uneven ego functions. 1987), and projective testing, such as drawing
Assessing the dynamics of emerging objects tests (Allan, 1988), storytelling tasks, and the
relations for the child requires familiarity with Rorschach (Kelly, 1999).
each of the six object-relations presentations, Finally, the assessment of the child requires an
which are detailed later in this chapter. Informa- evaluation of the broader systems in which the
tion relevant to determining the childs internal child functions, family and school being most
working models and interpersonal dynamics important. At the immediate family level, such
must come from several sources. The two pri- techniques as Marshak Interaction Method (Lin-
mary sources for this part of the assessment are daman, Booth, & Chambers, 2000), interviews
the parent history/interview and the child play of adult attachment status, direct observation of
assessment and interview. In the parent inter- unstructured parent-child interaction, and home
view, which is also used to obtain information visits can be extremely helpful when combined
relevant to a formal diagnosis, historical infor- with the history interview. The school environ-
mation, especially on any interpersonal or ment can be assessed using teacher behavior
attachment stress, should be combined with checklists and questionnaires, interviews with
clinical judgment about the parents personality the teacher, and school visits. Both for school
functioning, parenting, and relationship to the and for the broader family system, sources of
child. Many types of information are accessible strength for the child and factors that appear
in a diagnostic play/interview session with the to maintain the less adaptive child behaviors
child. By examining the play themes and inter- should be assessed (OConnor, 2000).
personal relationships presented in the play as Intervention planning is the ultimate goal of
well as the relationship with the examiner dur- assessment. In object-relations play therapy, the
ing the assessment, the assessor often can gain clinical and object-relations presentation level
a good understanding of the childs object rela- is determined and therapeutic goals and tech-
tions. In addition, children over age 5 often pro- niques are chosen that are appropriate to the
vide quite direct information about how they childs developmental level and diagnostic for-
approach the world and relationships and how mulation. Possible interventions in addition to
they understand themselves in an interview. play therapy, such as interventions at the family
Clinical evaluation requires obtaining a pic- or school level, are determined through the
ture of the symptoms shown by the child lead- same assessment process.
ing to a Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) diagnosis (American
Psychiatric Association [APA], 1994). Again, INTERVENTION
many sources of data are available to complete
this part of the assessment. In obtaining a for- When utilizing an object-relations approach, es-
mal diagnosis, historical information as well as tablishing the therapist-child relationship first
the observations, interviews, and developmen- initiates and then centers the entire therapeutic
tal assessment described above provide much process. When distortions or disruptions in the
needed information. Other tools that should be development of object relations occur, trust be-
used include behavior checklists, such as the comes the central issue in establishing the ther-
Child Behavior Checklist (Achenbach, 1991a, apeutic relationship. For many of the children
1991b), formal diagnostic interviews, such as most in need of object-relations play therapy,

establishing such trust can be an extended pro- and therapist are safe, maintaining physical
cess. The therapist should foster this secure proximity when the child chooses to jump or
base relationship through several means. First, climb on furniture, and even holding the child
the therapist must show a warm, caring, and ac- if necessary to keep the child safe.
cepting attitude toward the child. Second, the Psychological safety builds on the warmth,
therapist must be sensitive to the childs needs. attunement, consistency, and provision of phys-
In essence, the therapeutic relationship should ical safety described above. In addition, it re-
mimic the attunement characteristic of the quires that the therapist be able to comfortably
good-enough caregivers behavior across the handle the childs expected attempts to control
first few years of life needed to develop a strong the therapist as well as the childs distortions
attachment between child and caregiver. Such around anger. Because children who have expe-
attunement requires both understanding the rienced interpersonal trauma typically have
childs current situation as well as anticipating difficulties with anger, either expressing it in
the childs future needs. This can be achieved out-of-control ways or inhibiting it when it
through matching the childs affect or mood, should be expressed, the therapist must be able
using reflections to track the childs activities, to challenge such distortions in understanding
imitating the child, or accepting the childs re- of anger. This includes encouraging expression
quests to imitate him or her. In addition, at- of anger while providing containment of its ex-
tunement is demonstrated when the therapist cesses through limit setting. In addition, allow-
helps the child meet his or her needs. ing and containing expressions of anger
There are several additional ways to foster without either withdrawing emotionally from
the secure base relationship in play therapy. the child or returning anger with anger shows
Consistency on the part of the therapist helps the child that anger does not have to destroy re-
provide a sense of safety within which trust can lationships.
develop. Consistency of contact (e.g., weekly Once the secure base relationship is estab-
sessions) may be supplemented by consistent lished, the working phase of therapy begins. The
routines for beginning and ending the session therapeutic goal of this phase of treatment is to
and consistency of space. It is important that modify the childs internal working model of
the office/playroom remain as constant as pos- the self, other, and self in relation with other
sible. This requires that the toys be stored in through stimulating, challenging, and encourag-
predictable places from week to week, that chil- ing the development of alternatives to the exist-
dren not be allowed to take toys away from the ing model. The therapist accomplishes this goal
room, and that when new toys are added, the by integrating child-responsive and invitational
child is told so there are no surprises. play therapy techniques based on themes and re-
The therapist is responsible for providing a lationships encoded in the childs play with a
sense of safety, both physical and psychologi- theoretical formulation based on the childs de-
cal, throughout the therapeutic process. Physi- velopmental object-relations presentation.
cal safety would seem quite easy to provide.
However, many children with attachment dis- Object-Relations Play Therapy Technique
orders or a history of interpersonal trauma play Object-relations play therapy technique in-
dangerously and take many risks, making the volves three essential components for effective
assurance of physical safety something requir- intervention. First, this approach requires that
ing deliberate attention from the therapist. A the therapist be child-responsive: Each inter-
sense of safety can include stating the play- vention by the therapist occurs in attuned re-
room rules in terms of making sure both child sponsiveness to the childs play and patterns
Object-Relations Play Therapy 53

of interaction with the therapist (Benedict & possible responses from the child is fully ac-
Mongoven, 1997). The therapist participates ac- ceptable to the therapist.
tively in the therapeutic relationship, moving Child-responsive, developmentally sensitive,
between nondirective and directive interven- and invitational play therapy relies heavily
tions as needed in response both to the specific on the therapists understanding of the childs
therapeutic goals for the child and the childs play. That understanding is facilitated by
ongoing play content and interactions with the awareness of the possible meanings of various
therapist. common themes seen in therapeutic play. When
Second, object-relations play therapy requires engaging in imaginative or fantasy play, chil-
the therapist to be centered on the developmen- dren tend to play certain easily identified
tal level and needs of the child. As discussed themes having to do with such important broad
earlier, the therapists understanding of the content areas as aggressive and power concerns,
childs developmental level, both in terms of the family and nurturance, safety and control, ex-
childs progress in achieving object constancy ploration and mastery, and sexuality. A specific
and the childs ego functions, including lan- example of one of these themes is nurturing
guage, cognition, emotional, and social develop- play, where a character within the play is offer-
ment, serves to guide each intervention. Only ing some sort of nurturance by cooking for,
when the therapist adjusts interactions to the feeding, giving gifts to, or caregiving another
childs developmental level can the therapist be character. Another theme is fixing, where
fully attuned to the child. one character repairs a broken object or
The third aspect of this approach concerns doctors a sick or hurt (that is, broken in some
the interventions made by the therapist. To way) character.
maintain the secure base relationship while Recent research by the authors and their as-
challenging the childs internal working mod- sociates has codified the commonly seen play
els, each actual intervention of the therapist themes and examined the typical themes in
must be invitational in nature (Gil, 1991). Es- play for children with differing interpersonal
sentially, the therapist offers to the child new histories and different presentations of object-
directions for play and new possible ways of in- relations development (Benedict & Shelton,
teracting with the therapist (and, by extension, 1996; Benedict et al., 1966; Holmberg, Benedict,
others) through open-ended overtures within & Hynan, 1998; McClain, 1998; McGee, 1998;
the play. These invitations can be accepted and Narcavage, 1998; Wooley, 1998). By attending to
used by the child or ignored and even rejected these themes, the therapist can understand the
with no negative consequences to the relation- childs metaphoric presentation of concerns,
ship with the therapist or to the childs sense of confusions, and interpersonal relationship is-
safety in the play room. For example, a young sues. The therapist thus observes, and interacts,
boy might be playing a scene where the good in the childs play in such a way that the thera-
guy is trying to control the scary monster pist forms hypotheses about possible meanings
that is imagined to be in the room. The thera- each theme has for the child. The therapist uses
pist might offer the child an invitation, such as these hypotheses, in conjunction with his or her
Maybe the good guy can build a wall to keep understanding of the childs object-relations
the monster away. In response, the child presentation, to issue invitations within the play
might look for blocks to build a wall, even ask- metaphor that serve to challenge or stimulate the
ing the therapist to help with the building, or child to modify existing object relations in
the child might ignore the invitation or shift healthier directions. Play themes thus function
play to some other theme. Any of these or other as a major tool for the therapist. Understanding

the themes the child plays spontaneously pro- during play. For example, a child might alter-
vides a window to the childs object relations, nately kill and then hug the mommy figure.
and issuing invitations within the themes en- Similarly, a 4-year-old boy fed the therapist
ables the child to understand the therapists soup and, just as the therapist began eating,
communications and use them to facilitate calmly said it was poison.
growth in an environment of safety. A second type of process code important in
A second tool important to effective object- object-relations play therapy is stage mix. In this
relations play therapy focuses not on the con- play, the child has a character simultaneously
tent of the play but on the affects and play two distinct developmental stages at the
interactional patterns demonstrated through same time. This type of play suggests a lack of
the play. Our laboratory has codified these into boundaries between roles and is frequently
an interpersonal relations and affect coding seen when the child is parentified or bur-
system, which can also be reliably used to un- dened by needing to take care of a parent
derstand the childs object relations (Benedict, (Chase, 1999). An example of this is a child who
Hastings, Ato, Carson, & Nash, 1998). Some of put on the wedding dress in the playroom
the interactional patterns so coded are bound- and walked around the room in the dress suck-
ary setting and boundary violation, control, imi- ing on a baby bottle (Grigoryev, personal com-
tation, helping, sharing, and protecting. Some of munication, 1996). Trina, whose therapy is
the affective expressions coded are anger, sad- described at the end of this chapter, used stage
ness, and rejection. By observing the interaction mix in her play, where it seemed to reflect her
patterns and affects in the childs play, the ther- confusion about roles in her relationship with
apist gains insight into the object relations of the both her mother and her custodial grand-
child. By then offering child-responsive invita- mother.
tions, the therapist can sensitively challenge
and modify those object relations for that child. Conceptualizations of Developmental Level of
Finally, two process codes, which essen- Disordered Object Relations
tially codify relationships between themes or Disordered object relations can occur at several
interpersonal codes, have been identified that points in the development of object constancy,
greatly facilitate the therapists understanding as proposed by Mahler et al. (1975). The nature
of the childs object relations. The first of these, of the child-caregiver relationship, including
called doing and undoing, draws attention to the the contributions of the childs temperament
expression of ambivalence. Children who expe- and biological givens and the contributions
rience attachment disorders or interpersonal from the caregiver, determines whether the
traumas at a young age and thus show delays child develops healthy, distorted, or arrested
and distortions in development of object con- object relations. Disturbed object relations
stancy and healthy object relations often feel in- color the childs negotiation of subsequent de-
tensely ambivalent about the important people velopmental tasks and relationships. Six char-
or objects in their world. Yet, developmental re- acteristic patterns of disordered object relations
search by Susan Harter (1983) and others shows have been proposed by Glickauf-Hughes and
that childrens cognitive understanding and di- Wells (1997) as a framework for understanding
rect verbal expression of ambivalent feelings adult psychopathology. In our clinical practice,
develop slowly and do not appear consistently we have identified a parallel set of clinical pre-
until children are between 8 and 10 years old. sentations that appear to represent the early
Thus, young children express ambivalence by manifestations of disturbed object relations in
rapidly shifting the valence of the interaction young children.
Object-Relations Play Therapy 55

The six childhood presentations, although such a caregiver is not available, whether be-
similar in dynamics to the proposed origins cause of maternal pathology, such as severe
of adult personality problems, differ from the depression, substance abuse, or personality dis-
adult patterns in significant ways. Whereas adult order, or the childs inability to respond to the
patterns represent fully internalized object rela- world because of prematurity, neurological
tions, childrens patterns are a combination of problems, or sensory deficits, or some combina-
early, incompletely developed object relations tion of both, the infants emerging object rela-
and actual interaction patterns occurring in real tions show distortions in trust, interpersonal
time in the childs life with significant attach- connections, ability to accept nurturing, and
ment figures. Such emerging object relations are poor self-regulation. Table 3.1 outlines these dy-
more plastic than those seen in adults and more namics and presents the prominent play themes
open to clinical intervention. Therefore, the rela- and interpersonal relationships with their mean-
tionship between child and therapist has signifi- ings, as well as therapeutic goals and appropriate
cantly more elements of a real relationship that therapeutic techniques to meet those goals.
offers an alternative object around which object The second presentation to emerge develop-
relations can be formed or modified than has the mentally focuses on problems occurring during
relationship between adult and therapist. Al- two of Mahlers stages and is called a practicing
though the child may show some transference- and rapprochement presentation. The caregiver-
like elements, much of the therapeutic work child system for this presentation appears un-
occurs within the actual relationship between able to negotiate the childs attempts to sepa
child and therapist. The ongoing contributions of rate and individuate, resulting in a lack of self-
the current caregiver-child system to the childs constancy, self-fragmentation, splitting between
emerging object relations place an additional negative and positive thoughts and negative and
challenge for the therapist, requiring interven- positive part objects, and intense expression of
tion where possible in that system as an adjunct ambivalence. Table 3.2 outlines the characteris-
to therapy with the child. tics of this presentation. As can be seen from
Each of the six presentations can be charac- this table, a practicing and rapprochement prob-
terized in terms of the probable early experi- lem will produce quite different dynamics, play
ences in the child-caregiver relationship that set themes, relationship patterns, and therapeutic
the stage for the emergence of disturbed object goals than those characteristic of presymbiotic
relations and the internal working models of and symbiotic presentations.
self, other, and relationships that appear to The third presentation seen clinically, called
be emerging for the child. Each of the six pre- compromised rapprochement, emerges during
sentations also can be characterized in terms of or just after Mahlers rapprochement phase.
the childs prominent play themes, with their Here, the child seems to have resolved the am-
probable meanings for the child and the inter- bivalence in a way that severely compromises
personal relationships expressed in play. From the childs emerging internal working model of
these, one can create a dynamic formulation the self, others, and relationships. Table 3.3 out-
that in turn guides therapeutic goals and inter- lines the characteristics of this presentation.
ventions. These children present as estranged from gen-
The presymbiotic and early symbiotic pre- uine feelings and needs, relating to others as
sentation, the earliest presentation to develop, part objects to fill needs, with the result that
has its roots in the first few months of life, when they appear both pseudomature and pseudoau-
the infant requires an engaged, attuned care- tonomous. It is this group that most clearly
giver to develop a basic sense of trust. When demonstrates the false self of Winnicott (1965).

Table 3.1 Dynamics and treatment of presymbiotic and early symbiotic presentations.

Probable early experiences and relationships: Neglect, rejection, invalidation of childs being,
attunement failure.
Internal working model of self and other: Lack of basic trust of others.
Self that resists interpersonal connection and nurturing.
Minimal self-regulation or ability to modulate affect.
Internal working model of relationships: Withdrawal from others; largely defensive.
Dynamic formulation: Self is detached, with rigid boundaries between self and
other; underlying fear of self-fragmentation if needs and
feelings are expressed or acknowledged.

Prominent Play Themes Meanings of Play Themes

Aggression: Any general aggression or aggression where Child may have angry feelings without any clear sense
there is an aggressor and a victim. of why feeling angry; child may be affectively
stimulated, which leads to an explosion of feeling; child
may have strong angry feelings expressed in role of
aggressor; victim role may indicate a sense of no control
over daily life.
Constancy: Hide-and-seek, mirror play, and other Child has tenuous sense of trust and is using games to
activities that seem to focus on establishing the childs test therapists trustworthiness; child has difficulty
identity or the constancy of others identity. maintaining a constant image of important adults and
uses separation and reunion to help build such an image;
child has difficulty maintaining a constant image of self
and is fascinated by representations of self-constancy
(e.g., mirrors, self-naming).
Nurturing: Positive nurturing activities such as feeding, Child may need nurturance but feel unsafe expressing
giving, or holding. dependency needs.
Self-nurturing: Nurturing directed at self, as when the Child needs nurturance but doesnt trust the world to
child, as baby, feeds or comforts self. provide it so self-nurtures; child is pseudoautonomous
because of lack of confidence in others to provide care
and protection.
Instability: Play in which people or things are falling off Child may see danger in the world; child may feel
surfaces or are precariously balanced as if to fall, or fragmented and unstable in the world, especially
when things fall apart, such as the walls of a house when the child is the one about to fall.
falling down.

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Roughhousing: Child seeks to engage the therapist in Child may be regressing to toddler-type interactions in
positively toned toddlerlike physical play, such as the service of reworking symbiosis stage; child may be
tickling or being picked up. seeking physical comfort but needs to request it
indirectly; child may have limited sense of bodily self
and seeks roughhousing to establish boundaries and
closeness with therapist.
Object-Relations Play Therapy 57

Table 3.1 (Continued)

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Fusion: Child directly plays out a lack of boundary Child may be returning to the symbiosis stage as a
between self and therapist (e.g., drawing self and secondary presymbiosis-symbiosis reworking; suggests
therapists faces within a single head outline). progress.

Imitation-control: Child demands that the therapist Child uses projective identification to facilitate a
imitate the childs verbalizations or behaviors. symbiotic transference with the therapist; suggests
Doing and undoing: Child plays a theme immediately Change in meaning or valence suggests conflict and
followed by a theme with opposite meaning or valence, mixed feelings around issues expressed in play or
such as aggression followed by a display of affection. interpersonal behavior.
(a) Boundary setting/ boundary violation: Establishing and (a) Child is uncertain about the integrity of own
then violating boundaries, such as when a character boundaries.
closes a house door against a monster who then
breaks down the door and comes into the house.
( b) Anger/affection: Directly expressed anger or hostility ( b) Child has feelings of anger toward caregiver related to
toward a character or the therapist, followed by perceived deprivation, and feels expression of anger is
expressed affection. unacceptable, so tries to undo it with affection.

Therapeutic Goals Therapeutic Techniques toward Goals

Facilitate receptivity to nurturance, and then Create safe holding environment by emphasizing
connectedness. emotional and physical safety.
Establish symbiotic transference from which client can Show attunement by mirroring and reflecting childs
separate adaptively. feelings. Provide context of constancy by providing
transitional pictures, verbalizing shared memories, and
preserving traces of childs play.
Establish cohesive, nondefensively based sense of self. Provide safety for childs recognition and expression of
Facilitate self-regulation skills. Invite body expression of feelings and relate to verbal
expressions. Provide structure around physical contact
to establish boundaries, encourage self-awareness, and
facilitate self-regulation.
Promote ability to tolerate, label, and verbalize feelings. Contain, reflect, and provide safety around feelings.
Probable developmental trajectory: Schizoid personality.

Table 3.2 Dynamics and treatment of practicing and rapprochement presentations.

Probable early experiences and relationships: Caregiver withdraws attention, support, and/or approval
as child attempts to separate and individuate; likely to
be personality problems or severe psychopathology in
Internal working model of self and other: Lack of self-constancy, with splitting of negative and
positive thoughts, perceptions, and feelings.
Self-fragmentation and regression likely.
Objects not constant and fragmented with splitting
between positive and negative part objects, leading to
rapid shifts in mood and behavior.
Internal working model of relationships: Extremely ambivalent close relationships that alternate
between clinging and rage; moving into and away from
Separation-individuation process incomplete; often
arrested at rapprochement crisis.
Dynamic formulation: Anxiety related to conflicts around engulfment and
abandonment; strong fear of both self-fragmentation and
loss of object.

Prominent Play Themes Meanings of Play Themes

Constancy: Hide-and-seek, mirror play, and other Child has difficulty maintaining a constant mental
activities that seem to focus on establishing the childs image of important adults and uses the separation and
identity or the constancy of others identity. reunion to help build such an image; child has difficulty
maintaining a constant image of self and is fascinated by
representations of self constancy (e.g., mirrors, self-
Separation: Child plays out someone leaving or separating Child is reenacting separation/individuation through
from another character. play typical of toddlers either at the practicing or
rapprochement stage; child has an anxious attachment to
the caregiver and practices controlling who moves away;
child may view separation from caregiver as
Good guy versus bad guy: Aggressive play in which Child is engaging in splitting as a defense against
good/bad characters are clearly identified. simultaneous awareness of contradictory feelings about
self or others; child may not have made developmentally
appropriate progress in ability to accept and integrate
both good and bad parts of self and others.
Sorting: Child lines thing up or sorts them into Child sorts in an attempt to separate good from bad
categories, such as nice animals and mean animals. things as part of defensive splitting or ambivalence
about important relationships; sorting can represent the
emergence of compulsive defenses to manage out-of-
control internal experience.
Object-Relations Play Therapy 59

Table 3.2 (Continued)

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Control: Child or character is bossy or directive, ordering Child may feel world is chaotic, and attempts to gain
either therapist or another character around. security by means of controlling others.
Stage mix: Child plays two different stages of the life Child may be living in an environment where roles are
span simultaneously within one character (e.g., a baby unclear, such as a parent enacting projective
doing an adult activity such as driving a car). identification with the child; child may not have
developed stable object constancy and shifts roles
rapidly because of uncertainty about role boundaries.
Doing and undoing: Child plays a theme immediately Change in meaning or valence suggests conflict and
followed by a theme with opposite meaning or valence, mixed feelings around issues expressed in play or
such as aggression followed by a display of affection. interpersonal behavior.
(a) Fusion/separation: Child fuses with and then separates (a) Suggests conflict involving wish to fuse (and
from therapist. internalize good object) and simultaneous fear of
( b) Boundary setting/ boundary violation: Establishing and ( b) Child is uncertain about the integrity of own
then violating boundaries, such as when a character boundaries.
closes a house door against a monster who then
breaks down the door and comes into the house.
(c) Anger/affection: Directly expressed anger or hostility (c) Child has feelings of anger toward caregiver related to
toward a character or the therapist, followed by perceived deprivation, and feels expression of anger is
expressed affection. unacceptable, so tries to undo it with affection.

Therapeutic Goals Therapeutic Techniques toward Goals

Facilitate separation and individuation. Be a secure base from which child can explore.
Integrate split representations of self and other. Function as a container for childs ambivalence by
providing safety, empathy, and validation during play;
remain constant despite childs changeable affect and
Help develop object constancy. Foster constancy through facilitating memories and
preserving play traces, and providing constant
therapeutic setting.
Foster integrated sense of self. Encourage and support genuine self-expression, and
awareness and definition of boundaries, through
labeling motives, affect, and behaviors and their
interconnections in play.
Increase frustration tolerance. Set appropriate limits but give choices; verbalize limits
and anticipate consequences of dangerous or
inappropriate behavior.
Probable developmental trajectory: Borderline personality.

Table 3.3 Dynamics and treatment of compromised rapprochement presentations.

Probable early experiences and relationships: Rejection of childs expression of needs and feelings; use
of child to meet caregivers needs; admiration and
approval of child as reflection of caregiver, rather than
love and acceptance of child as own person.
Internal working model of self and other: Self estranged from genuine needs and feelings, with
little ability to self-soothe or be playful or spontaneous.
Relates to others more as part objects to fill needs than as
integrated people with needs and feelings of their own.
Internal working model of relationships: May manipulate or control others (as in controlling
caregiving), frequently idealizing or devaluing aspects
of others.
Dynamic formulation: Child presents a false self that is pseudomature and
pseudoautonomous, with little awareness of needs and
feelings. There is the illusion that separation-
individuation has been resolved, but this resolution is
based on maintaining connection to a good internal
object by compromising authentic needs and feelings.
Anxiety relates to fears of loss of object or approval.
Lack of playfulness reveals inhibition and anxiety about
play and self-exploration, as knowing self is perceived as
unsafe. Obstinate attachment, where child defensively
identifies with a bad object to maintain connection to
the good object, is often present.

Prominent Play Themes Meanings of Play Themes

Self-nurturing: Nurturing directed at self, as when the Child has been parentified and thus is hyperresponsible;
child, as baby, feeds or comforts self. suggests child does not trust others to meet needs and
must do it alone.
Nurturing: Positive nurturing activities such as feeding, Child has been parentified and tries to gain acceptance
giving, or holding. from therapist by nurturing or taking care of him or her.
Constancy: Hide-and-seek, mirror play, and other Hiding things may be hinting that there are parts of the
activities that seem to focus on establishing the childs self hidden; child hides as a way of maintaining
identity or the constancy of others identity. connection and constancy from a distance.
Store/shopping: Child sets up a store where child or Child wants to be in control of how needs are met.
therapist shops or a character goes shopping.
Mastery: Child builds something or shows ability to Child may need to be able to do more adult things to feel
perform some skill or ability. safe, especially if child has been parentified; child may
show mastery at the beginning of therapy to mask fear
and anxiety, or to prove to the therapist that the child is
somehow not bad or needing help.
Object-Relations Play Therapy 61

Table 3.3 (Continued)

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Control: Child or character is bossy or directive, ordering Child is trying to order world and empower self; child
either therapist or another character around. may feel internal world is chaotic and controls others in
an effort to feel more secure.
Independence: Child refuses help and insists on doing Child may be parentified and feel he or she must take
something alone in a context where child is realistically care of things by self; child may show a false or
dependent on adult for help. pseudoautonomy as a defense against feelings of
vulnerability; child is so threatened by unmet intense
dependency needs that he or she has resolved not to
need anyone.
Teasing: One character playfully tricks or teases another Child may be teasing to test the therapists psychological
(not hostile). safety; child may use teasing to keep the therapist at a
distance, especially when difficult issues are being
Imitation-control: Child demands that the therapist Child may use imitation as a way of controlling others
imitate the childs verbalizations or behaviors. (see Control).
Stage mix: Child plays two different stages of the life Child may have developed a false self and show both
span simultaneously within one character (e.g., a baby false mature self and unmet needs of infantile self
doing an adult activity such as driving a car). simultaneously; child may be parentified.
Therapeutic Goals Therapeutic Techniques toward Goals

Develop ability to connect with others in an authentic Model healthy boundaries and verbally address
way. boundary issues within context of genuine relationship
where therapist avoids blank slate in favor of sharing
selective appropriate parts of therapists real self.
Help child understand needs and feelings of others and Show attunement and respect boundaries, enabling
relinquish need to control others through caretaking. rather than challenging childs controlling play.
Encourage childs capacity for age-appropriate play. Provide a safe holding environment offering external
source of safety (e.g., invite rescue), and assure childs
safety during play.
Increase childs awareness of genuine self, both needs Encourage labeling and verbalization of hidden feelings;
and feelings. support strengths and empathize with vulnerabilities by
affirming abilities, encouraging problem solving, and
identification of childs coping and behavior patterns.
Help child develop ability to self-soothe. Model soothing and self-care with characters and
identify needs of characters in play; show ways they can
gratify needs adaptively.
Probable developmental trajectory: Narcissistic personality.

Table 3.4 Dynamics and treatment of On the Way to Object Constancy presentations.

Probable early experiences and relationships: Abuse and/or neglect, with inconsistent meeting of
dependency needs; scapegoating and/or parentification;
control of child by a caregiver lacking in self-control;
disempowerment of the child.
Internal working model of self and other: Self shows some constancy with at least some awareness
of needs and feelings, but overall self lacks integration.
Uneven ego strength, so will show difficulty with one or
more of the following: self-regulation, delay of
gratification, anticipation of consequences, or stress
Hidden self, where child is caught between the wish to
be found and the terror of being discovered.
Sees others as not constant, alluring but unreliable in
meeting childs needs.
Internal working model of relationships: Alternating anxious attachment and counterdependence.
Overtly compliant but defiant in covert, passive ways.
General passivity in relationships.
Dynamic formulation: A basic failure to identify with caregiver, and thus lack
of appropriate internalization of caregivers self-
soothing capacities, empathy, or auxiliary ego functions,
which at this stage of development should be part of self-
representations and functions. Anxiety relates to fear of
loss of approval and/or autonomy. Child lacks ability to

Prominent Play Themes Meanings of Play Themes

Safety: Focus is on establishing safety for the child or an Child may feel it is important to keep feelings contained,
identified character; can involve keeping something particularly angry feelings; child may come from a home
inside/outside a particular space, and keeping where it is not acceptable to talk about things, and uses
characters out of danger. containers to carefully enclose loaded issues; child may
feel a need to protect important others (including their
feelings); child is seeking to protect self from dangers.
Nurturing: Positive nurturing activities such as feeding, Child has been parentified and tries to gain acceptance
giving, or holding. from therapist by nurturing or taking care of him or her;
child may show self-nurturance because he or she does
not trust others to meet needs and must do it alone.
Danger: Potential danger is identified and needs to be Child may be indicating a sense that world is unsafe;
addressed; can include dangerous characters and indication of dangerous feelings inside, which cannot
dangerous places. be revealed, as well as perceived threat of exposure; can
represent perceptions of underground family tensions.
Aggression: Any general aggression or aggression where Child may be expressing formerly repressed anger about
there is an aggressor and a victim. previous victimization in real life.
Object-Relations Play Therapy 63

Table 3.4 (Continued)

Prominent Play Themes Meanings of Play Themes

Good guy versus bad guy: Aggressive play in which Child is engaging in splitting as a defense against
good/bad characters are clearly identified. simultaneous awareness of contradictory feelings about
self or others; child may not have made developmentally
appropriate progress in ability to accept and integrate
both good and bad parts of self and others; child may be
preoccupied with questions of good and badness, being
super good to win approval of others; child must be
constantly vigilant in play so that bad behavior
doesnt occur.
Broken: A character is broken, sick, or hurt and needs to Child may be indicating broken relationships in own
be fixed. life; suggests feelings that world is broken and thus
unsafe; broken house suggests that home is perceived as
unsafe, unstable, or breaking apart (as in divorce);
childs developing self-representation may be
fragmented or not yet integrated.
Fixing: Something broken is fixed by repairs. May be an attempt to undo previous aggressive play
that child fears is unacceptable.

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Positive connection: Play that emphasizes a positive Child is refueling on positive play before returning to
connection between two characters but is not openly major issues that are difficult to play about.
Boundary setting: Where play imposes a physical Child may use boundaries to establish a sense of
boundary between two people or characters. personal safety; represents an attempt to rework
rapprochement, with setting boundaries as part of the
struggle to individuate.
Protect: Play where a stronger (or adult) character acts to Child may be showing that a character needs protection.
protect weaker (or child) character.
Doing and undoing: Child plays a theme immediately Change in meaning or valence suggests conflict and
followed by a theme with opposite meaning or valence, mixed feelings around issues expressed in play or
such as aggression followed by a display of affection. interpersonal behavior.
(a) Safety/danger: Child establishes safe place and then (a) Child worries about lack of safety and vulnerability
danger intrudes. to danger, suggesting child is uncertain whether he
or she will be able to be safe in a threatening
( b) Broken/fixing: Something is hurt or broken, and then ( b) Child is concerned with perceptions of injury,
fixed. damage, or vulnerability in the self, caregiver, or
family; fixing suggests either hope or emerging
(c) Boundary setting/ boundary violation: See Table 3.1. (c) Child is uncertain about the integrity of own


Table 3.4 (Continued)

Therapeutic Goals Therapeutic Techniques toward Goals

Resolve ambivalent attachment to caregiver and/or Be emotionally available without being either controlling
grieve separation and loss. or infantilizing.
Build childs trust in those who can meet the childs Provide constancy and attunement to child, reflecting
needs. childs feelings and preserving childs play traces and
Foster appropriate levels of assertiveness. Model healthy boundary setting for child and verbalize
child being in charge of own boundaries and rights to
feel differently from others.
Increase frustration and stress tolerance, focusing on Help child anticipate consequences and verbally connect
self-soothing and self-esteem. distress and anxiety to sources of frustration and stress.
Encourage developmental body play for enhancing self-
Encourage childs valuing of own needs as much as the Provide safe holding environment for expression of
needs of others so child loses need to have a hidden self. needs and feelings and serve as a container for negative
Foster an integrated, stable sense of self. Encourage genuine self-expression, validate needs and
feelings, and affirm value of childs hidden self.
Probable developmental trajectory: Dependent, passive, avoidant features.

When a child experiences attachment or in- presentation are typically oppositional and
terpersonal trauma following relatively success- tend to be preoccupied with feelings of shame
ful negotiation of the rapprochement phase and doubt and a sense of being unable to meet
within Mahlers stages, the resulting dynamics high internal standards for behavior. The dy-
and internal working models are generally less namics, themes, interpersonal relationships,
impaired than when trauma occurs before this and therapeutic goals and techniques of this
point. The fourth presentation occurs during presentation are outlined in Table 3.5. Play dur-
the phase Mahler calls on the way to object con- ing therapy for these children is often inhibited
stancy and is outlined in Table 3.4. In some or stereotyped, with intense need to be in con-
ways, these children present like children show- trol of the situation, again requiring differing
ing compromised rapprochement, but the es- goals and techniques during treatment.
trangement from feelings is much less complete. The final presentation to emerge develop-
Thus, although these children do have some mentally is a post-Oedipal presentation, which
self-awareness, they lack an integrated self and is presented in Table 3.6. Although these chil-
show uneven ego strength with some difficulty dren appear to have self and object constancy
with self-regulation, delay of gratification, an- and generally good ego functions, they also
ticipation of consequences, or stress tolerance. tend to act out conflicts and fail to rely on the
Often passive in relationships, these children ego functions they have developed. They tend
tend to vacillate between overt compliance and to work to gain approval of others through an
covert resistance. exaggerated dependency and/or seductiveness
The final presentation prior to the develop- with a limited sense of initiative and often con-
ment of object constancy occurs in the late sepa- siderable confusion about affectional and sexual
ration-individuation phase. Children with this needs.
Object-Relations Play Therapy 65

Table 3.5 Dynamics and treatment of late separation-individuation presentations.

Probable early experiences and relationships: Overcontrolling caregiver, restricting the childs
impulses, affects, and autonomous behaviors.
Internal working model of self and other: Self preoccupied with feelings of shame and doubt, with
a restricted sense of autonomy.
Self-presentation is self-contained or inhibited with a
pseudoautonomous stance; sees self as unable to meet
high internal standards for behavior.
Sees others as potentially out of control or dangerous
and a threat to childs sense of control.
Internal working model of relationships: Relationships focus on power struggles with
considerable oppositionality, sometimes to the point of
little genuine connection outside of the need for control.
Dynamic formulation: Child has stable sense of self but lacks integration of
affective experience into core self. Child is preoccupied
with need to keep the world organized and manageable
to compensate for feelings of being out of control; the
result is compulsiveness and rigidity with feelings of
shame when control isnt maintained. Child often
engages in stereotyped, repetitive, or inhibited play and
lacks spontaneity. Any sense of losing control leads to
anxiety, as does failure to meet internal standards,
which are often excessively high and/or rigid.

Prominent Play Themes Meanings of Play Themes

Instability: Play in which people or things are falling off Child may feel or fear world is falling apart; child may
surfaces or are precariously balanced as if to fall, or see danger in the world.
when things fall apart, such as the walls of a house
falling down.
Cleaning: Cleaning spontaneously or talking about May indicate a child who manages anxiety by keeping
cleaning something dirty or nasty. everything clean and perfect.
Sorting: Child lines thing up or sorts them into Child feels or fears that world is chaotic and is trying to
categories; such as nice animals and mean animals. establish a sense of order.
Danger: Potential danger is identified and needs to be Child may be indicating a sense that the world is unsafe.
addressed; can include dangerous characters and
dangerous places.
Power: Involves power relationships, with emphasis on Child is feeling weak and wants to feel strong; child may
strength and differential power. be identifying with strong person.
Fail: Lack of ability to master tasks undertaken, or lack Child may set unrealistically high internal standards
of confidence in ability (e.g., giving up easily, apparent that engender anxiety, shame, self-doubt if/when not
frustration). met.


Table 3.5 (Continued)

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Control: Child or character is bossy or directive, ordering Child may feel internal world is chaotic and controls
either therapist or another character around. others in an effort to feel more secure; child is trying to
order the world and empower the self; child may need to
control the interpersonal interaction to maintain an
appropriate level of personal safety; maintains
connection with distance so that relationship is less
threatening and basic conflict stays out of awareness.
Boundary violation: Violation or overstepping of literal or Child may feel endangered physically or psychologically,
figurative boundaries, whether interpersonally or in play. as if boundaries are at risk of intrusions.
Refusal to cooperate: Child or character in play refuses to Child may be focused on establishing independence and
cooperate when such cooperation would normally occur autonomy; child may use oppositionality to test the
in the play. therapists willingness to give the control in the therapy
setting to the child.
Doing and undoing: Child plays a theme immediately Change in meaning or valence suggests conflict and
followed by a theme with opposite meaning or valence, mixed feelings around issues expressed in play or
such as aggression followed by a display of affection. interpersonal behavior.
(a) Independence/dependence: Child insists on doing alone (a) Child feels compelled to strive for self-sufficiency
a task where help is realistically needed and then because of perceived inability of caregivers to meet
insists on help on another task where none is needed. needs; conflict suggests that the child feels
unequipped to achieve self-sufficiency, though
perceives self-sufficiency as the safest, surest route to
getting needs met.
( b) Danger/escape: Child plays about a danger from which ( b) Child worries about danger but sees self as
the character escapes. responsible for avoiding or escaping danger.
(c) Mastery/failure: Child alternately succeeds and fails to (c) Child vacillates between successful mastery and a
mastery an activity. sense of failure because of impossibility of meeting
internal standards.

Therapeutic Goals Therapeutic Techniques toward Goals

Increase value of relationship itself over value of being Provide attunement, empathy, and validation. Mirror
in control. feelings and acceptance of feelings as part of self.
Encourage greater sense of genuine autonomy and move Accommodate childs need for control, asking child to
away from reliance on power struggles and reactivity. teach, encouraging child in making choices; accept
childs demands while maintaining safety.
Facilitate an increase in sense of safety within both Model appropriate risk taking while maintaining
connection and autonomy. physical and psychological safety of the room.
Increase affective expression and spontaneity. Encourage expression of feelings and model warmth
coupled with emotional expressiveness and spontaneity.
As about feelings, affirm and label feelings, especially
ones child is uncomfortable expressing.
Lessen impact of overly harsh self-expectations. Acknowledge, take responsibility for, and accept
mistakes. Model self-acceptance and realistic
expectations by reacting appropriately to own mistakes.
Probable developmental trajectory: Obsessive-compulsive personality.
Object-Relations Play Therapy 67

Table 3.6 Dynamics and treatment of post-oedipal presentations.

Probable early experiences and relationships: Seductive opposite-sex parent, or need of opposite-sex
parent for child to align against same-sex parent;
disallows any aggressive impulses and fosters passivity
and helplessness.
Internal working model of self and other: Sees self as unable to take initiative.
Guilty about sexual and aggressive impulses; confusion
of affectional and sexual needs.
Sees others as demanding approval from the child.
Internal working model of relationships: Child uses exaggerated dependency to please and gain
the approval of significant others, often with a highly
seductive quality.
Dynamic formulation: Child has self and object constancy with generally good
ego functions, but tends to act out conflict rather than
reflect and rely on these ego functions, at the same time
acting helpless and passive.

Prominent Play Themes Meanings of Play Themes

Aggression: Any general aggression or aggression where Child may have angry feelings without any clear sense of
there is an aggressor and a victim. why; may lose control because play touches on a difficult
issue and is angry that the feelings or events have been
recalled; child may feel powerless in daily life and acts
as aggressor to gain sense of control; aggressive role may
indicate way child is in daily life (may include
significant feelings of being unable to control angry
Power: Involves power relationships, with emphasis on Child is feeling weak and wants to feel strong; child is
strength and differential power. showing how it feels to be controlled by a power figure
in the childs life.
Seek: Character consults a power figure such as a parent, Child is showing a pattern of pseudodependency,
judge, or supernatural/mystical power like a wizard or turning to a power figure to please the power figure.
Adult: Child assumes adult roles and activities, such as Child has identified with older siblings or adults and
going on a date or going steady. wants to be like them either to receive their approval or
to magically provide safety or comfort to self as if the
other is present.
Fail: Lack of ability to master tasks undertaken, or lack Child may have a fear of taking the initiative and
of confidence in ability (e.g., giving up easily, apparent attempting to be competent.
Sexual activities: Play that shows or alludes to direct Child may have learned that sexual activities garner the
sexual behavior either between characters or between immediate attention of adults and may be seeking the
child and therapist. In the latter case, the child makes therapists attention; child may be in a covertly
overtly sexually seductive overtures toward the seductive relationship (e.g., with opposite-sex parent)
therapist. and engage in seductive behavior to gain affection.


