Contemporary Psychodynamic Psychotherapy for Children and Adolescents

Home , Anna Freud, Charles Rycroft, Edward Tronick, Electra complex, Mahler on the Couch, Margaret Mahler

Integrating Intersubjectivity and Neuroscience

Sergio V. Delgado Je rey R. Strawn Ernest V. Pedapati

123 Contemporary Psychodynamic Psychotherapy for Children and Adolescents

Sergio V. Delgado • Jeffrey R. Strawn Ernest V. Pedapati

Contemporary Psychodynamic Psychotherapy for Children and Adolescents Integrating Intersubjectivity and Neuroscience Sergio V. Delgado, MD Ernest V. Pedapati, MD, MS Division of Psychiatry Division of Psychiatry and Child Psychiatry and Child Psychiatry Cincinnati Children’s Hospital Division of Child Neurology Medical Center Cincinnati Children’s Hospital Cincinnati , OH Medical Center USA Cincinnati , OH USA Jeffrey R. Strawn, MD Department of Psychiatry and Behavioral Neuroscience University of Cincinnati Cincinnati , OH USA

ISBN 978-3-642-40519-8 ISBN 978-3-642-40520-4 (eBook) DOI 10.1007/978-3-642-40520-4 Springer Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014956865

© Springer-Verlag Berlin Heidelberg 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com) To my patients and students —SVD

To Elliott Nicole and Rachel Marie — JRS

To Carolyn, Noah, and Harrison — EVP

Foreword

Psychodynamic psychotherapy with children and adolescents is undergoing a transition. With the advent of this carefully crafted and wise volume, the sea change unfolds before our eyes. Setting full sail, billowing out with the strong and refresh- ing wind afforded by the creativity and responsiveness of working intersubjectively in the here and now, the authors chart the metamorphosis from a one-person psychology to a two-person relational psychology. This is done in such fashion that we want to take the voyage with them that they collegially invite us on. Sea metaphors aside, the book explains, integrates, and summarizes an incredi- ble amount of information between two covers. Building on and furthering concepts cogently developed in Delgado and Strawn’s striking fi rst volume, Diffi cult Psychiatric Consultations : An Integrated Approach, the present masterful volume, with an additional coauthor Pedapati, starts with a thorough grounding in the history, evaluation, distinct characteristics, and vocabularies of the one-person and two-person models. Additionally, contributions of key pioneers from both ways of conceptualizing and working, including transitional fi gures and long-neglected trail blazers ousted by the orthodoxy, are respectfully examined evaluated and contrasted. The advances in attachment theory, systems theory, developmental psychology, genetics, and neuroscience are synthesized and beautifully applied to the subject at hand. Case examples covering all phases of development synergistically illustrate the two-person relational approach. The neurobiology of intersubjectivity, alongside research advances in meaning- making processes, relational schemas, implicit working memory, social reciprocity, cultural factors, temperament, and cognition are explained and their application to psychotherapy demonstrated. These concepts dance along in the narrative and are combined in interesting ways, building into a deconstructing force upon stale ideas and bounding toward a joyous rendering of contemporary thinking, buoyed by the wealth of recent knowledge. Moreover, all of these contemporary concepts are admirably clarifi ed and explained and their therapeutic applications demonstrated, in the writing of these authors. When you put your own subjectivity fi rmly on the playing fi eld, you are no longer in the stands observing the fray; you are in the fray. The mindfully solid cornerstone of the book is the explication of the four pillars of the contemporary diagnostic interview, namely, temperament, cognition, cognitive fl exibility, and internal working models of attachment. As noted by the authors,

vii viii Foreword

“The four pillars are the synergy of innate and environmental processes that become the blueprint of how a child learns to develop and maintain self-regulation abilities and unique implicit relational patterns to successfully interact with others.” How this approach is applied and the variables involved in the application pave the way toward understanding how one arrives at accurate diagnostic formulations and how these are used in developing sequential treatment plans, tailored for each individual patient and their family, that have the best chance of a successful outcome. Useful tables, wise suggestions, and rich case vignettes give immediacy to the concepts that come alive in the here and now for the reader now fully absorbed in the material. This was my experience as a reader. Also, I experienced something very interesting when going through the four pillars chapter and indeed with the reading experience of the book overall. The book is put together and fl ows in such a way that a sense of safety and security becomes present in the reader. Even more importantly the book engenders a “space of vitality” that frees the mind as one experiences the welcoming and accepting atmosphere that pervades the book. In refl ecting on my personal “voyage” with the authors, with some surprise I perceived that I was learning the material at an implicit level. My recall had a clarity and substance that gave a conviction that I was prepared and ready to use these concepts without feeling the need to go back over things, reread paragraphs, or laboriously memorize anything. My reading experience was so attuned to the intentions of the authors that the material was entering into my implicit nondeclarative memory system. Extraordinary. In conclusion, I feel it is important to note that the lead author, Sergio V. Delgado, MD, was my supervisor and teacher throughout my child and adolescent psychiatry training at the Menninger Clinic as well as for the duration of my training in child and adolescent psychoanalysis through the Topeka Institute for Psychoanalysis. In addition he was vitally important in preparing me for my last position at Menninger as Director of the Child and Adolescent Psychiatry training program in the Karl Menninger School of Psychiatry. He also ensured that I graduated “under the wire,” so to speak, as the last child and adolescent psychoanalyst graduating from the Topeka Institute of Psychoanalysis. I never stop learning from him, and these preliminary remarks refl ect that. May the reader’s learning experience from this book be equally gratifying.

Topeka , KS , USA Kirby Pope , MD Pref ace

This book is written with several audiences and several goals in mind. First, we aim to expand, synthesize, and contextualize the contemporary two-person relational psychodynamic psychotherapy literature as it relates to children and adolescents. Second, we seek to integrate the contributions from developmental research, neuroscience, and intersubjectivity with regard to the clinical work of the two-person relational psychotherapist. These important contributions have historically been considered as having limited value by those of the traditional one-person model. Third, we hope to guide child and adolescent psychiatry trainees, as well as newly minted and experienced child and adolescent psychotherapists, to discover the advantages of a multidimensional, four-pillared contemporary diagnostic interview (CDI) in order to carefully develop well-informed diagnostic formulations. These formulations will allow the psychotherapist to identify those children and adolescents for whom a psychodynamic psychotherapeutic approach will be most helpful, as well as those for whom this approach may not be ideal. Here, we would also note that the CDI facilitates observing and participating in the interactions of patients and their parents or caregivers, which will ultimately capture a spectrum of information not accessed in a standard diagnostic interview that is based solely on criteria from the Diagnostic and Statistical Manual of Mental Disorders , 5th Edition (DSM - 5). In addition, the information obtained through a CDI (e.g., temperament, cognition, cognitive ﬂ exibility, and internal working models of attachment) enhances the relevance of the clinical signs and symptoms that are obtained through the “standard interview,” thus facilitating a comprehensive two-person relational psychodynamic formulation. Moreover, we include a CDI tool that will help guide the clinician to choose the interventions needed (e.g., psychodynamic, behavioral, or pharmacological). Further, we provide real-world cases that allow the reader to intimately follow the thought processes of the two-person relational psychotherapist in his work with children and adolescent. We recognize that, as with any approach, there will be skeptics about our thinking and way of working. The notion of a two-person, relationally based psychodynamic model of psychotherapy may not be well received by some clinicians, including those who may be anchored in traditional one-person psychoanalytic circles, as it challenges a key tenet of the one-person model: the archaeological approach of unearthing an unconscious and conﬂ icted past. However, we would argue that the traditional one-person model must accept the relevance of two-person

ix x Preface relational psychotherapeutic interventions within the context of accrued knowledge from attachment and temperament theories, contemporary neuroscience, developmental research, as well as cognitive and social psychology. Knowledge of the two- person relational approach to psychotherapy will allow for a more comprehensive understanding of the complexity of the human mind and how it works. A two- person relational model relies on an understanding of the bidirectional communication that is inherent in the here-and-now experiences between the patient and the psychotherapist. This bidirectional infl uence depends on continuous work with their mutual intersubjectivities (i.e., the participating in and understanding of the subjective experiences of another that occur in the psychological fi eld between the two participants) and involves an intimacy with the patient and his or her parents or caregivers that some may challenge as compromising the “true objectivity of the transference manifestations.” To this, we respond that “true objectivity” as a construct fails to take advantage of recent contributions from neuroscience, developmental research, attachment theory, and intersubjectivity. Additionally, our hope is that the reader may appreciate some of the persistent dilemmas that have evolved in the two-person relational model and that this book will provide the student, in the broader sense of the term, with a clear, relevant, and practical approach to the young patient, as well as an understanding of when a psychodynamic psychotherapy approach is deemed to be benefi cial. Ultimately, this book will have day-to-day clinical relevance to the practicing child and adolescent psychiatrist or psychotherapist. The seeds from which this book grew were sown by the lead author’s years of practicing and teaching in both the traditional one-person and two-person relational psychoanalytic psychodynamic theories. The lead author, as he has taught child and adolescent psychiatry trainees, as well as candidates in adult and child psychoanalysis, recognized that the traditional one-person model of conceptualizing the psychological diffi culties of the child and adolescent limited clinicians. Disenchanted by the prevailing explanations of unconscious drives, ego defenses, object relations, and self-psychological constructs for his patients’ struggles, he recognized that these approaches often fell short. He felt these formulations did not account for the psychotherapist’s here-and-now experience. Moreover, the experience of teaching two-person relational psychology to child and adolescent trainees and psychoanalytic candidates revealed the need for understanding the four pillars of a contemporary diagnostic formulation of patients’ diffi culties (i.e., an understanding of temperament, cognition, cognitive fl exibility, and the internal working models of attachment). There is an urgent need for a practical and clinically relevant approach to help trainees tease out their patients’ strengths and weaknesses and to help the trainees tailor treatment interventions. This is particularly relevant in the current era in which trainees now evaluate and treat more psychologically ill patients and increasingly struggle to “fi nd good psychodynamic psychotherapy cases.” Moreover, trainees now more than ever are treating children who need help learning how to survive and how to grow in their disruptive and unpredictable environments. Thus, the decision to write this book began with a number of active discussions among the authors, despite generational differences. The authors also became increasingly aware of a Preface xi disconnect between teaching and supervision in the contemporary model. This dys- synchrony occurs in the context of the traditional one-person psychology model, wherein the relevant and practical concepts from the contemporary relational and intersubjective theories are neither taught nor integrated into clinical practice. Importantly, this happens despite the increasing acceptance of two-person relational psychology in many psychodynamic venues, and it is perpetuated by a dearth of user-friendly material in the standard psychiatric texts and journals that are fre- quented by trainees. In fact, most articles regarding contemporary two-person relational psychotherapy are found in psychoanalytic journals and publications for psychologists and social workers, thus limiting its dissemination to the child and adolescent psychiatry trainee. The junior author began to nudge the lead author by asking, “Why don’t you start a relational advanced psychotherapy program or, even better, write a book about two-person relational psychotherapy in children and adolescents? The last book about relational child psychotherapy was published in 2002.” We are happy to say that what started as a collection of ideas has become a reality. The Relational Advanced Psychotherapy Program (RAPP) is in its second year with ten members—some being trainees and others faculty. We are also happy to say that we completed our book with the hope that it will become a “go-to” resource for child and adolescent psychiatry trainees and clinicians who may wish to learn about the captivating and rewarding contemporary two-person relational approach. Although the authors’ paths in learning about the two-person relational psychology were different, our destination has been the same: to share with our colleagues what we have learned and what has shaped us. Therefore, in this book, we have made efforts to represent the views of both the expert in the two-person relational model and the skeptic of the two-person relational model in order to help readers arrive at their own conclusions.

The Authors’ Journeys

Sergio V. Delgado

I was fortunate to train in child and adolescent psychiatry and child psychoanalysis at the Menninger Clinic in Topeka, Kansas, more than 20 years ago. This helped me be thoroughly emerged in traditional one-person psychology and also exposed me, in readings and in person, to the early pioneers of the two-person relational discoveries. At the Menninger Clinic, the faculty and supervisors were predominantly psychoanalysts who taught in a pluralistic and eclectic manner. Some were Freudian, others were skilled in teaching Kleinian object relations theory and ego psychology, and some adhered to self-psychology. In tandem with the psychoanalytic teachings, family therapy was a requirement for trainees and was taught by skilled social workers who favored understanding patients within the context of their family system. The skilled family therapy supervisors were instrumental in requiring exposure to the readings of the works of such well-regarded family therapy theorists and clinicians as Minuchin, Haley, the Milan group, Satir, and Bowen. xii Preface

My training included learning the value of using information obtained through cognitive psychological testing and of corroborating and expanding upon the information gathered from the clinical diagnostic interviews. This provided a wider base of understanding through adding clinical information on cognitive defi cits and learning problems. In essence, during my training, I learned that the psychological landscape of the child and his or her family was best understood when approached from different theoretical perspectives and integrated in a coherent manner to tailor useful and practical treatment recommendations, including psychotherapy, family therapy, tutoring, and medication management. Additionally, during my training, developmental research had begun to emerge and gain momentum across the country. I was fortunate to have participated in video recordings of the stranger anxiety experiments involving infants and toddlers of unwed teenage mothers, which were used to learn about the quality of these mothers’ attachment to their children and were reassessed at 6 and 12 months. As a resident, I met Sir John Bowlby, who, in spite of recovering from painful shingles, had the energy to discuss with great fervor the importance of internal working models of attachment between infant and caregivers necessary for survival. Several years later, I was exposed to Dr. Daniel Stern, who gave a Grand Rounds presentation at the Menninger Clinic. Stern had theoretically departed from Margaret Mahler’s work and discussed his research about the complex developmental strides of the child during the fi rst 2 years of life when their mother provides the necessary affective attunement. Further, I was asked by my colleagues and friends, Kathryn Zerbe and Glen Gabbard, to present at a clinical case conference to Dr. Robert N. Emde, a psychoanalyst and mentee of René Spitz, who was to be the discussant. Dr. Emde was distinguished by his work in infant research, explicating the role that emotional availability, affective attunement, and social referencing had in the child’s attachment to their caregivers. The clinical case presentation led to the publication, with Drs. Emde and Pope as coauthors, of An atypical eating disorder in a 2 -year -old female , which solidifi ed my thirst to learn two-person relational psychology in depth and began my questioning of the “truths” of the traditional one-person model. This proved to be a more challenging task, as I had begun the time- demanding training in adult and child psychoanalysis at the Topeka Institute for Psychoanalysis (TIP). At the TIP, I was exposed to an eclectic curriculum, with readings from such prominent authors as Freud, Jung, Suttie, Erikson, Horney, Sullivan, Klein, Kohut, Rinsley, Fairbairn, Guntrip, Fonagy, Benjamin, and Hoffman. I later became a training and supervising adult and child analyst and eventually the director of the child psychoanalytic training program. Becoming a training and supervising adult and child analyst in an eclectic institute permitted me to have a balanced and in-depth understanding of the pluralistic traditional one-person models and the two-person relational models, which is not common in all institutes. This gave me an advantage that allowed me to recognize the enchantment and limitations of the traditional one- person psychology with more clarity. In 2002, I moved to Cincinnati to join the department of child psychiatry at the Cincinnati Children’s Hospital Medical Center, with the goal of enhancing the child and adolescent psychiatry trainee’s psychotherapy courses. I also joined the Preface xiii

Cincinnati Psychoanalytic Institute as a training and supervising adult and child analyst, which has had a tradition of adhering to the one-person model and shown more reluctance in accepting the contemporary two-person relational model. However, two-person relational articles have gradually made their way into the readings at the Cincinnati Psychoanalytic Institute’s Faculty Study Group. My launching of the Relational Advanced Psychotherapy Program (RAPP) has been slow to garner signiﬁ cant institute support but has been very gratifying nonetheless.

Jeffrey R. Strawn

I completed my residency training in general psychiatry at the University of Cincinnati. Following my general psychiatry training, I completed a fellowship in child and adolescent psychiatry at Cincinnati Children’s Hospital. My training at the University of Cincinnati, a program with strong foundations in traditional one- person psychodynamic psychotherapy, and my early psychotherapeutic work were strongly infl uenced by Freud’s drive theory, object relations, and self-psychology, with an emphasis on neutrality and boundaries. However, I began to notice limitations of the “archaeological” approach to patients’ problems, which emphasized the unearthing of confl icts and felt, at times, limited by an emphasis on therapeutic neutrality and interpretation as the primary vehicle of change in the context of traditional psychotherapeutic treatments. As I began my child and adolescent psychiatric training, I was exposed to the two-person relational approach by the lead author of this book. I quickly began to recognize the importance of alternative intersubjectivity-based approaches. In parallel with this increasing exposure to and practice of two-person relational psychotherapy, I directed the Pediatric Anxiety Disorders Clinic and Research Program, wherein I was using functional magnetic resonance imaging (fMRI) to examine the neurofunctional basis of anxiety disorders in children and adolescents and working to understand the neurophysiology of emotional processing in youths. As I conducted these research studies with various fMRI paradigms (i.e., tasks), I began to observe activation in a number of structures and regions that subserve self-other processing. The fi ndings of this neuroimaging research reverberated with my contemporary two-person relational psychotherapeutic work with children and adolescents. I enjoy teaching the two-person relational approach to psychotherapy to medical students, general psychiatry residents, and child and adolescent psychiatry fellows at the University of Cincinnati and Cincinnati Children’s Hospital Medical Center.

Ernest V. Pedapati

In my ﬁ nal year of medical school at the University of Massachusetts, I still could not decide between the body and the mind. Instead, I embraced my ambivalence and pursued the Triple Board Residency at the University of Cincinnati and Cincinnati xiv Preface

Children’s Hospital Medical Center. Unlike conventional child psychiatry training, the Triple Board emphasizes pediatric medicine with later specialization in psychiatry and child psychiatry. Rather than distance myself from mental health, my training in pediatrics inspired a curiosity for childhood development and gave me a new lens to pediatric psychopathology. I struggled with understanding why a child rav- aged with bone cancer struggled so vigorously to live or why a child caught in the depths of depression would so earnestly wish for death. Although my early supervisors helped me understand children psychologically through a traditional one- person lens, over time I found common ground with my pediatric training as I began to deepen my understanding of attachment theory, neuroscience, and social cognition. This inevitably led me to wholeheartedly embrace two-person relational psychotherapy, and I am grateful for the lead author’s invitation to collaborate in writing this book, which will enhance my colleagues’ psychotherapeutic experience.

Cincinnati , OH , USA Sergio V. Delgado, MD Jeffrey R. Strawn, MD Ernest V. Pedapati , MD Acknowledgments

We wish to credit our respected and admired colleagues Robert Emde, MD; Paul Wachtel, PhD; and Neil Altman, PhD, who laid the foundation for our journey to two- person relational psychotherapy through their eloquent and clinically masterful writings. We are forever appreciative of the time and effort that they took to read selected chapters and to make insightful comments that have greatly improved this book. We also are indebted to our close friend Kirby Pope, MD, who read the fi rst drafts of this manuscript, as well as subsequent revisions, and was gentle in sharing comments that helped shape the fl ow of the content of this book. The editorial comments of Drs. Emde, Wachtel, Altman, and Pope were mindful that, in many respects, two-person relational psychology has evolved from what was a one-person psychology. We would like to express our heartfelt gratitude to our young patients, who unknowingly contributed intersubjectively to this book in remarkable ways. They provided the clinical material through their subjectivities in here-and-now moments with us as psychotherapists. We also wish to thank our mentors and teachers, who provided the foundation for our appreciation of the multiple theories and complexities that must be considered if we are to understand and help our patients and their families. Additionally, we are indebted to our students, who helped us appreciate the pressures of trying to “fi t in” learning about the evolution of two-person relational psychology and psychotherapy, due to the prevailing pressures by colleagues and supervisors loyal to the traditional one-person psychology and those loyal to solely psychopharmacological interventions. Our students were also pivotal in encouraging the authors to “put it in writing,” not only the tenets of two-person relational psychology but, more importantly, specifi c case examples discussed from both a traditional one-person model and a two-person relational model, which we realized was very much needed. We want to express our warm thanks to Corina Schaefer, associate editor of clinical medicine at Springer Publishing. We are grateful for her steadfast support when we requested Springer to sponsor our book. She has provided the energy behind these pages and both believed in us and supported this project. Also, we give a heartfelt thank you to Greg Ford for his masterful and sensitive editorial assistance, with attention to detail, and his ability to make clearer our sometimes muddled sen- timents with his skillful use of the written word and grammatical prowess. We are grateful to the colleagues and students who took the time to read selected chapters and generously provided constructive criticism. They were kind enough to

xv xvi Acknowledgments point out what was not clear, what was confusing, what required further elaboration, and what we had omitted. Among these colleagues are: Mary Ahn, MD; Mary Singeltary, DO; Amanda Jones, OTR/L; Chris Marrett, MD; Heather Adams, DO; John Vraciu, DO; Yesie Yoon, MD; Deborah Reynolds, LISW-S; and Kellie Ryan, LISW. We also express our gratitude to Michael Sorter, MD and John Kerechek, MAS, who provided the enthusiasm and support for our work to become a reality. To all we say, thank you! I am indebted to Erin, my true love and muse, for providing the inspiration and patience to complete this book. She provided the challenging and clarifying comments due to her expertise in traditional one-person psychology. I will always remember her sharp and “loving” comments—“it sounds too much like gobbledy- gook”—when the manuscript needed help clarifying the complexities of two-person relational psychology, which proved to be useful “unedited” critiques that improved the readability of this book. Finally, I want to thank my friends and coauthors, Jeff and Ernie, who tolerated my Hispanic grammar and my strong views about the limitations of a traditional one-person approach, which they at times felt needed to be softened. We were able to maintain our close and intersubjective friendship despite our not-so-subtle disagreements. Finally, I apologize to the readers who may feel more could have been written to further clarify two-person relational clinical concepts or that may have wished for more clinical cases with lengthier and more detailed explanations. To them I say, our work is incomplete; we all have much to learn and we could have easily taken more time and energy without being able to capture all the nuances of a two-person relational model. Therefore I kindly encourage the reader to make use of this book as a springboard to further read the many eloquent books and papers referenced throughout the book. —SVD This work would not have been possible without the loving support of my wife, Lara, who from the beginning helped me to balance our life with the writing of this book, although she may still not agree that we reached equilibrium. Also, I thank my daughters, Elliott Nicole and Rachel Marie, for their daily lessons in intersubjectivity and attachment theory. My regular reminders of implicit relational knowing and development ultimately made the writing of this book possible. Finally, I thank my friends and coauthors, Sergio and Ernie, whose encouragement and always-present enthusiasm were the driving force for this work. —JRS The efforts placed on this book were greatly inspired by my own desire to relate and be in relation with my dear wife, Carolyn, and my two young and rambunctious sons, Noah and Harrison. I also recognize the implicit imprints left upon me by the careful care of my father, Francis, mother, Elsie, and my sister, Sheila. Though many of my contributions were informed by my clinical work, much was crafted in the cauldron of the messiness of real life, learning how to be a good therapist, a loving husband, and a caring and inexperienced new father. I am truly grateful for the encouragement and wisdom of my great friend and mentor Bob Turner, who over the course of two decades, continues to inspire in me a passion to be curious. As we conclude this project, I am thankful for Sergio and Jeff, who began as my mentors and continue as my friends and to whom I feel deep admiration for their tenacity and creativity. —EVP Contents

1 Introduction ...... 1 1.1 Making the Case for Two-Person Relational Psychodynamic Psychotherapy: A Neurodevelopmentally Informed Treatment . . . 4 Introduction to Two-Person Relational Psychology ...... 5 1.2 Context and Key Concepts in Two-Person Relational Psychology...... 7 1.3 Limitations of Two-Person Relational Psychology...... 10 1.4 How to Use This Book ...... 11 References ...... 12 2 Traditional One-Person Psychology...... 15 2.1 Traditional One-Person Psychology ...... 16 2.2 Historical Background of Traditional One-Person Model of Child and Adolescent Psychoanalysis and Psychodynamic Psychotherapy ...... 17 2.3 Freud and Classic Psychoanalytic Theories ...... 17 Sigmund Freud (1856–1939): Drive Theory...... 17 First Child in Psychoanalysis: Little Hans ...... 19 A Two-Person Relational Psychology View: Little Hans ...... 20 2.4 Freud’s Colleagues ...... 21 William Stekel (1868–1940) ...... 21 Carl Gustav Jung (1875–1961) ...... 22 Hermine von Hug-Hellmuth (1871–1924) ...... 22 Berta Bornstein (1899–1971) ...... 23 2.5 Ego Psychology...... 23 Anna Freud (1895–1982) ...... 23 Heinz Hartman (1894–1970) Autonomous Ego Functions...... 25 Erik Erikson (1902–1994) Theory of Psychosocial Development ...... 25 Two-Person Relational Psychology View: Ego Psychology ...... 25 2.6 Object Relations Theory ...... 26 Melanie Klein (1882–1960) ...... 26 Donald Winnicott (1896–1971)...... 27 Margaret Mahler (1897–1985) ...... 28

xvii xviii Contents

Peter Blos (1904–1997) The Second Individuation Process of Adolescence...... 29 Personality Disorders in Children and Adolescents ...... 29 Two-Person Relational Psychology View: Object Relations . . . . . 31 2.7 Self-Psychology ...... 31 Heinz Kohut (1913–1981)...... 31 Anna Ornstein (1927–) ...... 31 Two-Person Relational Psychology View: Self-Psychology...... 33 2.8 Summary ...... 33 References ...... 34 3 Two-Person Relational Psychology for the Child and Adolescent Relational Psychotherapist...... 37 3.1 Two-Person Relational Psychology ...... 38 Making the Case for a New Paradigm ...... 38 3.2 Historical Background of Two-Person Relational Psychology in Adults...... 41 Freud’s Dissenting Colleagues ...... 42 British Relational Theorists...... 44 American Relational Theorists ...... 45 3.3 Historical Background of Two-Person Relational Psychology in Child and Adolescent Psychotherapy ...... 46 American Two-Person Relational Child and Adolescent Psychotherapists ...... 47 Other Two-Person Relational Child and Adolescent Psychotherapists ...... 50 3.4 Two-Person Relational Psychodynamic Psychotherapy ...... 50 Basic Principles of a Two-Person Relational Psychodynamic Psychotherapy Process ...... 51 3.5 Two-Person Relational Experiences Are Contextual ...... 53 Realities in the Environment That Trigger a Person’s Anxiety...... 53 Interactions with Another Person That Implicitly Trigger Anxiety ...... 55 The Patient Unknowingly and Implicitly is Trying to Engage the Psychotherapist into a Relational Pattern that is Contextually Familiar...... 56 Uncertainty in Two-Person Relational Psychotherapy ...... 57 Anxiety in the Two-Person Relational Psychotherapist ...... 58 3.6 Critiques of the Two-Person Relational Model...... 59 3.7 Summary ...... 60 References ...... 60 4 Key Pioneers of Two-Person Relational Psychology...... 63 4.1 Developmental Psychology Researchers ...... 63 René Spitz (1887–1974) ...... 63 Robert Emde (1935–) ...... 64 Contents xix

Daniel Stern (1934–2012)...... 65 The Boston Change Process Study Group (BCPSG) ...... 66 L. Alan Sroufe (1941–) ...... 67 Edward Tronick (1942–) ...... 68 Andrew Meltzoff (1950–) ...... 69 Colwyn Trevarthen (1931–) ...... 69 Peter Fonagy (1952–) ...... 70 4.2 Developmental Psychology Synthesizers ...... 70 Allan Schore (1943–) ...... 70 Daniel Siegel (1957–) ...... 71 4.3 Developmental Theory and Theorist’s ...... 71 Attachment Theory ...... 71 John Bowlby (1907–1990) ...... 73 Mary Ainsworth (1913–1999)...... 73 Mary Main (1943–)...... 73 Lev Vygotsky (1896–1934)...... 74 Adoption Policies ...... 74 4.4 Temperament Theorists...... 74 4.5 Summary ...... 75 References ...... 75 5 Key Concepts in Two-Person Relational Psychology ...... 79 5.1 Meaning-Making Processes ...... 81 5.2 Affective Attunement ...... 83 5.3 Emotional Availability and Social Referencing ...... 84 5.4 Temperament...... 86 5.5 Internal Working Models of Attachment (IWMA) ...... 88 Attachment Patterns: Secure, Insecure-Ambivalent/Anxious, Insecure-Avoidant/Dismissive, and Insecure-Disorganized ...... 89 Secure Attachment ...... 89 Insecure-Ambivalent/Anxious Attachment ...... 89 Insecure-Avoidant/Dismissive Attachment ...... 90 Insecure-Disorganized Attachment ...... 90 5.6 The Contextual Nature of Attachment ...... 91 5.7 Fundamental Principals of Two-Person Relational Psychotherapy: Implicit Relational Knowing and Intersubjectivity ...... 93 Implicit Relational Knowing...... 93 Intersubjectivity...... 94 5.8 Real Relationship, Present Moments, Now Moments, and Moments of Meeting ...... 96 Real Relationship ...... 96 Present Moment, Now Moments, and Moment of Meeting ...... 96 Fuzzy Intentions and Sloppiness...... 100 Mentalization and Intersubjectivity...... 101 xx Contents

5.9 Corrective Emotional Experience ...... 102 5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy ...... 103 Andrew: A Securely Attached Child ...... 103 Implications for Two-Person Relational Psychodynamic Psychotherapy ...... 104 Bonnie: A Child with an Ambivalent/Anxious Attachment ...... 104 Implications for Two-Person Relational Psychodynamic Psychotherapy ...... 105 Carlos: A Child with an Avoidant/Dismissive Attachment ...... 105 Implications for Two-Person Relational Psychodynamic Psychotherapy ...... 107 Daniella: A Child Who Grows in a Disorganized Environment . . . 108 Implications for Two-Person Relational Psychodynamic Psychotherapy ...... 108 5.11 Summary ...... 110 References ...... 110 6 Deconstruction of Traditional One- Person Psychology Concepts ...... 115 6.1 Two-Person Relational Psychodynamic Psychotherapy: A Historical Context ...... 117 6.2 Clinically Relevant Concepts from Traditional One- Person Psychology: A Two-Person Relational Perspective...... 118 6.3 Traditional Unconscious in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 119 Unconscious in Traditional One-Person Psychology ...... 119 Unconscious in Two-Person Relational Psychology...... 120 6.4 Psychic Determinism in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 121 Psychic Determinism in Traditional One-Person Psychology . . . . 121 Psychic Determinism in Two-Person Relational Psychology . . . . . 121 6.5 Drive Theory in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 123 Drives in Traditional One-Person Psychology ...... 123 Drives in Two-Person Relational Psychology...... 123 6.6 Id in Traditional One-Person Psychology and Two- Person Relational Psychology...... 124 Id in Traditional One-Person Psychology ...... 124 Id in Two-Person Relational Psychology ...... 124 6.7 Ego in Traditional One-Person Psychology and Two- Person Relational Psychology...... 124 Ego in Traditional One-Person Psychology ...... 124 Contents xxi

Ego in Two-Person Relational Psychology...... 125 6.8 Superego in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 125 Superego in Traditional One-Person Psychology ...... 125 Superego in Two-Person Relational Psychology ...... 126 6.9 Psychosexual Stages in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 127 Psychosexual Stages in Traditional One-Person Psychology . . . . . 127 Psychosexual Stages in Two-Person Relational Psychology . . . . . 127 6.10 The Oedipus Complex in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 128 Freud’s Oedipus Complex...... 128 Jung’s Electra Complex...... 129 The Oedipus and Electra Complexes in Two-Person Relational Psychology...... 130 6.11 Latency in Traditional One-Person Psychology and Two- Person Relational Psychology ...... 131 Latency in Traditional One-Person Psychology ...... 131 Latency in Two-Person Relational Psychology...... 131 6.12 Adolescence in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 132 Adolescence in Traditional One-Person Psychology ...... 132 Adolescence in Two-Person Relational Psychology...... 133 6.13 Defense Mechanisms in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 135 Defense Mechanisms in Traditional One-Person Psychology . . . . 135 Defense Mechanisms in Two-Person Relational Psychology . . . . . 136 6.14 Object Relations Theory in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 137 Object Relations Theory in Traditional One-Person Psychology ...... 137 Object Relations Theory in Two-Person Relational Psychology ...... 138 6.15 Transitional Objects in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 139 Transitional Objects in Traditional One-Person Psychology . . . . . 139 Transitional Objects in Two-Person Relational Psychology...... 140 6.16 A Review of the Most Commonly Cited Defense Mechanisms in Traditional One-Person Psychodynamic Psychotherapy: A Two-Person Relational View ...... 141 Introjection, Projection, and Projective Identiﬁ cation in Traditional One-Person Psychology ...... 141 Introjection, Projection and Projective Identiﬁ cation in Two-Person Relational Psychology ...... 143 xxii Contents

6.17 Fantasy in Traditional One-Person Psychology and Two- Person Relational Psychology ...... 144 Fantasy in Traditional One-Person Psychology ...... 144 Fantasy in Two-Person Relational Psychology...... 144 6.18 Splitting in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 146 Splitting in Traditional One-Person Psychology...... 146 Splitting in Two-Person Relational Psychology ...... 146 6.19 Identifi cation with the Aggressor in Traditional One- Person Psychology and Two-Person Relational Psychology ...... 147 Identifi cation with the Aggressor in Traditional One- Person Psychology ...... 147 Identifi cation with the Aggressor in Two-Person Relational Psychology ...... 147 6.20 Treatment Goals in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 148 Treatment Goals in Traditional One-Person Psychology ...... 148 Treatment Goals in Two-Person Relational Psychology...... 149 6.21 Neutrality in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 150 Neutrality in Traditional One-Person Psychology ...... 150 Neutrality in Two-Person Relational Psychology ...... 152 6.22 Transference in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 153 Transference in Traditional One-Person Psychology ...... 153 Transference in Two-Person Relational Psychology...... 154 6.23 Resistance in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 154 Resistance in Traditional One-Person Psychology ...... 154 Resistance in Two-Person Relational Psychology ...... 155 6.24 Interpretations in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 156 Interpretations in Traditional One-Person Psychology ...... 156 Interpretations in Two-Person Relational Psychology ...... 156 6.25 Dreams and Parapraxes in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 157 Dreams in Traditional One-Person Psychology ...... 157 Parapraxes (Freudian Slips) in Traditional One-Person Psychology ...... 158 Dreams in Two-Person Relational Psychology...... 159 Parapraxes (Freudian Slips) in Two-Person Relational Psychology ...... 161 6.26 Countertransference in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 161 Countertransference in Traditional One-Person Psychology . . . . . 161 Countertransference in Two-Person Relational Psychology...... 162 Contents xxiii

6.27 Boundaries and Self-Disclosure in Traditional One- Person Psychology and Two-Person Relational Psychology ...... 163 Boundaries in Traditional One-Person Psychology ...... 163 Self-Disclosure in Traditional One-Person Psychology ...... 164 Boundaries in Two-Person Relational Psychology ...... 164 Self-Disclosure in Two-Person Relational Psychology...... 165 6.28 The Role of Parents and Family in Traditional One- Person Psychology and Two-Person Relational Psychology ...... 167 The Role of Parents and Family in Traditional One-Person Psychology ...... 167 The Role of Parents and Family in Two-Person Relational Psychology ...... 169 6.29 Everyday Life of the Patient in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 170 Everyday Life of the Patient in Traditional One-Person Psychology ...... 170 Everyday Life of the Patient in Two-Person Relational Psychology ...... 171 6.30 Psychopharmacology in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 172 Psychopharmacology in Traditional One-Person Psychology . . . . 172 Psychopharmacology in Two-Person Relational Psychology. . . . . 173 6.31 Other Forms of Psychotherapy ...... 174 6.32 The Use of the Couch in Traditional One-Person Psychology and Two-Person Relational Psychology ...... 174 6.33 Fairy Tales in Traditional One-Person Psychology and Two- Person Relational Psychology ...... 175 Fairy Tales in Traditional One-Person Psychology...... 176 Fairy Tales in Two-Person Relational Psychology ...... 177 6.34 Summary ...... 178 References ...... 179 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity...... 185 7.1 Developmental Psychology: A Foundation for the Neurofunctional and Neurostructural Understanding of Two-Person Relational Psychotherapy ...... 186 7.2 Core Concepts of Development ...... 187 7.3 The Neurobiology of Two-Person Relational Psychotherapy. . . . . 193 Neurodevelopment: A Broad Overview ...... 193 7.4 Structures and Networks in Two-Person Relational Psychotherapy ...... 194 Anterior Cingulate Cortex...... 194 Medial Prefrontal Cortex...... 195 The Amygdala ...... 196 The Default Mode Network ...... 197 The Mirror Neuron System and Its Functional Neurophysiology...... 198 xxiv Contents

7.5 Genetics and Two-Person Relational Psychotherapy ...... 199 Neurochemistry and Two-Person Relational Processes ...... 200 Neurostructural and Neurofunctional Basis of Temperament. . . . . 200 The Neurocircuitry of Implicit Relational Knowing...... 201 Neuroscience of Reﬂ ective Functioning ...... 202 References ...... 203 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview ...... 207 8.1 Contrast of the Contemporary Diagnostic Interview (CDI) to a Traditional Diagnostic Interview ...... 208 8.2 Overview of the Contemporary Diagnostic Interview (CDI) ...... 211 8.3 The Contemporary Diagnostic Interview ...... 213 The Clinician Provides an Atmosphere of Safety ...... 213 Approaching the Patient and Parents or Caregivers with Vitality...... 214 The Alliance: Goodness of Fit for Mutual Curiosity ...... 214 The Clinician Has an Open Frame of Mind ...... 215 8.4 The Four Pillars of the Contemporary Diagnostic Interview . . . . . 218 8.5 Temperament...... 218 Temperament Traits Derived from Thomas et al. (1970) ...... 219 Temperament Styles ...... 219 The Easy or Flexible Temperament Style...... 220 The Slow-to-Warm-Up Temperament Style ...... 220 The Difﬁ cult or Feisty Temperament Style...... 221 The Mixed Temperament Style...... 221 8.6 Cognition...... 222 Cognitive Weakness and Learning Disorders ...... 222 Assessing Cognition and Learning in a CDI...... 224 Assessing Visual–Spatial Abilities ...... 226 8.7 Assessing Cognitive Flexibility (Sense of Agency, Theory of Mind) ...... 227 Cognitive Flexibility in Adolescents...... 228 Brief Assessment of Cognitive Flexibility in Adolescents ...... 228 Cognitive Flexibility in Preschool and Elementary School Age Youth ...... 228 Brief Assessment of Cognitive Flexibility in Preschool and Elementary School-Age Youth ...... 229 8.8 Internal Working Models of Attachment (IWMA) ...... 229 Secure Attachment ...... 230 Ambivalent/Anxious Attachment ...... 231 Avoidant/Dismissive Attachment ...... 231 Disorganized Attachment ...... 232 Emotional Availability and Time-Outs ...... 233 Contents xxv

8.9 Putting It All Together: The Four Pillars of a Contemporary Diagnostic Interview ...... 234 Beginning the Interview ...... 234 Attending to the External Attributes of the Patient and Parents or Caregivers ...... 236 Other Approaches ...... 240 8.10 Diagnostic Formulation and Treatment Plan...... 241 Diagnostic Formulation...... 241 Disclosure by the Child and Adolescent Psychiatrist or Clinician ...... 242 8.11 Treatment Planning ...... 243 Psychotherapies...... 243 Two-Person Relational Psychodynamic Psychotherapy ...... 243 Cognitive and Behavioral Therapies ...... 244 Criteria for Psychotherapies ...... 244 Formal Cognitive Testing ...... 245 Criteria for Formal Cognitive Testing ...... 245 Pharmacological Interventions ...... 245 Criteria for Pharmacological Interventions...... 246 References ...... 246 9 Setting the Frame...... 249 9.1 What to Expect from the Psychotherapist...... 250 9.2 “Setting the Frame”: The Contemporary Diagnostic Interview (CDI)...... 250 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy. . . . 251 Consent to Treat ...... 251 Goals of Treatment ...... 252 Working with Parents ...... 252 Time ...... 253 Fees for Service...... 254 Third-Party Payers...... 255 The Offi ce ...... 256 The Waiting Room ...... 257 Confi dentiality (HIPAA) ...... 257 Communication...... 257 Offi ce Rules...... 258 Consent for Video Recording ...... 259 Use of Electronic Devices...... 259 Telepsychiatry ...... 260 Home and School Visits ...... 260 Use of Medication...... 260 Medical Records ...... 261 Special Situations ...... 261 Families as Ambassadors for Two-Person Relational Psychotherapy ...... 262 xxvi Contents

9.4 Summary ...... 263 References ...... 263 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children ...... 265 10.1 Psychodynamic Psychotherapy in Infants and Preschool Age Children ...... 267 10.2 Adam...... 267 History of Present Illness ...... 267 Past Medical History...... 268 Past Family History...... 268 Adam’s First Appointment with the Child Psychiatrist...... 268 Allowing Subjectivities to Meet: Developmentally Informed Mental Status Exam ...... 269 Contemporary Case Formulation Following Use of the CDI . . . . 270 10.3 Case Conceptualization from a Traditional One-Person Model . . 271 10.4 Two-Person Relational Psychodynamic Psychotherapy in Infants and Preschool Age Children ...... 272 Facilitating Enactments Cocreating New Relational Schemas . . . 273 Timing Self-Disclosures ...... 274 Working with Parents Intersubjectively ...... 274 Letting Go...... 275 Follow-Up ...... 275 10.5 Dilemmas in Two-Person Relational Psychodynamic Psychotherapy ...... 277 References ...... 277 11 Two-Person Relational Psychotherapy: Elementary School Age Youth ...... 279 11.1 Psychodynamic Psychotherapy in Elementary School Age Youth ...... 280 11.2 Heather ...... 281 History of Present Illness ...... 281 Past and Family History ...... 282 11.3 Case Conceptualization from a Traditional One-Person Model . . 283 11.4 Two-Person Relational Psychodynamic Psychotherapy in Elementary School Age Youth ...... 284 Allowing Subjectivities to Meet ...... 284 Facilitating Enactments Cocreating New Relational Schemas . . . 286 Timing Self-Disclosures ...... 289 Working with Parents Intersubjectively ...... 290 Letting Go...... 291 Final Session...... 291 11.5 Summary...... 292 References ...... 292 Contents xxvii

12 Two-Person Relational Psychotherapy: Middle School Age Youth ...... 293 12.1 Psychodynamic Psychotherapy in Middle School Age Youth . . . 294 12.2 Charlie...... 294 History of Present Illness ...... 294 Past History...... 295 12.3 Case Conceptualization from a Traditional One-Person Model ...... 296 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth ...... 297 Allowing Subjectivities to Meet ...... 297 Facilitating Enactments Cocreating New Relational Schemas. . . 298 Subsequent Session...... 300 Timing Self-Disclosures ...... 301 Traditional One-Person Model ...... 302 Working with Parents Intersubjectively ...... 302 Letting Go...... 306 12.5 Dilemmas in Two-Person Relational Psychodynamic Psychotherapy ...... 308 References ...... 309 13 Two-Person Relational Psychotherapy: High School Age Adolescents ...... 311 13.1 Psychodynamic Psychotherapy in High School Age Adolescents ...... 312 13.2 Michelle...... 312 History of Present Illness ...... 312 Past and Family History ...... 313 13.3 Case Conceptualization from a Traditional One-Person Model ...... 314 13.4 Two-Person Relational Psychodynamic Psychotherapy in High School Age Adolescents...... 316 Allowing Subjectivities to Meet ...... 316 Facilitating Enactments Cocreating New Relational Schemas . . . 319 Timing Self-Disclosures ...... 326 Working with Parents Intersubjectively ...... 327 Letting Go...... 328 Postscript...... 329 13.5 Summary...... 329 References ...... 330 14 Supervision ...... 331 14.1 Historical Background of Psychotherapy and Core Psychotherapy Competencies ...... 332 Psychotherapy Supervision as a Core Competency ...... 333 xxviii Contents

14.2 Becoming a Supervisor ...... 334 Supervision: From a Traditional One-Person to a Relational Two-Person Model...... 335 Supervision in a Traditional One-Person Model...... 335 Critiques of the Traditional One-Person Approach to Supervision ...... 335 14.3 The Two-Person Relational Model and Its Relevance to Supervision ...... 336 14.4 The Two-Person Relational Supervisor...... 338 Goals for the Relational Supervisor ...... 338 Limitations to a Two-Person Relational Supervisory Approach. . 339 14.5 Case Conceptualization in Two-Person Relational Supervision . . 339 14.6 The Supervisee in Two-Person Relational Supervision ...... 342 Using Intersubjectivity in Two-Person Relational Supervision . . 343 Lying in Supervision: A Two-Person Relational Approach . . . . . 346 Spontaneity in Supervision...... 346 14.7 The Use of Video Recordings in Supervision ...... 348 14.8 Concluding Thoughts on Two-Person Relational Psychotherapy Supervision ...... 350 References ...... 351

Appendix...... 353

Index ...... 367

About the Authors

Sergio V. Delgado , MD Dr. Delgado is Professor of Psychiatry, Pediatrics, and Psychoanalysis at Cincinnati Children’s Hospital Medical Center and the University of Cincinnati. Dr. Delgado is a graduate of the School of Medicine of the University of Nuevo Leon, and the Psychiatry and Child Psychiatry programs of the Karl Menninger School of Psychiatry and Mental Health Sciences. He also completed training as a supervising and training analyst in adult and child psychoanalysis at the Topeka Institute for Psychoanalysis. Currently, Dr. Delgado is an adult and child supervising and training analyst at the Cincinnati Psychoanalytic Institute. He currently is the Medical Director of the Outpatient Child and Adolescent Psychiatric Services at Cincinnati Children’s Hospital Medical Center. Dr. Delgado is the co-chair of the psychotherapy committee of the American Academy of Child and Adolescent Psychiatry. He is the President for the Cincinnati-Dayton Regional Council of the American Academy of Child and Adolescent Psychiatry. He also serves as a Child and Adolescent Psychiatry Oral Board Examiner for the American Board of Psychiatry and Neurology. Dr. Delgado actively teaches in the adult and child psychiatry training programs and is Director of Psychotherapy for the child and adolescent training program. He is a frequent recipient of numerous teaching awards for his helpful and pragmatic teaching and supervising style. Dr. Delgado is frequently sought for supervision and consultation involving difﬁ cult psychiatric cases. He is a strong advocate for the integration of individual psychotherapy, family psychotherapy, and psychopharmacological interventions in the treatment of patients. Dr. Delgado has authored multiple journal articles and book chapters about the integration of psychopharmacologic and psychotherapeutic treatments in the youth, on the assessment and treatment of learning disorders, and on psychological development and intersubjectivity-based interventions in adolescents. Dr. Delgado is the Founder and Director of the relational advanced psychotherapy program (RAPP) in Cincinnati.

Jeffrey R. Strawn , MD Dr. Strawn received his bachelor’s degree in biology from the University of Kentucky and then completed his residency training in general psychiatry at the University of Cincinnati. Following his general psychiatry training, he completed a fellowship in child and adolescent psychiatry at Cincinnati Children’s Hospital.

xxix xxx About the Authors

Currently, Dr. Strawn is an Assistant Professor of Psychiatry and Pediatrics at the University of Cincinnati and Cincinnati Children’s Hospital Medical Center and is the Director of the Pediatric Anxiety Disorders Clinic at the University of Cincinnati. His clinical work focuses on the psychopharmacologic and psychotherapeutic treatment of anxiety disorders in children and adolescents, and his research program focuses on elucidating the underlying neural circuitry of these conditions, using functional magnetic resonance imaging. Additionally, he is actively involved in the testing of innovative treatments for youth with mood and anxiety disorders. Dr. Strawn has published more than 75 papers and book chapters, and his research has been acknowledged by numerous organizations, including the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry. He enjoys teaching and is actively involved in the teaching of psychotherapy with adolescents and the treatment of adult and pediatric anxiety disorders to medical students, general psychiatry residents, and child and adolescent psychiatry fellows at the University of Cincinnati and Cincinnati Children’s Hospital Medical Center.

Ernest V. Pedapati , MD Dr. Pedapati is an Assistant Professor of Psychiatry at the University of Cincinnati and maintains a joint appointment in the Division of Psychiatry, Neurology, and Pediatrics at Cincinnati Children’s Hospital Medical Center. He completed medical school at the University of Massachusetts. He completed his Triple Board Program at Cincinnati Children’s Hospital Medical Center which is a combined residency in pediatrics, adult psychiatry, and child and adolescent psychiatry. He is board certiﬁ ed by the American Board of Pediatrics. Dr. Pedapati is extensively involved in clinical and research work involving autism and developmental disabilities. He received the institutional Proctor Scholarship which supports the career development of early physician scientists. He is currently a child psychiatry consultant to the Division of Developmental and Behavioral Pediatrics at Cincinnati Children’s Hospital Medical Center. Dr. Pedapati is a member of the Autism Research Group at Cincinnati Children’s Hospital Medical Center and conducts clinical trials and basic psychological research in children with social impairments and repetitive behaviors. In addition, he is a part of an interdisciplinary research team which studies the neurophysiology of neuropsychiatric illness through transcranial magnetic stimulation. Introduction 1

If I had to give a young writer some advice I would say to write about something that has happened to him; it’s always easy to tell whether a writer is writing about something that has happened to him or something he has read or been told. — Gabriel García Márquez

This book will provide the novice or experienced child and adolescent psychiatrist or psychotherapist an objective view of how the advances in attachment theory, systems theory, developmental psychology, and neuroscience have contributed to the contemporary practice of psychotherapy in children and adolescents. Consequently, with these advances, child and adolescent psychodynamic psychotherapy has transitioned from a traditional one-person model to a contemporary two-person relational psychotherapy model to an understanding of the psychological development of children and adolescents. We defi ne traditional one-person psychology as that which is based on traditional psychoanalytic concepts and the form of technique that emphasizes the role of the psychotherapist as an objective observer (one-person) of the patient’s ego defenses (the symptoms) and the discoverer of the truth regarding the patient’s intrapsychic confl icts and object relations (the patient’s inner life). Further, a goal of the traditional one-person model is to make the repressed and unconscious confl icts conscious through the use of interpretations by the psychotherapist. We defi ne two-person relational psychology as a model based on the integration of innate genetic, biological, psychosocial, and cultural factors. The psychotherapeutic intervention occurs at an implicit level, with the goal of a new emotional experience to create more adaptive patterns of interaction with others. To this, the psychotherapist and patient are mutually engaged in each other’s subjectivities (two-person) and states of mind. The two-person relational psychotherapist facilitates the psychotherapeutic process through enactments and self-disclosures that frequently occur unknowingly by the psychotherapist, although, at times, can be carefully timed, to move along the psychotherapeutic relationship. As Wachtel (2010 ) states, “two-person psychology takes the relationships seriously.” The choice of the term two-person relational psychology is designed to convey to the reader that in any here-and-now interaction, there are two present and active people mutually infl uencing each other’s subjectivities in the intersubjective fi eld.

© Springer-Verlag Berlin Heidelberg 2015 1 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_1 2 1 Introduction

Although the interaction may be of two people (e.g., patient and psychotherapist), it is important to note that, in vivo, these processes are actively infl uenced and directed by previous relational experiences. In contrast to a traditional one-person model, the in vivo experiences in a two-person relational model require that the psychotherapist be “real” and genuine to allow the patient to implicitly know about his or her state of mind. That is, each person brings to the interaction a multitude of relational experiences stored in nondeclarative memory systems that infl uence the encounter, which are not limited to the relationship to their parents or primary caregivers. Nondeclarative memory refers to a dynamic nonconfl icted unconscious also referred to by the Boston Change Process Study Group as “nonconscious” (Chap. 5 ). The nonconscious processes begin during infancy and help the infant implicitly learn how to perform certain tasks without the use of conscious thought. Everyday examples include: walking, talking, smiling, laughing, playing, and riding a bike. The nondeclarative memory is also known as implicit or procedural memory. Infantile memories from early childhood are not accessible to verbal or symbolic recall, but rather are encoded within the nondeclarative memory system machinery that is unique to each child and is driven by their innate cognitive abilities (or limitations). A person’s representational models are fi ne-tuned in perpetuity as they make sense of the meaning, affect, and intentions of others within the intersubjective fi eld. Nondeclarative memory system is distinct from Freud’s “confl icted unconscious.” Freud’s confl icted unconscious is a central tenet to all one-person psychologies (i.e., drive, ego, object relations, and self) and is a concept that adheres to an innate psychic determinism, where nothing occurs at random; all mental events are caused by the interplay of the unconscious forces between the id, ego, and superego that preceded the event (see Chaps. 2 and 6) and are consciously retrievable through free associations and dreams. In this book, we will review the work of major psychodynamic psychoanalysts and psychotherapists over the last century (Table 1.1 ); our goal is to both applaud and critique their unique contributions. In addition, we will demonstrate the seductive nature of the pursuit of understanding human behavior by each theoretical school. For some, the transformation of the scientifi c advances in early childhood development into clinical applications has been viewed with a great deal of skepticism. It is reminiscent of the manner in which the works of John Bowlby, Donald Winnicott, and Donald Fairbairn were initially viewed, with skepticism, as they gave importance to the actual loving relationship between the infant and the mother while distancing themselves from Freud’s drive theory and Klein’s object relations theory. To date, the schism between the schools of traditional one-person psychology and two-person relational psychology remains, and we view this as problematic for the young clinician. Under the broad umbrella of psychodynamic psychotherapy for children and adolescents, there are those that hold to the importance of the Oedipus complex and the internal life of the child in the form of object relations when helping the child. In essence, the traditional one-person psychology model can be viewed as a long journey with the psychotherapist leading the patient to the excavation site considered by the psychotherapist to hold the valuable artifacts. Over time, 1 Introduction 3

One person Psychology Two person Psychology Contemporary Child Psychotherapists Neil Altman Barish Kenneth Alan Levy Robert Gaines Richard Briggs Frankel Jay Richard Bromfield Daniel Gensler Self-disclosure Inner world-Unconsciousconflicts Interpretations Co-construction, Enactment, Attachment Theory Attachment Mentalization Corrective Emotional Experience Corrective Harry Stack Sullivan Stack Sullivan Harry Mitchell Stephen Greenberg Jay HoffmanIrwin James Fossage Bromberg Phillip Paul Wachtel Wallin David René Spitz Robert Emde Ainsworth Mary Main Mary Greenspan Stanley Daniel Stern Beatrice Beebe Frank Lachmann Alan Meltzoff Mauro Mancia Gallese Vittorio Karlen Lyons-Ruth BCPSG* John Bowlby Donald Winnicott Ronald Fairbairn Peter Fonagy Individuation of Adol Individuation Intersubjectivity nd Affective Attunement, Developmental Psychology Psychology Developmental Heinz Kohut-Self Psychology Psychology Kohut-Self Heinz Anna Freud-Ego Anna Freud-Ego Psychology Melanie Klein-Object Relations Mahler-Sep-Individuation Margaret Peter Blos-2 Evolution of traditional one-person and two-person relational psychologies relational psychologies of traditional one-person and two-person Evolution Sigmund Freud Psychoanalysis Cognitive Psychology Cognitive Jean Piaget Erikson Erik Therapy Behavioral Cognitive Aaron Beck Dialectical Behavioral Therapy Marsha Linehan Family Systems Family Minuchin Salvador Bowen Murray Nathan Ackerman Deficits Temperament/Learning Thomas Alexander Stella Chess Joseph Palombo Table 1.1 *The Boston Change Process Study Group *The 4 1 Introduction using specialized tools, a careful reconstruction of the original site is accomplished by removing the suspected calamity, thereby ultimately resulting in a return to happiness. For many of us who are physicians or academics, this approach is not only personally appealing but consistent with our years of training. Yet, we would offer that such an approach to psychodynamic psychotherapy is somewhat lonely and distant for the patient, as the psychotherapist is an objective observer and thus considered a “one-person” model. Under the same umbrella of psychodynamic psychotherapy for children and adolescents, are those— authors included—that have incorporated the advances in developmental scientiﬁ c research in the form of meaning-making processes, emotional availability, social reciprocity, relational schemas, implicit working memory, and right brain regulatory functions into their theoretical understanding. These functions underscore the complexities in understanding that what may appear as a developmental or behavioral disturbance in the present may ultimately represent patterns imbedded in disturbances of the original caregiver–infant relationships (Sameroff and Emde 1989 ). We posit that the difference from a “one-person” model is that in the “two-person” model, the original caregiver–infant relationships are stored in a dynamic nonconscious at an implicit preverbal level and are not retrievable through autobiographic recall. As the title of this book suggests, the authors are very much immersed in a contemporary two-person relational model of psychodynamic psychotherapy for children and adolescents that integrates concepts of intersubjectivity —“the capacity to share, know, understand, empathize with, feel, participate in, resonate with, enter into the lived subjective experience from another” (Stern 2005 )—and neuroscience (see Chap. 5 ). Emde (2009 ) further states, “Much that is important to us as human beings is shared implicitly. We now have a neurobiology of intersubjectivity that is rapidly accumulating new knowledge; it involves basic nonconscious functioning and it has major implications for psychoanalytic work.” Additionally, Rustin and Sekaer (2004 ) state, “Although some psychoanalysts still dismiss the impact of neuroscience on psychoanalysis as ‘Darwinian,’ the general view is changing.” The two-person relational concepts reviewed in this book are written to help the reader expand, synthesize, and contextualize their applicability to a contemporary two-person relational psychodynamic psychotherapy, as it relates to children and adolescents. We seek to integrate the contributions from developmental research, neuroscience, and intersubjectivity. We emphasize that our book is strongly inﬂ u- enced by the works of Emde, Stern, Beebe, Lackman, Wachtel, Altman, Lyons- Ruth, and the Boston Change Process Study Group.

1.1 Making the Case for Two-Person Relational Psychodynamic Psychotherapy: A Neurodevelopmentally Informed Treatment

The book’s subtitle—“Integrating Intersubjectivity and Neuroscience”—was carefully chosen to underscore the critical neurobiological and neurodevelopmental basis of two-person relational psychotherapy. Importantly, recent advances in 1.1 Making the Case for Two-Person Relational Psychodynamic Psychotherapy 5 neuroscientifi c and behavioral research over the last two decades have greatly improved our understanding of relatedness, social cognition, and implicit memory. Moreover, these advances have given today’s two-person relational psychotherapist a greater understanding of “(1) the importance of early life experiences, as well as the inseparable and highly interactive infl uences of genetics and environment, on the development of the brain and the unfolding of human behavior; (2) the central role of early relationships as a source of either support and adaptation or risk and dysfunction; (3) that powerful capabilities, complex emotions, and essential social skills that develop during the earliest years of life; (4) the capacity to increase the odds of favorable developmental outcomes through planned interventions” (Institute of Medicine 2000 ). Thus, these advances in neuroscience serve as the bedrock for the work of the relationally informed psychotherapist’s practice. Increasingly, we appreciate the role of the infant as an active participant in the reciprocal meaning-making relationship with his or her parents or caregivers and the importance of the quality of this reciprocity with regard to his or her psychological development. Inherent to this social reciprocity is the brain’s ability to process and encode complex relational experiences and to manage complexity through the selec- tion, processing, and storing of memories that are interwoven with experiences. While the neurophysiologic processes that underlie these abilities (e.g., pruning, experience- dependent changes in functional connectivity, long-term potentiation, and neuromod- ulation) are discussed later in this book (Chap. 7 ), it is important to note that, in vivo , these processes are actively infl uenced and directed by relational experiences. We hope this book provides a path of collegial communication to better understand the contemporary two-person relational psychology “from the inside,” thereby clarifying misconceptions and minimizing misunderstandings. Additionally, we hope that it will plant seeds that will germinate with understanding in the fertile minds of the trainees, newly minted child and adolescent psychiatrists, and experienced clinicians alike, who are embarking in the use of this approach in their clinical work, and create cross-fertilization among different theoretical approaches to the children and adolescents who seek our help.

Introduction to Two-Person Relational Psychology

Two-person relational psychology, unlike its forerunners in the traditional one-person psychology arena, promotes the integration of concepts from intersubjectivity, mindfulness, family systems, cognitive therapy, dialectic therapy, interpersonal therapy, and client-centered therapy, when working with patients in psychotherapy. As such, two-person relational psychology encompasses the therapeutic work that is infl uenced by the real-life and genuine subjective experiences between patient and psychotherapist. The psychotherapist will make use of his or her own intersubjective experience to provide nonconscious or well-timed enactments and self- disclosures to promote new adaptive patterns of interaction that occur at the implicit level and may not be open to understanding at the explicit autobiographic level (see Chap. 3 ). In two-person relational psychology, the psychotherapist must attend to the ever-present fact that 6 1 Introduction interactions of mutuality are also infl uenced by context, bringing into the offi ce the realities of the child’s world (e.g., being bullied, witnessing family confl ict, diffi culties with learning). Thus, in two-person relational psychology, it is no longer necessary for the psychotherapist to feel that he or she must know the patient better than the patient knows him- or herself, in order to provide insight about the origin of their maladaptive ego defenses, which is a goal in traditional one-person models. Certainly, contemporary two-person relational psychology grew from a rich fi eld of traditional one-person psychologies. However, we no longer are allegiant in our loyalty to traditional, confl ict-based, and object relations theories. It is worth noting that even half a century ago, the psychoanalyst Donald Winnicott (Rodman 1987 ) wrote in his letters to Melanie Klein and Anna Freud that integration of increasingly disparate psychological schools was urgently needed. Winnicott , in pleading for integration, soon realized that those who were not loyal to the tenets of traditional one-person psychology and instead had divergent views would be described as “diffi cult,” “destructive,” or, simply, “dissenters.” Our hope is that we will not be viewed as “diffi cult or destructive” but rather that we will provide a much needed revision of the practice of psychotherapy integrating attachment theory, neuroscience, and developmental psychology. In Chap. 6 , we discuss the reasons why the concepts utilized by traditional one-person psychology are limiting in understanding a patient’s psychological struggles. For example, we describe the clear distinction between matters of unconscious, transference, resistance, defenses, etc. and suggest that the two-person relational psychotherapist jettison these terms in favor of a new two-person relational lexicon. We recognize that human interactions are shared experiences between two or more people. Furthermore, each interaction with others is also shaped by implicit stored experiences in nondeclarative memory systems of past relationships in the form of “relational schemas” of people with similar characteristics. The reader, at this point, may wonder whether the concept of relational schemas is similar to the traditional one-person forms of transference or object relations’ internalizations. Although at fi rst glance the distinctions of relational schemas between traditional one-person and two-person relational models may not seem necessary, with further study, the differences become evident. In a two-person relational model the relational schemas are formed through the complex array of a multitude of prior relationships (e.g., siblings, cousins, grandparents, neighbors, etc.) that nonconsciously infl uence new relationships (Emde et al. 1991 ). As an example, when a child approaches a teacher, his or her reaction is infl uenced by the authentic and personal attributes of the teacher, which will be implicitly processed through the child’s nondeclarative memories of many other people with similar attributes, resulting in the child inherently knowing how to relate with the teacher. If the teacher’s personal attributes are unfamiliar nonconsciously, the child will approach the teacher and create a new relational schema that will be stored in nondeclarative memory and can be used in the future. In the traditional one-person school, relational schemas are considered to be a person’s internalizations of the attributes of the other person in the form of “objects.” The internalizations are infl uenced by the unconscious forces of the id, ego, and superego. In using the example of the teacher, in a 1.2 Context and Key Concepts in Two-Person Relational Psychology 7 one-person model, the child approaches the teacher and unconsciously compares the teacher against internalizations of his or her original objects and will approach the teacher as a familiar good or bad object (i.e., transference). This concept of relationships infl uencing relationships helps understand the variability of how a person may relate in a certain way to one person and in a completely different manner with another person (Emde 1989 ). The familiar relational schemas that are nonconsciously evoked by to the characteristics of the other person are what are known as implicit relational knowing processes. When a person interacts with a person with unfamiliar attributes, a new relational schema is formed and stored in nondeclarative memory (Chap. 5 ). Therefore, those involved in the interaction will each have their own version of the truth of the cocreated experience . As an example, a toddler during a trip to a local store becomes obstinate and yells at his parents for not buying him the toy he wants. The toddler will likely experience some comfort when the parents recognize the need to help the child regulate his emotions. When things go well, the parent recognizes the appropriate developmental milestone that the toddler demonstrates—a wish for self-suffi ciency—but also that the toddler needs the parental affective attunement refl ecting back to the child that the action is not permissible and that the behavior is rewarded only after he or she settles down. The parent’s personal proclivities and past relationships with their own parents, siblings, cousins, peers, nieces, nephews, etc. allowed them to implicitly “know how” to help young children needing help self-regulating. That is, they had known how to help their child before his birth. In contrast, another parent may feel overwhelmed with the task at hand and become anxious or upset and be unable to help the child regulate his emotions, due to not having a nonconscious implicit relational model for this scenario, and confl ict ensues. The anxious parents did not have the relational schema to know how to help a child learn to self-regulate. When the interaction with the toddler is viewed through the lens of a traditional one-person psychology model, it seems reasonable for the clinician to think that the parent became anxious or upset due to their unconscious intrapsychic confl icts that were reawakened by the child’s negative request for affective attunement. This presumes that the anxiety, which was reawakened in the parents by the child’s demands, was the result of unresolved unconscious confl icts that originated in their own childhood.

1.2 Context and Key Concepts in Two-Person Relational Psychology

There is no doubt that psychological forces lead patients to tenaciously hold onto dysfunctional behavioral and relational patterns. In two-person relational psychology, the psychotherapist seeks to recognize the nonconscious infl uences (e.g., implicit memory systems reviewed in Chap. 3) of these patterns within the context of the patient’s world. The psychotherapist attends to the contribution of the patient’s contextual realities (e.g., physical limitations, genetic infl uences, 8 1 Introduction relational schemas, fi nancial hardships, etc.). The psychotherapist seeks to infl uence these dysfunctional behavioral and relational patterns through a here- and-now intersubjective and mutual approach in which he or she provides the patient, nonconsciously and implicitly, new and more adaptive patterns of self- regulation in the form of new emotional experience. As such, this notion is an important point of divergence from the traditional one- person model that presumes relational diffi culties and dysfunctional behaviors are strongly infl uenced by unconscious intrapsychic processes (e.g., drive and object relations) to their original parents. The one-person psychotherapist makes use of the patient’s autobiographic memories to understand the reason for the maladaptive ego defenses and, over time, provides insight through empathic suggestions or interpretations. As an example, the current obesity epidemic has not been helped by the barrage of advertisements about the dangers of obesity with regard to medical and psychological health. In fact, there are new federal guidelines that require fast-food res- taurants to display the calorie count of their meals, hoping that awareness will change behavior—consumption patterns. There is general agreement that internal psychological forces guide and shape our behaviors. In a traditional one-person model, the etiology of the eating behaviors that lead to obesity might be viewed as multifactorial, although they would generally be viewed within the context of unconscious drives and object relations; consideration would be given to whether the dysfunctional eating behaviors refl ect an oral fi xation to food, defense against recognizing the need for others, feelings of deprivation or confl icts regarding individuation and intimacy, etc. From a two-person relational viewpoint, the food choices and associated risk of obesity are infl uenced by: (1) genetic predisposition, (2) temperament (3) cognition—meaning-making processes with regard to risk and food, (4) implicit relational schemas, (5) early childhood socioeconomic factors, and (6) cultural preferences. Therefore the two-person relational psychotherapist of a patient who is struggling with obesity will need to carefully complete a contemporary diagnostic interview (Chap. 8 ) to assess the multifactorial aspects of the obesity and tailor the interventions to be practical and realistic, in regard to the patient proclivities—temperament, cognition, cognitive fl exibility, and internal working models of attachment. Additionally, in two-person relational psychology, the psychotherapist takes an active role with the patient, so that each becomes a partner to the other’s intersubjective experiences during the treatment. That is, the intersubjective experience incorporates both the patient and the psychotherapist’s personalities—temperament, cognition, cognitive flexibility, and internal working models of attachment—which are brought into the context of the therapeutic relationship. It is through this bidirectional process that the patient, over time, becomes able to implicitly use the psychotherapist’s healthier and more adaptive way of interacting with others, thus providing a corrective emotional experience for the patient, which will be stored in nondeclarative memory (implicit relational experiences). 1.2 Context and Key Concepts in Two-Person Relational Psychology 9

A Brief Glimpse into a Two-Person Relational Approach An 8-year-old boy was brought to an initial psychiatric evaluation for his anxiety. At the initial session, after creating an atmosphere of safety for the boy and his parents, the child psychiatrist proceeded to perform a card trick in which the boy selected a card from a deck and then replaced the card within the deck. The child psychiatrist invited the boy to snap his fi ngers and say, “Abracadabra!” At that point, the child psychiatrist showed the boy the deck of cards; the card the boy selected had “fl ipped over.” The boy smiled with excitement and asked to see another trick, demonstrating an easy/fl exible temperament (see Chap. 5), and the boy’s parents supported his excitement (i.e., refl ecting good affective attunement and secure attachment within the family system). Afterward, it was agreed that the boy would begin weekly play psychotherapy to help with his anxiety. During the fi rst several sessions, the child psychiatrist showed the patient a new card trick at each visit. The result: The patient was eager to come to the clinic and knew when his appointments were scheduled. Similarly, the boy’s parents were pleased by his initial progress and noted that their son was less anxious and that at home he would say that he felt better when he thought of the card tricks his psychotherapist had shared.

Thus, from a two-person relational model, the patient and psychotherapist had embarked on a path of mutual meaning-making processes. The psychotherapist took an active role in the here-and-now interactions with the child, to promote the mutuality of their subjectivities. The psychotherapist would make use of his intersubjective experiences to guide him about when the boy experienced the psychotherapist as “being like me,” joyful and happy. In these moments, he would match the boy’s tone of voice, language, and excitement, allowing for a new emotional experience (i.e., card tricks) and the development of new, less anxious, implicit relational patterns to be stored in nondeclarative memory, which will be described in detail in Chaps. 3 and 5 . This experience of change occurring at the implicit level is ubiquitous among two-person relational psychotherapists. Thus, although the changes may be noticed by the psychotherapist, he or she will need the fortitude to tolerate frequently not knowing specifi cally what led to the permanence of the changes. This is beautifully captured by Bromberg (2010 ) when he says, “the quality of uncertainty is basic to experience,” which is, ultimately, the vessel by which improvement occurs during a two-person relational approach. In the case of a child psychiatrist who is trained in the traditional one-person model, he or she may struggle to understand the 8-year-old boy’s improvement and might ask, “Was it a fl ight into health or unresolved transference manifestations?” “Was it a repressed confl ict that card tricks allowed to be worked through 10 1 Introduction in fantasy?” These hypotheses ostensibly exclude the nonconscious subjective contribution from the psychotherapist, which is sine qua non in two-person relational psychology.

1.3 Limitations of Two-Person Relational Psychology

We are keenly aware that, despite the advantages of the two-person relational approach, there will be skeptics, as is the case with any approach. Among the arguments that may be levied against this approach is that our method invites for closeness with the patient, and, potentially, the family, and that this intimacy could compromise true objectivity by the psychotherapist—although surely, based on contributions from attachment theory and intersubjectivity, we must recognize that “true objectivity” is a relative myth. Further, we believe that it is crucial to address the limitation of some two-person relational literature retaining the language of the one-person model. There is an urgent need to clarify the difference in meaning of the terms used in traditional one-person psychology, as these terms continue to prevail in the psychotherapeutic venacular and do not adequately represent two-person relational psychology. Additionally, we believe that some concepts within the context of two-person relational psychotherapy of children and adolescents need to be studied more extensively. Two-person relational psychology is a fairly new model of treatment, and many questions have yet to be quantitatively answered, which is a limitation of any new theory and could also be said to apply to some older theories. The two-person relational literature has not fully incorporated and researched the important infl u- ences beyond the two-person here-and-now relationship, i.e., siblings, extended family members, teachers, peers, etc. Therefore, we pose some questions that require further inquiry in a two-person relational approach. Might a two-person relational psychotherapist benefi t from more actively interacting with other important fi gures in the child’s life and have their input about how they subjectively experience the child and incorporate this information into the psychotherapy process? How would the two-person relational psychotherapist understand the collateral information, if ostensibly provided by psychologically healthy family members or teachers, if they subjectively experienced the child or adolescent differently than the psychotherapist? Is two- person relational psychology similar to the traditional one- person model, in that it relies on the child and parent as the primary source of intersubjective information during psychotherapy? Further, we are aware that intersubjectivity is inherently contextual. Might the context of a child’s or adolescent’s real-life experiences be helpful for the two-person relational psychotherapist to be familiar, beyond the here-and-now subjectivities with the patient? Wachtel (2010 ) answers, “The contexts in which we fi nd ourselves are very largely contexts that we have ourselves contributed to creating, that we have co-created with those who participate with us in that context.” Thus, how a two-person relational psychotherapist makes use of the variability in the “context” of a child’s or adolescent’s life warrants further research. Further, what are the infl uences of executive functioning 1.4 How to Use This Book 11 diffi culties in children with attention-defi cit/hyperactivity disorder in regard to their development of theory of mind and social reciprocity, essential for successful interactions with others? How do the developmental and hormonal shifts occurring during puberty infl uence nondeclarative memory systems? These are just a few of the many complex questions with which we will need to grapple with in the future.

1.4 How to Use This Book

This book is written with several audiences and several goals in mind. First, we aim to expand the contemporary two-person relational psychology literature and to present an effective method of using this model in psychodynamic psychotherapy of children and adolescents. Second, we have arranged the fl ow of this book to facilitate the reader being able to have a historical overview as to how these theories emerged in the landscape of psychotherapy for children and adolescents (i.e., the competing psychological theories: traditional one-person psychology and two- person relational psychology). Third, we aim to guide child and adolescent psychiatry trainees, as well as experienced clinicians, clinical psychologists, psychiatric nurse practitioners, and social workers, toward using a two-person relational approach in the practice of psychodynamic psychotherapy with children and adolescents. We have also included tables for effi cient review of relevant information while tailoring the interventions as needed, and we have provided relevant cases that allow the reader “to be on the shoulder of” the two-person relational psychotherapist during the sessions. We hope that this book additionally serves as a resource to colleagues and students of psychotherapy to better understand the work with their patients and to ask pertinent questions to their teachers and supervisors. Finally, we hope that the reader can use our book to integrate the rich value offered by contemporary two-person relational psychology, when asked to teach a psychotherapy course to students of their specifi c discipline. We begin in Chap. 2 , Traditional One-Person Psychology, by briefl y reminding the reader of the origins of the traditional drive, confl ict-based, object relations, one- person psychologies in working with children and adolescents and why its terminology remains in our everyday discourse when teaching or practicing psychodynamic psychotherapy. In Chap. 3 , Two-Person Relational Psychology for the Child and Adolescent Psychotherapist, we make the case that the work of contemporary two- person relational psychotherapists has evolved from traditional one-person psychological approaches, and we review the main differences and concepts of each model. After laying the groundwork for distinguishing between traditional one- and two-person relational psychologies, in Chap. 4, Key Pioneers of Two-Person Relational Psychology, we recognize the eloquent developmental researchers and theoretical synthesizers who gave legitimacy to two-person relational psychology. We follow with Chap. 5, Key Concepts in Two-Person Relational Psychology, in which we provide the reader the necessary understanding of the origin and meaning of two-person relational psychology concepts. In Chap. 6, Deconstruction of Traditional One-Person Psychology Concepts, we survey the differences of terms 12 1 Introduction used in both theories and provide a way to understand if they are interchangeable or incompatible and represent distinctly different concepts. Next, in Chap. 7 , The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity, we review the neurobiology of two-person relational psychotherapy that is ultimately subtended by a number of structures in the brain. In Chap. 8 , Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview, we outline an integrated approach to an initial evaluation of a child or adolescent that combines two-person relational psychology, neurobiology, and social science. We provide tables that help tailor appropriate treatment recommendations, not limited to psychodynamic psychotherapy. After the child psychiatrist or clinician has decided that psychodynamic psychotherapy in a two-person relational model is the treatment of choice, in Chap. 9 , Setting the Frame , we describe several important practical aspects for patient and parents or caregivers, as they prepare to become engaged in a psychotherapeutic process. This serves to provide reassurance about what to expect, to avoid having surprises when confl ict arises, and to have a sense of predictability about the process. In Chaps. 10 , 11 , 12, and 13, we will take the reader through a series of cases involving an infant, school age youth, and an adolescent. These vignettes and the accompanying discussion bring to life two-person relational psychology and illustrate the benefi ts and challenges of using this model. In these vignettes, we juxtapose the way in which treatment may have been developed using a traditional one-person psychological understanding so that the reader can have a better sense of the “then and now” psychodynamic perspectives. We close with Chap. 14 , Supervision , to help the supervisor of a two-person relational model have a better understanding of how the theoretical concept of intersubjectivity can infl uence the supervisory experience. For the child and adolescent psychiatry trainee or new- comer to two-person relational psychotherapy, our aim is to provide guidance in terms of what to expect in the context of a two-person relational supervisory hour and contrast this with a traditional one-person supervision. Finally, we hope this book will become a useful “go to” resource for child and adolescent psychiatry trainees and clinicians who may wish to learn about a contemporary two-person relational approach in helping children and adolescents achieve a more adaptive and happier life: to enjoy loving, playing, and learning.

References

Broomberg P (2010) The nearness of you: navigating selfhood, otherness and uncertainty. In: Petrucelli J (ed) Knowing, not-knowing and sort-of-knowing: psychoanalysis and the experience of uncertainty. Karnac, London, pp 22–45 Emde RN (1989) The infant’s relationship experience: developmental and affective aspects. In: Sameroff AJ, Emde RN (eds) Relationship disturbances in early childhood: a developmental approach. Basic Books, New York Emde RN, Biringen Z, Clyman RB, Oppenheim D (1991) The moral self of infancy: Affective core and procedural knowledge. Develop Rev 11:251–270 References 13

Emde RN (2009) From ego to “we-go”: neurobiology and questions for psychoanalysis: commentary on papers by Trevarthen, Gallese, and Ammaniti & Trentini. Psychoanal Dial 19: 556–564 Institute of Medicine (2000) From neurons to neighborhoods: the science of early childhood development. The National Academies Press, Washington, DC, p 31 Rodman FR (1987) The spontaneous gesture: selected letters of D. W. Winnicott. Karnac Books, London Rustin J, Sekaer C (2004) From the neuroscience of memory to psychoanalytic interaction: clinical implications. Psychoanal Psychol 21:70–82 Sameroff AJ, Emde RN (1989) Relationship disturbances in early childhood: a developmental approach. Basic Books, New York Stern DN (2005) Intersubjectivity. In: Person ES, Cooper AM, Gabbard GO (eds) Textbook of psychoanalysis, 1st edn. American Psychiatric Publishing, Arlington, pp 77–79 Wachtel PL (2010) One-person and two-person conceptions of attachment and their implications for psychoanalytic thought. Int J Psychoanal 91:561–581 Traditional One-Person Psychology 2

What Freud did not envision, however, is the extent to which useful theory has become relational. —Robert N. Emde

Our efforts in this chapter will be to establish an essential foundation for the fi eld of child and adolescent psychoanalysis and psychodynamic psychotherapy, a model that has radically changed over the past 50 years, in order to anchor the remainder of this book in a two-person relational psychology model. It is important to note that we do not intend to provide the reader with a complete review of all the contributors to child psychoanalysis and psychodynamic psychotherapy. Rather, we will focus on those that have become the pillars of the traditional one-person psychology model and how their contributions helped infl uence the transition to a two-person relational psychology for the current child and adolescent psychiatrist and psychotherapist. If the phrase “one-person psychology” does not initially appear puzzling, we would kindly ask the reader to reconsider. It is not lost on the authors the signifi cance of calling any approach to psychodynamic psychotherapy “one person” as clearly there are, at minimum, two people involved in any psychotherapeutic process. Therefore, the concept of one-person psychology refers to the fact that the “one person” is the objective observer and not an active participant who shares his or her subjectivities with the patient during the interaction. Wachtel (2010 ) and Hoffman (1998 ) capture the one-person process as seeing the person in a fashion that assumes that the seer [psychotherapist] has no effect on the seen [patient]. Further, Wachtel notes that the distinction between one-person and two-person psychology is a useful beginning when considering that two-person relational psychology evolved from a traditional one-person psychology. As such, we defi ne the concept of traditional one-person psychology as the psychodynamic clinical model in which the analyst’s or psychotherapist’s goal is to discover the patient’s unconscious confl icts that have hampered their ability to have a happy

© Springer-Verlag Berlin Heidelberg 2015 15 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_2 16 2 Traditional One-Person Psychology and successful life. One-person psychology model relies on the patient to transfer or displace early, unconscious unresolved conﬂ icted wishes and feelings about their parents or caregivers to the analyst or psychotherapist. Therefore, in a traditional one-person model, transference is considered a critical element for psychotherapeutic change to occur in the form of insight. Pine (1988 ) proposed that the unifying principle of traditional one-person models was a psychoanalytic pluralism: “The psychologies of drive, ego, object relations, and self…. While the four certainly overlap, each adds something new to our theoretical understanding, and each has signiﬁ cant relevance in the clinical situation.”

2.1 Traditional One-Person Psychology

Child and adolescent psychoanalysis and psychodynamic psychotherapy were developed under the umbrella of adult psychoanalysis and psychodynamic psychotherapy and were modeled on traditional one-person psychology. The goals of treatment were uncovering the child’s unconscious inner life to elucidate the intrapsychic confl icts that created maladaptive patterns that led to a developmental interference in their emotional growth and the working through of their confl icts in order to achieve a healthier state. Historically, fundamental psychoanalytic clinical concepts and treatments have been understood as one-person phenomena (Aron 1990 ). Therefore, in a traditional one-person model, transference is considered a critical element for psychotherapeutic change to occur. Transference was understood as a process occurring within the mind of the patient and not as an interpersonal event occurring between two people. Through the process of remembering and repeating past intrapsychic and unconscious confl icts, then transferring them onto the psychotherapist, the patient’s unhealthy ego defenses, in the form of resistances, can be “worked through.” The analyst or psychotherapist helps the patient identify what he or she needs to work through (i.e., unconscious confl icts and maladaptive defenses), which when brought to consciousness by the psychotherapist results in the patient developing insight and improving symptomatically (Freud 1914 ). Resnik (2004 ) summarizes, “The aim of analysis is self-knowledge largely achieved by the analysis and interpretation of defenses against the underlying impulses, drives, urges, fantasies and so on.” Freud’s “method” encouraged the use of neutrality, free association, dreams, and the psychoanalytic couch to facilitate transferences to develop. Freud believed that psychoanalysis had to be carried out in abstinence by the analyst (Freud 1914 ). Traditional one-person psychology over the years collectively became what Pine ( 1988) described as psychoanalytic pluralism. Pine deftly states, “Psychoanalysis has produced what I shall refer to as ‘four psychologies’—the psychologies of drive, ego, object relations, and self. Each takes a somewhat different perspective on human psychological functioning, emphasizing somewhat different phenomena.” Greenberg takes this a step further in defi ning this pluralism as “the widespread acknowledgment that a range of legitimately psychoanalytic points of view exists, whether or not there is any exchange of ideas among their adherents” (Greenberg 2012 ). 2.3 Freud and Classic Psychoanalytic Theories 17

2.2 Historical Background of Traditional One-Person Model of Child and Adolescent Psychoanalysis and Psychodynamic Psychotherapy

Child and adolescent psychoanalysis and psychodynamic psychotherapy developed under the umbrella of adult psychoanalysis and psychotherapy. Most early child psychoanalytic and psychodynamic literature considered the psychological development of the child in distinct psychosexual phases based on Sigmund Freud’s drive theory: pre-oedipal, oedipal, latency, and adolescence. Herein, treatment was based on helping the child overcome the confl icts of the psychosexual stage they were unable to master, and then resuming their developmental trajectory. Child and adolescent psychoanalysis is the treatment that relies in understanding the child and adolescents past unconscious inner life that infl uence his or her feelings, thoughts, and actions. The goal of child and adolescent psychoanalysis is the removal of symptoms and psychological roadblocks that interfere with normal development. Yanof (2005 ) reminds us that “for many years adult analysts questioned whether or not child analysis was ‘real’ analysis.” Child and adolescent psychodynamic psychotherapy is based on psychoanalytic principles and initially developed as an alternative method to those children who could adhere to the four to fi ve times a week schedule, due to its regressive nature. Subsequently, child and adolescent psychodynamic psychotherapy became a form of treatment used by psychoanalytically trained clinicians. In child psychoanalysis, the concept of transference was controversial. Anna Freud clarifi ed the diffi culties in the use of the concept of transference with children: “The adult tendency to repeat, which is important for creating transference, is complicated in the child by his hunger for new experience and new objects…” ( 1965). In spite of the differences, early child and adolescent psychoanalysis and psychodynamic psychotherapy were fi rmly grounded on the principle tenets of one- person adult psychoanalysis. To further illustrate the profound impact Freud’s work had in child and adolescent psychoanalysis and psychodynamic psychotherapy over the last 100 years, we will fi rst review his drive theories and then describe his classic fi rst case of child psychoanalysis, Little Hans. We follow by comparing selected elements of Freud’s Little Hans case formulation with a perspective of a two-person relational psychotherapist. We next proceed to describe the infl uence some of his most esteemed contemporaries had to his drive-based theories and conclude with a description of ego psychology, object relations theory, and self-psychology in the context of their contributions to child psychoanalysis and child psychodynamic psychotherapy.