Table 3.6 (Continued)

Interpersonal/Process Codes Meanings of Interpersonal/Process Codes

Help: A character helps through teaching, guiding, or Child may be seeking help in a pseudodependent fashion
rescuing another character. to engage therapist.
Protect: Play where a stronger (or adult) character acts to Child may be pseudodependent and elicit protection
protect weaker (or child) character. through helpless behavior, as a way to engage
Control: Child or character is bossy or directive, ordering Child may need to control the interpersonal interaction to
either therapist or another character around. maintain an appropriate level of personal safety;
maintains connection with distance so that relationship is
less threatening and basic conflict stays out of awareness.
Doing and undoing: Child plays a theme immediately Change in meaning or valence suggests conflict and
followed by a theme with opposite meaning or valence, mixed feelings around issues expressed in play or
such as aggression followed by a display of affection. interpersonal behavior.
(a) Broken/fixing: See Table 3.4. (a) Child is concerned with perceptions of injury, damage,
or vulnerability in self, caregiver, or family; fixing
suggests either hope or emerging empowerment.
( b) Independence/dependence: See Table 3.5. ( b) Child feels compelled to strive for self-sufficiency
because of perceived inability of caregivers to meet
needs; conflict suggests that child feels unequipped
to achieve self-sufficiency, though perceives self-
sufficiency as the safest, surest route to getting
needs met.
(c) Safety/danger: See Table 3.4. (c) Child worries about lack of safety and vulnerability
to danger, suggesting child is uncertain whether he
or she will be able to be safe in a threatening
(d) Anger/affection: Directly expressed anger or hostility (d) Child has feelings of anger toward caregiver related to
toward a character or the therapist, followed by perceived deprivation, and feels expression of anger is
expressed affection. unacceptable, so tries to undo it with affection.

Therapeutic Goals Therapeutic Techniques toward Goals

Develop self-assertion and appropriate levels of Provide warmth and avoid directing childs play,
initiative. fostering too much dependency, or responding to childs
seductiveness; affirm childs efforts at initiative and
Help child learn to differentiate sexuality and Clarify emotions and help verbalize when child seems to
dependency needs to gain needed affection without confuse affection with seductiveness. Connect child
seductiveness. behaviors with others perceptions of seductiveness.
Encourage child to use ego functions to self-regulate and Encourage childs positive self-statements and affirm the
self-monitor. child when he or she makes accurate self-perceptions
and observations.
Increase frustration tolerance and decrease acting-out. Help child anticipate consequences of actions and
encourage child to actively solve problems encountered.
Provide clear limits and provide choices around limits so
child will rely more on ego functions.
Probable developmental trajectory: Hysterical personality.
Object-Relations Play Therapy 69

Object-relations play therapy begins with an In the extreme, parental abandonment or im-
understanding of the specific developmental pingement may occur in the form of abuse
presentation of the child, including the dynamic or neglect. However, less extreme forms of
picture, characteristic play themes and interper- parental abandonment or impingement, partic-
sonal relationships, therapeutic goals, and spe- ularly when chronic and/or unpredictable, are
cific therapeutic techniques. This understanding also likely to precipitate maladaptive coping
is then integrated with the phases of treatment strategies (Lee & Gotlib, 1996; Levoy, Rivinus,
described earlier: establishing a secure base Matzko, & McGuire, 1991). A child is likely to
relationship, challenging the internal working feel abandoned under any circumstances in
models through invitations based on hypotheses which the parent is perceived as unwilling or
emerging from the childs play and relationship unable to provide support or protection when
themes, and finally through a carefully planned the child is feeling overwhelmed. For example,
termination phase, where the goal is to promote an emotionally unavailable parent (such as a de-
object constancy and extension of new internal pressed mother who is regaining equilibrium
working models into the wider world. after an episode of domestic violence, or a
mother anxiously preoccupied with her current
romantic relationship) is likely to be perceived
MAJOR SYNDROME S, as abandoning (Canino, Bird, Rubio-Stipec, &
SYMPTOMS, AND Bravo,1990; Hall, 1996; Kolbo, Blakely, & Engle-
P R O B L E M S T R E AT E D man, 1996; Lee & Gotlib, 1991; Radke-Yarrow &
Klimes-Dougan, 1997).
Object-relations play therapy is a relationship- Feelings of being overwhelmed are intensi-
focused approach. It is the treatment of choice fied when the parent is perceived as a threat, as
for a particular spectrum of child emotional when a parent is prone to outbursts or un-
and behavior problems. Child problems best predictability, such as a substance abusing par-
treated by this therapy primarily result from ent or one with a personality disorder (Levoy
chronic interpersonal trauma experienced in et al., 1991; Wooley, 1998). A child may feel over-
parent-child or significant other-child relation- whelmed not only when a parent is intrusive or
ships. Often, such children present as identi- the home environment is chaotic, but also when
fied patients with diagnoses secondary to a parent in compromised in his or her ability
parent-child relational pathology that is charac- to effectively and consistently set limits. Con-
terized by some degree of abandonment, im- versely, an anxiously overprotective parent may
pingement, or both. The childs emotional and be experienced as intrusive, at the same time
behavioral problems reflect attempts to cope promoting the development of perceptions that
with or adapt to an environment (and/or the re- the environment is threatening. Feeling chroni-
lationships within it) perceived as overwhelm- cally overwhelmed contributes to the develop-
ingly threatening, unstable, unpredictable, or ment of an internal model of self perceived as
inconsistent (Prior, 1996). Object-relations play alone and unprotected in dealing with the envi-
therapy uses the therapeutic relationship to re- ronment, and thus vulnerable, easily disorgan-
shape pathological internal working models of ized, and disempowered (Hamilton, 1990).
self and others in ways that promote more faith Internal models of others that develop based
in caregivers, encourage respect for limits, and on experience with others perceived as aban-
develop more adaptive strategies for relating in- doning and/or impinging are associated with
terpersonally and for coping with frustration intense affects (e.g., rage, shame) that are not
and stress. easily metabolized or integrated in a childs

experience without the development of mature of internal chaos in a way that strains inade-
and effective coping mechanisms (Prior, 1996). quate coping resources, insidiously escalating
The childs development of coping strategies is anxiety that may be manifested in either inter-
arrested at a primitive level, stunted by the ex- nalizing (e.g., anxiety or mood disorders) or ex-
perience of feeling chronically overwhelmed ternalizing (e.g., hyperactivity or disruptive
(Levoy et al., 1991). Such primitive coping strate- behavior) symptoms.
gies include avoidance (which builds tension These dynamics of disordered object relations
and results in periodic outbursts), externaliza- that underlie the development of primitive, inef-
tion (e.g., disruptive behavior), oppositionality fective coping strategies, in combination with
or defiance (an attempt to feel empowered by self-regulation problems, characterize a number
means of demonstrating counterdependence), of child emotional and behavior problems for
compulsivity (an attempt to impose order on which the object-relations play therapy approach
chaotic internal and external environments), is suitable. For example, Reactive Attachment
controlling interpersonal style (to regulate dis- Disorder of Infancy or Early Childhood (RAD),
tance and exercise rigid interpersonal bound- as defined in DSM-IV, includes criteria relating
aries), role-reversed or parentified caretaking, to both pathogenic caregiving and disturbance
inhibition of needs and feelings in an effort to in child social relatedness (e.g., compulsive
accommodate caregivers, and shutting down. In need to control others, interpersonal ambiva-
reliance on primitive coping strategies, which lence, inhibition or disinhibition in social rela-
are developed in adaptation to a chronic state tions). Additional symptoms often associated
of emergency, the child becomes extremely vul- with RAD include lying, lack of empathy, hy-
nerable to stress and inflexible in coping and, pervigilance, and oppositionality. Attachment
as a result, often develops maladaptive inter- disordered children can be viewed as arrested
personal strategies (i.e., controlling behavior, at the presymbiotic or early symbiotic develop-
whether in terms of oppositional defiance or mental stage of object relations, in which the
overaccommodation). The child acts out internal child has never established enough basic trust
conflicts interpersonally in an effort to establish to attach to, much less separate from, the care-
control over chaos in both internal and external giver. Attachment disorder subtypes as de-
environments (Prior, 1996). scribed by Zeanah and colleagues (Zeanah &
Self-regulation problems also often arise in Boris, 2000; Zeanah, Mammen, & Lieberman,
connection with parent-child relational pathol- 1993) characterize stages of developmental
ogy. Compromised ability to modulate needs progress that may be achieved despite ongoing
and feelings has its origins in parental lack unresolved disorder in object relations (e.g.,
of attunement, which is invariably associated self as vulnerable and counterdependent, other
with abandonment and/or impingement in the as untrustworthy and/or threatening). Attach-
parent-child relationship. When a parent is un- ment disordered children need relationship-
attuned, the childs needs and feelings go un- focused treatment to address distortions in
reflected, much less unmodulated by the object relations to rebuild capacity for trust,
caregiver. The child does not experience re- which underlies nurturing interpersonal con-
sponsiveness, which would promote awareness nection, empathy for others, and prosocial
of needs and feelings that need to be managed, respect for limits and provides a basis for de-
and has no model for internalizing the ability to velopment of adaptive coping strategies.
soothe self when such needs and feelings arise The diagnosis of so-called regulatory disorder,
(Hamilton, 1990). A childs inability to modu- as defined by the 03 diagnostic classification
late needs and feelings exacerbates perceptions system proposed as an alternative to DSM-IV
Object-Relations Play Therapy 71

for use in early childhood (Zero to Three, 1994), acted out in hyperactivity or disruptive behav-
most adequately captures the self-regulation ior, among children in the later developmental
problems associated with interpersonal trauma. stages of object relations. When depression or
In DSM-IV terms, such self-regulation problems anxiety is the presenting problem, it is useful to
are often captured in diagnoses such as disrup- consider whether disordered object relations
tive behavior disorders, Attention-Deficit/Hy- may be a contributing factor.
peractivity Disorder (ADHD), and, increasingly, Abuse and neglect constitute extremes in
Bipolar Disorder. Among children with such di- parent-child relational pathology. Under such
agnoses, it is useful to evaluate whether develop- circumstances, interpersonal trauma is likely to
ment of symptoms was influenced by adaptation be experienced as more pronounced. Regardless
to a chaotic environment in which it was not pos- of the developmental stage in which trauma is
sible to develop self-regulation skills. In such experienced, the intensification of trauma can
cases, problems that seem primarily to require be expected to contribute to increased rigidity
medication and/or behavior management also of distortions in object relations, inflexibility
would benefit from being addressed by object- in coping, and vulnerability to disorganization
relations play therapy, to reshape disordered ob- (e.g., either disorganized behavior or shutting
ject relations and resultant maladaptive coping down under stress).
strategies that underlie problems that look pri- Many childhood disorders result from multi-
marily behavioral. Self-regulation problems may ple contributing factors. It is useful to consider
be observed at any developmental stage of object whether disordered object relations may be
relations. involved when identifying treatment issues
Disruptive behavior disorders, such as Oppo- and formulating interventions. Although object-
sitional Defiant Disorder and Conduct Disor- relations play therapy is ideally indicated for
der, have their roots in attachment problems, treatment of disorders arising from the dynam-
though this is often overlooked. Underneath ics described above, in its promotion of healthy
the tough exterior of a defiant child with con- models of self, others, and relationships and en-
duct problems is a traumatized child who is act- couragement of respect for boundaries and lim-
ing out to cope with internal and external its, elements of object-relations play therapy can
chaos. Such children can be understood as ar- be gainfully employed to enhance any childs
rested at the practicing and rapprochement de- treatment plan.
velopmental stage of object relations.
Mood and anxiety disorders may emerge at
any development stage of object relations. Dys- CASE EXAMPLES
thymic Disorder is widespread among chroni-
cally overwhelmed children who struggle with Object-relations play therapy can be illustrated
coping deficits and ongoing perceptions of lack by examining briefly the therapy for two chil-
of support. Depression may result from percep- dren, one who initially presented as presym-
tions of abandonment associated with parental biotic and early symbiotic (Ann, age 10), and
emotional unavailability. In addition, children one who initially presented as compromised
with disordered object relations may experience rapprochement (Trina, age 4). Each case presen-
pervasive generalized anxiety that is rooted in tation is organized in keeping with the appro-
fundamental perceptions that the environment priate table, beginning with the history that
is not safe and people in it are either unavailable describes the childs early experiences and rela-
or present a threat. Depression and anxiety may tionships, continuing with a dynamic formula-
be more subjectively felt, as opposed to being tion, including the therapists understanding of

the childs internal working models, followed Anns first eight to nine years of life, in her abil-
by a description of the childs play and rela- ity to attach and attune to Anns needs. Recent
tionships within therapy. The therapeutic diagnosis of the mother with hypoglycemia
goals and treatment techniques used are de- when Ann was nearly 10 seemed to provide her
scribed as well. with an explanation of previous failures to meet
Anns needs and an openness to therapy. The
mothers therapist and Anns therapist had only
CASE 1: ANN occasional contact, and the two therapies pro-
ceeded relatively independently. The mother
Diagnosis and Assessment made good progress in this therapy and it is be-
Anns was a difficult and complex case and can- lieved that her increased psychological availabil-
not be fully summarized here. Instead, the de- ity contributed to Anns progress.
scription focuses on the major shifts in object Ann had been referred for evaluation and
relations seen during the first three phases of play therapy at age 5. She received several
therapy (see Table 3.1). Ann, age 10 at the time of months of treatment, which were terminated
referral and the only child of divorced parents, when the therapist moved out of the area. Ann
lived with her mother during the school year appeared to form a strong attachment to this
and her maternal grandparents in a nearby city therapist, which she recalled in surprising de-
during the summer. Her parents divorced when tail for the current therapist. It appears from
she was just 1 year old because her mother had the first therapists description that Ann found
discovered that the father was both physically in that relationship many of the things missing
and sexually abusive of Ann. The mother re- with her parents and she began to attach and
ported that Ann would cover her head with her move toward object constancy and healthier
arms in her crib if her father came near. Ann and object relations, progress that was halted by the
her mother continued to have contact with the relatively abrupt departure of the therapist.
father intermittently, and these visits, where the The mother rejected a referral for continued
father stayed in their home, were rather loosely treatment at that time despite clear indications
supervised by the mother. It became evident that Ann needed it. Anns early history in-
during therapy that this contact had been quite cluded frequent ear infections with significant
sexualized by the father, with the mother essen- hearing loss that was corrected surgically at
tially unaware of his behavior. The father had age 4. It was only after the surgery that she
significant alcohol problems, difficulty holding began to speak.
a job, and a probable diagnosis of Schizophrenia. At age 10, Anns presentation, which was
He had spent some time in jail for molesting a quite similar to that seen at age 5, suggested at
girl about Anns age and again for indecent ex- first a pervasive developmental disorder such as
posure, both jail terms occurring when Ann was autism or Aspergers Disorder, as she avoided
between 6 and 11 years of age. Thus, Anns early eye contact, was extremely rigid in her play, and
experience with her father was one of rejection, was impaired in social relating, alternately in-
abuse, and attachment failure. The mother, who discriminately friendly or extremely aloof and
reported being afraid of the father and therefore stiff in interactions. Extremely immature, she
unable to limit or control visits, had significant seemed much more like a preschooler than a
borderline features and only reluctantly entered 10-year-old. She seemed related to her mother,
therapy when Ann was 10 years of age at the in- but she had difficulties with peers and other
sistence of Anns therapist. Like the father, the adults and had been placed in a self-contained
mother appeared quite limited, at least for classroom for the emotionally impaired within
Object-Relations Play Therapy 73

special education. Despite appearing autistic- treatment. Ann was transported to therapy by
like, there were several signs that this diagnosis her school and one day she was brought early;
did not actually describe her accurately. Careful the therapist was not at the door of the building
assessment showed that she lacked the cognitive to greet her, as was usually the case. Ann made
disruptions and sensory sensitivities often seen no comments about this but seemed particularly
with such children. Ann was doing age-appropri- detached from the therapist. Her play became
ate academic work in school and related quite much more sterile, mostly lining up toys and
well to preschool children. Projective testing and separating them into groups and playing a
play assessment both revealed intense ambiva- highly ritualized game about several puppets
lence about relationships, considerable anger and deciding whether or not to go on a picnic. When
sad affect below the surface, and a complex of is- the therapist, after most of the session with Ann
sues around separation-individuation, sexuality, detached, reflected that Ann might be angry
and safety. Based on the impaired social related- about the incident, Ann began to play again in
ness and frequent indiscriminate friendliness as the ways she had played in earlier sessions.
well as the history of severe infant abuse by the
father and probable emotional neglect by the Treatment Approach and Rationale for Its Selection
mother, the diagnosis was Reactive Attachment Anns play in the early sessions confirmed both
Disorder of Infancy and Early Childhood, Disin- the presymbiotic-symbiotic dynamic with some
hibited subtype (DSM-IV). Although not usually elements of practicing and rapprochement.
diagnosed at such a late age, anecdotal informa- Therefore, the therapeutic goals selected were
tion from the first therapist suggests this was an initially those from the presymbiotic and sym-
appropriate diagnosis at age 5, and Ann appeared biotic presentation (Table 3.1), with a plan to
to be frozen at that level of functioning. shift goals once a therapeutic symbiosis was
achieved to the goals for practicing and rap-
Case Formulation prochement (Table 3.2).
The object-relations formulation for Ann sug- Much of Anns play was stereotyped and ap-
gested that she was currently showing presym- peared directed at keeping the therapist at a dis-
biotic-symbiotic functioning, which appeared tance. Her early play also had dolls hiding, with
in some ways to be a retreat from intense dis- the therapist as a mother doll trying to find
tress encountered when she attempted the sep- them (constancy play), several dolls falling off
aration-individuation steps in practicing and the roof or falling and hitting their heads (insta-
rapprochement. She had some elements of a bility play), and preparing food for several dolls
symbiotic bond with her mother, but it was (nurturing play). Constancy play was also seen
fragile and failed to offer sufficient support for in Anns giving names to all of the dolls in the
her to engage in relationships meaningfully. It playroom (and all of her dolls at home as well),
appears that Ann formed a strong attachment which she remembered and used consistently
to her first therapist, and when that person through the course of therapy. Other early play
left, she retreated into a secondary autistic suggested the ambivalence about separation.
stance. Thus, her withdrawal from others was The most striking feature of this play involved a
defensive in nature and she actively resisted in- small doll she named Angie, who ran away from
terpersonal connection and nurturing. She was the mother doll (held by the therapist) repeat-
limited in her ability to express affect openly, edly. When the mother doll was close to finding
although projective tests revealed considerable Angie, Ann would have Angie disappear by
strong negative affects and unmet needs. This claiming that the mother had really found a bal-
can be seen in an incident that occurred early in loon that looked like Angie, which then popped,

or a chalk drawing of Angie, which was then activities in the mirror (a large observation win-
erased. Whenever Angie moved away from the dow that covered one wall of the playroom), as
mother in the play, Angie somehow disinte- if she wasnt sure of where she was and what
grated. Her intense ambivalence about identity she was doing without checking in the mirror.
(and individuation) was seen in her designating The mirror was left uncovered during therapy
several dolls as pairs of twins whom the mother and the therapist verbalized Anns activities as
could not distinguish. she watched herself in the mirror. Second, Ann,
The initial challenge of therapy was to estab- a tall child for her age, often sat in a preschool-
lish a secure base relationship by facilitating size chair in the playroom and she frequently
Anns receptivity to nurturance and connected- fell off the chair (which did not hurt her, given
ness. This was a prolonged phase of therapy, as how low the chair was). Falling off the chair
Ann had become quite rigid in her defensive almost always occurred when she was talking
withdrawal. This relationship was slowly devel- about feelings or difficult subjects, as if she
oped primarily through the therapists provid- couldnt both handle feelings and regulate
ing consistency, remaining attuned despite her body activity. Both behaviors were inti-
Anns frequent detachment, and continual invi- mately tied to feelings issues. Work progressed
tations to recognize Anns feelings and needs in in this area through reflections by the therapist
a context of safety. of Anns feelings and needs and invitations
Once a relationship has been established, the by the therapist to talk about the feelings of
goal of therapy is to foster a symbiotic transfer- Anns play characters. Over time, Ann was in-
ence that can lead to adaptive separation and creasingly able to minimize both behaviors,
individuation. Ann required a prolonged phase showing increased trust of the therapist and an
of symbiosis with the therapist before she increased ability to recognize and express her
began the separation-individuation process. feelings directly.
This symbiosis could be seen in several ways. In some ways, the most interesting phase of
Ann learned everything she could about the Anns treatment occurred as she began to sepa-
therapist and incorporated it into the play, for rate and individuate from the therapist. At this
example, having a character that looked like the point, the therapy had moved to the practicing
therapist and had the same birthday with a last and rapprochement goals for therapy. Ann en-
name that matched the street name of the thera- gaged in two distinct play themes at this time.
pists home. On one occasion, Ann drew the let- First, she engaged in what can be called eleva-
ters of her name superimposed on the letters of tor therapy. Ann came to therapy directly from
the therapists name, as though Ann-Helen school; her mother was firmly convinced, based
were a single entity. She also engaged in imita- on her own history of hypoglycemia, that Ann
tion-control play, where she demanded that the needed a snack at the beginning of therapy. So
therapist imitate her own verbalizations and Ann had established a pattern of going on the
behaviors. Thus, the goal of forming a strong elevator with the therapist to get a drink and
symbiotic transference was met in the second snack from vending machines on another floor
phase of therapy. of the building. Ann was quite afraid of the ele-
During the work to establish a symbiotic vator, especially if other people were on it, and
transference, work focused on two other goals: never had used it without the therapist being
facilitating self-regulation and promoting abil- present.
ity to tolerate, label, and verbalize feelings. Ann One day, Ann decided she could get on the el-
showed poor self-regulation in two ways. First, evator alone. At first, she hopped on and off
she seemed to need to continually check on her again before the door closed. Soon, she would
Object-Relations Play Therapy 75

let the door close and go to the vending ma- room and paint one or more flea-flea germ-
chines on her own. Finally, she would spend germ paintings.
nearly half of each session getting on the eleva- After allowing both types of play for several
tor, going to one floor after another and explor- sessions, the therapist worked to foster an inte-
ing, each time returning to talk to or wave at grated sense of self by facilitating awareness of
the therapist. By remaining outside the elevator boundary issues. She chose to interpret the
on the playroom floor of the building, the thera- boundary issues conveyed by the paintings by
pist served as a secure base for the separation saying that the flea-flea germ-germ was like
process. In essence, Ann found a safe way to en- Ann. When she got too close to people, she felt
gage in the exploring and returning for refuel- like she would burn up and die but if she got too
ing seen by toddlers in the practicing phase. far away, she would also die. The flea-flea
The second way Ann proceeded with separa- germ-germ and, by extension, Ann could not
tion-individuation was through a set of paint- seem to find the middle. She had portrayed
ings she did each time she entered the playroom vividly the sense that she was vacillating be-
following elevator therapy. She began each tween fusion and extreme withdrawal, both of
painting with a red vertical line down the center which prevented an integrated sense of self
of the paper. On top of this, in the middle of with appropriate boundaries.
the page, she painted a filled circle on the line. Ann accepted the interpretation and ended
This drawing, by her verbal report, was a cross- both types of play. She seemed to be much
section of a flea-flea germ-germ. Then, on the calmer and more comfortable with the thera-
right side of the paper, she painted a yellow sun. pist, and therapeutic work in the final phase of
Next to the sun would be a small figure that therapy moved toward the goal of object con-
looked like a small animal lying on its back with stancy. Increasingly, Ann was able to identify
feet up in the air. On the left side of the paper, her own needs, be assertive about meeting
she drew an ill-defined blob, either in red or those needs in therapy, and show a more inte-
blue, with an identical upside-down animal grated sense of self. A detailed presentation of
next to it. Ann would announce that the first an- this final phase is not possible given the limited
imal was a dead flea-flea germ-germ that died space, yet the first three phases illustrate the
from getting too close to the sun. She would use of object-relations play therapy with a se-
then point to the other figure and say it was verely disturbed child.
also a dead flea-flea germ-germ, only this one
died because it got too close to the cold place or
too far away from the sun. Finally, Ann would CASE 2: TRINA
put identical numbers above each side of the
paper (usually either 350 or 500) to indicate the Diagnosis and Assessment
body count of dead flea-flea germ-germs for Case 2 demonstrates object-relations play ther-
the day. The paintings were highly predictable apy with a child initially presenting with com-
and stylized. Taken together with the elevator promised rapprochement. Trina, nearly 5 years
therapy, the flea-flea germ-germ paintings of age at the time of referral, had experienced
seemed to graphically demonstrate Anns am- considerable interpersonal trauma in her first
bivalence about separating and individuating four years of life. She was born to a young sin-
from the therapist and, by extension, from her gle mother, Angela, whose other child was
mother. She would begin each session by sepa- in the permanent care of the paternal grand-
rating and reconnecting with the therapist sev- parents, with no contact with the mother. An-
eral times using the elevator, then come into the gela partially abandoned Trina at age 2 months,

leaving her with her new boyfriends parents, Stress Disorder and intermittent Explosive Dis-
with a promise to return and get her. Angelas order, was consistently caring of Trina but also
mother intervened and got the infant, who demanding of her and frighteningly violent
began to live with her and her current husband with the grandmother in front of the child. The
(step-grandfather to Trina) when Trina was maternal grandmother showed good self-
about 4 months of age. Angela was in and out of awareness (the apparent result of several years
the home over the next several months, some- of psychotherapy) and was generally attuned to
times caring for the baby, but usually leaving Trina but had a history of experiencing severe
that to the grandmother. When Trina was 18 abuse during her childhood and Dissociative
months of age, her maternal grandmother went Identity Disorder. Thus, Trina had experienced
to prison for 18 months and Trina was cared numerous changes in her primary caregiver,
for exclusively by the step-grandfather. By this and each of these individuals appeared limited
time, Angela had largely abandoned Trina, in some ways in their ability to accept and love
moved to a nearby city, and had a third child by Trina without using her to meet their own psy-
a new boyfriend. The step-grandfather would chological needs.
not allow Angela to see Trina on the few times Trina showed few overt symptoms at the time
she tried to visit. The grandmother returned of referral by her day care teacher. She was
when Trina was 3, and both grandparents cared described as overly attached to the teacher, un-
for her. However, the marriage was marked by able to let her be out of sight while at school,
conflict and violence (each grandparent signifi- and also overly attached to her transitional ob-
cantly injured at least once), and they divorced ject, a much-repaired Raggedy Ann doll she had
when Trina was nearly 4. Trina was now in the had since birth. She also showed separation
care of the maternal grandmother with fre- anxiety with her grandmother and a tendency
quent visits by both her mother, who would to tantrums much like those of a far younger
take Trina for a few weeks and then return and child. Trina met the criteria for a formal diagno-
disappear for several months, and the step- sis of Separation Anxiety Disorder (DSM-IV).
grandfather, who appeared strongly attached
to Trina. By the time of referral, the grand- Case Formulation
mother was in a new relationship and living In terms of her object-relations development,
with Trina in a communal arrangement with Trina appeared to match the compromised rap-
several college-age adults in addition to her prochement presentation seen in Table 3.3. She
boyfriend. came to the evaluation session showing an un-
All three major adults in Trinas life had sig- usual combination of immature and pseudo-
nificant psychological problems. The mother, mature behaviors. She seemed quite adultlike,
Angela, had severe personality problems and continually monitoring the mood of her grand-
seemed minimally invested in Trina except to mother and declaring more than once that she
show her off to others as an example of her could take care of everything and did not need
mothering. Angela also lost custody of her any help from anyone (independence). At the
third child, who lived with his father but made same time, she pretended to be a baby, talking
several week-long visits to Angela. She would baby talk and sucking on a baby bottle. Al-
often have long visits with Trina at the same though she explored the room fully, she
time that she had the younger brother, so the showed almost no spontaneous play. She de-
two played together, although Trina and her nied any problems or bad feelings, even during
brother fought more than played. The grand- a later session when the grandmother was
father, a Vietnam veteran with Posttraumatic late returning to get her and Trina appeared
Object-Relations Play Therapy 77

extremely anxious and upset in her nonverbal questions were stimulated by the arrival of the
behavior. mothers fourth child when Trina was 512 . An-
gela, supported by her new husbands family,
Treatment Approach and Rationale for Its Selection seemed to be more attached to and able to care
The specific object-relations play therapy ap- for her fourth child than she had been with her
proach used in this case derived from the treat- other three children (although this interest and
ment goals and techniques outlined in Table 3.3 effort waned considerably as the baby began to
for compromised rapprochement. As treatment crawl), and Trina would ask why her mother
began, Trina was slow to form a trusting rela- could take care of the baby but hadnt known
tionship. Initially, she was extremely coopera- how to take care of her.
tive and well behaved, with a parallel lack of Once Trina began playing a baby who could
spontaneity in her play. When she did play, be cared for by the therapist, her play in general
Trina typically played out the themes and inter- became more spontaneous. She played over and
personal relationships expected with this pre- over a scene where the baby wasnt safe (climb-
sentation. She frequently showed a strong need ing unsafely, or taking medicine, or cooking
to make and build things (mastery) and then on a hot stove), while requiring the therapist
show them to both the therapist and her grand- to make the baby safe. She also played many
mother. At other times, she would draw and scenes where the mother figure (played by
then insist the therapist copy her drawing ex- Trina using the doll as her baby) was angry and
actly (imitation-control). She often set up a abusive or neglectful of the baby, eliciting invi-
store where she sold toys to the therapist tations from the therapist to talk about or
(store/shopping). In all of her play at this time, demonstrate the care babies need.
Trina was very controlling (control). She would Trinas relationship with the grandmother
sometimes care for the baby or pretend to be a changed during this time. She was more trust-
baby herself. When she was baby, she was ing, more comfortable separating from the
queen baby (stage mix), who fed herself and grandmother, and appeared to be more securely
took care of herself (self-nurturing). Another attached. At the same time, she began actively
frequent interaction pattern was to trick the resisting contact with her mother. It became
therapist (or her grandmother, who sometimes clear that Angela was often abusive of Trina,
joined her play sessions), usually in the context yelling at her, spanking her unusually hard and
of surprising them at a birthday party, set up often, hitting her at times or slapping her face,
with the sandbox serving as the cake. and failing to supervise her and keep her safe
The therapy proceeded with the therapists when she visited. It is noteworthy that Angela
working toward the goals in Table 3.3, espe- would take for herself any locket or other jewelry
cially using reflection of hidden feelings, relin- of Trinas that she liked. Angela had to be re-
quishment of therapist control of the setting ported to protective services and ultimately was
except for reasons of physical safety, and model- required to relinquish all custody of Trina. Hav-
ing good and soothing care with the babies. ing made a strong attachment to her grand-
Whenever Trina played with the babies, the mother, Trina worked extensively in play to
therapist would talk about what babies needed establish the baby as good whether the mother
and what good caretakers should do. As Trinas could care for it or not. She made a good adjust-
trust developed, she allowed herself to be the ment to the termination of her mothers parental
baby and be directly nurtured by the therapist. rights and actually seemed relieved that she was
She also began asking questions about why her now protected. The therapeutic relationship had
mother did not take good care of her. These evolved to one in which Trina expressed genuine

feelings and healthy boundaries. It served as a by concepts drawn from Fairbairn, Winnicott,
safe holding environment for Trina to strengthen and Bowlbys attachment theory. Six distinct
her attachment to her grandmother and facilitate clinical presentations were examined in terms
the development of object constancy and a posi- of their dynamics, typical play, therapeutic
tive internal working model of the self. goals, and therapeutic techniques. This model
is particularly appropriate for children who
have experienced attachment problems or inter-
P O S T T E R M I N AT I O N S Y N O P S I S personal trauma, such as abuse, neglect, family
A N D E F F E C T I V E N E S S DATA violence, or parents with severe psychopathol-
ogy, in the first several years of life.
Object-relations play therapy has been used
with numerous cases in therapy lasting be-
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Infant Mental Health


What emerged . . . was a form of psychotherapy immediate culture and community, and their
in the kitchen, so to speak, which will strike you societys health, and educational, legal, and po-
as both familiar in its methods and unfamiliar in litical systems. Childrens well-being, impor-
its setting. The method, a variant of psychoana- tance, and value rest on the attitudes expressed
lytic psychotherapy, made use of transference, through these very complex systems.
the repetition of the past in the present, and in- It seems appropriate to begin by sketching
terpretation. Equally important, the method in-
briefly the various perspectives on mental health
cluded continuous developmental observations
in infancy that have been expressed within dif-
of the baby and a tactful, non-didactic education
of the mother in the recognition of her babys
ferent disciplines over time. This includes rep-
needs and her signals. resentative contributions from psychologists,
psychoanalysts, and psychiatrists, child devel-
Fraiberg, S., Adelson, E., and Shapiro, V. (1980, opment researchers, investigators interested in
p. 171) infant capacities, and those who are active in
mental health intervention. Although we can-
not be comprehensive, we hope to give some
H I S T ORY O F sense of the different perspectives and their
T H E R A PE U T I C A P PROAC H mutual influences that have resulted in a clini-
cal focus on the emotional development of in-
EARLY ROOTS OF INFANT-PARENT fants and toddlers.
INFANT MENTAL HEALTH The Primary Caregiving Relationship
Interest in the mental health of infants
Childrens likelihood of survival and every as- emerged most dramatically around the system-
pect of their experience are shaped by the qual- atic recognition of the effects of the deprivation
ities of the social structures in which they live. of stimulation and interaction between caregivers
These include the nature of their family, their and infants housed in institutions. Early on,


Skeels and Dye (1939) had experimented with were observed both during institutionalization
providing greater and more personal care to or- and after placement. These included motor
phans by having institutionalized young development, language, reactions to people,
women with retardation act as surrogate par- control of impulses and capacity to defer gratifi-
ents. The positive effects on the infants devel- cation, difficulty making transitions, and im-
opment were clearly documented. pairments of thinking (i.e., thinking through
Much of the literature on deprivation was and anticipating, generalizing, overcoming ob-
summarized by Provence and Lipton (1962) in stacles, and concreteness of thought). They went
their own study of institutionalized infants. on to clarify that the permutations of strengths
They drew on the work of Chapin (1915), Levy and vulnerabilities they observed also could
(1947), Spitz (1945, 1946), and Bowlby (1960), as occur in any mother-child pair, again recogniz-
well as discussions of Bowlbys theories by ing the salient consideration of individual dif-
Anna Freud (1960), Shure (1960), and Spitz ferences in both, but particularly in the child.
(1960). Their investigation provided a more de- They acknowledged the singular contributions
tailed analysis of the nature of the deprivation of Escalona (1950, 1953) and Escalona and Leitch
itself and the differing effects on the infants (1953) to their understanding and appreciation
than had characterized prior efforts. They fo- of these differences.
cused on discerning what processes in develop- Coleman, Kris, and Provence (1953) pointed
ment were most vulnerable to this deprivation to both the variations in parental attitudes and
by closely analyzing the details of the infants the development of the mother-child relation-
responses. By adopting this careful, clinical ob- ship as important variables in infant develop-
servational approach, Provence and Lipton not ment. Ten years later, a volume in honor of
only supported previous findings that the ab- Milton Senn, the developmental pediatrician
sence of focused, emotionally charged, respon- who helped establish the Yale Child Study Unit
sive care (referred to as maternal deprivation) in 1948, addressed the biological aspects of de-
had an adverse impact on development, but also velopment, and included a variety of contribu-
drew a general conclusion that synthesized tions by pediatricians, child psychologists, and
their findings in an important way: psychoanalysts that served to expand the hori-
zon of medical education to include the heal-
Human development, even in infancy, is complex ing of mind as well as body, and to remind
and multi-determined. The effects of maternal physicians of their power and privilege as
deprivation on an infant in the first year of life de- well as the importance of helping parents to
pend upon the degree of deficit in both the quan- understand their young children (Solnit &
tity and quality of maternal care, upon the Provence, 1963).
infants biological endowment and upon age and Concurrently, Winnicott (1945, 1953, 1957)
length of time he is subjected to the deprivation. expanded on the subtleties and vicissitudes
Many individual combinations of these factors of development, culminating in his use of
are possible and produce a variety of clinical pic- the often-quoted phrase an ordinary devoted
tures in terms of severity of symptoms. (Provence mother, to acknowledge the importance of the
& Lipton, 1962, p. 162)
mother (or consistent mother substitute), the
need for maternal devotion, and the fact that
Recognizing the multiple determinants of the the skills and sensibilities of the ordinary
developmental process, Provence and Lipton mother are extremely complex and wholly
(1962) catalogued the affected areas of develop- good enough. (Many of Winnicotts papers
ment (different in individual children) that addressing these issues were collected in the
Infant Mental Health 83

1975 volume Through Paediatrics to Psychoanalysis: Intervention in the Social Environment

Collected Papers.) Additionally, Eriksons (1950a, Gradually, the probable usefulness of therapeu-
1950b) contributions outlining the stages of de- tic intervention with children and families at
velopment around their central tasks, the inter- earlier ages had emerged. Caplan (1951, 1955)
actions associated with each, and the central introduced the concept of a public health ap-
outcome to be achieved were widely influential. proach to child psychiatry. This was well rep-
Through all of these contributions, infants were resented by a number of observers (e.g.,
beginning to be viewed in two important new Langford, 1955; Lindemann, Vaughn, & McGin-
ways. First, the young childs intrinsic, influen- nis, 1955; Rosenfeld & Brandt, 1955), who ar-
tial role in his or her own development was rec- gued against a focus of attention on only the
ognized. Second, the infants demand to be individual patient and advocated for the inclu-
heard and responded to in supportive, positive, sion of all the emotional forces operating in
and growth-promoting ways was registered. smaller or larger sections of the community.
From his work in child guidance clinics, Caplan
Infant Capacities came to see the troubled child as embedded in
Another important contributing stream of great the environment and drew two important con-
influence to the understanding of early child- clusions. One focused on the need to support
hood development flowed from the growing treatment of the parents of a troubled child,
investigation of infant capacities. Bower (1974), using child-centered therapy or focused case
drawing on his own work (Bower, 1970; Bower, work as an important and effective endeavor.
Broughton, & Moore, 1970, 1971; Bower & This was understood as an effort to remove
Wishart, 1972) and that of others, such as children from the role of serving as a costly
Cruickshank (1941), Fantz (1961), and Lipsett solution to their parents unaddressed problem,
(1969), utilized studies of intentional reaching an attempt to interrupt the dynamic mispercep-
in neonates, coordination of vision and touch, tion of the child, and to free the child to be a
the development of object concept and object separate person. A second conviction was
permanence, and infant motivation to create a that it is highly likely that a child comes to be in
portrait of the infant as vigorously involved in a the center of family conflict because of a previ-
dynamic, interactive process of development. ous parental crisis, and that, following Linde-
He maintained that the infants intrinsic pleas- mann et al.s (1955) bereavement work in which
ure in problem solving and the dramatic role of the object is to achieve healthy coping as an out-
experience in development meant that infancy come of loss, it is important to track and inter-
was the critical period in cognitive develop- vene at points of ordinary or extraordinary
mentthe time when the greatest gains and the crisis. This is the perspective adopted by
greatest losses can occur. Simultaneously, it be- Brazelton in his book, Touchpoints (1992).
came clear that the infant had more skills, and Finally, Caplan urged that community work-
had them earlier, than anyone but parents could ers (i.e., nurses, physicians, teachers) should be
have imagined. equipped with necessary knowledge so that
Lewis and Rosenblums (1974) seminal work, they can swing the delicate equilibrium toward
The Effect of the Infant on Its Caregiver, ad- healthy coping and away from disturbance for
dressed deliberately what was felt to be previ- the benefit of both family and child. This un-
ous neglect of the significance of the interaction specified necessary knowledge was designed to
between mothers and infants in terms of the in- give community practitioners the tools to ad-
fants contributions in shaping those ongoing minister crucial mental health first aid. Ca-
transactions. plan felt that consultation with mental health

specialists should be regarded as the essential Beebe, Lachmann, & Jaffe, 1997); each has made
element in all programs of prevention, no important contributions from specific areas of
matter what the expertise or discipline of the interest and expertise. Greenspan (1981, 1994,
provider. Simultaneously, E. Furman (1957) 1997, 2000; Greenspan & Levis, 1999; Green-
provided treatment for children under 5 years span, Nover, Lourie, & Robinson, 1987) has con-
of age by way of their parents. R. Furman and ceptualized a widely influential developmental
Katan (1969) followed the same model in a model that integrates the infants constitutional-
nursery school setting, essentially the model maturational patterns and the environment as
utilized by S. Freud (1909/1955a) in his treat- mediated through the parent-child relationship.
ment of phobia in a 5-year-old boy. At one end He has organized his conceptualization of devel-
of the parent/child treatment continuum, par- opmental levels and their tasks around mean-
ents were instructed on how to understand ingful engagement, communication, and shared
and respond to their child; at the other, the un- meaning. This organization has been utilized by
derstanding of conflictual, personal dynamics Greenspan to suggest what to observe about
of the parents was included as a factor in child children and how, as well as how to provide
treatment. appropriate clinical treatment, specifically with
In 1976, a collection of articles by experts in children on the autistic continuum.
the field of child psychiatry and child develop- Emde (Emde 1983; Emde & Hewitt, 2001;
ment drawn from 14 years of publication in the Emde et al., 1976, 1982), utilizing data on infant
Journal of the American Academy of Child Psychiatry capacities and research on adult-child inter-
were brought together in one volume by Rexford, action in the context of psychoanalytic theory,
Sander, and Shapiro. In this volume, Shapiro has developed theories regarding the internal
issued a call for greater activity, within psychia- experience and resulting structures related to
try, in the area of infancy. He pointed to the in- self in infancy. His work on the nature and role
creasing interest in early childhood as a natural of affect and the complexity of interpersonal
outgrowth of adult retrospective reconstruction impact is subtle and complex.
utilizing the developmental point of view, and Stern (1977, 1985, 1989, 1994, 1995, 2000), also
noted that the psychiatric vantage point pro- utilizing infant research in the area of capaci-
motes an appreciation of the impact of early ties and mother-child interaction, created a
interpersonal relationships, supports a holistic vivid construction of the internal, developing
view of the child, and attempts to honor the role world of the infant embedded in an interper-
of the child in his or her own development. sonal perspective. He also pursued some of the
links between the understanding of mother-
child interaction and clinical treatment, and ex-
CONTEMPORARY APPROACHES plored a number of models of infant-parent
psychotherapy. The most recent perspective
Knowledge has continued to proliferate and the- now included stems from attempts of investiga-
ories have emerged that creatively utilize psy- tors to understand the significance of current
choanalytic theory and a range of infancy work on brain development. Research in this
research. Investigators working in this area in- area has been conducted by Schore (2001a,
clude Stern (1977, 1985, 1989, 1994, 1995, 2000), 2001b), Emde and Hewitt (2001), and others.
Emde (Emde, 1983; Emde & Hewitt, 2001; Emde, The complexity of what contributors have
Gaenbauer, & Harmon, 1976, 1982), Trevarthen come to consider, the respect for environment
(1995, 1996, 2001; Trevarthen & Aitken, 2001), and for the intrinsic qualities of the child, are
Beebe (2000), Beebe and Lachmann (1988, 1998; embedded in the work of many contemporary
Infant Mental Health 85

researchers and theoreticians. They are repre- moved to the Department of Psychiatry at the
sentative of many who have utilized the earlier University of California, San Francisco, in 1979
efforts of those interested in infancy, added to and continues its efforts there.
those efforts and continue, with others, to ex- Over the course of the past 23 years, the
plore the intricacies and complexities of human program has continued to develop and practice
development. infant-parent psychotherapy in a community
Though current investigators proceed in dif- mental health setting. The program is based
ferent ways and are personally captured by dif- at San Francisco General Hospital, and three
ferent aspects of development, the majority major services are offered under its auspices:
embrace a common point of view that honors infant-parent psychotherapy, developmental
the uniqueness of the infant and the parents, neuropsychological assessment, and mental
the mutual impact of the infant and its care- health consultation to child care. This work
givers, and the power of biology, interpersonal has been described and discussed by Kalman-
relationships, and the widest environmental son and Pekarsky (1987), Lieberman (1992),
context. These are the basic understandings Lieberman and Birch (1985), Lieberman and
that they have inherited and on which knowl- Pawl (1984), Lieberman, Silverman, and Pawl
edge continues to build. Perhaps the most (2000), Pawl (1993), Pawl, Ahern, Grandison,
important outcome has been the steadily in- Johnston, St. John, and Waldstein (2000),
creasing interest in the first three years of life Pekarsky (1992), Seligman (1994), and Selig-
and an awareness of their important and shap- man and St. John (1995).
ing influence. The Infant-Parent Program serves families
with infants or toddlers in which there are diffi-
culties in the relationship between the parents
T H E I N F A N T - PA R E N T and child. Families are referred by obstetric and
P R O G R A M : PA R A M E T E R S pediatric professionals, child care providers,
O F I N F A N T - PA R E N T child welfare workers, and others working with
P S YC H O T H E R A PY vulnerable parent populations, such as adoles-
cent mothers, chronically mentally ill adults,
Although there are many different infant men- and parents in recovery from chemical depen-
tal health programs that vary greatly in terms dency. The concerns that prompt referrals focus
of setting, scope, and style of service delivery, it primarily, though not exclusively, on the parents
is our intention to focus on the one with which capacities. Difficulties with which the parents
we are the most familiar. It was within and as struggle may, for example, prompt professional
part of the above broader context, that Selma doubts about the parents ability to provide for
Fraiberg (Fraiberg & Fraiberg, 1980) and her the childs physical and emotional well-being.
colleagues developed the model of infant-par- Alternatively or simultaneously, concern may be
ent psychotherapy, one of the earliest and most focused on a childs behavior or condition, such
influential programs in infant mental health as situations in which children are exhibiting a
intervention. This was developed at the Univer- diagnosable constellation of symptoms, or when
sity of Michigan in the Department of Psychia- their behavior consistently interrupts the
try (19731979). (Many of the papers describing smooth running of grown-ups lives. There are
the work of the program during the University also some instances in which the infants intrin-
of Michigan years are collected in the Clinical sic capacities are of primary concern.
Studies in Infant Mental Health: The First Year of As St. John and Pawl (2000) wrote, however,
Life, Fraiberg & Fraiberg, 1980.) The program Most often, by the time a family enters the

Infant-Parent Program, both the parent(s) and Furthermore, when parents histories are such
the child are showing signs of distress (p. 9), that their expectations of helping professionals
and it is the experience of each of the other that are very low, their sense of their rights to compe-
is the focus for treatment. As Pawl and Lieber- tent professional service of any kind precarious,
man (1997) wrote, One of the primary ques- and their sense of shame, vulnerability, or futil-
tions in infant-parent psychotherapy, and a ity regarding their circumstances high, the im-
question that renews itself in each treatment is: pediments to seeking or accepting mental health
Who is the patient [the parent or the child]? An treatment are formidable and justifiable. Selig-
accurate, but less than adequate answer is man and Pawl (1984) discussed the ways these
both (p. 340). The parent and the baby create factors can impede the formation of a therapeu-
a relationship, and each makes potent contribu- tic working alliance. They can also prevent par-
tions to it. Improvement in that relationship is ents facing multiple difficulties in their lives as
the goal of treatment. individuals and in relation to their small chil-
dren from seeking assistance at all. We offer
infant-parent psychotherapy as a home-based
T H EOR E T ICAL CONSTRUC T S service to make it a realistic, possible venture for
families who might otherwise be completely
THEORY, PRACTICE, AND REALITY: bereft of mental health treatment at a juncture in
HOME VISITING their family life cycle when they might most
sorely need it.
Home visiting has been an inherent compo- Beyond its necessity, however, home visiting
nent of and vehicle for the practice of infant- also offers a wealth of possibility to the process
parent psychotherapy since its inception. The of infant-parent psychotherapy, and is thus an
delivery of this mental health service in the important part of our theoretical orientation.
home setting represents both a response to The home visiting therapist is able to observe
a perceived community service need and a family life in all of its singular complex speci-
unique theoretical orientation. The perceived ficity, and to gain at a visceral level a sense of
need is here described first; the theoretical the material conditions that define a familys
constructs supporting the practice follow. day-to-day reality. For therapists, this reality
Most of the families with whom we meet is frequently an initially painful aspect of pro-
would not be seen regularly if they needed to viding treatment, because we most often treat
appear at clinic appointments. As anyone with a socially and economically disadvantaged fami-
small baby knows, the rhythms of infancy fre- lies, many of whose life circumstances are quite
quently do not coincide with the clockwork dire. One therapist, for example, discovered
schedules of most sectors of the external world. that the mother with whom she had spoken
Bus schedules also can be unpredictable, and initially on the telephone who complained that
traveling by bus, especially with small children, her son was hyperactive lived in a one-room
is inconvenient enough to be daunting even apartment with three small children. Although
when there is a clear idea of what will be gained the 3-year-old boy in question appeared to the
from such efforts. When the fruits of the jour- therapist to demonstrate a developmentally ap-
ney seem amorphous or the risks (e.g., exposure propriate level of energy, it was clear to her that
to scrutiny or criticism, or the threat of loss of for this mother, whose depression made even
custody of children) considerable, there is no trips to the neighborhood park difficult, the
initial motivation to expend such energy. boys needs were readily experienced as too
Infant Mental Health 87

much. Furthermore, when the therapist ac- protected, to provide and to be provided for, to
companied the family to the park one day, she belong, the yearning for community, for relation-
found that the mothers concern about broken ships that have been lost or are being strained or
bottles and hypodermic needles in the sandbox eroded, the memory of people or states or places
was justified. On another day, there was a to which access has been lost, the wish to feel
shooting in the same park, and a neighborhood that one mattersthis inchoate longing for a
child narrowly escaped injury. Although this sense of home has long been defended against
mothers depression was clearly an important via whatever strategies a parents personality
factor in this familys dynamics, the therapist and psychological disposition dictate.
would have been unable to imagine, include, or These subterranean difficulties influence
respond as appropriately to the contextual ele- and are reflected in the material ways a family
ments of the familys circumstances if she had inhabits the space they occupy. Three examples
not seen and experienced them herself. Wit- come to mind. One single mother treated in our
nessing the injury inflicted on infants, toddlers, program had had Eastern European grandpar-
and their families as a result of poverty, home- ents who were killed in the Holocaust. This
lessness, environmental illness, racial and sex- woman hoarded, and kept her apartment so
ual discrimination, anti-immigration policy, the cluttered that there was literally no room for
wedded threats of chemical dependency, vio- her twin sons to crawl without danger of their
lence, and incarceration, and the erosion of bringing piles of books or boxes tumbling down
social service support assists infant-parent psy- on them. Clearly, this is relevant on many levels.
chotherapists in meaningfully appraising fami- A Native American grandmother seen in our
lies difficulties and in conveying to families program was at risk of losing the custody of her
their awareness and sincere interest in under- grandson, whom she loved very much and who
standing the ways they experience their lives. looked to her as the sole source of gentleness,
Home visiting is an important part of our the- care, and protection he had encountered in
oretical framework for another reason. Often, his three years of life. The placement was
troubles in the relationship between parents and threatened by the condition of abject squalor in
their infants and small children are inextricable which this pair lived. It vexed county social
from complexities and sorrows in relation to the workers that the filth resulting from pigeons
parents sense of home and the childs experi- who roosted inside the house, a toilet that
ence of it. Whether because poverty and ghet- would clog and go unfixed for weeks, and food
toization prevent a parent from securing a home left to decay in various rooms appeared barely
that offers the family a basic sense of safety, or to trouble this grandmother. The infant-parent
because recent immigration to the United States therapist learned that this woman had been
has left parents feeling displaced and cut off raised as a migrant worker by abusive, alcoholic
from their own family, language, history, and parents. The family was homeless except during
culture, or because dislocation or deracination periods when they had a car and lived in that.
have been encoded and transmitted intergenera- At a very basic level, and for complex psycholog-
tionally within a family that has lived with ical reasons, this woman lived inside her house
hardship in one place for a long time, it is the as though she were still on the streets. The third
case that for many people, the place where they example involves a Mexican mother who was re-
live offers few of the comforts, pleasures, or ferred to our program because she had been ac-
protections more typically associated with the cused of medical neglect of her infant daughter,
word home. The wish to protect and to be who was sick and in need of ongoing medical

attention. It became clear that for this woman, the child exists. As Pawl, St. John, and Pekarsky
home was not the one-room urban apartment (2000) wrote, To be a regular visitor in a small
that she occupied with her daughter, but the childs home is to be a figure in his or her inner
Mexican village she regretted leaving and world (387).
longed for desperately. She had the idea that
it was only there, not in the big county hospital
in the foreign city in which she found herself, MATURATIONAL PROCESSES AND
that her daughter could be healed. Should her THE FACILITATING ENVIRONMENT:

daughter get well in the United States, it would INFANT AND PARENT DEVELOPMENT
represent to this mother an unbearable breach WITHIN THE RELATIONAL MATRIX

with her true home.

Sometimes, an infant-parent psychotherapist The writings of the pediatrician/psychoanalyst
can assist a parent in sorting through these D. W. Winnicott (1945, 1953, 1957, 1965, 1971,
complex issues (we might call them locopsycho- 1975) describe and inform many aspects of in-
logical) in the course of attending to the childs fant development as we understand and seek
experience of the parent and the parents expe- to support it through infant-parent psychother-
rience of the child in the context of their literal apy. Winnicott is perhaps most famous for hav-
home. Such domestic domains as sleep (e.g., ing coined the welcome phrase good-enough
whether, or for how long, an infant sleeps in the mothering. He described infants ever-present
same bed or room as the parents, how a child contribution to their relational matrix, the cru-
falls asleep or is expected to fall asleep, the cial and commonplace attentiveness of primary
manner in which a small child is awakened by caregivers (usually mothers) to their infants
or awakens the parents), eating (where, when, needs, and the ways this attentiveness enables
how, what, with whom and with how much rel- the infants increasingly differentiated partici-
ish, fuss, strife, or ceremony), hygiene, toileting, pation in relationships and the world. Winni-
discipline, housekeeping, and play are grist for cott (1965) wrote, for example:
the mill of infant-parent psychotherapy. When
families experience relief from struggle in some Parents do not have to make their baby as the
of these domains, they are better able to enjoy artist has to make his picture or the potter his
pot. The baby grows in his or her own way if the
and respond to each other and to live meaning-
environment is good enough. Someone has re-
fully in the place in which they dwell.
ferred to the good enough provision as the aver-
Finally, and closely connected with all of this, age expectable environment. The fact is that
home visiting is important because infants are throughout the centuries mothers, parents, and
phenomenological creatures: They deal in per- parent-substitutes have in fact usually provided
ceptions of texture, temperature, taste; register exactly those conditions that the infant and small
gradations of comfort and discomfort; establish child do in fact need at the beginning. (p. 96)
rhythms and express preferences through the
body-based systems that define them; seek and Winnicott (1965) distinguished between ordi-
organize themselves around and form their ex- nary situations in which parents are able to pro-
pectations of the world based on the bodies and vide in this good-enough way for their infants,
behaviors of the people on whom their lives and those worrisome situations in which, for
depend. When an infant-parent psychotherapy some combination of reasons, they are not. The
takes place in a small childs home, it is taking ordinary situations are in themselves quite
place where almost everything of significance to complex. Winnicott wrote:
Infant Mental Health 89

The infant . . . is at this first and earliest stage in be built into the developing childs most pro-
a state of mergence, not yet having separated out found sense of self, others, and the world.
mother and not-me objects from the me, so When infants are abandoned to states of dis-
that what is adaptive or good in the environ- tress, subjected to intermittent responsiveness
ment is building up in the infants storehouse of from caregivers, or responded to in a fashion
experience as a self quality, indistinguishable at radically out of keeping with their needs, they
first ( by the infant) from the infants own healthy
manage these intolerable situations in costly
functioning. (p. 97)
and problematic ways. Some of these manage-
ment strategies and the resulting developmen-
When we observe infants over time, we can tal difficulties are discussed below.
trace the ways their repeated satisfactory expe- Development as it is understood in infant-
riences in the world as it is mediated for them parent psychotherapy is a lifelong process.
by ordinary, reliable, devoted caregivers, in tan- Clearly, the physiological processes involved in
dem with the healthy development of their own infant and child development constitute a par-
innate capacities (motor, cognitive, and social- ticularly gripping and wondrous field of study.
emotional), give rise to senses of personal com- As babies grow older, they confront their par-
petence and confident interest in others. It is ents with new attendant developmental issues.
important to stress, as Winnicott (1965) did, Parenting is itself a role with important implica-
that experiences of being disappointed, frus- tions for adult development. Stern (1995) pro-
trated, and misunderstood are not only un- posed the term the motherhood constellation
avoidable in typical development, but crucial. to denote the phenomenon he observed:
He described these as necessary failures of
adaptation of the caregiver to the infants With the birth of a baby, especially the first, the
needs: These failures are again a kind of adap- mother passes into a new and unique psychic or-
ganization that I call the motherhood constella-
tation because they are related to the growing
tion. As a psychic organizer, this constellation
need of the child for meeting reality and for
will determine a new set of action tendencies,
achieving separation and for the establishment sensibilities, fantasies, fears, and wishes. . . . It is
of a personal identity (pp. 96-97). seen as a unique, independent construct in its
These remarkable conditions of typical de- own right, of great magnitude in the life of most
velopment may be contrasted with situations in mothers, and entirely normal. (p. 171)
which these processes are impeded. Winnicott
(1965) wrote, The maturational process only When things go awry in the parent-infant
takes effect in an individual infant insofar as system, parents as well as infants suffer the
there is a [good-enough] facilitating environ- consequences, and developmental opportuni-
ment (p. 239). The institutionalized infants ties are lost on all sides. But one of the most pre-
studied by Spitz (1945, 1946), whose physical cious findings of infant-parent psychotherapy is
needs were provided for but who were de- that, although the first months and years of a
prived of human connectedness, testified childs life frequently (if not inevitably) consti-
through their responses of abjection to the or- tute a time of special vulnerability for families,
dinary brilliance of the good-enough caregiver- they also often represent a time of unparalleled
infant relational matrix. opportunity for psychological growth and posi-
When caregivers are unable to provide suffi- tive change. In the 23 years of practice at the In-
ciently satisfactory responses to an infants needs fant-Parent Program, therapists have certainly
in a reliable, ongoing way, this unreliability can met parents who were unable to ensure their

own or their childrens safety and well-being or the representative of figures in the parental past,
to provide a good-enough facilitating environ- or a representative of an aspect of the parental
ment; we have never, however, met a parent who self that is repudiated or negated. In some cases
did not wish to, even when this wish took an in- the baby himself seems engulfed in the parental
choate form and was barely recognizable in its neurosis and is showing the early signs of emo-
expression. That these infant-parent relation- tional disturbance. In treatment, we examine
with the parents the past and the present in
ships are also embedded in further complicated
order to free them and their baby from old
relational matrices is also relevant.
ghosts who have invaded the nursery, and then
we must make meaningful links between the past
and the present through interpretations that lead
to insight. At the same time . . . we maintain the
WOUNDED: THE UNHARMONIOUS focus on the baby through the provision of devel-
COHABITATION OF CONFLICT AND TRAUMA opmental information and discussion. We move
back and forth, between present and past, parent
What model of the mind is assumed in infant- and baby, but we always return to the baby.
parent psychotherapy? The answer to this ques- (p. 61)
tion has changed over time. The phrase that has
become emblematic of infant-parent psychother- In one case, for example, Dianna, a woman
apy over the years is Fraiberg, Adelson, et al.s who had lost her own mother to a prolonged
(1980) image of ghosts in the nursery. This hospitalization when she was a young child,
image dramatized the psychoanalytic concept of experienced her 8-month-old son Joes newly
repetition in the present of unresolved conflict developed ability to crawl, and specifically
from the past, but addressed the special circum- his exploratory forays away from her, as an
stance in which this repetition is enacted not in abandonment. Unaware of this experience,
relation to a psychoanalyst, as it was conceptual- however, and focused only on the practical dif-
ized in classical theory, but rather in relation to ficulties her sons mobility introduced (mess
an infant. Fraiberg wrote: and mishap), Dianna decided that she needed
a break, and she planned a trip for herself. She
In every nursery there are ghosts. They are the weaned Joe abruptly in preparation for this sep-
visitors from the unremembered past of the par- aration. Joe responded to this baffling and up-
ents, the uninvited guests at the christening. setting change in a much more circumscribed
Under favorable circumstances, these unfriendly
way than many young children would, and
and unbidden spirits are banished from the nurs-
perhaps than he himself would had the arrange-
ery. . . . The baby makes his own imperative
claim upon parental love and, in strict analogy
ment persisted. On the first day that his mother
with the fairy tales, the bonds of love protect the refused to nurse him, he cried and protested. On
child and his parents against the intruders, the the second day, he accepted her refusals without
malevolent ghosts. (p. 164) protest, but developed a remarkable symptom: at
irregular intervals throughout the day, he hit
Sometimes, however, these ghosts persist and himself on the head with his fist. The infant-par-
prevent a family from perceiving and respond- ent therapist observed this startling behavior.
ing to one another in spontaneous, connected, Dianna, alarmed by Joes self-hitting, was quick
and mutually gratifying ways. Fraiberg wrote to make the connection in the conversation with
that infant-parent psychotherapy was devel- the therapist between her abrupt weaning of Joe
oped to treat situations in which an infant has and his unusual symptom. Dianna was also able
become: to identify her true motivation for traveling
Infant Mental Health 91

away from Joe: her experience of his moving consciousness, or even a collection of uncon-
away from her, the devastating feelings of scious ideas, memories, and feelings that are re-
abandonment rooted in her own history that pressed, but rather, of a severing of the ties
this separation evoked for her, and her inclina- between entire realms of experience and of
tion to ward off these feelings by turning pas- the capacity for reflective thought being itself
sive into active, by abandoning rather than impaired. Judith Herman (1992) wrote, Trau-
being abandoned. matic events produce profound and lasting
The case of Joe and Dianna illustrates the ap- changes in physiological arousal, emotion, cog-
plication in infant-parent psychotherapy of the nition and memory. Moreover, traumatic events
psychoanalytic model, in which the problem is may sever these normally integrated functions
understood as repression of a parental memory from one another (p. 34).
(or the affect associated with it) that gives rise Herman (1992) developed the concept of com-
to repetition. The solution inheres in making the plex Posttraumatic Stress Disorder to account for
unconscious conscious, or, as S. Freud (1914/ situations in which prolonged and repeated
1955b) wrote, remembering . . . and working trauma necessitates a diagnostic model that goes
through to break from the cycle of repetition. beyond Posttraumatic Stress Disorder, which is
This model continues to be useful in situations tied to a circumscribed traumatic event. Herman
in which a parent is able and inclined to think wrote:
about his or her past and, with the help of a
therapist, to bring into consciousness and into Survivors of prolonged abuse develop character-
words memories, ideas, and feelings that have istic personality changes, including deforma-
previously been banished from consciousness. tions of relatedness and identity. Survivors of
Sometimes, this process uncovers a particular abuse in childhood develop similar problems
memory or conviction of which the parent has with relationships and identity; in addition, they
been unaware and that has functioned as a are particularly vulnerable to repeated harm,
lynchpin for the parents psychological organi- both self-inflicted and at the hands of others.
zation. More frequently, there are multiple (p. 119)
nexuses of thought, feeling, and memory that
tend to remain remote from consciousness and Often, the parent-child dyads and triads we treat
to influence perceptions and actions. The pro- are in the clutches of this more fundamental
cess of reflecting in which the parent engages and pervasive kind of repetition of harma
with the therapist in relation to the infant in itself repetition that results not from repression, but
loosens unconscious convictions, challenges ac- from disassociation; not from forgetting painful
customed expectations, and opens up new possi- thoughts and experiences, but from building a
bilities of experience. personality structure around surviving intolera-
In other cases, this model is less resonant as a ble experiences that precludes the capacity to
central vehicle of useful understanding (though remember. These structures shape the way the
all modes may be relevant at different moments world is seen and experienced.
within any one treatment). Often, the injuries a Infant-parent psychotherapy in these in-
parent has suffered began early enough and stances involves identifying those aspects of the
have been pervasive and multilayered enough parents manner of holding themselves and mov-
to have negatively shaped in the most basic ing through the world that have been constricted
ways how the parent experiences self, others, or distorted as a result of known or probable his-
and the world. It is then not a matter of a partic- torical trauma. These aspects include style of
ular memory being too painful to bring to self-presentation, personality structure, ways of

organizing information, characteristic modes of range of capacities relevant to ordinary parent-

relating, and systems of self-regulation. Through hood. It is also necessary to appreciate the
intervention that focuses on the parents experi- levels of meaning of behaviors and to appreci-
ence of the child and the childs experience of ate the transactions within the infant-parent
the parent, infant-parent psychotherapy gently relationship.
but persistently challenges the worldview these Infants express preferences and experiences
patterns express. The dynamic context for this is, from the first moments of life. These expres-
of course, the relational matrix created. sions become more nuanced and complex as the
infants capacities unfold and expand. It takes
time and attention to get to know a particular
METHODS OF ASSESSMENT baby, and knowledge of the range of develop-
AN D I N TERV EN T ION mentally expectable behaviors of infants in gen-
eral is necessary. However, when things are
CLINICAL ASSESSMENT going well enough with an infant, it is possible
to determine a sound hypothesis regarding the
Assessment in infant-parent psychotherapy en- meaning of his or her behaviors. When things
tails initially identifying whether difficulties are going well enough, parents are very good at
of significant proportions exist in the relation- participating in this process, and undertake it
ship between an infant or toddler and his or her on their own. Consider, for example, a mother
caregivers, and if so, how these are expressed who knows the difference between the sound of
and what causes them. In large measure, this a hungry cry, a sleepy cry, a tummy hurt
information is gleaned through clinical obser- cry, and a just plain fussy cry in her 3-
vation and interview initially and continuing month-old.
over time. When ambiguity initially exists, When things are not going well enough for
persists, or arises in the course of therapy, it an infant, it becomes increasingly difficult to
may be appropriate in addition for the child to discern the meaning behind his or her behav-
be seen in the programs developmental neu- ior, although the meaning is always there, even
ropsychology unit. It may also be relevant to when it is an expression of the frustration or
seek an evaluation of a parent for diagnostic despair experienced in rudimentary attempts
purposes and/or medication consultation. If to make sense of the world. Concomitantly,
clinical assessment does not result in a confi- when things are not going well enough be-
dent understanding of the parent or raises other tween a parent and child, the parent is often il-
issues where further knowledge seems neces- literate with respect to the infants signals, and
sary, a referral for evaluation will be initiated. misreads or ignores them habitually. One axis
Ongoing clinical assessment entails consid- of assessment, then, is defined by these ques-
ering development as a range of expectable ca- tions: How legible is the infants experience?
pacities and dynamics. This concept is relevant How able is the parent to understand or form
to both child and parent development. It is im- hypotheses about the meanings of the infants
portant that clinical observations be under- behavior? Do parent and child engage in the
taken by therapists who are knowledgeable mutual construction of meaning, or is meaning
about infant/toddler and adult development. imposed unilaterally? These questions are an-
Recognizing and understanding what typical swerable much of the time through observa-
and atypical behaviors look like in infants, tod- tion. One watches for distortions in parental
dlers, and parents is central. It is crucial to perceptions and the creation of behaviors in
know infant and toddler capacities and also the babies and toddlers that seem primarily
Infant Mental Health 93

responsive to negative perceptions and treat- is written. The child is also included fully in the
ment. Sometimes, children resemble an assem- process. The written report has proved equally
blage of negative projections that serve as a useful to other professionals with whom the
framework for their own, barely discernable in- family is involved.
clinations of self. Such understandings emerge
through observation, hypothesis, and provid-
ing the necessary climate of curiosity for the THE ROLE OF ASSESSMENT WITH RESPECT TO
voices of parent and child to emerge in all their FAMILIES INVOLVEMENT WITH OTHER AGENCIES
singularity and duality.
Silverman and Lieberman (1999) have dis- Even when no formal developmental neuropsy-
cussed some of the ways in which negative chological assessment has been conducted, the
parental attributions not only prevent a parent information and understanding acquired with
from accurately perceiving the meaning behind the family through the process of clinical as-
a childs behavior, but can also constrict and sessment can be useful to other agencies in-
influence the childs experience of self, such volved with the family.
that the child may develop into conformity with The infant and toddler years are complex,
the parents distorted perceptual system. When action-packed, emotionally intense times for
these dynamics are underway in an infant- all families, and no one navigates them any-
parent or toddler-parent dyad or triad, identi- thing like perfectly. Sometimes, professionals
fying ruptures in the systemevidence of working in other capacities with families of
experiences and meanings that run contrary to very small children (pediatricians, day care
the dominant accountis an important part of providers, social workers, public health nurses,
the assessment process. etc.) are alarmed by the emotional pitch and
intensity and the apparent vulnerability of the
infant family system. When these issues are
DEVELOPMENTAL NEUROPSYCHOLOGICAL compounded by the stressors associated with
ASSESSMENT poverty, racial and ethnic discrimination, and
other social forces that make protecting and
Though aimed at thoroughly understanding and providing for a family difficult for parents,
including constitution and temperamental con- these professionals sometimes perceive greater
tribution to a childs apperception, this assess- individual and family pathology than exists.
ment embraces the understanding of this child Birch (1994) suggested that aggressive impulses
and his or her development in the context of the toward children are a much ignored, ordinary,
childs signal relationships. This is achieved in and nonpathological part of the parenting ex-
the course of four one- to two-hour sessions that perience for mothers. When a family comes
include child, parent(s), therapist, and develop- under professional scrutiny, sometimes profes-
mental neuropsychologist. It includes parent in- sionals allow little room for this side of what
terview, play observation, and formal testing of we consider to be normal parental ambivalence
the child, and attends to cognition, attention, toward children. Even when worrisome things
memory, motor skills, language, visual process- are clearly in evidence for everyone, a context
ing, and social-emotional functioning. Ahern for understanding helps other professionals to
and Grandison (2000) have described this work continue to work with the family in a way that
in detail. Most important, the parent is the ulti- emphasizes the familys strengths and sup-
mate recipient of what has been mutually ports them, rather than pathologizing their
learned and it is the parent for whom the report vulnerabilities.

INTERVENTION Concrete Support

Because the needs of small dependent children
Infant-parent psychotherapeutic intervention often evoke feelings of need in more or less con-
has been conceptualized as involving four scious and concrete ways in the adults who care
modalities: concrete support, nondidactic de- for them, need is frequently a themeeither
velopmental guidance, psychodynamic psy- overt or covertthroughout infant-parent psy-
chotherapy, and emotional support (Fraiberg & chotherapies. In addition, many of the families
Fraiberg, 1980; Lieberman & Pawl, 1993; Lieber- that have been seen throughout the course of
man, Silverman, & Pawl, 2000; Pawl & Lieber- the development of infant-parent psychother-
man, 1997; Pawl, St. John, & Pekarsky, 2000). apy have been families whose concrete cir-
Emotional support has been further conceptu- cumstances range from precarious financial
alized as the essential quality of the therapist- stability to abject poverty and homelessness. To
patient relationship and the overall relational fail to attempt to assist parents in securing the
matrix (Pawl, 1995b). These modalities of inter- necessities of life with a small child or not to ac-
vention come into focus as they are relevant knowledge the realities of their needs would be
to their impact on the parent or the child indi- to relegate the treatment to uselessness.
vidually, and on the relationship among all This does not mean, however, that the infant-
involved. parent psychotherapist enters a family with the
intention of forming a laundry list of things to
Emotional Support do and crossing them off one by one. On the
Fraiberg, Shapiro, and Cherniss (1980) initially contrary, the extent to which and the ways in
conceptualized emotional support as a discrete which a therapist assists a family in getting
modality of infant-parent psychotherapy: their concrete needs met and ambitions real-
ized is a matter of an evolving therapeutic con-
On the one hand, we provide an ongoing, non- tract. In some cases, parents have no hope
didactic education to facilitate the development initially that anything other than a ride to the
of the parent-child relationship and to lead par- pediatrician or the grocery store could ease the
ents into an understanding of their babys needs, strain they experience. Such offers then repre-
and the ways they, as parents, can promote devel- sent the first token of earnestness on the thera-
opment. On the other hand, we also address feel- pists part to really find ways to address the
ings and psychological stress the parents may be familys troubles as they experience them. Most
experiencing as they attempt to respond to the families come to find other modalities of inter-
infants developmental needs. (p. 65) vention equally or more helpful, and frequently,
concrete support becomes a much less relevant
These activities were seen to constitute emotional mode in the course of a treatment. Conversely,
support. This has been further conceptualized as some parents are uncomfortable accepting con-
the essential quality of the therapist-patient crete support from a stranger and are prepared
relationship, in which all of the other modalities to consider it only after they have gotten to
are embedded (Pawl & St. John, 1998). know the therapist and to find the therapist re-
liable and capable of taking care of himself or
Nondidactic Developmental Guidance herself.
This entails the sensitive provision of develop- Home visiting in itself constitutes a form of
mental information and observation as these concrete support. Beyond this, concrete support
seem relevant to the overall process. might involve providing rides or keeping a family
Infant Mental Health 95

company on errands or appointments; advocat- How might an infant-parent psychotherapist

ing on behalf of a family with landlords, social assist a family in realizing this potential for
workers, day care providers, or health profes- positive psychological change and growth? The
sionals; locating resources such as sources of standard fare of psychodynamic psychotherapy
diapers, formula, toys, clothes, or child equip- entails a verbal exchange between therapist and
ment; making referrals to support groups, patient focusing on observation of experience,
respite care, psychiatrists, pediatricians, or day ideas, feelings, and behavior, and speculation
care; navigating the process of their enrolling regarding the origins, functions, and signifi-
in school or job training or applying for work or cance of these. These are also the ingredients
child care leave; or joining a parent in folding of which infant-parent psychotherapeutic inter-
the laundry during a visit. These activities are ventions are made, with the difference that it is
understood and implemented such that they fit not an individual psyche that is at issue, but
comfortably with and can be a vital part of the the joint representational system of the infant-
complex therapeutic relationship. Vigilance parent matrix.
and self-awareness on the part of the therapist Lieberman, Silverman, and Pawl (2000) ap-
are, of course, vitally necessary, as they are in plied Sterns (1995) notion of ports of entry
any thoughtful treatment. into the parent-infant clinical system. They
noted that psychotherapeutic intervention in
Psychodynamic Psychotherapy infant-parent psychotherapy is aimed at the
Psychodynamic interventions with infant-parent web of mutually constructed meanings in the
dyads and triads can be remarkably powerful. infant-parent relationship. They identified five
The fact that babies so frequently function as commonly used ports of entry for intervention:
transference objects for their parentsas repre- the childs behavior, the parent-child inter-
sentatives of important figures from the parents action, the childs representations of the self
past, including their own parents, themselves as and of the parent, the parents representations
infants, and other key people in the parents of the self and of the child, and the parent-
liveshas potentially positive as well as nega- therapist relationship. We would add that the
tive consequences. Intervention directed at the child-therapist relationship can also represent a
infant-parent relational matrix can have reso- port of entry for intervention, although it is al-
nance throughout the generations; not only can ways inclusive interaction among the therapeu-
the present familial relationships be set on a tic cluster that is the goal (St. John & Pawl,
more promising path, but unresolved conflicts 2000). The infant is the agent of change only as
and sorrows from the parental past can be re- the infant can be experienced differently by the
solved and released, and a strong and flexible parent. The baby is the final solidifier and has a
foundation can be laid for the childs potential role in the entire process, but the therapists at-
future disposition as a parent. Fraiberg, Shapiro, titude and the parents experience of the thera-
et al. (1980) wrote evocatively about the transfor- pist, not only in relation to themselves but in
mational power of the infant in infant-parent relation to the baby, is the opening wedge to the
psychotherapy: The baby can be a catalyst. He babys effectiveness. Simply experiencing the
provides a powerful motive for positive change baby as the therapist sees him or her can posi-
in his parents. He represents their hopes and tively affect the parental view. This is different
deepest longings; he stands for renewal of the from a primary reliance on interpretation as the
self; his birth can be experienced as a psycholog- central effort in clearing away debris for the
ical rebirth for his parents (pp. 5354). new experience of the child by the parent and

by the child of the parent, although this may at care and dont say good-bye, it scares me that
times be useful as well. (A more detailed per- you could just disappear at any moment. Some-
spective on the parent-therapist relationship times, the therapist makes an observation-in-
has been described by Pawl, 1995.) action, such as when a toddler brought a broken
Specific techniques of psychodynamic infant- toy to a therapist after his father stepped on it,
parent psychotherapy can include many things. and the therapist in turn placed the toy in the
For example, the therapist might make use of in- hands of the father. This suggests that it is the
quiry that encourages parents to verbalize their fathers job to repair the things that are broken
ideas about the infant, and may perhaps implic- between him and his son. This is, in a sense, an
itly challenge these ideas by putting them into a emblematic comment in action.
question. Such a focus, however, must not be These and related psychotherapeutic tech-
disingenuous. Whatever the therapists hypoth- niques are aimed in general at assisting the
esis, it must be a hypothesis. Therapists ask be- family in symbolizing through words, actions,
cause they are genuinely curious. They might and interactions the issues that matter to
ask, How do you know when hes hungry? them, rather than remaining stuck in patterns
They might use observation-out-loud: He is of thought and action that are unfulfilling
trying to turn his head away from the bottle. or damaging to them. Domains that are fre-
They might use speculation-out-load: Maybe quently addressed via psychotherapeutic in-
he doesnt want any more milk right now. terventions include space, time, and energy.
Maybe he is full and wants to rest. Often, ob- The significance of home visiting with regard
servation-out-loud explores the possibility of to a familys situation in relation to the space
something positive about the parent-infant rela- they occupy has already been discussed. In ad-
tionship and brings it to light: Look how she dition, issues of connection, separation, and in-
follows you with her eyes when you walk across dividuation are navigated across space, both
the room. I think she doesnt want to lose sight physical and psychic.
of such an important person. Sometimes, it is The domain of time has to do with memory
aimed at exploring something negative and fo- and repetition (past), the capacity for spontane-
cusing on that: When you (parents) get so ity, flexibility, and connectedness (present),
angry at each other and yell so loudly, Timmy and the ability to be planful and hopeful (fu-
seems to make himself as little as he can. ture). One mother in our program had lost cus-
Sometimes, this kind of observation must be fol- tody of an older child and was arrested in a
lowed up with speculation: I wonder whether state of perpetual lamentation of the loss of that
he is afraid that you will hurt each other again? child, to the extent that she would hold her new
Sometimes, a straightforward statement of con- infant close, rock her, and cry I lost my baby. I
viction, with or without a piece of develop- lost my baby. Stranded in a kind of timeless-
mental guidance, is better than a speculation: ness, this woman was in the process of losing
Children can have funny ideas about what her potential connection with her present baby.
causes what, and they sometimes feel that they The infant-parent psychotherapy involved as-
are to blame even for things they had nothing to sisting this woman in moving from melancholia
do with. I believe that Timmy thinks you hurt to mourning (S. Freud, 1917/1957) with respect
each other because he did something wrong. to the loss of her first child, in becoming emo-
Representing a possible experience of the baby tionally available to her present child, and in
has been identified as another infant-parent conceiving of a future with this child that
psychotherapeutic technique: I wonder if what would be different from her own childhood and
hed like to say is, When you disappear from day from the pattern she had lived out with the
Infant Mental Health 97

older girl. (This case is described in more detail focus of the work, though they are totally rele-
later in the chapter.) Infant-parent psychody- vant and involved.
namic intervention in the domain of time also Without exception, the parents treated in this
frequently involves sorting out or establishing program are diagnosable, and these diagnoses
generational lines that are functional for a fam- range widely across the entire spectrum of dis-
ily, whether this means relieving the burden of turbances described in the DSM-IV (American
the parentified child of a depressed mother, as- Psychiatric Association [APA], 1994). Crucial as
sisting a father in assuming a position of part- this information is, it is not that disturbance
nership with a mother rather than remaining in that is directly treated, although treatment will
an infantile position in relation to her and a have some positive impact on those problems.
competitive relation to his child, or liberating a Directly treating the parents disturbance is not
woman who was deprived as a child from a sib- the main intent of infant-parent psychotherapy,
linglike rivalrous relation with her own child. even though the treatment may prove to have a
Infant-parent psychodynamic interventions main effect in improving the adults function-
in the domain of energy have to do with assist- ing in a variety of spheres in addition to being a
ing infant-parent dyads and triads in under- parent.
standing the ways their respective systems of Infants and toddlers diagnoses tend to be
self-regulation work in relation to one another, more limited, and include Depression, Reactive
how their temperaments complement or chal- Attachment Disorder, Separation Anxiety Dis-
lenge one another, and how the intense influx order, Attention Deficit Disorder, feeding and
of both life force and demand introduced by the eating disorders, sleep disorders, and syn-
presence of the baby influences the parental dromes that may be revealed by neurodevelop-
system. Furthermore, through psychodynamic mental assessment. Outside of DSM-IV, the
intervention, depression-related depletion and Diagnostic Classification Zero to Three (1994) di-
passivity may be lifted, trauma-related numb- agnostic framework offers a useful system for
ing may be reduced, and anxiety-related perse- discerning and describing what can go awry re-
veration may be arrested such that new reserves garding infants and toddlers capacities, rela-
of energy become available for relationships tional orientations, and ways of experiencing
and life. the world.
The problems treated using infant-parent
psychotherapy focus on what occurs between
MAJOR SYNDROME S, parent and child, even as the therapist must
SYMPTOMS, AND strive to understand the internal world of each
P R O B L E M S T R E AT E D participant.

The symptoms and problems of central interest

to the infant-parent psychotherapist are those CASE EXAMPLE
embedded within the transactions of the infant-
parent relationship. These are the focus of treat- DIAGNOSIS
ment. Frequently, these problems are seen as
nested in ideas of abuse, deprivation, and neg- Helen and her 1-year-old baby Angel were re-
lect, whether emotional or more physically man- ferred for infant-parent psychotherapy by the
ifested. Although problems may exist within social worker at the halfway house where they
parent or child and clearly contribute to the had been living for the previous six months.
troubled relationships, they are not the primary The referral was made because of this workers

concerns that Helens mental illness left her at Helens psychological disposition was adversely
risk of neglecting Angel. Helen carried a diag- affecting Angel, and that Helen was preoccu-
nosis of Schizoaffective Disorder, for which she pied with thoughts of her older daughter to
received disability assistance and was pre- Angels detriment. As was described previ-
scribed Stelazine. She was followed by a psychi- ously, Helen would clasp Angel to her and rock
atrist at the county hospital, who met with her her with a faraway look in her eyes, repeating,
on a once-monthly basis for medication moni- I lost my baby. I lost my baby. She rarely
toring. Helen had lived on her own since she spoke directly to Angel, except in an inauthen-
was 16 years of age, rotating between periods of tic-seeming syrupy babytalk. She attended to
precarious stability during which she managed Angel, but only in a noncontingent way. That is,
to maintain housing, usually shared with tran- she was given over completely to rituals of child
sient friends, and periods of decompensation tending such as feeding and bathing, but she
during which she was homeless or lived in shel- administered to her automatically, rather than
ters. She had suffered numerous traumas, in- in response to perceived needs and desires on
cluding a rape and a stabbing, and she exhibited Angels part, and treated Angel as though she
posttraumatic symptomotology such as dereal- were a much younger infant: a babe in arms. She
ization, disassociation, and numbing as well as tended to dress Angel (as well as herself) in
the severe mood and thought disturbances multiple layers of clothing that constricted her
present during periods of decompensation. She movement and to feed her more frequently and
also suffered from pervasive depression and her in bigger quantities than necessary or desirable.
thinking was extremely concrete. Helen found it anxiety-provoking to leave the
Helen had had another daughter, Cathy, house, and so the pair were confined to a small
eight years prior to this pregnancy and had interior space that was shared with other men-
lost custody of her on grounds of neglect when tally disabled adults and one other, younger
she was an infant. Angels birth had precipi- infant. Angel was receiving precious little stim-
tated a decompensation, and Helen had re- ulation and had few arenas in which to exercise
ceived more comprehensive mental health the expansion of motor, cognitive, or social-
assessment and treatment at that point because emotional developmental capacities. She had
Angels presence in her life brought her to the long since given up efforts to engage her mother
attention of multiple mental health and social in nuanced exchanges, and instead presented as
service systems. The two lived for a time in a an alarmingly placid 1-year-old. Helen experi-
residential psychiatric program for mothers enced Angels ability to smile on cue and her
and babies, and then were discharged to the compliance with and perhaps enjoyment of the
halfway house where they currently resided. cuddling sessions Helen initiated as evidence
The halfway house social worker who referred that Angel was a happy baby. On the contrary,
the pair for infant-parent psychotherapy re- we saw Angel as a depressed, deprived 1-year-
ported that Helen was so depressed she was old well on the way to developmental delay in
depressing the baby, and that all she talks many areas.
about is her other kid.