2.3 Freud and Classic Psychoanalytic Theories

Sigmund Freud (1856–1939): Drive Theory

Classic psychoanalytic theory was developed by Sigmund Freud, who based his theories on his work with adult patients. In his efforts to understand the human mind, Freud proposed several hypotheses. First, the topographic model (Fig. 2.1 ) posits that 18 2 Traditional One-Person Psychology

Conscious

Preconscious

Ego

Unconscious Superego

Fig. 2.1 Sigmund Freud’s topographic (left ) and structural (right ) models of the mind most mental life occurs in the unconscious and that preconscious and conscious life is rather limited. Later, in revising the topographic model , Freud developed the structural model (Fig. 2.1 ). In this model the unconscious is comprised of several intrapsychic agencies: (1) the id , which embodies the instinctual sexual and aggressive drives and seeks for immediate gratifi cation (Freud 1920); (2) the superego , which consists of the agency that seeks to obey cultural and societal norms incorporated into the person’s psyche; and (3) the ego , an agency that moderates the confl ict between the id (which desires free reign) and the superego (which urges civility). Freud posited that the key developmental task of children involved “taming the instinctual drives” of the id through the development of the superego and ego (Freud 1916–1917 ). Still later, Freud wrote about the importance of the sexual drive theory in the form of psychosexual developmental stages determined by the organ of predominant interest to the infant/child for pleasure. As can be seen in Table 2.1 , there are psychosexual stages of development —and each requires that confl icts from the previous phase be successfully resolved. For Freud, unresolved confl icts of the oral, anal, phallic, or oedipal phases led the person to have a neurotic fi xation that, when he or she is under stress, causes an unconscious regression of the ego functions to behaviors of the stage fi xated in. This is best exemplifi ed when a 5-year-old child’s newly born sibling arrives home and the 5-year-old child demonstrates his anger at being displaced by the newborn by a regression to earlier anal level defenses (e.g., soiling himself or withholding bowel movements) which had been mastered prior to the arrival of the infant. Freud proposed that when the anxieties of the Oedipus complex are resolved, the person achieves the healthy psychological genital phase of normal heterosexuality 2.3 Freud and Classic Psychoanalytic Theories 19

Table 2.1 Sigmund Freud’s psychosexual stages Oral Anal Phallic Genital Age 0–18 months 19 months to 3 years 3–4 years 4–6 years Erogenous zones Mouth, tongue, Anus, rectum, Genitals and Genitals lips, skin abdomen urethra Typical Sucking, licking, Bowel movements, Touching Loving pleasurable chewing, and elimination, and genitals, toward activities biting retention masturbation, parent of the urination opposite sex Developmental Needy or passive Feelings of Castration anxiety Oedipal confl ict omnipotence (boys) and (terrible twos), Electra sadism complex (girls) Confl ict resolution Curiosity, Autonomy, Competence, Sexual facilitated by exploration successful toilet identifi cation with identity psychotherapy training same-sex parent

(Freud 1924 ). According to Freud, pleasurable heterosexual intercourse was the goal of his psychosexual theories: “the subordination of all the component sexual instincts under the primacy of the genitals” (Freud 1905 ).

First Child in Psychoanalysis: Little Hans

Freud had encouraged his friends and colleagues to collect observations of the sexual life in their children to help him develop his theory of infantile sexuality (Freud 1909 ). In 1909, Freud wrote his famous case “Little Hans,” which is considered the ﬁ rst recorded psychoanalysis of a child. Little Hans’ father was a friend of Freud and a supporter of his theories. Although Freud did not conduct the analysis on the child, he helped Little Hans’ father conduct the analysis primarily through corre- spondence, although they met several times and Freud gave the father suggestions on how to approach the child. Freud applied his psychoanalytic theories to the treatment of Little Hans, a 5-year-old boy who had developed a phobia to horses for fear that they would bite him or hurt his father. At 3 years old, Little Hans became interested in who in his family had or did not have a penis. By 3.5, his mother found him touching his penis and threatened him with castration if he continued to touch it ( 1909 ). Freud marked the mother’s castration threat as the episode that began Little Hans’ neurosis. Soon after the episode, the child was moved out from his parents’ bedroom, as his new sister arrived and was to take his place in the crib. After being moved, Little Hans took a special interest in comparing his body parts with his mother’s, his father’s, and animals’, wondering if they had a penis, a “wee-widdler.” Little Hans’ father tells Freud about the dialogue Hans had with his mother ( 1909 ): 20 2 Traditional One-Person Psychology

While looking on intently at his mother undress, before going to bed: “What are you staring like that for?” she asked. Hans: “I was only looking to see if you’d got a widdler too.” Mother: “Of course, Didn’t you know that?” Hans: “No. I thought you were so big you’d have a widdler like a horse.”

Freud interprets the dialogue as representing the child’s Oedipus complex: fear that the father will punish him for desiring to have his mother and acting aggres- sively toward the father. Freud added that because Little Hans’ father was acting as the analyst, he was a real rival impeding the progress of the treatment. Little Hans continued to struggle with his phobia, and Freud requested that the child be brought to see him. Freud writes of this encounter:

I asked Hans jokingly whether his horses wore eyeglasses, to which he replied that they did not. I then asked him whether his father wore eyeglasses, to which, against all the evidence, he once more said no. Finally I asked him whether by “the black round the mouth” he meant a moustache; and I then disclosed to him that he was afraid of his father, precisely because he was so fond of his mother. It must be, I told him, that he thought his father was angry with him on that account; but this was not so, his father was fond of him in spite of it, and he might admit everything to him without any fear. Long before he was in the world, I went on, I had known that a little Hans would come who would be so fond of his mother that he would be bound to feel afraid of his father because of it; … “Does the Professor talk to God,” Hans asked his father on the way home, “as he can tell all that beforehand?” I should be extraordinarily proud of this recognition out of the mouth of a child, if I had not myself provoked it by my joking boastfulness. (1909 )

Freud believed that the case of Little Hans conﬁ rmed his theory of infantile neurosis described in his Three Essays on the Theory of Sexuality ( 1905 ) and remarked that he had learned nothing from the case that he had not already deduced from his analysis of adults. We conclude with Freud’s comments regarding child psychoanalysis:

What? You have had small children in analysis? Children of less than six years? Can that be done? And is it not most risky for the children? … It can be done very well. It is hardly to be believed, what goes on in a child of four or ﬁ ve years old. Children are very active- minded at that age; their early sexual period is also a period of intellectual ﬂ owering. I have an impression that with the onset of the latency period they become mentally inhibited as well, stupider. (1926)

A Two-Person Relational Psychology View: Little Hans

In the case of Little Hans, several points are worth reviewing from a two-person relational perspective. First, we note that he had slept in his parents’ bedroom until the age of 3, when his sister arrived. It appears that from an attachment theory perspective, he seemed to be openly loved and had a great deal of exposure to his parent’s interactions, including morning dressing and evening undressing. From a contextual perspective, we do not have knowledge as to whether it was typical for children in Vienna during 1909 to sleep in the parental bedroom. We also note that 2.4 Freud’s Colleagues 21

Little Hans was a bright and verbal child who spoke often with his parents about his excitements and worries. One can hypothesize that he had an easy/fl exible temperament and a secure attachment style (see Chaps. 5 and 8 ), refl ected by frequent open dialogue with his parents and the trips he took to parks with his father. Finally, he had good cognitive fl exibility (Chap. 8 ) demonstrated in his rich abstract reasoning: (1) He was aware of differences between female and male body parts, inquiring whether women can have a penis, and (2) he wondered about the size of horses as related to adult safety, fearing the horse could fall on top of his father. Herein, from a two-person relational model, it appears that Little Hans’ worries were occurring within the context of a normal developmental process of a child. Little Hans’ singu- lar horse phobia may very well have been part of his healthy curiosity or clinically a simple phobia. We do not know if there were any other symptoms, and it appeared that he was adjusting quite well socially and academically. In fact, when Hans was 19 years old, he met with Freud and shared that after having read his case history, he could not remember the discussions with his father and did not recognize the events discussed in his case and shared that he was ostensibly doing well in life. Considering that Little Hans may have been evaluated by a two-person relational psychotherapist, the treatment of choice would rely on here-and-now interactions between the patient and the active and present psychotherapist whose goal is to provide the patient a new emotional experience (see Chap. 5 ). Certainly the use of play would have been important to assess Little Hans’ capacity for social reciprocity and infl uence of the psychotherapist in the cocreated intersubjective fi eld. The two-person relational psychotherapist relies on intersubjective experiences cocreated in vivo, infl uenced by each person’s internal working models of attachment developed during the fi rst years of life and stored nonconsciously in nondeclarative memory systems (see Chap. 3 ). Additionally, in light of his fear of his father being hurt by a horse and his curiosity of whether others had a penis, it is reasonable that work with his parents would have provided a better contextual understanding of the complexities in the family system. The two-person relational approach is in contrast to a traditional one-person model which understands the patient’s symptoms as deriving primarily from confl icted internal experiences (e.g., fantasies, confl ictual life), and attention to the external factors for some may be seen as a dilution of the psychoanalytic approach.

2.4 Freud’s Colleagues

While Freud is well known as the founding father of psychoanalysis, many of his contemporaries and followers also contributed to the ﬁ eld. Here we will introduce some of his most notable colleagues and protégés.

William Stekel (1868–1940)

William Stekel, one of Freud’s earliest followers, was once described as “Freud’s most distinguished pupil” (Wittels 1924 ). Stekel was an adult psychoanalyst, 22 2 Traditional One-Person Psychology although he is recognized for being the ﬁ rst male psychoanalyst who worked psychoanalytically with children and adolescents. He claimed that parents and the environment in which children were raised were crucial to the development of a child’s psychological well-being (1931 ). Stekel believed that the psychoanalysis of children and adolescents was different from the psychoanalysis of adults, as it had to be adapted due to the child’s mobility and the importance in the use of play. According to Stekel, the analysis of children was not difﬁ cult because their neurotic symptoms disappeared more rapidly than in adults (Wittels 1924 ). Stekel eventually dissented from Freud’s drive theory, which led to his expulsion from Freud’s inner circle and his later ostracism. Stekel may have been an early two-person relational psychoanalyst in that he believed that when the analyst took an active role as a real person in the psychoanalytic process, it helped the patient feel safe and understood (see Chap. 3 ).

Carl Gustav Jung (1875–1961)

Although Carl Jung did not analyze children, he treated children in psychoanalytic psychotherapy as young as 6 years old and had an interest in the observation of infants. He had frequent communications with Freud about children’s emotional development and decided that women were best suited to practice child psychoanalysis due to their natural feminine intuition. He went on to provide child psychoanalytic courses to some of his female students who later became child psychoanalysts (Geissmann and Geissmann 1998 ).

Hermine von Hug-Hellmuth (1871–1924)

Hermine von Hug-Hellmuth was the fi rst woman to apply psychoanalysis to the treatment of children. She was described as among Freud’s favorite students; her writings remain unknown to many current child psychotherapists (MacLean 1986 ). Although her work was limited to children over the age of 7, in 1912 Hug-Hellmuth published her seminal paper, The Analysis of a Dream of a 5 -Year Old Boy (Drell 1982). Hug-Hellmuth was loyal to Freud’s psychoanalytic theories and was a strong advocate for the use of play in child psychoanalysis. She was an early proponent of children’s play being equivalent to free associations in adults, the royal road to the unconscious mind of children. She also believed that the goal of child psychoanalysis closely resembled the psychoanalysis of adults and that the transference neurosis of childhood was amenable to change through the interpretation of their symbolic play. Hug-Hellmuth was a teacher before she became a psychoanalyst, which helped her recognize the role parents had in their child’s neurosis and encouraged providing education to them in order to prevent from further confl icts in their child. Plastow (2011 ) states, “[Hug-Hellmuth’s] theory and practice heavily infl uenced the directions taken after her, in particular by Anna Freud and Melanie Klein, even if this infl uence is essentially unacknowledged by these authors.” 2.5 Ego Psychology 23

Berta Bornstein (1899–1971)

Berta Bornstein was an educator of handicapped children in Berlin. At the age of 20, she began her psychoanalytic training in Vienna and began to work closely with Anna Freud. She was the fi rst child analyst to emphasize defense analysis in children. She opposed the view that during latency instinctual confl icts were repressed and was among the fi rst to write about countertransference issues in child psychoanalysis ((Bornstein 1949 ). She had a strong infl uence in the use of child psychoanalysis in Berlin, Vienna, and New York. Bornstein was among the early Freudian child psychoanalysts in the United States. In 1945, she wrote her seminal paper, Clinical Notes on Child Analysis , in which she stated, “The id of the child and of the adult are alike, but the ego of each is unlike (Bornstein 1945 ).” She was an active teacher of child psychoanalysis at the New York Psychoanalytic Institute and the Institute of the Philadelphia Association for Psychoanalysis.

2.5 Ego Psychology

Anna Freud (1895–1982)

Anna Freud’s interest in psychoanalysis was clearly infl uenced by her father, although her interest in child psychoanalysis developed quite naturally as she had trained as an elementary schoolteacher. This gave her fi rsthand experience with children in all socioeconomic levels. She is best recognized for her book Normality and Pathology in Childhood (1965 ), in which she describes the defenses available to a child’s ego and linked their origin to the stages of psychosexual development, introducing the concept of “developmental lines”—expectable pathways based on subtle interactions of internal and external factors—which all children go through. The concept of developmental lines is rooted in psychoanalytic thinking and is based on observations of children’s behaviors to assess whether the child’s development is progressing in a healthy or unhealthy fashion. Anna Freud states, “The diagnostic profi le which we have set up serves the systematic assessment of childhood disturbances by seeing the picture of any given child against the background of a developmental norm into which the state of his inner agencies, his various functions, confl icts, attitudes, and achievements have to be fi tted. In our psychoanalytic theory, such developmental sequences are laid down so far as certain circumscribed parts of the child’s personality are concerned” (Freud 1937/1966 ). She further states: “We assume that with all normally endowed, organically undamaged children the lines of development indicated above are included in their constitution as inherent possibilities. What endowment lays down for them on the side of the id are, obviously, the maturational sequences in the development of the libido and aggression; on the side of the ego, less obviously and less well studied, certain innate tendencies toward organization, defense, and structuralization” (Freud 1965 ). Flashman ( 1996 ) refl ects on the importance of the developmental lines for the child analyst, saying, “provide precisely the framework necessary for distinguishing 24 2 Traditional One-Person Psychology as clearly as possible between the activity of the analysand and that of the analyst in the ongoing development that is taking place simultaneously in the continuous present and in the analysis.” Anna Freud’s pioneering work in child psychoanalysis led her to be known as one of the most infl uential people in the development of psychoanalytic psychotherapy with children. Her treatment relied on the application of psychoanalytic principles to the understanding of child’s psychopathology, with considerable efforts in loosening the rigidity of analytic abstinence common in adult analysis. Anna Freud believed that psychoanalytic treatment helped the child overcome the internal confl icts caused by the pressures of the different developmental psychosexual stages a child had to go through. She believed that knowing how a child or adolescent psychologically navigates through psychosexual developmental stages was best studied through the ego defense mechanisms employed in coping with daily-life anxieties and threats to self-esteem from intrapsychic confl icts. Although Sigmund Freud was the fi rst to describe such defense mechanisms, contemporary understanding of these processes comes from Anna Freud, who systematically classifi ed these defenses, compiling a comprehensive catalog in her classic work, The Ego and the Mechanisms of Defense (Freud 1937/1966 ). Anna Freud believed that the analysts should also serve as educators to the parents to improve their insight about their contribution to the child’s neurosis. Even though Freud was loyal to her father’s theories and techniques in her work with adults, particularly neutrality, she seemed to have had moments when she stepped away from the rigidity of the technique and demonstrated genuine empathy with her patients. Erik Erikson shared that during a period in his psychoanalysis, he would let Anna Freud know about his worry regarding his wife’s pregnancy and the impact of having a child. Erikson repeatedly expressed anger toward Freud because she did not speak and kept knitting. When Erikson announced that he had a baby boy, Freud gave him the blanket she had been knitting all along (Couch 1995 ). Although we do not know the comments Freud may have made to Erikson, we suspect that due to her work with mothers and infants, they likely were genuinely congratulatory. In traditional one-person psychoanalytic teachings, this interaction may have been described as a countertransference enactment, as the analyst gratifi ed the patient’s wish, contaminating the transference due to the fact the analyst showed her “real self” to the patient. In two-person relational psychology, the open expression of affective attunement is essential in cocreating more adaptive shared experiences (see Chap. 3 ). We are in agreement with Mayes and Cohen (1996 ) who described Freud as a contemporary in the field of developmental psychopathology: “She created a developmental psychoanalytic psychology that is remarkably current and draws upon principles of neurobiology, genetics, pediatrics, and social psychology.” Nevertheless, in spite of Freud’s wonderful theoretical contributions, most of her clinical work remained in the traditional one-person model, giving importance to the interpretation of the child ego defenses against intrapsychic conflicts. 2.5 Ego Psychology 25

Heinz Hartman (1894–1970) Autonomous Ego Functions

Heinz Hartman, a psychiatrist and psychoanalyst who was often described as one of Freud’s favorite students, became the leading Freudian theorist in the United States during the 1940s and 1950s. He developed the school of American ego psychology. Holding that the ego has a biological substrate that includes perception, memory, concentration, motor coordination, and learning, he believed these innate ego capacities had autonomy from the sexual and aggressive drives of the id and were not products of frustration or conﬂ ict. Hartman coined the term “autonomous ego functions” (Hartman 1958 ), and his ideas share much with recent concepts concerning implicit memory systems and internal working schemas stored in nondeclarative memory systems, which will be discussed in further detail in Chaps. 3 and 5 .

Erik Erikson (1902–1994) Theory of Psychosocial Development

Erik Erikson, the analysand and student of Anna Freud, made important contributions to psychoanalytic theory regarding the creative processes from the ego and proposed a theory of ego development. His theory encompassed eight developmental stages, from basic trust versus mistrust during infancy to integrity versus despair in old age. Libidinal stages and psychosexual development are incorporated into his epigenetic schema. Erikson also gave importance to the role play had in the psychoanalysis of children. He approached children’s play in a similar fashion to that of dreams in the psychoanalysis of adults. He believed that it was crucial to systematically interpret the meaning of play, although he recognized that perhaps play had a cathartic effect in which the child was able to “play it out” (Erikson 1940 ). He, like Anna Freud, noted the importance of the role a mother’s psychological state had on the emotional growth of a child.

Two-Person Relational Psychology View: Ego Psychology

In a traditional one-person psychology model, the ego is the mediator of confl icts between the id and the superego, and the psychotherapist helps the patient work through the pressures from the id: “where id is, there shall ego be” (Freud 1916 – 1917). In contrast, in two-person relational psychology there is attention given to that which occurs at a nonconscious and implicit level (see Chaps. 3 , 4 , 5 , 6 , 7, and 8). As such, the two-person relational model does not adhere to Freud’s structural theory; it therefore does not consider the ego as a necessary concept, which presupposes the need for an id and superego (see Chap. 6 ). As a note, Anna Freud’s later writings refl ect that she was aware of the work by her student John Bowlby, regarding the infant’s innate wish for a relationship with its caregiver and the development of internal working models based on these interactions. Freud supported Bowlby’s ideas and believed that for the development of the infant, early contact with their mother was essential. She observed that 26 2 Traditional One-Person Psychology depressive moods of the mother during the fi rst 2 years after birth could lead to depression in the child. Thus, we believe Freud intuitively set the stage for the contemporary clinician, contributions from attachment theory and developmental research is a major contributor to a move toward a two-person relational perspective.

2.6 Object Relations Theory

Melanie Klein (1882–1960)

From the 1940s to the 1960s, many psychoanalytic theorists increasingly recognized the importance of the child’s early interactions with primary caregivers and how these developmental experiences were crucial to the formation of the child’s ego functions. As a result, in the 1940s, a natural transition from ego psychology to object relations theory evolved. Melanie Klein was analyzed by Ferenczi (Chap. 3 ), who may have infl uenced her theories due to his work with children. Klein, a student of Sigmund Freud, is thought to be the fi rst object relations theorist. Klein noted that internalized “objects” were at the center of a person’s emotional life (Klein 1932 ). “Object relations” refers to the capacity to have stable and rewarding relationships based on the internalization of the early childhood representations of others in the form of “objects.” However, internalization of the early childhood objects is not a mere imitation of their attributes; rather, what is internalized is that which is fi ltered by the child’s desires, wishes, and needs (Delgado and Songer 2009 ). That is, the internalized objects are attributed an individualized signifi cance which may resemble the real person object, although it is not always the case. Klein posits that the infant, as part of a normative developmental phase, from birth to 4 months old, possesses a primitive fear. She refers to this period as being in the paranoid position, in which internalized representations of caregivers are experienced as part objects that are split into “good” and “bad” objects (e.g., the loving, nurturing mother and the depriving mother). For example, a child with an innate tendency to have primitive anxieties may internalize an emotionally available parent as depriving and critical and may resist the parents attempt to comfort and contain the child’s anxieties. In the early stages, the child maintains the self and object split to avoid the distress in recognizing that there are aggressive and depriving aspects of the self as well as of the other. Then, from 4 to 12 months old, the child learns to integrate and tolerate the idea that a person has both “good” and “bad” parts and enters a phase that Klein describes as the healthy depressive position (Klein 1932 ). Having psychologically achieved the depressive position, the child proceeds to develop a capacity of concern for others and guilt about one’s actions and thoughts about others, with desire for reparation (Winnicott 1965 ). Klein believed that individuals who are unable to work through the depressive position in their childhood continue to struggle to relate to others in adult life. In her psychoanalytic work with children, Klein’s interpretations were made early in the treatment and were described by Kleinian analysts as being “deep,” with 2.6 Object Relations Theory 27 the aim of containing the primitive feelings of hate and destructiveness projected unconsciously onto the analyst from unresolved confl icts in the paranoid position. The goal of the psychoanalytic treatment was to help the child achieve the depressive position with the integration of hate and love, a more integrated state of mind. Klein’s interventions were aimed at working through the early intrapsychic confl icts and anxieties that prevented the child from the use of stable ego functions. Klein emphasized that through play, the child expressed their unconscious sexual and aggressive fantasies toward split objects. She considered play as equivalent to the free associations of the adult patient. Klein believed that the transference neurosis could occur in children as young as 2.5 years old, as they were in the early stages of the formation of superego and the Oedipus complex at this age. Klein believed that the oedipal confl ict developed during the oral phase, when the struggle for the possession of the libidinal object—mother or father—was taking place. Klein, like Hug-Hellmuth, provided children with toys, houses, animal fi gures, and cars, which she believed allowed for the representation of people that existed in the child’s life. Klein was attentive to the fantasies of birth, the primal scene, and of aggressive wishes for destruction. Klein departed from Anna Freud’s belief that the parents needed to be educated on how to support their child during the psychoanalysis. Klein felt that this was not necessary and, in fact, felt that working with parents would interfere with the treatment.

Donald Winnicott (1896–1971)

In Donald Winnicott’s The Capacity to Be Alone , the British pediatrician and psychoanalyst introduced the concept that to be alone is not the same as to be lonely (Winnicott 1958 ). Rather, the capacity to be alone is the foundation for a sense of the self with growth-promoting introspective thought, imagination, and creativity. The capacity to be alone, he further noted, is a prerequisite for true intimacy, which is the ability to share openly and fully with another human being while maintaining a sense of oneself as separate from the other and not wholly dependent upon them. Winnicott’s psychosocial view was that the family and society were crucial as instinctual energy in psychosexual, emotional, and social development. He did not entirely abandon drive theory, and his theories were built on Freudian one-person foundations (Winnicott 1971 ). Winnicott is also known for the concept of “containment and holding,” which is similar to Wilfred Bion’s concept of “container and contained,” (Ferro 2005 ) which had a profound inﬂ uence in object relations psychoanalytic theory.

An 8-year-old boy needs a holding environment To the psychotherapist’s surprise, an 8-year-old child demanded that his mother bring him to his psychotherapy appointment even though he had been feeling tired and likely had a cold. He entered the session and promptly laid on the couch and said, “I don’t know why, but I really feel better being sick 28 2 Traditional One-Person Psychology

here. You know my feelings better than my parents.” He proceeded to sleep for 10 min, and after waking he felt somewhat better and was able to resume his play in the session. It was as if the boy had read Winnicott’s paper The Capacity to be Alone (1958) and conveyed: “I can be alone in your presence. I feel safe and emotionally held by you at a preverbal level.”

Another important contribution to the work with children was Winnicott’s (1953 ) description of the fi rst not-me possession by the infant, a “transitional object.” This allowed the child to transition from the fi rst oral relationship with the mother’s breast to a true object relationship. The transitional objects were typically in the form of a blanket, a doll, or a stuffed animal. He stated, “They are tangible—can be held onto, grasped, hugged. They lessen the stress of separation and soothe the infant,” adding, “the transitional object may therefore stand for the ‘external’ breast, but indirectly, through standing for an ‘internal’ breast.” He further described “transitional phenomena,” which were behaviors that served the same function as the transitional object (see Chap. 6). Winnicott (1953 ) identifi es himself as an object relations theorist in his statement, “I have introduced the terms ‘transitional object’ and ‘transitional phenomena’ for designation of the intermediate area of experience, between the thumb and the teddy bear, between the oral erotism and true object- relationship, between primary creative activity and projection of what has already been introjected, between primary unawareness of indebtedness and the acknowledgement of indebtedness (‘Say: ta!’).”

Margaret Mahler (1897–1985)

Margaret Mahler was a psychoanalyst interested in the research of the infant–mother dyad in young disturbed children. Her research took place during the 1960s, and she is known for the seminal book The Psychological Birth of the Human Infant (Mahler et al. 1975). Her team designed research models that allowed for the observations of the interactions between toddlers and their mothers and the impact of early separations of children from their mothers. Mahler’s work continues to be important in traditional one-person psychoanalytic theory, as it gives importance to pre-oedipal and early childhood attachments in the form of rapprochement and separation–individuation as intrapsychic processes, although the concepts are commonly thought to represent behavioral constructs. Mahler’s groundbreaking theory of separation–individuation was her most important contribution to the development of psychoanalysis. She described the separation–individuation process as occurring between 4 and 36 months old in distinct subphases: practicing and rapprochement. The terms “practicing” and “rapprochement” continue to be used in the psychodynamic formulations of children with psychological problems and are also used in the description of important pro- ductive moments during the course of psychotherapy. 2.6 Object Relations Theory 29

Mahler’s contributions, along with Winnicott’s, emphasized the importance of the infant being held physically and psychologically by the caregiver. Mahler and Winnicott lived in a period during which infant research was strongly inﬂ uenced by object relations theory. Thus, their work received similar reaction to that of the work by Bowlby, and the mainstream psychoanalytic community did not believe that the observations of interactions between mother and infant captured the inner life of the child’s internalized object representations and the fantasies that ensued.

Peter Blos (1904–1997) The Second Individuation Process of Adolescence

Peter Blos is recognized for his psychoanalytic developmental theory of adolescence. Blos described four preconditions for the adolescent character formation: (1) the processing of residual trauma from childhood experiences, (2) the development of sexual identity, (3) the resolution of negative oedipal complex, and (4) the second individuation process (Blos 1968 ). His most recognized contribution was the concept of “the second individuation process of adolescence” (Blos 1967 ), based on Mahler’s original separation–individuation phase of the infant (Mahler et al. 1975 ). The second individuation process is characterized as a phase in which the adolescent psychologically negotiates how to separate from the unconscious reawakening pressures of the internalized representations of the parents from childhood, due to the fear of loss of their support. Upon completing this process, the object relations of the adolescent become stable, with clear boundaries, and the adolescent becomes more “resistant to cathectic shifts” (Blos 1968 ). Moreover, Blos believed that the adolescent’s breakup with internalized objects made possible the quest for “extrafamilial love” (Blos 1967 ). It should be noted that not all theorists agreed with Blos’ view of adolescent psychological development; some argued that individuation occurs during childhood and that a second phase is not needed (Schafer 1973 ).

Personality Disorders in Children and Adolescents

Paulina Kernberg (1935–2006) Paulina Kernberg, a child psychiatrist and psychoanalyst known for her work with children and adolescents with character pathology, believed that the diagnosis of borderline personality in adolescents should be considered from descriptive, structural, and dynamic points of view (Terr and Kernberg 1990 ). She stated, “If we were to have no concept of childhood personality and personality disorder, child psychopathology would simply be a listing of symptoms and behaviors without an overall framework of interrelated symptoms and personality traits; we would have an accumulation of bricks without any mortar” (Kernberg 1990 ). Moreover, she emphasized that the main criteria for personality disorders in children was the presence of primitive defenses such as splitting, denial, omnipotence, and projective identifi cation, with lapses in reality testing. She believed that psychodynamic psychotherapy could help adolescents if it 30 2 Traditional One-Person Psychology helped achieve the resolution of aggressive and interpersonal skills defi cits. The suicidal behavior was the main goal to be addressed within the relationship to the psychotherapist (Kernberg 1983 , 1989 ). She also posited that narcissistic character pathology can exist in childhood and that family dynamics contributed. Further, Kernberg believed that narcissistic pathology in children refl ected a pathological formation of the self, used for defensive purposes. She cautioned on the unique countertransference dilemmas in treating children with character pathology. She is also recognized for her contribution to the Practice Parameter for Psychodynamic Psychotherapy with Children: American Academy of Child and Adolescent Psychiatry (Kernberg et al. 2012 ).

Efrain Bleiberg (1951–) Efrain Bleiberg a child psychiatrist and child psychoanalyst supported Kernberg’s contention that children with personality disorders exhibited distinctive patterns relating to and thinking about others and themselves, including traits such as ego- centricity and inhibition (Bleiberg 1994, 2004). Kernberg added that these patterns endured across time and warranted the designation of a personality disorder, regardless of age. Bleiberg also stated, “Borderline youngsters require a constant stream of emotional ‘supplies’—someone’s love and attention, sex, drugs, or food—to protect them against overwhelming feelings of dyscontrol, hyperarousal, and aloneness” (1994).

A case from a traditional one-person object relations perspective Cory was a Taiwanese 8-year-old girl adopted as an infant by a Caucasian family from the Midwest. When there were threats of separation from her adoptive mother, they would trigger a disruption in her contact with reality, as well as rage outbursts, both at home and in school. She had created a fantasy about her biological mother being an Asian princess. At times she seemed to believe the fantasy was real and would lash out when people failed to recognize her entitlement to royal prerogatives. In her dreams and play, the princess was replaced by a witch, whose appearance combined Asian and Caucasian features. This witch would mistreat her, and her only choice was to strangle the witch (Bleiberg 1994 ).

Bleiberg (1994 ) masterfully described Cory’s problems from an object relations perspective: “Cory’s attempt to produce a perfect, magical union, while keeping safely apart the dangerous, rageful, and frustrating aspects of herself and others, often fell apart in the face of separation or the threat of loss of control. The collapse of such fantasied scenarios is one of the triggers of self-mutilation and suicidal gestures.” He added, “The psychological landscape of these youngsters can sometimes be glimpsed only through the lens of psychological testing.” Cory’s psychological testing revealed rigid and primitive defenses: egocentric and arbitrary interpretation of reality, with disturbances in ego functions, unmodulated experience of affects and drives, and marked disturbances in the experiences of self and others. 2.7 Self-Psychology 31

Two-Person Relational Psychology View: Object Relations

In Bleiberg’s description of Cory, a two-person relational clinician would consider that the behavior and emotional reactions are typically seen in children 4–6 years old, according to developmental milestone norms (see Appendix A). Thus, there may be innate defi cits in cognition that interfere with Cory understanding the experiences with others as they are infl uenced by poor and maladaptive self-regulatory schemas based on cognitive misperceptions of his environment. That is, an infant’s innate forms of temperament and cognition serve as the foundation for internal working models of attachment to develop and allow cocreating experiences of the self with others. As such, object relations in a two-person relational model occur at an implicit level in the form of a complex nonconscious meaning-making process stored in nondeclarative memory (Chap. 3 ) and not the result of Freud’s instinctual drives or Klein’s objects. Concepts such as introjection, projection, projective identifi cation, and splitting are in the traditional one-person psychology domain, as they do not account for the psychotherapist’s intersubjectivity when relating with the patient (see Chap. 6). In the work with Cory, the two-person relational psychotherapist would consider making use of here-and-now experiences to improve her perception of his reality. Due to Cory’s likely cognitive limitations, active work with her family in developing a realistic behavioral plan at home and school would be imperative.

2.7 Self-Psychology

Heinz Kohut (1913–1981)

Like Freud, the American psychoanalyst Heinz Kohut based his theory of self- psychology on inferences made during the treatment of adult patients. He hypothesized that narcissistic disorders of the self were due to childhood parental empathic failures (Kohut 1971 ). Kohut believed that treating disorders of the self, required a therapeutic empathic reparation by the analyst of the patient’s maladaptive functions (e.g., idealizing , mirroring , and twinship “self-object”).

Anna Ornstein (1927–)

Anna Ornstein, a child psychiatrist and psychoanalyst, is a prolifi c writer with regard to the self–selfobject unit needed to provide an empathically responsive environment for the child. She stated: “Kohut’s discovery of selfobject transferences alerted child therapists to those parental functions which, became of their silent presence, by and large, have been taken for granted. With these discoveries, we are now in a position to recognize those clinical conditions in children that are the consequences of the absence or partial failure of certain specifi c parental responses to the child’s ordinary narcissistic developmental needs for affi rmation, validation, 32 2 Traditional One-Person Psychology and a feeling of merger with the omnipotence and power of the parent” (1981 ). Ornstein believed that defi cits in specifi c areas of parenting were the reason for the child’s psychopathology (Ornstein and Ornstein 2005 ). Ornstein proposed child-centered family treatment as “a method of treatment in which the depth-psychological understanding of the child is not sacrifi ced but in which the insights that the therapist gains into the inner world of the child (sometimes through play and sometimes through a therapeutic dialogue) are ‘translated’ to the parents.” The psychotherapist would encourage the parents to foster empathic and therapeutic interactions in their home to the help the child regulate fears, wishes, and anxieties, rather than the manifest behavior (1984 ). In Ornstein’s ( 1981 ) paper, she presented clinical vignettes “from the three rep- resentative age groups in childhood: preschool, latency, and adolescence.” The vignettes demonstrated her view of the theory of the self, which unfolds within its psychological (self-object) environment. She emphasized that this provides the child psychotherapist with a theoretical framework that facilitates the understanding of the psychological conditions in an in-depth manner rather than on a descriptive level. She added that problems of the development of the self cannot be categorized as either neurotic or psychotic conditions and that parental empathy is “the sine qua non of the execution of parental self-object functions.” The remobilization of these functions in the treatment will help the parents to become empathic toward the symptomatic child. In one such vignette, Ornstein (1981 ) described the case of a 7-year-old boy who was to be expelled from school unless his mother agreed to seek treatment for him. He had uncontrollable behaviors at school, which included threatening teachers and peers with pencils. The mother had divorced the boy’s father when the boy was 2 years old and had remarried. In psychotherapy, the boy approached the play session with caution and would not elaborate on his fantasies. On one occasion, the psychotherapist had promised to keep the child’s papier-mâché snake safe. When the boy returned the following day, he did not fi nd his snake and became irritable and destroyed the things he made in prior sessions, insisting there was nothing good about them. The psychotherapist told the child that the snake had disappeared and probably had been destroyed by a careless janitor. She proceeded to interpret that the child’s anger at her was due to her failure in protecting what they had made together. Further, she told the mother that her son’s provocative behaviors unconsciously served to protect him from recognizing that he wished other people would demonstrate that they cared about him. Ornstein made use of both self-psychology and object relations theory to understand the boy’s reaction to the lost snake. In using self-psychology, the psychotherapist serves as the boy’s self-object, mirroring and providing reassurance that he is valued in spite of her losing his snake. In contrast, in using object relations theory, the psychotherapist views herself, in the transference, as representing the child’s internalized depriving bad object representations, depriving him from comfort and empathy when distressed by the loss of his transitional object. 2.8 Summary 33

Two-Person Relational Psychology View: Self-Psychology

Many of the school of self-psychology describe themselves as being aligned with both traditional one-person psychology and two-person relational psychology. However, as Fosshage (2003 ) notes, “In my view, both self-psychology and relational psychoanalysis are at their best in addressing different domains of relational experience, each offering important understandings and guidelines for facilitative responses.” Although Fosshage attempts to highlight the similarities, he minimizes the differences not only in theory but also in technique. In the case of the 7-year-old boy described by Ornstein, from a two-person relational perspective, the lack of ownership by the psychotherapist for the loss of the boy’s snake is troublesome. This implicitly conveys a sense that the psychotherapist is not responsible for the hurtful feelings the child is experiencing. The loss of the snake was real. For a two-person relational psychotherapist, this moment provides an opportunity to model to the child how to apologize for failures: not being able to protect his snake. Additionally, the psychotherapist can provide a corrective emotional experience in asking the child to forgive the psychotherapist for being careless and would appreciate if they could together cocreate a new snake. This could be followed by a discussion on how to best protect the new snake. In the current era of readily available smartphones or tablets to take photographs, a two-person relational psychotherapist may consider asking the child’s mother to use such a device to take a picture of the snake, providing a retrievable here-and-now experience between the child and psychotherapist at a later time, if needed. These are a few of the many possibilities that may have been pursued between patient and psychotherapist to provide a corrective emotional experience (see Chaps. 3 , 5 , and 11 ). Stolorow (1994 ) captures the differences between self-psychology and two- person relational models as such: “How does the concept of an intersubjective fi eld differ from the concept of a self–self-object relationship? An intersubjective fi eld is a system of reciprocal mutual infl uence. Not only does the patient turn to the analyst for self-object experiences, but the analyst also turns to the patient for such experiences, and a parallel statement can be made about the child-caregiver system as well…. More important, subjective world is a construct that covers more experiential territory than self . ”

2.8 Summary

In this chapter we provide the reader with a critical foundation in the fi eld of child and adolescent psychoanalysis and psychodynamic psychotherapy, which has radically changed over the past 50 years, anchoring the remainder of this book in a two- person relational psychology model. We openly note that we do not intend to provide the reader with a complete review of all the contributors to child psychoanalysis and psychotherapy; rather, we limit our review to those that became pillars of the traditional one-person psychology model and how their contributions 34 2 Traditional One-Person Psychology infl uence the transition to a two-person relational psychology for the current child and adolescent psychiatrist and psychotherapist. In this chapter, we defi ne the concept of traditional one-person psychology as the psychodynamic clinical model in which the analyst’s or psychotherapist’s task is to discover the patient’s unconscious confl icts that have held them back from having a successful and happy life. The one-person psychology model relies on the patient to transfer early, unresolved introjected wishes and feelings about their parents or caregivers onto the analyst or psychotherapist. Therefore, in a traditional one- person model, transference is considered a critical element for psychotherapeutic change to occur. Traditional one-person psychology over the years collectively became what Pine (1988 ) described as psychoanalytic pluralism. Pine deftly states “Psychoanalysis has produced what I shall refer to as ‘four psychologies’—the psychologies of drive, ego, object relations, and self. Each takes a somewhat different perspective on human psychological functioning, emphasizing somewhat different phenomena.” We proceeded to describe the infl uence each of the four psychologies in a traditional one-person model: drive, ego, object relations, and self, in the context of their contributions to child psychoanalysis and child psychodynamic psychotherapy which was fi rmly grounded on the principle tenets of adult psychoanalysis. The goals of treatment were the inquiry and the uncovering of the child’s inner confl icts that created maladaptive patterns that led to a developmental interference in their emotional growth and the working through of their confl icts in order to achieve a healthier state. Further, we provide the reader a two-person relational view of each of the four psychologies, setting the stage for the remainder of this book, solidly anchored in a two-person relational psychology model.

References

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Ferro A (2005) Bion: theoretical and clinical observations. Int J Psychoanal 86:1535–1542 Flashman AJ (1996) Developing developmental lines. Psychoanal St Child 51:255–269 Fosshage J (2003) Contextualizing self psychology and relational psychoanalysis: bi-directional infl uence and proposed syntheses. Contemp Psychoanal 39(3):411–448 Freud S (1905) Three essays on the theory of sexuality. In: Strachey J (ed) The standard edition, vol 7. The Hogarth Press, London, pp 130–243 Freud S (1909) Analysis of a phobia of a fi ve-year-old boy. In: Strachey J (ed) The standard edition, vol 10. Hogarth Press, London, pp 1–149 Freud S (1914) Remembering, repeating and working through. In: Strachey J (ed) The standard edition, vol 12. Hogarth Press, London, pp 147–156 Freud S (1916–1917) Introductory lectures on psycho-analysis, Part III. In: Strachey J (ed) The standard edition, vol 16. Hogarth Press, London, pp 441–447 Freud S (1924) The dissolution of the Oedipus complex. In: Strachey J (ed) The standard edition, vol 19. Hogarth Press, London, pp 172–179 Freud A (1965) Normality and pathology in childhood: assessment of development. International University Press, New York, p 27 Freud A (1966) The ego and the mechanisms of defense. Hogarth Press, London (Original work published in 1937) Geissmann C, Geissmann P (1998) A history of child psychoanalysis. Routledge, New York, pp 24–34 Greenberg J (2012) Psychoanalysis in North America after Freud. In: Gabbard GO, Litowitz BE, Williams P (eds) Textbook of psychoanalysis, 2nd edn. The American Psychiatric Publishing, Arlington, pp 19–38 Hartman H (1958) Ego psychology and the problem of adaptation (trans: Rapaport D). International Universities Press, New York (First edition published in 1939) Hoffman IZ (1998) Ritual and spontaneity in the psychoanalytic process. Analytic Press, Hillsdale Kernberg PF (1983) Issues in the psychotherapy of borderline conditions in children. In: Robson KS (ed) The borderline child. McGraw Hill, New York, pp 223–234 Kernberg PF (1989) Narcissistic personality disorder in childhood. Psychiat Clin N Amer 12(3):671–694 Kernberg PF (1990) Borderline personality exists in children under twelve. J Am Acad Child Psychiatry 29:478–482 Kernberg PF, Ritvo R, Keable H (2012) Practice parameter for psychodynamic psychotherapy with children: the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). J Am Acad Child Psychiatry 51(5):541–557 Klein M (1932) The psychoanalysis of children. Hogarth Press, London Kohut H (1971) The analysis of the self: a systematic approach to the psychoanalytic treatment of narcissistic personality disorders. International Universities Press, New York MacLean G (1986) Hermine Hug-Hellmuth-a neglected pioneer in child psychoanalysis. J Am Acad Child Psychiatry 25(4):579 Mahler MS, Pine F, Bergman A (1975) The psychological birth of the human infant. Basic Books, New York Mayes LC, Cohen DJ (1996) Anna Freud and developmental psychoanalytic psychology. Psychoanal St Child 51:117–141 Ornstein A (1981) Selfpathology in childhood: clinical and developmental considerations. Psychiat Clin N Amer 4:435–453 Ornstein A (1984) The function of play in the process of child psychotherapy. Annu Psychoanal 12:349–366 Ornstein A, Ornstein PH (2005) Confl ict in contemporary clinical work: a self psychological perspective. Psychoanal Q 74:219–251 Pine F (1988) The four psychologies of psychoanalysis and their place in clinical work. J Am Psychoanal Assn 36:571–596 Plastow M (2011) Hermine Hug-Hellmuth, the fi rst child psychoanalyst: legacy and dilemmas. Australas Psychiatry 19(3):206–210 36 2 Traditional One-Person Psychology

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There is no such thing as an analysand apart from the relationship with the analyst and no such thing as an analyst apart from the relationship with the analysand. —Thomas Ogden

Attachment theory and infant developmental research have confi rmed the ubiquitous nature of the innate bidirectional mode of communication that exists in everyday human interactions. From birth, the infant learns to make meaning of the experiences with its caregivers in order to develop internal working models of attachment that refl ect implicit patterns of stable or unstable mental representations of self and others. When the internal working models of attachment are created in a secure and stable manner, it allows the child to understand and predict the intent of others in their environment, and it implicitly becomes a survival-promoting tool allowing for proximity with others, establishing a psychological sense of “felt” security (Bretherton 1985 ; Sroufe and Waters 1977 ). Further research has provided a better understanding of how cognitive and memory systems shape a person’s experiences when interacting with others in what are called moments of intersubjectivity —the dynamic interplay between two people’s subjective experiences (Chap. 5 ). Intersubjective experiences allow for “being with” and “getting” another person’s state of mind and their intentions. It is this dynamic interplay of subjectivity that, when things go well, leads to adaptive models of relating with others. These models are stored in nonconscious and nondeclarative memory systems in what is known as “ implicit relational knowing ,” which begins to be represented before the availability of language (Lyons-Ruth et al. 1998 ). Intersubjectivity promotes a cohesive and more fl exible way of refl ective abilities to know what works for healthy social reciprocity with implicit aspects of morality. Rustin and Sekaer (2004 ) aptly observe: “Experience, in an average expectable environment, enables genetic programs to unfold and puts the fi ne tuning on the genetic framework. From this new perspective the brain itself is relationally constructed.”

© Springer-Verlag Berlin Heidelberg 2015 37 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_3 38 3 Two-Person Relational Psychology for the Child and Adolescent

Thus, the advances from attachment theory, infant developmental research, and intersubjectivity have helped recognize that problematic and unstable early attachment experiences have a role in the development of mental health problems in children and adolescents. As a natural result, two-person relational psychology emerged as a theory of the mind that provided a path for the application of concepts derived from attachment theory, infant developmental research, and neurosciences in the practice of psychodynamic psychotherapy. As such, the notion of a two-person relational model of psychodynamic psychotherapy shook the foundations of traditional one-person psychoanalytic theory. Holmes (2000 ) suggests that attachment theory’s “most signifi cant contribution to contemporary psychoanalysis could be to help it accept the death of its founder…. Bowlby can help us let Freud go.” We suggest not letting Freud go, but rather acknowledging the important role he had in how two- person relational psychology evolved from the traditional one-person theories. In two-person relational psychology, the psychotherapist takes an active role to fi rst become an ally to the patient’s subjectivity and implicit relational knowing during the session. As Adler-Tapia (2012 ) states, “Psychotherapy needs to account for the signifi cant contribution of early attachment to mental health and behavioral issues.” That is, the intersubjective experience becomes a construct of the patient and psychotherapist’s personalities—temperament, cognition, cognitive fl exibility, and internal working models of attachment—brought into the context of a here-and- now therapeutic relationship. It is through this bidirectional process that allows the patient to implicitly, over time, become an ally to the psychotherapist’s healthier and more adaptive way of interacting with others. In essence, the psychotherapist provides a new emotional experience for the patient, which is stored in the patient’s nondeclarative memory at an implicit level. In this chapter, we provide a review of the trajectory of two-person relational psychology to give the reader an in-depth understanding of the importance and applicability it has to the clinical work with children and adolescents in psychodynamic psychotherapy.

3.1 Two-Person Relational Psychology

Making the Case for a New Paradigm

Over the last 30 years, with the emergence of a two-person relational psychology, there has been a signifi cant shift in the understanding of a person’s psychological problems, from intrapsychic and object relations confl icts to problems of temperament, cognition, affective attunement, cognitive fl exibility, and intersubjectivity (the complex interactions of the self, infl uenced by other persons, detailed in Chap. 5 ). This shift has led to psychotherapeutic interventions that are signifi cantly different than those of a traditional one-person model—the archaeological discovery of an unconscious confl icted buried past. A two-person relational model relies on open bidirectional, here-and-now subjectivities that are continually modifi ed by the reality of both persons—intersubjectivity. As expected the notion of a two-person, 3.1 Two-Person Relational Psychology 39 relationally-based psychodynamic model of psychotherapy was not received well by all clinicians in the traditional one-person psychoanalytic circles, as it challenged the legitimacy of its tenets. Friedman (2010 ) refl ects, “The chasm dividing classical and relational approaches is both wider and deeper than is acknowledged by psychoanalysts who attempt to either reconcile or minimize the differences between them.” The two-person relational model has gradually become a concept that most psychodynamic psychotherapists must contend with. Spezzano (1993 , 1996 ) suggests that “the phrase two-person psychology has become shorthand for our recognition that a new paradigm has taken a fi rm foothold in American psychoanalysis.” This method is widely spoken about in clinical circles, and many clinicians have found the freedom of being “authentic and real” with the patient as liberating from the traditional one-person approach. Two-person relational psychotherapy, in one form or another, is now practiced by a majority of mental health practitioners (Norcross et al. 2002 ). The two-person relational model has served as an umbrella for several forms of psychotherapies that endorse enactments and self-disclosures that frequently occur unknowingly, although at times can be well timed —mindfulness, dialectic, cognitive, patient centered, etc. Further, in the two-person relational model, the psychotherapist as an authentic and real person may implicitly disclose aspects of him or herself without quite knowing what has been revealed. In spite of the appeal of the two-person relational model, we have had colleagues who over the years have outwardly moved toward a contemporary two-person relational approach in their clinical work, although in reality they continue to be loyal to traditional one-person theory concepts and technique principles (Chaps. 2 and 6). They cautiously share that they do not want to throw out the baby— traditional one-person psychoanalytic concepts—with the bathwater, traditional one-person psychoanalytic technique. We fi nd an example of this dilemma in our colleague and friend, Andrew Gerber , illustrated in his commentary Neurobiology of Psychotherapy – State of the Art and Future Directions (Gerber 2012) in the outstanding book Psychodynamic Psychotherapy Research : Evidence - Based Practice and Practice - Based Research (Levy et al. 2012 ). Gerber is of the opinion that the intersection of neurobiological research and psychoanalysis “is fertile and growing…. That would have delighted Sigmund Freud.” He proposes four unifying principles. In the fi rst, he suggests that the description of psychopathology lies in a set of continuous trait and state variables representing the content and structure of an individual’s mental life. In the second principle, Gerber asks for a conciliatory stance, inviting the traditional one-person model clinicians to make mend with their own struggles in accepting that “the origins of most psychopathology are understood best as an interaction between inherited / genetic factors that lead to psychological traits , strengths , and vulnerabilities on the one hand and environmental factors , particularly experience , on the other” (italics ours). As such, two-person relational psychologies always include two “one persons.” His third principle emphasizes that psychological processes are best understood as a combination of cognitive, affective, and social categories. Finally, in his forth unifying principle, he seems to plea to the traditional one-person psychoanalytic community to accept their limitations: “The mechanism(s) of action in psychotherapies of all 40 3 Two-Person Relational Psychology for the Child and Adolescent kinds, including psychoanalysis and psychodynamic psychotherapy, overlap more than current clinical theories describe , thus beginning to explain the widespread fi nding that there are multiple effective ways to treat psychiatric illness with talk therapy” (italics ours). Gerber is implicitly moving the psychoanalytic movement toward a more integrative process—“we now have the opportunity to integrate multiple perspectives in our theory and research”—in line with two-person relational psychology, and concludes with “It is the task of psychotherapy to help the patient fi nd a set of narratives that are most useful for him or her. In psychodynamic thinking, this is often described as ‘co-construction ,’ whereas in cognitive therapy, it may be thought of as ‘cognitive restructuring.’” Although we mostly agree with Gerber’s principles and efforts for further dialogue among the divergent forms of psychotherapy, we caution his efforts toward an overly conciliatory stance with traditional one-person psychology clinicians as it attenuates the differences. The traditional one-person clinician believes that psychotherapy is effective when the inner confl icts of the child or adolescent are discovered and understood: through recognition of maladaptive ego defenses, the presence of transference manifestations (i.e., remembering and repeating), or by discovering object relations confl icts, which are amenable for being worked through by verbal insight-oriented suggestions or interpretations. Although the two-person relational psychology has built on the traditional one-person model, it has evolved to an approach that relies on the nonverbal, implicit cocreation of new experiences in the form of enactments and self-disclosures that frequently occur unknowingly, although at times can be well timed, to move along the psychotherapeutic relationship. The result of this is providing new and healthier nonconscious relational neuronal pathways in the here and now with the active and genuine psychotherapist—corrective emotional experiences— and later implicitly used when interacting with others (Fig. 3.1 ). Gaines (2003 ) suggests promoting new, more adaptive relational experiences, saying the “thoughtful use of therapist self- disclosure is an important tool for child and adolescent.” In two- person relational psychology, the terms “cocreate ” and “intersubjectivity ” are sine qua nons to the theory and technique. They refl ect the active participation by both patient and psychotherapist in the encounter, with continuous and novel moment-to- moment changes due to each other’s subjective experiences. Altman (1994 ) masterfully captures the differences between the two models: “As I argue, child psychoanalysts of all schools has been moving in the direction of a relational, two-person or multiperson psychoanalytic model in response to the diffi culties encountered in work with children on a drive theoretical basis. However, child analysts have done so while avoiding a clean break with drive theory. The result has often been a collage of one-person and two-person elements, which results in an internally inconsistent theoretical model with confusing implications for psychoanalytic technique. Specifi cally, a drive-based, one-person model directs attention away from the impact of the here-and-now interaction on patients.” As Hoffman (1994 ) states, “there is a feeling of ‘throwing away the book.’” We believe that is better stated as “let’s not forget that the original (one-person) book also has a second (two-person) part.” The mechanisms of therapeutic action may be different, but they still rely on an interaction of one and two person factors. 3.2 Historical Background of Two-Person Relational Psychology in Adults 41

New Emotional Experiences

IF Child/Adolescent Psychotherapist • Meaning making (++) • Affective attunement (+++) • Mirror/echo neurons/ Internal working • Emotional availability (+++) default mode network models • Social referencing (+++) • Social referencing (+++) of attachment • Temperament (easy/flexible) • Temperament • Cognition • Cognition • Cognitive flexibility (+++) • Cognitive flexibility

Co-create now moments Ruptures (Non-declarative) Implicit relational knowing New more adaptive emotional experiences Co-created moments Repairs of meeting

Fig. 3.1 Schematic representation of two-person relational psychotherapy representing the psychotherapist and patient. New emotional experiences occur in the intersubjective ﬁ eld (IF), the overlap of subjective experiences. Number of (+) denotes degree of strength in this dyad

In Chap. 6, “Deconstruction of Traditional One-Person Psychology Concepts,” we take a bold approach that we believe is much needed but cautiously avoided by most. In that chapter, we discuss in detail the steadfast terms from traditional one-person psychologies, followed by their deconstruction when viewed through the lens of a two- person relational psychology. We then further clarify the reasons why these everyday traditional one-person concepts have transformed to terms that attend to discoveries from developmental research, neuroscience, attachment, and temperamental theories to the clinical work of a contemporary two-person relational psychotherapist.

3.2 Historical Background of Two-Person Relational Psychology in Adults

The origin of two-person relational psychology in adults dates back to the 1900s in Europe by Sigmund Freud’s dissenting colleagues and students. It is mostly believed that two-person relational psychology took hold in the United States during the last 30 years. Herein, we will brieﬂ y provide the reader with the historical evolution of the emergence of the two-person relational psychology model in the landscape of the adult psychotherapist, followed by the subsequent inﬂ uence for the child and adolescent psychotherapist. 42 3 Two-Person Relational Psychology for the Child and Adolescent

Freud’s Dissenting Colleagues

Freud began with a small and closed group of colleagues loyal to his psychoanalytic theories and formed the Wednesday Psychological Society, which later became the Vienna Psychoanalytic Society. Among some of its members were Wilhelm Stekel, Paul Federn, Alfred Adler, Otto Rank, Sándor Ferenczi, Ian Suttie, Karl Abraham, and Carl Jung. Over time, conﬂ icts aroused, and Adler, Jung, and Rank broke away from Freud’s drive theories and formed their own societies. This was followed by the departure of Ferenczi, Stekel, and Suttie, who introduced the idea that the analyst needed to be a real and active participant in the process in order to help the patient feel understood. Though their progressive ideas had the potential of extending the psychoanalytic movement to greater scientiﬁ c inquiry, they instead were ostracized from prominent psychoanalytic circles for questioning Freud’s psychoanalytic theories and advocating changing neutrality to an empathic bidirectional relationship that allowed for gratifying the patient’s wishes in certain situations. The early dissenters provided the seeds needed to give birth to what later became two- person relational psychology.

Sándor Ferenczi (1873–1933) Sándor Ferenczi was considered the heir to Freud’s Psychoanalytic Society (Fig. 3.2 ). He later became critical of Freud’s authoritarian and patriarchal stance, as well as his centerpiece of psychoanalytic technique, neutrality. Ferenczi encouraged a certain degree of fl exibility and emotional availability of the analyst with the patient and encouraged the gratifi cation of certain wishes in the form of empathy. In retrospect, it is clear that Ferenczi had set the stage for two-person relational psychoanalytic psychology to emerge. In Berman ’s (1999 ) masterful review of Ferenczi legacy, he states, “He was ahead of his time, and our generation fi nds him more understandable than his own.” Soon after, others in Freud’s circle openly agreed with Ferenczi’s view, the importance of the analyst as a real person and not as transference object, now considered the sine qua non in two-person relational psychology. Most of the dissenters from that period were strongly infl uenced by the work of Ferenczi, who pioneered the analyst’s authenticity, emphasizing the mutuality of the relationship between psychoanalyst and patient (Aron and Harris 1993 ). Both Ferenczi and Rank believed that therapeutic change occurred when the analyst provided supportive experiences rather than only by the interpretation of the transference. For nearly a half century, the politics in the psychoanalytic community sup- pressed much of Ferenczi’s ideas; however, there has been a recent rediscovery about the importance of his work. In an excellent review of Ferenczi’s theoretical concepts and clinical practice, Rachman (1999 ) called him a “clinical genius of psychoanalysis.” Ferenczi was not simply deviating from his mentor, Freud; he was offering an alternative theory to understand the human mind. In his seminal work The Confusion of Tongue Between Adults and Children ( 1933), Ferenczi stated that negative early childhood experiences (e.g., parental depravation and empathic failures) could lead to adult psychopathology. Ferenczi’s contributions to psychoanalytic theory and technique include: (1) the introduction of empathy into the analytic 3.2 Historical Background of Two-Person Relational Psychology in Adults 43

Fig. 3.2 Sándor Ferenczi and Sigmund Freud (Image from The Sandor Ferenczi Center at The New School for Social Research (New York, NY)

relationship, (2) the importance of noninterpretative behavior by the analyst, (3) the function of experiential and emotional dimensions in the analytic therapy, (4) analyst self-disclosure, and (5) pioneering mutual analysis (Rudnytsky et al. 2000 ). To date, the ﬁ rst four contributions remain very much among the main tenets of the two-person relational model of psychodynamic psychotherapy.

William Stekel (1868–1940) William Stekel was known as Freud’s most distinguished pupil ( Wittels 1924 ). Stekel’s early contributions to psychoanalysis and child psychoanalysis while in Freud’s circle are described in Chap. 2 . Subsequently, though, Stekel strongly criticized Freud’s analytic method: “Orthodox analysis, which demands that man remember all occurrences as far back as childhood, has set up an impossible task for itself—impossible to accomplish in the way it is being handled. We can call orthodox analysis the passive analysis (Stekel and London 1933 ). The analyst commands his patient to tell everything which passes through his mind. These revelations are then explained and associated. The same method is employed in the interpretation 44 3 Two-Person Relational Psychology for the Child and Adolescent of dreams, Freud’s passive analysis.” Furthermore, he had strong words against Freud’s prohibition in giving advice to patients and believed it was necessary to assist pedagogically and to guide patients during the sessions. He said of Freud’s method, “No wonder that a treatment of this kind requires endless time and patience on both sides, on the part of the physician and that of the patient” (Stekel and London 1933 ). Stekel recognized that when the analyst took an active role during the analysis, the patients would feel safe and more open to reveal their conﬂ icts.

Ian Suttie (1898–1935) Ian Suttie posited that the infant had the innate capacities and wishes for human “companionship.” In his masterful and little known book The Origins of Love and Hate (1935 ), Suttie stated: “Formally, the tentative theory I have formed belongs to the group of psychologies that originates from the work of Freud. It differs fundamentally from psychoanalysis in introducing the conception for an innate need-for- companionship, which is the infant's only way of self-preservation. This need, giving rise to parental and fellowship ‘love.’” Suttie was interested in the emotional bond between infant and mother and the impact it had on adult psychopathology. Montagu ( 1953 ) writes, “Where the cornerstone of the Freudian system is sex, in Suttie’s it is love.” Sadly, Suttie died at the age of 46, although the legacy of his work at the Tavistock Clinic in London later inﬂ uenced John Bowlby, the father of attachment theory.

British Relational Theorists

Charles Rycroft (1914–1998) It was not until the 1950s that Charles Rycroft , a British psychoanalyst, left the Freudian psychoanalytic movement of Europe and openly questioned the scientiﬁ c credentials of psychoanalysis and became dismayed by the bitter rivalry between the Kleinian and Freudian camps (Rycroft 1985 ; Holmes 1998 ). He too questioned the psychoanalytic approach of the detached observer and emphasized the importance of the real relationship between the psychotherapist and patient as crucial and curative. Though he was also dismissed from traditional psychoanalytic circles, Rycroft rein- vigorated the ideas of two-person relational psychology through his proliﬁ c work in popular press, including The Observer and The New York Review of Books .

Jeremy Holmes (1943–) Jeremy Holmes is a contemporary British psychoanalyst whose instructive books The Search for the Secure Base: Attachment Theory and Psychotherapy (2001 ) and Exploring in Security: Towards an Attachment- Informed Psychoanalytic Psychotherapy ( 2010 ) make use of Bowlby’s concept of internal working models. Holmes proposed that psychotherapists need to take an active role in order to help adult patients break the negative cycle of self-defeating experiences. He believes that when patients and psychotherapists mutually cocreate a coherent new narrative of their experiences with others, they learn to manage their affects more effectively. He adds, “What good therapists do with their patients is analogous to what successful parents do with their children” (Holmes 2001 ) . 3.2 Historical Background of Two-Person Relational Psychology in Adults 45

American Relational Theorists

In the United States, there also were some dissenters who broke from the mainstream of Freud’s drive theory and the restrictive psychoanalytic techniques, speciﬁ cally the emphasis on analytic neutrality and psychic determinism (Chap. 6 ). The dissenters founded the William Alanson White Institute (WAWI) in 1946. The WAWI was strongly inﬂ uenced by the work of Ferenczi, and its members included Harry Stack Sullivan, Clara Thompson, Erich Fromm, Frieda Fromm-Reichmann, David Rioch, and Janet Rioch. Currently, WAWI is one of the leaders in the advancement of two-person relational psychology and has among its faculty member’s distinguished writers Philip Bromberg, Jay Greenberg, and Donnel Stern.

Harry Stack Sullivan (1892–1949) Harry Stack Sullivan is thought to be among the original important ﬁ gures in American psychiatry. He departed from Freud’s drive theory and Klein’s object relations theory and was considered a Neo-Freudian psychiatrist and psychoanalyst whose main contribution to the psychoanalytic movement was the interpersonal theory and interpersonal psychotherapy. He proposed that the most important contributor to the formation of a person’s personality was the interpersonal relationships created in early childhood within the context of society and culture (Barton 1996 ). Sullivan believed that a person “can never be isolated from the complex of interpersonal relations in which the person lives and has his being” (Sullivan 1940 ).

Jay Greenberg (1933–) and Stephen Mitchell (1946–2000) The shift from Freud’s one-person psychology to a two-person relational psychology occurred over several decades, and it was not until 1983—with the publication of Jay Greenberg and Stephen Mitchell’s seminal book Object Relations in Psychoanalytic Theory—that the differences and overlaps between relational and drive models were outlined. Greenberg and Mitchell were trained under the infl uence of Harry Stack Sullivan, the founder of the interpersonal theory of psychiatry (Sullivan 1953 ). Greenberg and Mitchell’s (1983 ) departure from Freud’s traditional drive theory led to the distinct two-person psychology concept of relatedness —referring to the analyst and patient—that represented a change in psychoanalytic thought. They stated, “Relations with others constitute the fundamental building blocks of mental life.” The psychodynamic theories that ensued were a clear departure from the traditional one-person model that considered the neutrality of the analyst to be a necessary component in facilitating the development of the transference neurosis onto the analyst. The contemporary two-person relational psychology model proposes a bidirectional form of treatment that features the mutual participation of the psychotherapist and the patient in a real relationship, with attention to here-and-now cocreated moments that are recognized as therapeutic in and of themselves. Greenberg and Mitchell saw the relational models as diverging from the traditional Freudian conceptualization of human motivation and the nature of the mind. So as to not recreate bitter confl icts, such as those that Freud had with his dissenters or the heated disagreements between the Anna Freudians 46 3 Two-Person Relational Psychology for the Child and Adolescent and the Melanie Kleinians, Greenberg and Mitchell were wise in taking a rather conciliatory approach when conveying their concepts to the psychoanalytic community (King and Steiner 1991 ). Ultimately, with Mitchell’s (1988 ) book Relational Concepts in Psychoanalysis : An Integration that the relational movement took hold in the United States. By 1991, Mitchell had become the most prolifi c and infl uential relational psychoanalyst in the fi eld and was instrumental in helping to launch the International Association for Relational Psychoanalysis and Psychotherapy. He also became the founding editor of Psychoanalytic Dialogues: The International Journal of Relational Perspectives , which remains a well-respected international publication for the contemporary psychoanalytic and psychodynamic community. Sadly, Mitchell died at the age of 54, and in honoring his work, his colleagues founded The Stephen Mitchell Center for Relational Studies in New York City in 2010. It continues to be an active educational and clinical center that counts many well-respected two-person relational psychoanalysts among its faculty, including Lewis Aron, Beatrice Beebe, Jessica Benjamin, Adrienne Harris, James Fosshage, Paul Wachtel, and Jay Frankel. Pearlman and Frankel ( 2009) refl ect on the relational movement, saying it “gained its fi rst institutional foothold when it became a separate offi cial ‘orientation’ within the New York University postdoctoral program in psychotherapy and psychoanalysis in 1988.” For an eloquent and detailed description of two- person relational psychology and attachment theory in psychotherapy of adults, we refer the reader to Buirksi and Haglund (2009 ), DeYoung (2003 ), Wachtel (2010 ), and Wallin (2007 ).

Paul Wachtel (1940–) Paul Wachtel is a psychologist and psychoanalyst and cofounder of the Society for the Exploration of Psychotherapy Integration (SEPI). The central themes of his writings focus on the theory and practice of two-person relational psychotherapy, which he eloquently distinguishes from the traditional one-person model. He posits that what transpires during a psychotherapy session goes beyond the patient and psychotherapist subjectivities. He emphasizes that the clinical encounter is best viewed from a fully contextual approach: accounting for the patients’ and psychotherapist’s experiences of each other as implicitly being inﬂ uenced by earlier relationships, as well as implicit social and cultural forces. He is best known for his books Relational Theory and the Practice of Psychotherapy (2008 ), Inside the Session : What Really Happens in Psychotherapy (2011 ), and Cyclical Psychodynamics and the Contextual Self (2014 ).

3.3 Historical Background of Two-Person Relational Psychology in Child and Adolescent Psychotherapy

We have provided the reader a review of the historical background of the two-person relational psychology pioneers in the treatment of adults with psychoanalysis and psychodynamic psychotherapy. We now proceed to provide an outline on how, over the last 20 years, two-person relational psychology began and was incorporated into the psychodynamic psychotherapy of children and adolescents. 3.3 Historical Background of Two-Person Relational Psychology 47

The importance of the two-person relational model in working with young children has expanded over the last two decades, largely due to the advances in developmental psychology and neuroscience. Developmental research has placed the early experience of the infant with its caregiver at the center of understanding developmental and relational diffi culties, as well as later formal psychopathology in children and adolescents. Although the two-person relational model of psychodynamic psychotherapy is gaining traction in clinical practice, it continues to remain largely elusive in child and adolescent psychiatry training programs. Newly minted child and adolescent psychiatrists currently are mostly focused on learning traditional one- person model psychotherapy, evidence-based treatments, cognitive behavioral therapies, and new psychopharmacological interventions. We also note that the rich fi ndings from developmental research and the eloquent writings regarding two-person relational psychotherapy in children and adolescents have been primarily limited to the literature available to relational psychoanalysts, psychologists, and social workers. Unfortunately, this inherently limits the exposure of the child and adolescent psychiatrist in training to these useful concepts. It is our hope that the trainee, newly minted child and adolescent psychiatrist, or psychodynamic psychotherapist fi nds this book helpful in increasing their knowledge of two-person relational psychology and its application to their day-to-day clinical work.

American Two-Person Relational Child and Adolescent Psychotherapists

We will now briefl y review the main authors that have infl uenced our journey as child and adolescent relationalists . These authors have been brave in sharing their work, even though it was seen by some as “not psychodynamic,” claims we clearly disagree with. As Gabbard and Westen (2003 ) state: “We would suggest deferring the question of whether these principles or techniques are analytic and focusing instead on whether they are therapeutic . If the answer to that question is affi rmative, the next question is how to integrate them into psychoanalytic or psychotherapeutic practice in a way that is most helpful to the patient.”

James Anthony (1916–) James Anthony , a well-respected child psychiatrist and child psychoanalyst who, although largely anchored in a traditional one-person model in his work with children and adolescents, also noted the importance of innate and contextual factors that need to be considered in their treatment. In his extraordinary paper Communicating Therapeutically with the Child—published in 1964 in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), a mainstream journal for child and adolescents psychiatrists—he emphasized the psychotherapist’s need to learn about the child’s outside world realities. 48 3 Two-Person Relational Psychology for the Child and Adolescent

To understand some children, you need to know especially about their unoccupied, unsched- uled hours when they are lonely and bored. Knowing how he spends his time and how he wastes his time will provide us with two important facets of the child’s life (Anthony 1964 ).

In contemporary two-person relational psychotherapy with children and adolescents, it is understood that a child has approximately 100 waking hours a week and that only 1 or 3 hours of psychotherapy during the week are “a drop in the bucket” if not accompanied by knowing what the child spends his time on and the realities of his environment. In the two-person relational model, the patient is viewed through the lens of the contextual. That is, the here-and-now interactions with a child or adolescent are inﬂ uenced not only by the context of the interaction with the psychotherapist but also by what the patient chooses to share within the context of their environment. Anthony makes the case for the child and adolescent psychotherapist to humbly recognize his limitations when solely relying on information obtained during the psychotherapy sessions, which is more commonly the case in a traditional one- person model. Anthony openly agrees with Anna Freud in that the child analyst who relies exclusively in the inner world, risks missing out on his patient’s activity concerning his equally important environmental circumstances (Anthony 1986 ).

A child who isolates Alex, an 11-year-old boy with an easy/fl exible temperament, well-developed cognitive fl exibility, and secure internal working models of attachment (Chap. 8 ), had begun to isolate in his room and avoid his family and friends. He was a good student and was doing well in school. He was brought to the psychotherapist by his parents to help with his “isolation from the world.” He played well during the initial two sessions at age-appropriate games, although the psychotherapist noted the subjective and palpable anxiety in the boy. The psychotherapist’s intersubjective experience allowed him to understand the boy’s subjective desire to share his struggles, as well as his fear in doing so. To this, the psychotherapist decided to genuinely say, “I really think we can fi gure out what bothers you. My idea is that if we go through what you do during the day before you go to your room and isolate, we can fi gure out where the problem is.” The boy, somewhat embarrassed, responded, “I don’t want to talk about it.” The psychotherapist respected the boy’s wish of not wanting to talk about his isolation and wondered if it would be easier if the boy wrote down everything he did during the day and brought these notes to the next appointment. The boy seemed relieved and agreed it would be easier, although he wanted reassurance that his parents would not see his notes until he had shared them with the psychotherapist, to which the psychotherapist agreed. In the following appointment, the boy gave the psychotherapist a sheet of paper with details of what occurred between sessions. He had written, “I hear voices during school, at home, and when I am with my friends. In the eve- nings I go to my room because I do not want my family and friends to know I hear them. Please help me feel better.” His parents had thought that he just needed space and did not know about the severity of his symptoms. 3.3 Historical Background of Two-Person Relational Psychology 49

This example captures what Anthony had in mind: to accept that children have a world with many experiences that infl uence and shape many aspects of their personalities. The two-person relational psychotherapist in this example is active, present, and uses his intersubjective experience to recognize the child’s distress. Rather than continuing with an active line of questioning or comments to the effect of “I know you are worried and it is hard for you to tell me” (essentially saying, “I know you are hiding something from me”), he respects that the child is not ready to share his worries. He also discloses his interest in the child’s life outside of the offi ce as much as that in his offi ce, demonstrating that daily experiences are important, which may include success that can be supported in addition to his worries. As Wachtel (2012 ) reminds us, “We do not adequately understand the meaning or implications of what is transpiring in the consulting room without understanding in considerable detail what happens in the patient’s daily life; conversely, our understanding of the events of his daily life is likely to be far less accurate and perceptive if it is not informed by the complex intersubjective exchange between patient and therapist in the consulting room.” He later adds, “the two approaches each offer valuable and important elements that must be included to achieve a maximally effective therapeutic effort.” Further, the two-person relational psychotherapist will work with the child’s parents, as he may learn about situations that may be relevant to the child’s life and important to bring into the process. Additionally, Anthony’s paper was clearly ahead of his time. He gave importance to the interface between the fi ndings from attachment theorists and developmental researchers to the practice of psychodynamic psychotherapy with children and adolescents, which is the essence of a two-person relational model of psychotherapy. Anthony refl ects:

The child’s capacity to communicate is closely related to the success or failure of his ﬁ rst communication environment when he was learning the language of gesture, of expression, of minimal cues, of kinesthetic communication, and, most important of all, of words. The various types of mother–child relationship favor or disfavor the development of a need to communicate with another person for the sake of the immeasurable satisfactions that it offers. It is clear, however, that in the majority of cases that Winnicott would call “good- enough,” the warm, sympathetic, empathetic, patient, and uniquely and mutually satisfying coupling of mother and infant brings about a good-enough level of communication that persists throughout life. This communication model would be an ideal one to strive after when we need to further communication, as we do in therapy.

In essence, he agrees with Levenkron (2009 ), who states that attending to prosody is a “rich vehicle for the expression of implicit relational knowing. Gestures, body language, sighs, eye movements, facial expressiveness, breathing and tone, cadence, rhythm and emphasis are among the many prosodie carriers of meaning.” Herein, in spite of Anthony’s introduction of two-person relational psychology concepts, it has taken nearly 20 years for two-person relational psychology in child and adolescent psychotherapy to take hold. Cohen (1997 ) adds to Anthony’s vision, “The shift in child work—theoretically and clinically—to a more equitable balance between internal and external 50 3 Two-Person Relational Psychology for the Child and Adolescent factors represents a shift that many would see as an extension of previous work but that others would see as a dilution….. Still, there are those who see this shift as a dilution, even a crisis for child psychoanalysis. There is the concern that focusing on the external world (e.g. working too much with parents) potentially undermines what has been considered the heart of psychoanalytic work: the ability to work with the transference and other aspects of unrecognised meanings and structures.”

Neil Altman (1946–) Neil Altman is a psychologist and psychoanalytic psychotherapist recognized for his clinical work in relational child psychotherapy. As with the 1983 publication of Jay Greenberg and Stephen Mitchell’s book Object Relations in Psychoanalytic Theory , which allowed the relational movement in adults to take hold in the United States, the publication of the seminal book Relational Child Psychotherapy (Altman et al. 2002 ) allowed the relational movement to take hold in child and adolescent psychoanalysis and psychotherapy. This book makes great strides in integrating concepts of two-person relational psychology in working with children. Altman (1994 ) states: “Child analysts, I suspect, have been working a great deal with the immediate interactions with their patients. Yet, in their efforts to preserve a one- person model, there is a risk of their attention being led away from the impact their own actions and interpretations on their child patients. A fully relational approach to child analysis would take account of such impact.” Notwithstanding, a limitation of their book is that the authors limit their work to diagnostic formulations and clinical work with infants and elementary school-age children and not with adolescents. In a later paper, Altman (2004 ) states, “With few exceptions, the child’s psychoanalytic world was, until recently…seemly unaffected by the relational turn in the literature.”

Other Two-Person Relational Child and Adolescent Psychotherapists

Other important contributors to two-person relational child and adolescent psychotherapy are Richard Briggs, Kenneth Barish, Jay Frankel, Daniel Gensler, Monica Lanyado, and Pasqual Pantone.

3.4 Two-Person Relational Psychodynamic Psychotherapy

The authors defi ne contemporary two-person relational psychodynamic psychotherapy as a rich and complex process that involves a child or adolescent and his or her psychotherapist, who through a process of mutual understanding of here-and-now moments of intersubjectivity cocreate corrective experiences that are stored in nonconscious nondeclarative memory systems, which are needed for successful clinical 3.4 Two-Person Relational Psychodynamic Psychotherapy 51 work (Fig. 3.1 ). Although the patient’s and the psychotherapist’s subjectivities are mutually infl uenced, the infl uences are not symmetrical. The asymmetry refers to the psychotherapist’s personal healthy attributes that allow him or her to be guided by the intersubjective experiences provided by the patient in the here-and-now moments of their interactions. Additionally, the asymmetry allows the psychotherapist to nudge the patient, by carefully timed enactments and self-disclosures, to move along the process in what are called moments of meeting, which may also occur spontaneously and unknowingly. Herein, together, the patient and psychotherapist cocreate new “ corrective emotional experiences ” (Alexander et al. 1946 ; Hoffman 2006 ).

Moment of meeting with an adolescent A 16-year-old adolescent male begins two-person relational psychotherapy for his depression. He shares with the psychotherapist that he is worried his father will not understand that he no longer wishes to participate in high school sports and would like to dedicate his time studying for his college admission exams to pursue a career in journalism. The psychotherapist intersubjectively experiences that the patient’s efforts to follow his dreams are being held back by his father’s pressure for him to pursue sports and by his depression. The psychotherapist enacts and self-discloses, “I have an idea and I would like your input about whether you think it may help. What do you think about inviting your father to our next session? I wonder if my help can lead to a better solution between the two of you.” With a visible sense of relief and affectively feeling understood, the patient states that his father (a high- level engineer) needs help understanding how difﬁ cult it is for an adolescent to struggle with depression and that his father would trust “a doctor’s opinion.” A moment of meeting was cocreated.

Basic Principles of a Two-Person Relational Psychodynamic Psychotherapy Process

In a two-person relational psychodynamic psychotherapy process, there is inherent emphasis on the importance of the active participation by both patient and psychotherapist during the encounter, with continuous and novel moment-to-moment changes due to each other’s subjective experiences (Aron 1990 ). The subjective experiences occur in the intersubjective ﬁ eld between patient and psychotherapist, and the changes occur at an implicit level. Cappas et al. (2005 ) suggest that a two-person relational psychotherapy process integrates seven principles:

• Genetics and environment interact in the brain to shape the individual. • Experience transforms the brain. • Memory systems in the brain are interactive. • Cognitive and emotional processes work in partnership. 52 3 Two-Person Relational Psychology for the Child and Adolescent

• Bonding and attachment provide the foundation for change. • Imagery activates and stimulates the same brain systems as does real perception. • The brain can process nonverbal and unconscious information.

Meanwhile, the Boston Change Process Study Group (BCPSG 2010 ) conceptualizes the two-person relational model of psychotherapy to be based on ﬁ ve basic premises:

• The dyadic nature of the therapeutic process • Fittedness and directionality in the therapeutic process • Sloppiness and creative negotiation in the therapeutic process • Increasing inclusiveness of the therapeutic process • Vitalization in the therapeutic process

Both conceptual views help the two-person relational psychotherapist understand the complexities in providing a here-and-now sense of mutuality needed to cocreate a corrective emotional experience for the patient (Table 3.1). Further, both views attend to the patient’s innate and acquired strengths. As Wachtel (2011 ) states, “Effective psychotherapeutic effort must have an equally clear vision of the patient’s strengths. It is on those strengths that change is built, and failure to see them clearly can make change extremely unlikely.” For example, from the time a person begins the day showering, brushing their hair, and eating breakfast, through the times he or she takes the children to school, calls a friend, completes work, and goes to the store to buy the ingredients to prepare dinner, to the time when he or she serves dinner, leaves the children with a babysitter, and goes to a movie with their spouse, their psychological functioning is difﬁ cult to distinguish from that of any other person, and these mundane moments are precisely the crucial building blocks upon which change is created (Wachtel 2011 ).

Table 3.1 Broadly accepted tenets of two-person relational psychotherapy The central, innate motive of mental life is to seek relatedness with others Early childhood implicit relational patterns of interaction manifest within the psychotherapy process in the form of intersubjective experiences between the psychotherapist and the patient Change occurs at the implicit level in the form of nonconscious moments of meeting that lead to the development of new neuronal pathways and more adaptive patterns of interaction The psychotherapist must be aware of his or her emotional states, to effectively attune to the patient and provide the intersubjective ﬁ eld necessary for moments of meeting to occur Co-construction of new reparative enactments is fundamental to the healing process and therapeutic change, new emotional experiences Insecure attachment in childhood disrupts healthy emotional and relational development 3.5 Two-Person Relational Experiences Are Contextual 53

3.5 Two-Person Relational Experiences Are Contextual

We are in agreement with Wachtel, and feel the essence of two-person relational psychology, that experiences between two or more people are contextual. We propose that in two-person relational psychotherapy, the concept of “ contextual ” represents three different aspects: realities within the environment that trigger a person’s anxiety; interactions with another person that implicitly trigger anxiety; and here-and-now moments in the psychotherapeutic process during which, in the intersubjective fi eld , the patient unknowingly and implicitly is trying to engage the psychotherapist into a relational pattern that is contextually familiar (Wachtel 2010 ). A traditional one-person model maintains that a patient’s symptoms or relational diffi culties represent ego defense mechanisms to manage intrapsychic drive or object relation confl icts. The clinician becomes the objective observer of the patient’s maladaptive defenses, develops a diagnostic formulation of the intrapsychic pressure for such behaviors, and later, through clarifi cations or interpretations, provides the insight needed for the patient to return to a healthy developmental track. In essence, a traditional one-person model psychotherapist does not give equal importance to the realities of the contextual as to his or her objectivity. We recognize that a person using a traditional one-person model may resort to distancing when in doubt about how to proceed during a moment in the clinical encounter, which generally takes the form of silence, withholding answers, or asking the well- worn question, “What do you think?”