The infant-parent psychotherapy assessment We saw Helen as suffering from a mental illness
confirmed the social workers impression that that had bearing on her ability to adequately
Infant Mental Health 99

parent Angel, but that might not preclude the a special communicative style with this pair
possibility that she could succeed in this re- in response to their combined difficulties. This
gard. That is, it was clear that her historical vul- style was characterized by a slight expansion or
nerability to decompensation put her at risk for amplification of responsessurprise, puzzle-
again finding herself in a state in which it was ment, amusement, consternationas a way of
impossible to care for Angel, and there were enlivening the affective field and highlighting
even now serious problems in her present rela- the expressive texture that most people take for
tionship with Angel. It seemed possible that the granted and deploy and respond to as a matter
care Helen was receiving now would enable her of course. She expressed both her own experi-
to maintain an adequate level of functioning ences and her understanding of Helens and
such that infant-parent psychotherapy could be Angels experiences in this way. For example,
beneficial. Specifically, Helen was in psychi- once, when Helen was methodically spooning
atric treatment and was medically compliant, oatmeal into Angels mouth despite the fact
was in a stable, assisted-living housing situa- that Angel seemed more and more reluctant to
tion, and was receiving a number of family sup- consume it, the therapist said, Angel, you look
port services that had not been available to her like youre so finished youre ready to say No
in the past. more oatmeal! and stuck out her tongue.
The infant-parent psychotherapy that ensued Angel laughed and stuck out her tongue too. As
focused on two areas. First, the therapist as- predicted, Helen found the therapists antics
sisted Angel in reinitiating and amplifying a amusing and intriguing rather than irritating
signaling system that had fallen into disuse as a or unremarkable. When Helen was treated
result of the failure of her environment to re- inconsiderately by a disability clerk, the thera-
spond. Second, the therapist focused on loosen- pist registered indignation and anger in a simi-
ing the grip of Helens perseverative ideas about lar, slightly intensified manner, and Helen
her older daughter so that she was able to per- responded with wonder that someone would
ceive and respond to Angel in the here and now. get their dukes up over me.
Both of these processes were facilitated by the From these initial sparks of affectively
therapists attentiveness to the immediate ob- charged exchange, a true system of signal and
servable experience of both mother and child. response caught fire between Helen and Angel.
She made use of all of the techniques of inter- Miraculously, as the flesh-and-blood child in
vention described previously to bring Helen her care became more real and present for
and Angel into focus for each other and to assist Helen, the older child receded to her place in
them in communicating with each other. the past. The therapist assisted in this process:
The therapist learned early on that it was nec- for example, when Helen made her global state-
essary to be very specific and clear with Helen, ment I lost my baby, she responded by saying
whose concrete thinking and pervasive sense of You are remembering Cathy and feeling sad
ominousness conspired to make the world quite about the things that happened to the two of
frightening for her. For example, the therapists you back then. Helen was able eventually to ar-
use on one occasion of the expression Ill keep ticulate her fear that she would inevitably lose
my eyes peeled inspired terror in Helen, who Angel just as she had lost Cathy, and the thera-
could not keep the gruesome image this phrase pist was able to reassure her Angel is right here
evoked out of her head. Any metaphors, in other in your arms. Helen and the therapist retraced
words, tended to be more baffling and unset- the events that had occurred in the past, identi-
tling than enlightening, and it was necessary to fied the elements of Helens life that were dif-
avoid them. In addition, the therapist developed ferent now, anticipated junctures that might be

difficult in the future, and planned ways of cop- world of her mothers disturbance, but she com-
ing and securing extra help should Helens dis- municated its intrigues successfully enough
tress increase. that others were motivated to stay in touch with
But they never strayed far in their conversa- her when she went there. And, unlike her
tions from their present interactions with Angel. mother, that world was one that she symbolized,
Angel herself became the most engaging advocate rather than one that impaired her capacity for
for the urgency of the present. Within a few symbolization.
months of the beginning of treatment, Angel Helen and Angel continue to live indepen-
became much more expressive and engaging dur- dently seven years after termination. Helen has
ing sessions. She demanded her mothers atten- continued to receive individual psychiatric treat-
tion with age-appropriate insistence. It took ment, but no educational or family support pro-
longer for her to maintain this persistence outside fessional involved with the pair has seen cause to
of the sessions; the therapists missing amplifica- refer Angel for mental health treatment or to
tions and focus resulted in less effectively re- bring the family to the attention of the Depart-
warding responses from Helen to Angel than ment of Human Services.
when in the therapists presence. Over time, how-
ever, Helens ability to engage on her own in en-
livened, responsive interactions with Angel took S U M M A RY
hold, and she became a devoted and effective, if a
somewhat odd and sometimes sad, mother. Although infant mental health programs vary
greatly in the structure and specific foci of their
services, many share a commitment to treating
POSTTERMINATION SYNOPSIS AND infants in the context of their family from a
EFFECTIVENESS DATA psychodynamic perspective, and the modality
of infant-parent psychotherapy has provided a
The two remained in infant-parent psychother- theoretical framework and a technical model
apy for three years. At the time of termination for doing so. Mental health professionals spe-
they were living independently, and Helen still cializing in infancy address clinical concerns in
made use of the psychiatric services available to a broad range of areas, including the internal
her through the county hospital. Angel attended experiences of infants and toddlers; the inter-
a family day care, where she had a positive nal experience of parents or primary caregivers;
relationship with the provider and enjoyed in- and the delicacy and power of expectations and
teractions with other children. Her vulnera- experiences of interpersonal exchange, includ-
bilities included a tendency to withdraw into ing exchanges between patients and therapists.
elaborate fantasy play when upset or anxious. These professionals are knowledgeable in the
Her strengths included her creativity and pleas- areas of mental health and its disturbances,
ure in artistic activities, an advanced vocabu- human development, and the practical de-
lary and appetite for conversation, and powerful mands of being the parent of an infant or tod-
imaginative capacities that drew certain adults dler. They are familiar with the multitude of
and children toward her. It seemed to us a social systems in which families routinely or
poignant picture of how this child had learned occasionally become involved, such as the med-
to survive in a world mediated by a mother as ical, educational, social service, and legal sys-
devoted but troubled as hers. When the going tems. They are committed to treating infants in
got rough, Angel retreated into a fantasy world the context of the relationships in which they are
that was perhaps a version of the mysterious embedded, and are inclined to think in terms of
Infant Mental Health 101

the child-caregiver dyad whenever difficulties of infants between 7 and 20 weeks of age. Journal
are presented by either. These professionals also of Experimental Child Psychology(2), 11.
are highly aware of the impact they themselves Bower, T. G. R., & Wishart, J. G. (1972). The effects of
have on their clients. Tracking the vicissitudes of motor skill on object permanence. Cognition (2), 1.
these relational networks is a vital aspect of the Bowlby, J. (1960). Grief and mourning in infancy
therapeutic endeavor. and early childhood. Psychoanalytic Study of the
Child, 15, 952.
Brazelton, T. B. (1992). Touchpoints: Your childs
emotional and behavioral development. New York:
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Psychodynamic Approaches to
Child Therapy

H I S T ORY O F T H E Over a period of 45 years of psychoanalytic

P S YC H O DY NA M I C A P P R OAC H writing, Freud gradually moved from seeing
TO CH ILD THERAPY psychological problems as arising out of sup-
pressed emotions, which gained expression in
THE EVOLUTION OF PSYCHODYNAMIC the form of symptoms, to an increasingly com-
THEORIES OF CHILD DEVELOPMENT plex view, where the counterbalance of psycho-
logical forces within the mind was seen as the
Freud was the first to give meaning to mental critical aspect of psychological adaptation. In
disorder by linking it to childhood experiences his last full formulation, the so-called structural
(Breuer & Freud, 1895) and to the vicissitudes of model, S. Freud (1923) envisioned three psychic
the developmental process (S. Freud, 1900). His agencies: (1) instinctual, principally sexual and
original developmental formulations (S. Freud, aggressive energies located in the id; (2) an in-
1905) radically altered our perception of the ternalized set of moral values encoded in the
child from one of somewhat idealized navet superego; and (3) adaptive mechanisms organ-
and innocence. He suggested that children are ized in the ego. In this complex model, normal
constitutionally predisposed to an inevitably adaptation could be seen as the harmonious
partially successful struggle to adapt their sex- functioning of these agencies, whereas psycho-
ual and aggressive instincts to the demands of a logical abnormality invariably reflected a break-
civilized society. S. Freud (1933) painted a pic- down of the egos capacity to respond to the
ture of the child as an individual in turmoil, con- demands of the id, the superego, and the exter-
stantly struggling to master biological needs and nal environment.
make these acceptable to society. He posited that Ego psychologists both elaborated and bal-
the drama takes place universally in the develop- anced Freuds view by focusing on the evolution
ment of every human being within the micro- of childrens adaptive capacities, which they bring
cosm of the family (S. Freud, 1930). to bear on their struggle with their biological


needs. Hartmann (1939) attempted to take a Margaret Mahler (1968) drew attention to the
wider view of the developmental process, to paradox of self-development: that the achieve-
link drives and ego functions, and to show ment of a separate identity involves giving up a
how negative interpersonal experiences beyond highly gratifying closeness with the caregiver.
the expectable range could jeopardize the evolu- Her observations of the ambitendency of chil-
tion of the psychic structures essential to adap- dren in their second year of life assisted under-
tation. He also showed that reactivation of standing of individuals who experienced chronic
earlier structures (regression) was the most im- problems consolidating their individuality.
portant component of psychopathology. Hart- Mahlers framework highlights the importance
mann (1955, p. 221) was among the first to point of the caregiver in facilitating separation and
to the complexity of the developmental process, helps explain the difficulties experienced by
stating that the reasons for the persistence of a children whose parents fail to perform a social
particular behavior are likely to be different referencing function for the child: evaluating for
from the reasons for the original appearance of them the realistic danger associated with unfa-
the behavior earlier in development. Among miliar environments (Feinman, 1991; Hornik &
the great contributions of ego psychologists are Gunnar, 1988). A traumatized, troubled parent
the identification of the ubiquitous nature of may hinder rather than help a childs adaptation
intrapsychic conflict throughout development (Terr, 1983). An abusive parent may altogether
(Brenner, 1982) and the recognition that genetic inhibit the process of social referencing (Cic-
endowment, as well as interpersonal experi- chetti, 1990; Hesse & Cicchetti, 1982). The patho-
ences, may have a critical influence on the genic potential of the withdrawing object, when
childs developmental path. confronted with the childs wish for separate-
Freuds daughter, Anna Freud, was strongly ness, was further elaborated by Masterson (1972)
influenced by these psychological ideas of and Rinsley (1977) and helps to account for the
the North American psychoanalytic tradition, transgenerational aspects of psychological dis-
although her practice was in London. Her turbance (see Baron, Gruen, & Asnis, 1985;
major contribution was linking normal emo- Links, Steiner, & Huxley, 1988; Loranger, Old-
tional development to diagnosable psychopath- ham, & Tullis, 1982).
ology (A. Freud, 1965). She charted normal Edith Jacobson (1964) and Joseph Sandler
development along a series of developmental (1987) further elaborated the ego psychological
lines and made the powerful suggestion that model. Both theoreticians suggested a move
equilibrium between developmental processes away from the mechanistic psychological
was a key aspect of normal development. Her model suggested by Freud to one that was far
work emphasized that symptomatology is more compatible with modern cognitive neuro-
not a fixed formation, but rather a dynamic en- science. They de-emphasized the biologically
tity superimposed on, and intertwined with, rooted notions of drives and instincts, replac-
an underlying developmental process. A child ing these with constructs such as wishes and
whose environment selectively compromised the role of representational structures in the
some but not other developmental processes childs mind and how these might mediate
was thought to be at risk of maladjustment and both reality and its distortion associated with
psychopathology. Anna Freuds vision of the internal conflict. Sandlers development of A.
relationship of development and psychopathol- Freuds and Jacobsons work (e.g., Sandler &
ogy lies, conceptually at least, at the heart of Rosenblatt, 1962) coherently integrated the
the new, integrative discipline of developmen- developmental perspective with psychoana-
tal psychopathology (see Sroufe, 1990). lytic theory. His comprehensive psychoanalytic
Psychodynamic Approaches to Child Therapy 107

model has permitted developmental researchers can exert a significant influence over the thera-
(Emde, 1983, 1988a, 1988b; Stern, 1985) to inte- pists state of mind. Klein believed that projec-
grate their findings with a psychoanalytic for- tion was the most basic mechanism available to
mulation, which clinicians also have been able children to deal with destructiveness: They rid
to use. At the core of Sandlers formulation lies themselves of their destructive fantasies by
the representational structure, which contains placing them onto other persons. It is only
both reality and distortion and is the driving through the therapists interpretive work, par-
force of psychic life. A further important compo- ticularly with such destructive fantasies, that
nent of his model is the notion of the back- children are enabled to reclaim disowned as-
ground of safety (Sandler, 1987), which is pects of themselves and allow for the develop-
closely tied to Bowlbys concept of secure at- ment of a less malevolent and more realistic
tachment (Bowlby, 1969). appraisal of others.
Concurrently, in the United Kingdom, a com- Studies of severe character disorders by psy-
pletely different approach to psychodynamic choanalysts in Britain focused on the early rela-
theory grew out of the work of Melanie Klein tionship with the caregiver as a critical aspect
(1946). One of Kleins fundamental postulates of development. Fairbairn (1952) shifted theo-
was the assumption of two radically different retical emphasis from the satisfaction of biolog-
modes of mental functioning. The first, the para- ical desires to the individuals need for the
noid-schizoid position, described a state of other. This helped shift psychoanalytic atten-
mind (prototypically in the human infant) in tion from structure to content, and profoundly
which loving and destructive feelings toward influenced both British and North American
the love object could not simultaneously be ac- psychoanalytic thinking. Working in this tradi-
commodated, so that the conflict had to be dealt tion, and also influenced by Klein, Donald
with by splitting, that is, creating separate im- Winnicott (1965) proposed a number of funda-
ages of the loved and the hated figure. With cog- mental psychodynamic developmental notions,
nitive development, this inevitably leads to what such as primary maternal preoccupation, the
Klein termed the depressive position, in which mirroring function of the caregiver, and the
children recognize that the object they love and transitional space in development between fu-
the one they hate are one and the same. Kleins sion and separateness, within which symbolic
ideas originally met with considerable skepti- thought and play were considered to be rooted.
cism because of her extravagant assumptions Most recent studies support Winnicotts asser-
about the cognitive capacities of infants, which tions concerning the traumatic consequences of
were incompatible with the state of developmen- early maternal failure, particularly maternal
tal knowledge at that time. More recently, devel- depression (see, e.g., Cummings & Davies,
opmental research has confirmed many of 1994), and the importance of maternal sensitiv-
Kleins claims (Gergely, 1991), such as those con- ity for the establishment of a secure relation-
cerning the perception of causality (Bower, ship (Ainsworth, Blehar, Waters, & Wall, 1978;
1989) and causal reasoning (Golinkoff, Hardig, Belsky, Rovine, & Taylor, 1984; Bus & van Ijzen-
Carlson, & Sexton, 1984). Kleins ideas rapidly doorn, 1992; Grossmann, Grossmann, Spangler,
became popular, principally because of the help- Suess, & Unzner, 1985).
fulness of her clinical observations. For example, Heinz Kohut (1977), who was probably influ-
she proposed the notion of projective identifica- enced by Winnicotts work, rekindled the inter-
tion, a concept that others subsequently devel- est of North American psychoanalysts in the
oped to provide a means of accounting for the interpersonal aspects of early development. He
common experience of therapists that patients saw the caregiver as having a mirroring role

and the goal of development as one of achieving John Bowlbys (1969, 1973, 1980) exposition of
a coherent sense of self. If the caregiver is able attachment theory shares this virtue of open-
to become a selfobject, empathically attuned ness to empirical scrutiny. Bowlbys work on
to the infants or young childs mental states, separation and loss focused developmentalists
the childs sense of personhood will be firmly attention on the importance of the security
established. Within a self psychology, drive the- (safety and predictability) of the earliest rela-
ory took secondary importance. Kohut (1971) tionships. Safety and predictability must be ex-
suggested that the dominance of drives was perienced for the child to acquire a capacity for
itself an indication of the childs failure to have relatively problem-free later interpersonal rela-
attained an integrated self structure, which nor- tionships. Bowlby assumed that representa-
mally would adequately regulate drive states. tional systems and internal working models
Kohuts formulations concerning narcissistic evolve based on a template created by the earli-
personality structures have been highly influen- est relationship of the infant to the caregiver. If
tial and helpful in extending the applicability the expectation that need and distress will be
of psychodynamic approaches from the strictly met by comforting is encoded into these mod-
neurotic to the so-called character disorder els, the child will be able to approach relation-
spectrum of disorders. ships in a relatively undefensive way. If this is
Kernbergs systematic integration of struc- not the case, if the childs caregivers lack sensi-
tural theory and object-relations theory (Kern- tivity (Ainsworth et al., 1978), the childs repre-
berg, 1976, 1982, 1987) is probably the most sentational system will be defensively distorted
frequently used psychoanalytic model, particu- to either minimize or heighten experiences of
larly in relation to personality disorders. His arousal and dismiss or become entangled in the
model of psychopathology is developmental, in response of others (Main, Kaplan, & Cassidy,
the sense that personality disturbance is seen to 1985).
reflect the limited capacities of the young child Daniel Stern (1985) took a novel approach to
to address intrapsychic conflict. Kernberg the psychoanalytic study of childhood. His mile-
followed Jacobson and Sandler in seeing the stone contribution to the psychoanalytic theory
mind as principally a representational organ. of development is exceptional in being norma-
He postulated the existence of relationship tive rather than pathomorphic and prospective
representations consisting of self, object, and af- rather than retrospective. Like Kohut, his main
fect that characterize the specific relationship. concern is the development of a coherent self
Kernberg reconceptualized the theory of drives, structure. His psychoanalytic model, however,
seeing these as developmental achievements, in- has much in common with Sandlers representa-
tegrations of multiple triadic self-object-affect tional theory as well as Kernbergs focus on the
representations. Whereas in neurotic cases, the affective aspect of early relationships.
integration achieved is relatively complete, in
personality disorders, the self and other repre-
sentations are only partial and are infused with THE EVOLUTION OF PSYCHODYNAMIC
overwhelming and extreme emotional states of TECHNIQUE WITH CHILDREN
both ecstasy and persecutory terror and ag-
gression. Kernbergs ideas have been enor- Specific therapeutic techniques that could help
mously influential in psychoanalytic thinking psychoanalysts to address the psychiatric prob-
and are particularly helpful because they lend lems of childhood did not appear until the
themselves relatively well to operationalization 1920s. S. Freuds observations concerning the
and empirical study (Clarkin, Kernberg, & Yeo- psychology of young children prepared the way
mans, 1999). for the application of the insights gained from
Psychodynamic Approaches to Child Therapy 109

psychoanalytic treatment of adults to the treat- Klein saw direct interpretation of the projec-
ment of children. Best known are Freuds grand- tive processes as critical. In Notes on Some
sons separation game (S. Freud, 1920) and his Schizoid Mechanisms (Klein, 1946) and The
case study of Hans (S. Freud, 1909), a 5-year-old Origins of Transference (Klein, 1952), she dis-
with an animal phobia, whose treatment by his cussed the importance of the common child-
physician father was supervised by Freud. hood unconscious fantasy of placing part of the
Freud used these observations principally to self into another person and perceiving un-
confirm his assumptions about infantile instinc- wanted qualities in the other rather than in one-
tual life through the direct observation of chil- self to relieve oneself of unwanted feelings
dren and to prevent him (and other adult (such as greed or envy). She regarded this form
psychoanalysts) from making false developmen- of fragmentation of the sense of self as part of
tal assumptions (S. Freud, 1926). normal infantile development, but as the cause
Hermine Hug-Helmuth (1920, 1921) was the of pathology and the key focus for interpreta-
first clinician to use the technique of play ther- tions when it persisted beyond infancy. She as-
apy. Her pioneering work, now largely forgot- sumed that although projective identification
ten, combined an insight-oriented technique, was distressing, it also helped children to create
focused primarily on the childs unconscious the fantasy, not only that the other was the con-
sexual fantasies, with a powerful developmental tainers of their own unwelcome traits, but also
perspective, whereby she saw children as need- that (as these unattractive attributes still partly
ing to be strengthened in the mental capaci- belonged to the self) the children could control
ties needed for their developmental tasks. This the other person (object). The clinicians under-
latter emphasis has echoes in present-day cogni- standing was enriched by the assumption that
tive therapy and psychoanalytic approaches. childrens perception of him or her gave clues
The other great pioneers of the field, Anna about conflictual aspects of their experience of
Freud (1946) and Melanie Klein (1932), inde- themselves. Bion (1959) showed how such pro-
pendently (but frequently with reference to one jective experiences could be expected to have an
another) evolved techniques to enable clinicians impact on the container and how the capacity
to take a psychoanalytic therapeutic approach of that individual to metabolize (understand
to children. Working under the influence of and accept) the projection may be critical
Karl Abraham (1927), a Berlin-based psychoan- in development as well as in the success of
alyst, Klein regarded childrens play as essen- therapy. Thus, the therapists subjective experi-
tially the same as the free association of adults: ence (countertransference) could be a clue to
motivated by unconscious fantasy activated the childs unconscious fantasies, and the ther-
principally by the relationship with the analyst apists capacity to understand and tolerate
and requiring verbalization (interpretation) if these became the key component of successful
the childs anxiety was to be adequately ad- treatment.
dressed. The interpretation of the childs deep Modern Kleinians (e.g., DeFolch, 1988;
anxieties concerning destructive and sadistic OShaughnessy, 1988) have, to some degree,
impulses was the principal focus of child ana- modified the classical Kleinian position; early
lytic work. She advocated that therapists estab- interpretations of assumed deeply unconscious
lish an interpretative relationship, even with material are less frequently offered, and there
preschool children, from the beginning. The is greater attention to the defensive qualities of
emphasis placed on the relationship with the many manifestations of the childs noncon-
analyst meant that work with parents and other scious processes. The immediate interaction
adults in the childs life (e.g., teachers) was not with the analyst, however, remains the core
seen as central. focus of therapeutic work, and the underlying

conceptualization continues to be based on Her approach to child analysis invariably

the notion of fragmentation of the self- takes into consideration the limitations im-
representational structure, which may be un- posed by development on the childs ego func-
done through verbalization and interpretation. tioning, and focuses primarily on the support
The countertransference experience of the of the development of the ego and the restora-
therapist is the central guide. tion of the child to a normal developmental
Drawing on the work of Klein, Winnicott path. Pine (1985) stressed that the analyst, like
(1965, 1971) reinforced Kleins emphasis on the the parent, creates a supportive environment
influence of early life on childhood pathology for the childs incompletely developed ego. He
while introducing additional techniques into saw such techniques as mutative in their own
child analysis. For example, specific drawing right and considered interpretations in the con-
techniques were used, and Winnicott also em- text of support to be qualitatively different from
phasized nonverbal aspects of the therapists interpretations in the context of abstinence, as
stance, in particular the importance of a hold- is recommended by Kleinian child analysts. The
ing environment and the central role of play. pressure for the analyst to be an active and
One of his major contributions was the concept real participant in the therapeutic situation
of a transitional area between self and object, has grown in recent years (see also Altman,
where the subjective object and the truly ob- 1992; Warshaw, 1992). However, many of these
jective object are simultaneously recognized reconceptualizations lack coherent theoretical
(Winnicott, 1971). This insight was critical in de- rationale and specific technical recommenda-
veloping an appreciation of the interpersonal na- tions as to how departures from abstinence may
ture of therapeutic interaction in child analysis be put to good therapeutic effect.
(Altman, 1994). Freudian child psychoanalysis became popu-
By contrast, Anna Freuds approach placed lar as a treatment in the United States in the
more emphasis on the childs developmental first half of this century, and was systemati-
struggle with adaptation to a social as well as an cally described by Anna Freud and her col-
intrapsychic environment. Her training as a leagues (Sandler, Kennedy, & Tyson, 1980); it
nursery school teacher led her to be very con- has also influenced many forms of psycho-
cerned with childrens actual external circum- dynamic treatment of children and families. In-
stances, as well as their unconscious internal dividual child psychodynamic psychotherapy,
world. She made fewer assumptions concerning based on these principles, is frequently used
the meaning of childrens play, approached ther- and highly regarded among child psychiatrists
apeutic work far more gradually, recommended and psychologists in the United States (Kazdin,
working in collaboration with parents and teach- Bass, Siegel, & Thomas, 1990). In the United
ers (particularly in communicating understand- Kingdom, as well as in Latin America, Melanie
ing derived from the therapy), and focused far Kleins model proved to be more popular.
more on the complications and conflicts arising
from childrens libidinal (sexual) impulses than
on innate aggression. Her focus was on chil- U N D E R LY I N G T H E O R E T I C A L
drens wish to protect their fragile internal CONSTRUC T S
world from conflict by adopting psychological
strategies (mechanisms of defense; A. Freud, As the historical review indicates, there is no
1936) such as denial, repression, or identification agreed upon formulation shared by all psy-
with the aggressor. The focus of her technique choanalytic schools. There are major theoreti-
therefore was the interpretation of defenses and, cal divisions, which overlap in part with
through this, the anxieties that motivated them. issues of technique originating from different
Psychodynamic Approaches to Child Therapy 111

understandings of the nature of development INTERPERSONAL INTERACTIONS

and psychopathology (King & Steiner, 1991).
Nevertheless, there are probably a core set of as- Like cognitive scientists, psychodynamic thera-
sumptions to which all psychodynamic thera- pists assume that the experience of the self with
pists would, to a greater or lesser extent, others is internalized, leading to representational
subscribe. They can be summarized as follows. structures of interpersonal interactions that, at the
simplest level, determine the childs expecta-
tions of others, and more elaborately determine
PSYCHOLOGICAL CAUSATION the shape of self and other representations
and the nature of the internal world of the
Psychodynamically oriented child therapists child. Psychodynamic clinicians from different
assume that mental disturbance may be use- traditions formulate this general idea somewhat
fully studied at the level of psychological causa- differently. Bowlbys (1973, 1980) concept of
tion, that is, that the representation of past internal working models of self-other rela-
experience, its interpretation and meaning, tionships based on the infant-mother relation-
largely unconscious, determines childrens re- ship is perhaps the closest to formulations from
action to their external world and their capacity other areas of clinical psychology. In essence,
to adapt to it. The emphasis on psychic causa- all so called object-relations theories posit that
tion does not imply either a lack of respect for the emotional life of the child (and adult) is
or inattention to other levels of analysis of organized around mental representations, how-
childhood psychiatric problems, such as the bio- ever partial, of the self in relation to an impor-
logical, the family, or broader social factors. tant figure, imbued with a specific affect (e.g.,
Nevertheless, psychiatric problems, whether at Kernberg, 1976).
the root genetic or constitutional or socially
caused, are seen by the psychodynamically
oriented child clinician as the meaningful con- CONFLICT
sequence of the childs unconscious beliefs,
thoughts, and feelings, and therefore as poten- The ubiquity of intrapsychic conf lict is as-
tially accessible in psychotherapy. sumed. It is seen as causing suffering (or a felt
lack of safety; Brenner, 1982). Adverse child-
hood environments may create intrapsychic
UNCONSCIOUS MENTAL PROCESSES conflicts of overwhelming intensity and/or fail
to equip the child adequately to deal with con-
Psychodynamic clinicians assume that the ex- flicts within the normal range of early experi-
planation of conscious ideation and intentional ence (Winnicott, 1965). Thus, trauma (such as
behavior requires the assumption of complex loss of a caregiver) or long-term abuse under-
unconscious mental processes functioning outside mines personality development by intensifying
of awareness. Psychodynamic clinicians pro- incompatible wishes or reducing the childs ca-
bably no longer think in terms of an uncon- pacity to resolve conflicts through mental
scious in the sense of a physical space where work.
forbidden or repudiated feelings and ideas are
stored. Yet, they assume that nonconscious fan-
tasies, associated with wishes for gratification DEFENSE
or safety, profoundly influence childrens be-
havior and their capacity to regulate affect and The child is predisposed to modify unaccept-
to adequately handle their social environment. able unconscious wishes through a range of

mental mechanisms aimed at reducing the context of the therapeutic relationship. They do
sense of conflict. Defense mechanisms form a so by means of the process known as transfer-
developmental hierarchy, which reflects the de- ence. The relationship to the therapist has pri-
gree of pathology experienced by the individ- macy, in that it provides a window to the childs
ual; developmentally early defenses, such as expectations of others and can come to be a ve-
splitting, or projective identification, are nor- hicle for the unwanted and disowned aspects of
mally associated with more severe distur- the childs thoughts and feelings. Transference
bances. A neurotic symptom, such as phobic displacement may include such aspects of past
anxiety, may be understood as a result of dis- relationships or past fantasies about these as
placement of fear from the representation of one well as conflictual aspects of current relation-
model of interaction (e.g., father-child) to an- ships to parents, siblings, or important others.
other (e.g., teacher-child). Considerably more The relative neutrality and ambiguity of the
resistant to therapy is the more primitive de- therapeutic relationship encourages external-
fense of splitting of affect, whereby a child izations of repudiated aspects of past relation-
alternately derogates and idealizes the caregiv- ships (R. L. Tyson & Tyson, 1986), but the
ing figure. Immature or early defenses are as- situation becomes more complicated because
sumed to reflect the absence of higher-level, the childs verbal and nonverbal behavior must
integrative capacities (Pine, 1985). naturally have an impact on the therapists ex-
perience. However, modern psychodynamic
therapists tend to make extensive use of their
MULTIPLE MEANINGS subjective reactions to understand the roles
that the child is implicitly asking them to play.
Psychodynamic therapists assume that chil- Through exploring the role they have been
drens communication in the session has mean- placed in by the child, therapists are enabled to
ing beyond that intended by the children and, by achieve a better understanding of the childs
analogous mechanisms, that childrens symp- representation of role relationships and feelings
toms carry multiple and complex meanings, reflect- about them (Tyson & Tyson, 1986).
ing the nature of their internal representations
of others and others relationship to the children
as they perceive it. The therapist is able to bring THE WHOLE PERSON
childrens attention to aspects of their behavior
that are ego-dystonic and hard to understand. By Modern psychodynamic child psychotherapy
making appropriate links, the therapist illus- emphasizes the current state of children in re-
trates to children that these behaviors may be lation to their environment, history of past
seen as rational in terms of unconscious mental relationships, and adaptations to these. Psy-
experience and psychic causation (Sandler et al., chotherapists generally recognize that the
1980). therapy they offer has an important holding or
containing function in the childs life, which,
beyond interpretation and consequent insight,
TRANSFERENCE creates the possibility of a reintegration or re-
organization of the childs internal world that
It is generally accepted that internalized repre- in turn facilitates the childs adaptive develop-
sentations of interpersonal relationships, which ment. The child therapist thus takes a whole
determine the childs behavior with others in person perspective, encompassing all aspects
the outside world, also become active in the of the childs unfolding concerns (biological,
Psychodynamic Approaches to Child Therapy 113

environmental, intrapsychic). The establish- 5. As the childs motivation for treatment

ment of a relationship with an adult that is stems from anxiety, guilt, or other unpleas-
open and nonexploitative may serve as the ant affects, these experiences are often
basis of new internalizations, bringing about a seen as essential to ensuring the childs
healthier resolution of pathogenic experiences. commitment to the treatment as well as a
sense of agency (a sense of responsibility
for ones problems and actions).
METHODS OF ASSESSMENT 6. It is assumed that a capacity to form rela-
AN D I N TERV EN T ION tionships and develop trust must be pres-
ent for psychodynamic therapy to operate.
There is evidently a group of children com-
Traditionally, psychodynamic therapists have monly treated by psychodynamic psychother-
worked with relatively less severely disturbed apy who do not meet the criteria discussed
young people. Hoffman (1993), Glenn (1978), above. We have described this group in our ret-
Sandler et al. (1980), and others have identified rospective examination of case records at the
the criteria of suitability for psychodynamic Anna Freud Centre (Fonagy & Target, 1996a,
psychotherapy as the following: 1996c). Other descriptions by Cohen, Towbin,
Mayes, and Volkmar (1994), Towbin, Dykens,
1. Good verbal skills and psychological-mind- Pearson, and Cohen (1993), and Bleiberg (1987,
edness, that is, the ability to conceive of 1994a) have arrived at strikingly similar de-
behavior as mediated by mental states scriptions. This group of children appear to
(thoughts and feelings). Equally important suffer from a variety of deficiencies of psycho-
here is the childs capacity to tolerate logical capacities, indicated, for example, by
awareness of conflicts and anxieties, partic- lack of control over affect, lack of stable self and
ularly those previously kept unconscious, other representations, and diffusion of their
without risking substantial disorganization sense of identity.
or disintegration of the personality. Whereas the two groups may be readily
2. A supportive environment that is able to distinguished in terms of descriptive criteria,
sustain the childs involvement in an in- elsewhere, we have tentatively suggested a con-
tense and demanding long-term interper- ceptual framework that may help to provide a
sonal relationship. Particularly important theoretically based psychodynamic distinction
here is the willingness of parents to re- (Fonagy, Edgcumbe, Moran, Kennedy, & Target,
spect the boundaries of the childs therapy 1993). In this model, we distinguish children
and promote the childs commitment to whose problems may be seen as a consequence of
the treatment. distortion in mental representations, either of
3. A diagnostic assessment that indicates the others or of themselves. Such distorted represen-
primacy of internal conflict underlying tations may arise out of exceptional environmen-
symptomatology. tal factors or defensive distortions associated
4. Traditionally, psychotherapists were reluc- with various forms of intrapsychic conflict.
tant to treat children with major develop- Broadly speaking, these children correspond to
mental deficits (ego deviations) that were what has traditionally been regarded as the neu-
not the result of unconscious conflict and rotic category. By contrast, children with more
therefore could not be seen as resolvable severe problems, who usually present with mul-
through insight. tiple disorders, low levels of adaptation, and

poor personality functioning, may be seen as Therapeutic Approaches Addressing Disorders of

suffering from defensive inhibition or distortion Mental Representation
of mental processes rather than just the mental It follows from the assumptions of psychody-
representations that such processes generate. namic psychotherapy reviewed above, that child
Thus, for this group of children, a wide variety therapists using these techniques expect chil-
of situations are likely to bring about maladap- dren to be using distorted and/or unconscious
tive functioning, as the very capacities that may mental representations in maladaptive ways.
be involved in achieving adaptive functioning For example, children may unconsciously rep-
are impaired. Although biological factors may resent their father as cruel and rageful, a repre-
play an important role in both types of pathol- sentation distorted by their own unconscious
ogy, in both cases, the focus on psychological aggression. Further, it is anticipated that these
causation is retained. For example, inhibitions distortions have a developmental dimension
on specific ways of thinking occur as attempts at whereby ideas or feelings are more appropriate
adaptation. to an earlier stage of development and are likely
to confuse the childs current perceptions
(Abrams, 1988). The separation (repression,
METHODS OF INTERVENTION denial, displacement) of such early ideas is as-
sumed to be defensive. For example, the percep-
Important considerations from the point of tion of a caregiver as cruel and destructive may
view of psychotherapeutic technique arise out be based on an infantile perception of that par-
of this distinction. Disorders of mental repre- ent. As a consequence of the pain associated
sentation are well served by a primarily inter- with this perception of a loving father, this rep-
pretive therapeutic process, which aims at resentation never came to be integrated into the
addressing distorted ideas and integrating re- evolving representation of the father in the
pudiated or incoherent notions of self and childs mind. It exists as a separate yet disturb-
other. The reintegration of split-off (repressed), ing idea. Children may react to the presence of
often infantile but troublesome ideas into the such a representation as potentially painful and
childs developmentally appropriate mental incompatible with their perception of the parent
structures is the therapeutic aim (Abrams, as loving and affectionate. By displacing this
1988). In the more severely disturbed group of perception onto others whom they then per-
patients, this kind of approach has limited use- ceive as frightening, children may exaggerate
fulness. There is a need for strengthening or the subjective likelihood of burglars or other
disinhibiting mental processes that may have intruders attacking them and their family. Of
been disengaged (decoupled) or distorted for course, if such ideas are based on the external-
defensive or constitutional biological reasons. ization of their own aggressive feelings toward
These patients may need assistance in labeling the father, it is these feelings that have to be ad-
and verbalizing affects and ideas. Much of psy- dressed in the context of the therapy.
chodynamic intervention aimed at the so-called The therapist, using the childs verbalization,
neurotic patient may change the organization nonverbal play, dream reports, or other behav-
or the shape of the childs mental representa- iors, attempts to create a model of the childs
tion (Sandler & Rosenblatt, 1962). To regenerate conscious and unconscious thoughts and feel-
mental processes, an alternative set of psycho- ings. On the basis of this model, the therapist
dynamic techniques, emphasizing a develop- helps children to acquire an understanding of
mental approach, is necessary. Our review of their irrational or at times inappropriate feel-
current therapeutic approaches is based on this ings and beliefs. This kind of understanding
distinction. may, under ideal conditions, result in the
Psychodynamic Approaches to Child Therapy 115

integration of developmentally earlier modes of are likely not to be aware and which they
thinking into a more mature and age-appropri- are likely to find difficult or totally unac-
ate framework. The structure of the treatment ceptable. It is therefore expected that chil-
appears to be relatively unimportant. Some dren will show a certain degree of
therapists use toys or games, others more read- resistance to such verbalizations on the
ily engage children in a process of self- part of the therapist. Interpretations have
exploration. In most contexts, the therapist to be carefully timed to maximize their ac-
works to draw attention to possible uncon- ceptability to the child. Ideally, therapists
scious determinants of the childs behavior. accumulate considerable evidence to sup-
Therapists tend to use material of the childs port their conjectures, making their accep-
fantasy and play in conjunction with other in- tance more or less automatic.
formation they have obtained about the child
(parental reports, school reports, etc.) to con- In formulating an interpretation, the thera-
struct a plausible picture of the childs emo- pist is well advised to concentrate attention on
tional concerns. The most common foci of the therapeutic situation itself, where evidence
psychodynamic child therapists tend to be chil- is most likely to become available. Although the
drens concerns about their body, anxieties therapist often may be able to identify signifi-
about conscious or unconscious destructive or cant connections between the childs behavior
sexual impulses, and concerns about relation- in therapy and what the therapist knows about
ships with or between caregivers or siblings or the childs past experience, interpretations, at
peers. least in the early phase of treatment, are best re-
Psychodynamic therapists use a range of stricted to the childs current conflicts, in the
standard techniques. These have been system- immediate context brought into the therapy.
atized on the basis of empirical studies by The ultimate aim of the therapist is to provide
Paulina Kernberg (1995), who observed a num- the child with an emotionally meaningful, com-
ber of somewhat overlapping but reliably distin- prehensive understanding of the connections
guishable categories of interventions. These between past experiences and current methods
include: of coping with conflict.
Kernberg (1995) distinguishes three kinds of
1. Supportive interventions aimed at reduc- interpretations: (1) interpretations of defenses,
ing childrens anxiety or increasing their (2) interpretations addressing repudiated
sense of competence and mastery using wishes, and (3) reconstructive interpretations.
suggestion, reassurance, empathy, or the The first of these draws the childs attention to
provision of information. actual exclusion of certain ideas from aware-
2. Summary statements or paraphrases of ness. This focuses attention on certain contents
childrens communication to that point but also invites the child to consider alternative
that support and develop the therapeutic strategies for coping with or expressing these
exchange with the children. ideas or feelings. The second kind of interpre-
3. Clarifications of childrens verbalization tation generally aims to explain the childs be-
or affect. These help prepare children for havior in terms of a putative nonconscious
interpretation or simply direct their atten- wish. Most frequently, the need for defense is
tion to noticeable aspects of their behavior, explained in terms of the presence of an uncon-
such as a repeated tendency to behave in scious wish. For example, the therapist might
self-defeating, self-destructive ways. say, I think you tend to forget your dreams be-
4. Interpretations attempt to identify and cause in these dreams, you are able to think
spell out representations of which children about how angry you feel with your father and

about your wish to punish him in cruel ways the self structure. Through verbalization of
for how he has treated you. these defensive aspects, children are gradually
Reconstructive interpretations aim not only able to modify their internal standards for ac-
to explain a current state of affairs in the ceptable ideas and feelings and take on board
childs mind, but also to give an account of the destructive aggression as part of their self-
how this may have come about. The reconstruc- representation, leading to greater integration
tion of early experience in this context is and flexibility in their psychic functioning.
somewhat controversial. Psychodynamically Thus, therapists interventions mostly tend
oriented psychotherapists frequently assume to combine a focus on defenses, wishes, and
that the representation the child constructs of past or current experience. Such interventions
them is powerfully influenced by the childs have in common a focus on the childs emo-
prior experiences with caregivers, but it does tional experience in relation to these domains.
not invariably follow that these experiences The therapeutic action of psychoanalytic psy-
find direct expression in such representations. chotherapy is assumed to be work in the
For example, a child might see the therapist as transference (Strachey, 1934). The childs in-
a critic who persistently undermines the teraction with the therapist becomes increas-
childs sense of confidence and well-being. The ingly invested with affect as the therapy
child is thus evidently externalizing an inter- progresses, as internal representations of rela-
nal representational figure who constantly tionships find expression in the relationship
bombards the self with disparagement and with the therapist. Working through, help-
criticism. Such a representation may well be ing children to understand their reactions to
the product of defensive maneuvers rather the therapist in terms of anxieties, conflicts,
than an indication of the presence of a severely and defenses, is regarded as the essence of
critical adult figure in the childs past. Thus, therapeutic work.
the therapist might safely interpret I think The development of the transference is facili-
you are worried about my criticizing you be- tated by (1) the therapists neutrality; (2) emo-
cause there is a voice inside your head that tional availability (attunement to the childs
constantly says that you are such a naughty predicament); (3) encouragement to freely ex-
child that nobody could love you. It would press thoughts and feelings; (4) the regularity
probably be unwise to assume, however, that and consistency of the therapeutic structure;
such a critical figure was actually part of the and (5) the childs underlying perception of the
childs earlier experience. Such an internal ob- therapist as a benign figure (Chethik, 1989).
ject is more likely to be a split part of the The transference relationship offers a window
childs self-representation, which may indeed on both the nature of the childs relationship
be based on the internalization of an actually with the caregiver, as experienced by the child,
destructive and aggressive caregiver or may be and aspects of the childs experience of the
a disowned destructive or aggressive part of the selfparticularly those aspects the child expe-
child, separated off precisely because the per- riences as unacceptable and wishes quickly to
ceived kindness of the actual parent made such externalize onto the figure of the therapist.
aggressive impulses seem totally unacceptable This role enables the therapist to learn about
and intolerable to the child. In either case, what the childs internal world. Distorted mental
needs to be addressed in reconstructive inter- representations are identified, clarified, and
pretations is how unacceptable a child finds understood and ideally reintegrated with
even a small amount of residual aggression and the mature aspects of the childs thinking
destructiveness that has remained as part of (Abrams, 1988).
Psychodynamic Approaches to Child Therapy 117

For example, a shy, frightened, and with- narcissistic, borderline, or severely conduct dis-
drawn boy, age 8, who was referred because of ordered and delinquent as well (see, e.g.,
his depression, developed an exceptionally acri- Bleiberg, 1987, 1994a, 1994b; Marohn, 1991;
monious relationship with his therapist. The Rinsley, 1989). From a psychodynamic perspec-
therapist frequently found herself shamed and tive, most children with so-called neurotic
ridiculed, endlessly failing in the tasks set by disorders may be understood in terms of distor-
the child, and accused of being stupid. The tions of mental representations of either self or
child simultaneously bullied and patronized other (Sandler & Rosenblatt, 1962). The dis-
the therapist. The therapist gently showed the torted ideas with which more severely dis-
child how he often considered himself not to be turbed children tend to present cannot be
good enough and placed himself in situations readily addressed solely by interpretative psy-
where this would be all too evident. Gradually, chotherapeutic work. Ideas that, in less severely
the idea was presented that being insignificant disturbed children, appear to be repudiated
and no good was preferable (safer) because it (aggression or aggressive sexual ideation) are
avoided the even more unpleasant possibility of often consciously accessible for such children;
observing that the therapist or his parents insight into these seems of little therapeutic rel-
might be disappointed with him. Eventually, evance. Defenses, as normally conceived, are
the problem was traced back to his guilt feelings often hard to identify. Referring to childrens
about his sadistic, aggressive feelings toward anxiety rarely makes them feel understood; it
his younger brother, whose birth precipitated simply leaves them confused. Psychodynamic
his depressive episode. understanding of these children is possible if
Termination of the treatment is signaled by we assume that defensive operations for this
(1) symptomatic improvement; (2) improved group do not simply entail the modification of
family and peer relationships; (3) the ability to specific ideas and feelings but rather the mental
take advantage of normal developmental oppor- processes responsible for generating the mental
tunities; (4) the ability to deal with new envi- representations (Fonagy et al., 1993). For exam-
ronmental stressors; and (5) the ability to use ple, children traumatized by their caregiver
the therapy more effectively (experience the find contemplating the caregivers feelings and
therapy as helpful, allow the therapists inter- ideas intensely painful because, at least in their
pretive work to continue, express feelings more eyes, these must involve the caregivers wish to
readily, show gratitude as well as criticism and harm them. Thus, they defensively inhibit the
anger, show insight, humor, and healthy self- psychological functions (mental processes) re-
mockery, etc.; Kernberg, 1995). Traditional sponsible for generating representations of
psychodynamic treatment of this sort is rarely mental states, at least in the context of attach-
prolonged; much may be achieved in once- ment relationships (Fonagy et al., 1995).
weekly meetings over one year, although treat- The therapeutic approach required to ad-
ment length is generally 18 months to two years dress problems of inhibited mental processes
(Fonagy & Target, 1996c). are qualitatively different from those that may
be helpful in treating neurotic children. The
Therapeutic Approaches Addressing therapists task is to make children feel that it
Disorders of Mental Processes is once again safe to make full use of their
Not all childhood disorders respond readily to mind. It may be assumed that most mental
psychotherapeutic intervention. Over recent processes are, at least potentially, available,
decades, the psychodynamic approach has been and the free exploration of thoughts and ideas
extended to children who are categorized as serves to disinhibit the childs pervasive

defensive stance. Therapeutic approaches with therapy and cognitive-behavioral therapy (CBT).
such children have increasingly emphasized For example, both CBT and mental-process-
the promotion of opportunities for playing with oriented psychodynamic psychotherapy aim to
ideas (Fonagy & Target, 1996b). To some degree, enhance the childs capacity to organize and
the therapeutic approach is unchanged. It is the structure experiences. The difference lies in the
aim of therapy that is modified (Fonagy & Tar- focus of the cognitive approach on particular
get, 1998). Neither the recovery of repressed mental schemata, whereas the psychodynamic
memories or feelings, nor arriving at an under- approach aims at promoting a broad set of capac-
standing of unconscious reasons for their avoid- ities. We expect that an important component of
ance is relevant to therapeutic change. The very the effectiveness of both therapeutic orientations
process of achieving understanding or the very may be mediated through the rekindling of the
act of contemplating feelings and ideas may, in childs confidence in the self-organization of in-
itself, help severely disturbed children to re- ternal states. A more focused approach is likely
cover their capacity to regulate, organize, and to be more appropriate to children with less per-
represent mental states. Some techniques re- vasive dysfunctions. As yet, there is no evidence
quired to achieve this end have been previously available to substantiate this kind of distinction.
systematically excluded from psychodynamic
work with neurotic children because of their ex-
pected interference with therapeutic neutrality. PROBLEMS FOR WH ICH THE
Effective interventions are surprisingly sim- P S YC H O DY NA M I C A P P R OAC H
ple and include strategies such as (1) the en- I S EXPECTED TO
hancement of reflective processes through B E E F F I CAC I O U S
observation and verbalization of the childs feel-
ings; (2) the enhancement of impulse control The psychodynamic approach to child therapy
through helping the child identify ways of chan- was designed to treat what has traditionally
neling impulses into socially acceptable forms of been referred to as neurotic disturbance.
behavior; (3) building cognitive self-regulatory P. Tyson (1992) describes neurosis as character-
strategies through symbolization and metaphor ized by (1) a predominance of internalized con-
and by the demonstration of the therapists own flicts producing symptoms, (2) a capacity for
capacities for the modulation of experience affect regulation, and (3) a capacity for self-
through reflective thinking and talking; (4) gen- responsibility. Kernberg (1975) has added to this
erating interest in the mental states of others, list the predominance of repression as a mecha-
often, at least initially, by focusing on the childs nism of defense. However, modern descriptive
perception of the therapists mental state; (5) de- psychiatry has largely discredited the term neu-
veloping the childs capacity to play, at first with rosis as lacking in clarity and reliability, and
objects, then with others, and finally with feel- probably also overinclusive and based on an out-
ings and ideas; and (6) the demonstration to the moded theory of psychological disorder.
child of multiple ways of seeing physical reality Despite this slight, neurosis refused to disap-
(Bleiberg, Fonagy, & Target, 1997). Looked at in pear. Empirical studies of psychiatric symptoms
this way, psychodynamic therapy is no longer in children (Achenbach, 1988, 1995) support a di-
considered a predominantly insight-oriented, chotomy between internalizing (emotional) dis-
conflict-solving psychological treatment, but orders and externalizing (conduct) disorders. In
rather a developmentally based mentalization- an oversimplified way, this dichotomy distin-
enhancing approach. It may link diverse thera- guishes children who make themselves miserable
peutic orientations such as systemic family (i.e., those who experience their symptoms as
Psychodynamic Approaches to Child Therapy 119

ego-dystonic) from children who make everyone Heinicke (1965; Heinicke & Ramsey-Klee, 1986)
but themselves miserable (i.e., those who experi- demonstrated that general academic perfor-
ence their symptoms as ego-syntonic). mance was superior at one-year follow-up in
Obviously, an easy differentiation between children who were treated more frequently in
inner suffering and outwardly directed misery psychodynamic psychotherapy. Moran and
does not stand up well to close clinical scrutiny. Fonagy (1987; Fonagy & Moran, 1990; Moran,
Aggressive, delinquent, and hyperactive chil- Fonagy, Kurtz, Bolton, & Brook, 1991) demon-
dren experience much suffering and inner tur- strated that children with poorly controlled di-
moil (Katz, 1992; OBrien, 1992), just as surely abetes could be significantly helped with their
as anxious and inhibited youngsters can entrap metabolic problems with relatively brief inten-
their parents and teachers in a tight web of con- sive psychodynamic psychotherapy. Lush and
trol and unhappiness. colleagues (Lush, Boston, & Grainger, 1991) in
Nonetheless, the internalizing-externalizing a naturalistic study offered preliminary evi-
dichotomy captures meaningful dimensions of dence that psychodynamic therapy was helpful
childrens psychopathology. Clinically, children for children with a history of severe depriva-
with internalizing disorders resemble the anx- tion who were placed in foster homes or
ious, inhibited, neurotic children that consti- adopted. Improvements were noted only in the
tute the primary indication for child analysis treated group. Negative findings, however,
according to the child analytic literature; inter- were reported by Smyrnios and Kirkby (1993).
nalizing disorders can be roughly described as In this study, no significant differences were
neurosis shorn of theoretical baggage. found at follow-up between a time-limited
There is little research available on the out- and a time-unlimited psychodynamic therapy
come of psychodynamic treatment that might group and a minimal contact control group.
guide appropriate application (Weisz, Weiss, All these studies suffer from severe method-
Morton, Granger, & Han, 1992). The most exten- ological shortcomings, including (1) small
sive study of intensive psychodynamic treat- sample size; (2) nonstandardized, unreliable
ment was a chart review of more than 700 case assessment procedures; (3) nonrandom assign-
records at a psychoanalytic clinic in the United ment; (4) nonindependent or overnarrow
Kingdom (Fonagy & Target, 1996c; Target & assessments of outcome; (5) lack of full specifi-
Fonagy, 1994). The observed effects of psycho- cation of the treatment offered; and (6) the ab-
dynamic treatment were relatively impressive, sence of measures of therapist adherence.
particularly with younger children and those Better evidence is available for the success of
with an emotional disorder or a disruptive dis- therapeutic approaches that cannot be consid-
order whose symptom profile included anxiety. ered as direct implementations of psychoana-
Children with pervasive developmental disor- lytic ideas. Kolvin et al. (1981), for example,
ders or mental retardation appeared to respond demonstrated that psychodynamic group ther-
poorly to psychodynamic treatment. There was apy had relatively favorable effects when com-
some evidence that more intensive treatment pared with behavior therapy and parent
was desirable for children with emotional dis- counseling, particularly on long-term follow-
orders whose symptomatology was extremely up. A sobering finding is reported by Szapoc-
severe and pervasive. znik and colleagues (1989), who randomly
Some smaller-scale studies demonstrated that assigned disruptive adolescents to either indi-
psychodynamic therapy could bring about vidual psychodynamic therapy, structural fam-
improvement in aspects of psychological func- ily therapy, or a recreational control group. Both
tioning beyond psychiatric symptomatology. active forms of treatment led to significant

gains, but on one year follow-up, family func- symptoms must be seen in the context of a
tioning had deteriorated in the individual broader disturbance of social and emotional de-
therapy group while the child functioning was velopment, including marked impairment of
improved for both groups. peer relationships, affect regulation, frustration
Interpersonal psychotherapy, although not a tolerance, and poor self-esteem.
psychodynamic treatment, (Klerman, Weiss- One subgroup, designated Cluster A, are char-
man, Rounsaville, & Chevron, 1984), neverthe- acterized by fragile reality contact and thought
less incorporates interpersonal psychodynamic organization, idiosyncratic magical thinking,
principles. In a preliminary implementation of ideas of reference, suspiciousness, and deep dis-
this therapy for depressed adolescents, Mufson comfort in social situations. They can neither
and colleagues (Mufson, Moreau, Weissman, & make full sense of the social world, nor commu-
Klerman, 1993) report promising results. In nicate adequately their internal states. They re-
terms of the conceptual framework outlined semble the Cluster A Diagnostic and Statistical
above, these children would be described as Manual of Mental Disorders (DSM-IV) personality
suffering from disorders of mental representa- disorder diagnoses for adults, and children de-
tion. Generally, pervasive developmental disor- scribed by Cohen et al. (1994) and Towbin et al.
ders, psychosis, and major deficiencies in (1993) as multiplex personality disorder. By con-
psychological capacities are regarded as nega- trast, Cluster B children (if referred below school
tive indications. Although there have always age) show a hunger for social response, intense,
been a number of child psychotherapists who often dramatic affect, clinginess, hyperactivity,
have attempted to work with psychotic and and temper tantrums. School-age children may
autistic children (e.g., Alvarez, 1992; Klein, meet Axis 1 criteria for Attention-Deficit/
1930), the majority have felt that they cannot Hyperactivity Disorder, Conduct Disorder, or
help these children using psychoanalytically Mood Disorder, but their lack of adequate affect
oriented work. More recently, however, the psy- regulation is the major feature of the picture; a
chodynamic approach has been extended to sense of elation and blissful merger with others
apply not only to so-called neurotic disorders, close to the child seems to alternate with rage
but also to the understanding and treatment and self-hatred. They have been linked to adult
of borderline, narcissistic, delinquent, and con- dramatic personality disorders (Cluster B) and
duct disordered youngsters (Bleiberg, 1987, have been described by Bleiberg (1994a, 1994b)
1994a, 1994b; Marohn, 1991; OBrien, 1992; Rins- and by Petti and Vela (1990). We have linked both
ley, 1989), as well as schizoid and even psychotic clusters to an impairment of reflective fun-
children (e.g., Cantor & Kestenbaum, 1986). We ction (Bleiberg et al., 1997). With the more se-
have seen how clinical work with these more verely disturbed children in these two clusters,
severely disturbed children quickly highlights the therapeutic approach that addresses disor-
the limitations of the classical analytic strat- ders of mental processes, described above, is
egy. Bleiberg, Fonagy, and Target (1997) identi- appropriate.
fied two clusters of youngsters who may be
regarded as suitable for modified psychody-
namic therapy, notwithstanding the severity of CASE ST U DY
their disorder. They suggest that these clusters
have in common the presence of at least one HISTORY, DIAGNOSIS, AND ASSESSMENT
emotional disorder (e.g., depression, dysthymia,
Generalized Anxiety Disorder, Separation Anx- A few days after his tenth birthday, David was
iety Disorder, social phobia); however, these found unconscious on the floor at school. He
Psychodynamic Approaches to Child Therapy 121

had refused to have breakfast and had had a hy- thinking about him. This intolerance mani-
poglycemic episode. Since the diagnosis of dia- fested itself in the form of a quite generalized
betes at the age of 7 years, he had had at least 12 unwillingness to contemplate the thoughts and
hospitalizations associated with hypoglycemic feelings that anyone might have about anyone
episodes. Davids referral for psychodynamic else close. David appeared to be almost phobic
therapy was preceded by several attempts at be- about the thoughts and feelings that people
havioral intervention and two years of family generally could be expected to experience. He
therapy. Davids referral was prompted by the protected himself from his therapists thinking
need to improve control over his diabetes, but about him just as he might have tried to blot out
his violence and provocation of family members his mothers rejection of him through her years
and peers was an equally grave source of con- of depression and then active hostility. His
cern. He was aggressive with his mother and fa- vehement attacks on his therapist and the thera-
ther and was immediately abusive with the peutic process attempted to obliterate the real-
therapist as soon as he showed curiosity and in- ity of the therapists interest and insight,
terest in David. David met the DSM-IV diagnos- maintaining an illusion of mutual lack of con-
tic criteria for Oppositional Defiant Disorder cern. Simply interpreting this state of affairs
and hyperactive-impulsive Attention Deficit was of little help to David. Cases such as his
Disorder, and suffered from anxiety and mal- highlight the limitations of conflict interpreta-
adaptive health behavioral problems that af- tion. They also point out that limited mentaliz-
fected his ability to control his diabetes. ing abilities are rooted in various combinations
Davids mother had had considerable diffi- of developmental deficitconstitutionally and/or
culties even before his birth. An unwanted and environmentally derivedand active defensive ef-
aggressive child, she had been sent away to forts against the awareness of mental states.
boarding school at the age of 5. David, her first
child, strained her meager resources. She was
unable to feed him or see him for two weeks TREATMENT APPROACH AND
after his birth and remained on antidepressants RATIONALE FOR ITS SELECTION
for most of his early years. When David was 3,
she was briefly hospitalized for depression. Ag- The therapeutic situation in itself pushes chil-
gression seemed to be an accepted part of life dren to become aware of another persons men-
in this household. In her fights with David, tal state. When children actively resist such
mother gave as good as she got, sometimes awareness, the therapist may focus the childrens
sitting on him, hitting him in the head, and attention on his or her own mental state rather
pulling his hair. Davids father was a conscien- than attempting to comment on their goals, be-
tious provider who retired to the sidelines after liefs, and desires. Clinical experience has shown
coming home from work, leaving his wife to that children find it helpful to focus interven-
handle the three children, but then denigrating tions around their perceptions of the therapists
her for her failure to manage them. mental states, as a precursor to self-reflection.
Many such children find the mental states of
adults around them either confusing or frighten-
CASE FORMULATION ing. The therapeutic environment provides a rel-
atively safe context for getting to know the way
David showed an unusual form of intense they are seen by others, which can then become
resistance from the very beginning of his as- the core of their own self-perceptions. Thera-
sessment: He could not tolerate his therapist pists, of course, do not necessarily reveal to the

children what they actually experience; rather, caused him to feel. David shrugged his shoul-
they share with the children their perception of ders, said his head was empty, and buried him-
how the children might be experiencing the self in his comic book.
therapists state of mind at that moment. Some Davids attacks on his therapist continued.
therapists have used guessing games along The more the therapist tried to forge links in
these lines (Moran, 1984), which seem to appeal Davids mind, the more hostile or withdrawn
to certain children, and we include an illustra- David became. Even when David felt under-
tion of this form of technique. The approach stood, the consequences were dire. About one
taken here was described elsewhere as psycho- year into his treatment, in an exceptionally
dynamic developmental therapy (Fonagy & Tar- lively session, David acknowledged feeling en-
get, 1996d). slaved by his mother, his diabetes, and his ther-
David entered treatment and wasted no time apy. This moment of rare therapeutic exchange
in launching vicious attacks and attempts to was short-lived. Soon afterward, David was
provoke the therapist. Although seemingly an hospitalized in a ketotic state and on return to
imaginative, creative boy, his material somehow the sessions, appeared even more withdrawn.
lacked the qualities of spontaneity and mutual- David frequently accused the therapist of
ity. David insisted on playing a stereotyped wearing a Darth Vader mask. At other times, he
board game of his own invention. The game would look at the therapist and ask, Whats
consisted of describing an alien culture of ex- the matter? Do you want a fight? Beyond high-
ceptional physical and intellectual prowess. The lighting the ever present fear of the therapist,
therapist interpreted that this helped him to these comments gave a clue as to the reasons
feel competent in the therapeutic environment, David could derive little help from interpreta-
which in so many ways felt frightening and tions that went beyond reflecting his current af-
alien. Such interventions, however, failed to fect. Looking at a person gave him no clear idea
alter the pattern. of the persons mental state. He could rely only
Indeed, David perceived his therapist as on a fixed, concrete image: a cruel, vindictive
frightening and as potentially violent. Interpre- other. His sense of himself as a being with a
tations of Davids projection of his anger onto mind was so poorly established that he would
the therapist were rarely effective in curtailing not conceive of his therapist as someone trying
his attacks, which often required direct physi- to understand a mental life that he could hardly
cal restraint. The alternative to attack was re- grasp himself. Davids obsessive fantasies of
treat. Increasingly, he would withdraw form the alien figures, incapable of affect and possessing
therapeutic encounter. When it seemed rele- destructive mental powers, became understand-
vant, the therapist commented on Davids un- able as proto-representations in which subjec-
certainty about his identity except when angry tive experience had been replaced by mindless
and fighting; on his secret pleasure in the phys- aggression.
ical contact with his mother, however violent Davids therapist was inventive; a game
and frightening this was; on his rebellion emerged in the second year of treatment in
against authority, his lack of acceptance of his which David and his therapist made notes on
illness, and many other themes. Such interpre- what I think you think I am thinking about
tations only led to more abusive behavior. He you today. David wished to repeat this game
claimed not to care about the therapist, whom day after day for months. Increasingly, he
he found stupid and irrelevant. In response, the would call for a round at times of heightened
therapist talked about Davids difficulty in un- anxiety during his session. Taking his cue from
derstanding or expressing what was going on in David, the therapist focused on clarifications of
his mind and the terrible helplessness this Davids current mental state, particularly in
Psychodynamic Approaches to Child Therapy 123

relation to him, rather than offering formula- think you think game. He wrote, frightened
tions of Davids unconscious feelings about his as his first guess about what the therapist
past and present relationships. thought David thought, then added get lost!
During one session, the therapist and David The therapist confirmed that he thought David
played tennis on the table. David won and was frightened because somehow he felt that
showed the guilty anxiety he often manifested his success would destroy the therapist and
on such occasions. He became highly excited then David would get lost.
and began to throw himself on the couch,
shouting the names of tennis stars. The thera-
pist said: I wonder if you think I might be less POSTTERMINATION SYNOPSIS
disappointed if I knew I had been beaten by a
great tennis player, and then you would not In this interchange, the therapist treated
have to feel so uncomfortable. Rather than re- Davids aggression as a defense against the anx-
plying, David stood up on the couch and hit the iety that close mental contact engendered in
therapist with his racquet. The therapist moved him. Gradually, David became more prepared
out of harms way but did not restrain David. A to contemplate fears, thoughts, and wishes in
few moments later, David shouted: You dont himself and in his therapist. In the third and
know me! The therapist replied: You dont fourth year of Davids treatment, his terror of
want me to know you, because then I might not being seen as bad began to surface. His un-
like how big and strong you feel. David spun provoked, excessively aggressive acts could now
round and round on his heels making himself be seen as aimed at people whom he experi-
dizzy and collapsed in a heap on the floor. He enced as seeing him in a negative way. Thera-
then said he had a headache, intimating that he peutic work on Davids avoidance of
was dangerously hypoglycemic. The therapist recognizing thoughts and feelings, and his anx-
assumed that David was feigning the headache ieties about being shamed, helped him to estab-
both to test the therapist and to take revenge lish diabetic control and settle into school. His
against him. Reflecting on the confusion he felt treatment, which lasted four years, was success-
about Davids possible urgent need for food, the ful in that his destructive outbursts were
therapist said, One can feel very helpless when greatly reduced and his deliberate self-harm
one doesnt really know how someone else feels, ceased. His relationships with others, however,
but its even worse when one doesnt know how remained restricted and somewhat mistrustful.
one feels oneself. I think you feel very fright-
ened that if you become strong and powerful, I
will no longer want to help you and perhaps S U M M A RY
just let you die. David, without saying a word,
emptied the contents of his pockets onto the Psychodynamic psychotherapy has a well-
carpet. He then proceeded to stuff everything developed and helpful body of theory that has
back in a careless way so that there was no room inspired many generations of clinicians. Psy-
for about a third of his pieces. Before the thera- chodynamic ideas are applied in contexts well
pist could say anything, David snapped, Why beyond the treatment of psychiatric disorders,
dont you just shut up? The therapist said, By such as the fields of psychology, other social
bullying me and shouting at me, I think you sciences, literature, and the arts. Psychody-
hope to get rid of all the thoughts and feelings namic psychotherapy is one of the oldest
that you feel we could not cope with. David theory-driven forms of psychological treat-
looked at his therapist for the first time in a ment of mental disorders (probably antedated
friendly way and suggested they play the I only by hypnosis). Nevertheless, in terms of

empirical investigations of either its underly- study of the psychological difficulties of child-
ing constructs or its therapeutic outcome, it is hood, but also as a method of clinical interven-
still in its infancy. tion with children whom we find it hard to
The shortcomings of psychodynamic ap- reach using other methods. Psychodynamic
proaches include: child clinicians are for the most part well aware
of the tremendous challenge they face in per-
1. Lack of operationalization in most descrip- suading health care organizations as well as
tions of technical interventions, whose ef- consumers of services of the unique value of
fectiveness is supported almost entirely by their approach. Considerable work remains to
evocative case illustrations. be done, but a new culture of research is now
2. Inadequate specificity regarding techni- emerging within the psychoanalytic commu-
cal interventions appropriate for children nity (Emde & Fonagy, 1997; Wallerstein & Fon-
with a particular diagnosis or clinical pre- agy, 1999). It is, we believe, a realistic hope that
sentation. over the next decade, substantial evidence will
3. Limited evidence of efficacy, specially evi- emerge that will delineate the specific value of
dence derived from randomized, controlled the approach for the long-term development of
trials. children with psychological disorders. Work is
4. A rather loose relationship among theory/ already underway at a number of centers inter-
ies of psychopathology (in turn, poorly nationally, and time will tell whether psycho-
supported by empirical data), theory of dynamic treatment works and, if so, for whom.
technique, and technique as actually car-
ried out in clinical practice.
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Chapter 6 Eating Disorders in Adolescence

Chapter 7 Psychodynamic Psychotherapy with Undergraduate and
Graduate Students

Eating Disorders in Adolescence


H I S T ORY O F T H E period. As is characteristic of ethnic disorders,

T H E R A PE U T I C A P PROAC H eating disturbances express themselves in vari-
ous degrees of intensity, ranging from mild to
Eating disorders are a major health problem severe. They are exaggerated extensions of nor-
in most Western countries and rapidly becom- mal and highly valued behaviors and attitudes
ing an issue of concern in the majority of West- in a culture and thus become a widely imitated
ernized cultures. They have become a frequent model for expressing distress.
prototypical disorder of female adolescent de- The contemporary craze about fitness, diet-
velopment in our time and the third most ing, and food control have become the vehicle by
prevalent chronic condition for this group. A which many individuals escape from seemingly
review of the studies of mortality rates for unmanageable personal suffering and thus at-
Anorexia Nervosa shows that compared to fe- tain an elusive sense of control. Eating disorders
males 14 to 24 years old in the general popula- represent a final common pathway for express-
tion, these patients are 12 times more likely to ing a wide variety of idiosyncratic problems,
die. When comparing death rates of Anorexia such as difficulty with autonomy, emancipa-
Nervosa with those of female psychiatric pa- tion, self-worth, control, and refusal to comply.
tients for this age range, the former are twice as It is common knowledge that eating disorders
likely to die (Sullivan, 1995). Only 10% of those generate fascination and awe, and in a sense,
presenting with eating disorders are males. they seem to mirror the conflicting pressure
Gordon (2000) refers to eating disorders as eth- to consume and control that is so prevalent in
nic disorders to emphasize the sociocultural our society. These disturbances also become po-
factors that explain their increase in our time. litical when viewed in connection with female
This concept, originally proposed by Deveraux submission to prevailing and unrealistic stan-
(1980) proposes that certain disorders express dards of beauty and slimness associated with
the contradictions and anxieties that are partic- discipline, success, and acceptance. The charac-
ular to a particular culture at a certain historical teristic experiences and dilemmas of anorexic


patients seem to exaggerate and reflect perva- and high school girls is 0.2 to 0.5% and 1 to 2%,
sive problems of female identity in the wider respectively (van Hoeken, Lucas, & Hoek, 1998).
culture. Cross-cultural studies of normal female Later additions to the diagnostic categories are
development show that despite the changes that Eating Disorders Not Otherwise Specified, of
feminism has brought along, most girls are still which Binge Eating Disorder and borderline con-
brought up to be people pleasers, very sensitive ditions are the most commonly found (Hoek,
to external demands. They are less encouraged 1995; Shisslak, Cargo, & Estes, 1995). This het-
than boys are to develop autonomous behaviors. erogeneous category accounts for 8% of the
Baker Miller (1976) suggests that womens adolescent female population and comprises in-
sense of self-worth is still determined by re- dividuals who struggle with body dissatisfaction
sponding to the demand to help others, and this and disordered eating patterns that produce
requires the subordination of ones own needs to significant physical, psychological, and social
those of others. Furthermore, women often feel distress (Austin, 2000; Shisslak et al., 1995).
that their achievements are not a proof to them- Taken together, the disordered eating behavior
selves of their worthiness; rather, a performance spectrum affects at least 10% of adolescent girls;
to please others is. In this frame of mind, their 8:1 is the estimate of the female-to-male ratio for
constant dread is not being certain of their abil- the more severe syndromes (Levine, Piran, & Irv-
ity to sustain that level of excellence. A conse- ing, 2001).
quence of this pattern of socialization is that the Due to the secrecy surrounding this problem
girl often reaches adolescence with a feeling of and the few community-based studies, the true
powerlessness and dependency, which hinders incidence of Bulimia Nervosa is not known,
the process of leaving home. This is one of the but surveys using questionnaires have revealed
main reasons for the emergence of eating disor- that as many as 19% of female students report
ders at this developmental stage in a girls life. bulimic symptoms. Regarding Anorexia Ner-
Her body is the only part of herself over which vosa, it is unclear whether the increase in cases
she feels that she has control. reported in health care facilities reflects an ac-
tual increase or is mostly due to improved
methods of case identification. Over 40% of
EPIDEMIOLOGY OF EATING DISORDERS cases of Anorexia Nervosa are detected by gen-
eral practitioners; conversely, only 11% of the
The most researched and well-known eating community cases of Bulimia Nervosa are de-
disorders are Anorexia Nervosa and Bulimia tected. Because of the secretiveness and shame
Nervosa. Anorexia Nervosa is characterized by associated with these disorders, probably many
a relentless pursuit of thinness, leading to a more cases go unreported. That is why studies
state of emaciation. Anorexia restrictors, reduce of clinical samples probably will always reflect
weight by severe dieting; anorexic bulimic pa- an underestimation of the incidence of these
tients, maintain severe weight loss by further disorders in the community (Hoek, 1995).
purging. This added stress on a malnourished
body often causes additional damage. Bulimia
Nervosa is characterized by cycles of binge eat- HERMENEUTICS OF THERAPEUTIC APPROACH
ing. The patient, in an attempt to control the
feared increase in weight, follows the binge, Hermeneutics refers to how the therapist un-
either by purging, by severe dieting, or excessive derstands the patients experience. In the case
physical activity. The prevalence of Anorexia of eating disorders, this understanding often
Nervosa and Bulimia Nervosa among middle does not suffice when attempting to change a
Eating Disorders in Adolescence 135

multidimensional syndrome of still enigmatic model) or nonsymbolic restitutional emergency

etiology; therefore, a multimodal approach is measures utilized to gain cohesion of the self
suggested (Pinsof, Wynn, & Hambright, 1996). (self psychology model).
In recent years, the therapists understanding
of the patients dynamic psychopathology often
has been clearly differentiated from the inter- THE SYSTEMIC PARADIGM
ventions needed to help the patient (Dare &
Crowther, 1995). This chapter presents an inte- The application of systems theory to psycho-
grated relational approach to eating disorders therapy can be seen most clearly in the general
that articulates constructs from systemic and in- literature on theory and practice of family ther-
dividual treatment paradigms (Magnavita, 2000). apy. Moreover, in recent years, the development
Eating disorders occur along a continuum of of family systems medicine increasingly has
severity, from mild to seriously disturbed. become the operational frame for conducting
Symptomatic expressions can occur in a rela- treatment of eating disorders, the epitome of a
tively intact psyche in the context of normal systems approach combined with a biopsy-
family development, or in a very impaired indi- chosocial model. Epistemology refers to the
vidual immersed in a family context that fails to rules we utilize to get to know and understand
further the process of separation and individua- the world and our experience. Cybernetic epis-
tion (Herscovici & Bay, 1990). Such is the case of temology is considered to have been a turning
imitative anorexics, who have had a healthy devel- point in the behavioral sciences (Nichols &
opment in a favorable family context, go on an Schwartz, 1998). This new understanding of
innocent diet with the goal of looking better, human behavior emphasizes the role of the
and then become trapped in the biological vul- social context in shaping individual behavior,
nerabilities to food restriction and the psycho- emotions, and ideas. General systems theory
pathology of starvation. Many of these cases deals with the study of the relation among the
remit spontaneously or with little therapeutic parts that interact in a context, stressing that
effort, if detected early. These are the ones that they are parts of a whole that is not equal to the
prove most amenable to self-help and psychoed- sum of its components. From this relational per-
ucational strategies. spective, symptomatic behavior in a family
A second group is composed of those for member is understood as the manifestation of
whom the disorder evolves in the context of a dys- interactive processes that take place in the here
functional family whose members are immersed and now of family life. Organization refers to
in the tension derived from unresolved issues the consistent way in which the components
of the past. Often, their equilibrium is threat- of a system relate to each other and provide
ened by the exogenous striving inherent in ado- its structure. This psychotherapeutic approach
lescence. They will benefit most from family aims at changing the family organization as a
therapy. means of changing the life of its members.
The third and most serious form of presenta- Changes are believed to last longer because the
tion is an eating disorder in the context of a dys- change in each member continues to affect the
functional family system where the patient has other members, thus reverberating through the
experienced a pervasive developmental impairment system and reinforcing change (Becvar & Bec-
resulting in a personality problem and ref lecting a var, 1996).
disorder of the self (Herscovici, 1996). It may take In the initial stages, family therapy relied on
the form of symbolic expressions of distorted more scientific disciplines such as cybernetics,
self and object representations (object-relations physics, and biology to be considered a valid

alternative to psychoanalysis. In the 1970s, when example, a case in which the social phobia of the
family therapy had attained a place of its own anorexic was related to her mothers depres-
in the mental health field, the animosity with its sion. If the young girl avoids going out, she can
early rival subsided. Nowadays, most family keep the mother company and thus mitigate her
therapists agree that it is equally important to depression. That the mother and daughter re-
understand the forces that are behind the rela- main overinvolved, with blurred boundaries, is
tionship among the family members as to under- maintained at the expense of distance with the
stand those that are inside the individuals. In angry father and husband, who is kept periph-
other words, to comprehend human nature, one eral; this reinforces the symptomatic structure.
must focus on and understand both the individ- Triangulation is the process by which a con-
ual and the system he or she inhabits. A relevant flicted dyad pulls in a third person to regain
caveat is the need to distinguish whether the un- its balance. In the above case, the marital dyad
derstanding of the individuals inner forces had been through significant conflict due to an
assists or misleads in bringing about necessary infidelity of the wife. This led to violence and
change (Herscovici, 1999). threats of divorce. At that point in time, their
The family system is viewed as a network of daughter started her weight-loss program,
interpersonal relationships. Haley (1987) said which turned into a severe case of Anorexia
that to look at symptoms in individual terms Nervosa. The parents rushed to rescue their
is similar to imagining a stick with only one daughter, and resolution of their conflict was
end. What we formerly thought of as emerging postponed. The subsequent social phobia kept
from an individual, in this theory is considered her at home at a stage when she felt her mother
a response to something that is somewhere in needed her.
the system. A relational perspective (Kaslow, Boundaries are a crucial concept in this theory.
1996) inevitably leads to changing the focus They refer to a way of describing the distance
from content to process. In other words, instead kept among members of the system (Minuchin,
of searching for the historical explanation of the 1974). In the case just described, the boundary
current problems, one looks for the maintaining between mother and daughter was blurred due
factors that operate on the current interactions. to their enmeshment. As a result, there was an
Instead of thinking in terms of who started excessive closeness and a permanent intrusion
what, family therapy deals with human prob- into the other persons feelings and thoughts.
lems as a series of movements that evolve in The mother would proudly state that words
repetitive cycles. The underlying premise is were unnecessary between them, that by simply
that insight per se does not bring about change. looking at her face, she would know exactly
Therefore, the focus of change is on behavior what was going on inside her daughter. Contrar-
rather than cognitions or emotions. One great ily, the impermeable boundary that separated
advantage of this perspective is that in lieu of the mother from her husband kept them alien-
inferring underlying causes that one cannot ated. Consequently, the daughter became trian-
observe and that often are not amenable to gulated; one way of avoiding taking sides was to
change, it focuses on observable, current inter- remain involved in her obsessive preoccupation
actions that perpetuate the problems. Because with food and calorie counting.
these can be accessed, change can take place. Boundaries can protect the individual from
Family structure includes dyads, triangles, outside intrusion so that autonomy can be nego-
subsystems, and boundaries. To think in dyadic tiated. In families with a chronic anorexic mem-
terms implies that both members of the rela- ber, it is frequent to see blurred boundaries
tionship are mutually defined. Consider, for among the members that result in overprotection
Eating Disorders in Adolescence 137

and enmeshment. The family members feel system, the eating disorder serves to reinforce
very close and often create a rigid boundary her permanence in that position. Rigid interac-
separating them from the outside world. This is tions commonly are seen in disturbed families.
expressed in the suspicion and fear that perme- They may have been functional at an earlier
ate interactions with individuals who do not be- stage in the familys development but have be-
long to the family system. One father said, We come outdated. These families often lack the
are like a hand with five fingers; they may move flexibility to adjust to normal life crises and
separately, but they all belong to one hand. thus become more dysfunctional at the transi-
In another case, a female patient who suf- tion points of developmental stages. They fail to
fered from Binge Eating Disorder and had a reorganize to respond to the new demands of
long history of eating disorders was part of a the context (Minuchin, 1974).
Jewish Orthodox family. The family motto was In the past decade, the focus of family therapy
that to be safe, you had to remain within the re- has expanded to include the way families are af-
ligious community. The mother was a phobic fected by gender roles, race, social class, and sex-
and a hypochondriac who always feared im- ual orientation. The feminist perspective (Baker
pending catastrophe. The parents main con- Miller, 1976; Brumberg, 1988; Walker, 1996) chal-
cern was that their daughters seemed to have lenges the malevolent influence of certain values
no interest in marriage. In fact, none of the three and cultural practices, such as gender stereo-
young women had ever become emotionally in- types and inequalities. There is tremendous so-
volved in a heterosexual relationship. They all cial pressure for women to be concerned with
studied and worked well but kept a guarded social judgments about their appearance. Girls
distance from the outside world. When the fam- are often brought up to put the needs of the
ily overinvolvement was pointed out, the girl re- other before their own. These patriarchal struc-
alized that she automatically called her home tures shape gender differences, and the dis-
every couple of hours, just checking to make proportionate gender representation of eating
sure everyone was all right. Leaving home disorders are a dramatic expression of this bias.
seemed like an overwhelming task. Instead, she Nevertheless, one should be cautious not to
resorted to daydreaming about unavailable can- overextend this line of thought. Pointing out op-
didates who would live with her in the family pressive cultural attitudes should not over-
home. Her binge eating and consequent over- shadow the role played by the patient and her
weight reinforced her staying at home, where family in the development and maintenance of
she fought and cried but felt safer than being problems. In essence, the therapist should strive
outside in the cold. for an inclusive both/and stance.
This is a case of what Magnavita (2000) calls The goal of structural family therapy (Min-
the developmentally arrested dysfunctional uchin & Fishman, 1981) is to tackle the symptom
personologic system, which thwarts individu- and to attain change in the family structure.
ation and maturation of its members (p. 64). Narrative therapists (White, 1991) assist clients
These families have difficulty tolerating differ- to emerge from therapy with a sense of empow-
ences and movements toward autonomy. Not erment that enables them to take a proactive role
surprisingly, the entry into the adolescent peer as an agent of change in their community con-
world with the accompanying sexual awaken- text. One therapeutic formulation of this is by
ing and decrease in family control is a challenge the Anti-Anorexia League. The purpose of this
for these families and their members. Addition- virtual organization is to educate individuals
ally, if the youngster is triangulated in the mar- about Anorexia Nervosa by identifying and cir-
ital conflict and is needed to stabilize the culating among the patients knowledge and