Realities in the Environment That Trigger a Person’s Anxiety

We begin with an example that can help shed some light on delineating the context of the situation in which the person experiences anxiety. Consider a person who is an avid hiker and frequently takes trips to rugged terrain where hiking poles are needed. Although this hiker (one of the authors of this book) is typically eager to climb moderate to challenging hills, he becomes anxious about slipping or falling when descending. On one occasion, while descending a steep rocky section with a friend, they stop and laugh upon seeing some other hikers descending rapidly without using hiking poles. The friend says, “Don’t you wish we could descend like them? They have a steady foot like goats.” Considering this example as psychodynamic psychotherapists, we may utilize Freud’s concept of psychic determinism to an extreme in understanding everyday life situations that are anxiety laden. From this vantage, it could be said that if the two friends separately sought a psychoanalyst to better understand their fear in descending, the psychoanalyst may consider the fear due to unresolved intrapsychic confl icts triggered by the steep descent, and that by having access to their free associations 54 3 Two-Person Relational Psychology for the Child and Adolescent or dreams—the traditional one-person archaeological excavation—the repressed confl icts that led to the inhibition in descending could be uncovered and later worked through. In contrast, when the avid hiking author discussed the diffi culties of descending steep terrain with a physical therapist, who knew plenty about the differences in body mechanics, she deftly captured, in non-psychoanalytic terms, the reason for the anxiety about descending: “Our genes defi ne us; your body mechanics are lousy for descending in treacherous terrains. Some individuals are genetically predisposed to be able climb and descend with dexterity and others, like both of you, can only do one or the other well.” She proceeded to share the complex aspects of body mechanics (i.e., balancing, positioning of feet, coordination, etc.) that contribute to having abilities or limitations. As Freud stated, “Anatomy is destiny” (1924 ). We provide this example to serve as a reminder to the reader that when the traditional one-person concept of psychic determinism is used to understand anxiety- laden daily-life experiences, it can be limiting. In this hiking example, the traditional one-person psychotherapist may have thought that the unconscious forces held the clue to the person’s fear in descending. It may be of interest that in dream analysis the fear of heights in men was once thought to be indicative of psychic confl ict regarding fear of success due to castration anxieties. (We happily note that the hiking author’s psychoanalyst attests that the castration anxieties were thoroughly worked through, even though the author continues to fear steep descents.) In contrast, contemporary two-person relational psychology understands that people have certain attributes and limitations as a result of their genetic blueprint, which infl uence how they respond to event in their environment at an implicit level; their response is not infl uenced by a confl icted unconscious. In the example of the hiking friends, it is clear they were aware of their inherent abilities and limitations in descending. Further, since the experience is shared in vivo (sharing subjectivities in the here and now), it becomes the context for their anxiety . They may implicitly understand, “We are in this together and we can laugh because we both know we can descend slowly and carefully,” alluding to nature and nurture factors. In contrast, if the person hiking were unable to share the experience with a friend in the same context, “being in the same shoes,” the anxiety may have been managed much differently and infl uenced by implicit relational knowing (Chap. 5). That is, the person hiking may have been overwhelmed, feeling unable to share the experience, and may have chosen not to descend the trail. A situation that is familiar to all of us is that of the innate and contextual differences among siblings. Differences in abilities and limitations among siblings are ubiquitous. One child may be skilled in sports, while the other is clumsy in sports but excels in music. A two-person relational model encourages the psychotherapist to consider the sibling differences as a result of the interactions of nature and nurture in many complex ways, and not due exclusively to their unconscious drives and parental object representations. Understanding this in terms of the patients, genetic differences can infl uence the abilities and limitations of their psychological functioning. With this in mind, in the case of the siblings, if the parents are not skilled at sports or music, they will need to implicitly learn how to attune with the affective states of their children in a manner that promotes curiosity and excitement supporting their talents. At the most basic level, the parents will need to intuitively learn how to share their excitement within the context of the situation—loudly in sports and quietly in musical events. 3.5 Two-Person Relational Experiences Are Contextual 55

Interactions with Another Person That Implicitly Trigger Anxiety

In considering the interactions between two people, we have made the case through this book that infant developmental research has elucidated that the infant’s meaning- making experiences with other people are many and ultimately infl uence personality development (Chap. 5 ). That is, the child’s implicit relational knowing takes into account a person’s attachment experiences evoked by the different people they have interacted with through their life span, relationships of relationships (Emde 1989 ). Wachtel adds, “It attends to what each party to the exchange or to the relationship is doing and feeling at any particular moment, and it asks what each person’s participation in the attachment relationship at any given moment is in response to and what it evokes in the other.” In contrast to a traditional one-person model that may see interpersonal diffi culties as solely due to the patient’s intrapsychic confl icts with others, in a two-person relational model, the nature of the context of the interaction is essential to consider. As Wachtel (2010 ) aptly states, “The contexts in which we fi nd ourselves are very largely contexts that we have ourselves contributed to creating, that we have cocreated with those who participate with us in that context.” Used clinically, the psychotherapist will need to maintain a keen ear for the interpersonal experiences a child and adolescent patients describe as challenging.

The 12-year-old child that excels at school The parents of a 12-year-old child brought her in for a psychiatric evaluation after she had been diffi cult and obstinate. The child was bright, excelling at school academically, and was well liked by peers. The clinician intersubjectively experienced the child as pleasant, bright with an easy/fl exible temperament, and easy to engage in playful here-and-now moments. In contrast, while the clinician was interacting with the child, the parents were outwardly critical of their daughter and demonstrated poor capacity to provide the emotional availability needed by their daughter. When the clinician inquired about what the parents considered their daughter’s obstinate and diffi cult behaviors to be, they shared that she had been disrespectful because she would not ask them to attend her sporting events and that she preferred spending time at her friends’ homes and did not like to have friends over to their home. While her parents were sharing their view, the child looked at the clinician and in a nonverbal manner implicitly was saying, “See why I don’t want to have my friends around my parents,” which the clinician intersubjectively understood.

This example helps illustrate the fact that, in many occasions, a child or adolescent may have diffi culties interacting with certain people. When viewed from the lens of the contextual, this knowledge allows the psychotherapist to appreciate that the here-and-now intersubjective experience may fail to capture what it is like for the patient in those “live” diffi cult moments with others (see section on limitations in Chap. 1). The example also brings the contextual aspects to the offi ce, where the clinician has a front-row seat to the bidirectional interactions and is able to 56 3 Two-Person Relational Psychology for the Child and Adolescent understand the vantage point of both parties: In this case, the clinician noted that the parents had a diffi cult/feisty temperament and a dismissive attachment style with defi cits in social reciprocity, while their daughter had the attributes needed (i.e., an easy/fl exible temperament, a good ability for social reciprocity) to seek the emotional attunement from other family members in early childhood, and later from teachers. The clinician understood the child when using the intersubjective experience of the child and parents.

The Patient Unknowingly and Implicitly is Trying to Engage the Psychotherapist into a Relational Pattern that is Contextually Familiar

Wachtel (2010 ) reminds us of the unique proclivities that each member brings into a psychotherapeutic dyad: “We begin to think that this is the way the person ‘is,’ when it is more accurate to say that this is the way he is with me (and, moreover, how he is with me when I am acting in a particular way, and he may not be that way even with me when I am being different).” Wachtel, like Anthony, emphasizes the importance in understanding that psychotherapy is a fully contextual process.

The 7-year-old child has problems playing The parents of a 7-year-old child brought their son in for a psychiatric evaluation due to him seeming unhappy and having diffi culties playing with family and peers. After gathering pertinent information from the parents, the clinician proceeded to see the child without the parents present. The child was friendly and seemed eager to play. The clinician suggested they play Connect Four, a developmentally appropriate game for his age, to which the child agreed. Within a few moves, the child became irritable with the clinician and said he no longer wished to play any games. Internally, the clinician thought, “Why do you make it so diffi cult to play with you,” which was not the typical reaction when the clinician had previously played with young children. The clinician recognized that he had unknowingly begun to implicitly give nonverbal cues to the child about his exasperation. The child had been struggling in fi guring out how to play Connect Four. Using a contextual lens, the clinician took a step back and recognized that his intersubjective experience was something familiar to the child, the idea that “it is diffi cult to play with you.” The clinician used this change of perspective to shift his approach and attune to the child’s needs. The clinician recognized some of the child’s cognitive limitations and suggested they play a different board game, one that was more appropriate for a younger-aged child. The child felt reassured in the intersubjective fi eld and said with some excitement, “I like this game.” 3.5 Two-Person Relational Experiences Are Contextual 57

This example helps to highlight the fact that some children and adolescents may have difﬁ culties interacting with others due to temperamental and cognitive weaknesses in spite of healthy and emotionally available parents and family. The example brings the contextual aspects to the ofﬁ ce, where the clinician becomes an active participant of the relational patterns the patient unknowingly sets up with others. As is commonly said, actions speak louder than words.

Uncertainty in Two-Person Relational Psychotherapy

When considering two-person relational psychotherapy, we have often been asked by trainees and experienced psychotherapists (speciﬁ cally those anchored in traditional one-person psychology), “Aren’t we all relational ?” It is not uncommon for the term “relational” to be understood in its narrow form, as being an empathic and active listener to the patient’s discourse. The differences between being relational and being empathic lie on whether the psychotherapist allow the patient to subjectively become, in a bidirectional transaction, aware of the emotions and states of mind in the psychotherapist. We agree that traditional one- person psychology allows for the psychotherapist to demonstrate some degree of empathy, the ability to share the feelings that another person experiences, although it limits the patient to become aware of the emotions and state of mind of the psychotherapist. Mitchell (1993 ) and Bromberg (2009 ) clarify that being relational occurs when there is an authentic and genuine process of empathic attunement between the people involved.

The girl that wants the psychotherapist’s toy An elementary school-age child at the end of a psychotherapy session wished to take home the toy she had been playing with. A traditional one-person psychotherapist empathically explained why the child would not be allowed to take the toy. The psychotherapist then asked the child about her wishes for taking the toy, and then added that by not taking the toy, it would be available in the next session. Further, the traditional one-person psychotherapist explored the intrapsychic meanings as to why the child wished to take the toy from the ofﬁ ce, breaking the frame of the process. The psychotherapist may have chosen to interpret that the child displaced onto the toy their wish to take the psychotherapist with them—with the toy serving as a transitional object (Chap. 6 )—if conﬁ dent that such a notion was the case for the child. To this, Beebe and Lachmann (2003 ) eloquently caution against this and state, “Too great a tilt toward an intrapsychic view of the organization of experience underestimates the contributions of the partner and the environment, and the intrauterine interactive organization of infant ‘biology’” (also see Chap. 5 ). 58 3 Two-Person Relational Psychology for the Child and Adolescent

In contrast, in a two-person relational psychotherapeutic process, the psychotherapist may refl ect on how he or she felt about the patient’s request before any response is given. If the relational psychotherapist intersubjective experience s the child’s request to take the toy due to feelings of deprivation or loneliness, which the child routinely experiences at his home, allowing the child to take the toy could serve as a new corrective emotional experience stored nonconsciously and in nondeclarative memory, similar to a song or memento. Viewed differently, the relational psychotherapist may intersubjectively experience the child as demanding and may gently state, “You know, that toy is important to me, and I wonder if we can agree for you to enjoy playing with it here with me.” The goal of the relational psychotherapist is to provide the child a new experience in which she can begin to value that here-and-now mutuality, “We both want the toy.” Herein, traditional one-person psychotherapy limits the freedom to open the intersubjective fi eld for back-and-forth subjectivities that serve as a guide for the psychotherapist on how to best proceed. In two-person relational psychotherapy, the possibilities for new experiences are infl u- enced by the patient’s and psychotherapist’s subjectivities, which are numerous and complex. Further, Rustin and Sekaer (2004 ) add: “Findings strongly suggest that memory is an intersubjective event based on an amalgam of the internal encoded experiences of the patient and the external retrieval cues provided by the analyst and external events. Patient and analyst co-construct memories each time, expanding and extending the neuronal networks. In each recollection the memory is constructed anew and is slightly transformed…. The neuroscience of memory explains how this happens.”

Anxiety in the Two-Person Relational Psychotherapist

The complexity of the two-person relational process has led trainees and experienced clinicians to pose several questions:

• Can I use traditional one-person neutrality when I don’t know what I should say or do, and later use a relational model when I feel I understand the patient? • Can I maintain my neutrality and ask questions in a Socratic method? • Can I make use of interpretations to help the patient develop insight about their problems? • Do I have to self-disclose? I am a very private person and would rather not disclose. • What are appropriate boundaries in a relational approach?

Typically, these questions are followed by statements: “Relational psychotherapy makes me nervous. Without guidelines about what is important to address or knowing what amount of self-disclosure is appropriate, it is easy to be overwhelmed.” These statements represent anxieties that not only are expected, they are helpful reminders to the two-person relational psychotherapist of the sloppiness and creative negotiations of shared subjective experiences (see Chap. 5 ). 3.6 Critiques of the Two-Person Relational Model 59

We would reassure our colleagues that a two-person relational approach requires extensive reading with an open frame of mind to new concepts from developmental research and neuroscience, and as is said, practice makes perfect. We invite the reader to review the clinical examples in Chaps. 10 , 11 , 12, and 13 in order to have an intersubjective feel for the process.

3.6 Critiques of the Two-Person Relational Model

There has been considerable criticism of the two-person relational model by some psychoanalysts and psychotherapists since the time the concepts of “corrective emotional experience,” “cocreativity,” and “intersubjectivity” entered the landscape. Mills (2005 ) states, “What perhaps appears to be the most widely shared claim in the relational tradition is the assault on the analyst’s epistemological authority to objective knowledge.” Mills further critiques relational psychoanalysis, saying, “It has opened a permissible space for comparative psychoanalysis by challenging fortifi ed traditions ossifi ed in dogma, such as orthodox conceptions of the classical frame, neutrality, abstinence, resistance, transference, and the admonition against analyst self-disclosure.” Prominent fi gures such as Wasserman (1999 ) reminded the psychoanalytic community how a traditional one-person model posed the greatest value when the psychoanalyst or psychotherapist maintained neutrality . By maintaining such a receptive posture, “the facts” of what the patient is truly experiencing may be discovered, “ideally uncontaminated by anything coming from the analyst.” For Freud (1900 ), the “ unconscious is the true psychical reality.” Even a traditional fi gure such as Wasserman , though acknowledging that the role of the psychoanalyst is to primarily help the patient discover a buried past, in fact supports a key tenet of two-person relational psychology, as he writes: “The analyst always actively infl u- ences what he discovers empathically. Specifi cally, the analyst’s theoretical biases always shape what he empathically understands” (1999 ). For further critiques or the two-person relational model, we refer the reader to the work by Jon Mills (2005 ) and Morris Eagle (2003 ). The authors have not been immune to the negative perception. We have colleagues who state, “New words for the same thing; just another way of looking at things we already know.” Others have said, “Why change things if the old model is working well?” Further, within the psychoanalytic community, some have gone as far as considering the two-person relational model “not psychodynamic if you promote enactments” or a form of “wild analysis” (Schafer 1985 ). These comments are misguided. They typically represent personal impressions of the two-person relational psychology concepts and theory rather than a careful review of the literature. Fossage ( 2003) deftly captures the dilemma a student of two-person relational psychotherapy faces: “to ‘get’ another approach requires extensive reading and living and breathing it within a community where a good deal of communication takes place verbally. In addition, each approach houses a wide range of differences in theory and practice, creating more confusion. Hence, misunderstandings from the ‘outside,’ not to mention from the ‘inside,’ are inevitable and frequent.” 60 3 Two-Person Relational Psychology for the Child and Adolescent

We agree with Fossage: A two - person relational approach requires extensive reading and living within a community open to new concepts, which at present is scarce in most child and adolescent training programs, departments of child psychiatry, and child psychodynamic psychotherapy programs, which we hope this book contributes to help correct.

3.7 Summary

In this chapter, we have demonstrated how the advances from attachment theory, infant developmental research, and intersubjectivity have led to a two-person relational psychology that emerged as a theory of mind that provided a path for the application of concepts derived from attachment theory, infant developmental research, and neurosciences in the practice of psychotherapy. As such, the notion of a two-person relational model of psychotherapy shook the foundations of traditional one-person psychoanalytic theory. We provide a reader the steps taken by two-person relational theorists and psychotherapists to establish broadly accepted tenets of two-person relational psychotherapy for children and adolescents. There is general agreement that: the central innate motive of mental life is to seek relatedness with others; early childhood implicit relational patterns of interaction will manifest within the psychotherapy process in the form of nondeclarative intersubjective experiences between the psychotherapist and the patient, rather than cognitive and verbal interactions and that change occurs at the implicit level in the form of nonconscious moments of meeting that lead to the development of new neuronal pathways of the more adaptive patterns of interaction. The psychotherapist must be aware of his or her emotional states, to effectively attune to the patient and provide the intersubjective ﬁ eld necessary for moments of meeting to occur. Ultimately co-construction of new reparative enactments is fundamental to the healing process and therapeutic change, corrective emotional experience (Table 3.1 ).

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There can be no knowledge without emotion. We may be aware of a truth, yet until we have felt its force, it is not ours. To the cognition of the brain must be added the experience of the soul. —Arnold Bennett

This chapter reviews some of the leading experts who have contributed to the ﬁ eld of child and adolescent two-person relational psychotherapy through their research. The list is by no means complete as it would be beyond the scope of this book to include all of those who contributed to further expand the understanding of the complexities of infant development . We limit this review to the authors who pursued infant–caregiver research—the “baby watchers,”—and spawned the concepts most applicable to the two-person relational psychodynamic psychotherapy of children and adolescents. We have organized this chapter into three sections. We begin by focusing on those researchers who were directly involved in developmental research studies, followed by those who have synthesized vast amounts of empirical research from neuroscience and summarized the relevance to the clinical work of the psychotherapist. We end by reviewing the developmental researchers who were instrumental in formulating what are now known as the attachment and temperament theories.

4.1 Developmental Psychology Researchers

Developmental psychology refers to the scientiﬁ c discipline that studies the biological, social, and cultural factors that affect development and advance the knowledge and theory of development of children and adults across their life span. Developmental theorists have been keenly aware that a key aspect in social interactions is the ability of one person to understand the mental states of others.

René Spitz (1887–1974)

René Spitz , a psychiatrist and psychoanalyst best known for his systematic observations and video recordings of the interactions between infants and their mothers,

© Springer-Verlag Berlin Heidelberg 2015 63 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_4 64 4 Key Pioneers of Two-Person Relational Psychology preceded many of the attachment theorists (Palombo et al. 2012). Spitz studied the infant’s relationship to their caregivers. He found that infants who were hospitalized and did not have direct exposure to their mothers or caregivers developed what he coined hospitalism , characterized by anaclitic depression and a failure to thrive syndrome, based on the infant’s reaction to maternal deprivation. Moreover, he was among the fi rst psychoanalysts to use the research laboratory to affi rm the importance of a child’s need for social interactions with other humans as essential for the child’s survival and biopsychosocial development. It is important to note that his work occurred nearly 10 years before Bowlby’s writings on attachment theory. Further, another important contribution is the fi ndings from observations of planned separations between the mother and the infant in prison nurseries. His fi ndings proved that early loving caregiving were internalized at an early age by the infant and that later separation had devastating consequences for the infants, i.e., grief and depression. Thus, what had become standard practice, that adoption was best when it occurred after the fi rst year of life, changed to promote early adoption when possible, to facilitate the bonding needed for affective reciprocity and ego development (Emde and Hewitt 2001 ).

Robert Emde (1935–)

Robert Emde, a psychiatrist and psychoanalyst, was a student and mentee of René Spitz during Emde’s residency at the University of Colorado. He wrote that he “got hooked in beginning a career in infant research and psychoanalytic thinking about the importance of the mothering for early social-emotional development” (Emde 2009 ). He continued Spitz’s work with regard to mother–infant dyads and later developed a distinguished research program for the systematic analysis of video recordings of the interactions between infant and mother or caregiver. Their research highlighted the infant’s need for social referencing and affective attunement by the caregiver. Emde’s team believed that there was a need for “ mutuality ” between caregiver and child for survival and emotional growth, indicating “the development of the self and the development of the other did not develop separately but were two sides of the same coin.” Emde’s team posited that social referencing was a form of active emotional communication thought to mediate behavior when the infant is confronted by a situation of uncertainty. For Emde ( 1980 , 1983 , 2000), emotional availability referred to the “receptive presence” of the parent to the child’s emotional signals. It connoted a type of presence and availability that had a great deal in common with the way a psychotherapist “is there” for a patient (Biringen and Easterbrooks 2012 ). Emde is recognized in the fi eld of psychoanalysis for his role in integrating the information gathered from research about childhood development with psychoanalytic theory. He suggested that the adherence to confl ict-based drive theory limited the understanding of the child, in that it failed to recognize the value of the new fi ndings from developmental research. In his paper “From Ego to ‘We-Go’: Neurobiology and Questions for Psychoanalysis,” he used the term “we-go,” 4.1 Developmental Psychology Researchers 65 which—as a concept—led contemporary psychoanalysts to begin to view Freud’s ego as a concept that did not take into account the intersubjectivities and mutuality between the infant and the “other.” The term “we-go ” had been credited posthu- mously to George Klein (1967 ). Emde writes that, in 1987, when presenting his “From Ego to ‘We-Go’” paper at a plenary address at the International Psychoanalytic Association annual meeting, he mentioned that psychoanalysis was in need of the theory of we-go to supplement the theory of the ego , and “it resulted in somewhat of sensation.” His contributions led to a surge in the interest of two-person relational psychology infl uenced by infant developmental research by many of his psychoanalytic colleagues. Emde traced the origins of the shared we-go to the beginnings of social referencing during the second half of the fi rst year of life. Emde is also known for a classic study in which healthy 3- and 4-year-old middle- class children were initially asked to play with toys in the presence of a researcher. Each child’s mother then entered the room and brought her child two new toys and would let her child know her wish that the new toys should not be played with after she left the research room. The mother then left the room, and the researcher challenged the prohibition given by the mother by tempting the children to play with the new toys. Surprisingly, a number of children resisted the tempta- tion, to which Emde states, “We came to the realization that these children had developed an executive sense of ‘we’ of the signifi cant other being with them, giving them an increased sense of power and control.” He goes on to say: “The self is a social self. Moreover, research indicates that from infancy, innately given brain processes support social reciprocity and the development of “we-ness ”” (Emde 2009 ). Further, Emde and his team believed that the infant’s autonomous self existed within the context of a social connectedness to the other and had the capacity to develop a rudimentary moral compass for empathy with others. For example, in an experiment they noted that as early as 3 years old, children had parental prohibitions internalized. When facing a challenge in their play, these children accessed and abided by these internalized rules. The team added that when 3- to 4-year-olds in their control group were read stories that conveyed moral dilemmas, the children “understood and struggled with the dilemmas, with many achieving pro-social outcomes” (Oppenheim et al. 1997 ).

Daniel Stern (1934–2012)

Daniel Stern , a psychoanalytically trained psychiatrist, was also a prominent infant researcher best known for his book The Interpersonal World of the Infant (1985 ). His detailed observations of the mother–infant interactions in the research laboratory led him to bridge infant developmental research to the practice of psychodynamic psychotherapy and psychoanalysis (Emde 2013 ). Early in his research, he departed from Mahler’s separation–individuation theories (Mahler 1974 ), and with the information gathered from his infant observations, he proposed that for the infant to organize a coherent and core sense of self, it would need to successfully 66 4 Key Pioneers of Two-Person Relational Psychology develop four interrelated senses of self-experience. He observed that the infant’s self-experience senses began within the fi rst 2 years of life and progressed as such: The process starts with the emergent self, continues through the core self and the subjective self, and then fi nalizes with the verbal self. Primary attachment fi gures played a critical role in helping the infant with this process, and the developmental achievements in each phase persist over the child’s life span. During the period of the subjective self (in the 7- to 15-month-old range), the child becomes aware that his thoughts and experiences are distinct from those of others, and with proper attunement by the primary caregivers, the child can cocreate dialogue with others that requires the use of mirror neurons. This allows the child to participate in another person’s actions without having to imitate those actions. He termed this as “affective attunement ” and described it as “the performance of behaviors that express the quality of feeling of a shared affect state without imitating the exact behavioral expression of the inner state.” Stern noted that in the case of a caregiver who suffers from depression and is unable to provide the affective attunement needed by the child, the child would be deprived of positive intersubjective experiences. This would interfere with the child’s development, which could lead to the child being unable to connect emotionally with others or make sense of another person’s action in any meaningful way. Stern’s important contribution, which infl uenced the writing of this book, is the concept of intersubjectivity, defi ned as “the capacity to share, know, understand, empathize with, feel, participate in, resonate with, enter into the lived subjective experience from another” (Stern 2004 , see Chap. 5 ). For Stern, intersubjectivity occurred in the implicit and preverbal domain. He felt that intersubjectivity was used in a continuous manner, and it expanded as the infant grew. Moreover, Stern believed that what was implicit occurred in the “nonconscious ” realm, a term Stern preferred over unconscious, because nonconscious resides in a dynamic system that is nonsymbolic and nonverbal and does not need to be repressed.

The Boston Change Process Study Group (BCPSG)

The Boston Change Process Study Group was created in 1995 by a small group of psychoanalysts, developmental researchers, and psychoanalytic theorists who proposed that here-and-now intersubjective experiences observed in infant studies shed light on how change could be facilitated by psychotherapy and psychoanalysis. The original members of the BCPSG were Nadia Bruschweiler-Stern, Karlen Lyons- Ruth, Alexander Morgan, Jeremy Nahum, Bruce Reis, Louis Sander (deceased), Daniel Stern (deceased), and Edward Tronick (no longer part of the group). The group was strongly infl uenced by Stern’s work in infant research. They made great strides in developing theoretical models that relied on the understanding of deeper psychodynamic levels of meaning based in implicit forms of representation, co- constructed by a person’s intentions during their interactions. Since its inception, the group has published several seminal papers and books. In addition, they asserted 4.1 Developmental Psychology Researchers 67 that the therapeutic relationship itself, even in the absence of interpretation, was suffi cient to promote a therapeutic change. They were also proponents of the co- constructed exchanges that occurred at the implicit domain and came to constitute implicit relational knowing with signifi cant psychotherapeutic effects. The BCPSG explains that when making reference to implicit relational knowing, the group is not referring to the infant’s cognitive function, but rather to the physiological and later to the social/behavioral regulation carried out between the infant and its caregiver, an act that is remembered by the infant. They see the earliest forms of biological regulation in the infant emerge for the basic capacity of adaptation: “The fact that these earliest forms of biological regulation are stored in memory systems, have mental concomitants and are psychologically meaningful has been intuitively grasped by some, but is not widely understood. Through representing these dyadic regulatory exchanges, the human infant moves from being a physiological to being a psychological being” (Nahum 2000 ). Further, they describe what they believe are the reasons why the implicit domain has signifi cant relevance to psychotherapeutic encounters: “Implicit processing consists of the representing of the relational transactions that begin at birth and continue throughout life. Such implicit processing guides the moment to moment exchanges that occur in any interaction, including the psychoanalytic situation. All the things that are the stuff of the interactive fl ow, such as gestures, vocalizations, silences, rhythms, constitute this moment to moment exchange, which we refer to as the local level”.

L. Alan Sroufe (1941–)

L. Alan Sroufe is best known for his work on the Minnesota Longitudinal Study of Parents and Children, which began in 1975 and is currently in its 38th year. The project’s researchers follow a sample of 267 ﬁ rst-time mothers who enrolled in the study during the third trimester of their pregnancy. They have followed these mothers and their children to monitor the course of the child’s individual development and to discern the factors that lead to good and poor outcomes. They have studied the subjects at different points in their lives and across diverse settings, including at their home, in social relationships, and at school. Sroufe’s team conceptualized attachment as a dyadic emotion-regulation process, in which infants are not capable of regulating on their own and therefore require their caregiver in this process. How the infant ultimately learns how to regulate their emotions will depend heavily on how the caregiver regulates his or her own emotions. The research from the project demonstrated a high correlation between the caregiver’s attachment status and the attachment status of the infant with that particular caregiver. Sroufe and colleagues’ research viewed a child’s behavior as a product of their past history within the context of the current environment. Further, his team proposed that parallel assessments of a child’s early experiences and the inﬂ uences of their environment predicted psychopathology better than either alone. Sroufe’s research articulated a general model of development and 68 4 Key Pioneers of Two-Person Relational Psychology psychopathology: “Within attachment theory, psychopathology is viewed as a developmental construction, resulting from an ongoing transactive process as the evolving person successively interacts with the environment. Individual transforms environment but also is transformed by it…. Patterns of infant-caregiver attachment and other aspects of early experience may have a special role in the developmental process via their impact on basic neurophysiological and affective regulation” (Sroufe et al. 1999 ). Sroufe believed that when children are able to safely express their emotional and physical needs, they developed better self-regulatory skills. Not surprising, children who grow up in chaotic environments have better outcomes when their attachment to caregivers is positive than those in which the caregivers are an extension of a chaotic environment, and the children are more prone to relational trauma. Children with histories of anxious attachment are more likely to have problems in adolescence or adulthood than are securely attached children.

Edward Tronick (1942–)

Edward Tronick is a developmental researcher and clinical psychologist at the University of Massachusetts and former member of the Boston Change Process Study Group. He collaborated with pediatrician T. Berry Brazelton in creating the Neonatal Behavioral Assessment Scale and Touchpoints tool, which is designed to interpret what newborns are communicating through their behavior. He is best known for the “still-face experiment” and the “mutual regulation model.” In his still-face disruptions, Tronick ’s work has led to signiﬁ cant contributions of how mental health clinicians think about biopsychosocial states of infant consciousness, the process of meaning making, and how and why we engage with others in the world. His work contributed to the understanding of the infant self-regulation processes when maternal scaffolding is temporarily and abruptly unavailable. During the experiment, infants initially signal to the mother hoping to get her to resume her normal behavior. When this fails, the infants express negative emotion and use self- regulatory behaviors. When the experiment is over, for the next few minutes there is a continuation of the infants’ negative mood and a reduction in visual regard of the mother (Tronick 1989 ). In the model of mutual regulation, Tronick states, “In our view, the infant–adult meaning-making system is a dyadic, mutually regulated communicative system in which there is an exchange of each individual’s meanings, intentions, and relational goals—what we call the mutual regulation model.” He adds that it does not necessarily lead to pathology: “The infant of a depressed mother might become exceedingly sensitive to her emotional state in order to read her better and to better regulate the interaction. Such sensitivity may be useful when the infant interacts with others” (Tronick 1989 ). Tronick’s current research focuses on infant memory for stressful events and the epigenetic processes affecting behavior. His research utilizes the still-face and other stress paradigms, as well as multiple other measures, including ERP (event-related potentials) and EEG (electroencephalography), salivary cortisol, alpha amylase, and skin conductance, in addition to behavior measures. Tronick was instrumental 4.1 Developmental Psychology Researchers 69 in making his ﬁ ndings accessible to the pediatric community and the lay public, emphasizing the importance of early mother–child interactions to promote the development of the infant’s emotional capacities. We suggest the reader take the time to view the helpful YouTube videos of Tronick’s still-face experiment.

Andrew Meltzoff (1950–)

Andrew Meltzoff is an American psychologist internationally recognized for his research on infant and child development. His discoveries about infant imitation have revolutionized our understanding of early cognition, personality, and brain development. The seminal work by Meltzoff occurred in the 1970s, when his team demonstrated that infants had rudimentary forms of imitative behavior early in their development. Later, his team suggested that a key form of learning that occurs early in life is through imitation. Another important theme that emerged from his developmental research is the functional link between imitation, empathy, and social cognition, in particular the ability to develop a theory of mind (Meltzoff 2007 ). Meltzoff (2011 ) masterfully states, “We are not born social isolates. We are fundamentally connected to others right from the start, because they are seen as being ‘like me.’ This allows rapid and special learning from people. I can learn about myself and potential powers by watching the consequences of your acts, and can imbue your acts with felt meaning based on my own self-experience. This propels infants beyond what they see or know innately. Social cognition rests on the fact that you are like ‘me,’ differentiable from me, but nonetheless enough like me to become my role model and I your interpreter.”

Colwyn Trevarthen (1931–)

Trevarthen is a professor of child psychology and psychobiology at the University of Edinburgh and vice president of the British Association for Early Childhood Education. He originally trained as a biologist before going on to study infancy research at Harvard in 1967. As Seligman eloquently states about Trevarthen, “He has distinguished himself for more than four decades as one of the most inventive and rigorous explorers of infant development and its implications” (Seligman 2009). Trevarthen has been an inﬂ uential contributor to matters of intersubjectivity, which he believes begins immediately after birth. He states about intersubjectivity , “We are born to generate shifting states of self-awareness, to show them to other persons, and to provoke interest and affectionate responses from them. Thus starts a new psychology of the creativity and cooperative knowing and meaning in human communities” ( Trevarthen 2011 ). His current research concerns how rhythm and expressions of musicality in movement help communication with children and may assist the parents, teachers, and psychotherapists who provide care to young children. 70 4 Key Pioneers of Two-Person Relational Psychology

Peter Fonagy (1952–)

Peter Fonagy is a British psychoanalyst and clinical psychologist best known for his efforts in integrating concepts between attachment theory and psychoanalytic theory. He is recognized for the concept of mentalization , the ability to interpret behavior as meaningful and as based on the mental states and psychological makeup of both the self and others, such as desires, needs, beliefs, reasons, and feelings. The infant’s ability to mentalize supports the self-regulation capacities. Some have said this is akin to “holding mind in mind” (Allen et al. 2008 ). Fonagy developed a mentalization-based treatment (MBT) that is rooted in attachment theory and based on the idea that people who lack the ability to mentalize—caused by an absence of affective attunement during early childhood—can use this treatment to improve their mentalization skills. Among his most recognized contributions are his books Attachment Theory and Psychoanalysis ( 2001 ) and Affect Regulation, Mentalization, and the Development of the Self, with Target, Gergely, and Jurist (2002 ). We suggest the reader take the time to view the helpful YouTube videos of Fonagy’s work regarding the importance in the capacity to mentalize as having a signiﬁ cant impact in the emotional development of the infant and in the treatment of patients with borderline personality disorder.

4.2 Developmental Psychology Synthesizers

Allan Schore (1943–)

Allan Schore is known as a clinician–scientist who has provided an extensive synthesis of data from the fi eld of neuroscience (neurobiology, behavioral neurology, and neuropsychology) and developmental infant research, integrating these with social, biological, psychological, and psychoanalytic theory. He also developed a theoretical model of a regulatory theory integrating data and models from a wide range of different fi elds. He hypothesizes that attachment theory represents a regulatory theory and sees the environment as having a signifi cant impact on the brain development of the infant, particularly during critical periods in early childhood. He believes, “Since the human face is a central focus of these transactions, studies of right brain appraisals of visual and prosodic facial stimuli, even presented at tachis- toscopic levels, may more accurately tap into the fundamental mechanisms that are involved in the processing of social-emotional information.” He later states, “This ‘neocortical network,’ which ‘modulates the limbic system’ is identical to the right- lateralized orbitofrontal system that regulates attachment dynamics. Attachment models of mother–infant psychobiological attunement may thus be used to explore the origins of empathic processes in both development and psychotherapy, and reveal the deeper mechanisms of the growth-facilitating factors operating within the therapeutic alliance” (Schore 2000a ). He defi nes attachment as the interactive regulation of biological synchronicity between organisms and says, “Future directions of attachment research should focus upon the early-forming psychoneurobiological mechanisms that mediate both adaptive and maladaptive regulatory processes” 4.3 Developmental Theory and Theorist’s 71

(Schore 2000b ). He further proposes that when ruptures of the attunement process between the infant and the primary caregiver occur and there is lack of repair of the rupture, it results in impaired development of the right hemisphere, which contributes to the inability to regulate emotions adequately, leading to an impaired relational capacity. In his work with the pediatric community, Schore emphasizes that a mother’s right brain has an active role in the infant’s right brain capacities in Schore’s effort to promote early childhood interventions in the medical ofﬁ ce to prevent negative outcomes from attachment problems (Schore 2005 ). We suggest the reader take the time to view the helpful YouTube videos of Schore’s work about his regulatory theory, where he explains his views about environmental factors having a signiﬁ cant impact in the brain development of the infant.

Daniel Siegel (1957–)

Daniel Siegel , a developmental synthesizer like Schore, is known for his book The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (2001 ), in which he reviews and integrates the extensive research from theories of interpersonal neurobiology and attachment. He advocates the use of mindfulness— a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and surrounding environment—as the central idea of his interpersonal neurobiology to enhance mental well-being. His work synthesizes theoretical concepts from multiple disciplines. Siegel’s book Mindsight: The New Science of Personal Transformation (2010 ) offers the public an easy-to-read in-depth exploration of the power the mind has to promote well-being. He also has written parenting books that explore the application of the “ mindsight ” approach to parenting and explore how brain development impacts teenagers’ behavior and relationships. We suggest the reader take the time to view the helpful YouTube videos of Siegel’s work about the mindsight approach.

4.3 Developmental Theory and Theorist’s

We will now proceed to review the main authors who contributed to developmental theories, keeping in mind that it is not an extensive review, but rather is limited to the authors who have contributed to the authors’ understanding of the landscape in two- person relational psychodynamic psychotherapy with children and adolescents.

Attachment Theory

The attachment bond a child establishes with his or her caregiver is essential for their safety, security, and protection. Similar, human attachment behaviors and emotions were also displayed by rhesus monkeys in Harry Harlow ’s (1905–1981) 1958 experiments. Harlow observed rhesus monkeys in the research laboratory during 72 4 Key Pioneers of Two-Person Relational Psychology

Fig. 4.1 Harry Harlow’s classic 1958 experiment in which terry cloth and wire “monkey mothers” ( left) were offered to infant monkeys. Infant monkeys preferentially spent time with the cloth “mother” (right ) (Image from Classics in the History of Psychology ) their fi rst year of life that were reared by two “ surrogate mothers ”—a bare wire model with a bottle for feeding and a wire model covered with terry cloth without a bottle (Fig. 4.1 ). The monkeys spent more time cuddling with the cloth mother and would only seek the bare wired mother when hungry (Harlow 1958). Bowlby, like Harlow, proposed that attaching to caregivers was innate and instinctive, characterized by specifi c behaviors, such as seeking proximity with the attachment fi gure when upset or threatened (Bowlby 1999 ; Harlow 1958 ). Attachment theory at its core is a two-person relational psychology. Slade (1999 ) recognizes the relevance: “In essence, attachment categories do tell a story. They tell a story about how emotion has been regulated, what experiences have been allowed into consciousness, and to what degree an individual has been able to make meaning of his or her primary relationships.” Although attachment is a complex process, it is important precisely because it serves to organize core developmental experiences. Sroufe (2005 ) deftly captures the importance of the organizing 4.3 Developmental Theory and Theorist’s 73 principle for the infant: “Infant attachment is critical, both because of its place in initiating pathways of development and because of its connection with so many critical developmental functions—social relatedness, arousal modulation, emotional regulation, and curiosity, to name just a few. Attachment experiences remain vital in the formation of the person.” Attachment is in essence a dynamic and a contextual process, which clinically underscores the infl uence patient and psychotherapist attachment patterns exert on each other. Bowlby (1999 ) proposed that the quality of the attachment predicts the ability to relate to many others, to establish trust, to form and retain friendships, and to engage in mutually satisfying emotional and physical relationships.

John Bowlby (1907–1990)

John Bowlby, a British psychiatrist and psychoanalyst, is best known for his contributions to our understanding the process of attachment. As such, he is considered the “father of attachment theory.” Delgado and Strawn (2014 ) believe “Bowlby may have preferred to be known as the ‘the primary caregiver of attachment theory,’” which would reﬂ ect his belief that an infant needs to develop a relationship with at least one primary caregiver, regardless of gender, for healthy psychological development to occur. Bowlby, an analyst himself, departed from traditional psychoanalytic school of thought when he posited that infants had an evolutionary, innate wish for close, shared experiences with their primary caregivers for survival, growth, and development (Bowlby 1999 ). He felt this urge was biologically rooted and distanced himself from Freud’s drive theory, which placed emphasis on sexuality and aggression as innate drives . Bowlby notes that early in life, the infant creates attachment behavioral systems that help it assess whether its caregiver is available not only physically but emotionally. He further suggests that the quality of the attachment between the infant and the parent or primary caregiver is a powerful predictor of a child’s later social and emotional facility (Benoit 2004 ). The caregiver strongly inﬂ uences how the infant develops the capacity for emotional regulation of their feelings, creating an “internal working model of social relationships” that serves as a template when relating to others (Bowlby 1999 ). Attachment theory subsequently provided a longitudinal view on how early dyadic relationships, with mother or primary caregivers, shape the quality of emotional relationships the child has with others throughout its lifespan.

Mary Ainsworth (1913–1999)

During the 1960s and 1970s, developmental psychologist Mary Ainsworth (1913– 1999), inﬂ uenced by her communication with John Bowlby , began to experimen- tally evaluate his basic formulations through studies of infant–parent pairs in Scotland and Uganda (Ainsworth et al. 1978 ). Her work led to the foundation of different descriptions of patterns of attachment between infants and caregivers based on observable traits of the mother and the infant during times of separation and reuniﬁ cation: (1) secure attachment, (2) avoidant attachment, and (3) anxious attachment (Ainsworth et al. 1978 ). 74 4 Key Pioneers of Two-Person Relational Psychology

Mary Main (1943–)

Ainsworth’s work was later expanded by Mary Main (1943–), a researcher who introduced the concept of “disorganized attachment,” which was instrumental in understanding the experiences of children exposed to chaotic and unpredictable environments and their tendency to seek the same type of interactions (Main 2000 ). Main is coauthor of the Adult Attachment Interview (AAI) which uses question- naire and interview to assess attachment status of adults. In the sixth year of follow- up of her AAI research, the classiﬁ cations of the adults were found to match the infant’s Strange Situation classiﬁ cation with their parent 5 years before. Not surprising, secure parents had secure infants; dismissing parents had avoidant infants; preoccupied parents had ambivalent infants; and disorganized parents had had disorganized infants (Main et al.1985 ).

Lev Vygotsky (1896–1934)

Lev Vygotsky is best known for his sociocultural theory of psychological development. He hypothesized that the development of an individual is determined by their experience within a group of other people’s activities. The child interactions with other people are internalized, after which the social and cultural values of the group also became personal values (Vygotsky 1978 ). Vygotsky coined the concept of the zone of proximal development , “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance, or in collaboration with more capable peers” (Vygotsky 1978 ). Vygotsky believed that when a student is at the zone of proximal development, if supported by a skilled teacher for a learning task, it will provide the student the nudge necessary to master the task.

Adoption Policies

The works by Harlow, Bowlby, Ainsworth, Main, and Vygotsky in attachment and sociocultural theory helped inﬂ uence current adoption policies. The current policies support early adoption to help meet the child’s emotional needs and prevent the detrimental effects of the institutionalization of children or the extended time living in foster homes.

4.4 Temperament Theorists

“ Temperament ” refers to the “stable moods and behavior profi les observed in infancy and early childhood” (Thomas et al. 1960). The concept of temperament came to the forefront in developmental psychology and child psychiatry in the 1960s and 1970s (Thomas et al. 1960). Although there have been many References 75 classifi catory schemes, Thomas and Chess (1999 ) are recognized for their landmark scientifi c contribution to the study of temperament. Their seminal work has achieved general consensus in that its expression has been consistent across situations and over time. In their study, Thomas and Chess longitudinally evaluated 141 children over 22 years, from early childhood until early adulthood (1977 , 1982 , 1986 ). The work of Thomas and Chess confi rmed what the British psychoanalyst and father of attachment theory John Bowlby (1907–1990) had hypothesized: A child’s temperament infl uences how the child is experienced by their parents and signifi - cantly shapes how the parents interact with the child (Bowlby 1999 ). This way of thinking, where an active and bidirectional relationship exists between the child and caregiver, represented a signifi cant point of divergence from the previously accepted understanding of the infant as a passive recipient and product of his or her environment (Mahler 1974 ). In essence, the child began to be seen as a full contributor to the “ goodness of fi t” (Thomas and Chess 1999 ) between the child and the parents or caregivers. Thomas and Chess were proponents for the theory and practice of psychiatry to take full account of the individual “uniqueness,” a strong contributor to the goodness of fi t (Thomas and Chess 1970). Furthermore, temperament in infancy and early childhood is infl uenced not only by heredity but also by environmental experiences (Emde and Hewitt 2001 ). As a consequence, temperament is recognized as pivotal to our current understanding of attachment theory. A review of the literature regarding child temperament reveals that much research has evolved in developmental psychology since the early work of Thomas and Chess 30 years ago, although some controversies remain (Zentner and Bates 2008 ). Jerome Kagan is an American psychologist and researcher considered to be one of the most infl uential psychologists of the twentieth century. He posited that an infant’s temperament is stable over time and that behaviors of infants were predictive behavior patterns later in life. He did extensive work on temperament and emotion. Kagan and his research team found that certain children’s behavioral inhibitions can be predictors of similar characteristics in adults (Moehler et al. 2008 ).

4.5 Summary

In this chapter we reviewed some of the leading experts who contributed to the ﬁ eld of child and adolescent two-person relational psychotherapy through their empirical research. The list is by no means complete as it would be beyond the scope of this book to include all of those who contributed to further expand understanding the complexities of infant development.

References

Ainsworth MDS, Blehar M, Waters E et al (1978) Patterns of attachment: a psychological study of the strange situation. Lawrence Erlbaum Associates, Hillsdale, p 37 Allen JG, Fonagy P, Bateman A (2008) Mentalizing in clinical practice. American Psychiatric Publishing, Washington, DC 76 4 Key Pioneers of Two-Person Relational Psychology

Benoit D (2004) Infant-parent attachment: defi nition, types, antecedents, measurement and outcome. Paediatr Child Health 9(8):541–545 Biringen Z, Easterbrooks MA (2012) Emotional availability: concept, research, and window on developmental psychopathology. Dev Psychopath 24:1–8 Bowlby J (1999) Attachment, vol 1, 2nd edn, Attachment and loss. Basic Books, New York Delgado SV, Strawn JR (2014) Diffi cult psychiatric consultations: an integrated approach. Springer, Heidelberg Emde RN (1980) Emotional availability: a reciprocal reward system for infants and parents with implications for prevention of psychosocial disorders. In: Taylor PM (ed) Parent–infant relationships. Grune & Stratton, Orlando, pp 87–115 Emde RN (1983) The prerepresentational self and its affective core. Psychoanal St Child 38:165–192 Emde RN (2000) Next steps in emotional availability research. Attach Hum Dev 2:242–248 Emde RN (2009) From ego to “we-go”: neurobiology and questions for psychoanalysis: commentary on papers by Trevarthen, Gallese, and Ammaniti & Trentini. Psychoanal Dial 19:556–564 Emde RN (2013) Remembering Daniel Stern (1934–2012): a legacy for 21st century psychoanalytic thinking and practice. Int J Psychoanal 94:857–861 Emde RN, Hewitt JK (2001) Infancy to early childhood: genetic and environmental infl uences on developmental change. Oxford University Press, Oxford Foangy P, Gergely G, Jurist EL, Target M (2002) Affect regulation, mentalization and the development of the self. Other Press, New York Fonagy P (2001) Attachment theory and psychoanalysis. Other Press, New York Boston Change Process Study Group (2010) Change in psychotherapy: a unifying paradigm. WW Norton, New York, pp 194–195 Harlow HF (1958) The nature of love. Amer Psychol 13:673–685 Klein GS (1967) Peremptory ideation: structure and force in motivated ideas (Monograph 18/19). Psychol Issues 5:2–3 Mahler MS (1974) Symbiosis and individuation: the psychological birth of the human infant. Psychoanal St Child 29:89–106 Main M (2000) Recent studies in attachment: overview, with selected implications for clinical work. In: Goldberg S, Muir R, Kerr J (eds) Attachment theory: social, developmental, and clinical perspectives. Analytic Press, Hillsdale, pp 407–474 Main M, Kaplan N, Cassidy J (1985) Security in infancy, childhood and adulthood: a move to the level of representation. Monogr Soc Res Child Devel 50(1/2):66–104 Meltzoff AN (2007) ‘Like me’: a foundation for social cognition. Dev Sci 10(1):126–134 Meltzoff AN (2011) Social cognition and the origins of imitation, empathy, and theory of mind. In: Goswami U (ed) The Wiley-Blackwell handbook of childhood cognitive development, 2nd edn. Wiley-Blackwell, Malden, pp 49–75 Moehler E, Kagan J, Rieke O-A et al (2008) Infant predictors of behavioral inhibition. Br J Dev Psychol 26(1):145–150 Nahum J (2000) An overview of Louis Sander’s contribution to the fi eld of mental health. Infant Ment Health J 21(1–2):29–41 Oppenheim D, Emde RN, Warren SL (1997) Children’s narrative representations of mothers: their development and associations with child and mother adaptations. Child Dev 68:127–138 Palombo J, Bendicsen HK, Koch BJ (2012) Guide to psychoanalytic developmental theories. Springer, New York Schore AN (2000a) Attachment and the regulation of the right brain. Attach Hum Dev 2:23–47 Schore AN (2000b) Attachment, the right brain, and empathic processes within the therapeutic alliance. Psychol Psychoanal 20(4):8–11 Schore AN (2005) Attachment, affect regulation, and the developing right brain: linking developmental neuroscience to pediatrics. Pediatr Rev 26:204–211 References 77

Seligman S (2009) Anchoring intersubjective models in recent advances in developmental psychology, cognitive neuroscience and parenting studies: introduction to papers by Trevarthen, Gallese, and Ammaniti & Trentini. Psychoanal Dial 19:503–506 Siegel DJ (2001) The developing mind: how relationships and the brain interact to shape who we are. Guilford Press, New York Siegel DJ (2010) Mindsight: the new science of personal transformation. Random House, New York Slade A (1999) Attachment theory and research: Implications for the theory and practice of individual psychotherapy for adults. In: Cassidy J, Shaver P (eds) Handbook of attachment: theory, research, and clinical applications. Guilford Press, New York, pp 575–594 Sroufe AL (2005) Attachment and development: a prospective, longitudinal study from birth to adulthood. Attach Hum Dev 7(4):349–367 Sroufe LA, Carlson EA, Levy AK et al (1999) Implications of attachment theory for developmental psychopathology. Dev Psychopath 11:1–13 Stern DN (1985) The interpersonal world of the infant: a view from psychoanalysis and developmental psychology. Basic Books, New York, p 142 Stern DN (2004) The present moment in psychotherapy and everyday life. WW Norton, New York Thomas A, Chess S (1977) Temperament and development. Brunner/Mazel, New York Thomas A, Chess S (1982) The reality of diffi cult temperament. Merrill-Palmer Q 28:1–20 Thomas A, Chess S (1986) The New York longitudinal study: from infancy to early adult life. In: Plomin R, Dunn J (eds) The study of temperament: changes, continuities, and challenges. Lawrence Erlbaum, Hillsdale Thomas A, Chess S (1999) Goodness of fi t: clinical applications from infancy through adult life. Routledge, New York, pp 39–52 Thomas A, Chess S, Birch HG (1970) The origin of personality. Sci Am 223(2):102–109 Trevarthen C (2011) What is it like to be a person who knows nothing? Defi ning the active intersubjective mind of a newborn human being. Infant Child Dev 20:119–135 Tronick E (1989) Emotions and emotional communication in infants. Amer Psychol 44:112–119 Vygotsky L (1978) Mind in society: the development of higher psychological processes. Harvard University Press, Cambridge, MA, p 86 Zentner M, Bates JE (2008) Child temperament: an integrative review of concepts, research programs, and measures. Eur J Dev Sci 2(1/2):7–37 Key Concepts in Two-Person Relational Psychology 5

Distorted developmental psychic programming can be repaired through psychotherapeutic experiences. —Eric Kandel

The empirical study of infants and toddlers conﬁ rmed what Bowlby ( 1969 ) and Winnicott (1971 ) had believed: that the infant was indeed a “social being.” This hypothesis inspired a generation of developmental researchers to search for the neurobiological underpinnings of childhood psychological growth and behavioral issues. Today, there is little debate that the human brain is a social organ (Cozolino 2010 ). The changes undertaken by the brain from infancy to adulthood are mediated by the processes of emotional availability, attachment, affect regulation, and cognition, which all play a central role in two-person relational psychotherapy. Cozolino, a developmental neuroscientist, writes, “A therapist attempts to restructure neural architecture in the service of the more adaptive behavior, cognition, and emotion” (2010 ). Additional research has demonstrated that infants have an innate bias toward self-regulation and mastery and work to create coherence of their perceptual experience and maintain organization of their happenings ( Sameroff 1992 ; Emde 1992 ). As such, we currently are in an era in which the importance of what happens during infancy, stored as relational schemas in nondeclarative memory systems, can be nonconsciously retrieved by the patient and changed through here-and-now new emotional experiences with the psychotherapist (Litowitz 2005 ). This is in contrast to Gilmore and Meersand (2014 ), who in their very much traditional one-person psychology book on child and adolescent development regrettably state, “Although we concur that certain basic interpersonal, emotional, and biological needs must be met in infancy for development to proceed, we do not see infancy as the preeminent developmental moment ” (italics ours). Therefore, we provide the reader the necessary information from infant developmental research to help elucidate that infancy is in fact a preeminent developmental moment.

© Springer-Verlag Berlin Heidelberg 2015 79 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_5 80 5 Key Concepts in Two-Person Relational Psychology

Table 5.1 Key concepts Meaning-making processes of two-person relational Affective attunement psychology Emotional availability/social referencing Temperament Internal working models of attachment Implicit relational knowing Intersubjectivity Real relationship Present moment Now moments Fuzzy intentions and sloppiness Moments of meeting Mentalization Corrective emotional experience

Child Parent • Meaning making (+++) • Affective attunement (+++) • Mirror/echo neurons/ Internal working models • Emotional availability (+++) default mode network of attachment • Social referencing (+++) • Social referencing (+++) • Temperament • Temperament • Cognition • Cognition • Cognitive flexibility • Cognitive flexibility

Many now moments Everyday ruptures

Implicit relational knowing Healthy development

Frequent “Aha!” Many Repairs Moments of meeting

Fig. 5.1 Schematic representation of intersubjective experiences between child and parent in the context of a secure attachment. Healthy development and maturation occur through intersubjective ﬁ eld (IF) which is the overlap of their subjective experiences. The number of (+) denotes degree of strength in this dyad

In this chapter, we present the reader a structured overview of the key concepts from developmental research that inﬂ uenced the development of child and adolescent two-person relational psychology and psychodynamic psychotherapy (Table 5.1 ). We have attempted to organize these key concepts loosely on how they evolve in a healthy and securely attached infant (Fig. 5.1 ). Few of these concepts are 5.1 Meaning-Making Processes 81 standalone and many that overlap in terms of clinical usefulness and will be grouped together. We conclude this chapter with several case examples to demonstrate the use of these important key concepts clinically.

5.1 Meaning-Making Processes

“ Meaning making ” is the process of how people make sense of their subjective experiences within the context of their relationships to others. During the ﬁ rst few months of life, an infant’s biopsychosocial development will be constructed from an amalgam of layered and complex meaning-making processes, which will inﬂ uence how they will make sense of themselves and their experiences with others. Tronick (1989 ) reminds us that developmental research has expanded the way we understand how infants organize their behaviors in the context of stimulating events, such as emotional expressions of the face, voice, gaze, and the psychophysiology of self and others. He writes:

…these processes include motor activity, emotions, temperamental reactivity, mirror neurons, cortical processes, and processes such as the dampening of the hypothalamic– pituitary–adrenal axis and the kindling effect of trauma on neuronal groups.

Damasio et al. (2000 ) adds that such internal meanings represent a “core biopsychosocial state of consciousness” for the infant. Such processes can have a profound impact on the developing infant, as it has been proposed that they represent a central mechanism that constructs both typical and pathological outcomes (Tronick and Beeghly 2011 ). The process of meaning making allows a person to construct mental models that ground their understanding in a deeply personal and unique fashion. Growing evidence suggests that these meaning-making processes continue throughout life (Kegan 1994 ). That is, a person’s representational models are fi ne-tuned in perpetuity as they make sense of the meaning, affect, and intentions of others within the intersubjective fi eld . Further, research has documented that infants have an innate bias toward self-regulation and mastery and to create perceptual–experiential coherence and organization of their happenings ( Emde 1998 ). Developmental research demonstrates that during the fi rst few months of life, children rely almost entirely on perceptual clues from others, which can help them identify temporospa- tial, “ amodal ” qualities ( Stern 1985 ), such as rhythm, intensity, sequence, affect, and tone in their interactions with others. Toward the end of the fi rst year of life, verbal–symbolic clues begin to gain ascendancy, leading to the construction of representational models with symbolic qualities. Developmental researchers Stern and Emde found that the infant’s brain is designed to make meaning of what goes together in reality. Dodd (1979 ) and Trevarthen (1977 ) demonstrated that infants as young as 3 months old can experience distress when there is a discrepancy between reality and their mental representation of the event. For example, when an image of their mother’s face is on a television screen and her voice is delayed by a few milliseconds, the infants detect the discrepancy, remaining upset until the discrepancy is corrected. In a review of infant research, Bleiberg (1994 ) states, “Infants (1) develop fairly realistic 82 5 Key Concepts in Two-Person Relational Psychology spatial-temporal models of reality and use them to anticipate what reality will be like, and (2) present a readiness to activate affective responses of anxiety when reality fails to match their mental model of it.” More recently, developmental researcher Andrew Meltzoff (2007 ) has found that infants can represent other people as “like me” and that their imitation of bodily movements is a meaning-making process that establishes a connection between self and other. Meltzoff and Brooks (2007 ) state, “Imitation shows a sharing of actions. This action, sharing is present at birth and tells us much about the intersubjectivity that infants bring to their fi rst encounters with others.” Further, Meltzoff and Brooks ( 2007 ) share that the duplication of the action patterns, mannerisms, and gestures humans use to communicate is part of the fabric of human communication and runs in the background, fostering emotional cohesion in everyday interactions, often times outside of explicit awareness. Thus, Meltzoff’s research experiments in essence defi ne the goals of a two-person relational psychotherapist, “Human parents often act as good therapists, mirroring (and interpreting) the infant’s thoughts, feelings, and behaviors.” We would clarify that the two-person relational psychotherapist’s mirroring and interpreting occur at the implicit nondeclarative level, which allows moving forward the psychotherapeutic process and creating new and more adaptive developmental pathways (Meltzoff 1999 ). Ed Tronick , a developmental researcher, who was a member of the Boston Change Process Study Group, designed the “still-face experiment,” in which mothers would present a “still” face to their infants in the midst of play (2007 ). Healthy infants, after being presented with their mother’s nonresponsive facial expression, would at fi rst continue to smile and gesture (learned implicitly during the interactions with his mother), attempting to reengage with her. However, when the mother continues with her still face, the infants became upset and would resort to vigorous verbal and motoric attempts to elicit their mother’s response. If not successful, they would become despondent and withdrawn. Tronick (2007 ) explains the infant’s reaction: “The (in)-action of the still-faced mother precludes the formation of the dyadic state of consciousness because there is no exchange of meaningful affect and action with the infant, no creation of meaning.” The meaning-making process has neural underpinnings and is further discussed in Chap. 7 . In this section, we briefl y discuss mirror and echo neuron systems, which are believed to play fundamental roles in imitation in infants and in understanding with regard to conspecifi cs. This system, which is localized in the frontoparietal regions, has been described by Rizzolatti and Craighero as a system responsible for the “neural basis of a mechanism that creates a direct link between the sender of a message and its receiver [and allows] actions done by other individuals become messages that are understood by an observer without any cognitive mediation” (2004 ). In infant research, infant attachment outcomes at 1 year can be predicted based on the degree of interactive coordination of vocal rhythms between mothers and infants at 4 months ( Jaffe et al. 2001 ). Literature supports that the mirror neuron system is complex and intertwined in electrophysiological terms with the scaffolding in degrees of functionality ( Iacoboni and Dapretto 2006 ). Mirror neurons are a particular class of visual motor neurons, and it seems natural that an audiovisual neuron system develops 5.2 Affective Attunement 83 to understand object-related actions. This encompasses a visual mirror neuron system and an auditory (echo neuron) system that allows for the understanding of the sound that accompanies the actions as in language; “object-related actions are not suffi cient to create an effi cient intentional communication system” (Rizzolatti and Craighero 2004 ). However, over the last decade, more than a dozen “mirror neuron” areas that involve Brodmann area 9 have been identifi ed, including in the inferior frontal gyrus, premotor cortex, primary visual cortex, cerebellum, and the limbic system, and these structures are functionally connected (Molenberghs et al. 2012 ). Thus, while the distinction may seem semantic, the extant and accumulating neurostructural and neurofunctional data argue that it is better to consider these “mirror neurons” within larger structures and regions that participate in coordinated refl ective functions and reciprocally modulate one another, rather than as isolated, auton- omously functioning regions (see Chap. 7 for a more comprehensive discussion).

5.2 Affective Attunement

Affective attunement is known as the sharing and alignment of internal states that occur during the interaction between the mother and infant, usually around the eighth month in the domain of intersubjective relatedness to others (Stern 1985 , 2005). Stern (1985 ) gives an example of an infant stretching and extending his ﬁ ngers to reach a toy. During this moment, a mother may recognize her son’s concentrated facial expression and may begin to utter encouragement, “uuuh… uuuh!” signaling implicit encouragement by the crescendo of her voice. The mother’s accelerating vocal respiratory effort matches the infant’s accelerating physical effort. In a securely attached relationship, affective attunement largely consists of implicit processes and is seemingly automatic. Stern reﬂ ects on this process:

It is a matching, more than an imitation, that is cross-modal, each partner using a mode of expression different, unconsciously * the most often. The reference for the match is the internal state and not the external behavioral act. Attunement is felt like an unbroken process in the time and leads to defi ne a new quality of feeling, vitality. The quality of the relation of attunement determines probably the ulterior level of the intersubjective relatedness of the ability to ‘be-with’, to share. *Stern’s use of the term “unconscious” is not Freud’s confl icted unconscious but rather a dynamic nonconfl icted unconscious also referred to by the Boston Change Process Study Group as “nonconscious .”

We would draw the reader’s attention to Stern’s careful delineation that successful affective attunement is based on the internal state and not on an external behavioral act. Stern then ties the quality of this attunement to the level of intersubjective relatedness, which is the ability to be with and implicitly share experiences with others. Emde and Hewitt (2001 ) consider the affective system as psychobiological dispositions with both organizing and communicative functions. Affective attunement is cross-modal and encompasses both verbal and nonverbal communications. Interactions encompass much more than a shared lexicon; they are strongly 84 5 Key Concepts in Two-Person Relational Psychology infl uenced by vocal tonality and intensity, and observable movements like touching, laughter, and singing are stored in preverbal amodal understanding, becoming precursors to affective regulation (Barsalou 2010 ). Ultimately, these various forms of expression should provide a sense of “I get what you need.” In clinical practice, the two-person relational psychotherapist’s affective attunement refers to the authentic and genuine responses given to the patient. Unlike empathy, the relational psychotherapist is not only refl ecting on the patient’s subjective state but also conveying his or her own internal perspective to the patient. Thus, in two-person relational psychodynamic psychotherapy of children and adolescents, there must be concerted attention made to matters of emotional availability and affective attunement, which play a critical role in psychotherapeutic change. Diener and colleague state, “The more therapists facilitate the affective experience/expression of patients in psychodynamic therapy, the more patients exhibit positive changes” (Diener et al. 2007 ), and concludes, “Research indicates that contemporary psychodynamic therapies place greater emphasis on encouraging experience and expression of feelings compared with cognitive behavior therapies.” According to Safran and Muran, “After approximately a half century of psychotherapy research, one of the most consistent fi ndings is that the quality of the therapeutic alliance is the most robust predictor of treatment success” (2000 ). Earlier, we described a typical example of a successful affective attunement between mother and her infant boy reaching for a toy. In contrast, when the primary caregiver does not provide appropriate affective attunement in the early months of life, the infant is at increased risk to develop poor self-regulatory abilities, which become the precursor to a variety of insecure attachment patterns. On one hand, consider an infant boy whose mother is very anxious and has diffi culty tolerating the child’s struggle in reaching for a toy. Instead, she reaches and gives the toy to the child and thereby prevents overt signs of distress, which make her anxious. This mother does not provide the emotional availability needed for the child to have a sense of vitality in his exploration and impedes the development of self-regulatory functions. Alternatively, a mother may be dismissive of the child reaching for a toy, and the child will learn that he or she cannot rely on his caregivers, and later others, for appropriate affective attunement. This will also lead to diffi culties with self- regulation and interrelatedness. Taking this scenario a step further, if the mother is critical and laughs at the boy when he reaches for the toy, and if this is typical of their mode of interaction, it is reasonable to consider that the child will develop a disorganized attachment style. All of these examples illustrate implicit patterns of relating that will likely over time form internal working models of insecure attachment, which is a considerable risk factor for maladaptive interpersonal behavior and formal psychiatric disorders.

5.3 Emotional Availability and Social Referencing

Emotional availability is a comprehensive construct based on the integration of fi ndings from developmental research and attachment theory. This construct is infl u- enced by both caregiver and child. Healthy emotional availability can be evident by 5.3 Emotional Availability and Social Referencing 85 mutual interest and openness within the dyad of child and parent. This may include a range of positive and negative emotions. Social referencing serves to expand emotional availability by introducing a sense of shared meaning about events. Emde (2000 ) discovered that there is a need for “reciprocity” between caregiver and child for emotional growth and the ability to ultimately enjoy mutually fulfi lling and healthy relationships. For Emde (1998 ), emotional availability referred to the “receptive presence” of the parent to the child’s emotional signals. Emotional availability is a vital aspect of the infant–caregiver relationship before the onset of social referencing (Emde and Easterbrooks 1985 ). Further, it connotes a type of presence and availability that has a great deal in common with the way a psychotherapist “is there” for a patient (Biringen and Easterbrooks 2012 ). Social referencing is a critical milestone in typical child development that refers to the process in which a child looks to a caregiver in an emotionally ambiguous situation in order to obtain clues on how to interpret and resolve the situation. Successful social referencing results in a capacity to self-regulate behavior, gain reassurance, and understand how to proceed (Oppenheim et al. 1997 ). Bleiberg (1994 ) in reviewing infant research literature states:

Beginning in the second half of the ﬁ rst year of life, infants respond to a novel or uncertain situation—that is, one for which they lack an internal model—in a predictable fashion: They search the caretaker’s face for clues to resolve the uncertainty. If the caretaker’s face signals encouragement, the infants explore with pleasure. If, however, the caretaker betrays anxiety, they become inhibited and distressed.

The visual cliff experiment is a well-recognized paradigm for studying how social referencing can regulate behavior and was used by Emde and Easterbrooks ( 1985) to assess the effect of maternal emotional signaling on 1-year-olds. In this experiment, infants were placed on a special table in which a transparent tabletop appeared to end and fall off between the infant and the mother. Remarkably, the majority of infants will cross the cliff in the face of apparent danger if the mother demonstrates a positive facial display. Conversely, when the mothers displayed a fearful face, none of the 17 infants crossed. The observation of social referencing appears to have real- world implications. In a study, Dickstein and Parke (1988 ) found that when marital satisfaction was stable, infants would equally use their father and mother as social referencing targets. Some research suggests that there is correlation between the security of attachment and maternal referencing (Klinnert et al. 1986 ). Dickstein et al. ( 1984) found a strong relationship between infant temperament measures and social referencing capacity, rather than attachment patterns. As demonstrated by the visual cliff experiment, negative expressions by caregivers can regulate infant behavior similarly to how positive expressions do so. When infants look at parents or caregivers and notice anxious or fearful expressions, they can develop maladaptive, problematic behaviors over time. As an example, starting school is generally an exciting time for parents, even though there may be some dif- ﬁ culty in allowing the child to separate. Though parents may be implicitly anxious, they understand they need to mitigate the child’s inherent anxiety, through facial and emotional expressions that provide reassurance to the child of the new endeavor: 86 5 Key Concepts in Two-Person Relational Psychology

Table 5.2 Key aspects of development for the relational child In utero, the infant begins to develop internal working models according to the sounds/voices that he or she hears After birth, the infant develops meaning making of sounds, smells, touch, and facial recognition, within implicit nondeclarative memory systems During infancy, psychological attunement to the emotionally available parent creates internal working models of attachment Intrinsic attributes of the child (e.g., temperament and cognition) affect the goodness of ﬁ t with the parent Social reciprocity between child and parent is inﬂ uenced by each others’ internal working models of attachment The child’s capacity for social referencing allows him or her to distinguish emotionally available family members Development occurs within a cultural context

“everything will be fi ne.” However, if parents or caregivers consistently provide fearful or anxious emotional expressions, the child may begin to refuse to go. Additionally, the child may be eager to go to school and rely on school personnel to provide the social referencing needed for reassurance. Importantly, Emde (1992 ) also reminds us that social referencing processes have largely been studied from the point of view of the infant and have neglected the caregiver’s side of the process. Observations of caregiver social referencing may help further knowledge and develop programs to promote maternal sensitivity and caregiver emotional response essential for the child’s growth. Additionally, the two- person relational psychotherapist emotional availability is also essential for the patient and family’s growth, as they will implicitly and nonconsciously make use of the psychotherapist’s more adaptive relational knowings. Several authors have thought of these early referencing patterns in social contexts as initially being dyadic. However, toward the end of the fi rst year, looking behavior becomes increasingly referential—or coordinated between many people— with relationships infl uencing relationships. The emergence of referential looking is of particular interest because it is a major milestone in the infant’s development of social cognition. It is a marker that the infant has an understanding, however primitive, that other people have intentions directed toward the outside world. These processes will grow increasingly more sophisticated and become the underpinnings of theories of the mind, emerging by the third year (Hala 1997; Striano and Rochat 2000 ). Up to now, most studies of infant–caregiver interactions suggest that multiple infl uences are likely to contribute to the emergence of individual differences in social referencing (Table 5.2 ).

5.4 Temperament

The concept of temperament has traditionally had limited use in the larger mental health community. In contrast, early childhood educators, developmental psychologists, and pediatricians have routinely embraced the concept of 5.4 Temperament 87 temperament. Temperament can be broadly defi ned as observable and persistent behavior patterns in early childhood that distinguishes one child from another. These patterns remain relatively consistent over situations and time. Many specifi c patterns of behavior have been identifi ed (McCrae et al. 2000 ; Windle and Lerner 1986 ) with several useful classifi cation schemes used across the lifespan. Thomas and Chess are credited with the modern concept of temperament. In Thomas and Chess’ New York Longitudinal Study of 141 youth (Thomas and Chess 1982 ), they described temperament as having four general styles: 45 % were classifi ed as “easy or fl exible,” 15 % “slow-to-warm-up,” 10 % as “diffi cult or feisty,” and 35 % as “mixed,” a combination of the three, which remained consistent at 22-year follow-up (Thomas and Chess 1999 ). Though we discuss temperament in greater detail in Chap. 8, we will briefl y visit this concept as it relates to two-person relational psychology. Behavioral inhibition is another important temperamental construct that should be clearly assessed prior and during the therapeutic process. In their pioneering work, Kagan and colleagues (1986 ) characterized behavioral inhibition as the tendency of children, when presented with an unfamiliar circumstance, to restrict speech and play and retreat to an object of attachment. These observations were not restricted to behaviors, but indeed, physiological differences such as higher and more stable heart rates were found in children who were classifi ed with extreme behavioral inhibition. Such temperamental traits in infancy have repercussions later in life. Through a series of studies, Biederman and colleagues found that infants with high levels of behavioral inhibition were at high risk for the later development of childhood anxiety disorders and comorbid psychiatric conditions (Biederman et al.1993 , 2001 ). Though temperament is presumed to have a biologic basis, environmental infl u- ences in a child’s early life may lead the child to selectively develop some traits over others necessary for adaptation. For example, two well-established temperamental traits, emotional reactivity and self-regulation, may be strongly infl uenced by a child’s early environment (Bronson 2000; McLaughlin et al. 2010 ). Temperamental traits may also be broadly shaped within a cultural and socioeconomic context (Bornstein and Cote 2009 ; Paulussen-Hoogeboom et al. 2007 ). Thus, temperament is a multifactorial process, including contributions from genes, neurobiology, observable behavior patterns of interaction, and culture. Ultimately, temperamental traits play an important role within any therapeutic relationship. Temperamental differences between individuals, especially within the parent– child and psychotherapist–patient relationships, can play a critical role in the quality of interpersonal interactions. As Roffman and Gerber (2012 ) state, “Genetics and temperament are two important (and likely related) areas of research that are undoubtedly relevant to the variability of patient outcome in psychodynamic treatment, and ultimately to our understanding of the mechanisms of psychopathology and therapeutic change.” We would encourage psychotherapists to consider not only the child’s or adolescent’s temperament but also that of the primary caregivers. In keeping with the two-person relational perspective, it is also important for the psychotherapist to refl ect on his or her own temperamental style, as it will also contribute to the goodness of fi t with the patient in the intersubjective fi eld . 88 5 Key Concepts in Two-Person Relational Psychology

5.5 Internal Working Models of Attachment (IWMA)

The principal tenet of attachment theory is that people have an innate predisposition to form close emotional bonds with others to assure survival. Bowlby ( 1969 ) proposed a construct, known as internal working models , to describe the mental representation of the self and others formed by early childhood relational experiences. In typical development, stable internal working models are formed to understand and predict the intent of others within a certain context and environment, conferring a survival beneﬁ t to maintain proximity to caregivers and establish a sense of “felt” security (Bretherton 1985; Sroufe and Waters 1977). Bowlby noted that early in life, the infant creates attachment behavioral systems that help assess whether the parent or caregiver is available not only physically but also emotionally. The parent or caregiver strongly inﬂ uences how the infant develops the capacity for emotional regulation of their feelings, creating an internal working model of attachment (IWMA), which serves as a template when relating to others (Benoit 2004 ). Further, the quality of the attachment between the infant and the parent or caregiver is a powerful predictor of a child’s later social and emotional abilities (Benoit 2004 ; Bretherton et al. 1990 ). The empirical evidence of the impact of caregivers’ behavior on infants’ behavior and development has steadily accumulated since Bowlby’s original proposition (Cassidy and Shaver 2008 ). In addition, individual patterns of attachment appear to remain relatively stable and persist over time (Grossmann and Grossmann 2005 ; Mikulincer and Shaver 2005; Sroufe 2005). In an elegant study, Johnson and colleagues (2010 ) found evidence of internal working models during a replication of the Strange Situation experiment. The infant participants and their mothers were observed watching an animated presentation involving either a secure or an insecure caregiver. Three unique patterns of expectations emerged: (1) secure infants demonstrated a desire for comfort and had an expectation of caregiver comfort, (2) insecure- resistant infants expected to be comforted but did not expect comfort from the caregiver, and (3) insecure-avoidant infants neither expected comfort for themselves nor expected comfort from the caregiver. Johnson and colleagues came to the following conclusions:

These results constitute direct positive evidence that infants’ own personal attachment experiences are reﬂ ected in abstract mental representations of social interactions…. These representations can now be traced as they emerge, well before existing behavioral measures of attachment can be employed.

Their data supports Bowlby’s original claims that infants form internal working models of attachment-relevant behavior, and these models are associated with infants’ own behavior. In recent years, neurodevelopmental research has begun to uncover the underpinnings of how IWMA are formed (Schore 2005 ). The attachment quality between a child and caregiver is multifactorial, and the developing IWMA subsequently allows for social referencing, affective attunement, implicit relational knowing, and intersubjectivity. 5.5 Internal Working Models of Attachment (IWMA) 89

Attachment Patterns: Secure, Insecure-Ambivalent/Anxious, Insecure-Avoidant/Dismissive, and Insecure-Disorganized

Developmental research experiments have delineated four attachment patterns that warrant further discussion given the central role they play in determining the patient’s and psychotherapist’s ability to interact with each other.

Secure Attachment

Secure attachment between the infant and caregiver develops when there is an implicit sense of safety, emotional availability, social referencing, and reciprocity within the relationship. The parent or caregiver provides the affective attunement necessary to help the child learn to manage normal and growth-promoting periods of disruption, such as the time between feedings, diaper change times, ﬁ rst visit to the pediatrician, and when setting limits. The parent or caregiver may choose to provide affective attunement in the form of holding, soothing with touch, rhythmic rocking, or singing with a melodic voice. This provides the child with a coherent, implicit, nonconscious , and cohesive narrative over time. The child begins to value attachments, whether pleasant or temporarily unpleasant, over time and is able to develop other early forms of social reciprocity (Meins et al. 2002 ). Children with secure attachment in the Strange Situation experiment were easily comforted after a brief separation from their mothers and then resumed exploration and play (Ainsworth and Bell 1970 ). In general, secure attachment has a protective tendency, even under stress. Children with secure attachment have physical and psychological skills that will allow them to manage normal periods of distress or relationship rupture while maintaining their core sense of self and their core beliefs about others (Edwards et al. 2006). Nevertheless, at times, even a securely attached child will be unable to tolerate and manage certain unexpected life events. In Chap. 12, we discuss this in particular by reviewing a case of a school age child who is overwhelmed with his father’s terminal cancer.

Insecure-Ambivalent/Anxious Attachment

An ambivalent/anxious form of insecure attachment occurs when the infant or toddler experiences anxiety due to a parent’s or caregiver’s inconsistent emotional availability. In the Strange Situation experiment, these infants were highly distressed by separation and had difﬁ culty being consoled after reunion, and they demonstrated resistance to the parent’s wish for reengagement (Ainsworth et al. 1978 ). From the perspective of the parent or caregiver, most commonly the anxiety conveyed to their child is based on their subjective experience of not being competent as a parent or resenting being in a responsible position. What develops within this dyad is a relationship that is characterized by superﬁ ciality and the implicit 90 5 Key Concepts in Two-Person Relational Psychology need for self-reliance. As the child grows older, he or she may hover close to neighbors, teachers, and peers but will fail to convey a sense of hoped reciprocity as the result of self-doubt and anxiety about rejection. Ultimately, this is an enactment of the original pattern established by the ambivalent/anxious parent or caregiver (Sroufe et al. 1999 ).

Insecure-Avoidant/Dismissive Attachment

The avoidant/dismissive type of attachment develops when the toddler grows in constant fear due to the unpredictability of the quality of the relationship with the parent or caregiver and cannot develop a stable internal working model of social relationships (Bowlby 1969 ). As the child grows, he or she shows a tendency toward passivity in the presence of the parent or caregiver and avoids the expression of affect in order to prevent the imagined or real rejection from the parent or caregiver. In the Strange Situation, these infants showed little distress at separation from the parent and then actively ignored the parent upon reunion (Ainsworth et al. 1978 ). In other words, children who develop avoidant/dismissive internal working models have stored in implicit nondeclarative memory the pattern of distancing themselves from others, which may proactively prevent feeling hurt when ignored. As an example, a mother while walking toward and waiting for the elevator is quiet, with a scowl face, and does not interact with her two children, ages 2 and 4 years of age, in spite of their attempts to engage with her. Once in the elevator, the mother continues to be silent and does not engage with other friendly people reaching out to her affectively. The children have learned to avoid and dismiss engaging with other people in the elevator who demonstrated willingness for some degree of social reciprocity. Further, the elementary school aged child with an avoidant/dismissive type of attachment often rejects closeness and help offered from teachers to complete assignments. The child is generally independent and self-reliant, avoids peer interactions, and spends more time alone watching TV or playing video games. When the child becomes an adolescent, he or she may prefer to play video games and spend time alone and also may resort to illegal substance use to help with the feelings of loneliness. They have heightened self-doubt about whether they will be of any interest to other people.

Insecure-Disorganized Attachment

Main and Solomon ( 1990 ) originally introduced the term “ disorganized attachment” to describe a series of 55 infants who did not ﬁ t either a secure, anxious, or avoidant attachment style within the Strange Situation experiment. Though this cohort of infants did not share any broad, patterned attachment behaviors, Main and Solomon observed that these infants shared “bouts or sequences of behavior which seemed to lack a readily observable goal, intention, or explanation.” Subsequently, a careful examination of the infant–mother dyads revealed that the mothers in these 5.6 The Contextual Nature of Attachment 91 dyads had themselves suffered from attachment traumas, i.e., physical or emotional child maltreatment (Ainsworth and Eichberg 1991 ). Winnicott ( 1971 ) similarly found there was a narrow window in which an infant could tolerate a rupture with a primary caregiver, such as an absence, but if that window were too wide, the experience of the infant would result in distress and confusion. Repeated ruptures within the dyad would devolve into a disorganized pattern of attachment that may general- ize to other social interactions and the development of poor capacity for social reciprocity. Disorganized attachment patterns appear to be strongly related to the effects of enduring relational trauma that intrudes into the interpersonal life of a child. The term developmental trauma is apt to describe the complexities of relational trauma in childhood and the devastating consequences it has throughout their life span (van der Kolk 2005 ). When children experience neglect or abuse by people responsible for their well-being, it is deleterious to their self-organization and can broadly affect the cognitive, physiological, emotional, and relational domains (Hertsgaard et al. 1995 ; Hesse and Main 2000 ). It is not surprising that there is often a history of abandonment or trauma in these children, who then grow to be frightened or hostile toward commitment in relationships and perpetuate cycles of incoherent life discourse. These children are unable to develop the self-regulatory functions needed to establish closeness with others and to envision a positive future. The preschool age child who angrily pushes his or her mother away after a brief separation and the mother who is unable to provide comfort but instead similarly responds with anger are assumed to indicate an insecure and disorganized form of attachment (Pietromonaco and Barrett 2000 ). As discussed by Schore (2000 ), relational trauma can persist into adulthood in the form of additional risk of repeated trauma and dissociative experiences. Herman (1997 ) offered the term “complex trauma” to delineate trauma that involves repeated and chronic abuse, instead of a single traumatic event that can cause posttraumatic stress disorder (PTSD). Some have suggested that this may represent an early precursor to borderline personality disorder (Holmes 2004 ).

5.6 The Contextual Nature of Attachment

As we have described previously (Delgado and Strawn 2014 ), when two people interact with each other, the attachment patterns observed are specifi c to those two people. It is not necessarily a representation of attachment patterns that may be exhibited when with others. For example, a child may be dismissive of the psychotherapist in his offi ce, and the psychotherapist may feel the need to make extra efforts to connect with the child, although neither behavior is the typical mode of interaction for them. Their interaction has been guided by the here-and-now intersubjective experiences of each other. The child, who may have a history of secure attachment, could still implicitly fear sharing his struggles with the death of a parent to avoid reexperiencing the sadness and anger of the event. In contrast, the relationally informed psychotherapist implicitly is reminded by the child’s anxiety 92 5 Key Concepts in Two-Person Relational Psychology in relating, of his own childhood diffi culties tolerating others’ dismissiveness, and nonconsciously and unknowingly attempts to speed up the process by actively encouraging the child to talk about the traumatic event, without recognizing that the child’s reluctance is well founded. Although both the child and psychotherapist typically use a secure form of implicit relational knowing when interacting with others, during the session the child uses dismissive behaviors and the psychotherapist, anxious behaviors, and both cocreate a disruption (i.e., a now moment, see below under Intersubjectivity) that will need to be repaired by the psychotherapist. The psychotherapist will ultimately recognize the child’s subjective anxieties in the here-and-now intersubjective fi eld and may choose to enact and self-disclose (Chap. 6) that as a child himself, experiencing negative feelings was diffi cult and that sometimes playing a game helped create a reprieve from the intensity of the feelings. He may then proceed to invite the child to play to implicitly convey, “I understand that you are uncomfortable in here with me. You do not need to tell me what worries you. Let’s play and cocreate a positive experience for you in the here and now.” Wachtel (2010 ) eloquently captures this dilemma:

We begin to think that this is the way the person “is,” when it is more accurate to say that this is the way he is with me (and, moreover, how he is with me when I am acting in a particular way, and he may not be that way even with me when I am being different). Thus, a fully contextual or two-person conceptualization of attachment not only attends to how the person varies in the attachment experiences that are evoked with one person or another; it also requires us to ask what is happening that leads the person to relate and to perceive and experience in a secure fashion, in an ambivalent or avoidant fashion, etc. It attends to what each party to the exchange or to the relationship is doing and feeling at any particular moment, and it asks what each person’s participation in the attachment relationship at any given moment is in response to and what it evokes in the other.… What is really being measured is a depiction of the person’s average or modal attachment status, not a measure that is unvarying through the days and weeks and years; our understanding of the person’s “central tendency” must be complemented by an understanding of the exceptions like inpatient, the ofﬁ ce of the therapist, the persistence of the child’s attachment behavior contributes to the continuity of the child’s environment just as the continuity of the environment contributes to the persistence of the attachment status.

Therefore, it is necessary for the two-person relational psychotherapist to be an active participant in the child’s or adolescent’s subjective experiences in order to be fully immersed and affected from the “inside out” of the attachment patterns as they are played out. It is within this intersubjective ﬁ eld that cocreation takes place and the psychotherapist can carefully plan how to effectively provide a new emotional experience in the patient’s own nondeclarative language, thus creating new neuronal pathways that improve a sense of identity and regulate affect. For example, props may be used, such as soothing (transitional) objects, toys, etc., to prevent feelings of abandonment and to foster a feeling of connection. Wachtel (2010 ) describes this process as helping patients to learn to implicitly seek “accomplices” more akin to the healthy psychotherapist and not repeat prior maladaptive attachment patterns (Chap. 3 ). 5.7 Fundamental Principals of Two-Person Relational Psychotherapy 93

This is in contrast to traditional one-person psychology, which has as its basic tenet the goal of helping the patient understand their dysfunctional unconscious conﬂ icts, ego weaknesses, object relations problems or self-object functions through the repetition of transference paradigms with the psychotherapist to allow for interpretations to make the unconscious conﬂ ict conscious (Chap. 2 ).

5.7 Fundamental Principals of Two-Person Relational Psychotherapy: Implicit Relational Knowing and Intersubjectivity

Implicit Relational Knowing

The concepts of implicit relational knowing and intersubjectivity go hand in hand as fundamental principals in two-person relational psychology and psychodynamic psychotherapy. We defi ne implicit relational knowing as the processes of social interaction and attunement that are largely nonverbal, based on nondeclarative memory systems (Table 5.3 ) and outside conscious experience (Lyons-Ruth et al. 1998 ). Though we discuss intersubjectivity in detail later in this chapter, it can be briefl y defi ned as the psychological “fi eld” between participants in which subjective experiences are inextricably intertwined with one another (Dunn 1995 ). Implicit relational knowing is a complex process that begins in infancy (BCPSG 2007 ), and then, as Nahum ( 2000 ) aptly described, “the infant goes from being a physiological being to a psychological being.” Implicit relational knowing is masterfully described by Lyons-Ruth et al. (1998 ):

[Implicit relational knowing] begins to be represented in some yet to be known form long before the availability of language and continue to operate implicitly throughout life.… Language is used in the service of this knowing, but the implicit knowing governing intimate interactions are not language-based and are not routinely translated into semantic form.