practices that counteract the culture-bound differ greatly at presentation in terms of person-
practices that contribute to fuel the spread of the ality, level of motivation for change, resources,
disorder (White 1991, p. 39). Bowen (1978) re- conflict-free areas, family context, and so on.
ferred to the family as a combination of emo- They also vary along the stages of treatment. Ac-
tional and relationship systems. The systemic cordingly, our lenses for understanding and in-
approach involves understanding of an individ- tervening should be flexible and coherent.
ual within the context of interactions and rela-
tionships. This view seems to lead to a logical Attachment Theory
link with a developmental perspective. Bowlbys (1969) attachment theory posits that
close, positive attachments are a core human
necessity. The quality of the early attachment
THE PSYCHODYNAMIC FRAME with the primary caretaker plays a leading role
in determining the quality of future relation-
The psychodynamic model may be oriented to- ships. It is held that deprivation of early bonds
ward traditionally analytic, interpersonal, ob- with or threatened loss of an adequate attach-
ject-relations, or self psychology. The core of ment to the primary caretaker will render the
psychodynamic thinking is the meaning of the child vulnerable to and subsequently result in
symptomatic behavior. It emphasizes the place adverse psychological reactions. If the innate
of infancy and early childhood experiences attachment need is satisfied via positive inter-
in shaping the person so that when the social, personal relationships, normal development
familial, cultural, biological, and cognitive pro- takes place. Contrarily, if this need is frustrated
cesses converge to render individuals vulner- due to disturbed interpersonal relationships,
able to an eating disorder, the syndrome choice the individual feels unworthy of love and low
and the tenacity with which they cling to it may self-esteem ensues. Disturbed interpersonal re-
be understood in terms of certain developmen- lationships include fear of abandonment or re-
tal characteristics. jection as well as loss of approval or acceptance
In contemporary psychoanalytic thinking, of affect and attachment.
eating disorders are understood in terms of dis-
orders of personal relationships and the organi- Object-Relations Theory
zation of the self. Each theoretical model has its This model, stemming from the British school
own language and emphasizes a specific devel- of theorists such as Mahler (1968), Klein (1957),
opmental phase when attempting to explain the Spitz (1965), and Fairbairn (1952), has focused
developmental failure associated with an eating on showing how past childhood experience is
disorder. Most authors agree that there seems to reflected in object relations. This developmental
be a maturational crisis inherent in eating disor- theory points out that we develop our patterns
ders (Crisp, 1980), and the symptomatic arrange- of relating following those of our early relation-
ment serves the ultimate purpose of avoiding ships, particularly with the parents who are in-
maturational fears and freezing conflicts. Never- ternalized as objects. Core issues in psychic
theless, there is no evidence of any such consis- development are the deficiencies or distortions
tent association implicated in the etiology of in the development of object relationships. The
eating disorders. Therefore, the main value of human drives naturally seek connections, they
the psychodynamic constructs is in giving thera- are oriented toward establishing relationships,
pist and patient a common ground for a psycho- and tension results in the context of frustrated
logical rationale for the disorder, expressed relationships. In fact, the term object is a mis-
in therapeutically workable concepts. Patients nomer that refers to the person toward whom the
Eating Disorders in Adolescence 139

drives are directed. Interpersonal contact is in- the mechanism by which these patients defen-
ternalized as a representation of that relation- sively focus on others instead of themselves,
ship (introject). Understanding of the individual thereby contributing to their impaired sense of
and his or her motivations is derived from com- self-worth. Sugarman and Kurash (1982), who
prehending how the relationships were inter- focus on bulimic patients, state that these pa-
nalized by that individual and transformed into tients lack the ego function of object constancy.
a notion of self or self-image. Therefore, when separated from their symbiotic
In this theory, the most important relation- mother, they are unable to soothe themselves by
ship is with the early caretaker, usually the automatically evoking a mental representation
mother or the primary parent surrogate, as a of the mother. Bingeing becomes a means of
pattern for subsequent relationships in life. If evoking the mother or primary caretaker and
the interactions of the infant with the caretaker thus being soothed.
are positive, the emotional experience will be For Kernberg (1994), eating disorders are a
one of satisfaction and the self will be experi- relentless sadistic attack on the patients
enced as loved and cared for. If the interactions body that alternately represents conflicting
are negative, the infant will experience the care- pleasure, femininity, and heterosexuality. This
taker as hostile and abandoning, will feel per- construct is easily applicable to those patients
sistent emotional hunger, and experience the who so often restrain from eating as a way of
self as frustrated and angry. self-punishment and depriving themselves of
For a child to tolerate separateness from the the pleasure derived from their favorite foods.
caregiver who provides support, nurturance, The symbolic component in the anorexics atti-
and comfort, the provider must be perceived as tude to food is intensified by restrictive behav-
reliable. In normal development, ambivalence is ior and food preoccupation. The capacity to
tolerated. Deficient early attachments will neg- resist eating can be felt as a victory against an
atively influence relating style in later stages of intrusive desire. Food and sexuality seem to be
life, not only in how but also regarding to whom closely intertwined in these patients inner
one relates. The goal of object-relations therapy world. The emaciation usually also serves the
is to understand how these childhood patterns purpose of blurring the adolescent body and
are repeated in adult life. thus postponing the desired and feared sexual-
Patients with eating disorders tend to have a ization of relationships. The possibility of an-
deficient sense of being in control of their lives other person exerting sexual attraction renders
and well-being, which feeds into their fear of the subject vulnerable to the desirable but dan-
novelty and striving for order and restraint. gerous loss of control and feared submission to
They feel that others have an overwhelming the other.
power over them and that they must strive to
be perfect; otherwise, they are totally bad and Self Psychology Theory
therefore hated and abandoned. These are some The main author of this model is Kohut (1971,
of the potent forces that shape the personality 1977), who developed self psychology based on
problems of many eating disordered patients. the construct of the self. He defines the self
According to this theory, the anorexics attempt as an organization of experience characterized
at separation and individuation is met with a by cohesiveness, vitality, and a sense of conti-
hostile, rejecting, withdrawing maternal intro- nuity in time and space. Starting in infancy, the
ject. Conversely, her clinging, regressive behav- self integrates and develops to produce either
ior is met with support and reward (Masterson, health or pathology. If caregiving is adequately
1978). More recently, Masterson (1995) described responsive to the infants needs and if early

relationships are healthy and nurturing, the re- plan is best for each stage of the therapeutic pro-
sult will be a healthy and mature organization cess (Beutler & Clarkin, 1990). Eating disorders,
of the self, capable of healthy relationships. Ac- specifically Anorexia Nervosa and Bulimia
cording to this theory, what drives us is the Nervosa, have been studied intensely over the
search for those relational experiences that are past three decades. As a result, we have gained
required to sustain a cohesive sense of self. A in our understanding of the disorders and the
stable, healthy, or true self will result in the abil- accompanying treatment issues. With Anorexia
ity to provide ones own regulation of tension, Nervosa, crude mortality rates increase with
self-esteem, and self-cohesion. Conversely, if longer follow-up periods, ranging from 5 to 20%
the early environment is one of emotional dep- over a 20-year period (Ratnasuriya, Eisler, Sz-
rivation, these functions will be impaired and mukler, & Russell, 1991). On the average, more
development will become derailed. The result than 40% of anorexics recover, 33% improve,
will be structural deficits and pathological de- and 20% have a chronic course (Gowers, Nor-
fenses that result in a vulnerability to a person- ton, Halek, & Crisp, 1994). A short interval be-
ality impairment, such as seen in those eating tween onset of symptoms and beginning of
disorders associated with personality disor- treatment is a favorable prognostic factor (Stein-
ders. Often, this takes the shape of a painful ex- hausen, 1995). These facts underscore the im-
periential state of emptiness and numbness, a portance of early intervention. In the case of
sense of being an automaton, not really living. Bulimia Nervosa, only 50% of patients have a fa-
Symptoms then represent attempts to restore vorable outcome and the associated mortality
cohesion or a sense of being alive. rate is uncertain but may be higher than ex-
Nevertheless, it is not only the early years pected when compared to the general popula-
that exert such a fundamental influence on de- tion (Hsu, 1995).
velopment. In the childhood years, if parents Eating disorders remain serious and poten-
are self-absorbed, overwhelmed, or depressed, tially lethal illnesses. Pinsof, Wynn, and Ham-
they often are unavailable to supply selfobject bright (1996) have shown that a multimodal
needs. The future anorexic tends to respond to approach is required for the treatment of seri-
this with a facade of pseudo-self-sufficiency ous disorders such as these. When focusing on
and believing she is the cause of burden; she eating disorders, many therapists are led to-
may embark on a rescue mission of maintaining ward a systems approach while considering the
the well-being or narcissistic balance of those convergence of biological, individual, familial,
close to her. Deprived from the satisfaction of social, and cultural dimensions in the form of
her selfobject needs, she devotes herself to the predisposing, precipitating, and maintenance
care, feeding, and narcissistic support of others, factors (Garfinkel & Garner, 1982).
thus embodying the compliant model child so
often described in families of anorexic patients.

T H EOR E T ICAL CONSTRUC T S Eating disorders are biopsychosocial in nature

(Engle, 1980). Etiologic components include
As we progress in the research and practice of biogenetic and sociocultural factors, individual
psychotherapy, we become ever more aware of personality traits, body dissatisfaction, and di-
the complexity and multidetermination of all eting history as well as life stressors. The fam-
human phenomena. Patients and their contexts ily of origin system often plays a leading role
are unique, and therapists are constantly faced both in the development of the eating disorder
with the challenge of selecting which treatment and as a health resource in treatment of child
Eating Disorders in Adolescence 141

and adolescent patients. Clearly, dieting and Dysphoric reactivity to stressful events
pursuit of thinness are rampant in Western soci- with low tolerance to emotionally charged
ety, and yet only a small proportion of those who experiences.
are terrified at facing the onset of adolescence Excessive rumination, frequently in the
develop Anorexia Nervosa. As Strober (1997) ele- form of nagging self-doubt.
gantly points out and consistent with the afore-
mentioned frame of reference, this disease is These personal dispositions undoubtedly play
perceived as originating in inherited extremes of an active role in shaping the way a youngster
personality traits that severely restrict a young responds to the demands of the developmental
womans ability to cope with the challenges of stage he or she is facing.
pubertal growth. Taking into account the impor-
tance of early failures in parenting and trauma Challenges of Puberty
or other hazards to the development of the self, This is a stage in which, typically, the young-
this author places special emphasis on three ster begins to withdraw from the family, feel-
main avenues of influence for the development of ing a pull in a different direction of belonging.
Anorexia Nervosa: personality traits, the chal- The peer group is assigned greater relevance
lenges of puberty, and the family context. in terms of determining what is appropriate;
more intimate and sexualized relationships
Personality Traits are established; family loyalties are under
There is evidence that major structures of our scrutiny and differentiation ensues. The fami-
personality are partly inherited, and these inter- lies of these patients often secretly share the
act with experience in shaping both normal de- anorexics fear of adolescent growth. In dys-
velopment and psychological illness (Cloninger, functional family systems, with intergenera-
1986). The notion that certain qualities of per- tional coalitions, it is frequent to find that the
sonality make a person vulnerable to Anorexia patient is convinced that her physical and emo-
Nervosa is consistent with the recurrence of tional proximity is indispensable to the allied
such traits in these patients. Sometimes, they are parents safety and well-being. The new dis-
accounted for prior to the onset of the disease tance introduced by adolescent peer relation-
but are often accentuated by the weight loss and ships is avoided. In those families in which
persist beyond weight recovery. The personality patients have experienced abuse, neglect, or
traits that Strober (1997, p. 233) describes for hostile criticism, the youngster feels threat-
Anorexia Nervosa patients are: ened by emotional relationships, which they
are certain will be intrusive and disappointing.
High emotional reserve and cognitive inhi- Additionally, there are changes in body ap-
bition, with subsequent emotional with- pearance, and sexual characteristics emerge.
drawal. All of these challenge the rigidity of those
Preference for routine, orderly, and pre- girls who approach this stage with the belief
dictable environments, with poor adaptabil- that safety and esteem are tied to compliance
ity to change. Avoidance of novelty and and the ability to keep the new and threatening
need to retain control of their surroundings. life changes at bay. The body, a symbol of matu-
Heightened compliance and perfectionism, rity, sexuality, and pleasure, becomes a source
with a tendency to persevere even in the ab- of unrest, and its growth must be arrested at
sence of ostensible reward. all costs. Her natural inclination to rigid disci-
Risk avoidance, including of intimacy, es- pline turns dieting into a way to gain an in-
pecially with those outside the immediate creasing sense of control. As the weight loss
family. progresses, the feared emotions and needs are

silenced. The biological and psychological re- changed in recent years, and the greater
gression that follows the increasing weight loss aggregation of Anorexia Nervosa in higher
allows her to move from impending fear to psy- social classes may no longer reflect the
chological safety. Anorexia Nervosa becomes current picture. No differences have been
the armor that shields her from being noticed found for anorexics or bulimics regarding
and discovered in her weaknesses and sense of birth order, family composition, or family
inefficacy. It allows for a display of discipline size (Eisler, p. 157).
and self-control. A tight grasp is kept on the dis- Parents of adolescents with minor neurotic
ease that becomes her raison dtre. signs are not more psychologically dis-
turbed than the parents of those with
The Family Context Anorexia Nervosa.
An eating disorder develops in the context of a The level of closeness among family mem-
particular relationship, which is quite different bers is often lower than what the subject
from saying it is caused by it. Even though it is would ideally like. Communication in gen-
obvious that patients vary and so do their fami- eral and affective expression in particular
lies, most of the characteristics that Minuchin are usually reported as restricted. Overall,
(Minuchin, Rosman, & Baker, 1987) postulated the differences found between eating disor-
decades ago as descriptive of psychosomatic der families and controls, accounted for by
families continue to apply, at least for many of questionnaires, may apply only to highly
the severe, chronic Anorexia Nervosa cases. select clinical samples (p. 166).
Rather than preceding the illness, these charac- Levels of expressed emotion (EE) are gen-
teristics may be a way of adapting to the gruel- erally low in families of anorexics. The
ing intricacies of the disorder. number of critical comments is small and
Any attempt to distinguish the current fam- hostility is rare. This is consistent with clin-
ily organization from the one clients had prior ical findings of these families as conflict-
to the onset of the illness will probably be ap- avoiding. There is moderate warmth and
proximate and certainly hypothetical. Recent relatively few positive remarks are made
literature has cautioned against confusing ob- (p. 167).
servations of current family functioning with Families of bulimics have a tendency to
the idea of a familial etiology of the disorder. blame and belittle, with raised levels of
As Eisler (1995) warned, clinical observation is hostility and criticism (p. 169).
likely to be idiosyncratic and will probably Studies show that emotional overinvolve-
highlight a striking aspect of family functioning ment, defined by EE scales of parents
that may be applicable to only most severe showing exaggerated emotional behavior
cases. Yet, over time, those accounts become in response to the childs problems, or
embedded in the professional folklore and are marked overprotective behavior, is consis-
mistakenly considered facts that apply to the tently low in these families. Eisler (1995)
syndrome (p. 156). Current beliefs should be suggests that this may be part of a
scrutinized carefully when one is reviewing the broader trait of subdued affective expres-
role of family factors in the etiology of eating sion (p. 167). It is also possible that this
disorders. Some facts that should be kept in difference may relate to how this feature
mind include: is defined in the scales.
Family members of bulimic patients have a
The pattern of distribution of eating disor- higher incidence of affective disorder and
ders according to social class may have alcoholism. Additionally, there is a higher
Eating Disorders in Adolescence 143

incidence of obesity and eating disorders type of family functioning style that can be con-
among the mothers of binge/purge-type sistently linked with eating disorders. This ar-
Anorexia Nervosa and Bulimia Nervosa gues against the disorders originating in a
patients. specific type of experience in the family. The
In the families of binge/purge-type An- difference between the clinical and community
orexia Nervosa and Bulimia Nervosa, con- samples suggests that much of what therapists
flict is more overt and explicit. This is prob- identify in the families they treat are factors as-
ably due to the nature of the symptoms and sociated with a more entrenched course of the
how family members react to their secrecy. illness (Eisler, 1995).
They usually feel cheated, disappointed,
and impotent to make things better. This
often translates into anger. The patient, in THE BODY IN EATING DISORDERS
turn, feels spied on, controlled, and frus-
trated in failing to control the bingeing. A path often leading to eating disorders is de-
When comparing families of eating disor- scribed by Sands (1989), who notes that devel-
dered patients with the general popula- oping girls are encouraged to show and thus
tion, the families that differ less are those obtain exhibitionist gratification mainly in the
of restrictive-type Anorexia Nervosa pa- sphere of physical appearance. In later life, the
tients. On the other hand, families of body becomes the privileged arena to reveal
binge/purge-type Anorexia Nervosa and psychopathology.
Bulimia Nervosa have more similarities Developmentally, the self starts out being the
among each other. site of bodily sensations. When the cohesion or
Anorexic patients tend to perceive their integrity of the self is threatened, it is experi-
mothers as more empathic and understand- enced by these patients as a loss of control of the
ing of their feelings. Conversely, their fa- body. One attempt at restoring control is to
thers usually are less expressive of their focus on the shape of ones body or the amount
emotions and their daughters experience of calories ingested. The ideas that accompany
them as more distant. the relation between eating behavior and the
Usually, bulimic patients are less pleased body are often delusional. One patient re-
with their families and report more con- mained awake all night because she was certain
flict and distress in family life. This may that the calories consumed at dinner would be
not reflect the parents appreciation of fam- greater if she fell asleep immediately. Another
ily life. Notably, as the patient recovers girl was so worried about her weight that she
from her eating disorder, she also improves developed a stiff neck when she stepped off the
her perception of her family. weighing scale after she had taken the commit-
ment of not looking at the scale numbers. A
In summary, many of the differences ob- young boy pleaded not to be made to cry any
served when comparing families of eating disor- longer, because his swollen eyes made him look
der patients and controls are found only in fat. Yet another patient would vigorously mas-
clinical samples. In community-based samples, sage her toothpick arms with reduction gel
the differences are smaller or even disappear. after each meal, to make sure the food wouldnt
There do not appear to be common family fac- settle there. All have in common the concept of
tors that lead to the development of an eating their body as a dangerous field where mysteri-
disorder. Furthermore, in light of recent re- ous forces operate and they must exert a frantic
search, there does not appear to be a particular attempt at control to keep these forces in check.

Other patients experience their bodies as a 30%, there is conflicting evidence as to whether
battlefield where the separation and individua- bulimic patients are more likely to have experi-
tion process is fought. Who decides what one enced sexual abuse than restricting anorexics
needs to eat and how much one needs to weigh (Waller, 1992). Even though this rate is higher
become the controversial issues. Such is the case than in the general population, it is comparable
of a young boy who had a grandiose and om- to that found in other psychiatric disorders
nipotent self that colored his stance in the (Vanderlinden & Vandereycken, 1995).
world. His e-mail address started with super- Reports indicate that manifestations of phys-
bobby@, and he demanded to be at the core of ical violence are more prevalent in bulimic
any family decisions regarding mealtimes, out- subjects (30%), who experience violence against
ings, and so on. The mealtime agreed on was themselves and/or directed at another family
never acceptable to him, and he threatened to member, compared to 7% of anorexics, who
not eat unless they yielded to serve his dinner experience violence against themselves. A thor-
at 11 P.M. He was a smart and sweet child, un- ough study comparing eating disordered pa-
less he wasnt getting his way; then, he would tients in terms of abusive experiences (Schmidt,
break out in a tantrum. When physical activity Tiller, Blanchard, Andrews, & Treasure, 1997)
was restricted to save the little energy he in- suggests that bulimics are more likely than
gested, Bobby resorted to doing push-ups vig- anorexics to experience a variety of childhood
orously to get his way. adverse circumstances, including indifference,
There has been considerable attention lately abuse, inconsistency in care arrangements, and
on the issue of child sexual abuse and its possi- discord. What remains unclear is to what extent
ble impact on the individuals who develop eat- these occur in their lives more frequently than
ing disorders. Needless to say, depending on in the general population.
the personal vulnerabilities, the relationship to
the perpetrator, and the developmental timing,
sexual abuse can have a devastating impact, af- HOSTILITY IN EATING DISORDERS
fecting the attitude not only toward ones body
but also toward a sense of self-worth. For the In Bulimia Nervosa cases, the impulsivity that
anorexic, ridding herself from her female body accompanies the syndrome facilitates the ex-
through starvation may be seen as a way of pro- pression of anger. Patients and their families
tecting herself from further assaults. Binge eat- tend to have a much more open expression
ing and purging can become ways of managing of conflict in their interaction. In contrast,
intolerable levels of tension. Waller (1992) has anorexic patients usually appear to be compli-
shown that those bulimic patients who have a ant and find it hard to express anger; their fam-
history of sexual abuse are more likely to en- ilies are frequently conflict-avoidant. Most
gage in the most violent purging. The reported anorexics usually are covered with layers of
figures range from approximately 10 to 60%, clothing that not only keep them warm but also
depending on how stringent the definition of hide the body they feel embarrassed about.
sexual abuse, with the highest prevalence for Sometimes, they take pleasure in exhibiting
the operational definition of any unwanted, their emaciated body, as though taking pride in
unpleasant or coercive sexual event (Palmer, exposing their disorder, a way of saying Look
Oppenheimer, Dignon, Chaloner, & Howells, at how miserable I am. Look at how I suffer.
1990). Comparison of studies is difficult due to Needless to say, this may be a nonverbal way
different methods and samples. Reviews indi- of accusing significant others of causing their
cate that, whereas most studies cluster around plight.
Eating Disorders in Adolescence 145

In one case, Lucia, a restrictive anorexic, currently in use that enable one to diagnose,
would wake up exactly one hour and a half score, and compare subjects and evaluate out-
after falling asleep to peel and slice the fruit she come (Christie, Watkins, & Lask, 2000). One
was about to eat. The fruit was then laid out in recent valuable addition is the Structured In-
strict order, matching colors, sizes, and flavors ventory on Anorexic and Bulimic Disorders,
organized by gradual increases in intensity. with special instructions for evaluating adoles-
This young woman refused to eat in the pres- cents (Fichter & Quadflieg, 2001).
ence of any family member. Her parents begged Initial evaluation is done at the individual
for compliance. Lucia inwardly felt that her re- and familial levels. The individual patient is
fusal was a way of punishing them for having evaluated regarding the severity of symptoms
made her break up a relationship with a man and time of onset as well as psychosocial per-
they disapproved of. Her Anorexia Nervosa formance and psychopathology. Once diagnosis
had been active for the prior 10 years, ever since of the eating disorder is ascertained, family and
this separation had occurred. Even though patient are instructed regarding the eating dis-
other therapists had pointed out this connec- order, the self-perpetuating nature of food re-
tion, she had been unable to transcend the sym- striction and purging habits, and the probable
biosis with her parents. She continued to use treatment pitfalls in future stages. This psy-
her body and her life as a means to relate to choeducation portion of treatment is extremely
them with all the ambivalence this entailed. relevant in helping families consolidate a ra-
She felt very guilty for being ill and causing her tionale that supports the treatment.
parents so much worry and pain and feared From the individual stance, attention is paid
being the reason of their feared premature to the meaning of the eating disorder at the
death. They, in turn, felt guilty because they behavioral, relational, and cognitive levels. The
had been told so often in previous treatment family system is assessed regarding its current
settings that they had caused their daughters life cycle stage and the developmental struggles
condition and so continued to spend a fortune the family members are dealing with or avoid-
on her treatments without realizing that they ing. Knowledge of the family structure in terms
had inadvertently given up their own lives. The of boundaries, intergenerational coalitions, and
only thing that mattered to these parents dur- alliances as well as the familys resources will
ing all those years was whether their daughter guide the treatment plan.
had gained a gram. Thus, the anorexia kept par- Assessment of the family system involves the
ents and daughter together in this crazy, miser- elaboration of a functional hypothesis of the
able fashion. eating disorder in the context of the family sys-
tem. This implies exploring the role the eating
disorder plays in stabilizing the family system
METHODS OF ASSESSMENT (e.g., Does it serve the purpose of keeping fam-
AN D I N TERV EN T ION ily members overinvolved? Is it related to diffi-
culty dealing with a developmental crisis
ASSESSMENT regarding career choice and leaving home?)
and, conversely, the ways the family contributes
Usually completed in two weeks, assessment to stabilizing the symptom (e.g., when the girl
has three main goals: initial assessment, psy- gains weight, the father expresses his fears of
choeducation, and the establishment of a treat- her becoming chubby, as in the past). It is im-
ment alliance. There are a number of refined portant to establish what the central theme is
instruments (self-report and interview-based) in this family that is organized by the eating

disorder and its consequences. Is it an issue of least intrusive to most intensive interventions.
power, of control? Is it an issue of separation Inpatient care is a valid option when there is
and individuation? Is it a matter of who is to lack of positive response to or availability of
blame for bringing this about (the fathers deci- outpatient care, significant weight loss, and/or
sion to divorce; the mothers new plastic sur- medical complications and a suicide risk. So far,
gery). Additionally, because patients usually the best therapeutic results for treatment of
present a therapeutic dilemma in terms of their Anorexia Nervosa are linked to nutritional re-
desire to change the existing problem without habilitation accompanied by family and indi-
having to change themselves, it is critical to ex- vidual therapy.
plore the feared consequences of change (Papp, Minuchins (Minuchin, Rosman, & Baker,
1983; Vanderlinden & Vandereycken, 1989). 1978) seminal insight regarding the wisdom of
An important goal is the establishment of a treating adolescent anorexics with family ther-
therapeutic alliance. Of the nonspecific thera- apy has been further demonstrated in later re-
peutic factors associated with good outcome, search. Of the few randomized controlled
it appears that instilling hope, defining the studies for Anorexia Nervosa that have been
problem as solvable, and setting up a therapeu- carried out so far, Russell, Szmukler, Dare, and
tic alliance are the most important. Anorexia Eisler (1987) found that family therapy was su-
Nervosa is commonly ego-syntonic; paradoxi- perior to supportive individual therapy for
cally, patients cling to their potentially lethal those patients whose onset of illness occurred
symptoms as though they were lifesaving. Not at 18 years of age or younger. At a five-year fol-
surprisingly, patients seldom seek treatment low-up, family therapy proved to have a radi-
but are usually referred for therapy and ap- cally superior effect both for recovery and for
proach it with hesitation and suspicion. Con- abbreviating the course of the disorder (Russell,
versely, Bulimia Nervosa is a very distressful Dare, Eisler, & Le Grange, 1992). Family coun-
and shame-producing disorder. Patients with seling, where parents were given advice in man-
both disorders share a morbid fear of fatness. aging their sick child, has shown a similar
The former group is totally opposed to weight effect. This option is recommended when par-
restoration as a crucial goal of treatment and ents have a hypercritical attitude toward the pa-
therefore, more often than not, come to therapy tient because evidence shows that this attitude
because they are brought, not because it is their further undermines the patients self-esteem.
choice. Therefore, the establishment of a thera- Once the parents are more at ease and less
peutic alliance is the critical issue at commence- angry, conjoint sessions can be resumed. The
ment of treatment and should be carefully possible common positive elements for change
monitored throughout. The challenge to the in these approaches deserve to be looked at.
therapist is to assure the patient that the re- Undoubtedly, weight restoration should be
wards of change will be more beneficial to her the first goal of treatment for the seriously
well-being than holding onto her eating disor- malnourished patient, not only because it is
der as an armor that protects her from the tur- lifesaving, but because it improves personality
bulence of developmental struggles. functioning and mood and reduces obses-
sional thinking and body image distortion.
Weight restoration is generally effective in
TREATMENT FOR ANOREXIA NERVOSA about 85% of cases (Hsu, 1990, p. 136) if it is
carried out in conjunction with family and in-
Ideally, treatment should be tailored to the re- dividual therapy, when the latter is necessary.
quirements of each case, with a progression from A major consideration is the patients trust
Eating Disorders in Adolescence 147

that the caring team will prevent her from be- patient approaches her target weight and envi-
coming fat. In this sense, the creation of a sions the crossroads of normality that she be-
safety net that protects the patient from her comes terrified of what lies ahead. The sick
fear of loss of control (e.g., meal plan) has identity has enabled her to access a seemingly
proven useful. At the beginning, therapy deals safe place in the world (Herscovici, 1996). These
with the patient and her family regarding the cases benefit most from ongoing individual ther-
conflictive aspects related to eating. Addition- apy that fosters a more realistic body image, self-
ally, the presence of psychiatric comorbidity assertion, self-esteem, and empowerment.
ought to be identified and dealt with.
Psychosocial interventions preferably should
include a shared understanding of the psycho- TREATMENT OF BULIMIA NERVOSA
dynamic conflicts underlying the disorder as
much as the complexity of family relationships The patient with bulimia is usually in her late
and developmental issues. The former are often adolescence or early adulthood. Contrary to the
useful constructs that contribute to enhancing patient with Anorexia Nervosa, who is brought
the therapeutic alliance by giving meaning to to therapy, the person with Bulimia Nervosa is
the patients plight. In this newly formulated, in desperate need of help to alleviate the dis-
workable reality, alternatives become apparent tress of the symptoms she wants to get rid of.
and change can take place. The weight of these patients is usually in the
Family and couples therapy are useful not normal range. Nevertheless, because these pa-
only for symptom alleviation, but also for deal- tients suffer from a morbid fear of fatness, when
ing with problems in the family system that they realize that the goal of treatment is not
may be contributing to the maintenance of the weight loss and they fear normal eating habits
disorder. Furthermore, these therapies have will undermine their cherished desire, they
been found to be a cost-effective way of tapping tend to have difficulty managing the anxiety
into the therapeutic resources of the family. derived from this. It is important to ascertain
There has been little study of the optimal role of motivation status before treatment is under-
either individual or group psychotherapy for taken, because dropout is frequent when this
Anorexia Nervosa. Nevertheless, because of the variable is not carefully considered.
enduring nature of many of the features that ac- Of the psychotherapeutic control studies for
company this disorder in the most entrenched Bulimia Nervosa, cognitive-behavioral therapy
cases, it is advisable to follow these patients (CBT) has been found to be the treatment of
with some form of individual therapy for at choice. Results show a significant reduction in
least a year. If group therapy is an available op- binge eating and purging, attitudes toward
tion, it should be considered only as an adjunct, body shape, and general psychological func-
and caution should be taken regarding a careful tioning. Recent studies show that early progress
selection and monitoring of patients to ensure in therapy is the best predictor of outcome
that they do not get caught in competitive loops (Agras et al., 2000). This marker (70% decrease
regarding who is the thinnest or sickest patient. in purging by the sixth treatment session) en-
When the anorexia becomes a chronic condi- ables clinicians to try other therapies for pa-
tion, it tends to provide the person with a tients who do not respond to CBT in the first
compensatory identity that allows for some sig- weeks of treatment. Interpersonal therapy has
nificant presence in the world. That is why the shown to be a good alternative (Agras, Walsh,
initial stages of weight restoration often are Wilson, & Fairburn, 1999). Antidepressant med-
sailed through rather quickly; it is when the ication, when combined with psychotherapy,

has been shown to be effective in dealing with THE TREATMENT FRAME

bulimic and depressive symptoms. Group ther-
apy and self-help groups also have shown posi- Due to the complex nature and outcome of eat-
tive treatment effects. ing disorders, it is advisable for the therapist to
The American Psychiatric Association treat- be specially trained in their treatment. Relying
ment guidelines (2000) recommend family ther- on ongoing supervision, collaboration, or con-
apy whenever possible, especially for adolescents sultation is always preferable. The therapist
still living with parents or older patients with should have a collaborative frame, with the abil-
ongoing conflicted interactions with parents. ity to negotiate strategies and interventions
Additionally, they caution that the nature and within a multimodal team approach. Comorbid
intensity of treatment depends on the symptom features as well as severity of clinical condition
profile and severity of impairment, not the DSM- are relevant to deciding treatment frame. It is
IV diagnosis (p. 25). preferable to have specialized inpatient or day
hospital care as a referral option if outpatient
treatment is not safe enough. Nevertheless, be-
THE PSYCHOTHERAPEUTIC PROCESS cause recent studies support that family-based
outpatient care has proven to be a good treat-
The therapeutic process follows certain general ment for Anorexia Nervosa patients living at
stages. It must be kept in mind that patients home (Lock, Le Grange, Agras, & Dare, 2000),
vary, and so does the amount of time and this cost-effective treatment option is always
specific interventions devoted to each stage. preferable for this group. The number of mem-
Research has shown that when treating young- bers of the treatment team should vary accord-
sters with eating disorders, it is better to focus ing to the requirements of the given case and
on the family context and empower the parents special care should be taken to avoid collusions.
rather than look at the intrapsychic level alone It is not uncommon for the members of the
(Russell, 1994; Russell et al., 1987). In the treat- treatment team to be inadvertently drawn into
ment of children and adolescents with eating the patient system and take sides with the indi-
disorders, it is critical to help parents move be- viduals. If this divisive strategy is not acknowl-
yond the sense of blame that seems inherent in edged and neutralized, often it has detrimental
most families. This translates into two major effects on the treatment.
distinctions: (1) Separate blame from responsi- The feminist model of family therapy fo-
bility, the latter creating a sense of agency cuses on how gender issues are perpetuated
while the former usually sets off a defensive through the family life. This approach empha-
and blaming spiral that fosters a malignant sizes cultural factors associated with eating
context; (2) Differentiate those family factors disorders as well as issues of power, so perva-
that might have precipitated the onset of an sively influential in womens everyday lives
eating disorder (excessive concern with body (Walters, Carter, Papp & Silverstein, 1988).
appearance, parental abuse or negligence, or These principles involve accepting and cele-
overinvolvement that discourages autonomy) brating gender-related differences and also
from current family patterns that might per- emphasizing personal responsibility for health
petuate the problem. The common denomina- and well-being. Enhancing autonomy, self-
tor along the entire therapeutic process is for worth, and standing up against a sense of
the clinician to help family members view weakness or ineffectiveness are central tenets
themselves not as guilty but as an irreplaceable in feminist ideology. These principles consti-
resource for recovery. tute a therapeutic attitude that should prevail
Eating Disorders in Adolescence 149

regardless of the gender of the patient or ther- problem, is especially useful in safeguarding
apist (Bryant-Waugh, 2000). the patients dignity and self-respect (White &
A pragmatic approach that takes into consid- Epston, 1990). It allows for detaching the prob-
eration the idiosyncrasies of the presenting lem from the person and, subsequently, the
problem and constantly monitors effectiveness problems establishing an identity of its own.
is more advisable than a stringent model. Fur- The joint exploration of the many ways in which
thermore, we have evidence from research and the problem (eating disorder) inflicts pain and
our clinical work that involvement of parents in suffering allows for those affected by the prob-
treatment is absolutely crucial. Regardless of lem to join in fighting it. This is a very practical
the family intervention chosen (parental coun- way of moving beyond explanations that em-
seling or family therapy), the goal is to go be- phasize pathology and blame and progress to-
yond blaming and empower the parents to feel ward positive change, enlisting the patient in
capable of helping their children overcome and this pursuit.
transcend such a life-threatening way of ex- To override the youngsters strongly held
pressing their often impaired sense of ability to views regarding eating behavior, the parents
deal with life challenges. need to be knowledgeable about the required
changes that will ensure long-term goals of well-
being. This can be achieved through parental
STAGES OF TREATMENT FOR EATING DISORDERS counseling. The goal is to create an environment
in which parents are helped to find their own so-
Stage 1: Symptom Management lutions, what works for them, keeping a balance
This phase is usually completed in two to four between acknowledging the patients experience
months. During this period, it is strongly ad- and enforcing her safety and health. When there
visable to focus attention on the family context is current or premorbid family dysfunction, it is
rather than the intrapsychic level. As we stated advisable to embark on family therapy. Neverthe-
earlier, in the treatment of young people with less, during this stage, other family conflicts are
eating disorders, it is important to enlist the deferred and focus is kept on enhancing motiva-
parents in the treatment system. For this part- tion for change of eating behavior and weight
nership to be viable, it is essential to move restoration.
beyond blame. Treatment seeks to enable the
parents to assume temporary control over the pa- Stage 2: Normalizing the System and
tients eating behavior until it is normalized. A Conf lict Resolution
technique that favors this is the behavioral para- This phase has a variable duration, usually
digm, by which the youngsters access to a nor- around two to four months. Once the sympto-
mal life is contingent on weight gain. In other matic behavior is in check, there is a gradual
words, a policy of bed rest and no privileges (so- restoration to the patient of control over her eat-
cial visits, physical activity, entertainment, etc.) ing habits. This allows for other family issues to
is enforced until weight recovery and normal be addressed. Additionally, siblings often en-
eating habits occur (Minuchin et al., 1978). It is dure suffering and postponement of attention
important that the therapist keep a critical bal- to their needs due to the stress of living with an
ance so that the patient doesnt perceive thera- eating disordered member. It is useful to have
pist and parents as ganging up against her, but family sessions that will allow for the explo-
rather that they are all united to battle the in- ration and planning of ways to minimize the
truding eating disorder. The narrative ap- impact of the illness on their everyday lives
proach, with its technique of externalizing the while routines havent yet normalized.

Another reason for moving from parental family members weaknesses and developmental
counseling to family therapy is the evidence pitfalls that might precipitate a family crisis or a
of ongoing marital conflict that involves the relapse of the eating disorder. During this pro-
identified patient. This does not imply that cess, therapists usually are rewarded when they
family therapy should turn into marital ther- ask the family what they think were turning
apy, with the children as onlookers; rather, this points that enabled change in the therapeutic
is an opportunity for marital conflict to be iden- process as well as what they learned from the ex-
tified as a stress-producing problem that the perience. Follow-up at scheduled intervals is a
parents need to work on and for which the cost-efficient safety net for preventing relapse
patient should not feel responsible. Other indi- that cannot be overestimated.
cators are when we observe difficulties with the In addition to the basic treatment frame de-
separation-individuation process that hinder scribed, multidimensional disorders sometimes
the youngsters voice from being expressed and require an array of ancillary interventions
heard in the family. Another possible focus of (physiotherapy, exercise, massage, group work,
family therapy is the enhancement of a context and/or assertiveness training). Of special note
that facilitates any disclosure of abuse. Because are techniques to improve body image dis-
one cannot underestimate the importance of the tortion. These are currently carried out at an
identified patient openly communicating such experimental level because we do not have con-
issues during the family sessions, it is essential trolled trials regarding their efficacy. Because
that the therapist monitor this process. this has been shown to be a feature predictive
In working with separated and stepfamilies, of outcome, we should follow this development
one must have a clear image of the roles played with care.
by the different adults involved. Because these
contexts strongly favor splitting and coalition
forming, it is likely that the patient will exploit TREATMENT OUTCOME
these to her disadvantage. A helpful interven-
tion is to acknowledge these divisions and the For all age groups, eating disorders represent
history of disagreements between the parents an extreme of psychiatric morbidity and have
while stressing the need for joint decision mak- an adverse impact on most areas of life. Evi-
ing (Honig, 2000). During this stage, the devel- dence shows that eating disorders tend to be-
opmental issues are dealt with and particular come refractory and autonomous over time.
focus is placed on age-appropriate autonomy Therefore, early, appropriate interventions may
and non-eating-disorder issues. Individual ses- significantly affect recovery. There is agreement
sions with the patient are often in order, spe- in the field that a four-year span from the onset
cially for older adolescents. of the disorder is the minimum time required to
evaluate outcome. A short duration of illness
Stage 3: Termination correlates with a good outcome. Dropout and
At this phase, which usually lasts no more than response to treatment in adolescent eating dis-
two sessions, the goal is to enhance family mem- orders have been associated with high scores of
bers sense of empowerment, focusing on their family EE (van Furth, 1991). Moreover, EE lev-
strengths in overcoming the eating disorder and els have been shown to decrease after success-
their capacity to grow from that experience. ful family treatment (Le Grange, Eisler, Dare,
Autonomy of the subsystems is checked and & Hodes, 1992). Additionally, a dysfunctional
future routes of development are anticipated. family environment negatively affects progno-
Additionally, special care is taken to highlight sis for all eating disorders (Herzog, Keller,
Eating Disorders in Adolescence 151

Lavori, & Ott, 1988; Steinhausen, Rauss-Mason, depression, Obsessive-Compulsive Disorder,

& Seidel, 1991; van Engeland, van der Ham, van and Anxiety Disorder (Neiderman, 2000, p. 87).
Furth, & van Strien, 1995). Thus, family therapy A follow-up study of adolescent-onset Anorexia
counseling is the treatment of choice whenever Nervosa showed that after six years of presenta-
possible and attainment of family support for tion, 30% qualified for Affective Disorder and
treatment is a critical goal. Authors are gener- 43% for Anxiety Disorder (Smith, Feldman,
ally in agreement that the wisest approach to Nasserbakht, & Steiner, 1993). A 56% rate of co-
multidetermined disorders such as Anorexia morbid Major Depression was reported in a
Nervosa and Bulimia Nervosa is multidimen- sample of adolescent bulimics (Herzog, Keller,
sional and biopsychosocial in nature. Lavori, & Bradburn, 1991). Often, Major De-
Most studies evaluating treatment efficacy pression and Anxiety Disorder develop prior to
contain poor descriptions of how therapy was the eating disorder.
conducted and are thus difficult to replicate. Psychometric studies assessing personality
Additionally, the majority of patients are treated factors report purging anorexics as more dis-
outside of research settings with a variety of turbed and emotionally labile, and more impul-
therapeutic approaches that differ significantly sive, oppositional, and antisocial (Leon, Lucas,
from those utilized in research. Even though, Colligan, Ferlinande, & Kamp, 1985). In other
more often than not, the therapeutic approach words, restrictive and binge/purge patients
chosen is determined more by therapists pref- vary along personality dimensions that involve
erence than by research findings, many patients control, and often disorders coincide with per-
seem to improve significantly. To this date, no sonality disturbances (Steiger & Stotland, 1995,
specific treatment factors have been found to be p. 52).
consistently effective. Because the silver bullet Evidence suggests that the patients premor-
is eluding us, it is important that we attend not bid traits are mostly timidity and perfection-
only to the hard scientific data but also to non- ism. Rastam (1992), when studying adolescent
therapeutic factors that have been studied more anorexics, estimated that 67% of them showed
recently. a personality disorder (PD) prior to onset of the
eating disorder and 35% showed Obsessive-
Compulsive Disorder. Others report that eating
M A J O R S Y N D R O M E S T R E AT E D disorders are associated with stable underly-
U S I N G T H I S A P PROAC H ing personality disturbances that exist inde-
pendent of the eating disorder. In fact,
The treatment outlined so far has been found obsessional traits in weight-restored anorexics
to be useful for most cases of Anorexia Nervosa are strikingly stable through the years, and
and Bulimia Nervosa (Herscovici & Bay, 1996). adult bulimic samples suggest the existence of
A difficulty associated with the treatment of primary characteristics that become exagger-
eating disorders is the fact that they so often ated during the active phase of the eating dis-
involve personality and trait disturbances. order (Strober, 1980; Windauer, Lennerts,
Available data show that adolescent sufferers Talbot, Touys, & Beaumont, 1993). Still, other
present a range of comorbid psychopathology studies show that weight restoration in
that is comparable in content to that of adults. teenage anorexics leads to a normalization of
These findings are striking when considering disturbed traits, indicating that an active eat-
that latent disturbances often do not become ing disorder will either color characterological
apparent during adolescence. Those most com- features or exacerbate latent personality prob-
monly seen, even in recovered patients, include lems (Leon et al., 1985; Strober, 1980).