Implicit relational knowing cannot be recalled in the explicit declarative memory system. Procedural nondeclarative representations guide a person on how to proceed in action and how to do things, and they are not symbolically coded. For example, when driving a car, we do not have a symbolic representation for suddenly

Table 5.3 Table distinguishing implicit and explicit. Memory is divided into implicit and explicit processes which differ in origin, neuroanatomic basis, and means of access Implicit (nondeclarative or procedural) Explicit (declarative) Present at birth Develops at 2 years of age Storing of meaning-making process Semantic meaning of language Affective attunement Autobiographic memories Involves parahippocampal processing Retrieval of episodic memories Hippocampal based 94 5 Key Concepts in Two-Person Relational Psychology stepping on the brakes and steering away when we see a vehicle collision in close proximity. Further, knowing what others typically would ﬁ nd as embarrassing or hurtful is also the domain of nondeclarative knowledge. The Boston Change Process Study Group, of which Lyons-Ruth is a member, emphasized that such implicit relational knowing is as much affective as it is cognitive (BCPSG 2007 ):

By implicit knowing in infancy we are not referring to the infant’s cognitive function, but to the way that physiological and then social/behavioral regulation is carried out between the infant and its caregiver, and represented and “remembered” by the infant. These earliest forms of biological regulation emerge from the basic capacity for adaptation in living beings as it intersects with the deeper biological origins for motivations, which are the source of the initiatives that trigger exchange. The fact that these earliest forms of biological regulation are stored in memory systems, have mental concomitants, and are psychologically meaningful has been intuitively grasped by some, but is not widely understood.

Lyons-Ruth et al. (1998 ) emphasized the role the concept of implicit relational knowing has for the two-person relational psychotherapist by pointing out that “these knowings are often not symbolically represented; they are also not necessarily dynamically unconscious in the sense of being defensively excluded from awareness.” A poignant example may be the nostalgia and pleasure evoked when listening to a favorite song and experiencing physiological effects, such as “goose bumps.” The two-person relational psychology would posit that the memories evoked by the song (e.g., contextualized in the company of loved ones or friends over the years) are stored and retrieved in an implicit nondeclarative memory system rather than in the realm of the dynamic conﬂ icted unconscious. In contrast, semantic representations are those that rely on symbolic representation in language, such as the words of a book. Further, it is important to note that implicit relational knowings are inﬂ uenced by culture and context.

Intersubjectivity

Intersubjectivity is a concept that over the last several decades has been the unifying pillar to two-person relational psychology schools (Table 5.4 ). Clinically, intersubjectivity has been deﬁ ned as “the capacity to share, know, understand, empathize with, feel, participate in, resonate with, enter into the lived subjective experience of another” and “interpreting overt behaviors such as posture, tone of voice, speech rhythm and facial expression, as well as verbal content…which assumes that [the psychotherapist] can come to share, know, and feel what is in the mind of the patient and the sense of what the patient is experiencing” (Stern 2004 ). Furthermore, Dunn (1995 ) eloquently deﬁ ned it as such: “Intersubjectivity embodies the notion that the very formation of the therapeutic process is derived from an inextricably intertwined mixture of the clinical participants’ subjective reactions to one another. Knowledge of the patient’s psychology is considered contextual and idiosyncratic to the particular clinical interaction. This interactional nexus is considered the primary force of 5.7 Fundamental Principals of Two-Person Relational Psychotherapy 95

Table 5.4 Three theorists’ conceptualizations of intersubjectivity Andrew Meltzoff Colwyn Trevarthen Daniel Stern Development of Innate, develops at Innate, develops at Develops at 6–12 months intersubjectivity birth birth of age Perception Cross-modal Cross-modal Cross-modal Relational schema Complex, pre- Complex, pre- Complex, develops at symbolic, motivated symbolic, motivated 6–12 months and is and intentional positive and intentional symbolic: a theory of emotion, playfulness, separate minds intimacy, and bonding Regulation of self Social mirroring Mutual regulation Mutual regulation model model of of communication communication (two-way) (two-way) Adapted from Beebe et al. (2003) the psychoanalytic treatment process.” Further, Krause (1997 ) studied the impact of facial expressions in a psychotherapeutic process. When the psychotherapist mir- rored the patient’s affective facial expression, it led to poor outcomes, while when the psychotherapist’s affective responses did not mirror but rather implicitly and intersubjectively moved the process toward a feeling of hopefulness, it predicted better outcomes. The ability to make use of the process of intersubjectivity subsumes that the infant has been successful in organizing experiences in which he can have subjective experiences of others and recognizes that during the interaction, the other’s experience is different than his. As described throughout this chapter, the organizing experiences by the infant require that certain processes serve as growth-promoting building blocks; these include meaning-making processes, amodal perceptive capacity for affective attunement and social referencing, innate temperamental attributes conducive for subjectivity, and secure internal working models of attachment. The infant’s self-regulatory abilities and self-representations are infl uenced by the schematic representations, in implicit form, of the interactions with their emotionally available parents, caregivers, and family members. Further, the schematic representations are infl uenced by the context of their culture. The process of intersubjectivity allows the infant, and later the child, to know how to infl uence the interactions and negotiate discontinuities when in the presence of others (e.g., disagreement about what the child should wear to a family event). Intersubjectivity promotes a cohesive and more fl exible way of refl ective abilities to know what works for healthy social reciprocity with implicit aspects of morality. In a longitudinal study, Emde and colleagues (1987 ) found that by 24 months, infants presented evidence of internalized rules for “don’ts” as well as for “dos,” as long as their parents were present and could be referenced (Emde et al. 1987 ). Children and adolescents who have genetic, biological, or relational impairments (e.g., autism, traumatic brain injuries, intellectual disabilities) that interfere in their ability to intersubjectively share, know, and enter into a live subjective experience 96 5 Key Concepts in Two-Person Relational Psychology of another person benefi t from psychotherapeutic interventions tailored to their basic needs. These children and adolescents do not benefi t from the theory of mind interventions, which require some form of cognitive and relational abilities (see Chap. 8 for a review of which children benefi t from behavioral and cognitive forms of psychotherapy).

5.8 Real Relationship, Present Moments, Now Moments, and Moments of Meeting

The following paragraphs represent a summary of important two-person relational concepts pioneered and developed by Stern and the Boston Change Process Study Group (BCPSG). We end this section brieﬂ y using these terms in composite clinical case vignettes to elucidate their applicability to clinical work.

Real Relationship

The “real relationship” in two-person relational psychodynamic psychotherapy is defi ned as the patient’s and the psychotherapist’s here-and-now bidirectional use of genuine and authentic implicit relational knowings in the intersubjective fi eld between them (BCPSG 2010 ). The intersubjective fi eld includes the authentic personal engagement and affective attunement, sensing each participant’s current “way of being with each other.” Further, for the psychotherapist, the real relationship also involves the here-and-now active participation in the form of nonconscious or carefully timed self-disclosures and enactments known as now moments (see Chap. 3 ). The concept of the “real relationship” permits to differentiate the two-person relational approach from the traditional one-person model’s approach which relies on the “therapeutic relationship,” a process in the transference–countertransference domain where the psychotherapist is an objective observer who uncovers the patient’s confl icted past. Further, the traditional one-person model relies on the use of semantic and declarative memory in the form of verbal exchange believed to represent the patient’s accurate memory of autobiographical experiences that when worked through lead to insight.

Present Moment, Now Moments, and Moment of Meeting

A present moment is ubiquitous to the interactions of everyday life. Stern (2004 ) viewed present moments as those that represent “schemas of ways of being with another.” Present moments are repeated many times and are weaved together to move along the relationship with others, and they later become implicitly familiar relational knowings unique to each dyad. They provide mutual regulation, such as recognizing when a child wants to play or needs to be fed and greeting our family 5.8 Real Relationship, Present Moments, Now Moments, and Moments of Meeting 97

Fuzzy and sloppy Affective attunement unfamiliar anxiety creating familiar provoking experience experiences Present Now moment moment

Moment of meeting

New more adaptive emotional experiences implicitly create new adaptive ways of managing interactions with others.

Fig. 5.2 Present moments, now moments, and moments of meeting after work. These moments can be considered the building blocks of relationships infl uencing relationships and contribute to the formation of internal working models of attachment. Although implicit relational knowing s are not in awareness, they are distinct from that which is repressed due to intrapsychic confl icts (Stern 2004 ). When the interaction between two people is unfamiliar, as in a patient–psychotherapist dyad, a disruption of reciprocity occurs and unexpected moments of anxiety emerge. That is, the disruption cocreates a now moment and a decision will need to be made by both persons on how to return to a mutually regulated experience: a past–present moment. When the decision is made intersubjectively and one person, through their implicit and nonconscious actions and behaviors, allows for the anxiety of the now moment to dissipate, this creates what is called a moment of meeting (Fig. 5.2 ). Moments of meeting are unique and infrequent experiences that are jointly constructed, in the here and now, by patient and psychotherapist. This is eloquently described by Lyons-Ruth et al. (1998 ): “A ‘moment of meeting’ occurs when the dual goals of complementary fi tted actions and intersubjective recognition are suddenly realized.” Moments of meeting are recognized as the special moment that most patients remember as being the time the authentic person-to- person connection with their psychotherapist altered their relationship, in that they were able to implicitly recognize that they knew what was in each other’s mind. The moment of meeting is the single most important opportunity for both participants to bring about implicit relational transformation and either lead to rupture or repair of the dyad. 98 5 Key Concepts in Two-Person Relational Psychology

The BCPSG (2010 ) adds:

[A moment of meeting]…requires that each partner contributes something unique and authentic as an individual in response to a now moment. The response cannot be an application of technique or a habitual therapeutic move. It must be created on the spot to ﬁ t the singularity of the unexpected situation, and it must carry the therapist’s signature as coming from his own sensibility and experience beyond technique and theory.

The transformative change that occurs during moments of meeting can best be understood as concepts drawn from infant research and systems theory. Tronick (1989 ) masterfully captured the contributions from developmental infant research in two-person relational psychodynamic psychotherapy:

Moments of meeting catalyze change in parent–infant interaction as well as in psychotherapy. In the process of infant development, the baby’s implicit relational knowing encompasses the recurrent patterning of mutual regulatory moves between infant and caregiver.

Thus, the special and unique moments of meeting open the intersubjective ﬁ eld for patient and psychotherapist to cocreate a more adaptive way of being together, with the associated change being stored in nondeclarative memory systems represented in a rearranged implicit relational knowing for the patient. As a colleague shared, these moments are addictive, and once you experience a moment of meeting with your patient, you know something important happened. Although there is a wish to provide more of these moments of meeting to the patient, they cannot be forced.

The adolescent that felt misunderstood. The lead author described an experience with an adolescent male with difﬁ - culties socializing who shared, “I worry that you will think of me just like my parents do. That I should stop dating Emily because I spend all my time with her and I don’t socialize like my parents think I should. They don’t get it; she is an honor roll student, and we have a lot in common. We connect.”

From a traditional one-person perspective, the psychotherapist may have believed that the statement “you will think of me just like my parents” was evidence of early transference manifestations: The psychotherapist was standing in for the perceived critical parent. The psychotherapist may have chosen to explore this further and states: “You experience me as your critical parent who will not approve of your dating Emily. You seem to avoid talking about the fact that perhaps you also have some worries about dating Emily, because you fear you would be agreeing with your parents, who in fact want to make sure you are happy and not get hurt.” This line of thinking would be consistent with the diagnostic formulation that the adolescent was struggling with the second individuation process of adolescence—due to the unconscious reawakening pressures of the internalized representations of the parents—and feared the loss of their support (Blos 1967 ). The traditional one-person 5.8 Real Relationship, Present Moments, Now Moments, and Moments of Meeting 99 psychotherapist would help the adolescent work through his unconscious struggles through transference and ego defense interpretations. The concept of making the unconscious conscious implies forms of symbolization and refl ection through language (Litowitz 2005 ). In contrast, in a two-person relational model, the real relationship is bidirectional. Both parties are authentic and genuine with each other in the here-and-now intersubjective fi eld , and both are subject to change by the processes. In using the same example, the psychotherapist would have experienced the adolescent as being genuinely happy with Emily. She had provided the reassurance and support he needed to feel like a competent adolescent: a present moment. In the intersubjective fi eld, the psychotherapist was also implicitly reminded of times when he was in high school and his parents voiced disapproval of his choice of college and, later, his pursuit of a career in medicine. The psychotherapist subjectively recalled that what proved to be of enormous help was the support of other family members, teachers, and mentors who recognized his abilities. The psychotherapist proceeded to self- disclose and enact in the here and now. He shared with the adolescent some of his parents’ anxiety and doubt about his future, and he openly offered support to the adolescent. He also wondered if the adolescent had family members or teachers who were supportive of his dating Emily. The adolescent was outwardly relieved, and his facial expression demonstrated a sense of “You understand me”—a moment of meeting. This opened the intersubjective fi eld, and the adolescent, with vitality, shared his worry about whether his parents would be hurt knowing that in fact his teachers, cousins, aunts, and uncles were supportive of his dating Emily: “They know she is a good student, attentive to me and others, and is active in sports.” The patient, smiling, shared, “My parents are good parents, but they were not happy in high school. They worry that I will repeat their mistakes. They do not know how good Emily is to me.” The psychotherapist empathized and shared that “allowing help from other people can be diffi cult on your parents.” The patient added, “It’s good to know that you went through this. I bet your parents are proud of you now.” To which the psychotherapist replied: “Thanks. There is nothing wrong with parents wanting the best for you. Sometimes they just need to learn to trust you. I am sure you have learned a lot from your parents.” The psychotherapist’s self-disclosing and enacting interventions in traditional one-person psychology would have been considered problematic. It may have been viewed as a countertransference enactment in which the psychotherapist gratifi ed the patient’s unconscious wishes for approval rather than analyzing his doubts and later interpreting his fear with individuation. It is important to note that the two-person relational psychotherapist had no way of knowing that the adolescent was going to elicit the feelings he experienced. In fact, if the adolescent’s description of Emily would have been made with a different affective state, tone of voice, gaze, and body posture, the psychotherapist may have not intersubjectively felt the adolescent was genuinely happy. If that had been the case, it is conceivable that the psychotherapist’s intersubjective experience, as a real person, may have been similar to that of the adolescent’s parents—disapproval of his dating Emily—and may have chosen to explore why the adolescent felt that his 100 5 Key Concepts in Two-Person Relational Psychology parents were wrong in worrying about his dating Emily. The goal would have been to provide a more adaptive new emotional experience for the patient—“I wonder if your parents have a point in worrying.” Herein, in two-person relational psychodynamic psychotherapy, the possibilities in this case are many and may have had a different outcome. Some of the factors that may have infl uenced differently the here-and-now subjective experiences between the adolescent and psychotherapist include the adolescent having diffi culties with social reciprocity, the relationship with Emily being less stable, and the psychotherapist being younger or a different gender, to name a few. As is aptly concluded by BCPSG (2010):

This is an engaged, interactive, dialogic view of understanding. We need the collaboration of the other. We cannot understand him by ourselves; we cannot somehow choose, on our own, to experience exactly what the other experiences. The value of empathy is not at issue. It is just that in a hermeneutic view empathy is not some kind of monadic immersion in the experience of the other. It is a process that requires the involvement of the one who is to be understood.

Fuzzy Intentions and Sloppiness

Sloppiness is a clinical concept coined by the Boston Change Process Study Group. They defi ne it as a spontaneous, improvisational, unexpected interpersonal event that “pops up” in interactions with others and can facilitate moments of meeting and bring about change. This process captures the inherent complex nature of what occurs in the intersubjective fi eld cocreated by two people. The BCPSG ( 2010 ) states, “We think of co-creation as a self-organizing process of two minds acting together that takes advantage of the sloppiness inherent in the interaction to create something psychologically new. What comes into being did not exist before and could not be fully predicated by either partner. Sloppiness is viewed as allowing the emergence of creative elements during the interaction.” Sloppiness involves unpredictability of what will occur during any interaction and permitting oneself to be surprised. For Stern, sloppiness is comprised of three elements: (1) the inexact nature of trying to express one’s intentions to others; (2) an error-fi lled process when trying to infer the intentions of another person thorough their words, behaviors, and context; and (3) reading another person’s intentional state is only an approximation and not an absolute. The BCPSG ( 2010) views sloppiness “not as errors or mishaps in the dialogue, but rather as a generator of potentially creative elements that may alter the direction of the dyad’s evolution in unexpected, even previously unimaginable ways,” an essential aspect of two-person relational psychodynamic psychotherapy. The BCPSG further adds, “Sloppiness is not to be avoided or regretted; rather it is necessary for understanding the almost unlimited co-creativity of the moving-along process” (2010 ). Returning the above example of the adolescent’s dilemma with his parents and girlfriend Emily, the intersubjective experience elicited in the psychotherapist can be considered a moment of 5.8 Real Relationship, Present Moments, Now Moments, and Moments of Meeting 101 unpredictable sloppiness. This is typically one of the reasons why newly minted and experienced clinicians initially fear using a two-person relational model of psychodynamic psychotherapy, as it requires tolerating the unpredictability and uncertainties of the experiences that occur in the intersubjective fi eld between patient and psychotherapist.

Mentalization and Intersubjectivity

Mentalization is a well-known concept that describes the ability to interpret behavior as meaningful and is based on the mental state of both the self and others, taking into account desires, needs, beliefs, reasons, and feelings. The term itself has long-standing roots in the psychoanalytic tradition and, as Target (2008 ) notes, “has been long recognized in philosophy and psychoanalysis.” The term gained popularity when Fonagy, a psychoanalyst and developmental researcher, associated the term in the context of attachment theory. Some have said that mentalization is akin to “holding mind in mind” (Allen et al. 2008). It is accepted that children with a history of being securely attached have good mentalizing abilities, while those who grew insecurely attached have difﬁ culties in mentalizing and make use of maladaptive ego defense mechanisms. Mentalization -based treatment (MBT) is a time-limited treatment that is widely recognized as helpful for adolescents with personality disorders (Bateman and Fonagy 2004; Rossouw and Fonagy 2012). An example of mentalization is captured by a toddler who is playing a board game with her mother and attempts to cheat. Without prompting, the child looks at her mother sheepishly to see if the move was noticed. Her mother returns with a disapproving look—one that the child is able to infer the intent, desire, and feelings and, while laughing, retraces her piece to the original location. The reader at this point may wonder whether there are differences between mentalization and intersubjectivity . We suggest that mentalization-based theories contain aspects of both one-person and two-person psychologies, whereas intersubjectivity is exclusively a two-person psychology concept. We recognize that both concepts are “theories of mind” and both are relational theories. Regarding mentalization, Allen et al. ( 2008 ) note, “The concept of mentalizing ﬁ rst emerged in psychoanalysis : Freud implicitly employed the concept of mentalizing in his initial neurobiological theory of the development of the mind.” They later add, “It is no accident that within psychoanalysis, object relations theory has been especially compatible with focusing on mentalizing in treatment.” They further clarify that mentalizing in clinical practice “might be viewed as equidistant between psychodynamic psychotherapy and cognitive therapy.” Although contemporary controversies are far from over, we believe that the concept of intersubjectivity is more aligned with the practice of two-person relational psychology psychotherapy than mentalization, which is fundamentally a one-person concept. 102 5 Key Concepts in Two-Person Relational Psychology

5.9 Corrective Emotional Experience

Alexander and colleagues (1946 ) coined the term “corrective emotional experience” to describe the explicit use of the relationship between the clinician and patient to bring about therapeutic change. They described the process as:

… to reexpose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic inﬂ uence of previous experiences.

Undoubtedly, the work of Alexander and colleagues set the stage for the integration of the discoveries from developmental psychology research in two-person relational psychoanalysis and psychotherapies. In the half century following their work, a large body of research expanded their fundamental principles, and it became clear that experiencing and processing painful, poorly resolved emotions within a secure, affectively attuned relationship could bring about a “new ending” (Bridges 2006 ). Thus, a new emotional experience is considered the main goal of two-person relational psychodynamic psychotherapy across all ages. Two-person relational psychodynamic psychotherapy by deﬁ nition is the process in which the psychotherapist helps cocreate a new and corrective emotional experience for the patient. Alexander and his successors speak frequently of the need for a present and active psychotherapist and caution against interventions that would repeat the maladaptive patterns of the patient’s parents or early childhood environment. Alexander, for example, carefully distinguishes between a neutral psychoanalyst and one who is objective :

A completely neutral psychoanalyst does not exist in reality, nor would he be desirable. While it is necessary that the therapist maintain an objective, helpful attitude at all times, within this attitude lays the possibility of a great variety of responses to the patient. Spontaneous reactions to the patient’s attitudes are frequently not desirable for the therapy, since they may repeat the parents’ impatience or solicitude which caused the neurosis and cannot, therefore, constitute the corrective experience necessary for cure.

The advances in developmental psychology—including attachment theory and discoveries from neuroscience—have bolstered and refi ned Alexander and French’s original ideas. There is broad agreement among relational psychotherapists that “intellectual insight alone is not suffi cient” for therapeutic change (Alexander and French 1946). Contemporary relational theorists and practitioners now recognize that rather than needing to remember and work through a specifi c confl ict (Bridges 2006 ), the new and corrective emotional experience can occur in the here and now between the psychotherapist’s and patient’s subjective experience at an implicit and preverbal level. Said differently by Fosha ( 2000), “Emotional processing that leads to therapeutic change is frequently associated with positive emotions regarding the self, associated with mastery, such as joy, exuberance, and pride, as well as positive feelings toward others such as gratitude and love.” We note that a new emotional experience does not need to be corrective; rather, it provides a new and more adaptive way of relating to other people that over time takes the place of the maladaptive implicit relational schema. 5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy 103

5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy

We will now proceed to illustrate, in a clinically relevant way, the key concepts reviewed in this chapter by providing composite clinical examples of four children who were raised by parents with different attachment styles and in different environments. Additionally, the examples are used to convey the importance of assessing dyads of patients and their parents or caregivers through the lens of a two-person relational contemporary diagnostic interview (Chap. 8 ). This interview model provides an integrated developmental approach (biopsychosocial) in understanding children and adolescents, and it concisely helps develop realistic and practical treatment recommendations. The basic premise of two-person relational psychodynamic psychotherapy is that a child or adolescent can benefi t from this model of treatment if they have the temperamental and cognitive abilities, albeit in a rudimentary form, to subjectively know how to interact and “be with” others. Two-person relational forms of psychodynamic psychotherapy are appropriate for those with easy/fl exible, slow- to-warm-up, or mixed temperaments; cognition of superior to below-average intelligence; good to fair cognitive fl exibility; and secure, anxious, or dismissive internal working models of attachment as assessed through intersubjectivity by the child and adolescent psychiatrist or clinician. In cases where the child or adolescent does not have these abilities due to intellectual disabilities, as in autistic spectrum disorders, traumatic brain injuries, or disorganized internal working models of attachment, as in the case of Daniella below, formal cognitive testing and specialized behavioral psychotherapeutic interventions are best considered as the fi rst choice.

Andrew: A Securely Attached Child

Andrew’s parents had welcomed the news of their pregnancy with excitement. After his birth, he was raised by his parents with active involvement from extended family members. In Andrew’s environment, the emotional availability and affective attunement from others were plentiful, promoting his active meaning-making processes. As a toddler, his parents continued to experience joy in seeing Andrew make progress developmentally and would implicitly convey, “We are going to have a lot of fun with each other.” The parents made the adjust- ments needed to match his temperamental attributes with sensitivity, using motherese that matched his vocal sounds and body movements: social reciprocity. In using Fig. 5.1, we notice that the contributions by both Andrew and his parents are generally symmetrical, and the intersubjective ﬁ eld is spacious and allows for many now moments, some of which will result in healthy discontinuities that allow for new moments of meeting to move along his development in a psychologically healthy and adaptive manner. 104 5 Key Concepts in Two-Person Relational Psychology

Implications for Two-Person Relational Psychodynamic Psychotherapy

Andrew develops well and does not require psychotherapy (unless, of course, he decides to become a psychoanalyst and is required to undergo personal training analysis by his Two-Person Relational Psychoanalytic Institute. In Chap. 12 we review a case of a school age child whose by all standards development was similar to Andrew’s until the unfortunate diagnosis of his father with terminal cancer— complicated by the fact that hospice care was provided at his home—and who ben- eﬁ ted from a two-person relational psychotherapy process.

Bonnie: A Child with an Ambivalent/Anxious Attachment

Bonnie’s parents received the news of their pregnancy with some excitement, although they promptly became anxious and worried about how this would negatively affect their life. After Bonnie’s birth, her parents continued to experience joy, although soon after, they became ambivalent and anxious about their ability as parents. They implicitly conveyed to Bonnie, “Let us know what you need, because we do not understand your subjective and nonverbal requests.” Their anxiety increased their hesitancy in interacting with Bonnie when she naturally requested their emotional resources through crying, which made it diffi cult for them to adjust to Bonnie’s physical and psychological needs. Fortunately, Bonnie’s parents had easy/fl exible temperaments, and when Bonnie was happy and content, they were able to provide some social reciprocity. Thus, Bonnie’s attempts to develop self- regulatory abilities were often diffi cult during negative affective states, as she needed help in the form of affective attunement and social referencing, which was dependent on her parents’ fl uctuating emotional states. The parents had diffi culty using motherese and being playful with Bonnie through facial gestures, vocal sounds, and body movements. Fortunately, Bonnie had an easy/fl exible temperamental style that implicitly allowed her to reach out to other family members and friends, when present, who were more receptive and playful with her. Bonnie grew with some anxiety and had some self-doubt while at home, although she had good interactions and was happy when other family members, peers, and teachers were around. In using Fig. 5.3 , we notice that the contribution by both Bonnie and her parents is generally symmetrical and the intersubjective fi eld is narrow in comparison to a securely attached child (Fig. 5.1). As such, this narrow intersubjective fi eld contributes many now moments as a result of daily healthy discontinuities, although the narrow fi eld does not allow for the forming of many moments of meeting to move along Bonnie’s development in an adaptive manner. In Fig. 5.4 we note that Bonnie is able to expand her intersubjective fi eld with other people who have more adaptive modes of interaction, which provides opportunities for moments of meeting in the form of a new emotional experience (e.g., a two-person relational psychotherapist). 5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy 105

IF Child Parent • Meaning making (++) • Affective attunement (+) • Mirror/Echo neurons/ Internal working • Emotional availability (+) default mode network models of • Social referencing (+) • Social referencing (++) attachment • Temperament • Temperament • Cognition • Cognition • Cognitive flexibility • Cognitive flexibility

Inconsistent Ruptures Now moments Anxious implicit relational knowing

Incomplete Some moments repairs of meeting

Fig. 5.3 Schematic representation of intersubjective experience between child and parent in the context of an insecure attachment. An ambivalent/anxious attachment forms through the intersubjective ﬁ eld (IF) primarily by inconsistent emotional availability leading to superﬁ ciality in implicit relational knowing. The number of (+) denotes degree of strength in this dyad

Implications for Two-Person Relational Psychodynamic Psychotherapy

Bonnie can benefi t from two-person relational psychodynamic psychotherapy, as she has some innate abilities for curiosity, exploration, fl exibility, novelty seeking, and creativity in spite of her parents’ anxiety. The two-person relational psychotherapist can help her improve her intersubjective fi eld and affective attunement by demonstrating in the here-and-now implicit nondeclarative experiences’ vitality and curiosity about Bonnie’s many states of mind. They can cocreate moments of meeting—intersubjectivity—in which she can implicitly learn how to regulate her anxiety in more adaptive manners through a new emotional experience and develop new forms of implicit relational knowing.

Carlos: A Child with an Avoidant/Dismissive Attachment

Carlos was a child raised by his single mother who lived with her family. She received the news of her pregnancy with some excitement in having a child, as well as anger at Carlos’ father for his refusal to be involved during the pregnancy and in 106 5 Key Concepts in Two-Person Relational Psychology

New Emotional Experiences

Child/Adolescent Psychotherapist • Meaning making (++) • Affective attunement (+++) • Mirror/echo neurons/ Internal working • Emotional availability (+++) default mode network models • Social referencing (+++) • Social referencing (+++) of attachment • Temperament (easy/flexible) • Temperament • Cognition • Cognition • Cognitive flexibility (+++) • Cognitive flexibility

Co-create now moments Ruptures (Non-declarative) Implicit relational knowing New more adaptive emotional experiences Co-created moments Repairs of meeting

Fig. 5.4 Schematic representation of two-person relational psychotherapy representing psychotherapist and patient. New more adaptive emotional experiences occur in the intersubjective fi eld (IF), the overlap of subjective experiences. The number of (+) denotes degree of strength in this dyad. Bold arrows in the IF represent here-and-now moments of meeting any of Carlos’ care after birth. After Carlos’ birth, his mother experienced some joy and implicitly hoped that Carlos would know what she, as a mother, needed: “Show me that you need me and love me.” Carlos’ mother and grandparents had a limited capacity for affective attunement and social reciprocity and ignored his overt request for interaction when crying. Carlos’ mother had a slow-to-warm-up temperamental style, which made it diffi cult for her to implicitly recognize her son’s need for her emotional availability. The family’s lack of cohesion made it diffi cult for Carlos to know who would attend to his physical and psychological needs, as their availability was inconsistent and unpredictable. Carlos’ attempts to develop self-regulatory abilities were irregular, as affective attunement was inconsistent and unpredictable. His mother and family had diffi culties in using motherese , and they generally com- municated with him as if he were an older, self-reliant child. Carlos’ attempts to make meaning of his interactions with caregivers proved to be diffi cult; some would infantilize him, and others would try to “man him up.” Carlos was overtly an unhappy child and avoided closeness with others. As an adolescent, he related better with peers who were also lonely and at times used illegal substances. In using Fig. 5.5, we note that the contributions by both Carlos and his mother and family are not symmetrical and the intersubjective fi eld is restricted and narrow 5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy 107

IF Child Parent • Meaning making (+/–) • Affective attunement (+/–) • Mirror/echo neurons/ Internal working • Emotional availability (+/–) default mode network models of • Social referencing (+/–) • Social referencing (+/–) attachment • Temperament • Temperament • Cognition • Cognition • Cognitive flexibility • Cognitive flexibility

Few now moments Many Ruptures

Dismissive relational knowing Limited mentalization

Few repairs Few moments of meeting

Fig. 5.5 Schematic representation of intersubjective experience between child and parent in the context of an insecure attachment. An avoidant/dismissive attachment dyad is depicted below. A (+) denotes strengths and (−) denotes weakness in this dyad. IF (intersubjective fi eld) is the area in which both overlap in comparison to a securely attached child (Fig. 5.1 ). As such, this narrow intersubjective fi eld allows for more than the usual now moments and discontinuities, which contribute to his developing an avoidant/dismissive form of attachment and implicit relational knowing. In Fig. 5.4 we note that Carlos has expanded the intersubjective fi eld with other people who have a more adaptive mode of interaction, with the opportunity for moments of meeting in the form of a new and corrective emotional experience (e.g., a two-person relational psychotherapist).

Implications for Two-Person Relational Psychodynamic Psychotherapy

Although Carlos has relational difﬁ culties that are similar to Bonnie’s, the psychotherapist will need to make a more concerted effort through a two-person relational approach in psychodynamic psychotherapy to help engage with him, gently pointing out when he avoids, which can be expected due to his avoidant/dismissive form of implicit relational knowing. The two-person relational psychotherapist will also have to actively and implicitly demonstrate to Carlos how to become curious about 108 5 Key Concepts in Two-Person Relational Psychology other people’s mental states and promote in the here-and-now healthy exploration and creativity in spite of his family’s likely critical comments of this.

Daniella: A Child Who Grows in a Disorganized Environment

Daniella was a toddler raised by a single mother. Daniella’s mother received the news of her pregnancy with anger; Daniella’s father was abusive and had abandoned Daniella’s mother who had been raised by a series of family members and foster homes after her own parents abandoned her. When Daniella was born, her mother treated her more like a sibling with limited understanding of the clear developmental mismatch. Despite having a large number of close relatives who participated in caregiving, the environment was harsh and provided inconsistent emotional availability with poor affective attunement. Although Daniella normally craved for interaction with others, she frequently resorted to screeching and aggressive behavior to gain the attention of her caretakers. Over time, she learned that crying and screeching in fact did elicit attention from adults, albeit in negative form. As such, this became her implicit relational knowing; the affect and language used by the relationships in her environment to communicate were disorganized. Rather than expect nurturing, Daniella learned to walk early, searching for food and learning to care for herself, a type of survival mode. Many members of the family, including Daniella’s mother, had diffi cult/feisty temperaments, which limited their ability to provide her with self-regulatory skills. When Daniella presented for her fi rst consultation appointment, she was 5 years old. Her mother’s disgust was apparent. When the clinician asked about her main concerns, she said, “Well, I wanna know, is she mental or something or just a spoiled brat’, cause that’s what I think. Someone said she has that opposition thing. She is so clingy and selfi sh. She’s not talking to me right now. I am tired; I’m a single parent workin’ 40 h. I’m sick and tired of her.” This vignette captures a generational pattern of disorganized attachment styles. In the absence of severe cognitive defi cits, Daniella demonstrates an implicit knowledge of her family’s lack of cohesion and disorganized interactions. She could not reliably predict who would attend to her physical and psychological needs. The hostile environment did not provide the self-regulatory abilities needed. Rather, it promoted Daniella to learn that self-reliance is essential to survive in her inconsistent and harsh environment. Daniella will likely end up similar to others in her family, characterized by poor affective dysregulation and frequent displays of anger and relational diffi culties.

Implications for Two-Person Relational Psychodynamic Psychotherapy

When a child is forced to grow with the real and constant fear of being abandoned by their caregiver, as in those with a history of disorganized attachment patterns, the abandonment by the parents is experienced by the child as real possibility. These same children who have adopted a disorganized internal model of attachment will 5.10 Key Concepts: Implications for Two-Person Relational Psychotherapy 109

Child Parent • Meaning making-unpredictable IF • Affective attunement-poor • Mirror/echo neurons/ • Emotional availability-minimal default mode network Internal working models • Social referencing-disorganized • Social referencing of attachment • Temperament (feisty) • Temperament • Cognition (+/–) • Cognition (+/–) • Cognitive flexibility (–) • Cognitive flexibility (–)

Unpredictable now moments Many Ruptures

Disorganized relational knowing Poor mentalization Scarce repairs Scarce moments of meeting

Fig. 5.6 Schematic representation of intersubjective experience between child and parent in the context of an insecure attachment. In a disorganized attachment, there is essentially a nonexistent intersubjective fi eld (IF) and limited emotional availability. The number of (+) and (−) denotes degree of strength in this dyad. Behavioral, family, and pharmacological interventions are recommended interventions implicitly repeat these patterns of distancing and abandonment onto their own children. Thus, the child with insecure forms of attachment develops chronic meaning pathways with ever-present anxiety, fear, and threat of abandonment, with little modeling in experiencing closeness with others. Viewed through the lens of a generational perspective, it is likely that children with insecure attachments have not had the benefi t of having their parents play games with them, sing songs to them, or read a story to them in a soothing way. Sadly, they may have had a story read to them in a threatening way, in which the adult may have felt that frightening their child was humorous. If a child grows up in an insecure environment, their maladaptive behaviors (impulsivity, uncontrollable anger, labile mood, unstable relationships) become part of their implicit relational knowing, which is repeated nonconsciously. They seek accomplices of that which is familiar, similar maladaptive behaviors. It is well documented that what becomes familiar exposes them to relational trauma and at times sexual and physical trauma. It is not uncommon for children who are yelled at by their parents to make yelling the internal working model they use when relating to others (e.g., nonconsciously seeking accomplices to yell at and to be yelled at by). Herein, in Fig. 5.6 we note that Daniella’s intersubjective fi eld is essentially nonexistent. As such, she would benefi t from early childhood behavioral interventions, case management with in-home services, and formal cognitive testing, rather than a two-person relational psychotherapy process. 110 5 Key Concepts in Two-Person Relational Psychology

5.11 Summary

In this chapter we provide the reader the necessary information to understand the origin and meaning of key concepts in two-person relational psychology. The key concepts reviewed in this chapter have become the new lexicon that allows for the understanding of the variability of how a person relates to another person, and how they may relate in a completely different manner with others, based on relational schemas that are nonconsciously evoked by each person differently. The changes undertaken by the brain from infancy to adulthood are mediated by the processes of emotional availability, attachment, affect regulation, and cognition, and they all play a central role in two-person relational psychotherapy.

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There is no creation without tradition; the “new” is an inﬂ ection on a preceding form; novelty is always a variation on the past. ― Carlos Fuentes

In the last two chapters, we laid the groundwork to distinguish between traditional one-person and two-person relational psychologies. The astute reader will recognize that the terms that are used within each theoretical model may, in fact, ultimately complicate one’s ability to distinguish between the two psychologies. As Bornstein (2001 ) states, “Many psychoanalytic terms and concepts became so widely known that they evolved into colloquialisms, recognized even by persons with little or no formal exposure to psychology.” In fact, some of the two-person relational literature often retains the language of the traditional one-person model. Nonetheless, it is critical to clarify the differences in the meaning of the terms used in one-person psychology, which continue to prevail in the psychotherapeutic lexicon, as ultimately these terms evolved to represent two-person relational model constructs. In this regard, there are numerous everyday examples involving clinicians using traditional one- person psychology concepts to understand another person’s behaviors, as if the clinician clairvoyantly knew the nature of the patient’s unconscious. For example, a clinician may describe an adolescent girl who dates older men as having “father/ daddy issues,” or a male adolescent who struggles with intense closeness and “needi- ness” in his relationships as having “mother/mommy issues.” These comments fore- stall a true understanding of the patient for several reasons. First, the clinician—in using these terms—assumes that the patient has unconscious intrapsychic confl icts (e.g., maladaptive behaviors represent ego defense mechanisms against the pressures from intrapsychic confl ict). Second, the clinician fails to take into account the many aspects of the adolescent’s innate temperament , cognition, and internal working models of attachment that infl uenced his or her relational patterns. Third, in the case of the

© Springer-Verlag Berlin Heidelberg 2015 115 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_6 116 6 Deconstruction of Traditional One-Person Psychology Concepts adolescent girl who dates older men, it is important to consider that in early childhood, she may have had the emotional availability and affective attunement needed provided by warm and caring men in her family (e.g., father, brothers, uncles, cousins, neighbors) and limited affective attunement from the women in her family. As such, her development occurred in an environment where older men may have represented, in a nonconscious way, implicit relational knowings, as safe and caring and likely adaptive. Herein, her wish for closeness to older men to provide the needed affective attunement may have been adaptive in spite of the age difference, as true compatibil- ity is not a simple issue of biology or social construct. Fourth, this also forestalls the fact that for another adolescent, an older man may represent maladaptive childhood experiences of demanding and abusive men that provided some support to her, seen in disorganized forms of attachment. Thus, in the case of the adolescent with a disorganized attachment style, her choice of older men refl ects a return to maladaptive implicit relational knowings during adolescence. For the adolescent boy, his clingi- ness to women may also represent cocreated experiences of safety when close to women and fearful being close to men as a child, stored in implicit nondeclarative memory. Further, both adolescents may have temperament or cognitive weakness that predisposed them to engage in maladaptive behaviors, and, as such, these behaviors may not be attributable to their parents or to their environment per se. Thus, a two- person relational model allows for teasing apart the complexities of nature and nurture through here-and-now experiences between patient and clinician. Additionally, we have observed the use of traditional one-person psychology terms (e.g., unconscious, transference) during discussions of two-person relational approaches, which increases confusion among students, clinicians, and supervisors. This tendency is described by Fossage (2003 ), a relational theorist: “Each of us gravitates toward and develops a theory and practice that resonates deeply with our subjective experience. For this reason, it is diffi cult for all of us to really know, to have a ‘feel’ for psychoanalytic approaches other than the one we practice.” Thus, the ability to meaningfully discuss two-person relational approaches and apply its key concepts in a clinically meaningful way requires extensive reading, living, and breathing of this approach. In order to clarify why we, as authors and two-person relational clinicians, view the traditional one-person psychology terms as limiting, this chapter is written to juxtapose case-based conversations of traditional one- person and two-person relational psychotherapists that will highlight differences in context and terminology. As such, we provide a list of the common concepts in traditional one-person psychoanalytic theory and compare these terms with those from a two-person relational psychology model. We will also explore conceptual differences from the two psychologies in each of the clinical cases discussed in subsequent chapters. At the most basic level, a traditional one-person psychology tenet is to help the patient understand, within the therapeutic encounter, his or her past intrapsychic confl icts and object relations (inner life) through his or her transference manifestations to the objective psychotherapist or by the autobiographic memories shared. Foangy and Target (2000 ) remind us that theories are shaped by what the clinician fi nds helpful and are intrinsically contaminated by technique and consequently run the risk of assuming that what is remembered by the patient is true and accurate. By 6.1 Two-Person Relational Psychodynamic Psychotherapy: A Historical Context 117 contrast, two-person relational psychology focuses on both players (i.e., the psychotherapist and patient), although not symmetrically. That is, the psychotherapist, through bidirectional here-and-now experiences with the patient, will cocreate and model new and more adaptive patterns of interaction with others in the form of a new emotional experience (Hoffman 2009 , see Chap. 5). A two-person relational psychotherapist is not neutral; rather, he or she makes implicit (nonconscious) or explicit self-disclosures and welcomes planned and well-thought-out enactments when believed to help the psychotherapeutic process of his or her patients (Delgado and Strawn 2014 ). Another contrast is that a traditional one-person model implies a confl icted unconscious, whereas two-person relational psychology implies that there is a dynamic, nonconfl icted unconscious stored in nondeclarative memory systems. This nonconfl icted unconscious provides the internal working models of “how to” implicitly engage in interactions with other people, known as “implicit relational knowing ” (Chaps. 3 and 5 ). The reader may then wonder: Are the concepts of the unconscious, transference, and countertransference helpful? Does the two-person relational model of psychotherapy “throw the baby (i.e., traditional psychoanalytic concepts) out with the bathwater (i.e., traditional psychoanalytic technique)”? In order to answer these commonly posed questions, we provide a guide for the reader to navigate through the two models of psychotherapy and the semantic differences. As Aron (1990 ) states, “My aim is to extract fundamental clinical concepts from the quasi- biological drive theory that has dominated both our metapsychology and our clinical theory and to reexamine the value of these clinical concepts within a relational, contextual, and intersubjective framework.”

6.1 Two-Person Relational Psychodynamic Psychotherapy: A Historical Context

For more than a century, traditional one-person psychoanalytic theories dominated the psychotherapeutic landscape and were used to develop constructs about the frailties of the human mind, with the notion that unconscious instinctual drives exerted a role in shaping the introjected representations of the parents—as “objects”—that served as a relational template for an individual when interacting with others. A failure to master the instinctual drives would lead to psychological symptoms, thought to refl ect the battle between the urges for gratifi cation of infantile drives and wishes, and the pressures for the repression of these wishes to remain composed. In this model, common treatment interventions were akin to archaeological explorations: efforts to uncover deeply buried intrapsychic phenomena (e.g., unconscious developmental intrapsychic confl icts and object representations). The treatment was directed at mastering the pressures from the instinctual drives and confl icted object relations through the use of healthy ego defense mechanisms. The psychoanalytic concepts that evolved were used broadly to create diagnostic formulations about conditions such as anxiety neurosis (harsh superego formations), obsessive–compulsive symptoms (anal level confl icts), and depression (internalization of the lost loved object). These psychoanalytic concepts were also applied to 118 6 Deconstruction of Traditional One-Person Psychology Concepts the understanding of conditions and problems of children and adolescents, such as enuresis, night terrors, toilet-training diffi culties, and oppositional and aggressive behaviors, all of which were believed to result from the compromise of unconsciously repressed intrapsychic confl icts, poorly integrated parental objects by the child, or poor ego functions. Over the last 40 years, the emergence of a two-person relational psychology shifted the understanding of psychological and relational problems. In this regard, the two-person relational model proposes that a child’s problems result from diffi - culties of the interplay of multiple complex processes, including temperament, affective attunement, cognition, cognitive fl exibility, internal working models of attachment, and intersubjectivity —the complex interactions of the relational self, infl uenced by other people. This shift fostered the development of treatment interventions that differed from traditional archaeological inquiries—which focused on the discovery of a confl icted and buried past—and instead focused on open, bidirectional, here-and-now subjectivities (i.e., the experience of each other’s mental states, in the context of treatment, that are continually modifi ed by both the patient and the psychotherapist). Herein, we provide the background of what have been historically viewed as confl icting approaches and theoretical orientations, and we attempt to clarify the reason for the seeming persistence of the confl ict that exists between the traditional drive-based, confl ict-based, object relations , one-person psychology theories and the contemporary relational , intersubjective, co-constructive, two-person relational psychology theories. Although both theories provide—implicitly or explicitly—a foundation for shared concepts for communication among psychodynamically oriented psychotherapists within their respective theoretical paradigms, their differences render them discordant with one another (Delgado and Strawn 2014). In this regard, while many psychotherapists are more familiar with the traditional one- person theory and terminology that they learned during their child and adolescent psychiatric training, and that is routinely used in understanding patients and families, they recently developed interventions are more aligned with and guided by contemporary two-person relational approaches and family systems. These contemporary theories give importance to both patient and psychotherapist, as well as to “the contextual model of psychotherapy focusing on common factors instead of treatment techniques, and actual trends in psychodynamic therapy, which accentu- ate critical moments of interpersonal experiences transforming the procedural knowledge of patients on attachment patterns” (Schiepek et al. 2013 ).

6.2 Clinically Relevant Concepts from Traditional One- Person Psychology: A Two-Person Relational Perspective

While it would be beyond the scope of this book to comprehensively deﬁ ne all of the terms relevant in working with children and adolescents from a traditional one- person model, we have chosen to focus on the concepts that are most relevant and 6.3 Traditional Unconscious in Traditional One-Person Psychology and Two-Person 119

Table 6.1 Two-person relational psychotherapy Relational Traditional Implicit and nonconscious Unconscious We-go Ego Intersubjectivity and cocreation Neutrality Implicit relational knowing Transference Emotional availability and social referencing Countertransference Regulatory schemas and Intersubjectivity Object relations Enactments and self-disclosures Boundaries New and corrective emotional experiences Insight The two-person relational psychotherapist gives importance to the context of the patient’s reality, as it allows to know the type of corrective emotional experiences needed by the patient, that will be stored in implicit nondeclarative memory and nonconscious, utilized in the future with more adaptive relational knowing frequently used in the clinical work of a psychodynamic psychotherapist. Moreover, the terms used in traditional one-person psychologies have been ingrained in our implicit nondeclarative memory and are ubiquitous in the psychotherapeutic ver- nacular. Thus, as we discuss two-person relational concepts herein, we do not intend to portray Freud and the traditional one-person model as the straw man to be deval- ued; rather, we hope to provide a broad perspective with regard to these competing concepts from both approaches and provide the information needed, in a succinct manner, for the reader to arrive at his or her own conclusion. Accordingly, we—as relationalists—seek to provide the reader a chapter that allows him or her to understand the differences in common terminology of psychodynamic practice and to have the tools to discuss these terms and concepts, given that he or she will invariably need to contend with skeptics and critics (Table 6.1 ).

6.3 Traditional Unconscious in Traditional One-Person Psychology and Two-Person Relational Psychology

Unconscious in Traditional One-Person Psychology

Freud believed that the unconscious was a hypothetical region of the mind. Further, he posited that the pressure from the instinctual drives resided in the unconscious, as they were repressed and only evident when the drives became conscious if acceptable to the superego or in the form of neurotic symptoms or maladaptive ego defense mechanisms. In traditional psychoanalytic theory, these drives reﬂ ect a conﬂ icted unconscious, which is hidden behind defenses derived from the ego and superego. In traditional psychoanalytic treatment, the primary goal is to make the “unconscious” conscious, a process best captured by Freud’s now famous maxim of psychoanalytic work: “Where id is, there shall ego be” (Freud 1916 –1917). In making the “unconscious” conscious, Freud suggested that insight is achieved and, thus, 120 6 Deconstruction of Traditional One-Person Psychology Concepts maladaptive defenses are relinquished in favor of more adaptive defenses (Delgado et al. 2011 ), and clinical improvement ensues. Accordingly, traditional psychoanalytic treatment focuses on the replacement of maladaptive ego defenses with mature ego defenses.

Unconscious in Two-Person Relational Psychology

In two-person relational psychology, the unconscious phenomena are dynamic and nonconﬂ icted and are commonly referred to as the nonconscious . Additionally, the nonconscious processes consist of (1) meaning-making processes and (2) internal regulatory and interpersonal schemas within nondeclarative memory systems in the form of implicit relational memory:

An everyday example of the relational nonconscious A young physician was walking from his ofﬁ ce to his car when he received a call on his smartphone from his 4-year-old daughter, who had just returned home from the zoo. The father implicitly knew which tone of voice to use when talking to his daughter, who was sharing her excitement about the trip to the zoo she had taken with her mother. As his daughter exclaimed, “Daddy, I saw two big elephants and one baby elephant!” the father, without explicitly thinking about the tone of voice, cadence, etc., responded to his daughter in a manner that allowed her to know that he shared her excitement and was curious about her trip—affective attunement. As the father was about to enter the stairwell of the parking garage, he encountered a colleague who asked him about the location of tomorrow’s staff meeting. The father covered the smartphone with his hand and, as he answered his colleague’s question, changed his tone of voice accordingly. This shift in tone of voice, between both conversations, was unrelated to the traditional ways of thinking about the unconscious (e.g., id, ego, or superego conﬂ ict models); rather, this shift in tone of voice was a result of information stored in nondeclarative memory systems that was nonconsciously accessed when needed to move along the interactions in present moments (see Chap. 5 ).

From a two-person relational perspective, the physician’s tone of voice implicitly communicates to his daughter and to his colleague that he is affectively and intersubjectively attuned to them at a nonconscious level. In a traditional one- person model, the decision to shift speech pattern, tone of voice, and affect refl ects a function of the ego, either as a compromise of instinctual drives or as a shift in internal object representations that are infl uenced by the superego. The view of a nonconfl icted, relational nonconscious thus creates contentious discussion in that slips of the tongue (i.e., Freudian slips), dreams, and oedipal confl icts have limited relevance in understanding the human mind by two-person relational psychology. 6.4 Psychic Determinism in Traditional One-Person Psychology and Two-Person 121

6.4 Psychic Determinism in Traditional One-Person Psychology and Two-Person Relational Psychology

Psychic Determinism in Traditional One-Person Psychology

The unconscious and psychic determinism are concepts at the heart of Freud’s psychoanalytic theories. They are the precursors to Freud’s universal Oedipus complex. Brenner (1974 ) describes psychic determinism as a concept that Freud adhered to and assumes that nothing in everyday life happens by chance or in a random manner, “Each psychic event is determined by the ones which preceded it. Events in our mental lives that may seem to be random and unrelated to what went on before are only apparently so. In fact, mental phenomena are no more capable of such a lack of casual connection with what preceded them than our physical ones. Discontinuity in this sense does not exist in mental life.” Freud’s concept of psychic determinism in its narrow view placed in doubt matters of free will. As such, Freud believed that if the analyst had unlimited access to an individual’s unconscious (e.g., free associations, parapraxes, and dreams), it would conﬁ rm that all psychic phenomena had meaning and did not occur by accident.

Psychic determinism in a 15-year-old adolescent John, a 15-year-old adolescent, appeared anxious in his weekly psychotherapy appointment and shared with his psychotherapist that he forgot to place a lock on his bike, which was in the front of the psychotherapist’s ofﬁ ce. From a psychic determinism standpoint, the psychotherapist might ask for associations of why this may have happened, believing that this “forgetting” represented unconscious conﬂ ict due to the fact that it happened within the context of his psychotherapy appointment and may have been evidence of possible transference manifestations. With the patient’s associations, the psychotherapist can then decipher the “meaning” of such act and may choose to explore further or interpret it.

Thus, it seems that the concept of psychic determinism attributes individuals to not being free to make decisions based on contextual circumstances and needs.

Psychic Determinism in Two-Person Relational Psychology

Psychic determinism and free associations, by virtue of the assumption that all psychic phenomena have unconscious meaning, cannot exist in true two-person relational psychology. Hoffman ( 2006) states, “Free association is still one of the sacred cows of the psychoanalytic tradition; it is a term one tampers with at peril of his or her psychoanalytic identity. Can you claim to be a psychoanalyst if you do not ‘believe in’ free association?” The two-person relation model of psychodynamic psychotherapy 122 6 Deconstruction of Traditional One-Person Psychology Concepts relies on here-and-now subjective experiences between patient and psychotherapist that are shaped and unique to the dyad. It is through moments of meeting cocreated by the dyad that change occurs, at the implicit level. Holland and Kensinger ( 2010 ) conclude that when memories are reconstructed at the time of retrieval, they are prone to memory biases and inconsistencies. The affective characteristics of the event can infl uence how a memory is encoded, stored, and retrieved. They add that emotional memories are never perfect representations of the past and are recalled through a distorted lens. They eloquently state how positive here-and-now experiences can help patients, “remembering our past experiences and behaviors as more positive than they actually were may allow us to maintain a coherent, positive sense of self and to forge positive social relationships. Similarly, the fl exibility in the construction of events at retrieval may enable us to direct our future behavior and to regulate our emotions.” In returning to the example of the adolescent who forgot to lock his bike, a psychotherapist utilizing a two-person relational model would see a variety of possibilities as to why this occurred. First, the adolescent may have simply forgotten to lock the bicycle due to other thoughts having taken priority. In this regard, he may have been preoccupied with other thoughts, such as thinking about being on time for his appointment, refl ecting on his girlfriend’s basketball game, planning his homework strategy for his evening assignments after the appointment, etc. In other words, the reasons that underlie his “forgetting” are many and may have not been related to the psychotherapist. Second, the adolescent having shared that he forgot to lock his bike may be a result of his feeling safe, in the intersubjective sense, with his psychotherapist, with whom he is able to share his dilemma, hoping that the psychotherapist recognizes his wanting to go out lock his bike and keep it safe. In two-person relational psychology, one cannot infer that the adolescent “forgetting” to lock his bike represents a repressed unconscious mental process, derived from a confl ict that can only be discovered through an archaeological excavation in which the psychotherapist seeks to uncover a hidden truth. Instead, the two-person relational psychotherapist will attend to the patient’s tone of voice and affect and, in parallel, will attune to his or her own experience as it is cocreated in intersubjectivity. These elements will direct the psychotherapist to determine the type of new emotional experience that would be most helpful for the adolescent. To return to our example, one might imagine a scenario in which the adolescent patient wanted to go and lock the bike in order not to risk losing it, although he waited for his appointment to start in order to not offend his psychotherapist. In this scenario, in a nonconscious manner, the adolescent relates in what is familiar to him—internal working models through implicit relational knowing—given that, for him, respecting adults is more important than asserting himself. The psychotherapist notices intersubjectively that he feels like telling the adolescent: “You don’t need to be so polite. Go ahead and lock it; I can wait a few minutes.” With this experience, he is reminded about the adolescent’s pattern of not asserting himself in most situations. This allows the psychotherapist to feel that one possible intervention, which could serve as a new and corrective emotional experience and cocreate more adaptive neuronal pathways, was, to say, “I know how much you value your bike and I am glad that you told me about not locking it. How about I wait here while you go lock it?” In a different scenario, the psychotherapist intersubjectively notes that the adolescent is anxious 6.5 Drive Theory in Traditional One-Person Psychology and Two-Person Relational 123 knowing that his bike is not locked, and his anxiety prevents him from feeling comfortable in the appointment, a similar pattern his parents had noted—their son struggled and was easily overwhelmed with anxiety when problem solving. In knowing this, the psychotherapist may say: “You know, at your age, my bike was very important to me. I see that your bike is very important to you, and I think we should not have to worry about this. Let’s go and make sure it is locked.” We are aware that the reader may think of many other possible scenarios that incorporate a two-person relational model of intervention. In summary, the devil is in the intersubjectivity.

6.5 Drive Theory in Traditional One-Person Psychology and Two-Person Relational Psychology

Drives in Traditional One-Person Psychology

Freud postulated that instincts or drives innately formed to eliminate any state of tension from the body. Accordingly, Freud believed that bodily tensions were aggressive and sexual in nature and were developmentally determined by the organ of predominant interest to the infant for pleasure. For Freud, the origin of the drive was a biological stimulus, although the drive itself was a psychic representation. In this model, he proposed that, “from a biological point of view, an ‘instinct’ appears to us as a concept on the frontier between the mental and the somatic, as the psychic representation of the stimuli originating for within the organism and reaching the mind” ( Freud 1915 ). Freud stated about the infant: “From the very start, the infant exploration of the external world is invested with libido. The drive towards taking things into his mind, towards looking, touching, listening and exploring, satisﬁ es some of the wishes frustrated by the original objects.” Accordingly, intrapsychic conﬂ icts are considered a normal occurrence in the development of a child, which is why Smirnoff (1971 ) and others consider child psychoanalysis as essential for symptomatic children to reduce their anxiety through the dissolution the maladaptive ego defenses, which ultimately permits an outlet for the instinctual drives.

Drives in Two-Person Relational Psychology

Two-person relational psychology does not adhere to Freud’s drive theory. Rather, two-person relational psychology proposes an innate relational matrix, the forerun- ner for which was theorized by Bowlby. In this regard, Bowlby distanced himself from the classical drive theory, as he believed that infants had innate prosocial “wishes” to be with and to get along with others. This has been supported by a wealth of infant developmental research (Emde and Hewitt 2001 ; Tronick and Beeghly 2011), with strong evidence of complex prosocial processes occurring throughout the life span: meaning making , social referencing , affective attunement , internal working model schemas, mentalization, dynamic nonconscious, and implicit relational knowing. We remind the reader of Tronick’s remarkable still-face experiments in 1975 (Weinberg et al. 2008 , Chap. 5 ) that capture the many efforts 124 6 Deconstruction of Traditional One-Person Psychology Concepts an infant can resort to in reengaging with their caregiver. Additionally, a brief clip of Tronick’s still-face experiment is available at www.YouTube.com .

6.6 Id in Traditional One-Person Psychology and Two- Person Relational Psychology

Id in Traditional One-Person Psychology

Laplanche and Pontalis (1974 ) in the classic text The Language of Psycho - Analysis , a dictionary of psychoanalytic concepts, defi ne the id as “the prime reservoir of psychical energy, [which] from the dynamic point of view, confl icts with the ego and the super-ego—which, generally speaking, are diversifi cations of the id.” Thus, in the simplest terms, the id is the agent of the bodily instinctual needs, desires, and impulses, particularly of sexual and aggressive nature without respect to reality or moral issues. The id embodies the instinctual sexual and aggressive drives and seeks for immediate gratifi cation (Freud 1920 ).

Id in Two-Person Relational Psychology

Two-person relational psychology does not adopt Freud’s structural theory and therefore does not consider the id as a necessary concept, which presupposes the need for an ego and superego. Instead, two-person relational psychology proposes an innate strong process in which infants seek to engage with other humans for comfort and survival and not for gratiﬁ cation of sexual or aggressive needs and desires. That is, the attachment system is a “hardwired” motivational system in the brain. The experience the infant has with his or her caregivers activates and encodes meaning-making processes that will directly shape the organization of the motivational system in nondeclarative memory (Siegel 2001). As such, the concept of the id is limiting, as it does not account for the active bidirectional mode of interaction that shapes neuronal pathways, as occurs in two-person relational psychotherapy. Additionally, genetically encoded information and neuronal activation can lead to the activation of genes that shape the structure of the brain (Kandel 1999 ).

6.7 Ego in Traditional One-Person Psychology and Two- Person Relational Psychology

Ego in Traditional One-Person Psychology

The ego , which has historically been viewed as the intrapsychic agency that negotiates between the superego, the drives, and the id, is noted by Laplanche and Pontalis (1974 ) to be “above all the expression of the defensive pole of the personality in neurotic confl ict; it brings a set of defensive mechanisms into play which are motivated by the perception of an unpleasurable affect (signal of anxiety).” Further, “the ego is an agency of adaptation which differentiates itself from the id on contact with 6.8 Superego in Traditional One-Person Psychology and Two-Person 125 external reality. It is also described as the product of identifi cations in the formation of a cathected love-object by the id.” In short, the ego is the mediator of confl icts between the id and the superego. In traditional one-person psychology, the psychotherapist helps the patient work through the pressures from the id: “Where id is, there shall ego be” (Freud 1916 –1917). Anna Freud focused on the ego’s unconscious defensive mechanisms that originated during the child’s stages of psychosexual development. She systematically classifi ed these ego defenses, compiling a comprehensive catalog in her classic work The Ego and the Mechanisms of Defense (Freud 1937/1966 ), which later led to the school of ego psychology.

Ego in Two-Person Relational Psychology

As two-person relational psychology does not support Freud’s structural theory, the ego, which presupposes the need for an id and superego, is not a useful construct. Interestingly though, with regard to “ego functions,” the psychoanalyst Heinz Hartman, who is often described as one of Freud’s favorite students, held that the ego had a biological substrate that includes perception, memory, concentration, motor coordination, and learning. He believed these innate ego capacities had autonomy from the sexual and aggressive drives of the id and were not products of frustration or confl ict. Hartman coined the term “autonomous ego functions” (Hartman 1958 ), and his ideas share much with recent concepts concerning implicit memory systems and internal working relational schemas stored in nondeclarative memory systems (Mancia 2006 , also see Chaps. 5 and 7 ). Further, two-person relational theory relies on the “we-go,” an intersubjective, mutually adaptive process—as opposed to structure (i.e., the ego)—that exists at a prerefl ective level and encompasses both “we” and “me” (Emde 2009 ; Iacoboni 2008 , 2009 ; Iacoboni and Dapretto 2006 ). Freud’s ego as a concept fails to account for the intersubjectivities of the person and those of the person they are interacting with; these intersubjectivities ultimately subserve self-regulatory functions. The psychoanalyst and developmental researcher Emde (2009 ) captured this failure of the established Freudian school as follows: “We came to the realization that these children had developed an executive sense of ‘we’ of the signifi cant other being with them, giving them an increased sense of power and control,” adding, “The self is a social self.” Moreover, over the course of development, there are substantial gains in the neurostructural foundations of social reciprocity and the development of “we- ness.” It is through we-ness of the nondeclarative memory systems that internal working models of attachment with self-regulatory functions are formed.

6.8 Superego in Traditional One-Person Psychology and Two-Person Relational Psychology

Superego in Traditional One-Person Psychology

The superego , an intrapsychic agency that limits the drives of the id, has been referred to as “the heir of the Oedipus complex in that it is constituted through the 126 6 Deconstruction of Traditional One-Person Psychology Concepts internalisation of parental prohibitions and demands” (Laplanche and Pontalis 1974 ). Further, the superego seeks to obey cultural and societal norms that have been incorporated into the person’s psyche. Returning to our example of the adolescent who had forgotten to lock his bike, a psychotherapist who utilizes the traditional one-person model notes that the adolescent experiences harsh superego pressures, feeling he has done something wrong and believes that his psychotherapist will confi rm this. In turn, the psychotherapist would consider the adolescent having forgotten to lock his bike as a transference manifestation with regard to the patient’s relationship with his parents. From a Kleinian standpoint, superego formation occurs before the age of 2 and is a requisite component of the infant’s foray into the depressive position, wherein “the child proceeds to develop a capacity of concern for others and guilt about one’s actions and thoughts about others, with desire for reparation” (Winnicott 1965 ). Further, Johnson and Szurek (1952 ) developed this concept of “superego lacunae” (gaps in ego and superego functioning) when working with a 6-year-old boy who chronically would run away. The authors understood the child’s running away as a result of his father unconsciously encouraging him to run away, seeking vicari- ous gratifi cation from his son’s behavior. This led the boy to have a weakened superego with lacunae or gaps in functioning. Johnson and Szurek concluded that serious antisocial behavior, such as stealing, fi re setting, and damage to property, in children and adolescents, as the result of acting out unresolved intrapsychic confl icts through parent-induced superego lacunae. An everyday example thought to be due to pressures from superego lacunae is when ostensibly bright children or adolescent do not complete school assignments. This is considered a form of acting out of unconscious confl icts.

Superego in Two-Person Relational Psychology

Just as we have seen for the ego and for the id, the two-person relational psychology does not adhere to Freud’s structural theory, and therefore the notion of a superego does not live in this theory. Rather, in two-person relational psychology, an implicit nonconscious social sense of morality develops as early as 9 months old as infants interpret the different expectations and intents of others, which suggest that infants (and adults) do not learn morality per se, but rather that morality is innate (Bloom 2013 ). The early development of self was not only fundamentally social but moral (Emde et al. 1991). This model developed from the work of the developmental psychologist Kohlberg, who in turn based his explorations of morality on Piaget’s work. Kohlberg proposed a set of six developmental stages in moral development, which served as the basis for ethical behavior (Kohlberg 1973 ); however, these stages were extended by Buchsbaum and Emde (1990 ), who found that “children as young as 36 months represent a considerable amount of moral development in narrative form. Children were able to articulate coherent stories about rules, reciprocity, empathy, and internalized prohibitions. Most remarkable was their ability to deal with alternative outcomes in order to resolve a moral dilemma.” Much is yet to be known about moral development, particularly in regard to cultural differences. 6.9 Psychosexual Stages in Traditional One-Person Psychology and Two-Person 127

6.9 Psychosexual Stages in Traditional One-Person Psychology and Two-Person Relational Psychology

Psychosexual Stages in Traditional One-Person Psychology

Freud proposed that children progressed through several psychosexual developmental phases that were determined by the organ of predominant interest to the infant/ child for pleasure (e.g., oral , anal, and phallic). For Freud, unresolved confl icts in a particular phase manifested themselves as a regression to the ego functions and behaviors of the phase that they were fi xated in. For example, it was believed that confl icts in the oral phase can result in eating problems or alcoholism, whereas unresolved confl icts in the anal phase can yield obsessional and anal-sadistic behaviors indicating pleasure in controlling and exercising power. As an aside, anal erotism was thought to refl ect sadistic forms of behavior by children with wishes to destroy the object or to possess it. Finally, regarding confl icts in the phallic phase, symptoms relate to masturbation, fantasies about pregnancy, and sadistic conception of parental intercourse. Importantly, Freud’s theories about psychosexual stages were formulated based on his observations of very few European Caucasian children.

Psychosexual Stages in Two-Person Relational Psychology

The notion that psychosexual stages occur in a linear manner and are punctuated by the resolution of stage-specifi c confl icts is antithetical to the two-person relational psychology. In the contemporary two-person relational model, development occurs in a multilayered and continuous manner in which a person may be in different lay- ers simultaneously. For example, in the two-person relational model, the development of a meaning-making process occurs in parallel with the development of affective attunement and social referencing, independent of zone-based interests and fi xations (e.g., oral, anal, phallic). In essence, in a two-person relational model, “the search for a theoretical structure that neatly places psychological disorders and character traits along a continuum of purported developmental levels does not do justice to what we know about the complex ways in which development proceeds as a continuing interplay between evolving personal characteristics and the environments encountered and, over time, created by the evolving personality” ( Wachtel 2003 ). Importantly, Erikson was the fi rst theorist to offer a model of development that extended over the entire life span, proposing that psychosocial stages of development are infl uenced by the social context and relate to an epigenetic principle: “Anything that grows has a ground plan, and…out of this ground plan the parts arise, each having its time of special ascendancy, until all parts have arisen to form a functioning whole” ( Erikson 1968 ). Developmental research has now begun to reveal the complex processes involved in the scaffold building of physical and psychological competencies over time, which are not derived from instinctual drives but rather from a genetically infl uenced developmental blueprint. Recent cross- cultural research suggests that it is diffi cult to delineate the transition from one 128 6 Deconstruction of Traditional One-Person Psychology Concepts developmental phase to another. Thus, the description of development in phases (i.e., preoedipal, oedipal, latency, and adolescence) is somewhat artifi cial. More likely, children have a developmental blueprint that is infl uenced by genetic, family, and environmental factors, which promotes development ( Delgado et al. 2011 ). For example, walking as a developmental milestone is typically attained between the ages of 9 and 15 months in a securely attached environment, wherein the infant has been provided ample opportunity for motor development as well as balance and gross motor coordination. The child that grows in an unpredictable and chaotic environment (e.g., an environment in which disorganized attachment styles predominate) may learn to walk at earlier ages for survival and, in doing so, will be able to access food or use mobility to distance themselves from violent situations. As such, both children will have different cognitive and environmental pressures that implicitly determine which developmental path promotes survival, rather than this being infl uenced by the resolution of stage-specifi c confl icts. Clinically, the two-person relational psychodynamic psychotherapist will need to be familiar with cognitive, psychological, and social milestones (see Appendix A), as a knowledge (and application) of these milestones provides clues as to whether developmental or psychological discontinuities may be due to neurodevelopmental (e.g., learning disorders) or environmental factors (e.g., deprivation). Such an understanding will aid the psychotherapist in being realistic in his or her expectations of the psychotherapeutic process. Additionally, it will be important for the two-person relational psychotherapist to have an awareness of variations in these milestones among non-Caucasian and minority populations, although we con- cede that, at present, the academic understanding of the development of cognitive, psychological, and social milestones in these populations is lacking. Finally, it is clear that we are in era that recognizes that sexual development comprises biological, psychological, and social aspects of experience that Freud did not consider as important during his time. Herein, sexuality in children and adolescents remains a complex subject, as it also pertains to children who live with lesbian, gay, bisexual, and transgender parents. This complex process is described in the AACAP Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents (Adelson et al. 2012 ): “Much of what has been learned scientifi cally about sexual orientation and gender development in the last generation has occurred in parallel with societal changes in attitudes toward sexual orientation and gender roles.” This is in alignment with the two-person relational model’s view of development.

6.10 The Oedipus Complex in Traditional One-Person Psychology and Two-Person Relational Psychology

Freud’s Oedipus Complex

In traditional one-person psychoanalytic theory, the Oedipus complex is the cornerstone of understanding a person’s personality structures (e.g., id, ego, superego, and ego ideal) and their psychopathology. This universal conﬂ ict in Freudian theory 6.10 The Oedipus Complex in Traditional One-Person Psychology and Two-Person 129 involves the child’s development of unconscious aggressive wishes toward the same-sex parent in order to possess the opposite-sex parent. According to Freud, the importance of the Oedipus complex came to him while viewing Sophocles’ play, Oedipus Rex , in Vienna. In a letter to Fliess he wrote, “The Greek legend seizes on a compulsion which everyone recognizes because he feels its existence within himself” (Freud 1897 ). He later added, “Every new arrival on this planet is faced with the task of mastering the Oedipus complex” (Freud 1905 ). In psychoanalytic theory, the Oedipus complex is at its peak between the ages of 3 and 5 years old, the phallic stage. Freud ( 1924 ) wrote of the Oedipus complex:

A little boy will exhibit special interest in his father; he would like to grow like him, and be like him and take his place everywhere…. He takes his father as his ideal…. At the same time as the identiﬁ cation with his father, or a little later, the boy has begun to develop a true object-cathexis towards his mother according to the attachment type…. The little boy notices that his father stands in the way with his mother. His identiﬁ cation with his father then takes on a hostile coluoring and becomes identical with the wish to replace his father in regard to his mother as well.

In traditional one-person child psychoanalytic literature, the understanding and, at times, interpretation of oedipal confl icts were considered essential for the child to achieve a healthy love object choice and to overcome castration fears typically seen in the form of ego inhibitions (e.g., poor performance at school, eating diffi culties, or self-defeating behaviors due to unacceptable wishes within the tri- angular relationship to parents). This position has been attenuated although not ignored. In writing about the Oedipus complex , Freud believed that a successful resolution led to a healthy love object choice by repressing incestuous wishes. The concept of object choice sets the stage for Klein’s object relations theory . The Kleinian school of object relations proposes that most of the child’s confl icts occur in the early stages of life, thus emphasizing early superego formation leading to the preoedipal confl icts based on split objects—the breast and penis—during the paranoid position. When the paranoid position is resolved, the child moved to the depressive position. The oedipal confl ict was thought as part of the depressive position, in which the child accepts the loved object as a whole object that can be loved and forgiven for the hated aspects.

Jung’s Electra Complex

Jung ( 1961) proposed the Electra complex, a negative Oedipus complex that affected girls and that emerged between 3 and 5 years old (in parallel with Freud’s phallic stage). Freud was reluctant to accept this concept, as he did not see the usefulness and did not believe girls experienced the castration complex as intensely as boys due to their preoedipal attachment to their mother. Freud believed that in girls, the “Oedipal complex culminates in a desire, which is long retained, to receive a baby from her father as a gift—to bear him a child” (Freud 1924 ). 130 6 Deconstruction of Traditional One-Person Psychology Concepts

The Oedipus and Electra Complexes in Two-Person Relational Psychology

Both two-person relational psychology and current neuroscientifi c data refute the Oedipus and Electra complexes. In fact, Kandel, an American neuropsychiatrist and recipient of the 2000 Nobel Prize in Physiology or Medicine for his research on the neurobiologic basis of memory consolidation, recognized the complexities in the area of infantile sexuality and questioned the relevance of the oedipal confl ict: “This is a complex area, because genotypic gender, phenotypic gender, gender identifi cation, and sexual orientation are distinct from one another but interrelated. Indeed, the recognition of this complexity can render standard terms such as male, female, masculine, and feminine imprecise and in need of qualifi cation. These are all early fi ndings, and their consistency over groups of people, both heterosexual and homo- sexual, is still being questioned.” He further added, “The methods at hand for establishing whether there are reliable anatomical differences between people with different sexual orientations…. [These] should greatly infl uence psychoanalytic thinking about the dynamics of sexual orientation” (1999 ). Thus, in a two-person relational model, what is considered to shape a child’s interaction with others regardless of their gender is set in motion early in life through meaning-making processes that provide the affective attunement and social reciprocity needed for present moments of intersubjectivity with others unique to the dyad throughout their life ( Emde 1992 ). The infant’s interaction with caregivers is singularly the most important task to ensure survival and adaptation to the world. As such, developmental research reveals that early interactions between child and caregiver are stored in nondeclarative memory systems and become part of declarative memory systems later. Thus, infantile memories from early childhood are not accessible to verbal or symbolic recall, but rather are encoded within the nondeclarative memory system machinery that is unique to each child and is driven by their innate cognitive abilities (or limitations). Therefore, it is well documented that securely attached infants can learn to elicit soothing experiences from their caregivers (both females and males), which are stored in implicit relational memory systems. For instance, the child can implicitly know that teachers who, regardless of their gender, are encouraging and warm are trustworthy and those that are critical and intrusive are worth maintaining distance—implicit relational knowing. In contrast, in a traditional one-person model, the psychodynamic psychotherapist may consider, in knowing that the child’s parents are critical and intrusive, that the child’s experience of a critical teacher is a displacement or projection of parental confl icts, when in reality, the teacher is critical like the child’s parents. As Emde ( 1992 ) aptly states, “Freud’s portrayal of the child’s experience during the family oedipal drama is oversimplifi ed. We know today that fathers do not appear later on the stage to interrupt an earlier affectionate relationship with mother when the child becomes 3 or 4.” He adds, “Research has shown that fathers, under normative conditions, develop early and qualitatively separate affectionate relationships with both young boys and girls.” 6.11 Latency in Traditional One-Person Psychology and Two-Person 131

6.11 Latency in Traditional One-Person Psychology and Two- Person Relational Psychology

Latency in Traditional One-Person Psychology

In traditional one-person psychoanalytic theory, latency is the period that begins with the dissolution of the Oedipus complex and extends to the onset of puberty, typically between the ages of 6 and 12 years old. It is believed that during this period, repression intensiﬁ es and brings with it amnesia of the early conﬂ icts, as well as the development of sublimation, moral values (including shame), and aspirations for future activities. This phase was thought to be of relative stability. Anna Freud argued that what fostered children in the latency period to shift their attention from their parents to their peers was diminished drive pressures (e.g., the pleasure principle) in favor or the reality principle. Surprisingly, during the last 50 years, in The Psychoanalytic Study of the Child , many of the clinical cases reviewed are of children in child psychoanalysis or psychotherapy who became symptomatic during the latency period, suggesting that this phase is thought of as lacking stability. This notion is consistent with Bornstein (1951 ), who believed that children, in the early phase of latency, struggle with increased incestuous wishes and masturbatory fantasies as a consequence of harsh superego pressures and rigid ego defenses (i.e., the externalization of superego pressures due to incomplete mastery of the oedipal phase). During the latency phase, ego functions acquire greater stability.

Latency in Two-Person Relational Psychology

Unlike in traditional one-person models wherein development occurs in a linear fashion involving distinct phases with discrete beginnings and endings, current research suggests that the maturation of physical and psychological competencies occurs in parallel. This is to say that the interrelated processes of temperament, cognition, cognitive fl exibility, internal working models of attachment, and culture—which are unique to each individual—serve as a scaffold for biological development (Delgado et al. 2011 ). Thus, the traditional one-person conceptualization of latency as a psychosexual phase is artifi cial. Children have a unique genetic developmental blueprint that is strongly infl uenced by family and environmental factors, which when interwoven can act synergistically (Delgado et al. 2011 ). As such, one does not have to look far to appreciate these complexities in personality formation of school age children. For example, consider the situation of two school age siblings: In the case of the fi rst child, good affective attunement and social referencing were present early in life and laid the groundwork for interpersonal success as a school age child. The second child, as a toddler, also had ample emotional availability, affective attunement and social referencing from his or her parents. Moreover, this second child exhibited receptive language defi cits and attention defi cit hyperactivity disorder (ADHD), as well as a diffi cult/feisty temperament, which collectively resulted in diffi culties engaging with peers due to his incapacity for social 132 6 Deconstruction of Traditional One-Person Psychology Concepts reciprocity. These defi cits in the second child resulted in episodes of verbal or physical aggression, which ultimately confi rmed, at an implicit level, that he was different. Thus, both children had secure attachment environments, and there was no suggestion of indolent, unresolved intrapsychic confl ict. However, one child struggled in making sense of the world as a result of his defi cits, and his “advancing” chronologically to the next developmental stage (i.e., adolescence) is unlikely to result in symptomatic improvement. Finally, it is worth noting that during the elementary school years, the developmental milestones are complex (see Appendix A ). Among the most salient developmental tasks are competition in games, enjoyment of group activities, enjoyment of conversation with others, increased interest in the opposite gender, and increased respect for parents. Returning to our example of the two siblings, we might expect that the fi rst child would readily play with peers, compete with classmates, and might play baseball in the neighborhood, whereas the second child would—as a result of his diffi culty to read the intent of others—chronically feel misunderstood and struggle to participate in similar activities. As such, the concept of latency is limiting as it does not account for the multifactorial complexities of development.

6.12 Adolescence in Traditional One-Person Psychology and Two-Person Relational Psychology

Adolescence in Traditional One-Person Psychology

In traditional one-person psychology, adolescence follows latency. The study of adolescent psychological development was based on patients with signifi cant psychopathology (Delgado et al. 2012 ). In his Three Essays on Sexuality ( 1905), Freud stated that the beginning of adolescence is heralded by the reawakening of the oedipal confl icts and asserted that the adolescent’s developmental tasks were “painful psychical achievements” to fi nd a nonincestuous sexual object. Freud’s daughter, Anna Freud, was among the fi rst to describe the adolescence period as a state of disequilibrium, or “turmoil” ( 1958). Subsequently, Blos ( 1968 ) introduced the notion of a second individuation process during adolescence based on Mahler’s ( 1974) separation–individuation phase of the infant. Blos believed that the adolescent’s break from the internalized objects made possible the quest for “extrafamilial love and hate objects” (Blos 1967). Upon completing this process, the object relations of the adolescent become stable, with clear boundaries, and the adolescent becomes more “resistant to cathectic shifts” (Blos 1968 ). In parallel, Erik Erikson asserted that adolescence was not “an affl iction but a normative crisis, a normal phase of increased confl ict characterized by a seeming fl uctuation in ego strength, and yet also by a high growth potential” (Erikson 1956). Taken together, the traditional psychodynamic understandings of adolescence posits four key intrapsychic developmental tasks: (1) loosening of infantile ties, (2) de-idealization of the parents and overcoming castration anxieties, and (3) character formation and the second individuation, all of which are dependent on the preceding process (Fig. 6.1 ). 6.12 Adolescence in Traditional One-Person Psychology and Two-Person 133

Puberty

Character formation

Introduction of the autonomous self (second separation individuation)

De-idealization of the parents and overcoming castration anxiety

Loosening of infantile ties to primary objects

Fig. 6.1 Key tasks of adolescent development in classical theory (Adapted from Delgado et al. (2012 ) )

The traditional one-person form of psychoanalysis and psychotherapy of adolescents focused on helping the patient overcome the regressive pull of the parental ties, which accordingly led to the self-defeating and maladaptive behaviors of the adolescent. Barrett (2008 ) views the adolescent’s self-defeating behavior as a manic defense: “The loneliness results from the adolescent’s need to transfer love from primary objects to new adult relationships not yet available to him. The resultant emptiness may be defended against by overuse of the Internet, alcohol, cigarettes, drugs, and food. These defenses are manic in quality in that they suggest an orally based regressive attempt to ‘take in’ and ‘expel out,’ preserving the felt ‘lost’ object and converting the loneliness into elation.” Importantly, however, these theories that are focused on ego functions fail to account for the inﬂ uence of family factors and have been aptly critiqued by the family psychotherapist Murray Bowen, who notes that psychoanalytic theory lacks the theoretical formulation for the individuation that occurs within the context of family triangles (Bowen 1972 ). Finally, a signiﬁ cant limitation of the traditional one-person psychodynamic model is that it does not provide a theoretical understanding of gay and lesbian adolescents or the physically, mentally, and learning disabled, areas where further research is necessary.

Adolescence in Two-Person Relational Psychology

The twentieth century saw substantial advances in understanding the biological, psychological, and sociological aspects of adolescent development. In two-person 134 6 Deconstruction of Traditional One-Person Psychology Concepts relational psychology, adolescence is a period in which the developmental complexities are viewed as having been built on the lifelong maturation genetic blueprint within the context of innate temperamental and cognitive abilities—nature—as well as environmental factors, including the availability of affective and social referencing and implicit relational knowing, nurture. That is, adolescence is not considered a distinct phase of a linear process as in the traditional one-person model. Accumulating data supports the notion that adolescent behavior cannot be reduced to purely psychological or biological phenomena. Imaging studies of adolescent brains show that during adolescence, the area of the brain responsible for organization, planning, and strategizing is not fully developed, as the gray matter continues to thicken, confi rming aspects of fl uidity in decision making and a number of other cognitive capacities (Giedd 1999 ). Offer and colleagues’ empirical research occurred with adolescents in the “real world” (rather than in clinical populations) and suggests that the majority (80 %) of adolescents managed the transition from childhood to adulthood quite well. Specifi cally, these longitudinal studies of adolescence (Offer and Offer 1975 ) suggest that most adolescents either progress “steadily” or with a sequence of developmental spurts, which are punctuated by episodic confl ict, whereas 20 % of adolescents appeared to take a more tumultuous route through adolescence. Contemporary psychodynamic understanding of the adolescent is strongly infl u- enced by attachment theory, developmental psychology, and intersubjectivity, the implicit nondeclarative memories of the interactions between self and others. The typical adolescent develops the ability to regulate the shifts of affective states and judges how to convey, within reason, autonomous opinion without compromising relationships—the use of an abstract self within the backdrop of early secure attachment patterns ( Delgado et al. 2012 ). Further, even with the advances in developmental psychology, the understanding of gay, lesbian, bisexual, and transgender adolescents is challenging and an area that requires further research. Additionally, in regard to physically, mentally, and learning disabled adolescents, although challenging, their psychological needs must be determined, and their treatment recommendations must be made after a careful assessment of the four pillars in a contemporary diagnostic interview (Chap. 8 ). This will lead to a better grasp of their cognitive strengths and weakness to tailor treatment of these individuals with realistic expectations, regardless of their chrono- logical developmental phase. As a note, an area that is of interest to sociological adolescent research is the impact that YouTube®, Facebook® instant messaging, text messaging, Instagram®, and Twitter® will have on matters of intersubjectivity , which typically depends on face-to-face interactions to discern intent of others through the tone of voice and facial expressions. This has become an issue too complex for psychodynamic theories alone. 6.13 Defense Mechanisms in Traditional One-Person Psychology and Two-Person 135

6.13 Defense Mechanisms in Traditional One-Person Psychology and Two-Person Relational Psychology

Defense Mechanisms in Traditional One-Person Psychology

The concept of defense mechanisms is part and parcel of the everyday lexicon of child and adolescent psychiatry trainees, their supervisor, and experienced clinicians. It is the “go to” manner of understanding a patient’s and their family’s psychological symptoms and behaviors. The concept is at the heart of the traditional one-person model in understanding others, with broad statements of “that patient is splitting,” “the patient is using reaction formation to deal with their anger about being diagnosed with diabetes,” “I like the patient because she sublimates and is able to get along with her parents,” etc. In essence, it involves understanding the patient’s inner life through their ego defense mechanisms, while excluding the clinician’s contribution to the patient’s discourse. In traditional one-person psychology, the ego generates defense mechanisms to psychologically mediate confl ict among the id (drives) and the superego (urging civility). Also, this theory contends that “the window into…[the] personality [derives from an] understanding of the ego’s defense mechanisms that an individual employs in coping with daily-life anxiety and threats to self-esteem from intrapsychic confl icts” (Delgado and Strawn 2014 ). While Sigmund Freud was the fi rst to describe defense mechanisms, much of our understanding of these processes comes from his daughter, Anna Freud . She com- piled a comprehensive catalog of these defenses in The Ego and the Mechanisms of Defense (Freud 1937/1966 ). Anna Freud further believed that defenses would be best assessed through the understanding of the child’s play and that this was the equivalent of free associations. She believed that the goal of a child’s psychoanalytic treatment was to improve their ego functions by interpreting their ego defenses, and she provided reassurance and gave suggestions to the parents on how to interact with their child (Freud 1937/1966 ). More recently, however, there have been subtle changes in our understanding of defenses, with a distinction being made between mature and immature levels and then being hierarchically categorized as mature, neurotic, immature, or pathological, as conceptualized in George Valiant’s seminal work, Ego Mechanisms of Defense : A Guide for Clinicians and Researchers ( 1992 ). Delgado and Strawn (2014 ) further state, “Sometimes we might consciously know which defense mechanisms we use in relation to others—as in humor to manage family confl ict, or denying or overlooking a colleague’s negative comments— but in most cases they occur unconsciously. Defense mechanisms usually are adaptive and can have a salutary effect, allowing an individual to function normally. Importantly, however, when used in a repetitive fashion, defense mechanisms can become maladaptive and induce further anxiety.” 136 6 Deconstruction of Traditional One-Person Psychology Concepts

Defense Mechanisms in Two-Person Relational Psychology

Two-person relational psychology does not endorse the existence of instinctual drives, which imply the need for the use of defense mechanisms against pressures from the id and superego. Two-person relational psychology posits that a person is not defending from intrapsychic pressures from the id or superego; rather, they defend against experiences that are unfamiliar and subjectively provoke anxiety. An example that occurred to one of the authors when supervising a child and adolescent psychiatric trainee happened when the trainee stated: “The patient missed their psychotherapy appointment. Last week I was on vacation, and I think she is mad at me and is resisting coming because she is afraid at expressing her anger at me.” Unfortunately, this is familiar to most of us; we all have had experiences of traditional one-person competency, when we fi rmly believed we clairvoyantly knew the reasons for our patient’s actions. In this case, the author suggested viewing the patient’s absence within the context of the patient having improved with healthier adaptive patterns of interaction with others that had occurred through a two-person relational approach, which provides new emotional experiences through moments of meeting (see Chap. 5). Although the trainee was reluctant in tolerating the ubiquitous uncertainty of a two-person relational model, she was able to consider several scenarios for the patient’s missed appointments. The following supervisory hour, the trainee was outwardly in a jovial mood. She stated: “Wow, it is so important to think about context. The patient missed because she interviewed for a really good job that morning, and they asked her to stay that afternoon to complete her paper- work. She was so excited that she forgot to call and cancel, and when she noticed she hadn’t called, she knew I would understand. She is so much better.” A note to the reader: Context is not only about the realities noted in verbal form; it also includes the intersubjective experiences with the patient, which will be different with each dyad. In this example, the intersubjective experience of the previous session set up the feelings experienced in the missed session: the patient felt the trainee would understand, while the trainee initially worried that the patient was resisting, but then was able to tolerate the uncertainty when taking into account her positive intersubjective experience of the earlier session. We also will not ignore that the reader may have noticed the comment by the patient “forgot to call,” which from a traditional one-person model may also be considered as resistance, and—depending on the psychotherapist’s school of thought—may be viewed as fear of sharing her success; fear in not receiving the mirroring needed for such an achievement, as had previously occurred with her parents; fear in destroying the relationship due to the psychotherapist’s vacation; etc. In a two-person relational model, the patient’s forgetting to call may genuinely be due to her excitement about employment, which is reasonable to have been a step forward in her well-being. Therefore, given that two-person relational psychology conceptualizes a patient’s behavior as infl uenced by nonconscious relational schemas initially set in implicit nondeclarative memory systems by interactions with the many people they had a relationship with, it is natural for the trainee or newly minted psychotherapist to have a certain degree of discomfort in their quest to understand the reasons for their 6.14 Object Relations Theory in Traditional One-Person Psychology and Two-Person 137 patient’s behaviors. As we have stated throughout this book, tolerating uncertainty and relying on change to occur in here-and-now interaction at the implicit nondeclarative local level may be a new concept to the reader that we hope to instill. Attachment and developmental researchers demonstrate that implicit schematic patterns of relatedness (i.e., internal relational knowing) are sensitive to the dele- tions and distortions that occur during interactions. For example, the child attending kindergarten who displays oppositional behavior when the teacher encourages him or her to participate during the story reading time may be avoiding participating in something that is not familiar to him or her if he or she has never been exposed to reading by caregivers. Thus, the child’s oppositional behavior occurs at an implicit level, likely having seen a caregiver also refuse to participate in an activity they did not master, perhaps also reading. In short, in a relational model, “all that happens in interactive and affective life…replace[s] the idea of confl ict between tripartite structures with this more dyadic view of complex patterns of confl ict between the intentional directions of the self and the intentional directions of important others that are represented at the implicit level” ( BCPSG 2002 ; 2005 ; 2007 ).

6.14 Object Relations Theory in Traditional One-Person Psychology and Two-Person Relational Psychology

Object Relations Theory in Traditional One-Person Psychology

More than half a century ago, a natural transition from ego psychology to object relations theory occurred. Melanie Klein (1882–1960), a student of Sigmund Freud, was the fi rst object relations theorist and postulated that object relations were at the center of a person’s emotional life (Klein 1932 ). In the simplest terms, object relations refers to the capacity to have stable and rewarding relationships based on the internalization (a process closely related to introjection ) of the early childhood representations of others in the form of “objects.” However, internalization of these objects is not a mere imitation. Filtered by the child’s wishes and needs, individualized signifi cance is attributed to these “objects” (Delgado and Songer 2009 ). Additionally, Klein proposes a paranoid position of the child when internalized representations of caregivers are experienced as part objects that the mind splits into “good” and “bad” objects (e.g., the loving, nurturing mother and the depriving mother). In the early years, the child maintains the self-object split and, in doing so, avoids the distress associated with recognizing that there are aggressive and depriving aspects of the self as well as of the other. Then, as development progresses, from 4 to 12 months old, the child learns to integrate and tolerate that a person has both “good” and “bad” parts and enters a healthy phase that Klein describes as the depressive position (Klein 1932 ). Having psychologically achieved the depressive position, the child proceeds to develop a capacity of concern for others and guilt about one’s actions and thoughts about others, with a desire for reparation (Winnicott 1965). For Klein, psychoanalysis in children alleviated the primitive anxieties from the harsh internalized objects and inner persecutors (i.e., paranoid position), and 138 6 Deconstruction of Traditional One-Person Psychology Concepts modifi ed this through transference interpretations that removed a blockage from the artery to the child achieving a depressive position. The object relations theorist and psychoanalyst Otto Kernberg, MD (1928–), suggested that when the patient’s internal representation of others remains “split,” they primarily use low-level defense mechanisms, including splitting , projection , and projective identifi cation (Kernberg 1976 ). According to Kernberg, these patients are best understood as exhibiting a borderline level of organization, with poor capacity for affect regulation, and are prone to impulsive actions, including suicide (Kernberg 2000 ; see Defense Mechanisms, this chapter). Paulina Kernberg was the fi rst to study the early signs of personality disorders in children and adolescents from an object relations point of view. She wrote, “The potential for psychological change comes through the activation of dissociated or repressed internalized object relations and through the empathic and shared inter- change with the analyst. This patient could discern more clearly what belonged to the present from what belonged to the past and what was being distorted in both present and past.” She goes on to state, “It is more relevant to the patient to understand the determinants of her object relationships than to determine what is intrapsychic or interpersonal” (Kernberg 1988 ).

Object Relations Theory in Two-Person Relational Psychology

An infant’s temperament, cognition, cognitive fl exibility, and internal working models of attachment that allow him or her to cocreate experiences of the self with others do not originate from Freud’s instinctual drives or Klein’s objects; rather, these relational processes are derived from complex nonconscious meaning-making processes stored in implicit nondeclarative memory systems (Chap. 5 ). The infant elicits and shapes experiences within the context of others and cocreates self- regulatory schemas based on the opportunities for affective attunement and social referencing in his or her environment. As eloquently described by Emde (2009 ), “We are dealing with human relations, not objects—‘we-ness’ introduces an important new domain that has not been encompassed. The mirror neurons research indicates that our neurobiology commits us to others at a basic prerefl ective level, and that there is a primary sense of ‘we’ as well as ‘us’” (Emde 2009 ; Iacoboni 2008 , 2009 ; Iacoboni and Dapretto 2006 ). Importantly, two-person relational theory emphasizes knowledge of a child’s or adolescent’s family and social systems and posits that this is essential to contextualizing to the developmental processes, accounting for cultural and social norms. Similarly, as with drive theory, object relations fails to attend to family and social systems in which the child lives and often fails to integrate the importance of multiple caregiving fi gures in the form of parents, aunts, uncles, and grandparents relating with the infant in early life, contributing to the infant’s developmental processes. Thus, object relations theory also limits the importance of cultural and social norms in the development of the child and adolescent. Finally, many object relations concepts (e.g., introjection , projection , projective identifi cation, and splitting) fail to account for the psychodynamic 6.15 Transitional Objects in Traditional One-Person Psychology and Two-Person 139 psychotherapist’s proclivities as a contribution to the cocreated moments of meeting in the therapeutic relationship (i.e., the psychotherapist’s own internal relational knowing when interacting with the patient, intersubjective experiences). Stated differently, the study of a nonsymbolically based representational system has become the central contribution from infant research (Beebe and Lachmann 2002 ; Tronick 1998 ). Thus, the older term, “internalized object relations,” connotes the “taking in from the outside,” rather than the “taking in” of the here-and-now implicit and nonconscious subjectivity that is inherent in two-person relational psychology (Tronick 1989 ). The older term is also more identifi ed with the literature on pathological rather than adaptive relatedness and is more often used to refer to past relationships and their activation in the transference rather than with more general representational models that are constantly accessed and updated in day-to-day encounters.

6.15 Transitional Objects in Traditional One-Person Psychology and Two-Person Relational Psychology

Transitional Objects in Traditional One-Person Psychology

Coined by the pediatrician and psychoanalyst Donald Winnicott , the transitional object (1953 ) refers to any material object, typically something soft (e.g., a blanket or stuffed animal), that serves as the infant’s ﬁ rst intrapsychic “not-me” possession. Winnicott believed that the infant’s reliance on the transitional objects was a normal phenomenon that allowed the child to transition from the ﬁ rst oral relationship with the mother’s breast to a true “object relationship” (Laplanche and Pontalis 1974 ). Conceptually, Winnicott (1965 , 1971 ) was clearly referring to both drive and object relations theories as demonstrated in his comments:

I have introduced the terms “transitional objects” and “transitional phenomena” for designation of the intermediate area of experience, between the thumb and the teddy bear, between the oral erotism and the true object-relationship, between primary creative activity and projection of what has already been interjected, between primary unawareness of indebtedness and the acknowledgement of indebtedness (“Say: ‘ta’”). By this deﬁ nition an infant’s babbling and the way in which an older child goes over a repertory of songs and tunes while preparing for sleep come within the intermediate-area as transitional phenomena, along with the use made of objects that are not part of the infant's body yet are not fully recognized as belonging to external reality.

Winnicott noted that the transitional phenomena occur between the ages of 4 and 12 months, and he postulated that these phenomena served as a defense against the feelings of depression and the separation anxiety that results from times when the mother is absent. Further, he believed that the overuse of transitional phenomena gave rise to psychopathology, if the projected object was of a persecutory nature, as it would have a fetish quality and could ultimately lead to drug addiction, pathological lying, and theft (Winnicott 1953). Not surprisingly, many Kleinian analysts 140 6 Deconstruction of Traditional One-Person Psychology Concepts criticized Winnicott’s concept of the transitional object, as it was an inanimate object that could not represent pathological manifestations of object introjections. The concept of a transitional object has found a home in the general and psychotherapy lexicon, although not necessarily in the way that Winnicott had conceptualized it. It is common to refer to “binkies,” stuffed animals, or “blankies,” as transitional objects, although, in reality, these objects are likely a soothing object rather than the transitional object in the Winnicottian sense: not-me possession, an intrapsychic representation of mother’s breast. The concept of medication used as a transitional object will be discussed in the psychopharmacology section below.

Transitional Objects in Two-Person Relational Psychology

The concept of a transitional object and, for that matter, transitional phenomena in two-person relational psychology holds broad and contextual meanings. The concept of a transitional object represents a transitional “real” soothing object, rather than a “not-me” object representation of Winnicott’s traditional one-person model. A “real” soothing object may have a variety of meanings within the context of implicit relational knowing . Put simply, soothing objects facilitate meaning- making processes. For example, we are familiar with the image of a young child dragging along their real soothing object, be it a stuffed animal or special blanket, and most parents have had the unforgettable, frantic, and even desperate experience of returning home, to a restaurant, or to a relative’s home when their child’s “binky,” “blankie,” or teddy bear has been forgotten and the child demands for it to be found. We empathize with the reader that is familiar with this scenario, and in reading this, he or she may implicitly smile as they are reminded of their own experience. That is, the reader has stored this experience in implicit nondeclarative memory that he or she retrieves affectively when recalling the moments. In thinking about this topic, the lead author is reminded of his friend and colleague Efrain Bleiberg, who frequently shares the story of his son forgetting his teddy bear at his grandmother’s house. Dr. Bleiberg was frantic with excitement upon learning that his friend would be traveling near the boy’s grandmother’s home and could bring back the teddy bear for his son. In fact, he pleaded on behalf of his son—and for his family’s sanity—to bring back the teddy bear. When the teddy bear was returned, Dr. Bleiberg welcomed the news with joy and relief and continues to reminisce and laugh about the experience, an example of an experience stored in implicit nondeclarative memory. We note that Dr. Bleiberg’s son’s teddy bear does not represent a transitional object in the Winnicottian sense, where the object represents the absent mother. In fact, on many occasions, a child who has forgotten his teddy bear may no longer be interested in the soothing object upon its return. Thus, the meaning-making process progresses developmentally, and the individual no longer seeks objects for soothing, but rather seeks affective communication and social reciprocity from family and friends. In short, the concept of transitional objects is ubiquitous, at least from a 6.16 A Review of the Most Commonly Cited Defense Mechanisms in Traditional 141 conceptual standpoint, and has been widely used in day-to-day psychodynamic psychotherapeutic work, although not necessarily in the way that Winnicott had set out to describe. The transitional soothing real object phenomenon plays an adaptive role for many individuals. For example, many young women, and some men, when leaving for college take an identifi able, real transitional object from childhood. In doing so, such an adolescent copes with the challenge of separation from his or her family, which is infl uenced by the complexities of temperament, cognitive, and affective fl exibility and attachment patterns and not developmentally confi ned to the fi rst years of life as Winnicott had believed. Put differently, the real soothing object represents a regulatory schema and nonconscious memory of an earlier experience not accessible through semantic memory. This action is not what Winnicott intended as an introjection as a “not-me object relation” experience. When a child grows up in an unpredictable and insecure environment, he or she has limited exposure to the emotional availability that real objects represent or may—developmentally—lack internal implicit nondeclarative abilities to store their positive affective experiences. Sadly, for some, the precursors of familiar soothing objects are made available by their family and may take the form of illegal substances or weapons. These children are prone to being teased, promoting further dismissive and disorganized forms of attachment (Chaps. 5 and 8). Further, in a traditional one-person model, the use of illegal substances or violence may be understood as identifi cation with the aggressor. For example, an adolescent girl who was removed from her home at an early age due to neglect had lived in several foster homes due to her oppositional and help-rejecting behavior stored in implicit nondeclarative memory. Several foster parents noted that she constantly sucked on her thumb at home and at school: “She goes to sleep and wakes up with the thumb in her mouth.” A traditional one-person psychology view may understand her behavior as unconscious self-soothing experiences that can represent the intrapsychic representation of a non-soothing, split-off, bad mother object. In a relational model, her thumb sucking may represent a maladaptive meaning-making process and may convey a physical indicator of possible psychological maltreatment or neurobiological survival skills of the implicit memory. The foster parents have repeated what she recognizes as being familiar at an implicit level—to be once again criticized and rejected for her behaviors.

6.16 A Review of the Most Commonly Cited Defense Mechanisms in Traditional One-Person Psychodynamic Psychotherapy: A Two-Person Relational View

Introjection, Projection, and Projective Identification in Traditional One-Person Psychology

Introjection and projection in traditional one-person psychology refer to the internalization of psychological characteristics that a child attributes to caregiving and parental fi gures, which are fi ltered by the child’s internal wishes and needs (Delgado 142 6 Deconstruction of Traditional One-Person Psychology Concepts and Songer 2009 ). When these characteristics are psychologically unbearable to recognize as one’s own, they are projected onto another person. For example, introjection of positive early childhood experiences is evinced when psychologically healthy children allow for a parent to reassure them in an empathic manner to overcome a negative life event. As a corollary, when the child has been a victim of neglect or abuse , he or she may unconsciously be loyal to the introjection of the bad object representations (i.e., negative experiences) and, unable to psychologically access a healthier internal experience to interpret the situations, are likely to recreate/repeat early experiences in which they were criticized for “being bad.” In psychodynamic psychotherapy, this individual is inclined to believe that the psychotherapist is a representation of the critical parents—transference of introjections onto the psychotherapist—and is prone to misinterpretation of the psychotherapist’s good intentions, which needs to be interpreted so the patient can accept and work through the harsh superego functions and improve ego functions. Further, when an individual needs to avoid recognizing that some negative attributes, desires, and emotions are their own, he or she may unconsciously project them onto another person (Akhtar 2009 ). At fi rst glance, the process may be seen as akin to Freud’s transference ; however, projection involves an individual transferring his or her own state of mind onto an object (e.g., the psychotherapist), whereas with transference, the past parental experiences are repeated with the psychotherapist who “stands in” for the parental object. In the school of object relations, projective identifi cation, a primitive phenomenon, involves the patient psychologically forcing the disavowed bad self-object onto a recipient who unconsciously returns the foreign bad self-object back to the patient as if the recipient had owned it. As such, projective identifi cation involves two components: (1) projection as described above, in which the person blames the other by projecting onto him or her the individual’s own confl icted unconscious object representations of the self, as they cannot be tolerated as being their own, and (2) the negative reactions by the “recipient” of the person’s projections, which “exerts interpersonal pressure that nudges the other person to [unconsciously identify with that which has been projected]” and unknowingly acts as the bad object (Gabbard 2010 ). Importantly, the ensuing behaviors on the part of the recipient are generally not considered “in character,” but rather represent a reaction to the feelings that belong to the person projecting (Delgado and Strawn 2014 ). These very reactions— the inability to contain and tolerate the affective states evoked by the projections— sadly confi rm what the patient believed to be the case all along. In short, the psychotherapist is caught up in identifying with a patient’s projections. Typically the psychotherapist feels, “This isn’t like me.” As with many traditional one-person psychodynamic or psychoanalytic theoretical concepts, projective identifi cation and countertransference remain controversial. In this regard, the difference between the two related concepts derives from the theoretical school that spawned them. Moreover, some contemporary theorists and practitioners consider these two mechanisms to be, for practical purposes, one and the same (Renik 2004 ). 6.16 A Review of the Most Commonly Cited Defense Mechanisms in Traditional 143

Introjection, Projection and Projective Identification in Two-Person Relational Psychology

Both introjection / projection and projective identifi cation originate from an unconscious fantasy within a one-person model, and thus, in two-person relational psychology—wherein an unconscious confl ict-based fantasy does not exist—reference to these phenomena is rare. Infant-based research suggests a bias of the infant toward self-regulation and mastery, as well as a bias to create perceptual–experiential coherence and organization of their happenings (Stern 1995 ). In this regard, the infant’s brain is designed to make meaning of what goes together in reality. Moreover, we now know that infants as young as 3 months of age experience distress when there is a discrepancy between reality and their mental representation of the event. For example, when an image of their mother’s face is on a television screen and her voice is desynchronized, the infants detect the discrepancy and remain upset until the discrepancy is corrected—in other words, they remain upset until a familiar and soothing experience is recreated (Dodd 1979 ; Trevarthen 1977 ). In essence, the infant does not introject objects, but rather cocreates experiences with the other person’s multiple representational “selves” or “schemas,” which allow the two to share and co-experience the other’s internal working models of attachment. This serves as the foundation for implicit relational knowing and facilitates the development of a coherent sense of self. Thus, in a two-person model, children, and later adolescents, seek implicit relational partners, a “nonconscious” search for that which is familiar and supports self-regulatory functions in the context of their environment. In a traditional one-person model, this represents a repetition compulsion that results from pressures from the id on the superego in the context of poor ego functioning. In two-person relational psychology, when a psychotherapist has a reaction that is not “in character” while interacting with a patient, this reaction is conceptualized as the psychotherapist being nudged by the patient’s nonverbal attributes to nonconsciously retrieve a familiar relational schema that is triggered by the patient’s particular attributes. For example, a psychotherapist may intersubjectively notice that he or she had been playing checkers with an 8-year-old child in a very competitive manner. Upon noticing this, the psychotherapist intersubjectively recognizes that the child’s aggressive form of play and nonverbal dismissiveness had elicited the response the psychotherapist uses when interacting with people who convey contempt. The psychotherapist can then proceed to use this intersubjective information to help the child learn to reduce using his or her dismissive style and may say, “I am thinking of making this move, although maybe this other move is better. Can you help me decide which is best?” The difference in a two-person relational model is that the relational schema that was triggered by the patient occurred at an implicit level and was not due to the reawakening of the psychotherapist’s intrapsychic confl icts, as would in a traditional one-person model. 144 6 Deconstruction of Traditional One-Person Psychology Concepts

6.17 Fantasy in Traditional One-Person Psychology and Two- Person Relational Psychology

Fantasy in Traditional One-Person Psychology

The central concept of fantasy (or “phantasy,” per Melanie Klein) in traditional one- person psychology represents an unconscious process that is defensive in nature and protects against the pressures from the wishes of the id and the punishment from the superego and internal object representations in the mind of an individual. In addition, fantasies—when they occur at the conscious level—may be conceptualized as daydreams. In the traditional one-person model, fantasies and daydreams are akin to free associations, revealing the unfi ltered inner life of the child. In routine clinical psychotherapeutic work, a traditional one-person psychotherapist might ask, “What are your fantasies about?” to access the patient’s intrapsychic confl icts and to tailor his or her interpretations. For example, a 16-year-old girl in weekly psychotherapy shared her wish to live independently from her perceived controlling parents. Her psychotherapist inquired as to her fantasies about what her parents or psychotherapist might say about her wish. In this model, her response guides her psychotherapist in interpreting the “fantasy” vis-à-vis transferential aspects, so as to provide insight about her wish. If her fantasy is that her psychotherapist might think the idea is unrealistic, her psychotherapist could interpret this as a projection of her own ambivalence. Fantasy begins in childhood and is revised throughout life, contributing to the organization of experiences. With young children, in a traditional one-person model, the concept of fantasy is essential, as it is considered a form of free association: play is the royal road to a child’s unconscious confl icts (Bettelheim 1987 ). Common fantasies of children include superheroes attacking “the bad guys,” or dolls wanting to “marry and have babies with daddy,” typically which are proposed to represent the child’s inner life with regard to unconscious wishes involving parental objects that later become transferentially displaced onto the psychotherapist.

Fantasy in Two-Person Relational Psychology

In two-person relational psychology, fantasy represents the nonconfl icted creative and imaginative abilities of the child or adolescent. Imagination or fantasy is developmentally a cognitive meaning-making process; it is a form of interpersonal communication through personal creativity. Therefore, the ability to create fantasies representing a person’s imagination of other persons or things, which does not abide by the norms of reality, originates during the meaning-making process in the infant and continues throughout life, infl uenced by culture. Confi rmation of this creativity persisting into adult life is confi rmed by popular fantasy literature (e.g., works by Edgar Allan Poe, Lewis Carroll, Mary Shelley, L. Frank Baum, J. K. Rowling) and popular movies (e.g., various fi lms by Disney, Steven Spielberg) whose popularity transcends many cultures. Moreover, fantasy 6.17 Fantasy in Traditional One-Person Psychology and Two-Person 145 role-playing games (e.g., Dungeons & Dragons , young children dressing as different characters during Halloween) also represent the creativity of imagination and appeal to broad audiences. In the example of the 16-year-old female who shared her wish to live independently from her controlling parents, the two-person relational psychotherapist may explore what she imagines her life will be like if away from her parents. Her response will guide the two-person relational psychotherapist to intersubjectively develop a here-and-now new emotional experience . This new emotional experience derives from realistic expectations (e.g., support her goal of moving out if she is experienced as being ready, caution her if she is experienced as being impulsive and unprepared). Importantly, in this example and in two-person relational psychotherapy, the psychotherapist does not base his or her guidance on transference that would objectively distance him in the interaction. Rather, the guidance in a two- person relational model derives from a “moving along” process, wherein both patient and psychotherapist will experience an “Aha!” moment of meeting. If these moments of meeting “feel right” intersubjectively, an implicit new and corrective experience ensues. Additionally, the two-person relational psychotherapist—by being active and present—recognizes when moments of interaction refl ect mismatches of their experiences and uses these moments to understand the patient from the inside out (Wachtel 2010 ). In our example, if the psychotherapist experiences the adolescent’s fantasy as foolish, he may self-disclose and share: “I just think it sounds too diffi cult right now, as you have so many things going on in your life. I think you should consider waiting. How does that sound to you?” In this interaction, the psychotherapist does not know how the adolescent patient will respond, although he expects that from his tone of voice and facial expressions that patient may implicitly recognize that the psychotherapist is invested in her success (i.e., a moment of meeting has occurred). When the young child fantasizes about superheroes “attacking the bad guys,” in a two-person relational model, it is typically thought of as a representation of the child’s use of imagination and not about his or her inner life or parental objects. If the psychotherapist’s intersubjective experience of the child’s imaginative play reveals that the play seems to represent fear of strong characters—seen in victims of bullying or trauma—it would be reasonable for the psychotherapist to self-disclose an alternate story to promote new and more adaptive neuronal relational pathways: “I think we can tell [name of character ] that you are also strong and smart. How about if we teach the bad guys that we can ask for help from our parents or teachers when we feel scared?” In this scenario, it will be important that the psychotherapist use the characters that are known to the child to facilitate this type of play. Additionally, if in the intersubjective fi eld the child’s play represents elements of a healthy and securely attached child, the psychotherapist may just observe the child playing, as it represents a growth-promoting fantasy that the psychotherapist might encourage. Regardless, the child will need to feel safe in the therapeutic setting in order for either intervention to be employed. We close with Einstein ’s quote “Imagination is more important than knowledge. For knowledge is limited to all we now know and understand, while imagination embraces the entire world, and all there ever will be to know and understand” (Mills 1983 ). 146 6 Deconstruction of Traditional One-Person Psychology Concepts

6.18 Splitting in Traditional One-Person Psychology and Two-Person Relational Psychology

Splitting in Traditional One-Person Psychology

Classifi ed within the hierarchy of defense mechanisms as pathologic, “splitting ” is a diffi cult-to-defi ne term secondary to some degree of conceptual heterogeneity. For example, “splitting of the ego ” is described by Sigmund Freud in his early work (Freud 1938 ) as representing splitting of reality as in fetishism, whereas Kleinian splitting represents a developmental stage for infants (Delgado and Strawn 2014 ) in which the self is split as good or bad. Thus, splitting represents a metapsychological concept in object relations theory. Herein, we have chosen to defi ne splitting as the inability to hold in mind that the person in a relationship is a whole entity with both positive and negative attributes. When it becomes unconsciously intolerable for a patient to accept that the person he or she experiences as depriving or abusive also has positive characteristics, splitting occurs. In order to modulate his or her inability to integrate and view himself and others as a whole objects with strengths and weakness, the patient resorts to the use of primitive ego defense mechanisms and, like the infant, “splits their self and other object representation into good and bad, self and other objects” (Delgado and Songer 2009 ). This process prevents closeness, as the relationship becomes distorted and no longer bound by reality (Delgado and Strawn 2014 ). Unfortunately, the term “splitting” in the colloquial sense is commonly mis- used to describe situations in which individuals are pleasant with one person and angry or belligerent toward another; this is actually a process of projection, rather than splitting. In Kleinian school, splitting arises from a child’s inability to successfully achieve the depressive position and experience persons as whole; instead, the child remains in the paranoid position and views others as either all good or all bad. If the child feels their schoolteacher is supportive, he or she will be idealized and the child will comply with her requests during class. When the relationship with the teacher is threatened (e.g., she praises another child in class), the child will unconsciously “split” her as an internal object and experience her as a cruel person who has neglected him.

Splitting in Two-Person Relational Psychology

Not surprisingly, there is scant reference to the concept of “splitting” in the two- person relational literature, and when found, the term generally refers to the splitting off or separating oneself in reality from unbearable affective states due to relational trauma, not within the realm of intrapsychic object relations theory. Due to the fact that splitting is a concept based on object relations theory, two-person relational psychology does not view this as a valuable concept. Developmental research demonstrates that the infant actively engages in meaning-making processes that do not imitate the caregiver’s actions, but rather accurately interprets 6.19 Identiﬁ cation with the Aggressor in Traditional One- Person 147 intentionality and states of mind when in a secure environment (e.g., availability of affectively attuned parents, etc.). Moreover, the infant or young child seeks to reestablish what is familiar (Chap. 5 ) rather than “ splitting ” as an experience of a “good” or “bad” object representation. Finally, two-person relational psychology allows for uncertainty with regard to the motivation or intentionality of others. In the above example, a psychotherapist utilizing a two-person relational model might view the child’s inability to tolerate seeing the schoolteacher praise a class- mate as due to the fact that the child had stored in implicit nondeclarative memory , familiar relational schemas of adults neglecting him or her and giving attention to other people. Conversely, when the child felt the schoolteacher was being supportive, the internal relational schemas of a kind caregiver were activated.

6.19 Identification with the Aggressor in Traditional One- Person Psychology and Two-Person Relational Psychology

Identification with the Aggressor in Traditional One- Person Psychology

In 1933, Sándor Ferenczi formulated a phenomenon now known as “identifi cation with an aggressor ” to explain the psychological (and intrapsychic) consequences of sexual or physical abuse. Accordingly, a victim identifi es with his or her abuser and employs this reversal to “protect the self from hurt and disorganization” (Howell 2014 ). In the case of a child, anxiety is reduced, and distress and fears of the abuse being repeated are attenuated as the individual becomes an aggressor, unconsciously adopting the behavior of the abuser. This tendency of introjected representation of the aggressor, which generates identifi cation and affi liation with the perpetrator of aggressor, appears to form the basis for “ Stockholm syndrome .” This condition, which may occur in nearly 10 % of victims (Fuselier 1999 ), serves the intrapsychic function of allowing the victim’s feelings of helplessness to be replaced with an illusion of control.

Identification with the Aggressor in Two-Person Relational Psychology

The repetition of earlier traumatic emotional experiences, often seen in the lives of survivors of relational, physical, or sexual trauma, occurs at the level of implicit nondeclarative memory. Moreover, marked differences in how a person will react to a traumatic event stem from differences in temperament, cognition, cognitive fl exibility, and internal working models of attachment. Analogously, a victim’s view of his or herself and the world invariably shifts following abuse or trauma. In parallel, implicit nondeclarative memory leads to implicit relational knowing which contributes to why people seek accomplices to that which is familiar. For example, children 148 6 Deconstruction of Traditional One-Person Psychology Concepts who are raised in chaotic and abusive environments form disorganized patterns of attachment, they unwittingly generally get involved with someone who mistreats or abuses them as their original caregivers had. Moreover, these processes appear to be infl uenced by differences in connectivity within emotional processing networks (e.g., prefrontal–amygdala-based circuits, see Chap. 7 ) and occur in parallel with neurostructural changes at the cellular level, including alterations in synaptic morphology and dendritic spine density. Individuals with disorganized attachment patterns often choose negative situations that are familiar over positive situations that are unfamiliar; many survivors of childhood abuse or neglect equate love and affection with trauma. This phenomenon is central to the process of transgenerational traumatization (Daud et al. 2005 ). Finally, resilience—which has a strong neurobiologic basis, described in Chap. 7—is an important factor, as not every person who experiences trauma in childhood will “fi nd” reexposure. Two-person relational psychology acknowledges the genetic- and sex-based contributions to developmental trajectories during childhood and adolescence, as in the case when a child takes on the aggressor’s characteristics. As an example, one recent study suggests that boys who experience trauma tend more often to identify with the aggressor and later victimize others, whereas women who were victims of early childhood trauma are prone to form maladaptive attachments with men that may further traumatize them and their offspring (van der Kolk 1989 ). Thus, the moderat- ing factors of this process that have received signifi cant attention in developmental research may inform the development of public health policy to prevent trauma in children.

6.20 Treatment Goals in Traditional One-Person Psychology and Two-Person Relational Psychology

Treatment Goals in Traditional One-Person Psychology

In a traditional one-person psychology model, insight is the ultimate goal of the treatment—it aims to help the patient develop insight about his or her unconscious, repressed confl icts and learn to make use of mature ego defense mechanisms. Accordingly, the psychodynamic psychotherapist helps the patient to work through the pressures from the unconscious drives or ego confl icts—“Where id is, there shall ego be” (Freud 1916 –1917) with regard to symptomatic improvement. It is not only the drive model that adheres to this perception. In fact, adherents of object relations and self-psychology approaches also subscribe to what has been aptly termed the “woolly mammoth model” (Wachtel 2003). This approach conceptualizes the patient’s diffi culties as originating intrapsychically through “early experiences, perceptions, and inclinations [that] are…essentially frozen in time, preserved in their original form like woolly mammoths buried in the arctic ice, prevented from changing and evolving over the course of development like other parts of the psyche that are not similarly walled off and preserved” (Wachtel 2003 ). 6.20 Treatment Goals in Traditional One-Person Psychology and Two-Person 149

In child and adolescent psychodynamic psychotherapy, symptomatic improvement occurs through the psychotherapist’s deft awareness of object relations, transference, conﬂ icts, defense mechanisms, dreams, and countertransference enactments. The psychotherapist intervenes in the form of insight-oriented comments about the maladaptive ego defense mechanisms used or gives interpretations of repetitive patterns of self-defeating behaviors when the child is ready and able to understand these interventions. As such, the clinician must remain relatively neutral, although they should not avoid empathic responses. Moreover, even in a traditional one-person model, when a clinician is working within children and adolescents, parental work is essential. The processes described above can be seen in an excerpt of a case presentation from A Handbook of Child Psychoanalysis (Pearson 1968 ):

A 14-year-old female adolescent had allowed her boyfriend to take photographs of her in the nude. He then showed these pictures to their mutual friends, which eventually came to the attention of her parents. The adolescent stated to her parents and psychotherapist that she believed that her boyfriend had done nothing wrong by showing the pictures to other peers. In formulating this patient’s struggle, the psychotherapist notes: “careful study of the patient found that this impulsive behavior was the result of an earlier over-severity of the superego and resultant neurotic conﬂ icts. The over-severe superego forced too much repression and the re-activated instincts overwhelmed the superego in an impulsive fashion.” In this formulation, the adolescent seeks to gain insight about her impulsive and acting out behaviors, which emerged as a result of harsh admonishments from her superego.

Thus, in this example, Pearson is very much embedded in a traditional one- person model in understanding the origin and nature of the adolescent’s behavior, and he omits any real personal contribution by the analyst to the interaction.

Treatment Goals in Two-Person Relational Psychology

In two-person relational psychology, the child or adolescent psychodynamic psychotherapist seeks active engagement with the patient, so as to become an ally with his or her intersubjective experiences during the session. The ensuing cocreated experiences facilitate a construction of both internal working models of attachment brought into the context of the therapeutic relationship, which ultimately provides a new emotional experience . Attachment theory and developmental research involving infants support the existence of a bidirectional mode of human interactions wherein cognitive and implicit memory systems shape an individual’s experience of moments of intersubjectivity . It is through the mutual understanding of these moments of intersubjectivity between patient and psychotherapist that allows for a change from a maladaptive model of relating with others to a new adaptive model cocreated in the here and now that allows for a new narrative in the nonconscious implicit memory systems needed for successful clinical work. Put differently, the goal of the two-person relational model is to help the child or adolescent learn to enjoy play, allow for the loving of others, and obtain satisfaction from school. 150 6 Deconstruction of Traditional One-Person Psychology Concepts

In the example of the 14-year-old female adolescent that had allowed her boyfriend to take nude photographs of her and believed that her boyfriend had done nothing wrong in showing the pictures to other people, a two-person relational psychotherapist might take a step back and review the information at hand. In thinking of the contemporary diagnostic interview (CDI, see Chap. 8 ), the psychotherapist could consider whether the impulsive behavior may be due in part to temperament or cognitive weakness, which may have contributed to her low self-esteem and not being able to see herself as a competent person. These events would also be assessed within the context of the psychotherapist’s intersubjective experience with the patient. In doing so, the psychotherapist will have a sense about her temperament, cognition, internal working models of attachment , and whether her implicit relational patterns lead her to nonconsciously seek accomplices of impulsivity. This gives the psychotherapist a blueprint on how to provide a new emotional experience that, over time, can be stored in implicit memory. Perlman and Frankel (2009 ) eloquently state: “Analysts and therapists commit- ted to a relational approach engage the therapeutic situation with a few clinical propositions in mind: (1) personality is formed through interpersonal interactions; (2) the clinical situation is inherently intersubjective and shaped by mutual inﬂ u- ence and must be conducted in a way that incorporates this fact; and, (3) the client needs some kind of authentic personal engagement from the therapist. These assumptions suggest a ‘model relational approach.’” In two-person traditional child and adolescent psychodynamic psychotherapy, the clinician will need to allow for the cocreation of implicit (nonconscious) or well-thought-out enactments and timed self-disclosures that promote new and corrective emotional experiences in the here-and-now moments of intersubjectivity. Finally, the work with the child’s or adolescent’s parents intersubjectively is also essential.

6.21 Neutrality in Traditional One-Person Psychology and Two-Person Relational Psychology

Neutrality in Traditional One-Person Psychology

Freud asserted that for the patient’s confl icted past to be “transferred” in the context of the treatment, a neutral analyst is critical. Moreover, the interpretations that would ultimately break down maladaptive defenses and allow the patient to make the unconscious become conscious and therefore gain insight could only be made in a neutral space. This approach emphasizes the analyst’s neutrality , as a lack of this neutrality could increase the patient’s regressive anxiety and contaminate the transference. As noted by Ellenberg (1970 ), “Freud rose up against the idea of the analyst giving emotional gratifi cation to the patient; the analysis should be conducted in an atmosphere of abstinence.” In essence, gratifying a patient’s unconscious confl icted wishes impaired the analysis of the transference. Moreover, Anna Freud, in approaching neutrality from a structural standpoint, noted that neutrality should be 6.21 Neutrality in Traditional One-Person Psychology and Two-Person Relational 151 maintained with regard to all intrapsychic agencies, advising that the psychotherapist “take his stand at a point equidistant from the id, the ego, and the superego” (Freud 1937/1966 ). Finally, Rubin argued that “evenly suspended attention” supports a neutral stance that renders the analyst capable of attending to a patient’s free associations with openness: “the capacity to decode or translate what we hear on the latent and metaphoric level” (Rubin 2009 ). However, despite a long history of striving for neutrality, true neutrality is seldom represented in the therapeutic frame. In fact, a survey of psychoanalysts ( N = 75) treated in a traditional psychoanalytic model reveals that areas that were related to “the analyst’s qualities, such as genuineness and openness” were rated as “most helpful” ( Curtis et al. 2004 ). Further, the “areas in which the analysts noted the most change in themselves were related to capacities for intimacy and a wider range of emotions and behaviors. The areas of change are not the traditional ones associated with symptom reduction, although serious symptoms were reported as ameliorated. These results suggest that the most effective interventions are active ones in a supportive relationship, suggesting that more than a good alliance is needed.” Additionally, Lynn and Vaillant (1998 ) review of “Freud’s method” from his clinical work of 43 cases and concluded that Freud frequently did not maintain neutrality, often deviating from his recommendations for anonymity, 43 cases (100 %); for neutrality, 37 cases (86 %); and for confi dentiality, 23 cases (53 %). In addition, there were signifi cant extra-analytic relations between Freud and 31 (72 %) of these analysands (Lynn and Vaillant 1998). More recently, Greenson (1967 ), described a patient who, during the psychoanalysis, noticed that Greenson was more active in the sessions when the patient spoke about a particular political party and was less active when the patient spoke about the opposite party. In spite of Greenson’s belief that he had maintained neutrality, the patient revealed he had concluded, through the analyst’s behavior, which party he favored. This example not only illustrates the limitations of neutrality but also illustrates the patient’s intersubjective experiences that implicitly allowed him to know how his psychoanalyst thought. Traditional one-person child and adolescent psychoanalytic approaches have attenuated the central importance of neutrality that is commonly emphasized in work with adults. This relaxing of the neutrality edict facilitates the child feeling safe and creates a transitional space, a bridge between subjective experience and objective reality. In this regard, child psychoanalyst Pearson describes the therapeutic alliance between the psychotherapist and child as unique: “The therapist may need to compromise his neutrality to a greater and greater degree in order to establish and maintain a suitable working rapport with the child” (Pearson 1968 ). Once the alliance is established, most of the work by the psychoanalyst or psychodynamic psychotherapist focuses on transference manifestations and makes use of the interpretation of defenses against confl icts. In the early child psychoanalytic movement, the entry into adolescence or pubarche signifi ed the capacity to develop a true transference neurosis, and therefore—at this point—it was important to not compromise the neutrality in the form of countertransference. As such, Pearson (1968 ) cautioned against countertransference manifestations, saying the “the nature of the treatment 152 6 Deconstruction of Traditional One-Person Psychology Concepts in child analysis permits of the greater possibility that the analyst will assume and gratify his wish to play one or another inappropriate parental role with the child: omnipotent, demanding, giving, overprotective, sadistic, seductive, positive or negative oedipal.” In this, he stresses the importance in maintaining a neutral stance in child and adolescent psychoanalysis and psychodynamic psychotherapy. Although the relevance of neutrality in child and adolescent psychotherapy has recently been decreased, it remains an important concept used in psychodynamic psychotherapy.

Neutrality in Two-Person Relational Psychology

In the two-person relational model, the role of the psychotherapist—particularly those working with children and adolescents—is to be an active participant in the psychotherapeutic process and to provide a mutual “empathic–introspective inquiry” (Stolorow and Atwood 1997 ). Not all children and adolescents know how to develop an introspective inquiry, and thus, the clinician demonstrates how to inquire about the patient’s affective states. As discussed in the example of the adolescent who forgot to lock his bike (earlier this chapter), the psychotherapist shares how he thinks about the situation: “You know, at your age, my bike was very important to me. I see that your bike is very important to you, and I think we should not have to worry about this. Let’s go and make sure it is locked.” By this, the psychotherapist demonstrates and educates the patient about the value in mutually sharing experiences and cocreates new neuronal pathways as part of the new emotional experience. DeYoung (2003 ) eloquently states the importance of mutuality, saying, “At the heart of relational therapy there is the therapist’s commitment to be present, with caring and focus, in the relationship.” Buirski and Haglund (2009 ) state it differently, “Intersubjective theory focuses on the fi eld created by the coming together of the subjective worlds of the patient and therapist. Each patient–therapist dyad creates its own unique intersubjective fi eld through the interplay of the patient’s and therapist’s distinctive individual organizations of experience.” Moreover, regarding the concept of “ evenly suspended attention” (Brenner 2000 ), in relational psychology, this may limit the psychotherapist, as it directs the psychotherapist’s view of what is important to attend to at any given time. Put simply, the child’s or adolescent’s view of reality is routinely infl u- enced by the psychotherapist’s attitude about the patient’s discourse. Finally, the importance of neutrality in traditional one- person psychology has been questioned by some as representing a form of suggestion—infl uencing a patient’s choice about what to share during the session. For example, an adolescent may implicitly notice that his or her psychotherapist demonstrates (also implicitly) interest in the adolescent’s confl icts, parapraxes, and dreams but not in his achievements. As a consequence, the adolescent may then consciously decide to share that what he or she assumes is of interest to his or her psychotherapist so as to be liked, while inhibiting the sharing of growth-promoting achievements made in between sessions. The authors have found that in child and adolescent psychotherapy training programs, when trainees are unclear as to how to proceed with a particular patient 6.22 Transference in Traditional One-Person Psychology and Two-Person 153 in the psychotherapy, regression to a neutral stance is common, and this is likely motivated by a hope that the child or adolescent will take the lead in the session. Having frequently observed this with our own supervisees, we agree with Ferenczi, who believed that when a psychotherapist makes use of anonymity and neutrality, in essence he or she is cocreating the original maladaptive internal working model of implicit relational knowing , contributing to the child’s and adolescent’s feeling of being alone when trying to discover how to ask and how to allow help from another person. This is particularly important in providing corrective emotional experiences for children exposed to adverse events, as neutrality does not allow for the child or adolescent to feel they are in the presence of a safe person or in a safe intersubjective fi eld conducive to learning new adaptive relational patterns.

6.22 Transference in Traditional One-Person Psychology and Two-Person Relational Psychology

Transference in Traditional One-Person Psychology

For much of the twentieth century, Sigmund Freud’s process of transference , considered central to psychoanalysis and psychodynamic psychotherapy, was felt to be a critical element for psychotherapeutic change to occur. In short, the phenomenon involves the transferring of early, unresolved wishes and feelings toward parents or caregivers onto the psychotherapist or another who has attributes that remind the patient of these early unconscious experiences. By remembering and repeating with the psychotherapist these unhealthy patterns, the patient’s confl icts are “worked through” in the psychotherapeutic process ( Freud 1914 ). Upon experiencing improvement in the symptoms that brought him or her to treatment, the patient starts making more mature life choices. Through the “interpretation ” of transference manifestations, the individual’s previously unconscious confl icts and maladaptive experiences are brought to consciousness, resulting in the patient developing insight and improving symptomatically (Delgado and Strawn 2014 ). In Anna Freud ’s The Psycho - Analytical Treatment of Children (1946 ), Freud reviews the many forms of transference and the infl uence of the child’s age on transference manifestations. While she had doubts regarding whether children could form a transference neuroses because they were still living with their parents (original objects), and the analyst frequently would take a similar role as the original parents, a caregiver, she still saw some working through of the transference as an important aspect of treatment, particularly with regard to older children. Freud and Klein agreed that child analysts and psychodynamic psychotherapists needed to pay attention to the transference manifestations in the play and to interpret the maladaptive defenses used by the child. As discussed previously (see Neutrality, this chapter), early child psychoanalysts believed that when children entered puberty or adolescence, they were capable of a true transference neurosis. 154 6 Deconstruction of Traditional One-Person Psychology Concepts

Transference in Two-Person Relational Psychology

In two-person relational psychology, transference might be seen as a two-step, nonconfl icted process. First, infants, early in life, form internal working models or relational schemas when relating to others, and these schemas are stored in implicit relational memory (e.g., nonconscious nondeclarative memory). Later in life, when an individual is encountered whose attributes and personality match this schema— in their here-and-now intersubjectivity —they nonconsciously remember the experience as familiar. For example, when a securely attached child sees their wonderful grandmother for the fi rst time, they may implicitly recognize the similarities of the grandmother with the positive attributes of their mother or father, at least in terms of stored relational schemas in nondeclarative memory. Therefore, in two-person relational psychology, transference does not represent a distortion of the patient’s perception of the psychotherapist. In essence, the equivalent of transference in two-person relational psychology is the process in which healthy internal working models or schemas of attachment are co-constructed between patient and psychotherapist (see Enactments, this chapter), and stored in implicit relational memory, and are nonconscious. The cocreated schemas of interaction can be used by the patient as a model when managing struggles of life outside of the session. Wallin (2007 ) suggests that the traditional form of understanding transference is potentially diffi cult for a patient, as it can evoke compliance, pseudo- therapy, or rebelliousness against the psychotherapist. Winer (1994 ) captures this in describing the inescapability of mutual infl uence between patient and psychotherapist and renders preposterous the notion that the psychotherapist could function as the equivalent of a featureless mannequin the patient dresses in transference. Thus, from a two-person relational viewpoint, we now appreciate that “the notion that transference [with regard to a one-person model] can develop without contamination is an illusion” ( Gill 1984 ).

6.23 Resistance in Traditional One-Person Psychology and Two-Person Relational Psychology

Resistance in Traditional One-Person Psychology

In traditional one-person psychology, resistance is ubiquitous and inevitable in all forms of treatments. A fi rewall against remembering neurotic confl icts of the past, an ego defense against remembering the desires of the id, resistance is a central tenet of treatment. Resistance is defi ned as “the patient’s unconscious opposition to the unfolding and deepening of a psychoanalytic process” ( Auchincloss and Samberg 2012 ). Patients “resist” through mental processes, fantasies, memories, character defenses, and behaviors. Resistance refl ects the patient’s unconscious anxiety about relinquishing familiar compromises and facing emotionally painful self-awareness. While resistance is born and gestates in the unconscious, it persists long after its conscious recognition. In psychoanalytic theory, resistance may also 6.23 Resistance in Traditional One-Person Psychology and Two-Person 155 exist in transference and at the level of the ego, id, or superego. In the child and adolescent traditional model of psychodynamic psychotherapy, resistance is observed when children refuse to enter the psychotherapy room, engage in repetition of certain types of play, or act out when the psychotherapist attempts to interpret fantasies or behaviors. For adolescents, resistance may take the form of forgetting appointments, using illicit substances, refusing to talk, etc.

Resistance in Two-Person Relational Psychology

In the two-person relational psychology, resistance is seen through a markedly different lens in terms of its phenomenology, origin, and function. Wallin (2007 ) deftly captures the view of resistance in two-person relational psychology: “To consider patients as opposing their own best interests, or opposing the therapist, risk giving the therapeutic relationship an adversarial aura; further, it can cast patients as individuals concealing you the secrets and therapists as morally superior detectives or confessors. Because neither context is likely to encourage patients to say what hasn’t been said or nor what has previously had to remain unknown, the classical conception of resistance may work as a barrier to exploration and integration.” It is best to consider that patients may have implicit diffi culty sharing what have been intolerable affective states if they do not feel safe in the here-and-now intersubjective experience with their psychotherapist. In the two-person relational model, resistance is not a concept that is useful, as it has a negative connotation and is commonly thought of as a confl icted unconscious process. In the case of the adolescent who during psychotherapy shares his dilemma about his bike not being locked, a relational psychotherapist will think of this not as resistance working in the session or unconsciously avoiding the therapeutic process. Instead, the relational psychotherapist’s subjective experience is noticing the adolescent’s dilemma, being compliant while risking his own bike, and is able to provide the affective attunement necessary to develop a new way of affective communication—“your possessions are also important to me”—a moment of meeting for the creation of new and healthier adaptive ways for the adolescent, rather than continuing to use relational schemas of compliance to the imagined or real wishes of others. Children who refuse to enter the psychotherapy room or engage in repetition of certain forms of play are, in essence, not resisting but rather repeating internal working models of attachment specifi c to the mutually cocreated relationship to their psychotherapist. The child may approach material differently with a psychotherapist who has a different personality style or temperament. Moreover, if the patient acts out with the psychotherapist, the origin of this may be multifactorial (see Chap. 3 ), perhaps refl ecting temperamental, cognitive (e.g., learning weakness), developmental, attachment, or medical diffi culties. Similarly, when an adolescent forgets his psychotherapy appointments, uses drugs, or refuses to participate, these behaviors warrant assessment within the context of a contemporary diagnostic interview (Chap. 8) and attending to the intersubjective experiences cocreated. As such, the two-person relational psychotherapist should consider whether the 156 6 Deconstruction of Traditional One-Person Psychology Concepts behavior is specifi c to the psychotherapist, or if it results from one of the diffi culties previously listed.

6.24 Interpretations in Traditional One-Person Psychology and Two-Person Relational Psychology

Interpretations in Traditional One-Person Psychology

Interpretation , a therapeutic action that “brings out the latent meaning in what the subject says and does” ( Laplanche and Pontalis 1974 ), is considered to be the sine qua non of traditional one-person psychodynamic and psychoanalytic treatment. That is, that which is to be interpreted is known by the analyst and not recognized by the patient due to the defense mechanisms at work, repressing the unbearable truth of their wishes and desires. In essence, interpretations are “at the heart of the Freudian doctrine and technique. Psychoanalysis itself might be deﬁ ned in terms of it, as the bringing out of the latent meaning of given material” (Laplanche and Pontalis 1974 ). Additionally, there has been little change in the role of interpretation in psychoanalytic work over the past century. Anna Freud, like Melanie Klein, believed that interpretations were central in psychoanalytic treatment of children and adolescents. Klein advocated for deep interpretations early in the process and of their primitive defenses to alleviate the child’s guilt for their destructive wishes and fantasies. Moreover, “each time the analyst offers an interpretation that goes beyond with the patient is consciously aware of, he or she invites the patient to see things, if ever so slightly, from the analyst’s own theory- rooted perspective. To that extent, interpretations are suggestions, and it is critical to the analysis to investigate whether the patient believes he or she must adopt the analyst’s viewpoint in order to maintain the therapeutic bond” ( Orange et al. 1997 ). In returning to the example of the adolescent who forgets to lock his bike upon arrival to his psychotherapy appointment, several possible interpretations seem reasonable from the vantage of traditional one-person psychology. If the psychotherapist believes that the event represents the repetition of a pattern in which the patient wishes to be caught doing something wrong, he or she may choose to interpret it accordingly. A different possibility may exist if the psychotherapist believes that the event represents a pattern of self-doubt, in which case he or she may interpret the wish for criticism by the patient unconsciously leaving his bike unlocked and so on.

Interpretations in Two-Person Relational Psychology

The Boston Change Process Study Group has promulgated the clearest explanation of interpretation in two-person relational psychoanalysis or psychotherapy: a need for “something more” than an interpretation to bring about change. Referring to this “something more,” Stern and colleagues (1998 ), in their seminal paper Non - Interpretive Mechanisms in Psychoanalytic Therapy , note: 6.25 Dreams and Parapraxes in Traditional One-Person Psychology and Two-Person 157

Using an approach based on recent studies of mother–infant interaction and non-linear dynamic systems and their relation to theories of mind, the authors propose that the something more resides in interactional intersubjective process that give rise to what they will call “implicit relational knowing.” This relational procedural domain is intrapsychically distinct from the symbolic domain. In the analytic relationship it comprises intersubjective moments occurring between patient and analyst that can create new organizations in, or reorganize not only the relationship between the interactants, but more importantly the patient’s implicit procedural knowledge, his ways of being with others. The distinct qualities and consequences of these moments (now moments, “moments of meeting”) are modeled and discussed in terms of a sequencing process that they call moving along.

Keeping with the vignette of the adolescent who forgets to lock his bike, upon arrival to his psychotherapy appointment, several “something more than interpretations” are plausible. If the psychotherapist believes that the event represents repetition of a pattern in which the patient believes he is always careless and constantly doing something wrong, the psychotherapist may choose to say, “That’s one way to look at it. Can we consider that you made it here on time as representing something you did right?” In a different scenario, the psychotherapist believes that the event represents a pattern of self-doubt and may choose to say: “I wonder what got in the way of you not going back and locking your bike, even if it led you to be a few minutes late? I didn’t think of myself as being that rigid in terms of when you got here.” In both scenarios, the fi rst step is taken by the psychotherapist to cocreate a here-and-now moment of meeting. This moment will need to be cocreated at an implicit level within the intersubjective fi eld. That is, the psychotherapist’s must concentrate his attention on the nonverbal communication: intonation, rhythms and tempi of speech, and musicality of the voice (Ferro 2002 ). The next step will depend on how the patient responds to the something more than interpretation comments by the psychotherapist. Wachtel ( 2011 ) states that for many patients, “interpretations can be experienced as a message that their efforts to move beyond their longstand- ing defensive way of communicating are not appreciated, that the struggle to be more open and expressive has failed, even that the restrictions and inhibitions that have limited their lives are simply too strong to overcome. Rather than promoting the goals of the therapy, the comment induces discouragement or even self- laceration.” In fact, we now recognize that psychotherapy no longer occurs “in an era in which interpretation…as the exclusive therapeutic arrow in the analyst’s quiver ( Gabbard and Lester 2003). Havens (1986 ) adds, “In the current interpretive climate of much psychotherapeutic work, patients sit waiting for the next insight with their fi sts clenched. Small wonder, for it is rarely good news”.

6.25 Dreams and Parapraxes in Traditional One-Person Psychology and Two-Person Relational Psychology

Dreams in Traditional One-Person Psychology

In early psychoanalytic writings, dreams are noted to occur during sleep when superego functions are suspended, and this represents a period of time during which 158 6 Deconstruction of Traditional One-Person Psychology Concepts ego defenses help the dreamer to remain asleep by making the dream incomprehen- sible so as not to allow the conﬂ icts into consciousness. Freud saw dreams as “the royal road to the unconscious” (Freud 1900 ) and “the task of interpreting the dreams is pretty well limited to psychoanalytic therapy, since it generally requires the application of psychoanalytic technique,” referring to the use of free associations to decipher the latent meanings of the dream content (Brenner 1974 ). In The Interpretation of Dreams ( 1900), Freud instructs that the “two separate functions [of dreams] may be distinguished in mental activity during the construction of a dream: the production of the dream-thoughts, and their transformation into the [manifest] content of the dream.” For Freud, dreams were composed of the manifest content (i.e., what we recall upon awakening) and the latent content (i.e., the unconscious wishes dis- guised in the dream). Thus, the psychoanalytic work of interpreting a dream utilized the patient’s free associations to the dream, while the psychoanalyst deciphers four elements: condensation, displacement, considerations of representability, and secondary revision. Pearson (1968 ) deftly illustrates the use of the dream in traditional one-person psychology in describing a dream by an adolescent:

Adolescent: “I saw one of the camp counselors and talked with him near my home. A friend who lives next door got on his bike. The counselor was carrying a basketball, gym pants, and sneakers. I saw two kids and mentioned their names. It wasn’t an unhappy dream.” Analyst: Mark’s associations to the dream were: he knew that the counselor in the dream was also a wrestler; the “two kids” reminded him of his peers (male and female) which he made split up by creating conﬂ ict between them; and he did not ﬁ nd the girl attractive. The analyst understands the dream as “the latent content of the dream appeared to be Mark’s wish to split up his parents up and to wrestle (sexually) with his mother. It was therefore an oedipal dream.” To note, Mark does not make reference in his associations to his parents or mother after the dream, he did mention that he occasionally had wrestled with his sister.

The analyst’s work with the adolescent’s dream is in line with Freud’s prescrip- tive dream work. Moreover, the adolescent’s associations guide the analyst, who discovers the latent content of the dream, the patient’s wish to split up his parents, and to wrestle (sexually) with his mother, giving the analyst the information needed to conclude that this particular dream is oedipal in origin.

Parapraxes (Freudian Slips) in Traditional One-Person Psychology

In regard to slips of the tongue, or parapraxes , Freud held that they represented repressed unacceptable instinctual desires that reach consciousness when they bypass the patient’s ego and superego. For example, an 11-year-old child states that he is frustrated with his demanding teacher who “always asks me to do more work.” He later adds, “My mother doesn’t give me a break,” referring to his teacher. This is considered to represent a parapraxis, “a compromise formation that serves the multiple functions of wish, defense, and adaptation” (Auchincloss and Samberg 2012 ). Parapraxes are also thought to occur as slips of the pen or keyboard. 6.25 Dreams and Parapraxes in Traditional One-Person Psychology and Two-Person 159

Dreams in Two-Person Relational Psychology

In two-person relational psychology , dreams are considered an amalgam of stored information now known to activate the default mode network, including the precuneus, cuneus, medial prefrontal cortex, and occipital cortex (Dresler et al. 2012 , Chap. 7). In this section, we will briefl y review selected work by dream researchers to illustrate the complexities of understanding dreams and the relevance of this work to the understanding of dreams in a two-person relational model. In 1953, Eugene Aserinsky and Nathaniel Kleitman, considered the fathers of modern sleep research, discovered the association of rapid eye movement (REM) sleep and dreams. In this regard, Aserinsky and Kleitman noted that dream recall remained intact when dreams occurred during REM (Aserinsky and Kleitman 1953 ). In a landmark 1977 study, John Allan Hobson and Robert McCarley proposed “an activation-synthesis hypothesis of the dream process,” in which the activated prefrontal cortex synthesizes the dream by comparing the information generated from specifi c brain circuits with the information that was stored in memory (Hobson and McCarley 1977 ). Later, Hobson contextualized this understanding noting that our current understanding of dreams “is so different from Freud’s as to make the use of a word like revision a euphemism. Because there is essentially nothing left of the Freudian hypotheses, what is needed is not revision but complete overhaul. Instead, what we see is a tenacious adherence to a faith in the interpretability of dreams using vague and unscientifi c terms like metaphor and hermeneutics ” (Hobson 1999 ). In addition, Hobson and colleagues (2000 ) suggested, “dreaming consciousness results from processes of arousal impinging upon selectively facilitated, dysfacilitated or input/output-blockaded forebrain structures.” Specifi cally, fMRI studies reveal activation of the default mode network during dreaming and further implicate the precuneus and cuneus, two structures that subserve self-versus-other processing and structures that are activated during self- referential processing during wakefulness. Moreover, using dream symbolism—a tenet of traditional one-person psychology—would be considered by some to be antithetical to two-person relational psychology. Currently, and somewhat contradictory to traditional one-person confl ict-based models of latent dream content in children, we have made limited progress in understanding the kaleidoscopic content of dreams in children. For example, Resnick et al. (1994 ) note that “young children are able to give long, detailed reports of their dreams that share many formal characteristics with adult dream reports,” and a recent study by Honig and Nealis (2012 ) found that “girls dreamed more frequently of family members. Boys reported more fi ghting and chasing. Dream themes of boys, compared with girls, were twice as likely to include monsters, wild animals, pets, and curiosity. Power themes were four times more prevalent in boys’ dreams . Girls were twice as likely as boys to report joyful dreams.” Thus, one can appreciate that a purely interpretive approach to dreams might be “unwise, for once we refuse to take the dream images for what they are, it is impossible to determine in any objective manner which dream images should be regarded 160 6 Deconstruction of Traditional One-Person Psychology Concepts as ‘symbols’ and what exactly they might symbolize” ( Revonsuo 2000 ). Additionally, in dream symbolism, an inherent danger will always persist in that “one can always get rid of dream elements that do not fi t in with one’s favorite theory by saying that they actually stand for something else (most likely for something that the favorite theory happens to be able to explain very neatly)” Revonsuo (2000 ). Understanding dreams in children and adolescents represents a complex endeavor in the two-person relational model. In this regard, the two-person relational psychotherapist working with children and adolescents attends to the patient’s experiences and affects while the patient shares their dreams, although the psychotherapist must also consider that what is being remembered does not represent a repressed intrapsychic confl ict, but rather the expression of a here-and-now conscious experience unique to the patient–psychotherapist intersubjective dyad. This allows for understanding dreams in many different ways, and the two-person relational psychotherapist has the task of allowing his intersubjective experience in the here and now with the patient to decide what elements of the dream may be relevant within the context of their relationship and the patient’s history. A brief return to the adolescent dream described earlier by Pearson (1968 ), but this time through a two-person relational view:

Adolescent: “I saw one of the camp counselors and talked with him near my home. A friend who lives next door got on his bike. The counselor was carrying a basketball, gym pants, and sneakers. I saw two kids and mentioned their names. It wasn’t an unhappy dream.” Relational Psychotherapist: Mark’s associations to the dream were: the counselor was also a wrestler; the “two kids” reminded him of peers he had made split up by creating conﬂ ict between them; and he did not ﬁ nd the girl attractive. A relational psychodynamic psychotherapist is not concerned with having to uncover the hidden meanings needed to understand the dream; rather, he attends to the shifts in affect as Mark shares the dream. This allows cocreating, in the here and now, the intersubjective mutuality needed to know what aspects of the dream are worth reviewing or ignoring. As previously noted, Mark does not make reference in his associations to his parents or mother after the dream; he did mention that he occasionally had wrestled with his sister.

The many possible avenues that could be taken by a two-person relational therapist regarding Mark’s dream may include the following:

• The psychotherapist demonstrates interest in Mark elaborating on the positive experiences (e.g., basketball, gym, friendships), as the psychotherapist notices Mark’s excitement when he shares those elements in the dream. The psychotherapist, through his intersubjectivity, feels pride in Mark’s achievements. • The psychotherapist experiences Mark as sharing the dream in a superfi cial or trivial manner, as if believing that the psychotherapist may like dreams. The psychotherapist does not feel—in the here-and-now moment—that it would be helpful to explore the dream and chooses to explore with Mark that it seems he is distant in the session. • The psychotherapist experiences Mark as feeling safe in their relationship and that in sharing the dream and associating to it, he seemed trying to fl aunt appropriately his ability to refl ect about the changes in his life. The psychotherapist 6.26 Countertransference in Traditional One-Person Psychology and Two-Person 161

chooses to demonstrate excitement to Mark’s comments in order to improve his self-esteem and asks what other aspects of the dream he found of interest. Internally, the psychotherapist believed that the new emotional experience was in showing interest in Mark’s thoughts, as he had felt that throughout the psychotherapy process, the adolescent’s internal working models and implicit relational knowing were that of not believing he was important to others. • The psychotherapist experiences Mark as being anxious when sharing the dream, although the psychotherapist intersubjectively felt the adolescent was reaching out for help with the dream. The psychotherapist uses this opportunity to help Mark feel safe and learn to explore his thoughts, and he proceeds to share that understanding dreams has been controversial and that he, as a psychotherapist, believes that what is most helpful is paying attention to how one feels when sharing the dream, which many times has problem-solving ideas embedded.

In short, when the relational psychotherapist attends to his experience of the shifts in the affect of a patient when sharing a dream, there are many avenues that can be taken that are unique to the patient–psychotherapist dyad in the here-and- now moments of intersubjective experiences.

Parapraxes (Freudian Slips) in Two-Person Relational Psychology

Like dreams, two-person relational psychology does not adhere to Freud’s understanding of parapraxes ; rather, these “slips” are considered to represent linguistic slips—that is, a problem with sequencing in grammar from inattention or insufﬁ - cient knowledge (Möller et al. 2007 ). They represent neural response patterns that have been primed by prior usage during anxiety-provoking events. Recent neuroimaging studies utilizing inhibition tasks suggest that the process of inhibiting automatic responses (e.g., a combination of words that have previously gone together or have been paired) activate the anterior cingulate cortex (Brown and Braver 2007 ), a region that is responsible for the integration of both affect and cognition. This region also represents a point of convergence for ventral (emotional) and dorsal (cognitive) processing streams in the brain (Yamasaki et al. 2002 ).

6.26 Countertransference in Traditional One-Person Psychology and Two-Person Relational Psychology

Countertransference in Traditional One-Person Psychology

Countertransference , the fl ip side of transference, occurs when the psychotherapist unwittingly participates in the patient’s transference. In the traditional one-person model, countertransference is generally seen as a negative process, as it may result in the psychotherapist breaking his neutrality and anonymity, which can interfere in the development of the transference by the patient onto the psychotherapist. In 162 6 Deconstruction of Traditional One-Person Psychology Concepts countertransference, the psychotherapist’s unconscious reactions to the patient are rooted in the psychotherapist’s own unresolved intrapsychic confl icts evoked by the patient. The concept of countertransference has direct relevance to the traditional model in child and adolescent psychodynamic psychotherapy. Pearson (1968 ) captures the complexities of this process deftly: “The varieties of countertransference in child analysis are numerous and parallel those which may be encountered in adult analyses. The nature of the treatment and child analysis permits of the greater possibility that the analyst will assume and gratify his wish to play one or another inappropriate parental role with the child: omnipotent, demanding, giving, overprotective, sadistic, seductive, positive or negative oedipal. Or, in his work with the parents, he may actively participate in the oedipal triangle, overidentify with the child’s attitudes towards the parent at various levels of development, or remain oblivious to certain aspects of the parental attitudes which are threatening to him.” As with many psychodynamic or psychoanalytic theoretical concepts, projective identifi cation and countertransference remain controversial. Certainly, both processes represent the reactions of the psychotherapist when he or she is the recipient of a displaced confl ict or projections from a patient, and they may share other psychological facets as well. For many, the difference between the two related concepts derives from the theoretical school in which they were indoctrinated. The classic drive-theory doctrine countertransference in relation to the unconscious confl icts with early objects, confl icts that are repeated when the patient transfers/displaces past experiences onto the recipient. By contrast, in object relations, projective identifi cation is a primitive phenomenon in which the patient psychologically forces the disavowed bad self-object onto a recipient who unconsciously returns the foreign bad self-object back to the patient as if the recipient had owned it. Interestingly, however, some contemporary thinkers believe that these two mechanisms are, for practical purposes, one and the same (Renik 2004 ).

Countertransference in Two-Person Relational Psychology

In a two-person relational model, the here-and-now active presence of the psychotherapist through implicit or explicit enactments and timed self-disclosures provides a new emotional experience that leads to change at the implicit level, akin to a parent providing an infant the affective attunement needed to mutually cocreate new and adaptive experiences that are stored in nondeclarative relational memory (i.e., intersubjectivity). Further, in two-person relational psychodynamic psychotherapy, this cocreated experience is an adaptive organizing principle in relation to others. The active and self-disclosing interventions by the relational psychotherapist are part and parcel of the relational and intersubjective approach. Relational interventions are intended to be co-constructed by patient and psychotherapist, sharing internal working models of attachment and implicit relational knowings from each. Thus, in two-person relational psychology, the concept of countertransference —as a construct—limits psychotherapists in that its use implies a unidirectional 6.27 Boundaries and Self-Disclosure in Traditional One- Person 163 infl uence (e.g., the psychotherapist reacting to the patient’s transference). As such, Aron (1990 ) explains that “referring to the analyst’s total responsiveness with the term countertransference is a serious mistake because it perpetuates defi ning the analyst’s experience in terms of the subjectivity of the patient. Thinking of the analyst’s experience as “counter” or responsive to the patient’s transference encourages the belief that the analyst’s experience is reactive rather than subjective.” Interestingly, Gill and Hoffman (1982 ) report that a panel of blinded judges reviewing audio recordings of psychoanalytic sessions noted that a patient’s perceptions of their analyst’s countertransference were often more accurate than their analyst’s self-assessments, supporting the relational tenet of intersubjectivity, wherein the patient implicitly knows how the psychoanalyst feels about him or her. Thus, the term “countertransference” “obscures the recognition that the analyst is often the initiator of the interactional sequences” (Aron 1991 ). Hoffman (2009 ) adds, “We cannot hide anymore. The cat is out of the bag,” and proposes that we admit that our infl uence is inevitable and ubiquitous and that we should take full responsibility. He shares that free associations and evenly hovering attention must be replaced by the active analyst with the patient as real people actively talking and sharing mutual subjectivities.

6.27 Boundaries and Self-Disclosure in Traditional One- Person Psychology and Two-Person Relational Psychology

Boundaries in Traditional One-Person Psychology

In Chap. 2, we reviewed how traditional one-person schools of psychoanalysis and psychodynamic psychotherapy—including drive theory, ego psychology, object relations, and self-psychology theories—overall maintain the need for anonymity, neutrality, and abstinence (Freud 1915) in order to allow the patient’s confl icted unconscious to surface in the form of transference. The adherence to the role as an active observer—anonymity, neutrality, and abstinence—and not a participant in the patient’s wishes for gratifi cation, was thought to provide some clarity about the crossing of boundaries , nonsexual and sexual, in the analytic and psychotherapeutic encounter. Boundaries are considered to represent an “edge” or limit of the appropriate behavior by the psychoanalytic psychotherapist in the clinical setting (Gutheil and Gabbard 1993 ). Patients require an atmosphere of empathy and predictability in their relationship to the psychotherapist in order to feel safe, which allows for the sharing verbally and not in action their wishes and desires. In contrast, the psychotherapist must recognize that the power differential exists and must maintain professional boundaries, defi ned as actions that are made in the best interest of the patient and not for gratifi cation of the psychotherapist. For an eloquent review of the complexities of this subject, we refer the reader to Gabbard and Lester’s ( 2003 ) Boundaries and Boundary Violations in Psychoanalysis . 164 6 Deconstruction of Traditional One-Person Psychology Concepts

In Psychodynamic Psychotherapy : A Clinical Manual ( 2013 ), Cabaniss and colleagues give importance on setting the frame before starting the psychotherapeutic process, in order to avoid boundary crossings and/or boundary violations. They give an example in which a psychotherapist extended a session by a few minutes to allow a patient to compose after having discussed some distressing events. They believe that the psychotherapist’s going over a few minutes is considered to be a boundary crossing—a benign deviation from the frame that does not harm the patient and allows for the advancing of the psychotherapy process (Guthiel and Gabbard 1993 ). In current day, the psychotherapy of one’s own child—Sigmund Freud and Melanie Klein analyzed their daughters—would be considered a boundary violation. What deﬁ nes a boundary crossing or violation is clearly more complex in the treatment of children and adolescents and must be viewed within the context of developmental issues. Holding an infant or helping a 6-year-old child remove their coat is appropriate, while touching an adolescent is likely not, unless in speciﬁ c circumstances (e.g., disability). The “American Academy of Child & Adolescent Psychiatry Code of Ethics” (2009 ) is designed to provide child and adolescent psychiatrists an ethical framework of practice, with attention to boundary issues.

Self-Disclosure in Traditional One-Person Psychology

In the traditional one-person psychoanalytic and psychodynamic literature, self- disclosure by the psychotherapist is seen as interfering with the treatment because it gratiﬁ es the patient’s libidinal wishes, limiting the development of transference projections needed for insight to unfold. Self-disclosure has also been thought of as a form of countertransference, an unconscious reaction elicited by the patient as a result of the patient’s transference projections (see section on countertransference above). In the traditional one-person model, attention to boundaries and self- disclosures is crucial for the analyst to monitor in order to avoid gratifying the patient’s wishes and contaminating the transference, prevent enactments from occurring that will allow the patient to know the real person behind the neutral analyst, and engage in countertransference phenomena in the form of projective identi- ﬁ cations. Herein, in the traditional one-person model, self-disclosures are rare, and when they occur, the content of the disclosure has been carefully scrutinized and thought to be necessary to the process (e.g., if the psychotherapist is in training).

Boundaries in Two-Person Relational Psychology

Boundaries in the two-person relational model receive the most critiques from clinicians practicing from a one-person model. In this regard, gratifying a patient’s wishes is viewed as a slippery slope, as it not only contaminates the transference, it may also complicate countertransference phenomena. Common examples in two- person relational psychotherapy of a psychotherapist gratifying a patient’s wishes, so as to move along the psychotherapeutic process, include allowing a child in 6.27 Boundaries and Self-Disclosure in Traditional One- Person 165 treatment to borrow a toy, hugging a patient before the psychotherapist’s vacation, sending birthday cards to a child or adolescent, and answering questions about the psychotherapist’s personal life. Importantly, these moments occur when the psychotherapist intersubjectively experiences that gratifying the wish is in the best interest of the patient, as it provides a new corrective experience that may have been lacking and, thus, would not be considered to be crossing a boundary (a deviation from a framework). Without a doubt, regardless to which psychotherapeutic theory one adheres, enactments occur and represent a continuum, from subtle issues helpful to patients to enactments with behaviors that are clearly harmful to the patient (e.g., exploitation, sexual involvement). Due to the complex nature of the psychotherapeutic work with children and adolescents, we suggest the psychotherapist to have regular consultation with a trusted colleague when they subjectively feel a dilemma regarding their interactions with their patients. Exactly what behavior from the psychotherapist deﬁ nes a boundary crossing or violation is clearly a complex matter in child and adolescent psychiatry, and it must be viewed within the context of developmental issues. The “American Academy of Child & Adolescent Psychiatry Code of Ethics” (2009 ) is designed to provide child and adolescent psychiatrists an ethical framework of practice. Boundaries in two- person relational psychology need to be ﬂ exible, intentional, and part of a well- thought- out enactment. Similar to a boundary crossing, in two-person relational psychology, the relaxing of a boundary occurs with forethought and intention and aims to advance the psychotherapeutic process. In the above example of the adolescent who forgot to lock his bike, the psychotherapist by going with the patient to lock the bike is enacting a form of relationship that he hopes will create a new and sustainable neuronal pathway stored nonconsciously in an implicit relational form. This is to say that the adolescent learns to defer to social etiquette over the safety of one’s own valuable property.

Self-Disclosure in Two-Person Relational Psychology

As discussed in Chap. 3 , emphasis on active participation by the psychotherapist in the psychotherapeutic process is essential but represents a major shift from a traditional one-person psychology to a two-person relational psychology. In this regard, “self-disclosure has gone from being forbidden to being universally acknowledged as therapeutic in the context of a good therapeutic alliance” ( Maroda 2010 ). Moreover, self-disclosure may be an inevitable aspect of a psychotherapeutic process ( Farber 2006 ) and occurs at both explicit and implicit levels. Regarding the integrative nature of self-disclosure, Ziv-Beiman (2013 ) notes that self-disclosure may “initiate a gamut of changes with respect to emotions, thoughts, motivation, behavior and interpersonal relationships…. Self-disclosure is powerful because it is integrative.” She further states, “Scholars of an intersubjective persuasion discuss therapist self-disclosure in positive terms, principally in the context of disclosure of countertransference. Relational scholars emphasize that exposure to subjective otherness is essential for the foundation of the self and view therapist self-disclosure as 166 6 Deconstruction of Traditional One-Person Psychology Concepts a form of intersubjective inquiry, which is part and parcel of every treatment. This mutual inquiry enables the development of the patient as a subject with awareness to the multiple self-states that emerge from the dialogue with the other within the context of a range of intersubjective dyads, including the therapeutic dyad.” In two-person relational psychodynamic literature, the psychotherapist’s self- disclosure not only represents an enactment but also is the keystone of the therapeutic alliance that advances the therapeutic goals in the form of new and corrective emotional nonconscious experiences. As discussed earlier (see Countertransference, this chapter), enactments are fraught with anxiety on the part of the novice psychotherapist or the traditional one-person psychotherapist attempting a foray into a relational model of work. As Altman (2004 ) states, “relationalists believe that the analyst is quite often not fully aware of the nature of his participation in the analytic interaction until an enactment.” However, it should be emphasized that self- disclosure is not providing education or giving advice to a patient; rather, it is a moment when the patient’s and psychotherapist’s intersubjectivities meet, and the psychotherapist believes a self- disclosure beneﬁ ts the process by facilitating anew emotional experience for the patient to store in nondeclarative memory. Thus, not all self-disclosures or enactments are conscious and will help the patient, and in fact some may lead to setbacks. There is not a “one rule ﬁ ts all” about when and what to self-disclose or enact, which is important for supervisors to keep in mind (see Chap. 14 ). What guides the psychotherapist is the here-and-now intersubjective mutuality, which leads up to the enactment of self-disclosure. Finally, the two-person relational psychotherapist “must concentrate his attention on the modalities of his communication such as intonation, rhythms and tempi of speech, in particular on the musicality of the voice” ( Ferro 2002 ). In essence, the psychotherapist’s actions speak louder than his or her words. It is worth noting that, despite the importance of self-disclosure as an enactment being at the heart of the two-person relational psychology technique, the decision to self-disclose may be complicated by many factors. Ziv-Beiman wonderfully illustrates this dilemma as she decides whether to self-disclose, and if so, what and how:

I am facing Naomi (age 34 years), one of my favorite patients, who is always hoping that her “knight in shining armor” will arrive to rescue her “sleeping beauty.” Eight months into treatment, we are stuck. I therefore take a calculated risk and, my heart beating, say to her, “most of my life I believed that only slim people are eligible for membership in the society called ‘humanity.’ My life would begin, I thought, only when I lost sufﬁ cient weight to gain entrance into this exclusive club. It took a lot of time—and pain—to realize that such waiting is useless. Finally, I gave it up and accepted my size. This acceptance comes at a price, however. Sometimes—fortunately not too often—I get rejected because of my weight. On the other hand, I am much less dependent upon external approval. Now I spend much more time expressing myself, feeling joy. I’m alive.”

In Ziv-Beiman ’s masterful self-disclosing example, it is not about what is said, but what is implicitly conveyed intersubjectively with her comments to the patient: “I have been there, I also felt insecure and had a difﬁ cult experience but it did not hold me back. I believe your feelings won’t hold you back either.” We recognize that there will be other clinicians with different internal working models of attachment and implicit relational schemas and they may choose a different way or a different 6.28 The Role of Parents and Family in Traditional One- Person 167

Table 6.2 Suggested practice guidelines in two-person relational psychotherapy Psychotherapists should generally self-disclose infrequently. The most appropriate topic for the psychotherapist to self-disclosure involves professional background, whereas the least appropriate includes sexual and religious beliefs. Psychotherapists should generally use self-disclosures to validate reality, normalize, strengthen the alliance, or offer alternative ways to think or act. Psychotherapists should generally avoid using self-disclosures for their own needs: removing the focus from the patient, interfere with the fl ow of the session, burden or confuse the patient, or blur the boundaries. Psychotherapists self-disclose in response to similar patient self-disclosures. Psychotherapists should observe carefully how patients respond to their self-disclosures, ask patient for reactions, and use the information to conceptualize the patient and decide how to intervene next. It may be especially important for psychotherapists to self-disclose with patients who have diffi culty forming relationships in the therapeutic setting. Adapted from Hill and Knox (2002 ) time to self-disclose. This refl ects the unique proclivities individual psychotherapists bring into the dyad that infl uence how they cocreate intersubjectively their experiences. Further, Renik (1999 ) believes that it is best to play one’s cards face up and states, “When an analyst is consistently willing to self-disclose, the patient is more fully authorized as a collaborator in the clinical work. The patient’s active participation may require the analyst to endure a measure of disconcerting exposure.” We have found useful the guidelines regarding self-disclosure by Hill and Knox (2002 ) in two-person relational psychotherapy (Table 6.2 ).

6.28 The Role of Parents and Family in Traditional One- Person Psychology and Two-Person Relational Psychology

The Role of Parents and Family in Traditional One-Person Psychology

The role of a child’s or adolescent’s parents in a consultation process (and in the course of treatment) is typically to provide the “objective” history of the child’s problem, to provide medical history, to review developmental milestones, and to consent to treatment. However, observing interactions between parents and their children provides the consultant an overview of the family’s object relations and dynamics. Upon completion of the initial diagnostic session or sessions, the pro- vider delivers the recommendation for psychotherapy, and if agreed to, he or she “sets the frame” for the process (see Chap. 9 ). Importantly, however, the role of parents in child and adolescent psychoanalysis has been controversial for many decades. The early controversies stemmed from Melanie Klein’s view that interpretations were essential for the treatment of children and that there was little need to 168 6 Deconstruction of Traditional One-Person Psychology Concepts include the parents. Moreover, Klein believed this would contaminate the process. The Neo-Kleinians took a more encompassing approach in working with parents. As such, Anna Freud believed that working in an educational context with the parents during the child’s psychoanalysis was important in order to become a developmental participant. Additionally, so as to avoid contamination of the transference necessary to learn about the child’s inner world, Freud believed that a different psychotherapist needed to be assigned to work with the parents. In this manner, the child analyst could communicate actively with the parents’ psychotherapist to learn about the realities of the child’s environment, without contaminating the process by working with the parents directly. Yet there has historically been limited attention paid to how to work with parents in traditional one-person psychology. For example, in the 11 chapters of A Handbook of Child Psychoanalysis ( Pearson 1968 ), only 3 of the 374 pages describe how to work with parents. The authoritative text suggests scheduling regular appointments with the parents throughout the psychoanalysis of their child and notes that there will be a “constant fl ow to the analyst of detailed reports as to how matters are going for the child in his home, his relationship with the parents and other signifi cant persons, his emotional variations in their precise settings, and the signifi cant expressions of his thoughts and attitudes with which the parents can supplement the analyst’s understanding of his young patient. And, at the same time, the analyst will be eliciting from the parents a more complete and detailed picture of the child’s entire life history, to be used as a background for understanding and as point of departure when specifi c recommendations for modi- fying the child’s program are made.” For some, work with parents was undertaken with caution as it was thought that the formation of the child’s inner confl icts were a consequence of the parent’s own unresolved confl icts and anxieties, and thus, the work with the parents had the potential to interfere with the psychotherapeutic process as a result of an unconscious encouraging of maladaptive defense mechanisms (Delgado et al. 1993 ). This notion parallels the central theme of Selma Fraiberg and colleagues’ (1975 ) classic treatise, Ghosts in the Nursery, which describes the parents’ intergenerational transmission of trauma with roots in their own history of confl icts that may unconsciously be repeated through the rejection of their own child. In child and adolescent psychoanalysis, when parents made efforts to be more involved in the child’s treatment, it was commonly thought to be related to the parent’s jealousy of their child for having a unique and positive relationship with the analyst. More recently, in traditional one-person psychology, the importance of having parents take an active role in the psychoanalysis or psychotherapy of their child or adolescent has been appreciated. For example, Yanoff (2005 ), in reviewing Kerry Kelly Novick and Jack Novick ’s book Working with Parents Makes Therapy Work (2005 ), writes, “[This] is a rare book. It is a book on a subject that is almost never written about in psychoanalysis, even though its subject matter, working with parents, is one of the most commonly encountered aspects of treating child patients. The reasons for this void in the literature have always been diffi cult to explain.” In traditional one-person psychology, the work with parents was partly educational and allowed attention to the interactions between parents and their children, the 6.28 The Role of Parents and Family in Traditional One-Person 169 parents’ fantasies and transferences toward the analyst or psychotherapist, and the countertransference reactions elicited by the parents. However, regarding these countertransference reactions, Pearson (1968 ) noted, “The nature of the treatment in child analysis permits of the greater possibility that the analyst will assume and gratify his wish to play one or another inappropriate parental role with the child: omnipotent, demanding, giving, overprotective, sadistic, seductive, positive or negative oedipal.”