Overall, estimates of PD in mixed anorexic grandmother and two aunts, whom Susana was
and bulimic samples are high and concentrate certain were virgins.
in the 50% to 75% range (Steiger & Stotland, She had always been extremely close to her
1995, p. 53). Restrictive Anorexia Nervosa ap- mother, who confided all of her troubles, includ-
pears to show the most consistent pattern, ing the fathers infidelities, to her daughter. Su-
aligned with the anxious-fearful (Cluster C) PD. sana was brought up in an adult atmosphere and
For normal-weight bulimics, borderline and always had wise comments regarding any issue.
histrionic PD are the most frequent; yet, compul- The girl seemed to be extremely independent,
sive, avoidant, and dependent are also common traveling often as an unaccompanied minor. She
personality disorders. Studies show that eating led a family-centered life with cordial but few
disordered patients have been found to have peer relationships. During the weekend, the
heavy loadings on risk avoidance, conformity, ob- men in the family would go to their summer
sessiveness, self-criticism, and narcissistic need home, but she would rather stay with her
for approval (Steiger & Stotland, 1995, p. 54). mother, reading at home. She had always known
In terms of relational diagnoses, eating disor- she was going to be a lawyer and was looking
ders occur in families showing variable forms of forward to moving to Buenos Aires.
dysfunction. Additionally, studies point to the The girl started her weight loss at age 16, fol-
idea that severity of family dysfunction may be a lowing a mastectomy performed on her mother
better predictor of personality disturbance in after she was diagnosed with cancer. The mother
the eating disordered sufferer than of eating dis- was cured but refused to have plastic surgery to
order symptom severity (Head & Williamson, repair the aesthetic damage. Soon, these con-
1990). Although we need more clarity as to the cerns were replaced by the terror that inundated
possible influences of individual and family the mother when she realized that her daughter
processes in the development of eating disor- was anorexic. The father was in stark denial; in
ders, we have enough knowledge about mainte- his eyes, his daughter was too smart and happy
nance factors to pursue meaningful treatment to embark on such a self-destructive enterprise.
that will enable recovery. They engaged in a long-distance treatment, trav-
eling to Buenos Aires monthly. During that time,
the mother took full charge of supervising the
CASE EXAMPLE daughters food intake. Susana regained weight,
although along with that, she became obses-
Susana, 18, was the only daughter of a very ra- sively preoccupied with her body image and
tional, articulate set of parents, both physicians calorie consumption in a way that was not evi-
who had three older sons, also physicians. She dent when she had been underweight.
had always been a bright student, very compli- The psychotherapeutic functional hypothesis
ant, and socially appreciated, mainly for her put to the family was that Susana, due to leave
helping ways. She was apparently cheerful and home two years later, had panicked over sepa-
full of life, a disciplined ballerina who didnt rating from her family. The Anorexia Nervosa
mind being chubby and seemed to please every- stunted not only the girls bodily transfor-
one around her. The family tradition was that at mation and subsequent sexual challenges, but
age 18 years, the youngsters would leave home also her leaving home process. This fear, which
and move 1,500 miles away to Buenos Aires to may have been triggered by the danger of losing
attend the university. The youngsters would her mother due to her recent cancer, was in fact
live in the maternal grandmothers home dur- imbedded in the family structure. Mother and
ing those years, under the supervision of the daughter were inseparable. Additionally, her
Eating Disorders in Adolescence 153

overinvolvement with this warm and generous very excited with this novelty and feared her
family left her experientially and emotionally parents disapproval. Her guardians became
unprepared to leave home. The family denied outraged that she should want to date in this
all this. They believed that the daughters intel- condition; they thought she wasnt emotionally
ligence and the mothers tenacity at controlling stable enough to handle such a volatile situa-
her food intake would suffice to overpower the tion. The mother became frightened and uti-
Anorexia Nervosa. What more proof than the lized the medication for her panic attacks as
fact that she was slowly and steadily gaining an excuse to demand that Susana not be given
weight? permission to go out. This formerly most serene
As the year ended, Susana was about to and predictable mother suddenly became in-
finish high school and move out of her parents creasingly frantic, interrogating Susana over
home. The day the girl reached her target the phone as though her daughter were a delin-
weight, she broke down and embarked on a re- quent. The girl became more disorganized each
lentless pursuit of thinness, which now openly day. When medication was increased, she
alienated her from the world. She became calmed down and started to restrict her food in-
tyrannical and fought her mother to tears for take, this time with a clear desire to die. Susana
every pea on her plate. She quickly became ema- felt lifeless, not entitled to have a life of her own,
ciated and was about to be hospitalized. At that naughty and guilty for not agreeing with her
point, the realization that she was in danger un- mother, who responded to her separation intent
leashed intense hypochondriac anxieties and with a hostile and rejecting stance. If this was
served the purpose of allowing her to eat and her maternal introject, it certainly became rein-
regain weight, not because she desired food but forced by her mothers real attitude.
simply to avoid death. With her nutritional re- The crisis that unfolded surpassed the imagi-
habilitation completed, the family brought her nable for this rational and most proper family.
to Buenos Aires to start her university studies The girl would make plans to go to the country
and embark on a formal therapeutic endeavor. for a weekend with her married brother and
The parents went back to their home town and family, and the mother would call in a rage,
Susana remained with the grandmother and demanding that the trip be canceled immedi-
virgin aunts. ately, threatening to have the police intervene to
Susana became totally out of control. She stop her daughter from going to a carnival pa-
would have panic attacks when going to the rade where nude bodies were being exhibited.
university. She felt terrified of failing at school When this sort of conflict ensued, the girl
and could not tolerate the anxiety provoked by would bang her head against the wall and crawl
just the thought of taking exams. Her childlike into a corner and refuse to eat. The parents were
grandiosity suffered a great disappointment summoned to Buenos Aires and the family un-
when she dropped out of school, unable to cope derwent intense family therapy until the symp-
with the possibility of not being able to achieve toms were under control and the maturational
at her A-plus level, as in the past. She was con- crisis became manageable.
vinced that she was a total failure and would
never amount to anything. Susana perceived
her idealized mother as someone who had been DIAGNOSIS AND ASSESSMENT
able to overcome adversity and strive for excel-
lence, regardless of the circumstances. The individual diagnosis (DSM-IV criteria;
She began dating a boy her age; this was her APA, 1994) was of Anorexia Nervosa, restric-
first brush with heterosexual love. She became tive type. Following this authors classification

stated earlier, this is an eating disorder in mothers world, which protected them from
the context of a dysfunctional family system, the fathers dangerous influence. The father
where the patient has experienced a pervasive participated only in medical (professional)
developmental impairment resulting in a per- matters, and the couple remained hindered in
sonality problem and reflecting a disorder their capacity to become emotionally involved.
of the self. Other assessment instruments uti- Triangulation was the interactional rule for
lized showed that this patient had an 85 to 95 this family. Susana, the only daughter and
percentile range on the body dissatisfaction, mother confidant, was the epitomized victim
perfectionism, maturity fears, and asceticism of this plight. Through her body, she expressed
subscales. Additionally, the somatization and the conflict around sexuality and pleasure and
paranoid ideation dimensions were signifi- punished herself by depriving her body of the
cantly elevated. The former reflects distress needed nourishment and by banging her head
arising from perceptions of body functioning against the wall while crying that she was use-
and somatic equivalents of anxiety; the latter less and bad because she was ruining every-
refers to suspiciousness, hostility, grandiosity, ones life. At a time when she felt totally out of
centrality, and fear of loss of autonomy (Dero- control of her circumstances, the one domain
gotis, 1994). The initial family assessment, she was still able to exert omnipotent power
which had led to a diagnosis of developmen- over was her food intake. In this, she was able
tally arrested dysfunctional personologic sys- to defeat her idealized mother and her bitter
tem (DevDps), had missed the overlap with guardians, who had attempted to control
another category: the covertly narcissistic dys- her life. Additionally, as her weight loss pro-
functional system (CNrDps; Magnavita, 2000). gressed and her adolescent body vanished, she
In fact, Susana was not only having difficulty became totally absorbed by this preoccupa-
in the separation-individuation process because tion; she forgot about boys, love, life, and the
of her protective role of the parental subsystem; pain of growing up and of separating. Now she
more important, this system was involved in an was no longer separated. Her mother opened
arrangement such that the offspring were serv- her arms to embrace her regressive daughter,
ing the unmet emotional needs of the parents. and momentarily this family regained their
The parents had always had an unhappy mar- balance.
riage, perhaps partly because each of them had
failed to differentiate from their own family of
origin. The trade-off for their financial and pro- TREATMENT APPROACH
fessional success as physicians was that they
left Buenos Aires early in their marriage but Interestingly, most of the above constructions
remained guilty and indebted to their elders were never openly shared with the family. Their
for this distance. They responded to this with main value was serving as a frame that allowed
implicit covert pacts. The father secretly chan- for the intense joining with each of these family
neled money to his mother. The mothers ar- members in their pain and dilemmas and to
rangement was more sophisticated; all their challenge them to act differently. From that
offspring were to come to Buenos Aires to fur- vantage point, it was possible to tap into their
ther their university education, but they were resources to further positive change. The initial
to live in the grandmothers home under her treatment stages did not follow the earlier
strict and loving care, in an atmosphere where stated outline because of the living conditions
sex was sinful and family loyalty was the high- and distance of the parents. During the indi-
est value. Thus, they became engulfed in the vidual sessions with Susana, it was possible to
Eating Disorders in Adolescence 155

piece together the family picture, at least from monitoring Susanas living arrangements
the girls perspective. This allowed for a good while in Buenos Aires.
joining with the therapist that enabled the new 6. The therapeutic system was opened to in-
experience of relating to someone outside the clude the siblings, maternal grandmother,
family circle and feeling understood and val- and grandaunts.
ued. One cannot underestimate the importance 7. The brothers difficulties with growing up
of the therapists being knowledgeable and ex- were worked through, highlighting their
perienced in eating disorders. Eating disor- educational value for Susana.
dered patients are often delusional and become 8. The father was connected with Susana in
more inclined to trust someone who is an em- new outdoor physical activities. They were
pathic connoisseur. During this stage, the main able to enjoy sharing time together.
achievement was to motivate Susana to over-
come her Anorexia Nervosa and gather the Conditions that enabled this therapeutic pro-
courage necessary to wander into the outside cess were:
world. For this, it was imperative that she dif-
ferentiate from her parents and construct her 1. The certainty that there was no malevolent
own identity. She realized there was a life intent in this family arrangement.
beyond the family that she had not felt entitled 2. The therapeutic alliance based on trust
to and that her life plan had been designed by and respect that permeated the whole
others. In her words, I am faced with the treatment, even at the most difficult times.
plight of transforming from a marionette to a 3. Susanas strong will and determination to
young woman. succeed in this therapeutic endeavor.
The turning points of this therapy were:

1. Defining the crisis as having reached a OUTCOME

life-threatening point. Her safety was se-
cured by enforcing adequate nutrition. Her Soon after family therapy started, Susana began
clinical condition was monitored by a spe- to recover her weight, eating habits, and hope.
cialized physician. Four months later, she successfully completed
2. Realization that the individual sessions her admission course and exams for entering
with Susana were augmenting her trian- the university. It was a very trying experience
gulation (she was encouraged to move for her, and as soon as she finished, she went
forward in her development, embracing back to her parents home for summer vacation.
peer-appropriate behaviors, and that was The psychometric data obtained six months
contrary to the family rule). after family therapy had commenced showed
3. Realization that her mother was trapped significant improvement in most subscales. The
beyond her will (and knowledge?) in this ones that remained stable were those of body
multigeneration pact and was unable to dissatisfaction and perfectionism. The former is
undo it alone. a known risk factor for eating disorder relapse;
4. The father was strongly encouraged and the latter is a personality trait characteristic of
supported to reenter the family system. Anorexia Nervosa patients. Further therapy
He challenged the mother in her child- will focus on these issues, and individual treat-
rearing values and approach. ment is more suitable for that work. It is impor-
5. Both parents were helped to sort out rea- tant to keep in mind that a systems frame is not
sonable expectations and put in charge of defined by the number of people in the therapy

room, but rather by how the problem is per- to attain the courage to strive for ageappropriate
ceived and understood. Since the last session, autonomy. This case clearly illustrates that
Susana has called on two occasions to say she when treating eating disorders, it is not a matter
was enjoying her social and family life and ex- of knowing all or more approaches, but rather of
perimenting with finessing her parents when utilizing interventions that are of clinical rele-
they tried to pull her into their issues. She trusts vance to the specific case.
this will prepare her to face the next semester,
living away from home and getting on with a REFERENCES
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Psychodynamic Psychotherapy with

Undergraduate and Graduate Students

n many respects, college and graduate stu- phasizes developmental struggles, but thrown
dents are model candidates for psycho- into the mix are also diversity concerns, real
dynamic psychotherapy. Young, attractive, life stressors, and considerable psychopathol-
verbal, intelligent, headed for success, they ogy. Students problems can be a conundrum to
are YAVISes par excellence. Developmentally, sort out, let alone treat, especially within such
theyre at just the right stage: mature enough to brief and uncertain time conditions.
reflect on their experience and see family dy- These, then, are the defining features of stu-
namics in perspective, yet still pliable and un- dent psychotherapy: gifted clients, scarce time,
fettered enough to make changes in their lives. and complex problems. This chapter describes
No wonder therapists delight in working with the therapy approach I have fashioned to work
this population. Students are the sort of pa- with this talented but challenging population.
tients insight-oriented therapies are designed Unless otherwise indicated, I refer throughout
to treat. to both undergraduates and graduate students,
Yet, for all they have going for them, students whom I see at New York Universitys Counsel-
still can be a therapeutic challenge. One reason ing Service (UCS) in roughly equal numbers.
is their unreliability about treatment. Brief ther-
apy is the rule at campus services anyway, but
students are not fastidious about sticking to H I S T ORY O F A P PROAC H
even brief therapy time schedules. A second
reason is the complexity of their difficulties. The field of college psychotherapy took off
Maybe at one time college psychotherapy was a slowly. Although the first mental hygiene pro-
cozy enclave, the treatment of the developmen- gram was set up at Princeton in 1910, roughly
tal struggles of emotionally healthy, ethnically half the nations colleges and universities had
homogeneous, economically privileged young no organized mental health programs in 1951
peoplebut no longer. The work today still em- (Reinhold, 1991). Even years later, many schools


still lacked such programs, leaving it to stu- these areas were now normally farmed out to
dents who had personal problems to chance separate campus offices. Most important, all
upon sympathetic faculty members or deans, services sought a middle ground between the
brave off-campus treatment, or, most often, suf- purely mental health service approach, which
fer in silence. At my own small, all-male liberal seemed too heavy-handed for the average case,
arts college in the late 1960s, not only was there and the purely counseling service approach,
no psychotherapy service, but nobody I knew which seemed ill-equipped to deal with psycho-
had ever seen a therapistor dared to admit it. pathology. The common goal became to reach
Perhaps antiwar and civil rights protests, out to everyone, from the healthy student to the
burgeoning drug use, and the advance of coed- severely disturbed.
ucation convinced the laggards. Whatever the As for college psychotherapys theoretical
reason, by the end of the next decade, psy- orientation, historically, the one area of general
chotherapy services had spread throughout aca- agreement, endorsed by mental health and
demia, and, despite budgetary vicissitudes and counseling services alike, is the relevance of a
occasional outsourcing experiments, theyve developmental perspective. (With a few excep-
remained a fixture ever since. Today, virtually tions [see Committee on the College Student of
all colleges in Americaand many institutions the Group for the Advancement of Psychiatry,
overseasprovide some sort of on-campus as- GAP Report, 1999], the development in question
sistance for students who have psychological has been that of undergraduates, not graduate
concerns. students.) According to the developmental per-
But what sort of assistance? Originally, there spective, college students are in a transitional
were two models: mental health services, which stage between adolescence and adulthood. To
grew out of the campus health service, and coun- negotiate this transition, they have to master
seling services, which were sponsored by psy- certain developmental tasks: separating from
chology departments and/or student personnel family, living autonomously, forging a positive
programs (Archer & Cooper, 1998). Mental and coherent identity, forming friendships and
health services had primarily psychiatrist staffs, intimacies, advancing toward career goals. The
specialized in personal issues, and attended challenges of the college experience push them
closely to psychopathologyeven though, by all to accomplish these developmental tasks. Thus,
accounts, there was less of it back then. In the the first-year students move from childhood
very physician-like words of two college psychia- home to on-campus housing is, if all goes well, a
trists 30 years ago, their fundamental task [was] maturational step toward separation and auton-
to prevent and treat illness (Farnsworth & omy. Choosing courses and an academic major
Munster, 1971, p. 1). By comparison, counseling during the middle college years are steps to-
services were more relaxed, welcoming places. ward identity formation. Making postgradua-
Staffed mostly by counseling psychologists, they tion plans during the fourth year is a step
dealt with academic and vocational concerns as toward career choice. In many such ways, the
well as personal problems and emphasized nor- time-ordered tests of the college years dovetail
mal student development over psychopathology. with the maturational tasks of becoming an
Over time, the differences between mental adult (Medalie, 1981). And so the college thera-
health and counseling services blurred. Fewer pists task is, in part, to help students simulta-
original mental health services could afford the neously manage college pressures and master
budgetary extravagance of all-psychiatry staffs. developmental tasks.
Fewer original counseling services bothered Although academics have churned out many
with vocational and academic counseling, as versions of student development theory, bristling
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 163

with formidable professorial language like psychotherapy has not stressed theory. My ex-
domains and vectors and modes (Slimak, perience attending college psychotherapy con-
1992), all college therapists more or less endorse ferences confirms this atheoretical slant. On the
the points outlined above. College therapy is whole, college therapists are more concerned
unanimously deemed to be about supporting with special problems, like substance abuse or
student development. On other theoretical ques- eating disorders, and special populations, like
tions, however, the unanimity disappears. Pe- first-year students and women, than with ap-
rusal of the literature shows therapists adopting plying the theories of Freud, Kernberg, Kohut,
a variety of theoretical positionswhen, that is, or Beck. When writings do incorporate theory,
they trouble with theory. There has been, and is, the approach tends to be integrative, as in
no consensual model of college psychotherapy. Mays (1988) broad-based psychoanalytic treat-
Modified psychoanalytic approaches turn up ment. To me, this makes sense. Day-to-day in-
regularly in college therapy writings. Blos teractions with students demand therapeutic
(1946), a pioneer writing from an ego psycho- flexibility, discouraging any inclination toward
logical perspective, frowned on on-campus clas- theoretical purity.
sical psychoanalysis for neurotic conditions, Two other recent trends remain to be dis-
recommending instead deal[ing] with the de- cussed: the ascendance of brief therapy and the
rivatives of [unconscious infantile] conflicts in diversification of the student population. Be-
terms of ego reactions (p. 577). Mays (1988) cause these topics are central to my own think-
Psychoanalytic Psychotherapy in a College Context ing and practice, they are reserved for the next
draws on Freud and other main psychoanalytic section.
theorists to apply the psychoanalytic approach
to college students in the college environ-
ment. Other psychoanalytically influenced col- T H EOR E T ICAL CONSTRUC T S
lege therapists have invoked Melanie Kleins
concept of projective identification (Romney & BRIEF THERAPY AND ITS VARIANTS
Goli, 1991), Mahlers research into the toddler
(Webb & Widseth, 1988), and Kohuts self psy- College psychotherapy naturally gravitates to-
chology (Schwitzer, 1997). ward brief treatment. The college semester, for
Nonpsychoanalytic approaches have been one thing, permits only about 16 weeks of unin-
adopted too, among them cognitive-behavior terrupted treatment, and then only for the
therapy, solution-focused therapy, paradoxical provident few who start at the beginning of the
interventions, and family systems therapy. I term. Although some students return to ther-
particularly want to pay homage to one work apy after the winter break or summer vacation,
that does not fall in with any of the popular usually the semesters end is a natural stopping
models, Eugenia Hanfmanns too seldom re- point.
membered Effective Therapy for College Students Brief therapy is also an economic fact of life.
(1978), which draws on the even more over- Most colleges and universities these days sim-
looked theoretical and clinical contributions of ply cannot fund enough therapists for a long-
Andras Angyal (1965). If I had to pick a single term, open-ended psychotherapy program. This
guide to explain the art of treating students reality has sparked debate, some college thera-
on campus, Hanfmanns wise, humane, and jar- pists optimistically calling brief therapy the
gon-free volume would be the clear choice. treatment of choice for many students anyway
Although various treatment approaches have (Hersh, 1988, Steenbarger, 1992), others decry-
been used, overall the literature on college ing session limits (Webb & Widseth, 1988).

Practically speaking, the debate is moot. The phase permitting an emphasis on termination
typical college service has no fiscal choice but issues (Mann, 1973; Sifneos, 1979).
to cut down on appointments by imposing a
brief therapy model. Nontraditional Attendance Patterns
But even if the academic calendar and college But the majority of college treatments play out
finances didnt limit therapy, students them- in less orderly fashion. Very brief contacts (al-
selves would. The reason is their fast-changing most one half of UCSs cases) last for only a ses-
lives. College stressors, as we have seen, change sion or two. Though their official purpose may
from first year to last. On a smaller scale, some- be to get referrals or receive information, they
thing similar happens over the semester, with are, in their own way, true therapy experiences.
students early in the term adjusting to new Abbreviated therapies start off like traditional
classes and perhaps new roommates, then to a brief therapy, but then come to an earlier con-
relatively tranquil but academically decisive sensual conclusion, slowly fizzle out, or stop
middle period, and finally to the pressure abruptly with a dropout. Irregular therapies
cooker of final exams, followed by another wend their wobbly way through cancellations,
leave-taking (Grayson, 1985). As if all these reschedules and no-shows, changes in appoint-
changes werent dizzying enough, on a day-to- ment day, and requests for spaced-out appoint-
day basis students are forever experimenting ments, emergency unscheduled appointments,
with relationships, sex, alcohol and drugs, aca- and perhaps a new therapist. After a while,
demic and extracurricular commitments, sleep their unpredictability becomes the norm. Fi-
schedules, and diet. Such a mercurial existence nally, intermittent therapies consist of multiple
inevitably bollixes up treatment schedules. As courses of brief treatment over a students col-
stressors flare up and fade, so goes students lege career.
therapy attendance. From students standpoint, all such trun-
College therapy is therefore brief, but not cated or erratic or discontinuous therapies
uniformly brief. In reality, we can discern sev- make perfect sense. Students show up at the
eral basic attendance patterns, each a distinct psychotherapy service when they feel dis-
treatment experience: traditional brief therapy, tressed. They miss appointments, as they miss
very brief contacts, abbreviated therapy, irregu- classes, because that is the casual way on cam-
lar therapy, and intermittent therapy. Confus- pus. And sooner or later, they leave therapy, be-
ingly, its usually unclear at the beginning of cause the latest crisis has passed, theyve had
treatment which attendance pattern will ensue. enough exploration, or theyre busy with other
Therapists must dive into the work without matters. Their original decision to visit the col-
knowing beforehand how deep or far they are lege service was not a commitment to under-
destined to go. take therapy but an immediate response to a
Before we turn to the nontraditional atten- pressing need.
dance patterns, which are so characteristic of But for therapists trained in traditional brief
college therapy, it must be stated that many stu- therapy (if trained in brief therapy at all), non-
dents do pursue traditional brief therapy, the traditional patterns disrupt the game plan. One
kind one reads about in treatment manuals. cant count on a set number of sessions to con-
These faithful souls show up reliably for every duct an inquiry, develop a relationship, and
appointment and proceed until arriving at the achieve treatment goals. One certainly cant
semester break or the session limit. Their treat- count on getting to all the issues one might like.
ments can be understood in terms of distinct The only recourse is to be ready for anything.
beginning, middle, and ending phases, the last Because the student may in fact continue in
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 165

treatment, thought must be given to follow-up with a person. For this reason, many campus
sessions and goals. But because every session psychotherapy services call themselves Student
may be the last, each must be a helpful experi- Development Centers, dissociating themselves
ence in its own right. Treatment must be both from anything smacking of traditional psycho-
cumulative and catch-as-catch-can. dynamic psychotherapy that might scare away
Nontraditional attendance patterns have a skittish students. But although one perspective
double-edged influence on the therapeutic al- sounds benign and the other incriminating, de-
liance. On the one hand, very brief and irregu- velopmental and psychodynamic explanations
lar treatments are neither conducive to nor are really two sides of the same coin. The major
reflective of strong student-therapist bonds. The psychoanalytic models are stage theories, after
student who flits in and out of the office may all, and the most renowned developmental the-
feel no stronger attachment to the therapist than orist, Erik Erikson, built his conceptualization
to faculty advisors, academic counselors, or half on Freuds foundation. In my own practice, it is
a dozen others on campusnot to mention difficult to imagine treating students develop-
group therapists, psychiatric consultants, or mental struggles without thinking and re-
other individual therapists. (One way or an- sponding psychodynamically.
other, many students acquire a number of Not that students on arrival at the psychother-
helpers.) And yet, the mere prospect of return apy service are necessarily ready for psychody-
visitsintermittent therapyprolongs a thera- namic ministrations. Although they show up for
pists influence; students feel attached to their all sorts of reasons, including the ever-popular
therapist even when not actively in treatment, I just want to talk and My roommates in
drawing consolation from the therapists ongo- counseling so I thought Id try it too, many
ing availability. What these therapy relation- come in, or are coaxed in by friends and family,
ships may lack in intensity is made up for in because something is acutely wrong that wants
staying power. putting right. The issue may be an academic set-
Nontraditional attendance patterns also de- back, anxiety attacks, homesickness, a romantic
fuse or cloud termination issues. Very brief and breakup, an unwanted pregnancy, or any of sev-
highly irregular cases generally have a low-key eral dozen other upsets. Often, a combination of
ending. Interrupted treatments may allow no stressors, on- and off-campus, does the trick: too
discussion of ending at all. The prospect of in- many sleep-deprived nights juggling job respon-
termittent treatment, meanwhile, renders last sibilities and study pressures, family strife and
sessions less final, more like trial separations roommate tensions. (Whoever imagines stu-
than a true goodbye. Throw in the fact that dents have it easy doesnt know them.) What-
many treatments are overshadowed at the end ever the presenting concerns, what students
by final exams anyway, and the result is therapy usually want is fast relief. Crisis management or
that often ends anticlimactically, not with a at least problem solving is where college therapy
bang but a whimper. tends to begin.
But students are resilient and their crises are
short-lived. They are also introspective (some-
PSYCHODYNAMIC OPPORTUNITIES times morbidly so), intensely curious about
themselves, their relationships, and their place
Compared to the developmental perspective, in the world, and even those not so inclined
which makes students problems seem like nor- have a hard time avoiding self-scrutiny when
mal growing pains, psychodynamic explana- so much at college shakes comfortable old as-
tions have a way of emphasizing whats wrong sumptions. A little prompting, therefore, is all

it may take to nudge therapy from crisis mode tying the inquiry together. Working with the
to self-reflection. Once the immediate upset focal theme is what makes meaningful change
calms down and before the next one erupts, possible: One changes significantly in ones
opportunities arise to dig deeper and work roots, not in ones branches (Angyal, 1965,
psychodynamically. p. 205).
As I apply it, the psychodynamic is an inclu- Exploring the past is important, as in any
sive model, in the spirit of Pines (1990) and psychodynamic treatment, but because of time
McWilliamss (1994) integrative view of the limitations, one must do so efficiently. The chief
drive, ego, object relations, and self perspectives. importance of mining the past is to illuminate
Sometimes, a students fears of and defenses the present, especially the focal problem and
against experiencing affects come to the fore- theme. Reviewing childhood experiences re-
front, a classically psychoanalytic theme that, veals to students how they unwittingly keep
among brief therapy models, best fits the ap- their histories alive in their current maladaptive
proaches of Malan (1976) and Davanloo (1980). perceptions and responses.
Sometimes, the spotlight shifts to lifelong mis- Another staple of psychodynamic therapy, at-
perceptions of other people and associated self- tention to the therapeutic relationship, is im-
defeating relationship patterns, a theme in portant toobut with a caveat. Unquestionably,
keeping with either an object relations or inter- when a students focal problem or focal theme
personal perspective and the brief therapy mod- comes up in relation to the therapist, gently cit-
els of Luborsky (1984) and Strupp (Strupp & ing this here-and-now example is therapeuti-
Binder, 1984). Salient too may be problems with cally useful, bringing the issue into sharp relief.
personal agency, authenticity, and self-esteem: And if a student has a negative reaction toward
self psychology emphases. The challenge isnt to the therapist, that reaction had better be dealt
find plausible perspectives. It is, rather, to select with promptly or the student may drop out of
an apt one for emphasis. Thus, although in- treatment. But, unlike in psychoanalysis (see
evitably and almost automatically I view stu- Schafer, 1980), in brief therapy the study of the
dents through different theoretical lenses at therapist-student relationship should not be-
different times, Im always on the lookout for the come an end in itself. When a students depend-
one perspective, and the one core issue, to ele- ent or flirtatious or superior manner has no
vate in importance. In very brief therapy, a single apparent tie to either focus, usually its best to
big theme thoroughly examined packs more wal- sit on the information until it may prove clini-
lop than a dozen loosely connected insights. cally relevant.
In practice, this approach involves looking for Interpreting resistances, another standard
a focus or, more accurately, two foci. The first, psychodynamic activity, similarly requires cau-
the focal problem, is a primary symptom or tion. Certainly, its sometimes necessary to
problem area, usually one of the students orig- point out how students deny, minimize, or
inal complaints. The focal problem not only make a joke of problems, how they hide feel-
keeps the initial inquiry from flying off in all ings, blame other people and events, and use
directions, but also points to a goal: One mea- their formidable reasoning abilities to explain
sure of therapys success will be progress on away the truth. But resistance interpretations
this problem. The second focus, the focal theme, to late adolescents risk being heard as conde-
usually evolves later. The focal theme is a scending or blaming or controllingin one
deeper issue or core themethe one big psycho- dread word: parental. They are best made,
dynamic insightthat speaks to the students therefore, in an egalitarian spirit, and then only
problems and serves as the therapys motif, when the student is ready to hear.
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 167

THE IMPACT OF DIVERSITY extracurricular activities and romance. Because

many Asian Americans simultaneously chafe at
In recent years, college campuses have dramat- and deeply respect parental control, their sepa-
ically diversified in race, ethnicity, and culture, ration and identity strivings can tie them in
sexual lifestyles, age, and level of psychopathol- knots. Another common complaint is the stereo-
ogy. Students from these newly represented type that all of them are, or should be, academic
groups face the same college stressors and de- geeks.
velopmental strains as everyone else, but their Having made these broad-brush statements,
adjustment is further complicated by their par- let me hasten to qualify them. Not only dont
ticular pressures. The tricky assessment task the generalizations apply to many individuals,
raised by diversity is teasing influences apart. but they give no hint of the scope of ethnic and
When are a students coping difficulties attrib- cultural diversity on campus, of all the inter-
utable to the burdens of being somehow dif- national and first-generation students, all the
ferent? When is diversity a smoke screen unlikely biracial and bicultural, multiracial
obscuring other factors? and multicultural combinations. In the week
The influence of race, ethnicity, and culture these words were written, I have seen a Niger-
on student adjustment deserves a volume in it- ian student raised in England, a Japanese na-
self. At the cost of oversimplification, let me tional new to America, an ethnic Indian raised
offer a few observations about the three princi- in the Middle East, a first-generation Ecuado-
pal racial minorities. African Americans, partic- rian, and an Irish Korean born in the United
ularly if from disadvantaged backgrounds, States. Not one of their stories neatly fits broad
often shoulder major outside burdensdebt, racial generalizations.
full-time jobs, family responsibilitiesand the And yet, along with the dazzling variety in
weight of being pioneers, the first from their experiences, one also finds an opposite phe-
family to attend college. On campus, they some- nomenon: students from dramatically differ-
times feel alienated, viewing White classmates ent backgrounds articulating certain common
and professors as uncomprehending and unsup- themes. Time and again, minority and interna-
portive. Yet, they cant win, because when they tional students speak of the clash between
do make White friends or academically shine, family and American mainstream values (to
other African Americans may ostracize them as say nothing of Greenwich Village values), the
too White. With all these pressures, the devel- feeling of being different and an outsider on
opmental tasks of separating from home, fitting campus, and the wish for more same-group
in on campus, and forming a positive sense of adult role models. Repeatedly, they remark
identity are made that much more difficult. that in their culture one doesnt go to therapy
The same themes crop up with Latino stu- or talk about feelings to outsiders, or at all. The
dents, again especially those from disadvan- speaker may be a Turkish international stu-
taged backgrounds, although Latino-White dent, an African American, a first-generation
student relationships, though hardly smooth, Korean American, or a Hasidic Jew, but the
are less charged than Black-White relations. But messages are remarkably alike.
Latinos sometimes face the additional handi- One final point before leaving race, ethnicity,
caps of English-language problems and families and culture: These influences can be crucial
living abroad. Asian Americans sometimes or they can be therapeutically beside the point.
have these last handicaps too, and many also re- Overestimating the ethnic factor is as much an
port intense family pressures to excel at stud- assessment risk as missing it. A foreign-born
ies, study only certain fields, and pass up student gave an account of her mothers harsh

style of upbringing. Was that typical of moth- and troublesome ex-spouses, mortgages, career
ers from your country? I asked, confident from changes, and enlarged prostates. Older under-
something Id read or heard that the answer graduates obviously have different concerns
would be yes. Oh no, she said. That was just from traditional-age undergraduates as gradu-
my mother. ate students have different concerns from un-
A second area of diversification is sexual dergraduates. Yet, certain aspects of the school
lifestyle. These days, students matter-of-factly experience can elicit the adolescent in anyone.
talk about their same-sex partners and their Educational expenses, to choose a prime exam-
jaunts to late-night sex clubs, and nobody on my ple, can oblige older students to depend on
campus gives it a thought that theres an Office parents again for financial support, even to
of Gay, Lesbian, Bisexual, and Transgender Stu- move back in with them. Student status brings
dents. Yet, just 30 years ago, homosexual stu- out child-parent overtones in relationships
dents were threatened with expulsion from with professors. Student activitiesreading
college and were viewed by comparatively toler- books and exchanging viewpoints, receiving
ant college psychiatrists as having a basic char- grades, thinking about career choices
acter disorder (Farnsworth & Munster, 1971, pulls for a quintessentially adolescent self-
pp. 101108). But though the times today are examination and doubt. Therapy with older
relatively open and tolerant, societal and inter- students, or for that matter with graduate stu-
nalized homophobia are of course still realities, dents, therefore involves an intriguing combi-
and students adjustment is still a struggle. Re- nation of concerns. Sometimes, it feels like
lations with unsympathetic parents, for one talking to an older adult, sometimes, to a
thing, leaves gay, lesbian, and bisexual stu- floundering 18-year-old.
dents two unhappy choices: either hiding their A final area of diversity is level and type
sexuality or coming out and facing estrange- of pathology. Unlike college therapys early
ment. Making friends, establishing intimacies, days, todays student population spans the full
and particularly maintaining self-esteem can spectrum of mental health. At one end are
be complicated. So can deciding on sexuality; healthy young men and women, the ones who,
students confused by erotic and sexual feelings when they stumble over the hurdles that college
sometimes feel pressure to prematurely de- and growing up place in their path, right them-
clare a sexual orientation. Again, these are selves with relatively straightforward therapeu-
broad generalizations. For many students, a tic interventions. At the other end are a large
minority sexual orientation, like minority eth- number of chronically disturbed individuals,
nic status, is a source of pride and identifica- many more than in years past, drawn to campus
tion but otherwise no big deal. They request partly because of laws requiring colleges to pro-
therapy not because of their sexuality but be- vide accommodations for psychiatric disabili-
cause they have other personal problems, just ties. And in the middle is the largest group of
like anyone else. psychotherapy service consumers, whose strug-
The influx of students today who are in their gles reflect some combination of traditional
late 20s, 30s, and sometimes far older are a student concerns and demonstrable pathology.
third, and growing, source of diversity. When I Added to the other kinds of diversity, the range
entered the field of college therapy two decades and variety of pathology keeps things clinically
ago, I didnt expect someday to listen to a soph- interesting. College therapists never know
omore weigh the pros and cons of disciplining whos coming into the office next. Each student
her teenage daughter. But so I have, as I have lis- poses a fresh clinical challenge calling for a
tened to other students describe marital affairs distinctive therapeutic response.
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 169

METHODS OF ASSESSMENT student response, I dont have problems with

AN D I N TERV EN T IONS drinking or drugs, too often translates to
downing 12 beers at a sitting or smoking mari-
ASSESSMENT juana every afternoon, but its no problem
because a friend consumes more. Suicidal con-
Although some college psychotherapy services cerns merit careful questions, and more and
use formal instruments (A. J. Schwartz, per- more these days, so do violence and abuseto-
sonal communication, 1999), most confine the ward or by the student. Throughout the inter-
assessment process to student-completed intake view, I listen for difficulties in separating from
forms and the therapeutic interview. UCSs (or ever attaching to) parents, establishing a
own three-page intake form packs in dozens coherent and positive identity, progressing to-
of questions about treatment history, academic ward career goals, and forming friendships and
history, current employment, and family back- intimate relationships: the overarching tasks of
ground. Included is a 46-item problem checklist late adolescent development.
that runs the gamut of student miseries from Several years ago, UCS experimented with a
Academic Performance to Suicide Concerns. formal intake system, assessing students first
The Intake Form takes 15 minutes to fill out and and then assigning them to an appropriately
5 minutes to review. At the end of reading it, matched therapist. But after a year, this experi-
one already has a fair idea of what to expect ment was scrapped, because too many students
from the student. objected to making the switch after opening up
The main assessment tool, the therapeutic to the initial interviewer. Besides, it seemed lu-
interview, is not much different from that in dicrous to separate assessment and therapy if
other time-limited settings. My first question most students came in for only one to four ses-
is the standard query about what brings the sions anyway. The current system matches stu-
student in for help at this time. I then ask about dents and therapists based on a mutually free
the history of these presenting concerns, key time; that pairing remains unless theres reason
symptom areas (mood, sleep, etc.), and any to change it. Assessment and treatment both
other areas of difficulty, using the Intake Form begin in session 1 and proceed in tandem for as
response as a guide: You checked off Sexual long as the student stays in therapy.
Orientation. Would you like to tell me about
that? As in any initial interview, I form
impressions of the patients overall level of TREATMENT
mental health, psychological-mindedness, ex-
pectations of treatment, attitudes about self, The First Session
and manner of relating to me. Assessment is not the only task of the first 45
Although the assessment interview is famil- minutes. Many students, especially interna-
iar, I stress student issues. When a student fails tional students and racial minorities, have never
to mention studies, I am sure to ask. Acade- talked before to a therapist, and theyre not cer-
mics, after all, are the point of college, and aca- tain how they feel about it. An early piece of
demic problems are often the channel through business, therefore, is to educate and reassure
which separation and identity conflicts are about the process: the preparatory work that
expressed. Eating and body image concerns, Hanfmann (1978) calls precounseling.
rampant among females and not rare among The particulars of precounseling vary, de-
male students, call for careful assessment. Alco- pending on the student. Sometimes, I state that
hol and drug use can be tricky; the knee-jerk going to therapy does not mean one is crazy or

abnormal, one is entitled to go even if a room- you had other losses that affected you like
mates problems are worse, and I am not sitting this? The student may not be ready yet, but the
in judgment of the student, or parents. Some- seeds are planted for later exploration.
times, I explain how talking helps, what is Toward the end of the session, I briefly sum-
expected of the student (some sit quietly and marize the main themes and open for discus-
obediently, as if at a medical examination), and sion what should come next. Should the student
why, despite all the hype, emotional problems have more sessions? (Almost always the re-
are not simply biochemical. If a student sponse is yes.) If so, should the sessions be with
seems uncomfortable because were somehow me, or should I give a referral for time-unlim-
different, I open this up for discussion. (Fortu- ited off-campus treatment? (Most students elect
nately, differences in ethnicity, gender, and on-campus therapy.) Is group therapy indi-
sexual orientation are seldom fatal to the thera- cated? (Often it is, although most students ini-
peutic alliance.) It goes without saying that no tially balk at the idea.) Is a medication consult
words at this stage can dissolve deeper resist- warranted? (Once anathema, medications have
ances. All patients want both to know and not become, sad to say, the only treatment some stu-
know about themselves, want to change and not dents value.) With luck, the students opinions
change; thats the challenge of any psychother- jibe with my own. If we disagree, I generally
apy. Still, sensitive early handling of a students suggest we put off final treatment decisions
fears, doubts, and misconceptions can tilt the until weve met at least one more time.
balance in favor of giving therapy a try. For the majority of students who will con-
Students who feel a sense of urgency about tinue to see me, the next step is to identify a
their problems need encouragement to be pa- focal problem (the first focus). This takes nego-
tient: When you insist on ending these anxiety tiation. The typical first response to my request
attacks all at once, you only make yourself more for a focal problem is anything but focused:
anxious. However, I do try from the very first Well, Id like to work on my temper, and my
session to relieve pressing problems, for maybe relationship with my father, and self-esteem,
this will be my only chance with the student. At and procrastination, and . . . And so I try again,
the beginning, then, I am at my most eclectic, using follow-up questions adapted from solu-
using whatever I have in my bag of tricks to alle- tion-focused therapy: But if one thing could
viate acute suffering and restore impaired func- change that would make you later feel glad you
tioning. In a case of panic attacks, I teach that worked with me, what would that change be?
the symptom is extreme anxiety rather than (Walter & Peller, 1992). Eventually, most stu-
something more sinister, point out the harm of dents are able to name a symptom or problem as
negative thoughts and the benefit of construc- their main priority. Next, I seek a therapeutic
tive thoughts, and give a quick demonstration goal: How would you know youve made prog-
of deep breathing and relaxation techniques. ress on this problem? What would be differ-
In the aftermath of a romantic breakup, I vali- ent? The goal introduces the idea that therapy
date the painfulness of the experience (nothing isnt just talk. Our sessions are to help change
wounds inexperienced young people like a something in the students approach to the
breakup), review coping methods the student focal problem.
has tried, and may advise spending a weekend At the end of the session, I give homework,
with family or close friends. Although I do not which reinforces the focus and sends the moti-
emphasize insight at this point, I do make a vating message that theres something con-
few gentle probes: Do you have any ideas what structive to do right away. My usual assignment
may be causing you to feel so anxious? Have is to notice examples of the focal problem:
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 171