The Role of Parents and Family in Two-Person Relational Psychology

A major role of a psychotherapist is to alleviate his patient’s parental anxieties, so as to prevent them from forestalling the psychotherapeutic process in the face of uncertainty. To this end, it is critical to involve the child’s parents early in the psychotherapeutic process and to make them active contributors. As previously noted, the role of the parents during the psychotherapy process of a child or adolescent is heavily infl uenced by the clinician’s theoretical stance. For the two-person relational psychotherapist, knowing about the child’s realities outside of the offi ce is emphasized, and this “knowing” demands help from the parents and occasionally from other family members and peers. Altman and colleagues (2002 ) remind us that “a relational approach to psychotherapy with children holds that there is no treatment that is devoid of the therapist participation. In this approach, the interpersonal nature of the work is one central theme rather than secondary or problematic. Taking a position with the parents as part of the work, then, is no longer an interference with the purity of the child’s therapy. Rather, it is an inevitable and useful part of the work, to be handled as thoughtfully as possible.” Additionally, it is worth noting that the psychotherapist has a tremendous infl uence on how other family members, teachers, mental health workers, and at times pediatricians approach the patient when knowing he or she is in psychotherapy. Thus, it is essential that the psychotherapist elicit their support in order to help strengthen the newly cocreated and more adaptive neuronal pathways of the child. However, it is generally best to take a supportive and educational approach when communicating with them. As will be seen in the clinical cases presented in the following chapters, an active role is taken by the relational psychotherapist in working with parents, and this role proves invaluable in helping the patient. For example, in the case of the 17-year-old adolescent female with relational problems (Chap. 13 ), the psychotherapist fi nds himself intersubjectively experiencing paternal and caretaking feelings toward his patient’s mother. This parallels the adolescent’s caretaking role of her mother, which allows the psychotherapist to appreciate his patient’s mother’s limitations in providing the affective attunement that his patient desperately needs. In the case of the infant with a feeding disorder (Chap. 10), the psychotherapist takes an active role in providing the infant’s parents a corrective emotional experience by teaching the importance in using motherese , with voice rhythmicity and an intonation that matched their son’s physical movements. 170 6 Deconstruction of Traditional One-Person Psychology Concepts

We wish to emphasize that a two-person relational approach allows the psychotherapist to consider a wider range of possible implicit relational problems of parents’ reactions to their child, if the child is part of a vulnerable population: chronic medical illness, a learning disability, or a developmental disability. Working with parents during the psychotherapy process allows the psychotherapist to intersubjectively attend to their experience of the problems and for providing the tools they need to implicitly feel as partners of the process, which goes a long way. Amerongen and Mishna (2004 ) capture this dynamic, saying: “Drawing from a body of knowledge about learning disabilities allows parents and therapists to more accurately grasp the meaning of the behavior which then guides effective management strategies. Informed empathy is a powerful tool in confronting the challenges of problematic behavior in children with learning difﬁ culties. By employing informed empathy, vicious cycles of family interaction can be reme- died and parents strengthened to provide more optimal developmental experiences for their children.”

6.29 Everyday Life of the Patient in Traditional One-Person Psychology and Two-Person Relational Psychology

Everyday Life of the Patient in Traditional One-Person Psychology

In a traditional one-person model of child and adolescent psychodynamic psychotherapy, the limits of active inquiries about the daily life of the patient are relaxed, an attenuation of “ boundaries .” Generally, traditional one-person psychotherapists understand that the child’s descriptions of their daily life represent aspects of the internal object representations of their parents. Thus, the everyday life of the child or adolescent is deemed important to confi rm the diagnostic formulation of the presenting symptoms, but not essential. Further, the availability of this information, as well as information gleaned from meetings with parents, inevitably infl uences what the psychotherapist considers to be of importance if it confi rms his or her theoretical formulation of the patient’s problems. For example, at a recent treatment panel discussion, a psychiatric consultant from a two-person relational model was invited to discuss the case of a 16-year-old intelligent adolescent boy with severe anxiety and diffi culties getting along with his peers. The presenting psychotherapist, trained in a traditional one-person model, formulated that the adolescent’s anxieties and diffi culties in getting along with peers resulted from oedipal confl icts and diffi culties with his second individuation process (Blos 1967 ) and that originated from living with his father and having limited contact with his mother following his parents’ divorce. The presenting psychotherapist shared a vignette in which the patient’s mother had left with his two younger sisters for New York for a weekend trip, while the remainder of the family remained in the Midwest. The psychotherapist viewed the trip as confi rmation that the patient’s mother “had a rejecting attitude toward him” because he was not taken on the trip, even though the patient had not given importance to this event. The two-person relational psychotherapist who was 6.29 Everyday Life of the Patient in Traditional One-Person 171 discussing the case questioned the notion that the patient’s mother was rejecting as she had sought treatment for her son, had been taking him regularly to his psychotherapy appointments, and had arranged for phone calls with her son while in New York. The relational consultant, in essence, raised the issue that frequently occurs in traditional one-person model: The information obtained is used to develop a case formulation that provides little room for the consideration of what the patient is sharing may be part and parcel of his everyday life (i.e., a mother taking her children on a trip). It would be beyond the scope of this book to provide the result of the consultation, but suffi ce it to say, it was agreed to reconsider the impression of the adolescent’s mother as rejecting. We are reminded of the quote attributed to Freud, “Sometimes a cigar is just a cigar.”

Everyday Life of the Patient in Two-Person Relational Psychology

In two-person relational psychology, the patient’s experience of his or her relationships outside of the sessions provides a window into the reality of his or her family and environment. It also allows one to assess the progress with regard to the use of more adaptive patterns in the face of everyday life obstacles. In the case of the adolescent described above, a relational psychotherapist might entertain several possible scenarios. First, the adolescent may have been jealous as he was not taken on the trip. Second, he may have been happy that his mother took his sisters, with whom he had a confl ictual relationship, to New York, and thus away from him. Third, he may have been relieved that all the females in the household were away. Fourth, he may have enjoyed the trust that his mother placed in him in allowing him to stay by himself. As we have discussed, the intersubjective experiences of the relational psychotherapist with the patient ultimately provide the roadmap for how to understand the event and how to proceed in order to provide a corrective emotional experience for the development of more adaptive neuronal pathways and implicit nondeclarative memory. A two-person relational psychotherapist attends to the everyday life events of the patient, as well as to the feelings experienced by the patient as he or she describes the events, in the here and now between the patient and psychotherapist. Ultimately, this contributes to a mutual cocreation of a new model in understanding the event and thus moves the therapeutic process forward. For example, an adolescent male who is seen in weekly psychotherapy shares with his psychotherapist his fright following his car having caught fi re while visiting a friend. He adds, “I was so lucky that I wasn’t in the car,” and uses his smartphone to show his psychotherapist a photo of the car after the fi re. Immediately, the psychotherapist realizes the serious- ness of the event and is able to genuinely comment, “I am glad you are safe.” The patient understands this a moment of meeting and says: “I know you care about me. More than I can say about my mother. She got mad and thought that it was my fault, until my grandpa told her it was not my fault; it was a faulty gas pump. I was scared, I could have been killed.” Thus, in this vignette, we see the sine qua non of two- person relational psychotherapy: “At the heart of relational therapy there is the 172 6 Deconstruction of Traditional One-Person Psychology Concepts therapist’s commitment to be present, with caring and focus, in the relationship. The commitment is particularly about being present while in session in the therapy room” ( DeYoung 2003 ).

6.30 Psychopharmacology in Traditional One-Person Psychology and Two-Person Relational Psychology

Psychopharmacology in Traditional One-Person Psychology

In the traditional one-person psychology model, the use of medication was fraught with doubt about its usefulness. The challenges to the psychoanalytic movement from the use of pharmacological interventions became prominent in the 1960s. This paralleled changes in the 1980 Diagnostic and Statistical Manual of Mental Disorders 3rd Edition (DSM -III , American Psychiatric Association 1980 ), when the infl uence of psychoanalytic theories began to lose ground. To this, articles that attributed many symbolic meanings to the use of medication proliferated in the psychoanalytic literature of the day. For example, in writing from a traditional one- person model, one psychoanalyst noted: “Unlike more generic or stereotypic meanings, object representations attributed to medication may refl ect the patient’s specifi c dynamics and object relations. These representations are many and mutable, and take on shifting and overlapping forms that evolve with the analytic process. Medication may represent a third person within the framework of an analytic treatment, expanding the analytic dyad into a triad and offering new transference paradigms to explore” (Tutter 2006 ). She added, “Defensive displacement of transferential qualities and attitudes, or split-off parts thereof, from the analyst onto medication can serve as a powerful resistance to the awareness of the transference to the analyst.” Over time, the psychoanalysts and psychotherapists acknowledged that the use of medication during psychoanalysis and psychodynamic psychotherapy could enhance both modalities. Thus, by the turn of the twenty-fi rst century, Gabbard and Bartlett (1998 ) noted that the question was “no longer whether combining medication and psychoanalysis is benefi cial; rather, a more compelling question is how the combination is benefi cial.” Nevertheless, in child and adolescent psychoanalysis and psychodynamic psychotherapy, the use of medications remains controversial. The benefi ts of the use of medication with children and adolescents have been questioned, and currently there continues to be signifi cant debate about whether the treatment of attention defi cit hyperactivity disorder (ADHD), anxiety disorders, and depressive-spectrum disorders with medications represents “best practice.” There is a negative perception from some colleagues working within a traditional one-person model with regard to the use of medication in children and adolescents. When a traditional one-person child psychoanalyst understands that a 6-year-old girl’s diffi culty sitting still and habit of interrupting others in class represent a form of acting-out behavior due to internal confl icts—and believes that helping the child understand the meaning of these 6.30 Psychopharmacology in Traditional One-Person Psychology and Two-Person 173 behaviors may lead to a decrease in symptoms—this understanding minimizes and dismisses the signifi cant evidence that she has ADHD ( Kaplan and Delgado 2006 ). Thus, in a traditional one-personal model, when, for example, the available clinical and collateral evidence supports a diagnosis of ADHD, countertransference enactments withholding the use of medication can be of signifi cant detriment to the child’s future. Additionally, in the traditional one-person model, a child’s resistance to taking medication may be considered a form of acting out of their internal confl icts. Generally, in the traditional model, when a child does not comply with taking medication for the treatment of their medical conditions (e.g., insulin for diabetes, an inhaled corticosteroid for asthma, chemotherapy for cancer), this resistance is attributed to internal confl icts that have been displaced onto the medication. A traditional one-person child psychoanalyst or psychotherapist may choose to help the patient understand the resistance as a matter of control, oedipal issues, fear of rejection, etc., and he or she may not recognize that the fear of taking the medication may be due to certain realities (e.g., the parents cannot afford it, the child knows of a peer that worsened taking the same medication, side effects not recognized by physicians). Finally, it goes almost without saying that the use of medication in children and adolescents can be a life-changing event. In the treatment of ADHD, the use of medication “is an important part of the therapist’s armamentarium, and often a necessary one” (O’Brien 1992 ). We have colleagues of the traditional one-person schools who openly state that medication limits what patients can learn in psychotherapy to improve self-regulation. We suggest that the psychotherapist recognize his or her biases about medication when working with a child, as they may be interfering with best possible results.

Psychopharmacology in Two-Person Relational Psychology

In the two-person relational model, the clinician’s choice to recommend medication is based on defi ned clinical criteria, paralleled with mutual intersubjectivity that provides the clinician an understanding of what it is like for the patient to struggle with their generalized anxiety, depressive symptoms, obsessions, tics, or attention defi cit hyperactivity disorder. Herein, with sensitivity, the psychotherapist can col- laboratively help the patient review the pros and cons of starting medication. When a two-person relational psychotherapist is reluctant to recommend medication, the child (or adolescent) or parents may implicitly recognize the reluctance and may withhold sharing the symptoms, thereby preventing the opportunity for a pharmacological intervention that may have provided marked improved functioning. This situation is not a form of countertransference or projective identifi cation in the traditional sense, but rather the psychotherapist’s nonconscious implicit working models of relating that cocreate a maladaptive emotional experience. It is hoped that over time the psychotherapist will attend to his or her intersubjectivity and recognize with humility that the patient may not be improving and, with the help of collateral information, may reconsider recommending the use of medication. 174 6 Deconstruction of Traditional One-Person Psychology Concepts

6.31 Other Forms of Psychotherapy

Traditionally, psychoanalysts and psychotherapists of traditional one-person orientation consider non-psychodynamic forms of therapies as not “real psychoanalysis or psychodynamic psychotherapy,” in that they give short shrift to the understanding of the inner life of the child or adolescent. In contrast, contemporary two-person relational psychotherapists consider the use of other forms of psychotherapeutic interventions as a necessary tool if one of those forms can recognize patient proclivities and allow for the moving forward of the process. Other forms of psychotherapeutic interventions used when appropriate include: (1) family therapy, (2) cognitive behavioral therapy (CBT), (3) dialectical behavioral therapy for adolescents (DBT-A), (4) interpersonal psychotherapy for adolescents (IPT-A), (5) trauma-focused cognitive behavioral therapy (TF-CBT), (6) group therapy, and (7) mindfulness-based cognitive therapy (MBCT). If the two-person relational psychotherapist does not have formal training in such therapies, he or she may consider referring the child to a colleague with expertise and work in tandem with them. As an example, an adolescent girl who has been engaged in making superfi cial cuts to her arms and is prone for further self-harm may benefi t from DBT-A, and then, when stable, a more formal two-person relational approach. A child with Tourette’s syndrome may benefi t from a combination of cognitive behavioral interventions— including habit-reversal therapy—as well as active psychoeducational family therapy and, after tic control has improved, a formal two-person relational approach to improve matters of self-esteem, if needed. An elementary school age child with a history of physical and sexual abuse may benefi t from TF-CBT, followed by a formal two-person relational approach.

6.32 The Use of the Couch in Traditional One-Person Psychology and Two-Person Relational Psychology

Traditionally, psychoanalysts have followed Freud’s suggestion of using a couch in psychoanalysis to allow patients to lie down and feel more relaxed when not looking at the analyst and thus freer to talk. Since the patients did not see the analyst’s facial expressions, they could focus on their fantasies, daydreams, and inner feelings. Ross (1999 ) notes that in lying down, a person’s perspective changes and they focus less on objects in the environment and more on images that arise from their own minds. Not bound by an awareness of the analyst’s facial expressions and gestures, the analytic patient is more readily able to imagine what the analyst is thinking or feeling, too, which enriches the experience of analysis. Emde (2009 ) raises the question that few have chosen to tackle: “Is the use of the psychoanalytic couch necessary knowing the importance of the face-to-face implicit meaning making which allows for the corrective emotional experience to occur at a nonconscious procedural level?” The use of a couch in traditional one-person psychology facilitates neutrality by treating the analyst as a blank screen, not interfering with the patient’s free associations. In contrast, the use of a couch in a two-person 6.33 Fairy Tales in Traditional One-Person Psychology 175 relational approach hinders the implicit reading of the facial expressions made by both parties needed for meaning making. The goal of the treatment is the co- construction of new emotional experiences based on the intersubjective and verbal reciprocity. As Emde ( 2009 ) states, “My impression is that more and more work is being done on occasions during analysis when there is sitting up and when there are face-to-face encounters.” The couch may be used at times if a patient is in the process of sharing traumatic events, and the patient will later need the face-to-face reciprocity of the available and present psychotherapist to reestablish the atmosphere of safety and cocreate new internal working models and schemas of implicit relational healthier patterns. Finally, Emde ( 2009) conjectures: “Perhaps sitting up, face-to- face interactions are especially important in early phases of traditional work when one needs to encourage trust and a sense of security as well as a positive hopefulness about adaptive change. Perhaps it is also especially important in the ending phase of work when the analysand is experiencing and trying out new beginnings, outside of the analytic relationship. Indeed, the role of taking up ‘practicing’ for new modes of adaptation in real life as part of the ﬁ nal phases of analytic work, with active encouragement of the analyst, is a topic deserving of more attention and is considered an aspect of the developmental orientation for psychoanalysis” (Emde 2005 ). In child and adolescent psychotherapy and psychoanalysis, the couch is generally not used. If it is used, it is an effort to allow the patient to feel comfortable, and typically he or she lies in a manner that allows him or her to see the psychotherapist face to face. Nevertheless, the authors wish to emphasize that in child and adolescent psychotherapy, there is a need for the psychotherapist to be visible (face to face) and to be present, demonstrated by his or her tone of voice—rhythmicity and through intonation—so that the child or adolescent feels safe and learns to be with others in healthier ways. The psychotherapist must ensure that this occurs and cannot take for granted what the patient will or will not implicitly remember. As Emde (2009 ) reminds us, much of the work with children and adolescents happens in the face-to-face encounters of social reciprocity with affective attunement.

6.33 Fairy Tales in Traditional One-Person Psychology and Two-Person Relational Psychology

If you want your children to be intelligent, read them fairy tales. If you want them to be more intelligent, read them more fairy tales. ― Albert Einstein

The popularity of a traditional one-person psychology among the lay public is evident in discussions of fairy tales, which are ubiquitous to the life of children. Exposure to fairy tales occurs when parents read to their children, when children read independently, and when children watch television. Moreover, fairy tales in the traditional one-person model are in many ways considered akin to dreams and fantasies in children. As such, in one-person psychology, a child’s interest in fairy tales reﬂ ects the child’s inner life conﬂ icts, whereas in the two-person relational 176 6 Deconstruction of Traditional One-Person Psychology Concepts perspective, fairy tales represent the imaginative skills of an author who keeps the child “hooked to the story,” much like a talented novelist keeps his adult reader hooked. The appeal to the fairy tales is its novelty that implicitly encourages children to develop their own imaginative skills in predicting (using nondeclarative memory ) what will happen next in the story.

Fairy Tales in Traditional One-Person Psychology

The importance of fairy tales in psychoanalytic thought dates back to Freud (1913 ), who wrote: “It is not surprising to fi nd that psycho-analysis confi rms our recognition of the important place which folk fairy tales have acquired in the mental life of our children. In a few people a recollection of their favourite fairy tales takes the place of memories of their own childhood; they have made the fairy tales into screen memories.” The popular Grimm brothers’ fairy tales Hansel and Gretel and Little Red Riding Hood have been staples of childhood for centuries and are represented in books, puppet shows, cartoons, board games, video games, and feature fi lms. In traditional one-person psychoanalytic literature, we fi nd that these two fairy tales have received signifi cant attention. In Fromm’ s (1951 ) review of Little Red Riding Hood , he wrote: “Most of the symbolism in the fairy tale can be understood without diffi culty. The ‘little cap of red velvet’ is a symbol of menstruation. The little girl of whose adven- tures we hear has become a mature woman and is now confronted with the problem of sex. The warning ‘not to run off the path’ so as not ‘to fall and break the bottle’ is clearly a warning against the dangers of sex and losing her virginity.” Additionally, in 1976 , Bettelheim published The Uses of Enchantment : The Meaning and Importance of Fairy Tales, in which he proposed that fairy tales help children face unconscious fears and confl icts, and he believed that through reading fairy tales, a child would be able to unconsciously work through these confl icts. Bettelheim believed that the main theme in Hansel and Gretel that appealed to children was their symbolic separation from their mother. Bettelheim examined Little Red Riding Hood’s journey through the forest and posited that this journey represented the task of dealing with the transition from childhood and entering adulthood (i.e., losing her virginity and reaching sexual maturity). In this treatise, he stated that Little Red Riding Hood unconsciously views the wolf as a representation of her Electra complex; the wolf is the unconscious father that has big arms, ears, eyes, and teeth. Further, when the wolf (Little Red Riding Hood’s father) asks, “What are you carrying under your apron?” he suggests an unconscious projection of her desire for her father to be aware of her sexuality. Additionally, Bettelheim believed that the hunter represented Little Red Riding Hood’s unconscious wish for rescue from her confl icted libidinal wishes toward her father, adding that when the hunter cuts open the wolf's belly, it represents her wish to have her father’s child. Later, a paper by the Finnish Psychiatry group (Psychiatria Fennica 1976 ) stated, “Fairy tales have a moral function, strengthening the ego by introducing it to realistic possibilities.” More recently, Jacobs (2011 ) reiterated the importance fairy tales have in traditional 6.33 Fairy Tales in Traditional One-Person Psychology 177 one-person psychoanalytic school of thought: “Fairy tales are understood as representing fundamental developmental confl icts, accounting for their enduring power over time. The analytic encounter is seen as an analogue of the fairy tale.” This is to say that traditional one-person school of thought often applies Freud’s drive theory and Klein’s object relations theory to understand fairy tales, which are believed to have an important role in the treatment of a patient’s unconscious confl icts represented by the story. Fairy tales from this view are also thought to represent children’s collective unconscious developmental struggles.

Fairy Tales in Two-Person Relational Psychology

We ask the reader to recall when, as a child, they were read the two popular fairy tales by the Grimm brothers— Little Red Riding Hood and Hansel and Gretel —or when the reader read them to their children. Of course, with new innovations in technology, some may have viewed the fairy tale through an electronic device or may have used such a device to play a video of the fairy tale to their child. It is our hope that the moment the reader recalls these fairy tales, he or she will use nonconscious implicit memory to recognize the story and then, seconds later, will recall the childhood experience, including who was present and in what context the story was read to them or to their child (e.g., in bed, in a playroom, at the park, read by a loved one). In doing so, the reader will have used an implicit relational knowing of the experience. This process occurs at a nonconscious level and allows for the retrieval, through sculpted neuronal pathways (chronic meanings), of the memories and experiences in regard to when the fairy tales were heard. Fairy tales are important to children who are fortunate enough to have caregivers that provide a secure environment that encourages reading or watching children’s stories in the presence of their emotionally available caregivers. Fairy tales promote the use of imagination and creativity. Additionally, they embody the fears and anxieties that are part of the developmental process that a child must master—with the help of his or her caregivers—toward a successful resolution and improved understanding of morals. Not surprising, parents, when reading or storytelling these fairy tales, make changes in their tone of voice to express reassurance to their child about the story’s anxieties and fears. There is a verbal dance between child and parent, but also a preverbal dance of meaning making ( Tronick 1989 ). Little Red Riding Hood begins, “Once upon a time, there was a dear little girl who was loved by everyone who looked at her, but most of all by her grandmother.” Hansel and Gretel begins: “Hard by a great forest dwelt a poor wood-cutter with his wife and his two children. The boy was called Hansel and the girl Gretel.” Both fairy tales begin by telling the reader that the children were loved and cared for. Nevertheless, when the story begins to speak about issues of fear and abandonment, it is immediately apparent that something about the story does not seem right. To wit, in Little Red Riding Hood , we hear: “‘Oh! But, grandmother, what a terrible big mouth you have!’ ‘All the better to eat you with!’” And in Hansel and Gretel, we hear: “Early tomorrow morning we will take the children out into the forest…and 178 6 Deconstruction of Traditional One-Person Psychology Concepts leave them alone. They will not fi nd the way home again, and we shall be rid of them.” Additionally, in the children’s version of the Grimm brothers’ tales, each tale ends by assuring the children that the characters return back safely and are loved: “Red Riding Hood thought to herself: ‘As long as I live, I will never leave the path by myself to run into the wood, when my mother has forbidden me to do so,’” while Hansel and Gretel “threw themselves round their father’s neck. The man had not known one happy hour since he had left the children in the forest.” It is worth noting that the Grimm brothers’ original tales were not thought not to be suitable for children due to their not so happy endings. They later revised some of their work in Children ’ s and Household Tales ( Ashliman 1987), and later it became known as The Complete Fairy Tales of the Brothers Grimm ( Zipes 2003 ). In fact, the original Little Red Riding Hood was written by French author Charles Perrault in the seventeenth century and originally titled Little Red Cap, later revised by the Grimm brothers to the form we are more familiar with today. Viewing these fairy tales from a two-person relational perspective, they implicitly reinforce traditional moral values in children—“Thou shall obey your parents, as they have loved and cared for you.” The loving parent asks their child to obey when walking through dangerous areas and to beware of seemingly friendly strangers. This is implicitly and explicitly understood between children and their parents. Thus, while Sandor Lorand , a psychoanalyst and prominent disciple of Freud (1935 ), in a traditional one-person model believed that fairy tales could help a child fi nd a solution to the confl icts from the Oedipus complex, he also viewed fairy tales in what we now consider a two-person relational model by taking into consideration matters of affective attunement. In this regard, Lorand noted: “The good or ill effect of fairy stories rests largely on the circumstances under which they are related to the child. The story must obviously be suited to the child’s age and condition. Care should be taken that the tale is told in the proper physical and psychological setting. The time of day when the storytelling takes place is, of course, important (for example, no ogre story before bed time). Even such a minor detail as voice modulation should be given careful consideration. Above all, the story teller should be certain that the tale is told for the child, and not out of a sense of duty, or merely to relieve certain tensions of his own.” We conclude by reminding the reader that fairy tales represent the essence of a child’s rich imaginative and creative skills. The fairy-tale author who understands children’s wish to master imagined and real-life worries will readily have the children “hooked to the story.” The appeal to fairy tales is their novelty that implicitly encourages children to develop their own imaginative skills in predicting what will happen next in the story.

6.34 Summary

We have described the different terms of concepts in traditional one-person psychology and our understanding of these concepts from a two-person relational model. We hope that, at the end of this chapter, the reader may distinguish between matters of unconscious transference, resistance, and defenses through a two-person References 179 relational lens. Finally, we suggest that the two-person relational psychotherapist jettison the terms of traditional one-person model in favor of a new two-person relational lexicon.

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Anatomy is destiny. —Sigmund Freud

Modern neuroscience has advanced signifi cantly since Freud ’s initial Project for a Scientifi c Psychology (Freud 1895), in which he hoped to apply scientifi c principles to the emerging discipline of psychoanalysis. As such, a sophisticated quest to understand the human mind—over the last 125 years—has led to the discovery of a radically different landscape than that which Freud had envisioned. In this regard, multimodal scientifi c investigations have openly questioned the validity of Freud’s concepts: “[Modern] science not only fails to support the central tenets of Freudian dream theory but raises serious questions about other strongly held psychodynamic assumptions including the nature of the unconscious mind, infantile sexuality, the tripartite model of the mind, the concept of ego defense, free association and the analysis of the transference as a way of effecting adaptive change” (Hobson et al. 2000 ). Moreover, recent advances in neuroimaging and neurodevelopmental research have profoundly advanced our understanding of the key areas of “the relational brain,” the substrate for two- person relational psychotherapy. Herein, we will briefl y review the historical developments of two-person relational psychotherapy, and in doing so, we will detail the specifi c advances in developmental psychology. Additionally, we will review the key theorists and researchers whose work and behavioral experiments made possible the neurophysiologic investigations, which have, in turn, given rise to our nascent understanding of the neurophysiology of attachment and intersubjectivity. Work in affective, social, and cognitive neuroscience and neuropsychology have had a signifi cant impact on psychodynamic psychotherapies. However, we distinguish between psychodynamic psychotherapies and psychoanalysis, because child and adolescent psychoanalysis is by and large guided by a traditional one-person

© Springer-Verlag Berlin Heidelberg 2015 185 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_7 186 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity psychology (Chap. 2 ) and has been reluctant to incorporate neuroscience and developmental psychology into current theory and practice.

7.1 Developmental Psychology: A Foundation for the Neurofunctional and Neurostructural Understanding of Two-Person Relational Psychotherapy

Developmental research, and in particular studies with infants, demonstrates that what is stored or represented in the form of memory seems not to involve words or images but rather experiences. Sander (1985 ) demonstrated that as early as 8 days old, an infant can store a mental representation of the experience of a feeding sequence that when disrupted (e.g., by a mother being asked to wear a ski mask during feeding) generates distress in the infant that is strong enough to suspend his or her feeding behaviors. Thus, memories of experiences are considered precursors to early forms of implicit relational knowing, a representation of how to be with another person that is not language based. The implicit domain is richer, more complex, and larger in terms of knowing about human behavior than explicit knowledge at all ages, not just in infancy. Thus, implicit relational knowing is based in affect and action rather than in word and symbol (i.e., preverbal) (Lyons-Ruth et al. 1998 ). This is to say, an infant knows that feeding is a pleasurable experience when seeing and feeling attuned by his or her emotionally available mother and disruptive when the feeding is not accompanied by the mother’s affective attunement. This process is also nonconscious and nonconﬂ icted, meaning it does need to be repressed, as was traditionally believed (Lyons-Ruth 1999). Moreover, this includes not only the desire and idea to act but also the action, the object of the action, and the goal. In an experiment, a preverbal infant observes a research assistant trying to drop an object into a bowl, but who fails by dropping the object in front of and then behind the bowl. Although the infant never sees the object dropped into the bowl, “with the invitation to imitate what he saw, he immediately drops the object directly into the bowl and seems contented with himself. The infant grasped the intention of the experimenter even though he never saw it successfully realized. He gives priority to the intention he has inferred over an action he has seen” (Meltzoff 1995 ; Meltzoff and Gopnik 1993 ). In another experiment, an infant watches an experimenter try to pull the spheres off the ends of a dumbbell-like object but fail. Later when the infant is given the object, he immediately pulls the spheres off and seems to feel good about what he has done. The control condition consists of a robot that, like the experimenter, tries to pull the ball-like ends off but also fails. However, when infants are given the dumbbell-like object after they watched the robot fail, they do not try to pull the ends off. These infants have implicitly understood that robots do not have intentions (Meltzoff 1995 ). Decety and Chaminade (2003 ) showed that an infant who would imitate a mother putting a doll to bed would not imitate her putting a toy car to bed. 7.2 Core Concepts of Development 187

7.2 Core Concepts of Development

The core concepts of development, as outlined by the National Research Council, Institute of Medicine, in the book From Neurons to Neighborhoods ( 2000 ), provide a clear and coherent road map of the developmental path of complex interactions between the infant’s innate attributes (i.e., nature) and the inﬂ uence of family and the environment (i.e., nurture ) in the context of social and cultural factors. Moreover, the dynamic complexities of the relationship between “nature” and “nurture” suggest that the concepts are best understood not as “nature versus nurture, but rather nature through nurture” (Institute of Medicine 2000 ). Herein, we will review each concept with regard to two-person relational psychotherapy in children and adolescents.

Human development is shaped by a dynamic and continuous interaction between biology and experience This concept is essential in understanding the complex dynamic world from which our young patients come. Relational theory, which encompasses two-person relational psychology, attends to the variability of neurobiology (e.g., innate temperament , mirror and echo neuron systems, attachment patterns, the family system, and the cultural aspects of both patient and psychotherapist). It is the amalgam of these factors that ultimately infl uences the interaction between the patient and psychotherapist and that allows for the cocreation of a unique intersubjective experience. Moreover, two-person relational psychotherapy can infl uence (through neuroplasticity -dependent mechanisms) the acquisition of a better model of adaptation to the relational world, and this process almost certainly has neurophysiologic foundations. This process in which experience facilitates neurostructural and neurofunctional changes has been eloquently demonstrated in several recent preclinical studies, which collectively suggest that the relationship between early stress and adversity, as well as poor-quality interpersonal experiences (e.g., being raised in an international orphanage), is associated with defi cits of functional connectivity between the amygdala and prefrontal cortex . Additionally, in lower animals, early-life adversity is associated with changes in neuronal architecture in regions that—in humans—likely subserve the encoding of relational experiences (e.g., hippocampal neurons) (McLaughlin et al. 2007 ) and in cortical areas responsible for the processing of interactions (e.g., cortical pyramidal neurons) (Vyas et al. 2002 ). Additionally, there is evidence, again in lower animals, that chronic, early adversity may drastically alter the morphology of the neurons within the amygdala, including increased dendritic arborization and the lengthening of dendrites (Fig. 7.1 ) (Vyas et al. 2006 ).

Culture infl uences every aspect of human development As we have reviewed elsewhere (Delgado and Strawn 2014 ), culture —the constellation of languages, social customs, traditions, beliefs, and values shared by a group of people linked by family, race, ethnicity , region, or culture of origin—profoundly infl uence human development. Additionally, an individual’s culture infl uences what is considered the norm for loving and stable relationships. This norm will guide prenatal care, birth 188 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

Fig. 7.1 Chronic environmental stress (blue ) results in increased arborization, increased dendritic spine density, and elongation of dendrites in the basolateral amygdala compared to dendrites from animals who have not experienced environmental adversity (red )

delivery systems accessed, feeding, sleeping, and parenting practices. Regarding concepts that are germane to two-person relational psychotherapy (e.g., “meaning making” and “implicit relational knowing”), it is clear that culture contributes to the shaping and development of these processes, as well as to the underlying neurofunctional and neurostructural bases of these processes. Recent functional neuroimaging studies of Asians compared to Caucasian Americans have demonstrated interesting ﬁ ndings in this regard. When individuals from cultures that “habitually attend to the needs, perspectives, and internal experiences of others compared to the self” viewed images of others in emotional pain, increased activation of the anterior cingulate cortex and insula is observed in the Asian subjects relative to the Caucasian American subjects. This suggests that 7.2 Core Concepts of Development 189 culturally bound “attunement to the subjective experience of others” may be associated with neurofunctional differences across cultures (Cheon et al. 2013 ). Additionally, the degree of dependency in cultures affects the processing of anger, “an emotion that implies the disruption of harmony.” In this regard, during a task of empathic processing, healthy Chinese individuals, who in this study are self- described as more interdependent than German individuals, have increased activity in the dorsolateral prefrontal cortex, while the Germans exhibited increased activation of the inferior and superior temporal gyrus (de Greck et al. 2012 ). Moreover, the activation in the inferior and superior temporal gyrus correlated with the degree of independence in the sample, suggesting that increased culturally related tolerance for anger is associated with activity in the inferior and superior temporal gyrus and insula (de Greck et al. 2012 ). Thus, while individual differences in empathy and experience may direct these neurofunctional differences and the process is likely multidimensional with genetic and state-dependent modulation, it is clear that culture is the ever-present factor that inﬂ uences the ways we communicate with patients, inhibits or enhances our understanding of their illnesses, and provides the context that explains their reactions to the event (Delgado and Strawn 2014 ).

The growth of self-regulation is a cornerstone of early childhood development that cuts across all domains of behavior Children have the complex task of implicitly and nonconsciously learning to manage emotions in the context of interpersonal interactions, in addition to learning to regulate their internal physiological states. This complex task is beautifully captured by Winnicott in his famous aphorism, “There is no such thing as a baby,” meaning that without a mother, an infant cannot exist, and we now recognize that infants have an intrinsic need for interaction with their caregivers. Put differently, Emde (1987 ) notes that “infants’ emotions are, by their nature, relational.” Thus, the child with a history of problems in self-regulation due to developmental or cognitive delays (e.g., autism , ADHD , learning disabilities) may benefi t the most from a more structured approach or a more behaviorally oriented approach (e.g., parent–child interaction training [PCIT], behavior management) or, in the case of ADHD, from pharmacotherapy. Nonetheless, we are not implying that psychodynamic psychotherapy is not helpful to some children with self-regulation problems; we are saying that a careful assessment of these aspects will allow for a detailed identifi cation of those that will not benefi t from psychodynamic psychotherapy. Additionally, it is important to note that the capacity for self-regulation may be signifi cantly infl uenced by trauma (Schore 2002 ). In this regard, children and adolescents with histories of maltreatment exhibit defi cits in a myriad of neuropsychological domains, including attention and abstract reasoning/executive function, which likely subserve the capacity for self-regulation (Beers and DeBellis 2002 ). Moreover, there is also evidence to suggest that the neural circuitry of self- regulation is altered in children and adolescents who have experienced signifi cant trauma. For example, Herringa and colleagues (2013 ) observed lower resting-state functional connectivity between the hippocampus and subgenual cingulate and 190 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity reduced resting-state functional connectivity between the amygdala and cingulate cortex in maltreated youth relative to healthy comparison subjects. Additionally, in this sample, resting-state connectivity for these structures mediated the association of maltreatment earlier in life and the presence of internalizing symptoms in adolescence, suggesting that early maltreatment “may alter the regulatory capacity of the brain’s fear circuit, leading to increased internalizing symptoms by late adolescence” (Herringa et al. 2013 ).

Children are active participants in their own development, reﬂ ecting the intrinsic human drive to explore and master one’s environment There is an innate developmental motivation on the part of a child to master his or her environment and to learn “getting along” with others. Moreover, early positive experiences with caregivers have a profound role in the developmental process in that it promotes affect regulation and the neurophysiological changes entailed. Herein, a child is an active participant in their development, seeking to elicit the affectively attuned responses needed from their caregivers for a successful process.

Human relationships and the effects of relationships on relationships, are the building blocks of healthy development Attachment theory (see Chaps. 3 and 8 ) provides a longitudinal view of the way in which a child establishes early dyadic relationships with his or her parents or caregivers. In turn, these relationships determine the quality of emotional relationships that the child will have with others throughout his or her life span. As such, the internal working models of relationships and the goodness of ﬁ t both serve as foundations for and ultimately facilitate interpersonal relationships. It is recognized that developmental or behavioral disturbances in infants and toddlers may be a product of disturbances in the infant–caregiver dyad (Bowlby 1999 ; Sameroff and Emde 1989 ). In this regard, this discordance appears to have a neurofunctional basis. As such, a recent functional magnetic resonance imaging (fMRI ) study involving mother–infant dyads observed that mothers who were more sensitive to their infants had increased activation of the right prefrontal cortex , including the right inferior frontal gyri, in response to their infants’ cry, compared to those mothers who were less sensitive to their infants (Musser et al. 2012 ). Additionally, in this study, mothers who exhibited more intrusive responses to their infants had increased activation in the left anterior insula and temporal pole, whereas mothers who had more harmonious interactions with their infant displayed greater activation in the left hippocampal regions (Musser et al. 2012 ).

The broad range of individual differences among young children often makes it diffi cult to distinguish normal variations and maturational delays from transient disorders and persistent impairments Differences in cognitive and affective ability affect one’s ability to achieve developmental competency or, in other words, to participate in rewarding experiences with others. In this regard, neuroimaging studies suggest structural and functional brain abnormalities associated with the presence of cognitive and linguistic communication disorders that 7.2 Core Concepts of Development 191 underlie these differences in cognitive and affective ability (Delgado et al. 2011 ; Frodl and Skokauskasm 2012; Lai 2013; Webster et al. 2008 ). Specifi cally, regarding learning disorders, 10 % of the general population may have learning weaknesses, and among this group, many have formal learning disabilities (Altarac and Saroha 2007 ; Cooper et al. 2007 ). Considering these statistics, there is a selective group of children and adolescents that have persistent impairments that make it diffi cult to assess maturational norms. Further, there is a group of children with physical disabilities, including individuals with visual impairments, hearing impairments, speech disorders, etc., who may experience maturational delays. However, it is critical to recognize that within such a group, there will be signifi cant variability in apparent cognitive and affective ability, and it is of great importance to carefully characterize any defi cits in the context of these sensory limitations.

The development of children unfolds along individual pathways whose trajectories are characterized by continuities and discontinuities as well as by a series of signifi cant transitions Development in children and adolescents occurs as a series of transitions that are typically punctuated by physiological and physical changes that parallel adaptive psychological advances (Emde and Harmon 1984 ). A range of putative mechanisms likely mediate these developmental processes, as well as heterotypic continuity and psychopathologic progression. These mechanisms include gene x environment interactions , “‘kindling’ effects, environmental infl u- ences, coping mechanisms and cognitive processing of experiences” (Rutter et al. 2006 ). Moreover, when developmental transitions are due to or coincide with a serious illness or traumatic event, signifi cant physiological and physical changes that end in psychological discontinuities with maladaptive mechanisms may ensue. An example frequently seen by mental health professionals that captures the continuities and discontinuities of children is toilet training. This process can occur along several possible pathways. For some, it may occur when developmentally expected (between 24 and 36 months) and without major diffi culties, while for others, parental anxieties and wishes to have toilet training occur sooner or more quickly may result in discontinuity with varying psychological sequelae. We clearly have come a long way from early psychoanalytic thought in which problems with toilet training were considered to be due to a fi xation or regression of anal-level intrapsychic confl icts.

Human development is shaped by the ongoing interplay among sources of vulnerability and sources of resilience The way in which a child adapts to physical and emotional life challenges depends on the innate factors that activate speciﬁ c gene expression patterns, resulting in the production of protective and regulatory factors. However, some children may be more vulnerable than others and may be less affected by family or environmental adversity. The susceptibility to stressful or traumatic events for a particular child continues to be difﬁ cult to determine, and it will be critical for future work to explore these factors, particularly in “dandelion children” (i.e., those youth who are psychologically resilient and able to survive 192 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

Probability of developing Probability Major depressive disorder Major depressive

Number of stressful life events

Fig. 7.2 Serotonin transporter promoter polymorphism predicts likelihood of developing depression as a function of stressful life experiences. The red line represents individuals who contain two short alleles (s/s), whereas the green line represents individuals who contain one short allele and one lone allele (s/l) and the blue line represents those individuals who are homozygous for the long allele (l/l) (Adapted from Caspi et al. (2003 ) ) under adverse circumstances) (Boyce and Ellis 2005; Dick et al. 2011 ). Recently, several studies of the genetic basis of resilience have focused on functional polymorphisms in the serotonin transporter promoter region. Caspi and colleagues ﬁ rst described this mechanism in a longitudinally followed cohort study in which this particular functional polymorphism moderated the effect of adverse events on the subsequent development of depression. In this regard, individuals who had one or two copies of the short alleles exhibited increased depressive symptoms compared to individuals who were homozygous for the long allele when they had experienced signiﬁ cant life adversity (Fig. 7.2 ), “thus providing evidence of a gene-by-environment interaction, in which an individual’s response to environmental insults is moderated by his or her genetic makeup” (Caspi et al. 2003 ).

The timing of early experiences can matter but, more often than not, the developing child remains vulnerable to risks and open to protective infl uences throughout the early years of life and into adulthood The recognition of a children’s neurodevelopmental plasticity in response to environmental changes refl ects “the capacity of the brain to reorganize its structure or function, generally in response to a specifi c event or perturbation” (Institute of Medicine 2000 ), and “varies inversely with maturation,” affi rming the need for early interventions in order to achieve the best outcomes. Accordingly, the two-person relational psychotherapist facilitates brain neuroplasticity through here-and-now, intersubjectivity-based experiences, which promote the development and strengthening of specifi c brain circuits that are increasingly capable of processing mutual understandings when relating to others. 7.3 The Neurobiology of Two-Person Relational Psychotherapy 193

The course of development can be altered in early childhood by effective interventions that change the balance between risk and protection, thereby shifting the odds in favor of more adaptive outcomes The most effective two- person relational interventions occur early in the course of development and are tailored to the physical and emotional needs of each child or adolescent and their family. The interventions should be tailored to help the child or adolescent resume their developmental tracjectory and should also facilitate the family unit’s return to a homeostatic state, rather than relying on a theoretical formulation that may limit the breadth of interventions needed.

7.3 The Neurobiology of Two-Person Relational Psychotherapy

To understand the neurobiology of two-person relational psychotherapy and of the developmental concepts described in this text, we must understand a number of key concepts in neuroscience. In the sections that follow, we will explore the neurophysiology of these key concepts: (1) neuroplasticity , (2) the mirror neuron system , (3) the default mode network, (4) social referencing and affective attunement, (5) temperament , and (6) reﬂ ective functioning. For each of these processes, the relevant brain structures and connectivity will be described.

Neurodevelopment: A Broad Overview

The development of the human nervous system is dependent on a myriad of genetic and environmental factors. Additionally, there is signiﬁ cant remodeling of the nervous system throughout development as an effect of experience, exposure to events, learning, and through various epigenetic processes. Importantly however, while neural connectivity changes throughout life, it is during infancy, the early school age years, and then puberty that the greatest rate of change occurs. It is also during these periods that there are signiﬁ cant regional changes in gray matter volumes (Fig. 7.3 ). Many of these neurodevelopmental processes rely on neuroplasticity - related phenomena. In short, neuroplasticity refers to the changing of neural networks through both “pruning ” and also through the strengthening of synaptic connections. Thus, as the brain processes sensory information, frequently used synapses are strengthened while unused synapses weaken and eventually cease to exist. Certainly, neuroplasticity has critical importance in two-person relational psychotherapy as summarized by Buirski and Haglund (2009 ): “Successful treatment leads to the formation of new organizations of experience, new ways of understanding oneself, and new expectancies based on these new understandings…. What happens to the archaically formed ones? They neither disappear, are forgotten, nor are completely replaced by the newly formed ones. Rather, they persist in weakened form within the organization of the personality.” They conclude by stating that when a 194 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

1.0 0.9 Age 0.8 0.7 0.6 20 0.5 0.4 0.3 Gray Matter Gray 0.2 0.1 0.0

Fig. 7.3 Gray matter density signiﬁ cantly varies as a function of development, with latter maturation occurring in the prefrontal cortex in late adolescence (Adapted from Gogtay et al. ( 2004 ) ) person is under “duress, old maladaptive organizing principles can reemerge, reviving past negative, self-defeating experiences.” In essence, two-person relational psychodynamic psychotherapy aims to provide a corrective emotional experience (Alexander et al. 1946 ).

7.4 Structures and Networks in Two-Person Relational Psychotherapy

Anterior Cingulate Cortex

The cingulate cortex forms the superior boundary of the limbic system and over- lies the corpus callosum from the rostrum to the splenium (Devinsky et al. 1995 ) and is functionally and anatomically divided into several regions—anterior, mid, and posterior—which have been further divided (Fig. 7.4 ). The anterior cingulate cortex subserves the dual processing of cognitive and emotional information, as well as the functional integration of these two streams (Allman et al. 2001 ; Yamasaki et al. 2002 ). fMRI studies of this region in anxious youth have revealed increased activation of this region during the viewing of fearful faces (McClure et al. 2007 ), and activation in this region correlates with amygdala and 7.4 Structures and Networks in Two-Person Relational Psychotherapy 195

Fig. 7.4 The cingulate cortex, shown in this cortical reconstruction, forms the superior boundary of the limbic system and is comprised of several distinct subregions, including the subgenual and pregenual anterior cingulate (light purple ) as well as the dorsal anterior cingulate (red )

Fig. 7.5 The ventromedial prefrontal cortex (vMPFC , yellow ) is shown in this cortical reconstruction

ventrolateral prefrontal cortex activation in anxious children and adolescents (McClure et al. 2007 ). Importantly, the anterior cingulate cortex is functionally connected with a concert of other structures that collectively orchestrate relational processes (Fig. 7.5 ).

Medial Prefrontal Cortex

The medial prefrontal cortex (Fig. 7.5 ) is distinct in that, unlike the anterior cingulate or amygdala , it is large and comprised of multiple gyri, including the middle frontal gyrus, inferior frontal gyrus, orbital gyri, etc. This structure is consistently implicated in functional neuroimaging studies of social relatedness, social decision making (Lin et al. 2012 ), empathy , and anticipation of social engagement. Moreover, it has been suggested that the medial prefrontal cortex is “an action-outcome predictor concerned with learning and predicting the likelihood of outcomes associated with actions” (Alexander and Brown 2011 ). Additionally, this structure is connected 196 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

DLPFC Hippocampus

Subgenual Dorsal ACC ACC

Thalamus (MD)

Amygdala Ventral Striatum

Hypothalamus Sympathetic Nervous System VLPFC

Emotion Attention- Cognition

Fig. 7.6 The neurocircuitry of relational processing. The neurocircuitry of relational processing is highly connected with the prefrontal network. ACC anterior cingulate cortex, VLPFC ventrolateral prefrontal cortex, DLPFC dorsolateral prefrontal cortex. Dotted lines represent inhibitory relationships with other regions within the prefrontal cortex, as well as the amygdala, hippocampus , cingulate cortex, and some posterior regions, including the precuneus and cuneus (Fig. 7.6 ). Given the interconnectivity with other structures, the medial prefrontal cortex is a key structure within the default mode network (see below).

The Amygdala

The amygdala resides deep within the limbic system and is principally responsible for generating central fear responses. This bilateral structure is composed of multiple nuclei that are reciprocally connected to the hypothalamus, hippocampus , and neocortex. The amygdala gives rise to two major efferent projections: stria terminalis and ventral amygdalofugal pathways. The stria terminalis innervates the nucleus accumbens and the hypothalamus, whereas the ventral amygdalofugal pathway innervates the medial thalamus and anterior cingulate cortex . In general, most but not all functional neuroimaging studies have demonstrated increased amygdala activity in adolescents with a myriad of psychiatric disorders and traits, including anxiety (Strawn et al. 2014). It is noteworthy that this structure appears to not only be functionally hyperactiviated in children and adolescents with anxiety disorders but also those who are anxious in situations involving uncertainty and, in particular, the intolerance of uncertainty, particularly with regard to relational phenomena. 7.4 Structures and Networks in Two-Person Relational Psychotherapy 197

Fig. 7.7 The precuneus ( light blue ) and cuneus ( orange ), shown in this cortical reconstruction, are contiguous structures which are frequently implicated in self-referential and self- versus- other tasks

Fig. 7.8 Intrinsic connectivity network data from an adolescent utilizing ICA components that were best matched to templates, respectively, using spatial correlation (Image courtesy of James Eliassen, PhD, University of Cincinnati, Center for Imaging Research)

The Default Mode Network

The default mode network consists of a number of connected structures, including the medial temporal cortex, the medial prefrontal cortex , the posterior cingulate cortex, the precuneus (Fig. 7.7 ), and the parietal cortex . It has recently been deﬁ ned based on resting-state connectivity observations from independent component analysis (Beckmann et al. 2005 ; Schopf et al. 2010 ; van den Heuvel and Hulshoff Pol 2010) (Fig. 7.8). This network is preferentially activated during “internal” tasks (e.g., daydreaming, anticipation of the future, memory retrieval, and when imagining another’s experience or perspective). 198 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

Of particular relevance to implicit relational knowing, the default mode network may be responsible for generating spontaneous thoughts and linking experiences, and it includes many of the same structures and regions that are implicated in temperament , attachment, and mentalization (see below). Additionally, this network—in particular the medial prefrontal cortex (Fig. 7.3 )—subserves the “social understanding” of others, and the functioning of this complex relational process is subserved by a number of subregions within the medial prefrontal cortex. In this regard, Li et al. (2014 ) have noted that these subregions of the medial prefrontal cortex participate in disparate processes as a function of their subsystem role within the default mode network. First, the ventromedial prefrontal cortex connects with other regions subserving emotional processing that are engaged during social interactions. Second, the anterior medial prefrontal cortex, along with other medial cortical structures, is highly connected to the cingulate cortex (both anteri- orly and posteriorly), and this connection appears to subserve self- (with regard to other) distinctions. Third, the dorsomedial prefrontal cortex, along with connections to structures within the temporoparietal junction, appears to be activated during the reading and understanding of another’s mental state. In a recent review of the medial prefrontal cortex within the context of the default mode network, Li and colleagues (2014 ) note that “as behaviors become more complex, the related regions in frontal cortex are located [anatomically] higher…. This reﬂ ects the transfer of information processing from automatic to cognitive processes with the increase of the complexity of social interaction.” Given our current understanding of the default mode network, this system appears to be critical for both social reciprocity and implicit relational knowing—central tenet of relational psychotherapy.

The Mirror Neuron System and Its Functional Neurophysiology

Without question, of the recent discoveries of neuroscience, the concept that has had the most impact in the ﬁ eld of psychodynamic and other forms of psychotherapy is the mirror neuron system. While knowledge of this system originates from intracerebral recordings from lower primates, the system has been hypothesized to exist in humans. The early primate studies suggest that neurons within the inferior parietal lobule and inferior frontal cortex are activated when an animal observes another individual perform a speciﬁ c action and are similarly activated when the individual is performing the same action. While the existence of this system in humans is somewhat controversial and limited direct data are available regarding humans, should such a system exist in humans, it would be of critical importance in two-person relational psychotherapy. In this regard, Rizzolatti and Craighero (2004 ) eloquently capture the potential importance of this system with regard to understanding other people: “Mirror neurons present the neural basis of a mechanism that creates a direct link between the sender of the message its receiver. Thanks to this mechanism, actions done by other individuals become messages that are understood by an observer without any cognitive mediation.” 7.5 Genetics and Two-Person Relational Psychotherapy 199

Thus, the mirror neuron system represents key neural elements needed for the understanding of the intentions of others. Additionally, recent data from transcranial magnetic stimulation studies “indicate that a motor resonance system may exist in humans and that it possesses important properties not observed monkeys,” and the dysfunction of the mirror neuron system in humans may be an underlying core deﬁ cit in autism , perhaps shedding light about the social isolation common in persons with autistic spectrum disorders. Moreover, studies of mirror neuron systems suggest that one participates in the intentional states of the other at a neuronal level by activating the motor neurons corresponding to the intentional actions observed in the other but without having to imitate the other’s actions (Decety and Chaminade 2003 ). It is important to note, however, that mirror neurons do not simply code the actions of others but also their intentions (Iacoboni et al. 2005). In this regard, recent fMRI studies demonstrate that areas presumed to represent human mirror neuron areas (e.g., the inferior frontal cortex and superior parietal cortex ) respond differently to the observation of the same grasping actions, and these reactions seem to be embedded with recognition of the different contexts of the intentions associated with the grasping actions, such as drinking or cleaning (Iacoboni et al. 2005 ). Thus, the mirror neuron system may not only code the action (e.g., grasping) but also code the intention associated with it (e.g., grasping to drink). A corollary system to the mirror neuron system, related to language processing, has also been described in lower animals. This system, the echo neuron system, may in fact represent a subgroup of mirror neurons (Lotto et al. 2009 ); Rizzolatti and Craighero (2004 ) suggest that the system may be activated “when an individual listens to verbal stimuli, [and] there is an activation of the speech-related motor centers.” Further, Zatorre (2013 ) notes “recent evidence indicates that individual differences in anatomical and functional properties of the neural architecture also affect learning and performance in these domains.” If additional evidence supports this theory, it will likely have signiﬁ cant implications regarding the importance of the tone and rhythm of the psychotherapist’s verbal communications to the child and adolescent in psychotherapy.

7.5 Genetics and Two-Person Relational Psychotherapy

In the early 1990s, an explosion of developmental research in infants shook the foundation of traditional one-person psychological approaches, and their impact continues to reverberate. These studies have called for increased attention to be put on the very early developmental factors—during the critical phases—that serve as the foundation for development of the infant brain. Along with this has been increased attention to genetic infl uences. To date, genetic studies have focused on associations of specifi c polymorphisms with structural and functional neuroimaging fi ndings and have also explored the relationship between specifi c genes and temperamental traits, with the latter largely relying on genome-wide association studies (GWAS). 200 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

Neurochemistry and Two-Person Relational Processes

While we primarily focus on the neurostructural and neurofunctional factors that infl uence the two-person relational concepts in this chapter, it is important to remember that the brain is inherently “wet,” and as such, it is bathed in a number of neurochemicals that affect both relational processes and the neural substrates of these processes. In this regard, recent attention has focused on the “social hormone,” oxytocin , a peptide hormone that was discovered and synthesized more than a half century ago (Du Vigneaud et al. 1953 ). Data from lower animals suggest that oxytocin is involved in affi liative and bonding actions. Similarly, in humans, intranasal administration of oxytocin increases interpersonal trust (Kosfeld et al. 2005 ) and increases gazing at the eye region of human faces (Guastella et al. 2008). Thus, the clinical potential for oxytocin to promote pair bonding, maternal behavior, social attunement, and socialization in certain psychiatric syndromes, including autism , depression, and posttraumatic stress disorder (PTSD), has received considerable attention. One recent study of oxytocin that is of is of direct relevance to two-person in two-person relational psychotherapy involved an examination of the synchrony of maternal and paternal brain responses to infant cues. In this study of parents of 4- to 6-month-old infants, coordination of both maternal and paternal functional brain activation in social–cognitive networks that had been previously implicated in empathy and social cognition was observed when participants viewed their children playing in a video. Interestingly, maternal amygdala activation correlates with oxytocin concentrations. Taken together, these fi ndings suggest that “social-cognitive networks that support intuitive understanding of infant signals and planning of adequate caregiving may be gender specifi c [and that]…synchrony in the brain response of two individuals within an attachment relationship…develops within the matrix of biological attunement and brain-to-brain synchrony between attachment partners” (Atzil et al. 2012 ).

Neurostructural and Neurofunctional Basis of Temperament

Recent investigations of temperament have revealed both anatomical and functional differences in a variety of structures, although these investigations have often utilized broader dimensions of temperament than the classic four dimensions as described by Thomas and Chess ( 1982). Speciﬁ cally, many of these investigations have focused on inhibited temperament , “a tendency to avoid novelty,” which is a risk factor for anxiety disorders and may be associated with anxious attachment. Inhibited temperament is associated with increased amygdala activity when subjects view unfamiliar and unexpected faces (Blackford et al. 2011), and it is also associated with attenuated activity within the dorsal anterior cingulate cortex , which suggests that, functionally, “enhanced amygdala sensitivity coupled with weak inhibitory control from the dorsal anterior cingulate may form a neural circuit mediating behaviors characteristic of inhibited temperament” (Clauss et al. 7.5 Genetics and Two-Person Relational Psychotherapy 201

2011 ). Additionally, Blackford and colleagues recently examined the functional connectivity of this amygdala–anterior cingulate circuit in individuals with inhibited temperament and observed that increased inhibition was associated with decreased connectivity within the default mode and dorsal attention networks and increased connectivity in salience and executive control networks (Blackford et al. 2014 ). This fi nding is of particular relevance to two-person relational psychotherapy in that the default mode network is intimately involved in self-referential thought processes. Additionally, and of direct relevance to relational psychotherapy, behavioral inhibition is also associated with group x time effects with regard to amygdala activation. As such, Blackford and colleagues recently demonstrated in young adults who were classifi ed as having behavioral inhibition that habituation of both the amygdala and hippocampus varied as a function of temperament: Youth with uninhibited temperament demonstrated habituation in both the amygdala and hippocampus, whereas youth with inhibited temperament failed to habitu- ate in terms of amygdala and hippocampus during repeated presentations of faces (Blackford et al. 2013 ). Finally, the temperamental trait of behavioral inhibition observed in young children (<5 years of age) not only subtends relational and neurofunctional aspects of an individual, but it is also associated with persistent structural differences that appear to persist throughout development (Hill et al. 2010). In this regard, Hill and colleagues have observed signifi cant relationships between orbitofrontal cortex volume and markers of behavioral inhibition that were observed when subjects were 5 years old or younger. Specifi cally, when the behaviorally inhibited children were reported to have spent more time proximal to their mother and greater time staring at other children, larger amygdala volumes were observed during the adolescent period (Hill et al. 2010 ).

The Neurocircuitry of Implicit Relational Knowing

Examinations of the neurocircuitry of implicit relational knowing have focused primarily on the medial prefrontal cortex, as well as the cingulate cortex, precuneus, and cuneus. Interestingly, different aspects of relational knowing appear to be subserved by subregions of these structures. In this regard, neuroimaging studies have identifi ed “intention detection centers” that are activated in a subject when he or she observes behaviors in another that lead the subject to infer an intention (Ruby and Decety 2001 ). Specifi cally, in a fMRI task that involved a fi rst-person perspective versus a third-person perspective, the right inferior parietal, precuneus, posterior cingulate, and prefrontal cortex were activated, suggesting that these regions subserve the detection of “self-produced actions” compared to those of others (Ruby and Decety 2001 ). In addition, work related to implicit relational knowing has employed the use of a social feedback task in which individuals received and—of particular importance—anticipated social feedback. During the period of time they were awaiting the social feedback, there was increased activity in the ventral striatum, a structure 202 7 The Neurodevelopmental and Neurofunctional Basis of Intersubjectivity

Fig. 7.9 Decreased average cortical convexity (i.e., primary curvature) in the medial prefrontal cortex in anxious adolescents, in whom anxious attachment patterns predominate ( p < 0.05, Monte Carlo corrected with 10,000 iterations) that is generally implicated within the brain’s “reward circuitry” and also in the dorsomedial prefrontal cortex. Moreover, individuals who tended to experience rejection (i.e., had high scores on a rejection sensitivity) had greater responses in both the striatum and the dorsomedial prefrontal cortex when they were expecting positive responses (Powers et al. 2013). Needless to say, this has almost direct relevance to clinical relational work. Finally, at the extremes of social cognition (e.g., autism and DSM - 5 anxiety disorders), there have been interesting developments with regard to neurostructural ﬁ ndings. A recent postmortem study (Stoner et al. 2014) suggests that differences in cortical maturation between weeks 19 and 27 underlie social deﬁ cits observed in the most severely relationally impairing disorders—the autism spectrum disorders. Thus, it is quite likely that milder alterations in cortical maturation and migration, if present, could result in more subtle alterations in relational capacity and attachment. In this regard, we observed that in anxious adolescents—in whom anxious attachment patterns predominate—cortical thickness in regions that have been linked with anxious attachment and self-versus-other processing (e.g., medial prefrontal cortex) exhibits increased cortical thickness and decreased primary cortical curvature (Fig. 7.9 ) (Strawn et al. 2014 ).

Neuroscience of Reflective Functioning

The functional neuroimaging of mentalization has focused on a series of medial structures, which are often implicated in “ theory of mind ” fMRI tasks as well. Mitchell and colleagues (2006 ), using fMRI, observed that when individuals mentalize about someone who is “similar” to themselves, ventral regions of the medial prefrontal cortex are activated, and these activations are linked with self-referential thoughts. By contrast, when individuals mentalize about someone who is dissimilar from themselves, the dorsal regions of the medial prefrontal cortex are activated (Mitchell et al. 2006 ). Interestingly, these ﬁ ndings suggest that the ventromedial References 203

Fig. 7.10 The neurocircuitry of relational processing shown is in this cortical reconstruction, including the medial prefrontal cortex ( light blue ), pre- and subgenual anterior cingulate cortex (periwinkle blue ), dorsal anterior cingulate ( red ), and the precuneus and cuneus (green and yellow, respectively ) (Adapted from Strawn et al. ( 2014b ) )

prefrontal cortex (Fig. 7.5 ) preferentially subserves “using knowledge about oneself to mentalize about others.” The neurobiology of two-person relational psychotherapy is ultimately subtended by a number of structures, including the amygdala , medial prefrontal cortex, anterior cingulate cortex , precuneus, cuneus, and hippocampus . These structures, which at least cortically are located in the midline (Fig. 7.10), coordinate with the limbic networks and default mode networks to subserve social referencing , affective attunement , and reﬂ ective functioning —the foundation processes of two-person relational psychotherapy.

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Such is the wonder of the human condition; the emergence of new ways of being together and new meaning in relation to the world and to one’s self. —Ed Tronick and Marjorie Beeghly

The modern child and adolescent psychiatrist is well trained, familiar, and comfortable with the use of the structured DSM - 5 ( Diagnostic and Statistical Manual of Mental Disorders , 5th Edition, APA 2013 ) interview style. In some contexts, an even more structured interview may be desired, and several well- validated tools are available to achieve this, including the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) and the Schedule for Affective Disorders and Schizophrenia for School Aged Children: Present and Lifetime Version (K-SADS-PL ), which have both been demonstrated to have high levels of interrater and test–retest reliability (Sheehan et al. 2010 ; Kaufman et al. 1997 ). Thus, our assertion is not that these methods are invalid or unreliable; rather, they are somewhat limited when seen within the context of a contemporary two-person relational psychology model in understanding human behavior and psychopathology. In our experience, the well-worn biopsychosocial model of diagnostic formulation is an uneasy trinity of disparate disciplines (Engel 1980 ). As commonly practiced, each of these domains is derived from a different historical origin and maintains its own set of beliefs. Given these inherent differences, the limited capacity for true integration becomes apparent. However, by substituting the traditional one-person model with the contemporary two-person relational approach, we have fundamentally transformed the biopsychosocial model by bringing harmony within its ranks. Considering that two-person relational psychology was developed over the last century hand in hand with advancements in the ﬁ elds of genetics, attachment theory , developmental research, neuroscience, and social and cognitive sciences, it is

© Springer-Verlag Berlin Heidelberg 2015 207 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_8 208 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview natural that the standard diagnostic interview needed to be revised into a more ﬂ exible and comprehensive approach. We have structured this chapter with the goal of helping the child and adolescent psychiatrist in training, the newly minted, or the experienced clinician learn how to use the two-person relational contemporary diagnostic interview model. This interview model provides an integrated developmental approach (biopsychosocial) in understanding children or adolescents, which can help develop realistic and practical treatment recommendations. The integrated interview is intended to be helpful in any setting and not limited to the evaluation of a child’s or adolescent’s readiness for psychotherapy.

8.1 Contrast of the Contemporary Diagnostic Interview (CDI) to a Traditional Diagnostic Interview

The goal of any diagnostic interview is to help the child and adolescent psychiatrist or trainee tailor the treatment approaches that best suit the patient and ideally take a biological, psychological, and social integrated approach (McConville and Delgado 2006 ). The child and adolescent psychiatrist traditionally asks the child, adolescent, and/or their parents to share the history of their present illness, with a timeline that establishes when they fi rst noticed the symptoms, the frequency of symptoms, and variations in the intensity of symptoms over time, along with precipitating and per- petuating factors. Over the course of a traditional psychiatric evaluation, the child and adolescent psychiatrist or clinician may quickly become focused on elucidating risk factors, identifying predictors of treatment response, and determining which “symptoms ” meet threshold criteria for a disorder. Thus, with the standard use of the Diagnostic and Statistical Manual of Mental Disorders , 5th Edition (DSM - 5 , APA 2013 ), the diagnosis is based on a collection of signs and symptoms that have been well defi ned. The child and adolescent psychiatrist or clinician is charged with incorporating the information obtained from the patient, his or her family, and also other multiple sources (e.g., prior medical or psychiatric treatment records) into the formulation of effective recommendations, whether psychotherapeutic or psychopharmacological. It is agreed that an integrated biological, psychological, and social interview is valuable when assessing patients and developing well-thought-out treatment plans (Delgado and Strawn 2014 ). However, it is generally agreed that child and adolescent psychiatrists in training learn to switch interview and diagnostic approaches rather than integrate them, as Cardoso Zoppe et al. ( 2009 ) state, “There is still tension between biological and psychosocial tendencies.” They further highlight that current teaching methods for trainees routinely lack integration and are heavily infl uenced by the setting in which the patient is seen (e.g., academic, local hospital, community mental health center) and their supervisors’ school of thought (e.g., traditional one-person, psychopharmacologist, behaviorist). 8.1 Contrast of the Contemporary Diagnostic Interview (CDI) 209

A 12-year-old male with poorly controlled bipolar disorder A 12-year-old male with poorly controlled bipolar disorder has been increasingly agitated at home and at school. In supervision, it is suggested that the child and adolescent psychiatrist trainee consider increasing the dose of the patient’s mood stabilizer. A few months later, in the same setting but with a two-person relationally informed supervisor, the trainee shares that the child has continued to respond poorly to the medication changes. Though a combination of two mood-stabilizing agents intended to treat a rapid-cycling bipolar disorder was considered, the supervisor considers an alternative diagnostic formulation. The possibility within the integrative model is that the child may have cognitive weaknesses, which could explain his poor abilities for behavioral self-regulation when asked to complete complex tasks (e.g., schoolwork, homework, and chores); medications had been of limited value in these contexts. The supervisor asks if the trainee had inquired about whether the trou- bling behaviors were also reported when the child was involved in simple tasks, such as games with family and peers, or when engaged in sports. In fact, there were differences, although the trainee had thought they were due to the ebb and ﬂ ow of a mood disorder and not suggestive of temperamental and cognitive problems. Furthermore, the trainee shares that the patient had a psychotherapist who described the child as difﬁ cult with a poor moral compass and who asked the trainee to consider changing medications as the current “are not working.” In short, the trainee and psychotherapist had not taken an integrated developmental approach in their diagnostic formulation of the child.

From a biopsychosocial perspective, we propose that when an integrated developmental approach is used in developing a comprehensive diagnostic formulation , as in the case of the 12-year-old boy described above, it facilitates the complex decision making needed to outline the sequencing of the interventions to ensure successful outcomes. One might describe this approach as a grasp of the interplay between the forces of nature and nurture (Table 8.1 ).

Table 8.1 The biopsychosocial model

Biological The biological information should include: a history of present illness, past personal and family’s medical and psychiatric history as well as the patient’s innate temperament style, developmental milestones, and cognitive function.

Psychological The psychological data, when seen through a contemporary two-person relational model of inquiry, includes: psychological developmental milestones, internal working models of attachment, cognitive flexibility, and implicit relational patterns observed during the back and forth of the co-created subjective experiences between patient and the clinician.

Social The social component of the integrated approach assesses: observed attachment patterns between patient and family, within the context of social norms influenced by their cultural beliefs, values and rituals. 210 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

We are aware that the skeptic child and adolescent psychiatrist trainee would ask whether a biopsychosocial developmental interview is useful or practical. Further, some feel that the child and adolescent psychiatrist should practice at the top of their license: the evaluation of a psychiatric DSM - 5 diagnosis with pharmacological recommendations and a referral to an allied professional for psychosocial interventions if considered appropriate (Drell 2007 ). The authors are frequently asked, “Isn’t a detailed biopsychosocial evaluation needed only if we are going to recommend individual or family therapy?” This could not be farther from the truth, when considering that an integrated approach provides the critical information needed in designing treatment recommendations and gives insight about whether the patient and family is likely to comply. In using a traditional DSM - 5 type of interview, generally the child and adolescent psychiatrist’s diagnostic formulation is based on the assumption that the responses by the patient and parents or caregivers are factual and accurate, unless due to psychotic processes or developmental disabilities . Delgado and Strawn ( 2014 ) aptly capture the limitations of the DSM - 5-style interview in child and adolescent psychiatry, namely, that it ignores the patient’s temperament, internal working models of attachment, learning abilities or weaknesses, and cognitive ﬂ exibilities within the backdrop of the family and of the social and cultural environment in which they have lived. Herein, the careful assessment of the patient’s innate and relational factors allows the child and adolescent psychiatrist or clinician to obtain in a succinct manner critical information as to whether the responses provided are actually factual and accurate and then use this information to tailor an effective treatment regimen (Delgado and Strawn 2014 ). Although attending to temperament , internal working models of attachment, learning abilities or weaknesses, and cognitive ﬂ exibilities may initially seem like a

A 12-year-old male with poorly controlled bipolar disorder (continued) As we continue the case of the 12-year-old child with bipolar disorder, the agitation and behavioral problems were seemingly due to temperamental dif- ﬁ culties, insecure attachment style, and learning disabilities that contributed to poor cognitive ﬂ exibility and suggest why medications were changed often and with limited results. In knowing this, the trainee can begin to sequence the interventions: This is done by requesting formal cognitive testing, beginning wraparound in-home services, developing visual behavioral strategies at school, and educating the family and teachers about having realistic expectations for the child. daunting task for the child and adolescent psychiatrist or clinician, it avoids poly- pharmacy and reduces the likelihood of serious side effects. We are not minimizing the lifesaving experiences some children and adolescents can have with the appropriate use of medication; rather, we are cautioning about the tension between 8.2 Overview of the Contemporary Diagnostic Interview (CDI) 211 biological and psychosocial interventions that can be limiting to a child’s future (Kaplan and Delgado 2006 ).

8.2 Overview of the Contemporary Diagnostic Interview (CDI)

Although we have identifi ed some of the weaknesses of the traditional DSM - 5 structured interview model, our primary goal is to add and enhance the techniques available to the child and adolescent psychiatrist or clinician’s toolbox to improve the diagnostic reliability needed. However, we would not expect many of the “tools” to initially fi t neatly into current clinical practice. The contemporary diagnostic interview (CDI) is aimed at observing and interacting with patients and their parents or caregivers, and it is designed to capture a different spectrum of information that is inaccessible by the standard DSM - 5 -style interview. As with the adoption of any new useful and practical technique, the initial challenge will be overcome through careful study and frequent practice. We have found that the CDI increases reliability, consistency, and accuracy in the description of the signs and symptoms endorsed by children and their parents or caregivers, allowing for the development of a comprehensive diagnostic formulation , as well as a two-person relational psychodynamic formulation. Herein, we will outline a “how to” guide to complete a detailed CDI for the reader to consider using in his or her day-to-day clinical work. In certain medical situations such as a stroke or a dangerous arrhythmia, we would argue that all the evidence needed for an accurate diagnosis and assessment are plainly visible. However, we would argue that neuroscience has demonstrated that human behavior does not readily play by the same rules of the observable to the plain eye. Human behavior is exquisitely contextual and is infl uenced by numerous factors, including both internal and external cues. Thus, a traditional unilateral approach may, despite the best intentions of the clinician, result in obscuring the true nature of the psychological diffi culties and thus prevent optimal treatment. In contrast, we suggest that engaging in the complex process of understanding our patients and their parents or associated caregivers requires the active participation by the child and adolescent psychiatrist or clinician to create an atmosphere of safety, curiosity, and exploratory inquiry of all participants’ subjective experiences, which will result in a more accurate representation of the patient’s lifestyle and concerns at hand. To illustrate this point, we consider our colleagues in pediatric cardiology . The astute reader may claim that any form of a psychiatric diagnostic interview is not different than a pediatric cardiology evaluation, as they are both based on a collection of signs and symptoms that have been well defi ned. In fact, child and adolescent psychiatrists, like pediatric cardiologists, have begun to use neurological diagnostic tests, computerized testing, and laboratory tests with increasing frequency. We propose that the difference lies in the moment in which the pediatric 212 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview cardiologist intently listens to the quiet perturbations of the heart with his stethoscope on the chest of the young patient. In these few seconds, the pediatric cardiologist integrates his or her own subjective sense of what the young patient needs to feel safe as the pediatric cardiologist reaches for the patient’s chest with exquisite sensitivity to the patient’s unique physiology, quietly responding to what he or she hears and rapidly adjusting his or her attention and exam based on this moment of cocreation. The pediatric cardiologist’s future actions are tempered by the observable and the implicit feedback provided by the young patient in the here-and-now moments during the examination. Here, we must stress that this is not a “mystical” moment but rather one informed through the unique clinical intuition about working with children that was acquired during the cardiologist’s early childhood experiences as implicit relational patterns stored in his or her implicit nondeclarative memory systems and also through his or her subsequent rigorous training grounded in an in-depth understanding of anatomy and physiology. Herein, in a recent study, pediatric cardiologists could identify a pathologic heart condition using only their physical exam nearly 92 % of the time (Mackie et al. 2009 ) even when they did not have access to an electrocardiogram (routinely performed at most visits). Thus, there is both an explicit and implicit comparison between the pediatric cardiologist’s and the child and adolescent psychiatrist’s exam. The moments during the time a stethoscope is on the chest, the awareness and interpretation of these “moments of meeting” (Chap. 5 ) shared by both parties are critical to any subsequent decision making. The child’s experience in the situation will infl uence their heart rate and their willingness to cooperate. Scientifi c advancements have broadened our understanding of the importance of nonverbal communication and implicit nondeclarative memory when people interact with each other. For the pediatric cardiologist, the lines are blurred between a verbal history and the telltale physical signs; both stories are provided by the young patient yet neither is suffi cient. We hope to demonstrate through the fi ndings of modern developmental research and neurosciences that the tried-and-true semistructured verbal interview is only a narrow slice of the raw spectrum of data available to the child and adolescent psychiatrist.

The Contemporary Diagnostic Interview • The clinician provides an atmosphere of safety • Approaching the patient and parents or caregivers with vitality • The alliance: goodness of ﬁ t for mutual curiosity • The clinician has an open frame of mind

The Four Pillars of the Contemporary Diagnostic Interview • Temperament • Cognition • Cognitive ﬂ exibility • Internal working models of attachment (IWMA) 8.3 The Contemporary Diagnostic Interview 213

Putting It All Together: Diagnostic Formulation and Treatment Plan • Two-person relational psychodynamic psychotherapy • Cognitive and behavioral therapies • Criteria for formal cognitive testing • Criteria for pharmacological intervention

8.3 The Contemporary Diagnostic Interview

The goal of a contemporary diagnostic interview is to facilitate the expression of the patient’s and his or her parent’s temperament, cognition, cognitive fl exibility, and the patterns of relating with each other and with others. The child and adolescent psychiatrist’s or clinician’s initial approach is best received when all parties are included in the interview. This allows for an initial in vivo subjective experience of how the patient and family have “danced together.” This is heightened by the fact that a request for a psychiatric evaluation of a family member places the system in a stressful situation. The advancements in developmental research and neuroscience inform us that many more people are implicitly present during the encounter than what appears. In addition to the personality attributes of the child and/or adolescent and his or her family, the child and adolescent psychiatrist also brings, through his personality, his or her own set of early childhood implicit relational experiences. Thus, given our understanding of internal working models of attachment, the interview room is actually crammed by nonconscious neurological imprints of past and present from each individual. We will now describe how the child and adolescent psychiatry trainees and experienced clinicians alike can effectively perform a contemporary diagnostic interview (CDI). Thus, to effectively perform a CDI, the child and adolescent psychiatrist or clinician will need to do the following simultaneously: (1) provide an atmosphere of safety in which the patient and his or her parents realize that they are more than a set of signs and symptoms to be fi xed; (2) approach the patient and parents and/or caregivers with vitality ; (3) provide a genuine emotional alliance that allows for mutual curiosity about each other’s subjectivities, including temperament, cognition, cognitive fl exibility, and internal working models of attachment (IWMA) from childhood experiences; and (4) begin the interview with an open frame of mind that allows for the psychiatrist or clinician to respond intersubjectively and in a meaningful way to the patient’s and his or her family’s subjectivities. As Buirski and Haglund say, “There is no subjectivity without intersubjectivity ” (2009 ).

The Clinician Provides an Atmosphere of Safety

Patients and families approach mental health appointments with a great deal of trep- idation and anxiety. Without an effort to create an atmosphere of safety to reduce their implicit anxiety, the information obtained will be ﬁ ltered through their lens of caution and thus will be partially true but not complete. We can implicitly help 214 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview patients and families feel safe if they subjectively experience that the psychiatrist or clinician is considering them as a system that has lived together for many years rather than as persons with symptoms. With practice, the clinician can initiate a conversation with friendly and jovial joining comments about external attributes of the patient and parents or caregivers to create an experience for them in which they feel important as persons and not simply entities with signs and symptoms.

Approaching the Patient and Parents or Caregivers with Vitality

In our experience, approaching the patient and their parents or caregivers with vitality as part of a CDI provides the child and adolescent psychiatrist or clinician the opportunity to engage with an openness and willingness to be known as a person that is interested in who the patient and their parents or caregivers are as both people and members of a larger unit. There is one teaching metaphor that resonates across demographics and captures the core principles of the CDI vitality: approaching the patient and parents or caregivers as a young family member. We propose that the contemporary approach to a patient and their parents or caregivers should be similar to that of approaching a young family member (e.g., cousin, niece, or nephew). When adult family members meet a young family member, and it occurs as a welcoming and desirable moment (albeit with some anxiety), secure internal working models of attachment implicitly create a space of vitality that allows the young child and parents to “fi gure out” how to successfully and emotionally attune to each other. The adult family member’s active sense of curiosity allows the young child, in the nonverbal realm, to search for social reciprocity and affective attunement with the adults, which then become coded and stored in nondeclarative memory (Chap. 5 ). The loving family members fi rst learn to be like them (the young child) by synchro- nizing their gaze and with rhythmicity matching the voice and body movements of the young child. This facilitates the process of the young child recognizing the adult family member as like me ( the young child). Both sides can then begin to store each other’s state of mind in nondeclarative memory (Meltzoff 2007 , see Attending to the external attributes of the patient, this chapter). In using this as a metaphor for interacting with our patients, we encourage the child and adolescent psychiatrist or clinician to set the open frame of mind necessary to help create an atmosphere of curiosity , which facilitates the “fi guring out” process of the patient’s and their parents’ or caregivers’ capacity for curiosity of others’ mental states. In doing so, the child and adolescent psychiatrist or clinician will be in a position to know if the verbal discourse matches their nonverbal communication, giving reliability to accuracy of the information disclosed.

The Alliance: Goodness of Fit for Mutual Curiosity

Studies on temperament recognize the importance in having a goodness of ﬁ t between a child and his or her parents or caregivers for the child to develop self- regulatory abilities and adaptive models of interactions with others effectively 8.3 The Contemporary Diagnostic Interview 215

(Huizink 2008 ). We propose that the concept of goodness of ﬁ t between patient (and their parents or caregivers) and the child and adolescent psychiatrist or clinician is equally important in a CDI. Exploring the patient’s and their parents’ or caregivers’ ability to be curious by being curious about them is essential. For example, a jovial child and adolescent psychiatrist with an easy/ﬂ exible temperament will facilitate a patient with generalized anxiety disorder to share details about their anxiety. This is because the patient implicitly is reassured by the child psychiatrist’s manner that they will be understood. Further, the jovial child and adolescent psychiatrist may need to make a concerted effort in slowing their tempo—voice and rhythm of verbal inquiry—when interviewing a child and family with a slow-to-warm-up temperament, as his jovial attitude may inhibit the patient if it is perceived as pressure to talk. In contrast, we have seen occasions when child and adolescent psychiatrists approach patients and their family in an overly professional and serious manner, which does not allow for an atmosphere of safety and, in essence, limits the reliability of the information shared by the patient and family.

The Clinician Has an Open Frame of Mind

In child and adolescent psychiatry textbooks, setting the frame of mind by the clinician when interviewing the patient and parents is superfi cially described as the need to be empathic in order to establish rapport. We have found extant literature about the importance in setting the frame of mind in the child and adolescent psychiatrist or clinician during an integrated developmental biological, psychological, and social contemporary diagnostic interview process. We submit that the frame of mind of the child and adolescent psychiatrist when preparing for a CDI is crucial for gathering information. Setting the frame of mind is essential for creating an atmosphere of safety for the patient and their parents or caregivers in order to increase reliability, consistency, and accuracy in the description of the signs and symptoms they endorse. We cannot emphasize enough that during a CDI, the child and adolescent psychiatrist’s or clinician’s personal attributes and beliefs will undoubtedly infl uence what and how the patient chooses to share in regard to the problems and symptoms they endorse. The patients (and their parents or caregivers) will be nonconsciously and implicitly (see Chap. 3 ) looking for nonverbal cues and behaviors by the clinician to learn about his or her frame of mind and authenticity when in the room. The child and adolescent psychiatrist or clinician brings his or her own temperament, cognitive fl exibilities , internal working models of attachment , and implicit relational knowing models formed in early childhood to the interaction (see Chap. 5 ), which will contextually infl uence what the patient and his family feel comfortable disclosing. The reader may ask how the child and adolescent psychiatrist or clinician sets his or her frame of mind to allow for bidirectional subjectivities to develop with the patient and parents or caregivers that are conducive for the necessary relational closeness . We defi ne an open frame of mind as when the psychiatrist or clinician meets the patient and their family without preconceived opinions about how patients of certain ages should think and behave. The suspension of analytic thought allows 216 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview for bidirectional subjectivities to develop. Therefore, the clinician’s assumptions and beliefs regarding what is generally considered normal developmentally will need to be constrained as best as possible during the initial phase of the interview.

The clinician has an open frame of mind A 16-year-old African-American adolescent female patient had a close relationship with both of her parents, in spite of their divorce two years prior. What led to the evaluation was that when her father began to date another woman, the patient began to feel unhappy and unmotivated about completing her schoolwork. She felt that her father’s girlfriend was critical of the closeness she had with her father, “and my father would just let her criticize me.” The child and adolescent psychiatrist intersubjectively experienced the patient as being genuine and realistic about her current dilemma and stated in a jovial, slightly humorous and somewhat sarcastic manner: “It sounds to me like your father avoids getting in the middle, although he is the one who created the dilemma. This leaves you and his girlfriend needing to ﬁ gure it out. That seems quite unfair. I think we need to ask your father to openly share that both of you are important to him.” The patient, with excitement and appreciating the sarcasm, responded: “Wow, that’s it. Kind of funny the way you said it. I was letting his girlfriend win when I began to act like a stubborn kid, proving I was immature. My dad set us up, he needs to know I can share him if he tells his girlfriend how much I mean to him.”

The example shows that the clinician’s open frame of mind and authenticity helped the patient refl ect on the reasons for her anger and self-defeating behavior. The interaction was facilitated by the personal attributes of the clinician, who had experience in working with adolescents from divorced families. He openly shared his view of the dilemma and, in doing so, cocreated more adaptive ways for the patient to manage her dilemma. The interaction may have had a very different outcome if the clinician had preconceived opinions about the tumultuous confl icts adolescents have with their parents after the parents’ divorce. It may have led the clinician to nonconsciously assume that the patient was somewhat unrealistic, diffi cult, and demanding, which would have prevented allowing the intersubjective experiences between patient and clinician to guide the process. The clinician’s closed frame of mind may have led him or her to suggest less adaptive solutions to the dilemma based on generalizations about the adolescent’s problem, encourage the patient to limit her wish for closeness with her father, ask the patient to address her father’s girlfriend directly, or hypothesize that the patient’s unhappiness would be best managed with medication, to name a few. Additionally, if the patient struggled with a nonverbal learning disorder or other cognitive limitations, the description of her confl icts with her father may not have been accurate and the clinician would have intersubjectively experienced the patient as superfi cial and unable to view matters from her father’s vantage. 8.3 The Contemporary Diagnostic Interview 217

Herein, the child or adolescent psychiatrist or clinician, by having an open frame of mind during the CDI interview process and regardless of the age of the child or adolescent, can accept that there is no true objectivity without taking into account the intersubjectivity cocreated by all involved.

The clinician’s initial preconceived notion and the importance of culture A 14-year-old Asian-American adolescent male, who had a close relationship with his parents, began to display oppositional behavior and refused to participate in family activities related to his parent’s Asian culture. He also declined to continue with violin classes, which were important to his parents, who hoped it would lead to a scholarship in music for college. His parents were reluctant to seek psychiatric help, feeling it was a personal family matter. They fi nally were forced to seek help for their son when he voiced having suicidal ideation to a school counselor. The child and adolescent psychiatrist typically used a jovial and humorous approach. He recognized that culturally his approach could be experienced as disrespectful—unlike in his own culture—and set his frame of mind to approach the family in a tempered manner to allow for the intersubjective experience to guide his approach. In meeting the patient and parents, he felt intersubjectively that the family was not interested in his opinions; they believed their son’s problems were foolish and requested the clinician to reiterate to their son that he had to obey them as they had given him everything he needed to pursue a college education. The patient stated in a sarcastic manner, “I am not their cultural experiment. They do not understand me.” The clinician intersubjectively initially noticed feeling like the parents; the adolescent was being abrasive and unrealistic, a common view where it is thought that fi rm limit setting by parents is needed. The clinician intersubjectively noticed a wish to step in for the parents asking the patient to appreciate their efforts to educate him. In doing so, the clinician recognized that his feelings stemmed from an implicit relational pattern familiar in his family: “children should be seen and not heard.” With this in mind, he recognized that he did not have an open mind, as he had preconceived notions about what the family needed, which did not allow his intersubjective experiences to guide him. With this realization, he opened the intersubjective fi eld and was able to take the vantage point of the cultural dilemmas in both parties (the parents, Asian, and the patient, Asian-American). He proceeded to say, “This must be diffi cult for all of you. As parents, you are correct in wanting to remain culturally loyal to your values and beliefs, and your son is also correct on wanting to fi t in his peers’ social and cultural environment.” This allowed the parents to consider the possibility that their son’s oppositional behavior was due to the fact that he was struggling with integrating the social and cultural discrepancies in his life and was hoping for his parents’ understanding.

This example captures the potential difﬁ culties that can be created when the clinician has a preconceived opinion of the nature of the patient and family’s 218 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview situation. In this case, he had a preconceived notion that because the family was Asian, their beliefs and values needed to be respected and adhered to. Fortunately, in allowing the intersubjectivity cocreated with the adolescent to guide the process, he recognized that his preconceptions were limiting his ability to help the adolescent.

8.4 The Four Pillars of the Contemporary Diagnostic Interview

Mental illness does not exist in a vacuum; it is a set of signs and symptoms that affects a person within the context of their personality and their environment. The treatment must be of the person and not only of their illness. The four pillars of a CDI are essential for understanding a patient from the inside out. The authors defi ne the four pillars of a CDI as those that defi ne a person’s unique personality within the context of others. The four pillars are the synergy of innate and environmental processes that become the blueprint of how a child learns to develop and maintain self- regulatory abilities and unique implicit relational patterns to successfully interact with others. The fi rst three pillars—temperament, cognition, and cognitive fl exibility—form the foundation of the fourth pillar, internal working models of attachment (IWMA). By understanding the contribution from each of the pillars, the clinician will have a true biopsychosocial understanding of the patient and their parents or caregivers, as well as their needs. Although many psychodynamic and attachment-theory-based texts pay limited attention to temperament and cognitive functioning in forming personality, contemporary developmental research has demonstrated that an individual’s genetic makeup is a determining factor in the formation of a personality, which some consider the basis of the psychodynamic self (Mancia 2006 ). We now will review each of the four pillars obtained during a CDI. The pillars are outlined in the order in which they emerge in the psychological development of a person. We note that when using a CDI, the four pillars are simultaneously elucidated.

8.5 Temperament

Temperament refers to the “stable moods and behavior proﬁ les observed in infancy and early childhood” and came to the forefront in developmental psychology and child psychiatry in the 1960s and 1970s (Chess et al. 1960 ). Thomas and Chess ( 1999) are recognized for their landmark scientiﬁ c contribution to the study of temperament. Their seminal work has achieved general consensus in that its expression has been consistent across situations and over time. In their study, Thomas and Chess longitudinally evaluated 141 children over 22 years, from early childhood until early adulthood (1982 , 1986). Over the course of the evaluation, nine temperament traits became apparent. 8.5 Temperament 219

Temperament Traits Derived from Thomas et al. ( 1970)

• Activity level • Rhythmicity or regularity • Approach or withdrawal responses • Adaptability to change • Sensory threshold • Intensity of reactions • Mood • Distractibility • Persistence when faced with obstacles

The work of Thomas and Chess confi rmed what the British psychoanalyst and father of attachment theory, John Bowlby , MD (1907–1990), had hypothesized: A child’s temperament infl uences how the child is experienced by their parents and signifi cantly shapes how the parents interact with the child (Bowlby 1999 ). This way of thinking, where an active and bidirectional relationship exists between the child and caregiver, represented a signifi cant point of divergence from the previously accepted understanding of the infant as a passive recipient and product of his or her environment (Mahler 1974 ). In essence, the child was seen as a full contributor to the “goodness of fi t ” (Thomas and Chess 1999 ) between the child and the parents or caregivers. The issue of goodness of fi t between patient, parents, and clinicians is often overlooked in spite of it being one of the most signifi cant factors that lead to successful evaluation processes (see section “The clinician has an open frame of mind ” this chapter). Thomas et al. (1970 ) found that “some children with severe psychological problems had a family upbringing that did not differ essentially from the environment of other children who developed no severe problems” and later added that “domineering authoritarian handling by the parents might make one youngster anxious and submis- sive and another defi ant and antagonistic.” Thus, “theory and practice of psychiatry must take into full account the individual and his uniqueness” (Thomas and Chess 1977). Furthermore, it is important to note that temperament in infancy and early childhood is infl uenced not only by heredity but also by environmental experiences (Emde and Hewitt 2001 ). A review of the literature regarding child temperament reveals that much research has evolved in developmental psychology since the early work of Thomas and Chess 30 years ago, although some controversies remain (Kagan 2008 , Rothbart and Bates 2006 , Zentner and Bates 2008 ). In essence, the matter of temperament is multifactorial—it involves genes, neurobiology, and the individual’s capacity to interact with others in an acceptable manner—and “its regulation is culturally dependent” (Paulussen-Hoogeboom et al. 2007 ).

Temperament Styles

In Thomas and Chess’ New York Longitudinal Study of 141 youth (Thomas and Chess 1982 ), they described temperament as having four general styles; 45 % were classifi ed as “easy or fl exible,” 15 % as “slow-to-warm-up,” 10 % as “diffi cult or feisty,” and 35 % as “mixed,” a combination of the three (Thomas and Chess 1999 ). 220 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

While this may not seem surprising, the knowledge of these temperament styles may guide the child and adolescent psychiatrist or clinician in having realistic expectations based on the understanding of how genetic and biological factors contribute to the variability of a patient’s psychological responses to life events. When recognized, certain clusters of temperament traits can be predictive. In a given situation, for example, the combination of negative mood , high intensity, irregularity, and slow adaptability might point to a “diffi cult” child who is likely to have and cause problems during their life and who may have diffi culties with a two-person relational psychotherapeutic approach and may be best suited for behavioral approaches. Conversely, those with a cluster of positive mood, positive approach, and high adaptability usually can benefi t from a two-person relational psychotherapeutic approach.

The Easy or Flexible Temperament Style

This style was found to be present in approximately 45 % of the children studied by Thomas and Chess (1999 ). The child or adolescent with an easy or fl exible temperament style typically has a history of being happy overall and not easily upset by negative news or events. They typically can transition, with a display of healthy and mild forms of anxiety , from confl icted situations to a positive stance and engage in a cooperative approach with others. Generally, children with this type of temperament who have grown with secure internal working models of attachment do not show up to our offi ce unless an adverse life event occurs that creates disequilibrium in their self-regulatory abilities or in their family system.

Jason was a 13-year-old adolescent who had an easy and ﬂ exible temperament and a secure form of attachment. He had been doing well until the unexpected death of his father in a car accident 1 month before his referral for psychotherapy. Although Jason was doing well in school, his mother brought him to psychotherapy because “since his father died, his personality has changed.” When the family learned of the father’s death, Jason began to wear his father’s T-shirts to school, stating that “they help me keep going on.” Jason was of above- average intelligence, empathic, and eager to talk about his feelings because “I know my father’s death is bothering me” (Delgado 2008 ).

The Slow-to-Warm-Up Temperament Style

The child or adolescent with a slow - to - warm - up temperament style (present in 15 % of the children studied) can quickly withdraw when faced with new and difﬁ cult situations that involve complex issues with some degree of uncertainty. Children and adolescents who present with anxiety and shyness may have the temperament style conducive to two-person relational psychotherapy in which the psychotherapist learns to match intersubjectively the patient’s tempo of interaction, which allows for an atmosphere of safety to cocreate healthy models for self-regulation.

Bobbie was a 5-year-old girl who was referred by her pediatrician due to severe constipation not due to a medical condition. A trial of laxatives, including mineral oil, were not only 8.5 Temperament 221

unsuccessful but also made her feel “embarrassed and sad; she would leak the mineral oil all over herself and not have a bowel movement.” Bobbie’s family was by all standards well adjusted and healthy. Bobbie was an intelligent and shy girl who related well to her family. She demonstrated a slow-to-warm-up temperament, in that she feared playing with friends and preferred to stay close to home due to her abdominal pain from constipation. Her slow-to-warm-up temperament was also evident in the evaluation process. Bobbie began a two-person relational play therapy in a rather constricted manner, as was expected. Over a short period of time, she felt comfortable with the psychotherapist and began to enjoy the vitality cocreated through their play. The new emotional experience permitted her to develop healthier ways of managing her anxiety (Delgado 2008).

The Difficult or Feisty Temperament Style

The child or adolescent with the diffi cult or feisty temperament style (present in 10 % of the children studied) often avoids or refuses to interact with others unless they can control the interaction. They often create distance when not feeling they are in charge of the interaction and at times resort to aggression. This temperament style is often thought of as being part of a continuum with disorganized internal working models of attachment, and it is diagnostically thought of as having oppositional defi ant disorder (ODD) or disruptive mood dysregulation disorder (DMDD). The child with diffi cult/feisty temperament style frequently behaves poorly in the child and adolescent psychiatrist’s or clinician’s offi ce and makes statements like, “I hate being here. I am not going to cooperate; I don’t need this torture.” In approaching this child, it will be important to determine the degree to which the diffi cult/feisty temperament style is typical or if this refl ects the child’s fear and anxiety attributable to the evaluation process. This can be achieved through a here-and-now intersubjective experience.

Ernie, a 5-year-old boy, had persistent behavioral patterns with an angry and irritable mood. He was also argumentative and displayed defi ant behavior toward authority fi gures. He was expelled from two day care centers due to the intensity of his negative behavior toward others. When redirected or when limits were set, he would yell and blame the day care providers for being angry at him. His parents believed that the day care center children were provoking their son and that the day care staff was instigating the diffi culties because they did not like their son. The parents and son viewed the world through the lens of a diffi cult/ feisty temperament and disorganized internal working models of interaction.

The Mixed Temperament Style

This style of temperament was observed in 35 % of subjects studied by Thomas and Chess (1982 ) and, as the name implies, reﬂ ects that children and adolescents utilized a mixture of the nine temperament traits that did not allow for a classiﬁ cation into one of the three groups.

Mary was a well-adjusted and healthy 9-year-old girl. She was intelligent and related in an easy/ﬂ exible manner with her family and peers, but she was slow-to-warm-up and anxious around adults she did not know, including teachers and medical providers. 222 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

8.6 Cognition

The human brain is the center of the cognitive abilities that infl uence the emotional and behavioral regulations within the social context. In understanding a patient, it is important to take into account their cognitive abilities, particularly with regard to the norms of their age and developmental milestones (see Appendix A ). In routine practice, clinicians commonly perform a mental status examination and may write a brief comment about the patient’s cognitive function (e.g., fund of knowledge, logical process). Such an evaluation may be disadvantageous, though, as the clinician may remain unaware that core cognitive capacities are the root of the problem. The issue of cognition is multifaceted and should not be thought of as a static fi nding. Cognition may be infl uenced by many factors during the life of a child. In a DSM - 5-style interview, a patient’s “mental status” may be reported as “average intelligence.” This reduction would fail to capture the cognitive defi cits in receptive language that would likely place the patient in a below-average range for reciprocal verbal exchanges. In short, when one embarks in clinical decision- making, it is critical to assess the patient’s cognitive abilities. Not only can cognitive strengths and weaknesses affect a patient’s ability to share personal experiences with others, they can also signifi cantly infl uence the patient’s understanding of others’ intentions and states of mind. Children and adolescents need to view “the world as a safe and predictable place and seeing oneself as a competent agent in that world are important psychosocial resources for handling stress” (Turner and Roszell 1994 ). In extreme cases of bereavement , depression, or trauma, the patient may present with what appears as severe cognitive defi cits, and having access to a base- line cognitive evaluation can help the clinician discover and appeal to the patient’s innate strengths.

Cognitive Weakness and Learning Disorders

The authors wish to emphasize the importance in assessing the impact a learning weakness or a formal learning disorder can have on how a clinician understands a child or adolescent in a CDI. As Delgado et al. (2011 ) state: “Patients who present with impairment in academic, cognitive, social, and vocational functioning might be struggling with an unrecognized learning disorder. Ten percent of the US population has some form of learning disability, and up to 40 % of those with learning disorders may meet diagnostic criteria for a psychiatric disorder.” This will have signifi cant repercussions in how we understand the patient and the treatment recommendations we make. Moreover, by some reports, 10 % of the general population has learning weaknesses, and among this group, many have formal learning disabilities (Altarac and Saroha 2007 ; Cooper et al. 2007 ). Considering these statistics, it is not surprising that children and adolescents with learning disorders or learning weaknesses may frequently be described by child and 8.6 Cognition 223 adolescent psychiatrists or clinicians as “diffi cult to connect with” or cause them to say, “I am not sure about their motivation.” The intersubjective experience created by this type of patient in the child and adolescent psychiatrist or clinician is of frustration. The feelings of frustration may also occur in their family members, who may not recognize that the poorness of fi t is due to the patient’s cognitive limitations. At times, the parents’ own cognitive defi cits may prevent them from appreciating their child’s struggles. Delgado and Strawn (2014 ) illustrate this in a vignette: A learning-disabled 16-year-old girl who was admitted to a general pediatric inpatient unit for the treatment and management of her diabetes shares that she was feeling overwhelmed trying to manage her diabetes. The patient and her mother had usually been agreeable to recommendations made by doctors, “even though sometimes we have trouble understanding them.” They both feared being seen as diffi cult and had withheld their problems with memory and verbal comprehension in order be perceived as a pleasant and compliant family. Although they were “willing,” they were not “able” to assume full responsibility with the treatment recommendations made. When the social worker from the diabetic clinic was made aware of the patient’s and mother’s learning problems, she was asked that the treatment recommendations be shared in visual from. The social worker’s response—“We have never approached matters this way”—was discouraging in that it suggested that in subspecialty clinics, limited attention is generally given to cognitive skills, and this may explain the frequent issues of noncompliance by children and adolescents with chronic conditions. It is mostly agreed that children like to attend school if it is an area of safety and where they make progress cognitively, emotionally, and socially. There are many children and adolescents with learning weaknesses that struggle with school and present to our offi ce in the form of school refusal, school phobia, and somatic complaints depending on their age. Children and adolescents with learning weakness typically use their fi ngers to count and recite the alphabet in song form, typical of young children, to recall letters. They typically state that their favorite classes are recess, gym, music, and art. Therefore, it is important that the clinician not conclude that all forms of school refusal are due to psychological or family problems. Without a careful assessment of cognition and cognitive fl exibility, the treatment approaches may further increase the child’s feeling of inadequacy and increase his or her school avoidance. Thus, in these diffi cult situations, the family or clinician may benefi t in obtaining formal cognitive testing . In these situations, families who have a secure attachment (see Chap. 5 ) are usually relieved to have concrete evidence of their child’s relative strengths and limitations; once these strengths and limitations are understood, their anxieties diminish. With cognitive testing results in hand, the clinician can best tailor the treatment interventions and improve the child’s self-esteem. We are not advocating for the child and adolescent psychiatrist or clinician to be profi cient in interpreting cognitive testing results. Rather, it is essential to col- laboratively work with skilled psychologists or educational specialists that can 224 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview help translate the results into clinically practical information (e.g., what behaviors can be expected at home and school due to their cognitive limitations). We believe that for a child or adolescent with cognitive weakness, to feel emotionally safe, an individualized education plan (IEP) should be designed to be used at home by his or her parents or caregivers. This plan will help parents know what realistic expectations are and how to best provide the emotional and educational support they need.

Assessing Cognition and Learning in a CDI

At this point, it is necessary to briefl y outline some interventions we have found helpful in using a CDI to tease out matters of cognition and learning in children and adolescents. The CDI conversation style of interviewing permits assessing whether the patient and their parents or caregivers are able to give developmentally appropriate responses or if their responses are poorly formulated due to cognitive weaknesses that have contributed to their feelings of being misunderstood or picked on by others. When the child and adolescent psychiatrist or clinician notices that the patient’s and/or the parents’ or caregivers’ conversations have poor sentence structure—syntax —it should alert to a few possibilities: a lack of education due to socioeconomic or cultural barriers, cognitive limitation, and/or a learning disorder. As such, the clinician will be rewarded by continuing to use a conversational CDI approach to tease out these factors in order to later be aware of the likelihood that perhaps the signs and symptoms they endorse may not be accurate or reliable, at which point collateral information is essential. Additionally, diffi culties in understanding basic humor or the fl ow of the conversation should also alert the clinician to these issues. As such, information obtained through a structured interview (e.g., K-SADS-PL) may provide inaccurate information and may explain why some children and adolescents do not respond well to certain pharmacological interventions. There are several ways that a child and adolescent psychiatrist or clinician may choose to assess cognitive abilities. This is best done using a conversational approach, and to illustrate this, we will describe several inquiries that we have found helpful. We start with the Mother’s Day conversation (May in the United States) and a Super Bowl conversation (February in the United States), although this can be tailored to the month in which the interviews takes place (e.g., if in June, a Father’s Day conversation is appropriate). This line of inquiry can also be used during relevant holidays (e.g., Thanksgiving, Christmas, New Year’s). As you read through the examples, note the complex interplay as this approach to assessing cognition also intertwines clues on a child’s early childhood experiences, social cognition, and current relational sphere.

Mother’s Day Conversation In the United States, during the month of May, it would be appropriate to explore with a child over the age of 4 how their family will be celebrating Mother’s Day. 8.6 Cognition 225

Cognitive level Possible responses Above average We are going to take her out to eat at her favorite restaurant and then go visit her mother. She will like that. [ Sense of pride ] Average I like my mother. I might make or buy something for her. Below average When is it? I don’t know? [ Some frustration or lack of interest ] Learning disorder Not sure what my mother wants. When is it? [Puzzled ] Nonverbal LD Not sure what my mother wants. When is it? [Uncertain and embarrassed ] Intellectual disability Is unable to understand, and the clinician will need to ﬁ nd a more reasonable form of verbal interaction

Super Bowl Conversation In the United States, during the month of February, it would be appropriate to wonder with a child over the age of 7 who in their family will be watching the Super Bowl , the country’s national championship professional football event. If over 12, it would be appropriate to explore which team they think will win the game.

Who in your family watches the Super Bowl? Cognitive level Possible responses Above average I will watch the game with my friends, and my dad is going to watch it at home with my family. Average My dad and his friends. Below average I don’t know. [Feeling frustrated with clinician ] Learning disorder I think my dad. [Conveys uncertainty on how to respond ] Nonverbal LD Responds with a topic vaguely connected to the Super Bowl Intellectual Is unable to understand, and the clinician will need to ﬁ nd a more disability reasonable form of verbal interaction

The clinician may follow this line of inquiry with: Which team do you think will win? Cognitive level Possible responses Above average Clearly, [name of team] will win; they have a better defense, although the other team has great offensive players. Average I like both teams. [Patient wonders if he or she is correct in which teams are playing ] Below average When is it? [Looking puzzled ] Who’s playing? [Feeling embarrassed ] I don’t know. [Indifferent to question and interviewer ’s affect ] Learning disorder Not sure who’s playing. Not sure when it is. [ Displays a sense of failure , an experience he or she seems to be familiar with ] Nonverbal LD Begins sharing their view of the game, and within a few sentences, they changed topics and likely did not realize Intellectual Is unable to understand, and the clinician will need to ﬁ nd a more disability reasonable form of verbal interaction 226 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

Assessing Visual–Spatial Abilities

The importance in assessing visual–spatial abilities in children and adolescents has not received the importance it deserves (Table 8.2 ). Children and adolescents with defi cits in this area will have diffi culties in school performance and completing chores, and they are frequently criticized by their parents and teachers. Visual–spatial ability is having the capacity to understand and remember the position of objects in relation to other objects and to themselves and is required to understand directional verbal descriptions. This ability is necessary to know where to fi nd things (e.g., one’s home), where things go, and how to get to places. Unfortunately, many times these defi cits are viewed by parents, caregivers, or teachers as stubbornness or moodiness. This has implications on how the type of internal working models of relating to others these children develop, as they typically feel criticized and frequently are ridiculed. When knowing this, the child and adolescent psychiatrist or clinician can have a better grasp on the reasons why the child or adolescent not only struggles academically but also has chronic low self-esteem . A question that the authors frequently use to assess an adolescent’s visual–spatial abilities is asking for directions from the clinician’s offi ce to their home. Often the patient’s response refl ects what their cognitive abilities or weaknesses are. For example, they may not know which direction their home is, they may not be able to remember landmarks near their home, or they may remember taking an interstate highway but do not know which one. In the case of these responses, it becomes clear that the child or adolescent has defi cits in visual–spatial abilities , which will negatively affect their school performance and their ability to complete chores. In completing a CDI, the child and adolescent psychiatrist or clinician may fi nd themselves unknowingly and intersubjectively feeling frustrated and giving many leading questions, in a rapid-fi re manner, hoping the adolescent will eventually “get it right,” as if the adolescent is withholding their ability to think clearly. It is through

Table 8.2 Brief assessments of visual–spatial abilities in youth

Preschool children Ability to replicate simple block designs or pictures. Stack or spell their name with blocks. Ability to play with LEGOS with ease.

Elementary school age youth Ability to draw the floor plan/layout of their room. Capacity to enjoy simple magic tricks or illusions with playing cards. Ability to play Jenga, Uno, Connect Four.

Adolescents Knowledge of directions to their home from the clinician’s office. Ability to give details of landmarks near their home. 8.7 Assessing Cognitive Flexibility (Sense of Agency, Theory of Mind) 227 here-and- now moments that the child and adolescent psychiatrist or clinician will understand the reasons the patient unknowingly and implicitly is familiar creating accomplices in the form of critics or enablers due to their cognitive weakness. This sadly reinforces the implicit relational pattern of feeling unwanted and incompetent. In younger populations, the lead author of this book makes use of simple magic card illusions diagnostically, utilizing what he calls the “wow moments.” Once he establishes an atmosphere of safety and feels there is goodness of fi t with the patient and family, he proceeds to show a magic card illusion. Generally, children with above-average and average cognitive abilities and good visual–spatial abilities appreciate the illusions and genuinely are surprised—the wow moment—and smile with excitement and approval. For other children, the same card illusion is diffi cult for them to appreciate due to cognitive or visual–spatial limitations, and they do not seem to know what is unusual about what transpired. We encourage the child and adolescent psychiatrist or clinician to develop his or her unique skills that can be useful in a CDI for similar diagnostic testing. Another activity that is appreciated by elementary school age children is drawing in a small easel board. This permits the clinician to assess visual–spatial abilities in asking the children to draw or copy certain structures (e.g., shapes, cars, and a house). We remind the reader that the responses not only refl ect the patient’s cognitive level of functioning, but they are also infl uenced by the patient’s temperament, cognition, and internal working models of attachment. Herein, the clinician will need to allow the interaction to unfold so as to have the necessary intersubjective experiences that allow him or her to use the CDI Case Formulation tool (see Appendix B ) based on here-and-now experiences between patient (and their parents or caregivers) and clinician.

8.7 Assessing Cognitive Flexibility (Sense of Agency, Theory of Mind)

As part of any evaluation of a patient’s cognitive function, the capacity for cognitive fl exibility —also referred as social cognition , sense of agency, and theory of mind— should be assessed. Cognitive fl exibility encompasses the aspects of cognition that allow the individual to psychologically approach situations with a degree of openness about the fact that their experience is infl uenced by another person’s state of mind and by the contextually, socially, and culturally appropriate norms, as well as allow the individual to tolerate some degree of uncertainty (Delgado and Strawn 2014). At a minimum, the child and adolescent psychiatrist or clinician should assess whether the patient has the ability to interpret the intent of others. Cognitive fl exibility involves several components: executive function, attention, working memory , and emotion regulation (Johnson 2009 ; Schmeichel et al. 2008 ). An example of cognitive fl exibility would be a child who reacts with glee when he or she infers that it is acceptable to play with the toys in the clinician’s offi ce because 228 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview they are available in an open bin. Cognitive fl exibility precedes the development of language skills that typically emerge from the ages of 2–5 years old (Blackwell et al. 2009 ). In addition, cognitive fl exibility permits people to expand their awareness and to accept the idea that there can be multiple solutions to novel or unpredictable events. Needless to say, complex situations are best handled when appraised as opportunities for growth rather than as personal threats. Assessing cognitive fl exibility can be done briefl y during an integrated developmental biological, psychological, and social approach, as in a CDI. The child and adolescent psychiatrist or clinician can assess cognitive fl exibility by asking the patient to share their view of themselves, their life achievements and accomplishments, and the importance of their relationship to their parents, siblings, and friends. The child and adolescent psychiatrist or clinician will be better able to know whether the patient and family system will have the cognitive fl exibility needed to make use of a two-person relational psychotherapeutic approach.

Cognitive Flexibility in Adolescents

How a child and adolescent psychiatrist can best communicate with an adolescent will depend on the adolescent’s level of cognition and cognitive ﬂ exibility . Assessment in adolescents is less complex than with younger children, in that in terms of development, adolescents begin to have cognitive capacities similar to those of adults in understanding themselves and their environment.

Brief Assessment of Cognitive Flexibility in Adolescents

• History of the patient’s preferred activities with others, including parents, friends, and those they have dated. • History about the patient’s birthday celebrations, favorite persons that attended, and gifts received. • Review achievements and accomplishments they feel proud of. • History of favorite video games and music played. Favorite sports events attended. • Review what they are hoping to achieve in the future.

Cognitive Flexibility in Preschool and Elementary School Age Youth

Assessment of preschool and school-age children’s cognition and cognitive ﬂ exibility for social reciprocity is complex in that it needs to take into account the norms of their developmental stages (developmental milestones, Appendix A ) and make use of age- appropriate activities (e.g., drawing and coloring books, board or card games, reading). As with any patient, particularly children, there is no one-size-ﬁ ts-all approach. 8.8 Internal Working Models of Attachment (IWMA) 229

In working with children, and at times adolescents with some cognitive limitations, the child and adolescent psychiatrist or clinician may utilize a “time-tested” projective technique often referred to as the “three wishes scenario.” In this frequently employed technique, children are asked to imagine they ﬁ nd a magic genie’s lamp, from which they release a genie who will grant them three wishes. The children are encouraged to request whatever they hope for. In using this technique, the clinician can assess their cognitive ﬂ exibility while avoiding the anxiety produced by direct questioning. The patient’s responses may be concrete and limited, indicating the impoverished age-related imaginative life of a child with cognitive weakness or formal intellectual disabilities.

Brief Assessment of Cognitive Flexibility in Preschool and Elementary School-Age Youth

• Elicit the child’s recollection of prior birthday parties and favorite gifts received. • Ask who the child enjoyed having attend the birthday parties. • Review the child’s achievements and accomplishments as well as other experiences that have made him or her feel proud. • Obtain a history of their favorite toys, games, video games, and movies. • Use the common “projective technique” of asking the child, “What would you ask for if a genie granted you three wishes?” • Ask what they hope to be when they grow up.

Another activity that elementary school age children enjoy is drawing a rudimentary family tree in a small easel board (with the help of the clinician). This conveys the child’s cognitive ﬂ exibility within the context of others in the family, as well as his view of his role in the family.

8.8 Internal Working Models of Attachment (IWMA)

As covered in Chap. 4, Bowlby’s internal working model of attachment serves as a template when relating to others and is an important element to obtain in a CDI. Given the central role they play in determining the patient’s ability to interact with others, the four attachment styles warrant further discussion (Table 8.3 ). Of note, the attachment styles can be used to guide the treatment interventions the child and adolescent psychiatrist or clinician may choose to recommend. Research has demonstrated that children can create cognitive–affective schemas of self and others that direct subsequent behaviors during the interaction with the caregivers (Bretherton and Munholland 1999 ). A more detailed description regarding the impact a patient’s and their family’s internal working models of attachment have in a psychotherapeutic process is reviewed in more detail in Chaps. 10 , 11 , 12 , and 13 . 230 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

Table 8.3 Experiences implicitly and nonconsciously expected from others according to internal working models of attachment (implicit relational knowing)

Attachment Style Experience of others Typical interaction with others Implicit relational knowing

Secure I know and feel cared by my family Interacts well with parents and peers. and friends. Is in sync with emotional states of others and I know that when I need help, I can follows themes of conversations. ask others to help me. Recognizes when to ask for help. Insecure Anxious My parents don’t like me because I Avoids initiating interactions. worry all the time. Shares many somatic complaints and uses these to avoid being in school or social I do not think I am good enough. activities. Prefers to be near parents. I can’t please anybody. Dismissive I am ignored by the adults in my life. Gives one word answers. Demonstrates lack of interest in others They always think I am a failure. activities or discussions. Disorganized I will be yelled at. Demanding of age inappropriate privileges, i.e. activities without supervision, late curfew, Nobody loves me. smoking with parents, and use of weapons.

Secure Attachment

The ﬁ rst type of attachment, secure attachment, occurs when the infant is cared for by a person who provides a sense of safety and reciprocity. The caregiver also exhibits empathic affective attunement and helps the infant handle normal periods of distress with actions such as holding, soothing with touch, rocking rhythmically, or singing with a melodic voice. The child develops a coherent discourse over time; values attachments, whether pleasant or temporarily unpleasant; and is able to provide others a sense of reciprocity. We revisit the example of the 13-year-old adolescent previously discussed as having an easy/ﬂ exible temperament because it coveys how, in the same conversation, matters of cognition and attachment were also elucidated.

Secure Attachment and a Traumatic Event Jason was a 13-year-old adolescent whose father died in a car accident 1 month before his referral for psychotherapy. Although Jason was doing well in school, his mother worried because “since his father died, his personality has changed; he has become the class clown at school.” Jason was of above- average intelligence, empathic, and eager to talk about his feelings because “I know my father’s death is bothering me” (Delgado 2008 ).

Jason had a coherent discourse of his life over time; valued attachments, whether pleasant or temporarily unpleasant; and was able to demonstrate his skills in social 8.8 Internal Working Models of Attachment (IWMA) 231 reciprocity with his psychotherapist. In addition, he also demonstrates good cognitive ﬂ exibility in knowing that his father’s death “is bothering me.”

Ambivalent/Anxious Attachment

Ambivalent/anxious attachment is an insecure form of attachment that occurs when the infant feels anxious because the caregiver is mostly available but persistently displays worry, anxiety, and inconsistent parenting. The infant develops a pattern of relationships with others based on superﬁ ciality. The ambivalent/anxious infant grows to be a child or adolescent that wishes for closeness with others but who often fails to convey his or her hope for social reciprocity. As a result, the child or adolescent is frequently rejected, repeating the original pattern established with the caregiver and increasing their anxiety.

Ambivalent/Anxious Attachment Rachel, a 9-year-old girl, was referred for psychotherapy by her pediatrician due to severe anxiety. The child and her mother were anxious during the CDI, as the conversational style invited a closeness they were not comfortable with. The clinician’s attempt to explore day-to-day activities of their life was fraught with anxiety by both. When the clinician shifted to a more intellectual approach, they became less anxious, although still with a great deal of trepida- tion. The child remained close to her mother and declined to engage in playful activities. When she was invited to respond verbally, her mother interrupted and answered for her, outwardly asking the child if her answers were correct. Rachel’s mother stated, “You can answer if you want,” although subjectively preferred her not to.

Parents who have ambivalent/anxious attachment styles often seek help for their children because they have implicitly created an inadequate view of their role as parents. They hope to alleviate their children from the normal disruptions needed to promote a successful sense of independence.

Avoidant/Dismissive Attachment

Avoidant/dismissive attachment is an insecure form of attachment that occurs when the infant is in a state of constant fear due to the unpredictable availability of the relationship with the caregiver and cannot develop a stable internal working model of attachment (Bowlby 1999 ). As the infant grows, he or she shows a tendency toward passivity and avoids the expression of affect with others to prevent feelings of rejection and to protect against the psychological distress when being ignored. 232 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

The avoidant/dismissive infant as a child or adolescent develops patterns of self- suffi ciency and independence and consequently has diffi culties experiencing closeness with others. With this form of attachment style, the child and adolescent psychiatrist or clinician in a CDI will intersubjectively experience working more than the patient and their parents or caregivers in developing a bidirectional dialogue. The child and adolescent psychiatrist or clinician may fi nd that the patient is implicitly withholding any form of reciprocity and the clinician begins to nonconsciously ask many questions and has little to show for his or her efforts at the end of the interview. In essence the clinician has been dismissed.

Avoidant/Dismissive Attachment Joey, an 8-year-old boy, had persistent behavioral patterns of becoming upset and avoidant when asked to participate in group activities or play sports, in spite of his wishes to be included. He approached the interview in a distant manner and would display deﬁ ant behavior toward the clinician when asked about his new glasses, nice T-shirt, etc. His parents were distant and looking at their smartphones, occasionally giving the clinician one-word responses and blaming others for thinking their son was being difﬁ cult. The clinician intersubjectively experiences them as rejecting his efforts for reciprocity (e.g., their implicit relational knowing, avoidant/dismissive).

Parents who have avoidant/dismissive attachment styles often decline to seek help for their children because they have implicitly created an inﬂ ated model of themselves with little awareness of the need to change how they or their children affect other people. Some consider this as an early precursor of narcissistic personality disorders (Bardenstein 2009 ).

Disorganized Attachment

Disorganized attachment is an insecure form of attachment that occurs when the infant experiences a lack of coherent attachment patterns from their caregivers and relates with a poor sense of reciprocity. There is a common history of abandonment or trauma in these children, who grow to be frightened of commitment and have signiﬁ cant vulnerabilities that prevent them from sustaining stable relationships, causing a repeating cycle of their incoherent life discourse. They seek accomplices of their internal models of interaction by arguing, yelling, and being deﬁ ant, which they experience as familiar actions. As adolescents, they are prone to trauma and dissociative experiences. Some authors believe this is an early precursor of borderline personality disorders (Bleiberg 1994; Kernberg 1990). 8.8 Internal Working Models of Attachment (IWMA) 233

Disorganized Attachment Ernie, a 5-year-old boy, is described above in the context of a diffi cult or feisty temperament style. He had persistent behavioral patterns with an angry and irritable mood. He was also argumentative and displayed defi ant behavior toward authority fi gures. He was expelled from two day care centers due to the intensity of his negative behavior toward others. His parents requested a psychiatric evaluation for their son, and early in the appointment, they begin yelling at their son for not responding to the CDI comments made by the clinician. When the clinician attempted to redirect the child as he was attempting to use the clinician’s computer, the child looked back to his parents as if hoping for their support. His parents loudly said, “Ask him if it is OK to use his computer,” showing little appreciation for the clinician’s efforts to redirect their son by making comments that it was his space and that would not let him use the computer.

Parent’s Negative Reaction to the Treatment Recommendation The child and adolescent psychiatrist shared that the child would beneﬁ t from behavioral forms of psychotherapy, to which the parents became upset and then escalated, stating that they had come to the appointment for the child psychiatrist to prescribe medication “to control his anger.” They implicitly and outwardly demonstrated a disorganized pattern of attachment with poor capacities for affective attunement and self-regulatory capacities. The disorganized form of attachment implicitly contributed to the child’s repetition of the relational patterns: arguing with others as the parents were with the clinician. The clinician intersubjectively experienced the poorness of ﬁ t between the child and his parents.

Emotional Availability and Time-Outs

A note on time-outs, the authors teach parents that time-outs are for children to have a moment to refl ect and self-regulate. We explain to parents that the goal of a time- out is for the child to be successful in self-regulating. A time-out should not be intended as punishment, which implicitly leads to further battles down the road. During a time-out, the child needs help from the parent or caregiver to self-regulate, which seldom happens. We are sure the reader has seen or heard of time-outs being extended, by adding minutes, when the child is unable to calm down and self- regulate. By this point, the parent subjectively feels the need to win the “battle” and uses the angry tone of voice and attitude they were hoping to model how to avoid. In the end, the time-out is not completed and both parties are upset. We encourage the reader to help parents fi nd a pleasant manner to help children self-regulate and not to treat the child with fi rm and anxiety-producing limit setting. Herein, we 234 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview suggest that a time-out should be a minute or less (30–45 s), and parents should help the child learn how to settle and calm down. When successful, the parent will benefi t from saying “god job” upon completion of the time-out. At the end of the time, both child and parent will have stored in nondeclarative memory how to self-regulate, and at a later time, the child may ask the parent to help. As an example, a colleague shared with us that after a phone call in which she was visibly upset at a friend, her 3.5-year-old daughter says, “Mommy needs a time-out.” The young child had stored in nondeclarative memory what was helpful to self-regulate and conveyed it in the pleasant manner she had remembered her mother had.

8.9 Putting It All Together: The Four Pillars of a Contemporary Diagnostic Interview

Beginning the Interview

The CDI is not based on a standard format to be followed as is common in a structured interview. The questions suggested are broad and intended to be of help to child and adolescent psychiatrists and clinicians to discern, in the here- and-now moments of subjectivity , the patient’s and their parents’ or caregivers’ temperament style, cognition, cognitive fl exibility, and internal working models of attachment. Additionally, the clinician will need to consciously delay the use of questions of a DSM -5 - style interview, as this line of questioning is implicitly experienced by the patient and parents or caregivers as demonstrating a lack of genuine interest in them as people and instead considering them as a set of signs and symptoms. The art in using a CDI is for the clinician to make a concerted effort to approach the patient and their parents or caregivers in a manner that allows for their interactional process to emerge. As such, the clinician will be rewarded by approaching the patient in a similar fashion as to when he or she approaches an infant or a young family member they have not met before (e.g., a niece or nephew, grandchild). The clinician will benefi t from approaching them with vitality and genuine interest as demonstrated by the tone of voice—akin to a parent with good ability for affective attunement—body movements, and affect used. The clinician does not have prior knowledge of what temperament style the patient and their parents or caregivers have nor of their cognitive abilities. Thus, options on how to begin the CDI are plentiful. We use brief examples to clarify this approach. The interview goes well when the clinician takes a conversational approach to assess the four pillars. There will be plenty of time for a structured interview after the clinician feels he or she has a genuine understanding of the patient and their parents or caregivers. Initially, the conversational approach may seem nonproduc- tive and may even lead to some fear of creating some closeness with the patient and their parents or caregivers. Although when subjective closeness is cocreated, it allows the clinician to use his or her intersubjective experience as a guide regarding how the patient and family relate to each other and with others, how they view their 8.9 Putting It All Together: The Four Pillars of a Contemporary Diagnostic Interview 235 problems, and what would be helpful for them. Herein, the initial comments made should have the goal of eliciting the four pillars of two-person relational psychology, which is the foundation for understanding other people and helps discern whether their view of the problems is reliable and accurate. Thus, the opening 10–15 min of the interview provides the clinician a window into the four pillars of the subjects interviewed. In using a CDI, a common concern trainees describe goes as such: “This approach seems like a regular conversation; the patient might not know they are talking to a doctor.” This alludes to the fact that the information provided by the patient may not be clinically or diagnostically helpful. It is important to recognize that the child and adolescent psychiatrist or clinician using a CDI will need to allow himself or herself to be immersed in the patient’s and his or her family’s subjective world, formed in the subjects’ early years—internal working models of attachment—with their nonconscious set of rules on how to relate to and what to share with others. In other words, the child and adolescent psychiatrist or clinician is in essence asked to perform two tasks at once: (1) maintain a genuine and friendly attitude to allow the patient’s nonconscious relational working models to emerge in the here-and-now interactions and (2) use his or her intersubjective experience with the patient’s communications to understand them from the inside out, by temporarily experiencing being “like them,” improving his diagnostic acumen, and tailoring realistic integrated treatment recommendations. The reader may wonder which are the most useful comments or questions to use in a CDI. The initial comments and questions suggested to open the interview are designed to be easily changed to fi t the personal qualities of each clinician. We will describe the initial comments that we have found to be helpful in opening the CDI, and later we demonstrate how we used the information gathered to develop case formulations and tailor the treatment recommendations. It is detrimental to begin with open-ended questions about the reasons patients or parents are seeking help, such as, “How can I help you?” “What brings you here?” or “How do you understand your problem?” This style of questioning is conducive in making the patient and their parents or caregivers feel broken rather than people who are seeking help within the context of a larger system. The value in joining and holding their anxieties before one delves into stressful aspects of their life is that it facilitates increased reliability, consistency, and accuracy in the description of the signs and symptoms they endorse (Delgado and Strawn 2014 ). In teaching child and adolescent psychiatry trainees, we emphasize that as part of initial CDIs, the fi rst question or comment should not be the reason for coming to the appointment. In using a two-person relational model for a CDI, rather than asking questions in the third-person style, it is best to begin with phrases like “I would like to know,” “I wonder if,” etc., to help the patient and their parents or caregivers feel that the clinician is part of the process and not only an observer; this style implicitly validates the importance all members have during the interaction. This step involves more than just being empathic and friendly; it is recognizing the contribution a clinician has on how they experience the interview process , which will guide how it will unfold. 236 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

Attending to the External Attributes of the Patient and Parents or Caregivers

The initial comment used during a CDI is helpful when it attends to the external attributes of the patient and their parents or caregivers—shy, tired, appearing angry, etc.—and the clinician’s subjective experience of them. If the patient and family look tired, it is helpful for the clinician to openly acknowledge the experience. On one occasion, a child’s parents shared that they had rushed to make it to the appointment on time as they lived 2 h away and had to leave early, which did not allow them time to have breakfast. Without giving attention to nuances of human interaction, their presentation may have easily been misconceived and inferred that “the family looked depressed or cognitively slow.” It is well received when the child and adolescent psychiatrist gives positive recognition to some of the outward attributes of the child, such as their age, height, eyeglasses, clothing, backpacks, etc. In doing so, the psychiatrist can assess whether the child feels safe interacting with others and also their capacity to cognitively be able to understand the back-and-forth of a typical conversation, something that is not captured in a symptom base interview.

Easy/Flexible Temperament, Good Cognitive Flexibility, and Secure Attachment Clinician: Good morning. I am Dr. Jones. Please come in. [ Tone of voice and body movements demonstrate excitement and vitality of the encounter ] Clinician : [While walking to the ofﬁ ce ] I really like those eyeglasses, they look good on you. [ To the patient ] Patient : Thanks, I’ve had them a long time. [Smiling and pleased to share the information ] Clinician : I wonder who took you to buy them and who helped you chose the frame. [Continues demonstrating excitement through tone of voice and facial expressions ] Patient : My mother took me and I choose them myself. [Happy to share and turns to look at her mother , and they implicitly attune (e.g., mother con- ﬁ rms by nodding in agreement )] Clinician : Nice. Does anybody else in your home also wear glasses? Patient : Yeah, my older brother and my mother. [ Turning toward her smiling , and by this moment, she is very engaged and at ease in the process ]

In this brief interaction, we notice that the clinician has allowed the patient and mother to demonstrate their implicit attuned relationship; the mother allows the child to give details of the family and nonverbally supports and approves. Used clinically, we see the emergence of what appears to be an easy and ﬂ exible temperament in both 8.9 Putting It All Together: The Four Pillars of a Contemporary Diagnostic Interview 237

(reciprocity of excitement), good cognition and cognitive ﬂ exibility (recalls details and the affective state in which they occurred), and an implicit internal working model of secure attachment between them. This exchange also provides the clinician the ability to notice the ease in establishing a bidirectional here-and-now experience of mutuality and subjectively noticing the likability of the patient and mother. This also allows the clinician to know that the information obtained throughout the interview will be accurate and reliable and that the patient and family will be able to follow through with the treatment recommendations at the conclusion of the evaluation process.

Difficult/Feisty Temperament, Limited Cognition, and Cognitive Flexibility and Insecure Attachment Clinician: Good morning. I am Dr. Jones. Please come in. [ Tone of voice and body movements demonstrate excitement and vitality of the encounter ] Clinician : [While walking to the offi ce] I really like your T-shirt, nice logo. [ Tone of voice and body movements demonstrate excitement and vitality of the encounter ] Patient : I don’t know what it is. [Unable to engage in affective reciprocity ] Clinician: I notice your hair is short. [ Affectively implying “ I like your short hair ”] Patient : [Does not respond , appears not interested in engaging with the clinician ] Clinician : I would like to know what you do for fun on weekends. Patient: I am always grounded; my parents don’t let me do anything. [ Demonstrates anger ] Parents : You know why you’re grounded. You never do what we tell you to do, and you break things. [Raising their voice and implying that he is a bad child ] Patient: Whatever, you guys are stupid. [They engage with the same implicit relational knowing model ] Clinician : Wow, looks like we have some work to do here. [ Subjectively feels that they genuinely do not have the ability for implicit recognition of the clinician ’ s attempt to use nonverbal communication of excitement and notes that they rely on established insecure internal working models of attachment , likely due to diffi cult / feisty temperaments , limited cognition , and limited cognitive fl exibly ] Parents : He always has bad mood swings, anger issues, and doesn’t do his homework. [Continue blaming and using similar interactive patterns the child uses — implicit relational knowing ] Patient: I hate school; nobody helps me. I need you guys to get off my back. 238 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

In this brief interaction, we notice that the clinician has allowed the patient and parents to demonstrate their implicit style of interaction: The parents berate their child in front of the clinician and do not have a spirit of inquiry as to the reasons why he may be diffi cult. Used clinically, we see the emergence of a feisty or diffi - cult temperament style in all family members, average to below-average cognition and cognitive fl exibility (sentence structure is limited to a few words), and a lack of understanding that their negative interactions in the presence of the clinician implicitly reveal their inability to view the other person as helpful (internal working model of insecure attachment among them). This exchange also allows the clinician to notice the inability to establish a bidirectional here-and-now sense of mutuality, and he subjectively notices the dismissive and disorganized nature of their interactions. This permits knowing that the information obtained throughout the interview will likely be inaccurate and not reliable, giving more importance to the need for collateral information . An alternative way of opening a conversation is by making a comment about the child’s name and wondering if they know how their name was chosen and whether they like their name. This approach helps in several contexts; it allows the patient to feel recognized as important, it gives context to their experience within their family, and it provides the opportunity to assess whether the patient is able to respond with depth and details or in a cognitively limited manner.

An engaging 6-year-old girl A 6-year-old girl was seen for possible separation anxiety disorder, as she had been crying when being taken to school, although her teachers shared that once she arrived, she stopped crying and adjusted well to school activities and peers. The child psychiatrist approached the child in a jovial manner and stated that he liked her name, Madison, and wondered if she liked it. She cheered up and said that her parents choose the name and that she liked it because “it is fun to say.” The child psychiatrist proceeded to wonder if she liked to write her name at school. She replied that she liked writing her name at the top of all her assignments and that she liked her teacher, who was very funny and polite. During the interaction, her parents nonverbally supported her and encouraged her to feel free to engage in a conversation with the clinician.

In this vignette, the child psychiatrist intersubjectively quickly experiences the child as very likeable, engaging, and easy to affectively attune with. The patient also demonstrates secure internal working models of attachment, with above-average cognitive and affective skills. During the dialogue, he also fi nds her parents to be supportive of their child’s relational efforts with the child psychiatrist. In this quick conversational approach, the child psychiatrist has been able to assess many 8.9 Putting It All Together: The Four Pillars of a Contemporary Diagnostic Interview 239 elements of the CDI, and after a few more comments about her personal attributes (e.g., color of hair, height), he continues to have the same subjective experience of her not having any developmental interference in her cognitive and psychological growth. The clinician intersubjectively recognizes the likelihood of a formal separation anxiety disorder and proceeds with a DSM - 5 - style structured interview to assess the severity and tailor the treatment: cognitive behavioral and/or a pharmacological. Furthermore, it is important to gauge how adolescents respond when the child and adolescent psychiatrist or clinician uses a jovial and empathic approach, as not all will appreciate this approach, instead fi nding it to be an experience of “too close too soon.” In attending to the intersubjective experiences, the child and adolescent psychiatrist or clinician may say, “I sometimes think that teenagers feel comfortable when I try to share my excitement in doing my work, and I forget that when I was a teenager it was very diffi cult to talk with professional adults. I notice you seem cautious, and I will need your help in knowing how you experience being here with me.” This creates a moment of meeting, where the adolescent reads in the behavior of the clinician his willingness to repair the disruption of their attunement (BCPSG 2010 ).

The adolescent that regulates affective states A 16-year-old male sought help for his feelings of sadness after breaking up with his girlfriend. By all standards, he was a successful adolescent; he helped in his family’s landscaping business, did well in school, and had many good friends. During a CDI, the child and adolescent psychiatrist or clinician stated, “I see that you have a lot going on for you. I think that you now know that having a girlfriend and later breaking up is very confusing and painful,” to which he replied, with excitement of being understood, “Yeah, I love my parents and sisters. I just don’t know why breaking up hurts so much.”

The adolescent that cannot regulate affective states A 16-year-old female sought help for her feelings of sadness after breaking up with her boyfriend. She presented in a parentiﬁ ed manner, stating that she helped her father and stepmother take care of her young half sisters (ages 10 and 12) and that she thought that school was “a waste of time.” During a CDI, the child and adolescent psychiatrist or clinician stated, “I see that you help your parents a lot and they let you decide what to do with school and friends, including your boyfriend.” She replied in a dismissive manner and with indif- ference, “Yeah. As long as I help my parents they don’t care what I do. I am 240 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

Table 8.4 Example of familiar clinician’s subjective experiences in the intersubjective fi eld during a contemporary diagnostic interview (CDI), and how they can be used diagnostically Psychotherapist subjective experience Diagnostic impression of patient/family I have the urge to fi x the patient’s problems. Limited cognitive fl exibility I do not feel I have the patience I typically do. Learning diffi culties I experience myself being a parent to the patient Anxious attachment and wanting to give advice about what he or she Learning diffi culties should do to get along with others. I am feeling bored; the patient continues to repeat Cognitive defi cits the same story and is not aware. I experience the patient as dismissive of my Dismissive or disorganized internal comments. working models of attachment I would rather not interact with the patient as I feel like a punching bag. I feel I am a friend to the patient and parents. Secure or anxious internal working models of attachment with possible formal psychiatric disorder

really not that sad; they brought me to see you because I got mad when they took my smartphone away. They thought I was suicidal. I was mad because I wanted to text to a new guy I like.” She did not have the internal self-regulatory tools to negotiate conﬂ icts with her parents and resorted to extreme behaviors.

When the clinician is aware of an adolescent’s history of maladaptive behaviors (e.g., hitting others, running away, use of drugs, shoplifting), it would be appropriate to openly recognize having this information and wonder in an empathic manner if it is correct, with the implicit “joining” message that it seems unlikely the information is correct. This allows inquiring, in a noncritical manner, about the patient’s cognition and implicit relational view of their world. Once the clinician becomes familiar using a two-person relational approach, the differences between a child’s responses if securely attached, with good cognitive abilities, in contrast to a child that struggles with disorganized forms of attachment, poor temperament, and cognitive weaknesses, will be evident. The second and third comments or questions are inﬂ uenced by the clinician’s intersubjective experience with the patient’s responses to the ﬁ rst (Table 8.4 ).

Other Approaches

There are many ways of opening a CDI that allow for engaging with patient and their parents or caregivers. We have shared some of our favorite approaches and now provide the reader with a list of alternative comments that he or she may ﬁ nd ﬁ t better with their personal attributes and of their patients (Table 8.5 ). 8.10 Diagnostic Formulation and Treatment Plan 241

Table 8.5 Examples of comments and questions that may be used when beginning a contemporary diagnostic interview (CDI) I really like your glasses, hair, backpack, smartphone, etc. I wonder where you bought the [glasses, backpack, smartphone, clothing, etc.]. Do you remember who took you to buy [the item]? You know, I feel better when I remember a funny or happy memory. I would like to hear one of yours. Who do you live with? When is your birthday? I wonder what you got on your last birthday. Who bought the gift for you? What do you want for your next birthday? I wonder who your favorite person is. I wonder what you like to play with your parents. I wonder what you like to play with your friends. I wonder what you do for fun after school. Are you on any team? Have you joined the Boy Scouts or Girl Scouts? I wonder what your best friend is like. Do your parents show love for each other? I wonder if you remember your ﬁ rst boy-/girlfriend.

8.10 Diagnostic Formulation and Treatment Plan

Diagnostic Formulation

After the child and adolescent psychiatrist or clinician has intersubjectively elucidated the patient’s and their parents’ or caregivers’ temperament, cognition, cognitive fl exibility, and internal working models of attachment, he or she can embark in formalizing the diagnostic formulation and tailoring the treatment plan sequencing for best outcomes. The integrated CDI has served as the foundation by which the child and adolescent psychiatrist or clinician has identifi ed the reliability of the signs and symptoms endorsed and the likelihood of the patient and family to adhere with treatment interventions recommended: psychotherapy, pharmacotherapy, or request for formal cognitive testing (Fig. 8.1 ). As Adler-Tapia (2012 ) masterfully captures, “To enhance treatment effi cacy and improve the trajectory for children’s lives, case conceptualization in child psychotherapy must integrate developmental theory, neuroscience, and best practice models into clinical practice.” With the use of the CDI Case Formulation tool (see Appendix B ), the child and adolescent psychiatrist or clinician will have a visual representation of the strengths and weaknesses of the patient and family and can proceed to address the areas that require intervention with the knowledge of what type of interaction would provide a new and corrective emotional experience for the patient and family system in order to develop healthier adaptive patterns of self-regulation and interaction with others. 242 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

Fig. 8.1 A contemporary Contemporary diagnostic interview (CDI) diagnostic formulation CDI formulation

Cognitive Attachment Temperament Cognition flexibility style

Formal psychiatric disorder

CDI treatment planning and interventions

Psychotherapy Cognitive testing Pharmacologic

Two-person Alternative therapies Best practices relational (OT, PT, speech) based on diagnosis Cognitive Classroom Accommodations Behavioral Compliance Parent training monitoring

Disclosure by the Child and Adolescent Psychiatrist or Clinician

In completing the CDI, we suggest that the child and adolescent psychiatrist or clinician disclose his or her diagnostic formulation about what has been shared by the patient and their parents or caregivers. This allows them to be the child and adolescent psychiatrist’s or clinician’s consultant. It encourages them to give an opinion about their problems and may shed light about their ultimate willingness to adhere to the treatment recommendations. We have noticed that in academic settings, some child and adolescent psychiatrists and clinicians share the diagnostic formulation in a direct and paternalistic approach. To a child they may say, “You need to obey your parents,” and to the adolescent, “You need to make sure you stop [arguing, smoking marijuana, etc.].” They may say to a parent, “You need to stop being critical of your child” or “You need to be ﬁ rm and give the child time-outs, a minute per age,” which is an eternity for 3- to 5-year-olds. Needless to say, the paternalistic approach is implicitly familiar to the child and their parents or caregivers who experience the clinician as standing in for critical persons of their past—nondeclarative memory—and dismiss the suggestions. In contrast, generally child and adolescent psychiatrists or clinicians who are actively practicing psychotherapy, in all its forms, have the innate temperamental attributes and implicit relational models that help create an atmosphere of safety for children and their parents or caregivers to engage in a process that facilitates the bidirectional approach to obtain the information needed to know how to 8.11 Treatment Planning 243 disclose an in-depth diagnostic formulation in a manner that allows for input from the patient and family.

8.11 Treatment Planning

Psychotherapies

It would be beyond the scope of this book to review the many forms of psychotherapy that can be considered for children, adolescents, and their parents or caregivers who present to our ofﬁ ce with mental health and relational problems. Instead, we will narrow our focus to the forms of psychotherapy that are most commonly considered for children and adolescents.

Two-Person Relational Psychodynamic Psychotherapy

Patients that benefi t from a two-person relational model of psychodynamic psychotherapy are those that have innate abilities for curiosity , exploration, cognitive fl exibility, novelty seeking, and creativity . Two-person relational forms of psychodynamic psychotherapy are best suited for those with easy and fl exible, slow-to-warm-up, or mixed temperaments; above-average cognition; average or below-average intelligence; good to fair cognitive fl exibility; and internal working models of attachment in the form of secure, anxious, or dismissive, assessed through a CDI intersubjectively by the child and adolescent psychiatrist or clinician. The reader may notice that we have intentionally excluded two-person relational psychodynamic psychotherapy of children and adolescents that likely would benefi t from a behavioral approach. There are situations where the use of traditional or contemporary psychodynamic theories may be of limited assistance or, in some cases, may be counterproductive, as in the case of children or adolescents who have signifi - cant cognitive diffi culties, severe learning disorders, or autistic spectrum disorders (ASDs). While some may say that traditional one-person psychodynamic principles also apply to these children and adolescents, we disagree in that the limitations and impairments in social reciprocity, affect regulation, and/or mentalization have a negative impact on the patient’s awareness of others. Nevertheless, further longitudinal research about the outcomes regarding children’s progress and the view from parents is needed. We are aware that there have been some case reports in both traditional one-person and two-person relational psychology where a psychodynamic approach is used for children with autism and other developmental disabilities (Sherkow 2011 ; Tustin 1988). In our opinion, these children and their families are best served by an integrated biopsychosocial developmental and behavioral approach. The integrated approach encourages active collaboration among all other disciplines that provide services to help the child—developmental psychologists, occupational and speech therapists, school base behavioral programs, etc.—in contrast to a psychodynamic approach that may lead to further isolation during their formative years. 244 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview

As a note, we have made it clear throughout this book that in a two-person relational model, the characteristics of children who would benefi t from psychotherapy are based in the integration of innate genetic, biological, and psychosocial factors and that the intervention must occur at an implicit level without the goal of insight through verbal communication. This approach is distinct from a traditional one- person model that characterizes children who would benefi t from psychodynamic psychotherapy as those that have intrapsychic drive or object relations confl icts that have led to their symptoms, confl ict-free areas of functioning, some awareness of their symptoms, a wish for change, the ability to use metaphor , and some capacity for ambivalence, all of which require the capacity to verbally understand what is learned in the psychotherapeutic process (Delgado et al. 2012 ).

Cognitive and Behavioral Therapies

Typically, these forms of psychotherapy are appropriate for those with all forms of temperament and cognitive abilities, although for the children or adolescents with intellectual disabilities , as in autistic spectrum disorders , specialized behavioral psychotherapeutic interventions are instrumental in helping them develop skills needed to help with their integration to mainstream education and socialization.

Criteria for Psychotherapies

In using Table 8.6 , the child and adolescent psychiatrist or clinician can quickly identify which forms of psychotherapy may be best suited for children and adolescents when the four pillars of a CDI are considered as they tailor and sequence the interventions according to the integrated approach.

Table 8.6 Visual guide matching contemporary diagnostic interview (CDI) with treatment options

Cognition Temperament Cognitive flexibility Internal working models of attachment Above average Easy/Flexible High Secure

Average Slow-to-warm-up Adequate Anxious

Below average Mixed Limited Dismissive

Intellectual or learning Difficult/Feisty Impaired Disorganized disability

Green boxes indicate that two-person relational psychotherapy and cognitive approaches may be considered as ﬁ rst choice. Red boxes suggest that the psychotherapist might consider behavioral and pharmacologic approaches as ﬁ rst choice and may need formal cognitive testing 8.11 Treatment Planning 245

Formal Cognitive Testing

Although it is recognized that children and adolescents with below-average intelligence and intellectual disabilities benefi t from formal cognitive testing , for the two- person relational psychotherapist, it is important to note that those with average or above-average intelligence may also be struggling with weakness in cognition. They may have cognitive weaknesses that can impact their social reciprocity, self- esteem, and problem-solving skills and, at times, can lead to formal depressive states. The children and adolescents who would benefi t from formal cognitive testing before embarking in a psychotherapeutic process include the gifted student in math with defi cits in receptive language, the pleasant child with good temperament and secure forms of attachment who has dyslexia , the adolescent who is “streetwise bright” but who struggles educationally (e.g., a nonverbal learning disorder), to name a few. Additionally, some cases that may require an integrated approach include children or adolescents that display the following: innate or acquired cognitive weakness or disabilities, temperamental diffi culties, and limited cognitive fl exibility that has negatively shaped the patient’s and parents’ or caregivers’ internal working models of attachment (implicit relational knowing, see Chap. 5) in maladaptive ways. The treatment plan for these cases will require an integrated approach of all of the parties involved—parents, psychotherapist, case managers, teachers, special education specialists, troop leaders, etc. The interventions should be based on the results from the information gained through formal cognitive tests. This allows for the improvement of their fragile sense of self and prevents others from becoming critics of or accomplices to the patient and family’s maladaptive patterns.

Criteria for Formal Cognitive Testing

In using Table 8.6 , the child and adolescent psychiatrist or clinician can quickly identify which patients can beneﬁ t from a referral for formal cognitive testing.

Pharmacological Interventions

Children and adolescents who have a formal psychiatric illness will also have signifi cant self-regulatory (anxiety and mood) or behavioral (impulsivity and aggression) defi cits that may benefi t from the integration of pharmacological and psychotherapeutic interventions tailored to be sequenced for best outcome. For some, the use of medication is needed for the stabilization of their anxiety and mood in parallel with providing education to their parents about what to expect during the course of their child’s illness before a psychotherapeutic intervention can be introduced. For others, providing education to the parents and engaging the child or adolescent in a psychotherapeutic process can help them overcome the fears about the use of medication. When the child and adolescent psychiatrist is also the 246 8 Putting It All Together: The Four Pillars of the Contemporary Diagnostic Interview psychotherapist, he or she is in a unique position to provide both psychotherapy and pharmacological interventions, with the added ability to monitor the benefi ts or problems of each, rather than feeling that one is better than the other (Kaplan and Delgado 2006 ).

Criteria for Pharmacological Interventions

In using Table 8.6 , the child and adolescent psychiatrist or clinician can quickly identify the patients that may beneﬁ t from a formal pharmacological consultation as part of the sequence of interventions in an integrated approach.

References

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Let us be grateful to the people who make us happy; they are the charming gardeners who make our souls blossom. —Marcel Proust

In this chapter, we discuss some of the everyday challenges facing the psychotherapist who embarks upon the regular practice of two-person relational psychodynamic psychotherapy. By actively “setting the frame” for the patient and parents, a psychotherapist starts the psychotherapeutic process on a strong foundation. There is consensus that in most forms of psychotherapy, the psychotherapist benefi ts by providing an outline of what the patient and his or her family can expect once they agree to participate. It is best to launch the psychotherapeutic process after the psychotherapist sets the frame with the patient and their parents or caregivers so they can have some predictability about what will occur during the process and avoid having surprises when confl ict arises. Many of our practical suggestions, including those on confi dentiality, compensation, and time, will be useful to clinicians of any psychodynamic persuasion. However, as we will discuss, there are certain key contrasts between traditional one- person and the two-person relational form of psychotherapy. In traditional one-person psychotherapy, the frame is clearly set by certain principles. The psychotherapist will attempt to preserve some form of neutrality , provide empathy judiciously, observe for inner confl icts of the patient (as well as those present within the parents), attend for maladaptive defense mechanisms, and infer a patient’s object relations through a child’s play or through verbal interactions in adolescents. Further, frequently missed appointments are generally understood to be a form of an unconscious resistance by the patient or parents. For the two-person relational psychotherapist, matters are not as clearly defi ned. The psychotherapeutic process occurs in the intersubjective fi eld, a space that is cocreated by all parties’ subjectivities (temperament, cognition, cognitive fl exibility,

© Springer-Verlag Berlin Heidelberg 2015 249 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_9 250 9 Setting the Frame and implicit relation knowing), including the patient, the parents or caregivers, and the psychotherapist. Each member brings a unique set of nonconscious internal working relational models of attachment on how they implicitly chose to interact with others. Thus, it is quite possible that when the same child and his family are seen by two different relational psychotherapists, a different intersubjective ﬁ eld would be cocreated as a result of the unique sets of temperament, internal working, and implicit relational models of each. An inherent “sloppiness” forms as these intersubjective experiences brush into each other (Chap. 5).

9.1 What to Expect from the Psychotherapist

The following section is intended to succinctly remind the reader of the role the psychotherapist has within the psychotherapeutic relationship as envisioned by two- person relational theory. Though a relational psychotherapist may strive to be empathic, it is more important to recognize that the psychotherapist has a crucial role in the development of the psychotherapeutic process itself. Rather than relying on an approach that “discovers” the patient’s diagnosis or confl icts, the relational psychotherapist must carefully attend to the intersubjectivities in the treatment relationship so as to cocreate interventions that account for the patient’s cognition, temperament, and internal working models of attachment. That is, the inquiry occurs in the form of mutual here-and-now interactions, which allows the psychotherapist to know subjectively the patient’s and their family’s implicit relational models of relating. As an atmosphere of safety sets in, a mutual alliance is created, and new and different information may then be available to the psychotherapist. For example, there are psychotherapists that are natural at using humor with their patients across a wide range of ages. They may be comfortable using a melodic tone of voice, allowing for a here-and-now mutual subjective experience that facilitates a new emotional experience to unfold in the psychotherapeutic process. Other psychotherapists are less fl exible and, although empathic, are somewhat more cautious in their approach toward children, which may not initially provide the atmosphere of safety needed by the patient. The inquiry of maladaptive patterns is through the active participation by the psychotherapist in the process. To give a broad example, when a family begins to demonstrate confl ict during their fi rst appointment and the psychotherapist intersubjectively wants to step in and “join in the confl ict,” this becomes a warning sign. It refl ects on how the family system nonconsciously seeks to elicit negative interactions from each other, although the family unit outwardly hopes to stop the maladaptive patterns of relating.

9.2 “Setting the Frame”: The Contemporary Diagnostic Interview (CDI)

As we have stressed throughout this book, performing a contemporary diagnostic interview (CDI, Chap. 8) does not necessarily imply a future commitment to begin psychotherapy. Rather, the purpose of the diagnostic interview is to provide a critical 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 251 form of psychiatric triage and to help guide the patient and family to the best possible setting to ﬁ t their needs, which in some cases may not be regular psychotherapy. We would recommend completing the CDI over the course of two or more appointments if possible. In our experience, this allows the psychotherapist the necessary time to learn about the patient’s and the family system’s strengths and weaknesses. Rather than depending on a verbal history or a review of medical records, the relational psychotherapist must carefully examine the intersubjectivity , which will yield knowledge about the internal working models of attachment and implicit relational knowing. With this information in hand, the psychotherapist can examine the goodness of ﬁ t needed to work in a relational psychotherapy approach and embark on the process of providing a new emotional experience in a safe atmosphere.

9.3 “Setting the Frame” in Two-Person Relational Psychotherapy

After the decision has been made and agreed upon by all parties to start an ongoing two-person relational psychodynamic psychotherapy process, it is important to directly address some of the formalities of the treatment relationship. Many patients and families, especially those who are in treatment for the ﬁ rst time, may not understand the logistics of how psychotherapy works. These parents may be more accustomed to regular doctor visits, such as with a pediatrician or even a psychiatrist for medications, which are quite different in structure and function than a course of psychotherapy. We have laid out important matters that should be discussed with the family before entering into psychotherapy (Table 9.1 ).

Consent to Treat

We strongly encourage the child and adolescent psychiatrist and psychotherapist to provide a written contract in the form of “ consent to treat ” for the patient and their parents and/or legal caregiver to review and sign, which is then placed in the medical record. This contract should include, but is not limited to, language about the risks and beneﬁ ts of psychotherapy. Many of the logistical issues of treatment may be spelled out in this document and discussed with the patient and family in an organized fashion. Relying on verbal exchanges may lead to misunderstandings and disrupt the overall psychotherapeutic process, which may be particularly frequent in persons with temperamental difﬁ culties, cognitive weaknesses, or disorganized attachment styles. The reader is strongly advised to have his or her personal attorney review any legal document before he or she implements a binding document. There are a wide variety of business practices among child and adolescent psychiatrists and psychotherapists that include differences in payments (e.g., self-pay, insurance), treatment settings (e.g., academic, community based, private), and emergency availability. There are also many state and local regulations and laws that govern certain institutional settings, such as hospitals and mental health clinics, that are different than those governing a private practitioner. 252 9 Setting the Frame

Table 9.1 Pragmatic aspects of “setting the frame” Necessary discussions for Discussing communication establishing a treatment Discussing the before psychotherapy is relationship appointment frame initiated Obtain consent/assent for Discuss frequency of Discuss frequency of telephone treatment sessions, including the calls, when the patient should frequency of parent expect return phone calls sessions Establish goals of treatment Discuss time demands Discuss voicemail procedure with regard to psychotherapy Discuss fees and payment Review cancellation Discuss e-mail (and text policy (e.g., fees for “no messaging, if applicable) with shows”) regard to HIPAA compliance, confi dentiality, etc. Assure confi dentiality and Familiarize the patient Obtain consent for video discuss situations in which with the offi ce, including recording confi dentiality may not apply toys, etc. (e.g., child abuse, suicidality) Discuss medical records with Waiting room and Discuss electronic devices with regard to disclosure etiquette regard to their use in the session If medications are a component Discuss policies regarding Families as ambassadors for of treatment, discuss frame “out-of-offi ce” visits two-person relational (e.g., refi lls) psychotherapy Provide contact information Special situations (see next column)

Goals of Treatment

After the CDI, the psychotherapist should be able to share his or her initial goals with the patient and family and ask if the goals are consistent with their expectations. The most important goal of a two-person relational psychodynamic psychotherapy will be to provide the child or adolescent with the opportunity to develop a healthier sense of self and more adaptive patterns of social reciprocity—ability to love, play, and learn.

Working with Parents

In our experience, working with parents regularly is essential. We recommend that the psychotherapist schedule appointments with the patients’ parents individually after every three to four sessions with the child or adolescent. This provides the parents or caregivers a sense of relief in knowing that they will have time to speak to the psychotherapist after he or she has become more familiar with their child or adolescent. In preparation for meeting with the parents, it is important to ask the child what they think should be shared with the parents about their work together and whether they have ideas about what the parents may be asking the psychotherapist. 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 253

Contemporary Contemporary Session with child diagnostic interview I diagnostic interview II

Session with child preparing Parent session Session with child psychotherapist to meet with parents

Session sharing with child topics reviewed in Session with child Session with child meeting with parents

Fig. 9.1 Suggested course of two-person relational psychotherapy

Asking the patient to be a contributing participant in the parent session without being present is a valuable model of the new adaptive ways of trusting others, which is stored in the patient’s implicit nondeclarative memory. Then, after meeting with the parents, it is helpful to review with the patient what had been discussed with the parents (Fig. 9.1 ). It is expected that some disagreements will occur among the patient and the parents as a result of these meetings, and this will likely occur more frequently in families that have poor internal working models of relating with others to begin with. Their disagreements should be considered as an example that the process is beginning to serve the cocreation of new adaptive ways of relating—communication rather than isolation or distancing—that the psychotherapist has inﬂ uenced. Oftentimes, their disagreements are the result of their desire to collaborate in helping to achieve the goals set out when the process began, although early in the process they will continue to be inﬂ uenced by maladaptive relational patterns.

Time

The matter of time is an important aspect of the psychotherapeutic process. It not only involves the length of the appointment but also the frequency of the appointments. Typical appointments last about 50 min and are scheduled either once or twice a week. The appointment length and frequency should be agreed upon jointly by all parties. The patient and parents will appreciate knowing that they have a voice 254 9 Setting the Frame in the decision-making process. In fact, there are occasions when a 25-min appointment is best, particularly for patients with severe forms of anxiety. The matter of setting the time for the appointments is infl uenced by many factors and should be addressed sensitively up front. We have intimately learned about the importance of recognizing the diffi culties for parents in managing time constraints, especially if there is signifi cant distance between the psychotherapist’s offi ce, the child’s school, and the parents’ place of employment. When the psychotherapist does not have available appointment times that are convenient for the parents, an open discussion may reveal the realities of the constraints—distance, employment confl icts, etc.—and it may be best to transfer the patient to a colleague with more fl exibility. Similarly, if the patient needs more than one session per week, this is also an opportunity to consider a referral to colleague with a more convenient location, rather than set the stage for fi nancial hardship or missed appointments (e.g., risk of the ubiquitous traffi c problems in urban settings). For any patient in attendance during the school day, it is good practice to work with the patient’s schedule to fi nd a regular meeting time, such as an activity period before lunch, to avoid academic confl icts. Once the frequency and appointment times have been agreed upon, it is important to review offi ce policies involving late arrivals, cancellations, inclement weather rules, and any dates on which the psychotherapist may be out of the offi ce. Unlike in cognitive behavioral therapy (CBT), considered a short-term psychotherapy process in which termination is defi ned by the achievement of goals and by the number of sessions, two-person relational psychotherapy is more open ended. Plans for termination are typically made after all parties have had an opportunity to learn how to develop adaptive patterns as they “dance” together ( Delgado and Strawn 2014 ).

Fees for Service

The child and adolescent psychiatrist or psychotherapist that wishes to work in a private practice, and if not part of a group, should discuss with his or her colleagues what the customary charge is for psychotherapy in the local community. Discussing matters relating to payment is likely one of the most sensitive issues and should be handled with a great deal of openness. The child and adolescent psychiatrist or psychotherapist should discuss the reason why the fees for the initial consultation are typically higher and then explain the fees for an ongoing psychotherapy process openly. The child and adolescent psychiatrist or clinician should be prepared for parents that had hoped that the evaluation process would have “cured” the child’s problems or provided the pharmacological intervention to “ﬁ x” the concerns. The parents and their child will need to be educated about how the psychotherapeutic process can help meet the proposed goals. How the parent or caregiver will be billed and how and when payments are expected must be agreed upon at the beginning of the process. Some psychotherapists prefer payment at the time the session is held, while others prefer it to be delivered on a monthly basis. 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 255

The psychotherapist should be prepared to accept multiple forms of payments, including cash, checks, and credit cards via a service on a tablet or other mobile device. Families should know in advance that the step of using legal means to secure the payment may be taken by the psychotherapist when their account has not been paid for more than 60 days. It is not unusual to have a provision in the treatment contract to state what patients will be charged if the psychotherapists provide additional services, such as taking phone calls, reviewing legal documents, writing reports, and/or participating in legal proceedings. Other provisions may include collaboration with teachers or other physicians, as well as visits outside of the offi ce, such as the patient’s school. It is also important to review the policies regarding charges the psychotherapist has for explained or unexplained missed appointments (e.g., cancellation fees). It is common for psychotherapists to have policies wherein if the patient or parent can- cels a set number of days in advance and the psychotherapist can schedule a different patient in that vacated hour, the family will not be charged. We emphasize that in two-person relational psychotherapy, there will be ample opportunity to discuss these matters in an atmosphere of safety, as we have found that, at times, early cancellations are due to fi nancial hardships and parents have shame or guilt in admit- ting to this. For many years, those of the traditional one-person school considered cancellations as having a layer of an unconscious resistance to the treatment, which we posit that the reasons for cancellations are more complex and strongly infl u- enced by the realities of the patient and family. A side note on this matter: For the newly minted child and adolescent psychiatrist, the task of graduating and beginning a private practice or joining a group is daunting, as this is their fi rst experience in collecting payment for their service (e.g., to play or talk with children and adolescents), which can elicit some feelings of guilt. The trainee had been accustomed to seeing their psychotherapy patients in an academic setting, where it is typically not appropriate to charge for the service. We encourage the newly minted child and adolescent psychiatrist or psychotherapist to consult with prior supervisors (see Chap. 13) and colleagues available who can share valuable personal experiences regarding this familiar matter.

Third-Party Payers

Given the complexity among insurance policies, if the child and adolescent psychiatrist or psychotherapist accepts payment from insurance companies, it should be explained clearly to the parents how this process is handled. For many clinicians in a private practice, the parents will have to do much of the legwork in terms of sub- mitting their claims. In some group practices, as well as large hospitals, this may be processed by ancillary staff. Insurance plans are often limited to short-term treatment approaches designed for speciﬁ c Diagnostic and Statistical Manual of Mental Disorders, 5th Edition DSM - 5 (APA 2013 ) categories. It should not be assumed that 256 9 Setting the Frame the matter of co-pay is clearly understood by the parents or caregivers or that it is not a hardship for them. The family should also be aware that most insurance companies require treatment plans that include a clinical diagnosis and, at times, a copy of the medical record to authorize reimbursement. To this, some families may choose to pay for services out of the pocket to avoid potential issues, as they would rather not have the insurers handle this sensitive material. It should also be noted that many insurance companies have a set limit on certain types of treatment, including psychotherapy. It may be necessary for the psychotherapist to complete deﬁ ned treatment plans to submit and to request approval for additional psychotherapy sessions from the insurance company. This should be discussed ahead of time in the case that this request may be denied. Finally, if the insurance company denies reimbursement, the parent should be well aware that they will be responsible for the full payment of fees. Some families may not be able to afford the weekly co-pays or the full fee, and depending on the practitioner’s judgment, the family should be referred for continued care at a low- fee clinic or a child and adolescent psychiatry or psychology training program psychotherapy clinic. One cannot be prepared for all situations, which is why an atmosphere of safety provides the space necessary to share and cocreate realistic solutions in the best interest of the child or adolescent.

The Office

The child and adolescent psychiatrist’s or psychotherapist’s offi ce will become an important relational space for the patient and parents; it becomes the environment that they hope will provide the tools to feel better emotionally. They implicitly bestow the psychotherapist with trust. As such, the offi ce shall be in a safe location, featuring adequate space and a comfortable environment. Attention must also be given to parking, to bus routes, and to the rules of where can the child be safely dropped off and picked up if 14 years of age or older and by whom. (For patients under the age of 14, it is essential that a parent or other approved adult be present in the waiting room with the child, both before and after the appointment.) In regard to trainees, it is important to disclose to the patient and their parents or caregivers if they are using offi ces that are not unique to them. This allows for an open discussion of the impressions created by the offi ce used, as in the case of a small offi ce that may not capture the personal subjective experience of the trainee’s character. It is also important to disclose that the tools accessible for the process— toys, Crayolas, paper, etc.—are not the trainee’s, and both parties can openly and in the here and now discuss their experiences of the situation if it proves to be limiting (e.g., very few toys) or overwhelming (e.g., abundance of toys and games). This allows both the patient and trainee to have the freedom to compliment or criticize aspects about the borrowed offi ce. 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 257

The Waiting Room

The waiting room will need to have comfortable chairs for adults and children; reading material for parents and adolescents; and toys, games, or access to television for younger children. Fortunately, in this time of advanced technologies, many patients and their parents bring their own electronic devices while they wait for appointments. If the waiting room is shared with other psychotherapists, the patient and parents would likely appreciate the psychotherapist’s disclosure about whether they should expect other children or adults to be present. It is also important when the psychotherapist’s ofﬁ ce is within a pediatric environment that the patient and parents know where they can wait to avoid the fear of becoming ill if sick children will be present.

Confidentiality (HIPAA)

Confi dentially is paramount for mental health-care providers, who have a profound responsibility for its safeguard. There are federal and state laws that protect the privacy and confi dentiality of medical information. To this end, the Health Insurance Portability and Accountability Act standards were established in 1996 and imple- mented in 2003 as the Privacy Rule ( HIPAA 1996 ). The Privacy Rule assures that individuals’ health information is properly protected while allowing for the fl ow of health information needed to provide quality health care. The Privacy Rule is designed to be fl exible and comprehensive. In the modern medical centers, however, there are varying levels of confi dentiality and potentially confl icting edicts related to its enforcement. Clearly, this is a complex process when parents are divorced, and interventions should be tailored to best help the patient maintain his or her treatment confi dentiality. Herein, patients and their parents or caregivers benefi t in knowing that the front offi ce staff will have their privacy in mind. Some offi ces refer to patients and parents only by their fi rst name, others allow them to press a button to alert the psychotherapist they have arrived, while others use a paging system. There are many opportunities for their privacy to be compromised, especially in larger settings, so measures to minimize this from happening should be used when possible.

Communication

How to communicate with the psychotherapist in between appointments is an important piece of knowledge for the patient and family. The reasons for families and patients to reach out are many, so it is helpful for the psychotherapist to share their basic rules of communication in order to set realistic expectations with the patient and family. Typically, telephone calls are received during offi ce hours by front offi ce staff, confi dential voicemail, or an answering service. Patients and 258 9 Setting the Frame families need to know what time frame they can expect to have their phone call returned (e.g., same day, before a certain time, 48 h). They should also be made aware of the process for handling after-hours telephone calls, common procedures for when emergencies occur, and how to access local emergency rooms for assessment of the patient’s safety. There are some psychotherapists that use e-mail or a smartphone as a practical vehicle of communication with patients and their families. Each clinician will need to be thoughtful on setting some parameters on how these methods are used, and they must consider matters of confi dentiality and HIPAA discussed above. In its most simple form, the use of e-mail is best when the patient, parent or caregiver, and psychotherapist are using a personal account from a secure server. The use of social media is not recommended for communication, as it is not carefully regulated and can easily lead to misuse in a psychotherapeutic process. Communication with other important sources can help the treatment process, including pediatricians, subspecialty physicians, school personnel, and social agencies. To this, the psychotherapist and their front offi ce staff should routinely request parents and adolescents to sign a release of information (ROI), which gives the psychotherapist and their offi ce staff permission to communicate with the important sources. It should be noted that the release of information can be tailored to the needs of the patient and family, such as allowing the psychotherapist to obtain information without disclosing information about them. Further, the ROI is generally time limited (e.g., 60 or 90 days), and a new form must be signed if needed at a later time. The patient and their family or caregivers have the right to cancel the form at any time.