Why dont you be aware of times during the Sometime in the first few sessions, I briefly
week when the problem happens. Pay attention but systematically ask about the past, asking for
to the situation and how you react. Then next characterizations of each family member, each
time, we can explore these instances together. ones relationship with the student, and the stu-
dents role within the family. If I sense some-
Next Sessions thing, I also ask about early relationships with
In contrast to the first session, I begin follow-up peers and teachers. If necessary, I inject imme-
sessions without structure, inviting students to diacy into the exercise: If you could be 10 years
bring up whats on their mind. (In later ses- old again, what would you say to me about your
sions, the simple prompt So can get the ball parents divorcing? The answers are culled for
rolling.) Given the encouragement to begin any- further clues about the focal problem: So your
where, many students strike off in unforeseen father would blow up whenever he saw you cry-
directions and show new sides of their person- ing. What impact do you think that has on you
alities. Someone who in the first week seemed now, during this period of depression? I won-
to be falling apart may now composedly muse der how all those times feeling like the odd per-
about friendships and career options; someone son out with your sisters is related to your
else who seemed to have run-of-the-mill home- social isolation now.
sickness may now confide a horrific history of Throughout, Im on the alert for changes in
childhood sexual and physical abuse. I expect to the students affect, level of resistance, reactions
be surprised by students and am always ready to me, and my own reactions to the student.
to revise early assessment conclusions and re- Sometimes, these phenomena are pronounced
visit the question of the most suitable focal enough to comment on without knowing if they
problem. relate to the focal problem: You seem to be hav-
Although subsequent sessions begin nondi- ing a strong reaction right now. What are you
rectly, there is an agenda. If the student brings feeling? I am most inclined to pounce, though,
up previously undisclosed problems, I look for when I sense a relevance: Youve explained how
connections to the focal problem, assuming the you always stop yourself while writing papers. I
original problem still seems to be the main pri- wonder if youre not doing the same thing right
ority: How do you think this topic youre talk- now, stopping yourself from talking to me.
ing about now might be involved in your central There quickly emerges, as can be seen, an
concern? If the student directly talks about the embarrassment of therapeutic riches: the stu-
focal problem, I ask questions about it: How dents current life in its many aspects, the past,
does the student understand that the problem here-and-now reactions during the session,
happened again this week? What thoughts and any reported dreams or fantasies. Theres a
feelings accompanied its occurrence? When wealth of material, but precious little time to
else do these thoughts and feelings surface? mine it. The challenge, therefore, is to sift
How does the student feel about the problem through it all and extract a focal theme, a dom-
(anxious? ashamed? defeated? guilty? secretly inant trend or pattern that pulls the material
proud?), and how might this feeling affect its together and bears on the focal problem. Obvi-
perpetuation? How do other people under- ously, selecting a focal theme is a matter of
stand, and react to, the problem? Through this judgment and simplification. The more one
directed inquiry, I invite the student on a collab- speaks to a student, the more connections, par-
orative search, the two of us together following allels, and explanations come to light, the more
up leads on the nature and source of the focal nuanced an understanding of the relative in-
problem. fluence of external stressors, developmental

strains, diversity factors, and pathological ele- strong, healthy daughter in an emotionally
ments. Students are complicated, their prob- troubled family. These versions, in turn, were
lems amenable to different interpretations. further modified as more information came to
Ideally, however, one theme stands out that light. Refining the focal theme is an ongoing
makes sense to both of us, comes up recur- process.
rently in the clinical material, and lends itself The purpose of all this attention to the focal
to change. Ideally, theres a big idea around theme is to help the student break free, to
which we can organize our investigation. change. Change, of course, is a mysterious phe-
The focal themes I favor are plainly observ- nomenon. Why certain students make progress,
able in students day-to-day lives and statable and precisely what makes it possible, is impos-
in simple language. They are often, at least in sible to pin down. Still, the dogged investiga-
early formulations, rather homely ideas, which tion of a central theme surely plays a part. Once
taken out of context can sound trite. But the test students understand their self-defeating ways
of a good focal theme is that it registers as true. and the price they pay for them, the natural ten-
Often, the truth is something the student al- dency is to try a healthier path. And once the
ready hazily knows but hasnt faced up to. first step is taken, it becomes easier to take the
A few examples will demonstrate. A students next, and then the next.
focal problem was puzzling anger outbursts. To support change in relation to the focal
The focal theme we arrived at, which hed half theme, I look for it, scanning for even small ex-
realized before, was his sensitivity to slights; amples of movement in the students day-to-day
his anger boiled over whenever he felt put down. life: But you see, you actually spoke up this
Another students focal depressive symptoms time. What was that like for you? And: How
were traced to the sweeping extent she denied were you able to do it? Setbacks are treated as
herself wishes and needs, which therefore be- opportunities to learn more: So you held your-
came our focal theme. With a third student, also self back from speaking up. What do you think
mired in depression and at a loss to explain it, made it hard to do? And: If you could rewrite
the thrust of our discussionsthe focal theme history, how would you handle the situation
became her depression-inducing guilt and fear differently? Occasionally, I assign homework
about breaking away from her traditional Indian inviting change, although Im wary of pushing
family. students before theyre ready.
Once a focal theme is identified, its explo- The general strategy, then, is as follows: Iden-
ration takes center stage. The initial focal prob- tify a focal problem, examine it from all angles,
lem is by no means forgotten, other topics are arrive at a deeper focal theme, then concen-
fair game, and new insights accrue, but every- trate on the theme with an eye to encouraging
thing is tested for its relationship to the pre- change. That, at any rate, is the plan. In actual-
dominant theme. Exploration of the focal theme ity, many cases take a different path. Some stu-
leads to ever more precise and elaborate formu- dents, especially the very brief and irregular
lations. The angry student whose focal theme attenders, finish therapy without our homing
was sensitivity to slights was later understood in on, let alone sinking our teeth into, a viable
to be unconsciously getting back at anyone who focal theme. They still may part gratefully,
reminded him of his sadistic older brother and whether due to improved fortunes, my support-
demanding, rejecting father. The depressed stu- ive listening, or who knows what factor (it helps
dent fearful of asserting her wishes and needs treatment outcomes when cases start in the
was later found to be trapped in her role as the gloomy winter and finish with the flowers in
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 173

bloom), but we never arrive at that aha mo- what this means?), and couch statements in
ment when their story yields a larger meaning. tentative, nonauthoritarian language (Tell me
Other students do come away with insight into a if Im getting this right, but it sounds as if . . .).
focal theme and perhaps determination to pur- Even so, some students hear my remarks as
sue long-term treatment, no mean accomplish- parentally intrusive or critical, and so I ask
ments for a handful of sessions, but they finish about that: What does it feel like when I make
still mired in their basic struggle. But then there an observation? You often have a pained expres-
are the successes, when the students surface sion on your face. Other students solicit a
problems yield to a deeper understanding, and parental response, which also warrants com-
deeper understanding fosters genuine change. ment: It sounds as if youre asking me what to
Trainees whove slogged through slower thera- do here, as if you cant decide for yourself. What
pies at other settings marvel at witnessing this do you think thats about? On occasion,
phenomenon. Their college patients who were though, a student seems so lost or bent on self-
bogged down in problems suddenly grasp some- destruction that I put aside my theoretical scru-
thing fundamental about themselves and deter- ples and deliberately act in loco parentis:
mine to act differently. Its a heady process to Youre feeling so desperate now that I sense
witness. youll only make matters worse if you try to
study again tonight. Why dont you take the
The Role of Nondirective Responses evening off and do something with your
Brief therapy requires activity and structure, friends. Once students get past the rough
particularly in directing attention to the foci. spots, I gladly relinquish my parenting duties
But a healing ingredient of any treatment is and return to supporting their autonomy.
simply talking to an empathic listener. Active
interventions must be balanced, therefore, with Transference, Countertransference, and Termination
a softer therapeutic response: patient listening. In addition to the child-parent undertones, other
In the same vein, I favor liberal use of mirroring relationship themes inevitably come up with
responses, brief restatements (the briefer the students. Late adolescents relate to therapists in
better) that clarify students meaning, affirm all the ways adults do: warmly, hyperrationally,
their worth, and encourage further disclosures. demandingly, placatingly, dismissively, suspi-
Theres no need to say more about the univer- ciously, seductively. College therapists in turn
sal techniques of listening or mirroring, but I have a full complement of countertransference
do want to make clear that, focal emphasis reactions, among which I would single out
notwithstanding, I actually spend more time in protective feelings (students are like children
sessions patiently attending to a students sometimes), exasperation (they can be like diffi-
words than directing the inquiry. cult children sometimes), overidentification
Nimble balancing is also required around (theyre at a pivotal point in their lives), at-
a possible parental role. As a rule, I take pains traction (theyre so young, good-looking, and
to avoid playing the parent, because late adoles- charming), and fascination (their life stories can
cents struggling to be free of adult control dont be the stuff of romance and drama). Although
need controlling by me. To establish a collabo- many transference and countertransference
rative, egalitarian relationship, I open up for themes may enter the room, I generally do not
discussion the decision to work together, the direct attention to these currents unless they
choice of focal problem, and the meaning of threaten the treatment alliance or clearly pertain
clinical material (What are your ideas about to the focus, in which case, I tackle the issue

head-on: Weve seen how hard it is for you to trivial in their own right. (Who among us
confront people directly. I wonder if something would want to be cooped up again with a
like that isnt going on here today between you roommate or saddled with four midterms?)
and me, because after I started the session late, Add to the equation the particular adjustment
youve seemed much quieter than usual. challenges faced by diverse groups and by
Because the end of treatment is often indeter- emotionally disturbed students, and inar-
minate, there may be no opportunity to discuss guably, the problems of students are both
it. When a case does come to a known finish, I wide-ranging and substantial.
emphasize termination to the extent that it Although students fall into most Axis I and II
seems emotionally salient. My sense is that categories, certain diagnostic trends can be
many students have only mild feelings about noted. Adjustment disorders are prevalent,
the finish of brief treatment, and so I dont bela- reflecting both the stressfulness of students
bor its significance. For those who view termi- lives and the fluidity of their symptoms. A few
nation as a repetition of past abandonments, studentsthe once common, now quaint, pure
rejections, or neglect, I do point out and ask developmental casesare most accurately de-
about their reactions. As with any other aspect scribed by V-codes: parent-child relational
of treatment, I particularly stress termination problems, partner relational problems, academic
reactions when they relate to the focal theme. problems, and identity problems. Many others
have an Axis I or Axis II feel but are hard to
pigeonhole diagnostically, partly because of lim-
PROBLEM AREAS itations in the diagnostic system, but also be-
A N D DI AG NO S I S cause of their puzzling variability. Sometimes,
the best recourse is to create a composite diag-
I am sometimes asked at social gatherings to nostic picture by putting a question mark next
name the typical problems of todays students. to several Diagnostic and Statistical Manual of
The expectation seems to be that theres a Mental Disorders categories.
bumper sticker answer, the top two or three Problems and diagnoses are one factor deter-
concerns defining the current college genera- mining which students to treat in brief therapy.
tion. In fact, users of the psychotherapy service All things being equal, serious eating disorders,
have just about every personal difficulty imag- substance abuse, Bipolar Disorder, recurrent
inable, save mental retardation and senile de- Major Depressive Disorder, and Obsessive-
mentia. On UCSs intake form checklist, they Compulsive Disorder call for referral to off-
most frequently check off Anxiety, Stress, and campus providers. Other indications are vague,
Depression, but there are plenty of mentions diffuse, or chronically entrenched problems, an
too of Eating or Weight Concerns, Family extensive treatment history, and a history of
Problems, Identity Concerns, Romantic Prob- losses or unstable relationships: negative experi-
lems, Academic Performance, Suicide, and so ences that short-term therapy might duplicate.
on. Another popular misconception is that the Conversely, students who present a clear focal
undergraduate and graduate school years are a problem, are new to treatment, recognize their
cushy respite from real-life pressures. Actu- own role in their difficulties, and are motivated
ally, todays students are as likely to be to change hold promise for brief therapy. But
weighed down by full-time jobs, credit card with the majority of students, I would say, one
debt, and family obligations as by homesick- can build a case for either on-campus or off-cam-
ness, midterm exams, and roommate squab- pus treatment. Often, the inclination of student
bles, and its not as if on-campus pressures are and therapist alike is to start a trial of on-campus
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 175

treatment and see how it goes, reserving the pos- could remember, until she woke up having her
sibility of referral for later. Besides, a college ser- stomach pumped in the emergency room.
vice serves the entire student community and As Sonia spoke, I had something of the expe-
cant be too fussy about selection criteria. rience of watching a slick and stylish European
Some students unmistakably wrong for brief film. This sweet-looking, vivacious, smiling
therapy flatly refuse to take a referral or arrive young woman gave enough cinematic detail
too late in the academic year to refer out. The that I could picture every scene, from the
only alternative is to tide them over for a time boyfriends jarring phone call to her disorient-
and pave the way for a future referral. Even in ing hospital stay among psychotic patients and
these cases, students are unpredictable. Some- brusque aides. The story was riveting, the
times, the unlikeliest patients register meaning- teller charming. But almost entirely missing
ful short-term therapeutic gains. from her account was access to her inner life,
her emotions and motives. How had she felt, I
asked, when Laurent dropped his bombshell?
CASE ST U DY She couldnt say. What went through her mind
while deciding to take her life and carrying out
Sonia came to my attention in ominous fash- her meticulous plans? Shed simply decided to
ion, via a phone call from a local hospital. A do it; shed always been intrigued by death.
social worker called to ask what follow-up ser- (Some of her responses had an existential fla-
vices we could provide for a 25-year-old French- vor.) But surely shed been thinking about Lau-
speaking NYU graduate student from Belgium. rent during this time? No, not really; she was
A week earlier, Sonia had been taken uncon- too busy with her plans. How did she feel now
scious to the hospital after making a serious about taking her life? Oh no, shed never do it
suicide attempt. Now that she was ready to be again, shed had that experience and so
released, could University Counseling Service wouldnt repeat it. Besides, Laurent had called,
treat her? it was all a big misunderstanding, and hed
It wasnt clear from the social workers de- just flown in to stay with her for a week.
scription what to expect, beyond the assurance Sonias manner was lively, almost merry, as if
that Sonia was emotionally stable and willing therapy, like suicide, were an interesting adven-
to meet with me. Indeed, at our first meeting, ture shed happily experience. Yes, she said, she
Sonia spoke freely and amiably, although her would very much like to continue meeting so
shifting gaze and fluttering hands betrayed we could understand her suicide attempt. And
anxiety and she had some difficulty finding the yes, shed take my office and the Protection Ser-
right words in English. She explained that her vices phone numbers in case of an emergency.
Belgian boyfriend, Laurent, had unexpectedly
called 10 days earlier to break up with her.
Though she had never before seriously consid- INITIAL DIAGNOSIS AND ASSESSMENT
ered committing suicide, on hearing this news
she promptly made up her mind to do it. After After the first session, I wrote down this reluc-
two days of planning, she left her roommate and tant diagnostic impression in Sonias chart: Ad-
off-campus apartment, checked into a hotel, at justment Disorder (this doesnt at all do justice
first tried to cut her wrists with a kitchen knife, to the puzzle she presents, but I cant think of
and then, when that proved too painful, swal- anything closer). The hospital report, which
lowed a half bottle of champagne and 32 over- arrived a week later, also settled on Adjustment
the-counter sleeping pills. That was all she Disorder with Depressed Mood, putting none

next to the Axis II space. My diagnosis was cho- seeker. In later sessions, she periodically picked
sen by default. At this initial session, it seemed up this thread again. Her mother was moody
evident that despite her suicide attempt, Sonia and easily hurt, prone to depression, and, if she
did not meet the criteria for a depressive dis- felt wronged or disappointed, sometimes re-
order, let alone any other Axis I category. And fused to acknowledge Sonia for days afterward.
although a suicide attempt following a threat- The little girl did everything possible to avoid
ened abandonment suggests Borderline Person- her mothers displeasure, indeed, to stay out of
ality Disorder, there were no clear indications the mothers way. But children cannot escape or
of instability of relationships, identity, or affect, do without their mother for long. When contact
intense anger, or other borderline signs. Nor was unavoidable, the girl learned to placate,
did any other personality disorder seem to fit. cheer up, and essentially parent the mother,
Adjustment Disorder seemed the best diag- and mercilessly drove herself to be the aca-
nosis available, but it revealed nothing about demic success her mother insisted on. These
what was most conspicuous about Sonia: the strategies came at a steep price. Attentiveness
disconnection between the events she reported to her mothers feelings, wishes, and needs had
and her feelings and motives. She seemed all made her a stranger to her own inner life. The
pleasant surface, no inner life. I had no idea cheerful, stoical, and good false self she pre-
at this point what the disconnectedness was sented to her mother and, inevitably, to her
about, only the conviction that it was impli- teachers, friends, and boyfriendand now to
cated in her suicide attempt and would have merequired ignoring the unfulfilled person
to be central to her treatment. As for her sui- inside. In developmental terms, this 25-year-old
cidal potential, I wasnt sure what to think. woman had neither separated from her mother
Her cheerful manner and ready assurances be- nor consolidated her own sense of identity.
spoke someone not at all at risk. Yet, this same Coming to New York, I suspect, was to be an
lively young woman had methodically carried escape from her straitjacket, but it almost
out a lethal plan that surely would have suc- proved her undoing. Although out of touch
ceeded had chambermaids not happened into with her feelings, Sonia surely missed her
the bathroom where she lay unconscious. Sup- boyfriend and Belgian friends, and she felt
pose Laurent had a change of heart and left her lonely and isolated in a strange, anonymous
again; how would she react? Suppose she was city, at a disadvantage because of her language
deceiving meor herselfabout her suicidal difficulties. Being far from home allowed her to
inclinations? question her academic direction and career
plans and simply to have funliberating possi-
bilities, but also threats to her lifelong adapta-
CASE FORMULATION tion. Already, then, she was feeling vulnerable
and uncertain, when Laurents abrupt long-
As might be expected, Sonias emotional inac- distance rejection overwhelmed her limited
cessibility had a long history; she couldnt even coping resources. Without experience in reach-
remember reacting when at age 8 she learned of ing out to others or soothing herself, or even
her parents divorce. The third session brought tolerating or making sense of what she was feel-
the first clue about where this emotional block- ing, and with a philosophical view of suicide
age originated. Her mother, she said, pressured blinding her to the horror of what she was
her to be productive, studious, and strong: a doing, she almost inevitably latched onto sui-
doer and help giver, not a feeler and help cide. Sonia plotted to kill herself because at her
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 177

darkest moment she was psychologically unpre- or couldnt find emotions at all, such as in her
pared to do anything else. dealings with Laurent. More and more, she
The irony is that her attempt came just as her grasped the extent of her self-unawareness and
sense of self finally was awakening. Merely self-denial.
coming to New York was a break from the The next step was to discover what blocked
mother. Questioning her course of studies was her from experiencing feelings. Questioned
an unprecedented look inside herself. Even the about family background in the third session,
suicidal plan expressed a fledgling, if cockeyed, she cautiously ventured her first statements
self-assertion. Only far from home, she ex- about her mothers inhibiting influence. From
plained, did she feel free and selfish enough to then on, I looked for opportunities to return to
disregard other peoples wishes and do as she her relationship with her mother and to note
pleased: end her life. similar self-inhibiting tendencies in her other
In session 5, I referred Sonia to a womens
TREATMENT APPROACH therapy group at UCS. My intention was to en-
courage further emotional expression and as-
Despite her eagerness, I wasnt optimistic after sure her of continued support, as our individual
our first meeting that therapy would be of much sessions were due to run out several weeks be-
help to Sonia. The focal problem, understanding fore her one-year program ended. Two weeks
the suicide attempt, and the immediate goal, later, she scheduled an emergency session. She
preventing another, were both clear enough. But couldnt talk about herself in the group, she told
how could we fathom her motives if she was un- me, visibly upset. Instead, she felt obligated to
able or unwilling to access her inner life? As help out the other members, to put their con-
it happens, I underestimated her therapy re- cerns ahead of hers. When I commented that
sources. After I twice pointed out the startling this confining role sounded familiar, she said
discrepancy between her scary actions and her yes, more and more she realized this had been
bubbly manner, she readily agreed in the second true her whole life. She then launched into a
session to work on discovering her emotions. full-blooded lament about her parentified rela-
This issue, a promising focal theme, struck tionship with her mother. Lately shed felt
home. In the next sessions, she reported feeling angry at her mother, she said. She looked
sad when Laurent returned to Belgium, but straight at me as she spoke, for once, not smiling.
happy to test herself by being alone again. She Throughout the therapy, I was sensitive to
felt fed up working on a major paper, was calibrating the degree of structure. As I always
starting to enjoy New York, and in a dream do, I related material to our focal theme, which
felt angry with herself for having distanced in her case meant drawing attention to the con-
friends from home. Sonia reported these feel- tents of her emotional life and the reasons for
ings in a tentative way, the usual half-anxious, and consequences of keeping it at bay. What-
half-ingratiating smile pasted on her face (which ever we discussedher mother, her studies,
I pointed out), but something genuine seemed her manner in the sessionwas examined
to be getting through. It was as if she was learn- through this prism. But I also felt it crucial with
ing to speak the language of emotions as she was this young woman whod devoted a lifetime to
also studying to improve her English. In focus- obedience to allow her room to talk about
ing on her inner life, we also looked for situa- whatever she pleased. Given this license, Sonia
tions where shed kept her emotions bottled up discoursed on her displeasure with the cold

hospital attendants, her wish to be more affec- diversity factors (an international students ad-
tionate with Laurent, her obstacles as a female justment to New York and the English lan-
scholar in a male-dominated field, her love of guage), family dynamics (the relationship with
taking walking excursions in Manhattan, and her mother), personality deficits (renunciation
her ambivalence about telling her mother about of her feelings and wishes) associated with
the suicide attempt. She did not delve deeply stunted development (separation and identity
into her parents divorce or her relationship problems), and the catalytic jolt of an unfore-
with her father, nor did I push her to. Encour- seen stressor (her boyfriends phone call).
aged to say what she wanted, she seemed to get But most of all, Sonias case illustrates college
in touch with herself at her own pace. psychotherapys characteristic lightning transi-
In our ninth meeting, Sonia asked if she could tion from crisis management to productive
conserve her remaining sessions. She wanted to exploration. In her initial presentation, Sonia
meet me several times right before leaving New seemed a genuine suicide risk and a poor bet for
York to talk about dealing with her mother and psychological insight. It appeared dubious
readjusting to life back home. In the meantime, whether I could break through her merry facade
she would continue group sessions, which were and make contact with the genuine human
going better now. As it turned out, she returned being. But the suicidal threat never materialized,
only once more, a week before her departure and almost from the beginning, she showed cu-
(I was pleased to see her on my schedule) to riosity about breaking through her facade, our
bring me up to date and say goodbye. She had well-chosen focal theme. In the span of weeks,
decided, she said, to tell her mother about the her manner in my office advanced from emo-
suicide. Shed been more open and affectionate tional inarticulateness and a pleasing falseness,
when Laurent came for a second visit, although to hesitant emotional expressiveness, to signs of
she wondered why she didnt have stronger sex- genuine communicativeness. Outside the office,
ual feelings for him or for any of her prior she became more responsive to her boyfriend,
boyfriends. She also noticed herself still feeling enjoyed city strolls without beating herself up
angry about his original phone call breaking up for it, set her sights on a more congenial career
with her. Her plan was to continue individual path, and steeled herself to be real with her
therapy and consider couples therapy when she mother. More work remained to be done, which
returned to Belgium. Would it be all right, she she recognized. But in a remarkably short time in
asked at the end of the session, if she let me treatment she had grasped a fundamental self-
know how things turned out? I told her I would defeating pattern and promptly set off in a
be delighted, and squeezed her hand as she got healthier directionthe kind of results that
up to leave. makes treating students such a distinctive and
deeply gratifying experience.

Although I wouldnt call Sonias therapy typi-
calno such case exists in my case loadit Although college and graduate students are
does illustrate how college treatments can stop well suited for psychodynamic psychotherapy,
and pick up again unpredictably, and how more the work is complicated by students erratic
than one clinician, in this case, the group leader attendance in treatment and by their complex
and I, can work collaboratively with a student. problems, which typically embrace late ad-
Her case also exhibits the familiar jumble of olescent-young adult developmental struggles,
Psychodynamic Psychotherapy with Undergraduate and Graduate Students 179

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pathology, and, more and more in recent years, apy. New York: Plenum Press.
the particular problems of diverse groups. To Mann, J. (1973). Time-limited psychotherapy. Cam-
bring order to the complexity, therapists should bridge, MA: Harvard University Press.
strive to home in on a focal problem area and a May, R. (Ed.). (1988). Psychoanalytic psychotherapy in
focal psychodynamic theme. Even in a few ses- a college context. New York: Praeger.
McWilliams, N. (1994). Psychoanalytic diagnosis. New
sions, a directed psychodynamic inquiry can
York: Guilford Press.
help students surmount their immediate stres-
Medalie, J. (1981). The college years as a mini-life
sors and also start to understand and change cycle: Developmental facts and adaptive options.
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30, 75 79.
Pine, F. (1990). Drive, ego, object and self. New York:
Reinhold, J. E. (1991). The origins and early devel-
Angyal, A. (1965). Neurosis and treatment: A holistic opment of mental health services in American
theory. New York: Wiley. colleges and universities. Journal of College Stu-
Archer, J., Jr., & Cooper, S. (1998). Counseling and dent Psychotherapy, 6, 3 14.
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Jossey-Bass. tion and eating disorders on a college campus.
Blos, P. (1946). Psychological counseling of college Journal of College Student Psychotherapy, 6, 53 74.
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Committee on the College Student of the Group for Schwitzer, A. M. (1997). The inverted pyramid
the Advancement of Psychiatry. (1999). Helping framework applying self psychology constructs
students adapt to graduate school: Making the to conceptualizing college student psychother-
grade (GAP Report). Journal of College Student Psy- apy. Journal of College Student Psychotherapy, 11,
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Davanloo, H. (1980). A method of short-term dy- Sifneos, P. E. (1979). Short-term dynamic psychother-
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Aronson. model for university and college counseling cen-
Farnsworth, D. L., & Munster, P. K. (1971). The role ter professionals. Journal of College Student
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C. C. McArthur (Eds.), Emotional problems of the Steenbarger, B. N. (1992). Intentionalizing brief col-
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Crofts. dent Psychotherapy, 7, 4762.
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Hanfmann, E. (1978). Effective therapy for college stu- focused in brief therapy. New York: Brunner/Mazel.
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Chapter 8 Supportive-Expressive Psychotherapy

Chapter 9 Brief Psychodynamic Therapy
Chapter 10 An Object-Relations Approach to the Treatment of
Borderline Patients
Chapter 11 A Relational Approach to Psychotherapy
Chapter 12 Mastering Developmental Issues through Interactional Object-
Relations Therapy
Chapter 13 The Activation of Affective Change Processes in Accelerated
Experiential-Dynamic Psychotherapy (AEDP)
Chapter 14 Short-Term Dynamic Psychotherapy of Narcissistic Disorders
Chapter 15 A Relational-Feminist Psychodynamic Approach to Sexual Desire

Supportive-Expressive Psychotherapy

H I S T ORY O F T H E widespread influence on modern dynamic ther-

T H E R A PE U T I C A P PROAC H apy in the United States and abroad (Gabbard,
1994, 1996).
The term supportive-expressive (SE) psycho- The specific codification of SE developed by
analytic psychotherapy was used originally Luborsky has been further defined in a series
to describe the open-ended, psychoanalytically of treatment manuals (Book, 1998; Luborsky,
oriented therapy conducted at the Menninger 1984, a revised edition of Luborsky, 1984, is
Foundation (Knight, 1949; Wallerstein, 1986; in preparation) that are appropriate for a wide
Wallerstein, Robbins, Sargent, & Luborsky, range of patients and conditions. Additional
1956). As a theoretical orientation, SE is rooted adaptations of SE have been developed for
in Freuds work on technique (Freud, 1958a, depression (Luborsky & Mark, 1991; Luborsky,
1958b, 1958c, 1958d, 1958e, 1958f) and that of Mark, et al., 1995), generalized anxiety-disorder
some of Freuds main followers in the psycho- (GAD; Crits-Christoph, Crits-Christoph, Wolf-
analytic tradition (e.g., Bibring, 1954; Fenichel, Palacio, Fichter, & Rudick, 1995), opiate
1941; Stone, 1951). (Luborsky, Woody, Hole, & Velleco, 1995), co-
SE is a succinct description of dynamic ther- caine dependence (Mark & Faude, 1995, 1998),
apy as conceptualized by important theorists, and avoidant and obsessive compulsive person-
such as Gabbard (1996), who wrote that the ac- ality disorders (Barber, 1990).
tual interventions used in dynamic therapy and SE manuals do not prescribe therapist in-
psychoanalysis can be conceptualized on an terventions on a session-by-session basis, but
expressive-supportive continuum (1994, p. 519). provide general principles of treatment and
This continuum lies at the root of SE as manual- guidelines for therapists. This degree of specifi-
ized by Luborsky (1984). SE is a codification of cation is consistent with dynamic therapys
commonly practiced dynamic therapy. In our ex- need for the flexible use of techniques as they
perience, clinicians readily consider SE a form of are relevant to the configuration of defenses and
dynamic therapy that is not very different from conflictual relationship patterns of each patient.
their own therapeutic approach. SE has had a The SE treatment manual for depression, for


example, includes specific techniques and issues ship patterns and how these patterns are
related to the treatment of depression, such as associated with their symptoms. The CCRT
suicidal risk, helplessness and hopelessness, (Luborsky & Crits-Christoph, 1990) refers to
dealing with loss, anger, and poor capacity to patients characteristic interpersonal and in-
recognize depression. Nevertheless, the SE treat- trapsychic conflicts. The CCRT has received
ment manual for depression is very similar to the substantial empirical support (see reviews by
general manual, but with an emphasis on under- Barber & Crits-Christoph, 1993; Luborsky, Bar-
standing the depressive symptoms in the con- ber, & Crits-Christoph, 1990; Luborsky & Crits-
text of interpersonal/intrapsychic conflicts. In Christoph, 1998) and has been employed for
SE, these are called the core conflictual relation- many years in clinical work. Clinicians can de-
ship theme (CCRT; Luborsky & Crits-Christoph, fine a specific CCRT for each patient coming for
1990, 1998). treatment, without necessarily having a precon-
ception of the CCRT ahead of time. Patients
self-understanding (greater insight) of their
T H EOR E T ICAL CONSTRUC T S CCRT and changes in the CCRT are hypothe-
sized to mediate changes in symptoms. The
The CCRT method has been used to assess and mechanism of change and treatment techniques
study central relationship patterns in SE ther- are discussed in further detail later in this
apy. It refers specifically to patients recurrent chapter.
main wishes (or needs or intentions), main re- Some of the central concepts of SE, such as
sponse of others (imagined or real; RO), and pa- transference, insight, interpretation, and the
tients response (response of self in terms of therapeutic alliance, can be traced back to ear-
feelings, cognitions, or behaviors; RS) in inter- lier generations of psychoanalytic theorists and
personal relationships. The three components clinicians:
of the CCRT are inferred for each interpersonal
interaction the patient describes.
Luborsky (1990) has compared the Freudian
The CCRT, like other similar concepts in
(1958b) observations on transference and the
other forms of dynamic therapy (e.g., Barber &
CCRT and found that the two concepts share
Crits-Christoph, 1993), serves as a springboard
much in common. However, the specific oper-
for the therapists interventions throughout
ationalization of transference in the SE model
treatment and is developed separately for each
in the form of the CCRT (wishes, ROs, and
patient. In this way, the CCRT is utilized to ad-
RSs) is original to Luborsky (1977).
dress the patients idiosyncratic way of relat-
ing, which may or may not be similar to that of With the introduction of Freuds structural
other patients. The use of the CCRT enables SE model, the goal of psychoanalysis, insight,
therapists, like some other therapists (e.g., cog- changed from making the unconscious
nitive therapists), to treat patients with a vari- conscious to emphasizing the integration
ety of conflicts and disorders. The SE model of intrapsychic structure. In SE therapy, un-
assumes that gains in self-understanding about derstanding the interrelations of the CCRT
the CCRT and subsequent change in the CCRT components and the connections between
mediate symptom improvement. Furthermore, these components and symptoms in current
these changes are facilitated by the positive and past relationships is the main focus of
therapeutic alliance. treatment.
SE and other dynamic therapists try to help Insight or self-understanding is achieved
patients become aware of their central relation- by therapists repetitive interpretations of
Supportive-Expressive Psychotherapy 185

interpersonal themes across situations and addressing interpersonal themes facilitated

across relationships (working through). Es- the development or maintenance of a positive
pecially important in SE, but not necessary, is therapeutic alliance (another variable central
the interpretation of the transference. Work- to change in SE) over the course of treatment.
ing through of the transference is used to These findings are particularly important
help patients understand how early relation- because they document that the alliance is not
ships distort their present relationships, in- an unchangeable patient characteristic, but
cluding the relationship with the therapist. that therapists actions do indeed impact the
SE therapists follow traditional short-term alliance, opening the door for further re-
dynamic therapists (e.g., Malan, 1976) rec- search on specific attempts to improve the al-
ommendations of interpreting components of liance through altering therapist actions. In
the interpersonal themes in the three apexes addition, this research suggests that support-
of the triangle of insight (present relation- ive and expressive techniques do not conflict
ships, transference, and past or parental rela- with each other but instead enrich each other.
tionships). In SE, interpretations are guided The concept of the alliance used in SE has a
by the CCRT formulation and the interpreta- rich history in psychoanalytic writings. For
tions target the components. Studies have example, Greensons (1965) concept of the
explored the accuracy of therapists interper- working alliance and Zetzels (1958) concept
sonal interventions (i.e., the extent to which of the therapeutic alliance contributed to
the therapist addresses the interpersonal pat- Luborskys (1976) concept of the helping al-
terns that have been identified by indepen- liance. But, in contrast to many Freudians
dent judges to be salient for each patient). who saw the alliance as a background for
Crits-Christoph, Cooper, and Luborsky (1988) transference interpretation, Luborsky views
showed that accurate interpretation of the pri- the alliance as curative. There is a substantial
mary CCRT wishes (W) and ROs was signifi- body of empirical evidence indicating that a
cantly related to good outcome in a sample of good alliance predicts positive treatment out-
neurotic patients treated with SE, even after come (Horvath & Symonds, 1991).
controlling for the effects of general errors in
technique and the quality of the therapeutic
alliance. Delivering expressive techniques METHODS OF ASSESSMENT
(i.e., interpretations) in a competent manner AN D I N TERV EN T ION
(Barber, Crits-Christoph, & Luborsky, 1996)
was associated with lower depression in SE, ASSESSMENT
controlling for patient severity, quality of the
therapeutic alliance, and delivery of support- Assessment is usually done through clinical in-
ive techniques. More recent research indi- terview, as in standard practice. The therapist
cates that accurate interpretations of the collects information in the first sessions about
CCRT predict change in depression over the the patients background, current living and so-
first eight weeks of cognitive therapy for cial situation, presenting problem, history of
depression, and also predict retention in cog- psychological difficulties, and past treatment.
nitive therapy for opiate addiction (Crits- The case formulation also evolves over the course
Christoph et al., 1996). Considering another of the first few sessions by reviewing patient nar-
aspect of the impact of accurately interpreting ratives to develop the CCRT. Either therapist
the CCRT, Crits-Christoph, Barber, and Kur- notes, case material, or transcripts can be used to
cias (1993) showed that therapist accuracy in develop the CCRT. The case formulation based

on the CCRT serves as the basis for intervention in the struggle to overcome aspects of self-
and is modified as new data are provided by the defeating CCRT problems through the helping
patient over the course of therapy. alliance with the therapist. Third, the patient
When SE therapy is used in research settings, leaves therapy with an internalized mastery of
a patient typically receives a full structured the CCRT patterns by both internalizing the
diagnostic interview with a separate clinical image of the supportive therapist and internal-
evaluator prior to meeting with the therapist. izing and being able to use the understanding of
Luborsky and Crits-Christoph (1990) have the CCRT outside of the therapy room.
described the Relationship Anecdotes Para-
digm (RAP), a semistructured interview used Beginning Phase of Treatment
to gather narratives from which a CCRT can be The beginning stage involves setting the goals
created. Patients are asked to tell about specific and establishing the therapy arrangements. The
and meaningful events that involved them with therapist works with patients over the first few
another person; they are asked to provide spe- sessions to establish the goals of treatment,
cific information about the place and time of the which usually focus on the alleviation of symp-
event and what happened and was said during toms. Some patients start with an interpersonal
that incident. Patients are asked to tell 10 of focus, seeking help specifically for difficulties
these interactions involving diverse people. It in interpersonal relationships. The therapist
has been found that RAP narratives told prior works to ground the symptoms within an inter-
to treatment are very similar to narratives told personal framework by summarizing recent or
in the first sessions of therapy (Barber, Lu- past interactions when symptoms arose.
borsky, Crits-Christoph, & Diguer, 1995). Another therapist task is to explain the treat-
ment process or how treatment works. A num-
ber of researchers have found that informing
INTERVENTION or even educating patients about the treatment
process can aid in retention in or satisfaction
What Changes in SE Therapy? with treatment (e.g., Hoehn-Saric et al., 1964).
The Principles of Psychoanalytic Psychotherapy: Many patients are uncertain of what therapy
A Manual of Supportive-Expressive Therapy (Lu- entails and often expect advice or more direc-
borsky, 1984) serves as the foundation for tive treatment than is offered in dynamic ther-
CCRT-based therapy or SE psychodynamic apy. Patients need to be advised that they will
psychotherapy. This general manual is cur- take the lead in determining the course and
rently under revision by Luborsky; other au- content of the session. In addition, a therapist
thors have expanded or modified the work for goal is to aid patients in developing their own
specific patient populations (see below). In the understanding of their problems, leading to pa-
general manual, Luborsky (1984) suggests that tient-generated solutions rather than telling
there are specific changes that occur in SE ther- the patient what to do. The therapist can also
apy. First, the patient comes to an increased un- tell patients that they will be focusing on inter-
derstanding of the core conflictual relationship personal relationships. The Luborsky (1984)
problems and symptoms. This understanding manual contains a socialization script that can
leads to changes in symptoms and greater mas- be used for these purposes. Finally, the thera-
tery over deleterious expressions of the CCRT pist clarifies the treatment arrangements as to
and changes in some components of the CCRT where, when, and how frequently sessions will
(e.g., responses of other or self) (p. 16). Second, occur. It