Office Rules

As we have described throughout this book, how we approach our patients and their families is infl uenced by our own unique set of internal working models of attachment and temperament. We briefl y reviewed how we practice and encourage the reader to refl ect on their offi ce rules vis-à-vis the patient’s needs (e.g., wheelchair bound, needing a therapeutic dog). In our practice, an academic hospital setting, we do not recommend the use of puppets or sand trays, as these allow for easy cross-contamination of viral processes during viral high seasons, which is not appropriate for our patients. To this point, we use toys, character fi gures, dry erase markers with small easel boards, and games with plastic fi gures, all of which can easily be washed or cleaned with instant hand- sanitizing wipes. As with most issues, no one size fi ts all, and appropriate decisions to preserve the medical health of patients should be made at each practice. A special situation that is important for the psychotherapist to keep in mind is when a child attempts or succeeds in destroying personal property in the offi ce, a very complex aspect of psychotherapy when working with young children. This is attenuated in two-person relational psychotherapy, as it assumes that the psychotherapist’s efforts are to teach the child, at the implicit level, to self-regulate in more adaptive patterns that are not conducive for regression, often seen in the verbal and interpretative insight-oriented work of the traditional one-person model (see Chap. 2 ). 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 259

However, aggression may still appear without warning. How this is managed in the here and now and the possible ﬁ nancial repercussion to the parents or caregivers is best handled when discussed early and during the consent for treatment.

A 6-year-old boy’s wrestling match with the psychotherapist A 6-year-old boy in two-person relational psychotherapy was playing with the psychotherapist using wrestling character ﬁ gures, and he began to jump on the wrestling play ring with force that could break it. The psychotherapist uses his own wrestling character and said with excitement to the boy, “I am going to show you how we can play and be tough guys without breaking the ring,” and proceeded to demonstrate how. The child seemed relieved; they cocreated a moment of meeting that became a new and corrective emotional experience at the implicit level.

Interestingly, when we shared the video recording of this play sequence to the trainees, it was brought up that perhaps the psychotherapist could have interpreted the boy’s aggression as wanting to be strong and protect himself from his abusive father. We refer the reader to Chaps. 3 and 4, where we explain that this way of formulating is very much a traditional one-person form of psychotherapy. We do not adhere to it since it implies knowing the intrapsychic reason of the play rather than it being a pattern the child had stored in implicit nondeclarative memory, of which the observer cannot know its multifaceted origins.

Consent for Video Recording

The lead author frequently uses video recordings for teaching purposes, which is helpful for allowing the in vivo demonstration of how the patient’s and psychotherapist’s subjectivities can be experienced in the here and now by the participants. There are several aspects in regard to the consent of video recording that are important to be familiar with. It must be clariﬁ ed if the recording is for teaching purposes and, if so, with whom it will be shared. It is best to disclose if the recording will be shown in the academic setting where the psychotherapist works, which is different than if it is also planned to be used at a national conference. In these situations, a new consent will be needed that speciﬁ es the new purpose. There are some signed consents that expire, and this will need to be discussed with the patient and family, as well as legal counsel when possible.

Use of Electronic Devices

The use of electronic devices and smartphones is ubiquitous among children and adolescents nowadays. As such, we believe it is no longer helpful to have a rule in 260 9 Setting the Frame place that prohibits the use of electronic devices during sessions, since that prevents the psychotherapist from knowing what the child is like in the context of his or her world. We suggest that it is best to convey the subjective experience the two-person relational psychotherapist has when the patient uses the electronic device, thus allowing the patient to learn how their actions have had an impact on the here-and- now mutuality of their interaction.

Telepsychiatry

Regarding the use of telepsychiatry ( e.g., Skype, VSee, FaceTime), the American Academy of Child and Adolescent Psychiatry (AACAP 2008 ) has developed practice parameters for this type of intervention, and we encourage the child and adolescent psychiatrist to familiarize themselves with these parameters before engaging in this form of communication. Telepsychiatry is guided by medical state boards.

Home and School Visits

The authors recommend that when possible, trainees should meet their psychotherapy patients both at home and at school. It is a great learning experience seeing patients in their natural surroundings. Most of the time, patients and families are grateful for the home visit. An in vivo visit speaks louder than words in regard to intersubjective experiences of patients and families with two-person relational psychotherapists. However, it becomes a complicated issue when the psychotherapist is not a trainee, as the visit to the home or school will need to be agreed upon due to issues of billing for the time involved, which may include travel time.

Use of Medication

Many patients in two-person relational psychotherapy, including children and adolescents, may benefi t from the use of medication (e.g., for depression, anxiety, ADHD). This is a complex issue that needs defi ned parameters that can be shared with parents or caregivers up front to avoid misunderstandings. To this point, the child and adolescent psychiatrist or psychotherapist will need polices that explain how to request refi lls and the time frame in which the parents or caregivers can expect the medication to be called into their pharmacy. This issue is very important in the case of stimulant medications, which is more complex and bound by state pharmacy laws. We suggest that the child and adolescent psychiatrist develop stimulant medication refi ll policies that are reviewed up front. If the patient is being treated by a nonprescribing psychotherapist, it is necessary to have the parents sign a release of information so the clinician can collaborate with the prescribing psychiatrist or pediatrician. 9.3 “Setting the Frame” in Two-Person Relational Psychotherapy 261

As previously stated, the psychotherapist should not underestimate the possibility that the cost of medication may be a ﬁ nancial hardship and a possible reason for noncompliance rather than a resistance to treatment.

Medical Records

Most states have laws that require mental health professionals to keep and maintain treatment records. Patients and their parents are entitled to a copy of their records, although sometimes a summary will sufﬁ ce, as complete records can be misinter- preted. In line with two-person relational psychotherapy, reading the medical record together with the patient and their family can be helpful, as it can provide them with a feel for the psychotherapist’s view of the progress.

Special Situations

Special situations are part and parcel of the work with children and adolescents. It would be beyond the scope of this book to encompass them all. Suffi ce it to say, the two-person relational psychotherapist will need to refl ect on the comprehensive treatment formulation developed through an integrated contemporary diagnostic interview (CDI) and then focus on the new emotional experiences needed by the patient and family. In most diffi cult situations, the patient and family’s implicit relational model will nonconsciously attempt to turn the psychotherapist into an accomplice of their maladaptive patterns. The most common special situations that arise in child and adolescent psychotherapy are the separation or divorce of parents, custody disputes, self-destructive or suicidal behaviors, bullying, and chronic medical conditions. We would encourage consultation with a colleague when the situations lead the psychotherapist to feel intersubjectively pressured into action in the space with the patient or parents.

An unhappy father attempts to sabotage his daughter’s treatment A 16-year-old Caucasian female—who had been in weekly two-person relational psychotherapy for being unhappy due to her parents’ conﬂ icts after their divorce 4 years prior—was hospitalized after voicing serious suicidal ideation during her psychotherapy session. Her parents were successful professionals and had two older children that were doing well academically— achieving honors—and socially. The patient’s father asked her inpatient physician to ﬁ nd a new psychotherapist, stating, “She is not making progress; she is becoming suicidal, and I pay for her insurance,” in spite of the fact that the patient shared to her mother and inpatient treatment team that her psychotherapist was instrumental in allowing her to share her suicidal ideation “without feeling ashamed.” The patient asked if she could see her psychotherapist 262 9 Setting the Frame

while on the inpatient unit at her regular times. For this to occur, the parents would need to agree to cover the fee for the psychotherapist, as it was likely their insurance would not reimburse due to her being in the hospital. Furthermore, the inpatient treatment team suggested that the parents and psychotherapist attend a meeting to discuss the patient’s discharge plans, which would also involve the parents covering the fees for the psychotherapist to attend. Although the patient’s father refused to help pay for the psychotherapist’s fees, he agreed she could attend the meeting, saying: “I guess she really connects with my daughter.” The patient’s mother recognized the importance of the psychotherapist and stated, “I will pay for her [the psychotherapist’s] time; my daughter needs her support.”

This case conveys the importance for a psychotherapist to have a clear and complete treatment contract before launching the psychotherapeutic process. The parents understood the importance of signing a release of information for the hospital treatment team to communicate with the psychotherapist who had a good therapeutic alliance with their daughter and was instrumental in helping the parents take her suicidal ideation serious. Although the parents were aware of the fees involved in having the psychotherapist see their daughter and attend the treatment team meeting, the patient’s father’s implicit relational problems, which his daughter had dif- ﬁ culty with, became apparent to all. A brief comment of caution: In this case, the psychotherapist was allowed to see the patient in psychotherapy while on the inpatient unit, as she had hospital privileges to do so. If this had not been the case, the psychotherapist may have only been allowed to see her patient as a visitor and would legally not have been able to practice psychotherapy or charge for her services, as this would not be considered a professional service. This may vary in many hospital settings, and it is best to request formal privileges of the hospital likely to be used with child and adolescent acute care inpatient units.

Families as Ambassadors for Two-Person Relational Psychotherapy

Occasionally, we fi nd that parents wish to obtain information from other families— similar to a letter of reference—that supports our ability to help. They hope to fi nd a person that has traveled the road before who can help them with their apprehen- sion in engaging in a psychotherapeutic process. We have found this to occur more often when play psychotherapy is recommended, as most parents do not have a frame of reference about how this can be helpful. To this, the lead author has found that many families are eager to discuss their personal experience regarding the relational psychotherapy process. In fact, some adolescents are eager to share their References 263 experience with others. These families openly share the complexities regarding appointment time management during the process and the benefi ts of the treatment. As a reminder, if this is to be pursued, the psychotherapist will need to have signed consents for release of information from both parties to communicate with each other. Clearly, not all families wish to share their experiences, for a variety of reasons, including privacy, guilt for their child’s psychological problems, etc.

9.4 Summary

Setting the frame is one of the most important elements in psychotherapy. Langs (1988 ) eloquently states that the psychotherapist’s use of ground rules constitutes his or her most fundamental form of intervention, which inﬂ uences all other dimensions of the therapeutic encounter and experience. Finally, we provided the reader with many practical suggestions, including those on conﬁ dentiality, compensation, and time, which are useful to clinicians of any psychodynamic persuasion.

References

American Academy of Child and Adolescent Psychiatry (2008) Practice parameter for telepsychiatry with children and adolescents. J Am Acad Child Adolesc Psychiatry 47(12):1468–1483 American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. 5th edn DSM-5. American Psychiatric Association, Washington, DC Delgado SV, Strawn JR (2014) Difﬁ cult psychiatric consultations: an integrated approach. Springer, Heidelberg Langs RJ (1988) A primer of psychotherapy. Gardner Press, New York U.S. Congress, House of Representatives, Committee of Conference (1996) Health Insurance Portability and Accountability Act of 1996. 1996 July 31 Two -Person Relational Psychotherapy: Infants and Preschool Age Children 1 0

Every child at play behaves like a creative writer, in that he creates a world of his own, or, rather, rearranges the things of his world in a new way which pleases him. — Sigmund Freud

We open this chapter with Freud’s masterful quote that captures the role children have as active participants in their development. For many years, infants were thought of as being dependent and unaware of the world around them (Mahler et al. 1975 ). The work by early developmental researchers—including Bowlby, Spitz, Emde, Stern, etc.—helped elucidate that infants were hardwired to develop complex abilities for social reciprocity, and if raised by parents with “good enough” capacities for affective attunement, the infants were quite busy in meaning-making processes. Tronick and Beeghly (2011 ) state, “In developing systems, such as human infants, sufﬁ cient resources must be obtained to enable them to increase their coherence and complexity and to self-organize new capacities.” Further, Bretherton and Munholland ’s (1999 ) work reinforced the notion that interactions between infants and their parents gave meaning to their shared experiences, with the development of internal working models of attachment giving coherence to their relationships. When infants have emotionally available and affectively attuned parents, they develop secure working models in relating with others. When parents provide a secure base for the infant, it increases the likelihood of the infant acquiring the emotional resources needed in the short run, and in the long run, these growth-promoting social interactions will contribute to self-regulatory capacities and resiliency. Over time, infants become part of a larger and more complex system, and they become more ﬂ exible and better able to reorganize when confronted by day-to-day discontinuities in their care.

© Springer-Verlag Berlin Heidelberg 2015 265 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_10 266 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children

Two busy, securely attached infants We informally asked two of our colleagues, who had each recently given birth to a child, how many people had held and jovially interacted with their child during their ﬁ rst three months of life. The ﬁ rst colleague laughed and said, “In our culture we have very close and large families; my son has interacted with more than 30 family members and friends. He loves all the excitement.” The second colleague shared that her son had interacted with more than 10 family members and also loved the excitement.

This example aptly captures the idea that the emotional experiences that can promote the infant’s self-regulatory capacities are dependent on the variations in the quality and intensity of early social interactions. These capacities are sculpted by the relationship between the infant, parent, and family within the backdrop of contextual and cultural factors. Brief periods of disorganization in everyday life of the parent–infant relationship are inevitable and normative. The two healthy and secure infants described in the example will learn to develop self-regulatory abilities that allow having the psychological skills needed to tolerate everyday demands, such as being hungry, needing their diaper changed, etc. Infants attempt to make coherent meanings of the variations in the environment, through a combination of their own unique temperamental traits and the self-regulatory abilities they develop. It is not surprising that infants who have limited exposure to growth-promoting social interactions have diffi culties with self-regulation and closeness throughout their life. When life is not as idyllic for the infant and their parent’s emotional availability is unpredictable, the infant will have diffi culty developing meaning-making processes and self-soothing abilities. The experience from chronic parental inconsis- tency can lead to altered brain development, compromised socioemotional functioning, stunted mental growth, and even death ( Nelson et al. 2007 ). As an example, infants that avoid interactions with other people for fear that these people may have similar characteristics as the original intrusive parent may experience short-term relief from anxiety. However, in the long run, it will be detrimental and lead to limited growth-promoting social engagements with others and potential long-term developmental consequences ( Beeghly and Cicchetti 1994 ; Tamis- LeMonda et al. 1996 ; Sroufe 2009 ). As such, these infants exhibit affective and behavioral reactions consistent with sadness, anger, withdrawal, and disengage- ment. Furthermore, they likely experience signifi cant anxiety and fear due to the loss of organization, they become easily dysregulated, and their sense of self is threatened. Parental depression and anxiety, as well as infant medical, behavioral, and temperamental issues, can result in prolonged periods of dyadic disorganization and maladaptive infant outcomes. Child health clinicians can help parents anticipate the normal periods of disorganization and assist parents to develop optimal parent– infant relationships (Beeghly and Tronick 2011 ). Infants with harsh and unrespon- sive parents learn that by minimizing the interactions with their parents, they increase the likelihood of survival, albeit without developing the adaptive 10.2 Adam 267 self-regulatory mechanisms needed for continued psychological growth (Cicchetti and Barnett 1991 ). This signifi cantly increases their risk of long-term maladaptive and insecure attachment relationships with others in later life (Fraley and Shaver 2000 ). Andersen (2003 ) describes early periods of development as critical windows of opportunity essential for “brain wiring.” Further, Pearson et al.’s (2013 ) work with depressed mothers and their babies fi nds that “treating maternal depression antenatally could prevent offspring depression during adulthood, and that prioritiz- ing less advantaged mothers postnatally may be most effective.”

10.1 Psychodynamic Psychotherapy in Infants and Preschool Age Children

The reasons why parents of infants and preschool age children seek help are generally due to feeding, developmental, or behavioral diffi culties. As such, the child psychiatrist or clinician will benefi t from using the contemporary diagnostic interview (CDI, Chap. 8 ) in order to understand the child’s unique attributes—temperament, cognition, cognitive fl exibilities, and internal working models of attachment—albeit in a rudimentary form due to age and within the context of the environment in which they live (including family and culture considerations). Careful attention should be given to the norms of development (see Appendix A ). During this age, meaning-making processes, social reciprocity, and the ability to regulate affective states, as well as the improvement of their motor skills, become central in the infant’s or child’s development. It is important to note that the maturation process can be uneven with regard to innate temperamental and cognitive attributes, further infl uenced by the availability of the parents or caregivers for the affective attunement needed for maturation. Language is a major milestone that typically occurs at the 18-month-old mark. Consequently, the two-person relational psychotherapist of infants and preschool children will need to understand the role parents and caregivers have played in the child’s developmental process.

10.2 Adam

History of Present Illness

Adam was an 11-month-old male infant referred by his pediatrician for failure to thrive. Though no organic cause was identiﬁ ed, the pediatrician was concerned that if no behavioral solution were found, a gastrostomy tube (G-tube) would have to be placed for feedings. The pediatrician recognized the psychological consequences of such intervention. It is not unusual for child psychiatrists to be consulted in such cases. The week prior to the appointment, the family had celebrated Thanksgiving at a friend’s house. However, Adam became very upset and irritable. Despite many efforts by his parents to comfort him, he refused to eat for over 14 h. As this pattern 268 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children was becoming more common, his pediatrician placed a nasogastric (NG) tube (which was present at the time of the appointment) in Adam for involuntary feedings.

Past Medical History

Though his birth and delivery history was unremarkable, Adam had a long history of diagnoses and medical procedures despite his young age. Soon after birth, he was diagnosed with milk protein allergy and acid refl ux. Within the fi rst few months of his life, he was diagnosed with severe craniosynostosis (a birth defect in which one or more of the suture lines between the bones of an infant’s skull close prematurely, before their brain is fully formed). By his fourth month, he had undergone an esophagogastroduodenoscopy (EGD), a chromosome analysis, a computed tomography (CT) scan of the head, and a magnetic resonance imaging (MRI) scan of the brain. The results confi rmed severe craniosynostosis. After having corrective surgery, at his follow-up appointment with the surgeon, it was noted that Adam’s surgical site was healing normally, although “the infant cried repeatedly during the exam. His mother reports this is typical in new environments for him.” Five months later, the surgical team felt that the defect had been adequately corrected, although they noted a mild developmental delay “due to the fact that he was quite a poor eater .” He had fallen below his weight and height developmental curves, and their pediatrician gave him the diagnosis of “ failure to thrive .”

Past Family History

Adam’s father was a 32-year-old man who worked as a delivery driver. He spoke about having a confl icted relationship with his own parents. As a child, he suffered from low self-esteem, which worsened when, as an adolescent, he developed motor tics—eye blinking, oral–buccal movements, and chewing fi ngernails. “They always made fun of me. I was and am always anxious.” Adam’s mother was a 27-year-old woman who struggled with a signifi cant amount of pain due to endometriosis and polycystic ovarian problems. She also had a history of an anxiety disorder that she did not have treated, “I was ashamed to get help for it.” She reported that she had never fl own in an airplane and said that she would never fl y, because she would be sure that it would be time for her demise due to anxiety: “I couldn’t handle it.”

Adam’s First Appointment with the Child Psychiatrist

Upon greeting Adam’s parents for the fi rst time, the child psychiatrist noted that the parents seemed ready to share their anxieties, as they promptly exclaimed, “No offense, but we feel very bad that Adam has to see a child psychiatrist; he is not even 10.2 Adam 269 a year old.” The parents experienced the consultation as an ominous sign of their failures, rather than as an opportunity to fi nd ways to help their child. The child psychiatrist’s fi rst intersubjective experience was that of genuine sadness for the parents; they conveyed a pervasive feeling of being inadequate as parents. From a two-person relational psychology perspective, the parents intersubjectively were experienced as using an internal working model of ambivalent/anxious attachment, and both displayed a slow-to-warm-up temperament style. As the interview progressed, it became clear that the parents had frequently cocreated experiences in which they conveyed to physicians and other caregivers the implicit sense of insurmountable fear they had of not being adequate parents. The child psychiatrist intersubjectively felt that there were actually three people in the offi ce that needed consoling. Within the framework of a contemporary diagnostic interview (CDI, Chap. 8 ), the child psychiatrist made use of comments that helped create an atmosphere of safety for the anxious parents. He complimented the parents about the nice outfi t their son was wearing and the sophisticated stroller they were using. From a nonverbal standpoint, when the parents conveyed a sigh of relief, the child psychiatrist intersubjectively experienced in the here-and-now moment that he had helped them feel validated as caring parents. They proudly shared that they had saved money for such a high-quality stroller because they wanted “the best for our fi rst child.” With this, the child psychiatrist intersubjectively felt hopeful for them. Nevertheless, in the next comment, they conveyed the nature of their chronic patterns of an ambivalent/anxious internal relational knowing: “With all this stress, he will likely be our only child. We are not good parents.” With these comments, the child psychiatrist intersubjectively experienced them as having constant feelings of anxiety and feeling inadequate as parents. As anticipated, the parents’ affect became more anxious as the consultation evolved. Exasperated, they said: “We don’t know how to be good parents. He started vomiting almost every day since he was 10 months old. By the end of the day, we would run out of outfi ts; we had to keep buying more. Our families told us we were not good parents. We now know they were right.”

Allowing Subjectivities to Meet: Developmentally Informed Mental Status Exam

Adam was a cute and likable 11-month-old child. Surprisingly, in the fi rst appointment, he was eager to interact with the child psychiatrist and had a full range of facial expressions for most of his affective states. He stuck his tongue out, imitating the child psychiatrist. He smiled and allowed for gentle touch. The child psychiatrist subjectively felt surprised at the child’s resilience and sophisticated capacities used to engage in social reciprocity with a stranger. It was as if he were hungry for interaction. The child psychiatrist asked the parents if they would allow their child to crawl in the offi ce. The child psychiatrist proceeded to sit on the fl oor, and as soon as Adam was allowed to crawl, he began to play with some of the age-appropriate 270 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children toys and looked with a smile at the child psychiatrist for social referencing. In the next interpersonal sequence, after the child psychiatrist asked Adam’s parents’ permission to hold him and reached out for him, Adam expressed discomfort and became anxious and irritable. Intersubjectively, the child psychiatrist felt that Adam had found the optimal distance comfortable for him when relating with others. When the distance was infringed—when the child psychiatrist tried to hold him— he noticeably let others know that this was not comfortable. He was playful and engaging as long as there was a safe distance between him and the other person. These in-session interactions highlight the value of nonverbal communication. Without losing sight of the parents, the child psychiatrist noticed their excitement seeing their son happy and playful, although it was also noticeable that they seemed unaware that they had been invited to join in the playfulness. What intersubjectively puzzled the child psychiatrist was that Adam’s parents had shared that they were overwhelmed with their child being diffi cult to console in new environments, which was not the case in the child psychiatrist’s offi ce, also a new environment.

Contemporary Case Formulation Following Use of the CDI

After the ﬁ rst appointment, the initial impression of Adam by the child psychiatrist was that of a complex case with severe medical problems within the context of his parents’ anxieties, compounded by his sensitivity and anxiety to social situations. Given his multiple medical procedures that required periods of time in which he needed to be separated from his parents during his ﬁ rst 10 months of life, this likely played a contributing factor to his failure to thrive and his developmental delays. Eating disorder of infancy and an acute stress disorder were diagnosed. Early infant feeding problems are often best understood through the complexities of the relationship between parents and their infant (Daws 1993 ).

Contemporary Case Formulation Following Use of the CDI: Adam Summary: An 11 - month - old Caucasian boy who presents with functional feeding impairment timed with the onset of his medical problems Internal working models of attachment (IWMA): Ambivalent/anxious Temperament: Mixed; predominantly easy/ﬂ exible with some slow to warm-up Cognition: Average (see developmental milestones Appendix A ) Cognitive ﬂ exibility: Average for his age during consultation Formal psychiatric disorder: Eating disorder of infancy and an acute stress disorder Treatment recommendation: Begin parent–infant two-person relational psychotherapy to help the parents provide the tools necessary for Adam to develop self-regulatory functions and to improve his eating behaviors. 10.3 Case Conceptualization from a Traditional One-Person Model 271

Contemporary Case Formulation Following Use of the CDI: Adam’s Parents Summary: A 32 - year - old Caucasian male and a 27 - year - old Caucasian female who presented with functional impairment in providing the affective attunement needed by their 11 - month - old son. Of note , their families of origin were not supportive of their role as parents . Internal working models of attachment (IWMA): Ambivalent/anxious and avoidant/dismissive Temperament: Slow to warm-up Cognition: Average Cognitive ﬂ exibility: Limited by their anxiety Formal psychiatric disorder: Parent–child relational problem Treatment recommendation: Begin parent–infant two-person relational psychotherapy to help the parents provide the tools necessary for Adam to develop self-regulatory functions and to improve his eating behaviors.

The formulation based on the CDI was consistent with an infant with an average to above average cognition, some decreased cognitive ﬂ exibility (likely further restricted by the limitations imposed by his medical conditions and treatment), and a slow-to-warm-up temperament. There were also symptoms that met the diagnostic criteria for formal psychiatric disease, including an eating disorder of infancy and acute stress disorder. The predominant internal working models of attachment in the child’s parents were that of an ambivalent/anxious style, although it was less so in Adam, who seemed more willing to seek secure forms of relatedness if the person was able to spark his curiosity for exploration, which the child psychiatrist was easily able to provide. That is to say Adam may have not been as pleasant and willing to explore if a child psychiatrist with different attributes were evaluating him. We are reminded of Emde and Harmon’s account of the growth-promoting discontinuities for the infant when the parents or caregivers are available to repair the temporary ruptures of the interactions (Emde and Harmon 1984 ). Adam had been exposed to many discontinuities in his care, although he seemed to actively seek engagement with the child psychiatrist, which spoke to his resiliency and willingness to tem- peramentally tolerate emotional disruptions.

10.3 Case Conceptualization from a Traditional One-Person Model

When Adam’s fi rst appointment is viewed through the lens of a traditional one- person model, we can consider several hypotheses to understand the interactions. At the most basic level, Adam used oral-level ego defenses—refusing to eat, scream- ing, etc.—to cope with the gratifi cation-seeking intrapsychic pressures. This was further complicated by his parents’ inability to provide “good enough parenting,” due to their own intrapsychic confl icts and constitutional weak ego capacities, 272 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children which contributed to Adam’s developmental delays. Another reasonable way to understand the interaction between Adam and the child psychiatrist is that he represented a good intrapsychic object, which had seldom been available to Adam. Further, when the child psychiatrist invites Adam for closeness, intrapsychically he may have represented the bad intrusive object in the parents and medical personnel. Thus, Adam splits off the child psychiatrist—a good object but only at a distance. In Kleinian theory, this is characteristic of children who remain in the paranoid position. From a traditional one-person model, Anna Freud states that early in life, the infant has no concept of where he ends and the environment begins. For Freud, the only important principle in the infant’s life is the pleasure principle. As such, Adam’s refusal to eat may have been a defense against unpleasure. Salomonsson ( 2012 ) argues that infantile sexuality plays an important role in many mother–infant disturbances. Thus, Adam’s diffi culties may have been understood as a result of constitu- tionally having weak ego development, which prevented the emergence of the autonomous ego functions needed to manage the pressures from his drives (id) in the form of wishes for gratifi cation of his oral needs. Further, the introjections of his early primary object relations were unstable due to his chronic state of anxiety from the inconsistencies in care by his parents and the many medical problems and procedures. Adam’s refusal to eat represented primitive ego defenses, against the psychological pain experienced from his rejecting parents’ demands. Both Adam and his parents were threatened by each other’s rejection and were locked in mutual avoidance. The growth of Adam’s personality by imitation and identifi cation with his parents was impaired. From a psychosexual point of view, he remained fi xed in the oral phase and was unable to successfully make steps needed to move onto the anal phase. From the perspective of traditional one-person psychoanalytic treatment interventions, it likely would have involved working with the parents in exploring their own intrapsychic confl icts rooted in their past experiences that interfered in providing an average expectable environment for Adam. The parents’ ghosts in the nursery ( Fraiberg et al. 1975) interfered with their ability to successfully parent and provide Adam the transitional space needed to negotiate his struggles with the development of adaptive ego functions. A traditional one-person child psychoanalyst or a psychoanalytically informed psychotherapist may have considered beginning with a combination of parent–infant work with some individual play psychotherapy with this young child with the goal of helping the parents work through prior unconscious confl icts interfering in their parenting skills and improve their ego function.

10.4 Two-Person Relational Psychodynamic Psychotherapy in Infants and Preschool Age Children

In two-person relational psychology , the psychotherapist takes an active role to fi rst become an ally of the patient’s and parents’ subjectivities and implicit relational knowing during the sessions. Two-person relational psychotherapy has evolved 10.4 Two-Person Relational Psychodynamic Psychotherapy in Infants and Preschool 273 from the traditional one-person model and taken it a step further. It is now well known that child and adolescent psychotherapy must account for the contributions of early attachment to mental health and behavioral issues. That is, the intersubjective experience becomes a construct of the patient’s and psychotherapist’s personalities—temperament, cognition, cognitive fl exibility, and internal working models of attachment —brought into the context of a here-and-now therapeutic relationship. This bidirectional process allows the patient to implicitly, over time, become a partner to the psychotherapist’s healthier and more adaptive way of interaction with others. In essence, the psychotherapist provides a new and corrective emotional experience for the patient and their parents or caregivers when appropriate, which is stored in their nondeclarative memory at an implicit level. Rustin and Sekaer (2004 ) aptly state that the experiences in a relatively healthy environment enable the unfolding of genetic programs that promote the child’s relational needs at an implicit level. From a two-person relational perspective, the work will be primarily to fi rst learn about the child’s capacity for meaning making and affective attunement and subsequently helping the parents implicitly provide the infant or preschooler the physical and emotional tools necessary to resume their self-regulatory developmental process successfully.

Facilitating Enactments Cocreating New Relational Schemas

With Adam and his parents in mind, the child psychiatrist sequences his interventions: (1) He will need to help Adam’s parents implicitly learn to develop secure models of attachment in order to feel at ease in helping their son be curious and explore the world with them. (2) He will need to provide Adam encouragement to explore and be curious about his surroundings, initially with the child psychiatrist and later with the parents after they learn to manage their anxieties in a more adaptive manner. (3) He will need to explore the possibility of seeking family members or day- care facilities that could provide Adam the affective attunement needed to increase his social referencing abilities, which was difﬁ cult for his parents to provide. In the second appointment, the child psychiatrist began to sing children’s songs to Adam, which Adam liked and expressed excitement for as he began to follow with body movements in sync with the melody. Additionally, the child psychiatrist would ask the parents to join in, to which they would anxiously state that they did not know any children’s songs. The child psychiatrist proceeds to invite the parents to sing Adam familiar songs to them. The parents began to laugh and then shared the names of the songs of their era. They started singing ﬁ rst toward each other and later, with gentle help from the child psychiatrist, they sang to Adam. They stated that they had been so overwhelmed by all the medical concerns and their own anxiety as new parents; they had forgotten what it was like to be playful. Adam, in turn, displayed both nonverbal and verbal signs of joy and excitement. Intersubjectively, the child psychiatrist felt that implicitly things were moving along, and what remained was to help Adam’s parents learn to use “motherese ” to facilitate social reciprocity. 274 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children

In essence, the child psychiatrist carried out the treatment by focusing on the here- and-now, moment-to-moment social experiences of the infant and his parents. Adam’s parents needed to learn “how to attune with him emotionally,” which over time would be stored in nondeclarative memory, so as to be retrieved automatically and nonconsciously when needed. In relating with an infant, parents and caregivers must actively scaffold the infant’s intentions and meaning-making processes. This approach is likely to succeed if it is begun early and repeated often, as an infant’s regulatory systems are open for change when growing in a secure and affectively attuned environment (Sander 2004 ; Gottlieb and Halpern 2008 ). As Anna Freud aptly stated, the goal of therapy is to get children back on their developmental track (Freud 1974 ).

Timing Self-Disclosures

In two-person relational psychotherapy, after an atmosphere of safety and vitality is created for the patient and his or her parents or caregivers, the genuine and active psychotherapist will undoubtedly and unknowingly make implicit self-disclosures or enactments which will be pointed out as helpful or disruptive. Additionally, the psychotherapist can also make use of explicit and well-thought out enactment s and self-disclosures (Chaps. 3 and 5 ) to help the process develop. Being aware that Adam’s parents conveyed a great deal of anxiety, which was noticeable in their facial expressions, the child psychiatrist intersubjectively recognizes that he needs to foster interactions that could visually convey to Adam a sense that “things will be OK.” Herein, he has to be careful in cocreating enactments with Adam’s parents. In looking at matters from Adam’s parent’s vantage, the child psychiatrist allows himself to feel what it would be like “thinking like them.” He subjectively thinks that what might be helpful to them is to self-disclosure as having “been there” before, namely, taking care of a child that is crying and difﬁ cult to console. With this in mind, the child psychiatrist begins singing nursery rhymes to Adam and at the same time faces the parents and self-discloses that he had learned that singing and rubbing his daughter’s back with baby oil helped soothe her when she was crying inconsolably. He wondered if they—Adam’s parents—could try and see if the approach might also help Adam at their home. In this intervention, the child psychiatrist provides both a self-disclosure about what helped his own child and an enactment by demonstrating how to rub Adam’s back while singing to him. The multifaceted nature of infants’ meaning-making processes suggests that a wide variety of physical interventions with infants can be useful (e.g., gentle touch, rocking, massage, and holding) (Tronick and Beeghly 2011 ). Such approach is in contrast to a traditional one-person model, in which the child psychiatrist may educate the young parents on how to improve their care of the child and thus could inadvertently and implicitly collude with familiar experience of others: being told they were inadequate parents.

Working with Parents Intersubjectively

In order to help Adam resume his development, it was important for the child psychiatrist to work with Adam’s parents to promote their ability to provide Adam the 10.4 Two-Person Relational Psychodynamic Psychotherapy in Infants and Preschool 275 affective attunement needed to improve his self-regulatory abilities and promote his curiosity for social reciprocity. For this to occur, it was necessary for the child psychiatrist to model, in vivo, how to approach Adam with excitement. Tronick and Beeghly (2011 ) aptly state, “In some cases, having infants develop a therapeutic relationship with a person other than the disturbed caregiver may protect them because it enables them to develop ways of being with others that not only are gen- erative for future relations with others but also, reciprocally, may help induce change in their caregiver(s).” To this, the child psychiatrist fosters a relationship with Adam that serves as a model for his parents to change the manner in which they approached him during the meaning-making moments. The parent’s anxieties confused and impaired the growth-promoting attunement Adam was seeking. Therefore, the child psychiatrist supports Adam’s parents and helps them cocreate mutual interactions with new and more adaptive coping capacities to promote change in Adam’s behavior and internal affective states. Tronick and Beeghly (2011 ) clarify the variability in approaching the parent–infant dyad or triad: “Our focus on the dynamic moment- to- moment interchanges between infant and caregiver highlights the concept that every infant–caregiver relationship is unique, and therefore treatment plans should not be overly formulaic or rigid but rather should focus on individual differences.”

Letting Go

During the initial phase of the treatment, the child psychiatrist saw Adam and his parents weekly for three occasions, and then on a bimonthly basis, as they could not afford to take off work and travel the one and a half hours each way weekly. Nevertheless, weekly phone calls were scheduled to maintain contact and assess Adam’s progress and his response to the medication. The progress that occurred from month to month was remarkable. After eight visits, the parents decided that “now that Adam can walk, smile, and go to parties without freaking out. We think we will stop seeing you. We will keep you posted and come back if we need to, if that’s OK with you.” Without a doubt, letting go was difﬁ cult, as the child psychiatrist intersubjectively had a sense of ownership in helping the family system improve. In a similar case, in which the child had feeding difﬁ culties that improved by the child psychiatrist helping the family manage their anxiety and provide a growth-promoting environment with the affective attunement necessary for the child, Delgado et al. (1993 ) state: “The case represents a good success story where the family says, ‘I don’t need you anymore.’ The self- correcting features of the family are taking over and empowering them. That is the best kind of outcome.”

Follow-Up

We don’t always have the luxury of having a follow-up visit from our young patients after they are helped and return to their healthy physical and psychological developmental track, as they likely prefer not to be reminded of the diffi cult period they had gone through. In Adam’s case, a follow-up visit occurred 2 years after his last 276 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children appointment with the child psychiatrist. His parents returned and happily said, “We wanted to show off how well he’s doing, although we also have a few questions.” Surprisingly, Adam was eager to hug the child psychiatrist, demonstrating the importance of implicit nondeclarative memory (“my implicit memory system remembers you”). He was happy and spontaneously began to count to 10. His parents then said, “Give the doctor his gift.” Adam proceeded to count to six in Spanish. It is diffi cult to do justice, in written form, describing the excitement in the intersubjective here-and-now moment between Adam and the child psychiatrist. There was glee in Adam’s eyes, as well as those of his parents and the child psychiatrist, in his being able to count in Spanish. During their work together, the child psychiatrist had sang a few songs in Spanish, which he shared he had sang to his daughter, as a way of “being like them” in the here-and-now moments—we are all parents with our own personal styles raising our children. Further, the parents shared that the only time Adam had been overwhelmed was during the Christmas family gathering, “but it only lasted a few minutes and he was back to normal.” At the end of the follow-up session, they stated that they had brought Adam to make sure he could recognize the child psychiatrist, in case “he needs help when he is in school.” There must be recognition that the process of making sense of the world we live in is a lifelong one and early experiences or genetics alone do not determine later outcomes (Kagan 1998 ). We remind the reader that we are not proposing that Adam’s improvement was solely due to the work during the parent–infant process. Rather, we believe that his improvement was due to many factors within his environment that worked in synergy and provided support to the parents. For example, the fact that Adam could count to 10 in English and to six in Spanish suggests that his preschool was a growth-promoting environment. In two-person relational psychology, knowing, not knowing, and sort of knowing (Petrucelli 2010) is something we must be comfortable accepting. It is known that the developmental tasks infants have are multifaceted and include the maturation of sensory, perceptual, and motor functions, as well as emotional and social attachments through the meaning-making process with others. The importance of the infl uence emotional availability of others has on the infant is underscored by the fact that a wide variety of infant therapies have proven to be useful (e.g., gentle touch, massage, holding, play, parent–infant, and other psychosocial interventions) ( Tronick and Beeghly 2011 ). Thus, we propose that the concept of internal regulation models that have inherent plasticity can change through a variety of new emotional experiences and that this holds true for contemporary two-person relational infant psychotherapy. We are cognizant that from a traditional one-person model, Adam’s parents’ return to see the child psychiatrist may be considered to represent residual transference manifestations of the parents to the child psychiatrist. Furthermore, it may refl ect their unconscious request for the child psychiatrist to provide a holding environment and an invitation to resume a psychotherapeutic process. In this case, the child psychiatrist intersubjectively viewed matters differently; they returned because they needed a here-and-now moment of meeting that said, “Look, we are better parents now. We want you to be happy with us.” References 277

10.5 Dilemmas in Two-Person Relational Psychodynamic Psychotherapy

Without a doubt when a child psychiatrist makes a recommendation for the use of medication in an 11-month-old child, it is worrisome for any parent and at times frowned upon by colleagues. The child psychiatrist working with Adam and his parents had experience in treating infants with low doses of liquid SSRIs for the management of their anxiety on a short-term basis, until they were able to resume the healthy developmental process. Adam was prescribed 2.5 mg of fl uoxetine liquid every morning for 10 days, which was increased to 5 mg in the subsequent 30 days. His parents shared that they believed he had a good response to the medication, saying, “We can take him to play with other children and even go to the grocery store.” Adam did not have any negative effects from the medication. In following the recommendation that if improvement was noticeable within 40 days, the medication would be gradually discontinued on day 41, the fl uoxetine began to be tapered off— reverse sequencing. Over the next several months, Adam continued to do well. Whether the positive changes seen in Adam were a result of the combination of the psychotherapeutic process and the medication is diffi cult to be certain. We would like to clarify that most would like to think that what made the difference in Adam’s improvement was the result of the integrated relational biopsychosocial parent–infant approach taken. As any contemporary two-person relational psychotherapist knows, we have to learn to tolerate that there will be many uncertainties about the reasons why one patient improves and others do not. The extent of the interplay in the process of nature and nurture in each person will remain diffi cult to defi ne. When we do not have a formal way to measure our outcomes, we rely on the development of observable new and more adaptive ways of managing adversity by our patients. It is important to note to the reader that the many implicit and nonverbal interactions that occurred in the psychotherapeutic process are diffi cult to capture with the use of written language. Nonetheless, we hope to have provided, implicitly, the reader a glimpse into the vast amount of nonverbal communication that transpires in a two-person relational psychotherapeutic process, with ubiquitous disruptions and moments of meeting.

References

Andersen SL (2003) Trajectories of brain development: point of vulnerability or window of opportunity? Neurosci Biobehav Rev 27(1–2):3–18 Beeghly M, Cicchetti D (1994) Child maltreatment, attachment, and the self system: emergence of an internal state lexicon in toddlers at high social risk. Dev Psychopathol 6:5–30 Beeghly M, Tronick E (2011) Early resilience in the context of parent-infant relationships: a social developmental perspective. Curr Probl Pediatr Adolesc Health Care 41(7):197–201 Bretherton I, Munholland KA (1999) Internal working models in attachment relationships: a construct revisited. In: Cassidy J, Shaver PR (eds) Handbook of attachment: theory, research, and clinical applications. Guilford Press, New York 278 10 Two-Person Relational Psychotherapy: Infants and Preschool Age Children

Cicchetti D, Barnett D (1991) Attachment organization in maltreated preschoolers. Dev Psychopathol 3:397–411 Daws D (1993) Feeding problems and relationship diffi culties: therapeutic work with parents and infants. J Child Psychother 19:69–83 Delgado SV, Emde RN, Pope KK (1993) An atypical eating disorder in a 2-year-old female. Bull Menninger Clin 57(2):242–251 Emde RN, Harmon RJ (1984) Continuities and discontinuities in development. Plenum, New York Fraiberg S, Adelson E, Shapiro V (1975) Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry 14(3):387–421 Fraley RC, Shaver PR (2000) Adult romantic attachment: theoretical developments, emerging controversies, and unanswered questions. Rev Gen Psychol 4:132–154 Freud A (1974) Normality and pathology in childhood: assessments of development, vol 6. International Universities Press, New York Gottlieb G, Halpern CT (2008) Individual development as a system of co-actions: implications for research and policy. In: Fogel A, King BJ, Shanker SG (eds) Human development in the 21st century. Cambridge University Press, New York Kagan J (1998) Three seductive ideas. Harvard University Press, Cambridge Mahler MS, Pine F, Bergman A (1975) Symbiosis and individuation: the psychological birth of the human infant. Basic Books, New York Nelson CA, Zeanah CH, Fox NA (2007) The effects of early deprivation on brain-behavioral development: the Bucharest early intervention project. In: Romer D, Walker EF (eds) Adolescent psychopathology and the developing brain: integrating brain and prevention science. Oxford University Press, New York Pearson RM, Evans J, Kounali D et al (2013) Maternal depression during pregnancy and the post- natal period: risks and possible mechanisms for offspring depression at age 18 years. J Am Psychiatry 70(12):1312–1319 Petrucelli J (2010) Knowing, not-knowing and sort of knowing: psychoanalysis and the experience of uncertainty. Karnac, London Rustin J, Sekaer C (2004) From the neuroscience of memory to psychoanalytic interaction. Psychoanal Psychol 21:70–82 Salomonsson B (2012) Has infantile sexuality anything to do with infants? Int J Psychoanal 93:631–647 Sander L (2004) Living systems, evolving consciousness, and the emerging person. Analytic Press, New York Sroufe LA (2009) The concept of development in developmental psychopathology. Child Dev Perspect 3:178–183 Tamis-LeMonda CS, Bornstein MH, Baumwell L et al (1996) Responsive parenting in the second year: specifi c infl uences on children’s language and play. Early Dev Parenting 5:173–183 Tronick E, Beeghly M (2011) Infants’ meaning-making and the development of mental health problems. Am Psychol 66(2):107–119 Two-Person Relational Psychotherapy: Elementary School Age Youth 1 1

It’s crucial that we start our children off on the right foot in school. The stakes are high in these ﬁ rst years and what we do really matters. —Margaret Spellings, Secretary of Education

Children typically begin elementary school—primary education—at 5 years old, after kindergarten. Elementary school generally goes through the sixth grade, typically to 11 years old. In elementary school, children learn the basics of reading, math, science, and other subjects on which later learning will build. Socialization skills are an important aspect of this period. Granic and Patterson (2006 ) eloquently stated, “Parents and children are confronted with a variety of daily tasks (e.g., clean- up time, playing games, problem solving when confl ict arises, eating dinner together). From our perspective, the extent to which parents and children can fl exibly and appropriately respond, emotionally, cognitively, and behaviorally, to shifts in contexts may tap a repertoire of alternative strategies that correspond to how children will adapt to future challenges at school and with peers.” Thus, during this age, the child’s most skilled way in communicating his or her affective states is initially through playing and making drawings, and later, in preadolescent years, verbal communication takes hold. In two-person relational psychology, importance is given to the innate variability within the context of norms of development for a child and throughout his or her life span, with attention to the infl uence by family systems and cultural factors. Developmental research has provided evidence regarding the complex processes in the scaffolding of physical and psychological competencies over time derived from biogenetic developmental infl uences. More likely, children have a genetic developmental blueprint that is strongly infl uenced by family and environmental factors, which are interwoven and can act synergistically to promote further development ( Delgado et al. 2012 ). During elementary school age, the developmental milestones

© Springer-Verlag Berlin Heidelberg 2015 279 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_11 280 11 Two-Person Relational Psychotherapy: Elementary School Age Youth that children need to achieve are complex (see developmental milestones Appendix A). Among the most salient developmental tasks are competition in games, enjoyment of conversation in groups, increased interest in the opposite gender, and respect of parents. In traditional one-person psychologies, this period is viewed within the context of psychosexual stages and is described as a latency period, “a biologically based phase characterized by decreased sexual drive intensity (compared to the preceding oedipal phase and the succeeding adolescent phase)…. During latency, a greater equilibrium is established between defenses and drives” ( Auchincloss and Samberg 2012 ). In traditional psychoanalytic theory, latency is defi ned as a period that begins with the dissolution of the Oedipus complex and extends to the onset of puberty , typically between the ages of 6 and 12 years old. It is believed that during this period, there is intensifi cation of repression, which brings in amnesia of the early confl icts, development of sublimation, moral values including shame, and aspirations for future activities. This phase was thought to be of relative psychological stability.

11.1 Psychodynamic Psychotherapy in Elementary School Age Youth

The reasons for which school age children come to our offi ces are many, from inhibitions—social and academic—to disinhibitions—verbal or behavioral. The child and adolescent psychiatrist or clinician will benefi t from a careful use of the contemporary diagnostic interview (CDI, Chap. 8) in order to understand the child’s unique attributes—temperament, cognition, cognitive fl exibilities, and internal working models of attachment—within the context of the environment in which they live in, which includes family and culture. During this age, play becomes central in children’s development. Virginia Axline ( 1969) believed that children used play to communicate in a frank and honest manner. Anna Freud and Melanie Klein were pioneers in viewing a child’s play as equivalent to free associations of the adult. They believed that through the interpretations of the confl icts caused by the pressures of the different developmental psychosexual stages represented in their play, psychoanalytic treatment helped children overcome their unconscious inner confl icts. Consequently, the psychotherapist of young children will need to understand the role play has in the child’s life, which allows using this form of communication in the psychotherapeutic process. The authors agree with Krimendahl ’s (2000 ) view: “I do not view my role as fi nding ways to ‘get’ school age children to talk, for talking is not the most developmentally natural medium for children.” For children that arrive to the psychotherapist’s offi ce with play inhibitions, the task will be to implicitly help the child to be able to enjoy playing, as Krimendahl (2000 ) states, “getting children to ‘play’ at playing games.” 11.2 Heather 281

The Association for Play Therapy (2014 ) defi nes play therapy as “the systematic use of a theoretical model to establish an interpersonal process wherein a trained play therapist uses the therapeutic powers of play to help clients prevent or resolve psychosocial diffi culties and achieve optimal growth and development.” Additionally, Schaefer (2011 ) states, “Children use play to communicate when they do not have the words to share their needs and look to adults to understand their language.” From a two-person relational perspective, the use of play is a form of communication that will always be infl uenced by the ever-present implicit contribution of the psychotherapist’s personal characteristics to the child’s choice of play. In children who often bend the rules in their play, Krimendahl further states, “rather than focusing on the child’s reasons for cheating, it is more important to assess why we let a child win or not, for we are more swayed to do this with some patients than with others.”

11.2 Heather

History of Present Illness

Heather, a 9-year-old girl, was referred by her pediatrician who noticed that she was an anxious girl that worried constantly: “She just can’t stop worrying. I think this child needs therapy.” Heather’s parents described her as a bright girl that worried about completing her schoolwork, “even though learning comes easy to her. She really doesn’t need to study that much.” Heather was brought to the consultation appointment by her mother and father. They said: “We know she needs help. She is a good kid but we can’t ﬁ gure her out. She suffers so much.” They added that she avoided going out with friends after school or on weekends because she would spend hours completing schoolwork, which at times was weeks in advance, or spend most of her time reading. They had reassured her that she was doing well at school and wanted her to go out and have fun with other children. They had attempted to arrange play dates with other children for her although she would refuse to go. They noticed she was unhappy and sought help from her pediatrician. Heather would worry every morning before going to school, fearing she had forgotten an assignment or a book and would anxiously say that she was not happy. Her mother would feel guilt ridden after leaving her at school, although somewhat comforted to know Heather was excelling academically and well liked by her teachers. At school, the teachers noted she was overly self-critical. She would become worried when a peer was corrected, fearing the child would feel bad. Her parents and extended family described Heather as an easy, jovial, and intelligent child. At the time of the evaluation, her teachers described her as a very bright and active fourth-grade student with excellent grades. 282 11 Two-Person Relational Psychotherapy: Elementary School Age Youth

Past and Family History

Heather was the product of an uncomplicated full-term pregnancy who achieved most of her developmental milestones on time. She was precocious in spelling, reading, and math (reading and math were at a second-grade level when she was 5 years old). She was a healthy child in a close-knit family. Heather lived with her stay-home mother, 32 years old, and her father, a 35-year-old engineer. Heather’s parents had a good relationship and were well respected in their community. She had a 6-year-old brother and a 4-year-old sister, who ostensibly were doing well. The family was close to both paternal and maternal grandparents, who lived in the same community. All family members were in good health.

Contemporary Case Formulation Following Use of the CDI: Heather Summary: A 9-year-old female who presents with new functional impairment timed with the beginning of fourth grade Internal working models of attachment (IWMA): Secure and ambivalent/ anxious Temperament: Mixed—slow to warm-up and easy/ﬂ exible Cognition: Above average/gifted (see developmental milestones Appendix A) Cognitive ﬂ exibility: Adequate Formal psychiatric disorder: Symptoms of anxiety but did not meet DSM-5 criteria Treatment recommendation: Twice a week two-person relational play psychotherapy to address her anxiety and social inhibitions, and consider use of formal cognitive behavior psychotherapy (CBT) or medication after 6 months, if needed.

Contemporary Case Formulation Following Use of the CDI: Heather’s Parents Summary: Parents were very caring and supportive of their daughter, and were easy to engage by the psychotherapist. One possibility is that they may have implicitly had contributed to her inhibitions during her early years by implicitly rewarding her precocious abilities in reading and math at the expense of playfulness. Internal working models of attachment (IWMA): Secure and ambivalent/ anxious Temperament: Easy/ﬂ exible Cognition: Above average/gifted Cognitive ﬂ exibility: High/adequate Formal psychiatric disorder: Did not meet DSM-5 criteria Treatment recommendation: Work with Heather’s parents as part of her two-person relational play psychotherapy. 11.3 Case Conceptualization from a Traditional One-Person Model 283

11.3 Case Conceptualization from a Traditional One-Person Model

From a traditional one-person model, Heather’s case conceptualization may take several paths depending on whether it is viewed from a drive theory, ego psychology, object relations, self-psychology perspective, or a combination of these theories, which is known as being pluralistic. What is common to pluralistic traditional one-person approaches is that they rely on a wait-and-see approach by the psychotherapist in order to organize the information obtained through the play and verbal narrative of the child. After which, the psychotherapist conceptualizes the case as representing unconscious intrapsychic confl icts (those the patient is unaware of), maladaptive ego defenses, and object relations confl icts. It would be beyond the scope of this book to review all the possible case conceptualizations that may be considered by a traditional one-person child psychotherapist. Thus, we limit our review to a broad overview of the conceptualizations likely to be considered and contrast them to the two-person relational model used in Heather’s treatment. In traditional one-person psychoanalytic literature, Heather may have been thought of as having an obsessional neurosis. That is, she unconsciously used ego defense mechanisms to defend against the painful feelings from her unconscious confl icts: isolation from peers, displacement onto schoolwork, reaction formation in being an overly compliant child, and negation of her anger. With this in mind as a diagnostic conceptualization, the psychotherapist would let the play develop and wait for the correct time to point out the use of maladaptive ego defense mechanisms used by Heather during the play, if they were thought to be interfering with her ability to resume her healthy psychosexual developmental track. In the school of self-psychology, Heather’s obsessional neurosis may have been considered to be due to an empathic failure on the part of her parents and not because of regressive and angry feelings directed at them. Soavi (1993 ) states, “The symptoms should be seen in connection with the attempt to defend oneself from various forms of anxiety and with the failure to create within the self the capability of ori- enting oneself in the world of affects.” From a Kleinian view, Heather’s problems may have been conceptualized as due to her angry feelings toward her objects—parents—who she unconsciously experienced as rejecting. Her intense desire for knowledge and avoidance of play were defenses against the destructive fantasies. Reading and knowledge represented her anger at the internal representations of her parents as bad objects, an obsessional neurosis ( Klein 1932 ). The psychotherapist would help Heather work through these confl icts by promoting strong transference feelings toward the psychotherapist, who would later make comments regarding the unconscious ambivalence, guilt, and fear of her angry and destructive fantasies toward her parents. Regarding Heather’s parents, in the traditional one-person model, the psychotherapist may have provided regular educational sessions during the psychotherapeutic process to help them understand their daughter psychologically and to support the process. In the Kleinian model, there may have been little contact with Heather’s parents during the psychotherapeutic process. 284 11 Two-Person Relational Psychotherapy: Elementary School Age Youth

11.4 Two-Person Relational Psychodynamic Psychotherapy in Elementary School Age Youth

Two-person relational child psychotherapy has evolved from the traditional one- person model. Two-person relational child psychotherapy has incorporated the contributions of developmental research, attachment theory, and neuroscience to mental health and behavioral issues. In a two-person relational model, the psychotherapist takes an active role to ﬁ rst become “like them”: to be immersed in the patient’s and parent’s subjectivities and implicit relational knowing during the sessions. It is through this bidirectional process that occurs in the intersubjective ﬁ eld that allows the patient to implicitly become, over time, an ally to the psychotherapist’s healthier and more adaptive form of interaction with others. In essence, the two-person relational psychotherapist provides new emotional experiences for the patient and parents, which will be stored in nondeclarative memory at an implicit level.

Allowing Subjectivities to Meet

Context Heather, in the presence of her parents, was a very charming young girl during the consultation. The family readily agreed for Heather to begin a twice a week psychotherapeutic process. The psychotherapist, after fi rst establishing an atmosphere of safety for Heather, proceeds to sit on the fl oor and invites her to join him and choose what to play. Heather joins him and sits on the fl oor. She notices that on the psychotherapist’s desk there is a picture of a young girl.

Patient: Do you have children? Psychotherapist: Yes, a daughter. Patient: Is she your kid? [Pointing at the photograph] Psychotherapist: Yes. Patient: Do you play with her? Psychotherapist : Yes I do, like I am playing with you right now.

Intersubjective The psychotherapist’s intent is to make use of his intersubjectivity to guide him on how to cocreate experiences with the patient that implicitly provide her with a subjective feeling that there is a blueprint on how to be playful with each other, a sense of “We can play together.” Heather implicitly recognizes by the psychotherapist’s gestures and excited tone of voice when talking about his daughter that “he likes children and he is also playing with me.” From a traditional one-person model, this interaction may be viewed as a countertransference enactment in which the psychotherapist self-discloses about having a daughter, gratifying the patient’s wish to have her questions answered and knowing about the psychotherapist’s personal life. Further, it may be hypothesized that the self-disclosure does not allow Heather to later work through feelings of anger and jealousy of her psychotherapist’s daughter. We highlight that from a traditional 11.4 Two-Person Relational Psychodynamic Psychotherapy 285 one-person model, the hypothesis will depend on the school of thought that the psychotherapist adheres to. The traditional one-person model does not consider the here-and-now mutuality of intersubjectivity —which guides the relational psychotherapist—as curative because it does not allow for the working through of the child’s maladaptive use of neurotic or immature ego defenses (see Chap. 3 ).

Patient : Does she worry like I do? [Appears to be seeking for reassurance that she is not alone in worrying] Patient : What does she like to play? Psychotherapist : Children, like you and my daughter, are happy about many things, although they sometimes worry about other things. I think the best part of being a child is that playing is a good way to forget about worrying. My daughter plays with many of the games I have here. [Pointing at the games] Patient : Does she worry about school assignments? Psychotherapist: Only when they are diffi cult. Which are the most diffi cult for you? Patient : I worry about getting things completed on time. I am a good student and I like getting good grades. Psychotherapist : I wonder what you would think if you were really good at playing, just like you are at learning. What do you think? Patient: I would worry that if I spend too much time playing, I might not complete all the assignments. I think that my parents are happier if I get good grades, and they might get mad at me if I play a lot. Psychotherapist : Thank you, I think I understand. [The psychotherapist attends to the nonverbal communication as the autobiography is infl uenced by her implicit relational knowing. He knows that by cocreating playful moments of meeting, they will implicitly allow her to develop more adaptive implicit relational patterns and lead to change, rather than pursuing the insight-oriented verbal dialogue]

Intersubjective The psychotherapist attempts to accomplish several issues at once. First, the psychotherapist builds an atmosphere of safety, mutuality, and playfulness in the here and now. Second, he reinforces that anxieties are part and parcel of everyday life for children. He further reminds Heather that pleasant experiences can occur throughout the day, even though there may be moments of anxious feelings at times. The implicit relational nonverbal experience is conveying, “Yes, I know you are anxious at times, although I suspect that you have happy moments throughout the day.” The psychotherapist does not take a neutral stance; rather, he intersubjectively believes Heather is able to handle his moving the process along by implicitly and verbally sharing that he is familiar with her struggles. In contrast, if the psychotherapist had experienced intersubjectively that Heather was overly anxious or inhibited, he may have chosen to point out with his facial expression and verbally that he noticed her discomfort and suggests to play a game of her choice, rather than engage in conversation. He used the here-and-now mutuality to guide him in the action of moving the process along. Finally, he accepts the nonverbal communication of Heather’s reason for not having time to play and understands that 286 11 Two-Person Relational Psychotherapy: Elementary School Age Youth for this to change, she will have to learn to enjoy playing, which he plans to help her in vivo during the following sessions. In a traditional one-person model, the psychotherapist may hypothesize about the unconscious conﬂ icts that contribute to her play inhibition and may choose, in the right moment, to point out her dilemma—making the unconscious conscious.

Facilitating Enactments Cocreating New Relational Schemas

Context In early sessions, Heather would come to the appointment and jovially state that she had homework to complete and would then ask if she could do so during the session.

Patient : Is it OK if I work on my schoolwork? I want to make sure I ﬁ nish it all, and I have a lot. Psychotherapist : Of course. It will help me get to see how much work you have. Patient : Good, I like to ﬁ nish my work so I don’t have to worry when I go to bed. Psychotherapist: I might even be able to help you, if it is easy of course. [Smiling and joking about his ability to help] Do you mind if I ask questions about your work? I like to know what you are learning . [Nonverbal communication: homework can be done playfully]

Intersubjective The psychotherapist is keenly aware of his intersubjective experience, wanting to ﬁ ll in for a parent, and state, “No, let’s play and you can complete your work later.” He also recognizes that it is best for him to initially engage in her implicit relational knowing style and to see matters from her perspective, although he is aware of his wish to say “something that will help Heather loosen up.” In traditional one-person model, this would be akin to interpreting her using studies as a defense against becoming aware of her inner feelings, commonly thought of as an obsessional neurosis. The psychotherapist, in using two-person relational model, decides to intervene in a manner that can serve as a new nonverbal meaning-making process and later in their intersubjectivities become a moment of meeting . Herein, while she completes her schoolwork, he proceeds to sit on the ﬂ oor and play against himself in a card game of Uno and at times plays with the game of Connect Four. While playing— and while she completed her schoolwork—he shares with Heather his excitement when he wins and with gestures of disappointment when he loses. The psychotherapist’s goal is to provide Heather, in a nonverbal here-and-now manner, a new meaning-making process of the joyful aspects of playing in the presence of another person–social referencing. The expectation was that at an implicit level, she eventually would wish to join.

Context In a later session, Heather uncharacteristically came to the appointment somewhat anxious and wanted the psychotherapist to help her know what she should play during the session. 11.4 Two-Person Relational Psychodynamic Psychotherapy 287

Patient : I want you to tell me what I should play today. [Anxious and with uncharacteristic slight restlessness] Psychotherapist: OK, how about drawing something that you enjoy doing. [Implicitly appealing to something that was helpful to her, thus managing her current state of anxiety] Patient: Good, I like to draw. I can make drawings about the story we read at school today. [Outwardly looks relieved and returns to her jovial self] Psychotherapist: By the way, I noticed that you looked worried when you walked in. Let me know if I can help you in any way. [Implicitly letting her know, “I noticed you are anxious, but with my tone of voice and gestures, I hope to help you feel your anxiety does not make me anxious and what you are experiencing is part of life and bearable”]

Intersubjective The psychotherapist provides an intersubjective experience of “sure I can guide you” and allows for curiosity and creativity to emerge. He will keep in mind her early uncharacteristic anxiety and is aware it may have been due to a wide range of possibilities: disagreement with her mother on her way to the psychotherapist’s ofﬁ ce, difﬁ culties at school, something occurring in the waiting room as there were other children, etc. In other words, in the here-and-now moment, the psychotherapist intersubjectively felt that it would have been detrimental to focus on her anxiety and opted for agreeing with her request to be guided on what to play. In agreeing to guide her, it helps her feel safe. This provides the psychotherapist time to allow the intersubjective experience to guide him on how to proceed. If he would have noticed that her anxiety continued to bother her, he may choose to note, “You are very anxious today, can I help?” If her anxiety subsides, he may mention he noticed her anxiety when she arrived and compliment her on how she managed it. Herein, he cocreates an implicit nonverbal moment of meeting “Look what you can do on your own” rather than “I (the psychotherapist) believe that if you talk about it you will feel better.” We recognize that some children would rather put into words what troubles them, and in a two-person relational model, the psychotherapist would have known to pursue this by his intersubjective experience in the here and now.

Later in the Same Session

Context The patient later in the session volunteered that her mother had surprised her during their drive to the appointment that they were going to her same-age cousin’s birthday party, which made her anxious and angry.

Patient : Why did my mother do that? She knows I don’t like parties. [Anxious although less restlessness and more reﬂ ective and implicitly invites the psychotherapist for guidance] Psychotherapist: Help me understand. Parties are events for children to have fun and you are telling me you will not have fun, right? [Implicitly demonstrates his excitement about parties] 288 11 Two-Person Relational Psychotherapy: Elementary School Age Youth

Patient : I am afraid that I won’t have fun. I don’t know any of the other kids; I only know my cousins. [The psychotherapist intersubjectively feels she actually would like to go] Psychotherapist : Let me tell you a story. When I was a kid, I always worried about whether I was going to have fun when I was invited to parties. So I really understand you. The funny part about it is that my parents and friends would encourage me to go, and I would always have fun. Later when I was a teenager, when I would tell my parents that I was going to a party, we would laugh together remembering the times I used to worry if I was going to have fun. [Implicitly letting her know, “I noticed you are anxious, but with my tone of voice and gestures, I feel you are ready to go to a party and I have the sense that you will have fun. What you are experiencing is part of life and bearable”] Patient: That’s a funny story. I know I have to go to the party. I am not promising you that I will have fun. Psychotherapist : I will have fun hearing to how it goes. If you have fun at the party, that will be great. If you don’t, great as well, you will have more stories to tell me. [Actively engaging and smiling. Intersubjectively feels the patient seems less worried about going]

This interaction captures the sloppiness in a two-person relational psychotherapy process. That is, allowing the patient’s subjectivities to guide the psychotherapist as to how to proceed is essential and at times leads to unexpected moments of meeting. The authors are frequently made aware by colleagues and students that the sloppiness of a two-person relational model is difﬁ cult to tolerate, in contrast to a traditional one-person model. To this, we reply, “It may be initially difﬁ cult to tolerate the uncertainty in knowing what here-and-now verbal and nonverbal interactions mean or when they take hold. The advantages of cocreated new and corrective emotional experiences are unique to each dyad, and the rich here-and-now experiences that lead to change occur without us knowing and will be stored in nondeclarative memory .” We commonly share with our trainees “Trust your heart; even if you don’t know why things improve, you will notice the improvement intersubjectively.”

Two Months Later

Patient : I want to play Jenga. [She is jovial and demonstrates excitement] Psychotherapist : Sure. [Matching her excitement] Patient : I bet I can beat you. I have been playing after school with my friends. Psychotherapist : You have practiced more than I have. [Accepting the challenge in a playful manner]

Intersubjective In the two-person relational model, the psychotherapist experiences intersubjectively that the child’s request in the here and now reﬂ ects her progress in enjoying playing with others. The psychotherapist matches her enthusiasm in playing to move along the process. 11.4 Two-Person Relational Psychodynamic Psychotherapy 289

In this scenario, from a traditional one-person approach, the psychotherapist may have considered that Heather’s play may be unconsciously related to her being able to work through issues of rivalry and anger, perhaps toward her father, hypothesized as transference manifestations when she states “I bet I can beat you.”

Timing Self-Disclosures

Patient: Did you study a lot at school to become a doctor? My dad had to study a lot to become an engineer, and he is really good. He reads a new book almost every week. Psychotherapist: Yes, I did study a lot. Although I remember that as a child, I also enjoyed being outdoors and riding my bike to go play with my friends. Patient: Did you have your schoolwork completed before you went out? [Active moment of jovial curiosity] Psychotherapist: Most of the time. [Smiling] Sometimes I had to make sure I completed my schoolwork after I returned from playing with my friends. Patient : I am beginning to try that, and I really have enough time for both. Psychotherapist: What I remember as being difﬁ cult was that I thought my parents did not want me to spend too much time playing, even though they said they were happy for me to play as long as I ﬁ nish my schoolwork later. Patient : [Interrupts psychotherapist—a moment of meeting] Yeah, I have the same feeling. [Smiling] You know what? Even when we play in here, I still have time to complete my school assignments at home. Psychotherapist : [Matching her excitement with gestures and tone of voice] Great. Psychotherapist: He subjectively notices the urge in wanting to say “And the days you don’t come here, you could even play with your friends and still have time for your schoolwork.” He recognizes that the urge to make the comment comes from his role as a parent, and he is keenly aware that intersubjectively Heather is asking him to enjoy her progress in the here and now, without the intrusion of the psychotherapist’s own subjectivity.

Intersubjective When Heather asks how much the psychotherapist had to study to become a doctor, he intersubjectively experiences Heather as asking whether there is room for play in a good student. He chooses to self-disclose about his avid interest in schoolwork when young and the ubiquitous dilemma of good students: Do parents really mean it is OK to play? He affectively conveys the excitement in play and how he learned to manage play and school. In a two-person relational model, the psychotherapist experiences intersubjectively that Heather has begun to develop more adaptive patterns in her life and has a wider sense of curiosity. The psychotherapeutic process has moved forward, reﬂ ected in the progress of her enjoyment of being more engaged in play during the sessions, “Even when we play in here, I still have time to complete my school assignments at home.” We note that at times, self-disclosures and enactments occur unknowingly to the psychotherapist and its presence is revealed by the patient, “Yeah, I have the same feeling”. 290 11 Two-Person Relational Psychotherapy: Elementary School Age Youth

In contrast, from a traditional one-person approach, the psychotherapist’s self- disclosure may have been frowned upon, as it would prevent understanding the nature of Heather’s inner conﬂ icts about her play inhibition.

Working with Parents Intersubjectively

Context The parents say: “We are glad that Heather is seeing you. She doesn’t worry as much, and we enjoy seeing her play with her friends. Why do think she worried so much? She is only a child. Do you think we did anything wrong?”

Mother: Do you think we did something wrong raising her? We were always there for her, and she was an easy baby. Psychotherapist : I understand. It’s not easy to have a child that needs help with their feelings, without feeling that in some fashion one is to blame. Both parents : That is so true. Psychotherapist: Heather has what we call play inhibition, due to her anxiety. It does not meet the criteria for a formal psychiatric disorder, and it is poorly understood.

Intersubjective The psychotherapist intersubjectively begins to review the four pillars of a CDI (Chap. 8 ) and posits that her temperament and gifted cognitive abilities at such a young age likely inﬂ uenced her cognitive ﬂ exibility. He explains that her shyness toward same-age peer playfulness may have led her to implicitly be more attuned to adults, displayed by her being an avid reader and very compliant at school.

Mother: Do you know think that’s why she would spend hours reading and not playing? Father : That reminds me of how I was as a child, always reading, although I did have a lot of fun playing with my friends. Is this what you mean about genetics? Psychotherapist : Yes.

Intersubjective The psychotherapist intersubjectively wonders if the parents had been playful with Heather when she was a toddler. He chooses not to pursue this further, as he is aware that what they recall may be different to what Heather implicitly experienced, if due to her temperamental issues—goodness of ﬁ t—or other realities in the family, at the time, that may be unavailable for recall. Additionally, intersubjectively, the psychotherapist found Heather’s parents as jovial and with a good sense of humor. Herein, as in any two-person relational psychotherapeutic process, the truth regarding the origin of the patient’s symptoms will remain elusive, although the changes in the form of a new emotional experience will be curative. During the process, the psychotherapist met with the parents regularly to provide education on how to support Heather’s efforts in balancing her playfulness with her schoolwork. 11.4 Two-Person Relational Psychodynamic Psychotherapy 291

Letting Go

Context Heather used the psychotherapeutic process well and gradually began to express her genuine excitement in developing more adaptive patterns of interaction with her parents and peers, recognized by the psychotherapist as a result of a new emotional experience. Heather became more involved in extracurricular activities, and her parents had encouraged her to ask her psychotherapist if she could decrease the frequency of appointments or stop the psychotherapeutic process. The psychotherapist agreed with stopping the process, with intersubjective feelings of “She can manage without me now,” and they—the patient, parents, and psychotherapist— agree to end the process after three more sessions.

Final Session

Patient : I really like you, your ofﬁ ce, and your toys. I don’t think I need to keep coming to see you. I will miss you and your toys. I feel a lot happier. [She is actively seeking for the psychotherapist to respond to her comments] Psychotherapist: I would agree with you. You are a lot happier. I like that you now are able to play with your friends without it affecting your schoolwork. I will miss seeing you too. I will also always remember how we played with the toys and all the drawings you made. Patient : I am happy you helped me. I might see you someday at a store or restaurant. Psychotherapist: I really like how you handle things now. If you become worried, I am sure you will remember how much fun we had in here. [Smiles empathically and with conﬁ dence]

Intersubjective The psychotherapist intersubjectively experiences Heather as having stored in nondeclarative memory the progress made when she says, “I really like you, your ofﬁ ce, and your toys.” He notices not having the sadness that usually occurs when there is a feeling the work is not complete; rather, he intersubjectively felt, “We accomplished a lot.” A note about why the psychotherapist agrees to end the process in three sessions. In a traditional one-person model, it is hoped that the termination phase will allow for the mourning in letting go of the “good object” in the psychotherapist and may need resolution of transference manifestations that may have developed. In contrast, in a two-person relational model, the letting go process is based on the accumulation of cocreated moments of meeting that permit the psychotherapist to intersubjectively know when the corrective emotional experience has taken hold. For some, it may have been done in a longer fashion. In this case, Heather had a very supportive family and good nucleus of friends in which the new adaptive patterns of implicit relational knowing were welcomed. As Adler-Tapia (2012 ) states, “The best psychotherapy is when it is no longer necessary.” 292 11 Two-Person Relational Psychotherapy: Elementary School Age Youth

11.5 Summary

In this chapter, we have provided the reader a detailed description of the work that transpired in the case example of a 9-year-old school age female child with anxiety. We began with a description from a traditional one-person model and follow with a contemporary two-person relational psychotherapeutic approach, with attention paid to the patient’s and her parents’ temperament, cognitive and affective ﬂ exibility, and internal working models of attachment—within the context of intersubjectivity with the psychotherapist. This serves as a broad review of the main differences that exist between both theoretical approaches.

References

Achincloss EL, Samberg E (2012) Psychoanalytic terms and concepts. American psychoanalytic association. Yale University Press, New Haven, pp 136–137 Adler-Tapia R (2012) Child psychotherapy: integrating developmental theory into clinical practice. Springer, New York, p 267 Axline VM (1969) Play therapy. Ballantine Books, New York Delgado SV, Strawn JR, Jain V (2012) Psychodynamic understandings. In: Levesque RJR (ed) Encyclopedia of adolescence. Springer, New York, pp 2210–2218 Granic I, Patterson GR (2006) Toward a comprehensive model of antisocial development: a dynamic systems approach. Psychol Rev 113(1):101–131 Klein M (1932) The psycho-analysis of children. The Hogarth Press, London, p 57 Krimendahl E (2000) “Did you see that?”: a relational perspective on children who cheat in analysis. J Infant Child Adolesc Psychother 1(2):43–58 Schaefer CE (2011) Foundations of play therapy, 2nd edn. Wiley, Hoboken Soavi GC (1993) Deﬁ cit of the structure of the ‘Self’ and obsessional neurosis fusional deﬁ cit and the structure of the self. Rivista Psicoanal 39A:33–42 The Association for Play Therapy (2014) Play therapy makes a difference. doi: http://www.a4pt. org/ps.playtherapy.cfm . Accessed 12 May 2014 Two-Person Relational Psychotherapy: Middle School Age Youth 1 2

The most important thing is to enjoy your life—to be happy—it’s all that matters. ―Audrey Hepburn

Middle school age youth are those from ages 10–14 years old. This period is also referred as prepuberty , preadolescence , and early adolescence . During this period, youth experience biological, psychological, and social changes. There are dramatic changes in physical development, encompassing height, weight, and sexual development. Although maturity during this period occurs at variable rates, generally in girls it occurs 1.5–2 years earlier than in boys. One of the major cognitive changes that occur during this period for youth is the transition from concrete thinking to abstract thinking. According to Erikson ’s theory of psychosocial development (1968 ), during this period youth undergo confl icts of industry versus inferiority. During this stage, youth experience mixed feelings about where they fi t into society and may experiment with several different roles until they achieve a sense of identity ( McDevitt and Ormrod 2010 ). Furthermore, they develop a better understanding of higher levels of humor, are inquisitive about adult roles, and often challenge their authority. During this period, youth are psychologically curious and idealistic about the world and themselves. Regarding morality, they develop their own personal values, which are consistent with those of their parents. Social relationships and roles change dramatically as they join youth programs and become involved with peers and adults outside of their family. During this period, they develop a sense of individuality by actively comparing themselves with their peers and seeking approval from them. This facilitates having close friends their own age, which can provide the sense of “belonging” to a larger similar group. In traditional one-person psychology, middle childhood is thought to be a post- latency period in which drive pressures increase and boys may have a reawakening of anal humor as a defense, and the relationship to their father and male teachers becomes less troubled, which facilitates ego-ideal identifi cations. In traditional

© Springer-Verlag Berlin Heidelberg 2015 293 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_12 294 12 Two-Person Relational Psychotherapy: Middle School Age Youth one-person psychology, for girls, this phase is believed to lead to a regressive attachment to their mother to preserve the bisexual and postpone ﬁ nal acceptance of their femininity ( Call et al. 1979 ). This phase was thought to be of relative psychological instability.

12.1 Psychodynamic Psychotherapy in Middle School Age Youth

Middle school age youth are dealt the diffi cult task of balancing increasingly complex interactions with parents, caregivers, teachers, and peers within exponentially complicated environmental factors. This population is referred to our offi ces for diffi culties regarding self-regulatory abilities (e.g., problems with impulsivity and aggression, diffi culties with social reciprocity, and academic problems). The child and adolescent psychiatrist or clinician will benefi t from a careful use of the contemporary diagnostic interview (CDI, Chap. 8) in order to understand the child’s unique attributes—temperament, cognition, cognitive fl exibilities, and internal working models of attachment—within the context of the environment in which they live, which includes family and culture. As such, the evaluation will rely on collateral information from other sources familiar with the child and his or her family. This information is essential to a complete CDI, as likely the problems originated at an earlier age and are now interfering with their psychosocial development (see developmental milestones Appendix A ). During this age, the child’s cognitive abilities expand, and he or she is better able to problem solve and hold two opposing viewpoints in mind. This allows for the vitality needed to remain engaged in peer group activities, and diffi culties in this area frequently refl ect cognitive and relational complications. Many times diffi culties in peer group activities are viewed from a traditional one-person model as a result of neurotic or immature ego defenses against the angst experienced. We propose that from a two-person relational model, the angst of children at this stage is generally due to diffi culties with temperamental, cognitive, or relational abilities, infl uenced by innate internal working models and not from unconscious intrapsychic pressures from the id and superego or object relation problems.

12.2 Charlie

History of Present Illness

Charlie, an 11-year-old boy, was brought by his mother with a specifi c request to help him cope with the inevitable death of his father, who was suffering with terminal cancer. His mother shared that his worries were affecting many areas of his life. After school, Charlie had begun to cry and yell at his mother for not helping his 12.2 Charlie 295 father seek treatment earlier to prevent his cancer from spreading. He was angry with her for “thinking God is good.” He would cry, “I am angry with God because it is not fair to lose my father!” He was troubled by a dream he had several weeks before his appointment, in which he had a premonition that his father would die in a car accident several months later and on a specifi c date. He was terrifi ed that his premonition would come true. He began to believe and worry that if his father died on that day, it would be his fault, and others would think that he had wished for it to happen.

Past History

Charlie was the product of an uncomplicated full-term pregnancy and achieved his developmental milestones on time. He was an only child in a close-knit family. His parents, teachers, and extended family described him as an easy, jovial, and intelligent child. At the time of the evaluation, he was an active sixth-grade middle school student. He was a good student with above average grades, and he was involved in competitive swimming. Though overall he was a healthy child, for the past 2 years he had been treated for attention deficit/ hyperactivity disorder (ADHD) with extended release methylphenidate with good results. Charlie lived with his mother, 40, and his father, 46, who were well-respected professionals. Two years prior to the evaluation, his father was diagnosed with Stage IV basal cell carcinoma. Despite numerous surgeries, chemotherapy, and radiation treatments, his cancer was deemed terminal after metastases were discovered in the liver and brain. Though several doctors provided the option for hospice, concerned that Charlie might be burdened by seeing his father deterio- rate, Charlie’s mother made the decision to care for Charlie’s father at home.

Contemporary Case Formulation Following Use of the CDI: Charlie Charlie: An 11-year-old male who presents with new functional impairment timed with the terminal illness of his father Internal working models of attachment (IWMA): Secure Temperament: Easy/ﬂ exible Cognition: Above average (see developmental milestones Appendix A ) Cognitive ﬂ exibility: High Formal psychiatric disorder: ADHD and met DSM-5 criteria for adjustment disorder, acute with mixed anxiety and depressed mood Treatment recommendation: Two-person relational psychotherapy. The psychotherapist would promote the cocreation in the here and now of more adaptive patterns to cope with his struggles in the midst of the tragic circumstances. 296 12 Two-Person Relational Psychotherapy: Middle School Age Youth

Contemporary Case Formulation Following Use of the CDI: Charlie’s Mother Charlie’s mother: A 46-year-old woman who presents with new functional impairment timed with the terminal illness of her husband Internal working models of attachment (IWMA): Secure Temperament: Mixed—primarily easy/fl exible, with some diffi cult/feisty (see below) Cognition: Above average Cognitive fl exibility: High Formal psychiatric disorder: None Treatment recommendation: Work with Charlie’s mother as part of Charlie’s two-person relational psychotherapy to help her and her son cope with his struggles in the midst of the tragic circumstances.

12.3 Case Conceptualization from a Traditional One-Person Model

When seen from a traditional one-person model, the case conceptualization may take several paths, depending on whether it is viewed from a drive theory; ego psychology; object relations, or self-psychology perspective; or a combination of these theories, which is known as being pluralistic. To this, we provide the reader a broad view from a traditional one-person perspective and hope that it can serve to contrast the differences of case conceptualization and therapeutic interventions with the two- person relational model used in this case. In the traditional psychoanalytic literature, the death of a parent is considered to have a signifi cant impact on a child’s intrapsychic processes, which leads a child to use defensive mechanisms to deny the reality of the death. Menes (1971 ) captures this masterfully: “There is also wide agreement that a particular set of responses tends to occur in children who experience the death of one of their parents. These reactions include unconscious and sometimes conscious denial of the reality of the parent’s death; rigid screening out of all affective responses connected with the parent’s death; marked increase in identifi cation with and idealization of the dead parent; decrease in self-esteem; feelings of guilt; and persistent unconscious fantasies of an ongoing relationship or reunion with the dead parent.” Further, Menes believes that the child’s responses serve to avoid the acceptance of their parent’s death and there is a need for a reorganization of the object attachments that such an acceptance would require. For Furman (1964 ), mourning in children occurs only when a psychoanalytic treatment is initiated in order to facilitate the mourning process to develop through the transference to the analyst. Further, it is suggested that the death of a parent reawakens oedipal confl icts. This is best captured by Gill (1987 ): “Death of the oedipal rival results in a confusion of the unconscious wish with an external happening. The child, unable to cope 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 297 with the consequent guilt, resorts to repression. Thus, the critical aspects of the oedipal triumph remain potentially operative in the unconscious, hindering the patient’s functioning in all closely associated areas.” Therefore, in the traditional one-person model, Charlie may have been thought as defending himself from the painful mourning process with a decrease in self- esteem and unconscious feelings of guilt for his anger at his mother and at God. To this, the psychotherapist’s interest in the verbal narrative of the events with some attention to neutrality allows for transference manifestations to develop and be best understood. The psychotherapist will likely be initially experienced as the good— father object—which Charlie unconsciously and in the transference will use to deny the reality of his own father’s imminent death. This will also be noted by an increase in ego-ideal identifi cations and idealizations of the ill parent, likely to increase after his death. The traditional one-person psychotherapist will be attentive to the patient’s use of ego defenses and be alert to pressures from his superego, typical during this phase of development; his fear about the death of his father; and his guilt for his age-appropriate anger and possible unconscious feelings of oedipal triumph. Regarding Charlie’s mother, in the traditional one-person model, the psychotherapist may have provided regular educational sessions during the psychotherapeutic process to help her understand her son psychologically and to support the process. She may have initially been seen as also struggling in not wanting to be reminded of the loss of her loved object (her husband) by her son’s need for psychotherapy. In the Kleinian model there may have been little contact with her during the psychotherapeutic process.

12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth

The two-person relational psychotherapy is a rich and complex process that has evolved from the traditional one-person model. For an in-depth deﬁ nition of contemporary two-person relational psychotherapy, we refer the reader to Chap. 3 . In short, it is an interaction between patient and psychotherapist that promotes the cocreation of more adaptive experiences for the patient in the form of a new emotional experience, from the psychotherapist’s personal healthy attributes, which is then stored in nondeclarative memory. The relational psychotherapist makes careful use of timed self-disclosures and occasional enactments. We note that at times self- disclosures and enactments occur unknowingly to the psychotherapist and its presence is revealed by the patient.

Allowing Subjectivities to Meet

Context During the ﬁ rst appointment, Charlie was invited to draw a family genogram with his mother guiding the process, a common technique used by the authors that provides an intersubjective experience of the family’s affective states when referring to other family members ( Delgado and Strawn 2014 ). 298 12 Two-Person Relational Psychotherapy: Middle School Age Youth

Observations of the Patient Charlie appeared happy as he drew the genogram of his family. He beamed with pride as he demonstrated his knowledge about his extended family, despite the many medical illnesses in them. He stated, “You (psychotherapist) are going to be surprised by all the cancer in my dad’s family!” While drawing the genogram, he frequently showed interest in his mother’s comments about each family member. He appeared pleased to know more about his extended family. He was reminded that both his paternal grandparents had passed away when he was an infant. His paternal grandfather, a heavy smoker, died of lung cancer, and his paternal grandmother had died of brain cancer. Charlie demonstrated an ability to reﬂ ect and empathize with his father’s genetic vulnerabilities, as he wondered, “I can see why my dad has cancer; it runs in the family.”

Intersubjective The clinician’s initial intersubjective experience of Charlie and his mother, when they were creating the genogram , was a great feeling of sadness as well as recognizing their resilience, in particular a deep sympathy with Charlie’s grasp of his family’s long-standing history with terminal cancer. In contrast, Charlie’s attitude in the room conveyed a sense of “Life is good and must go on.” He seemed able to easily retrieve implicit memories—positive and adaptive cocreated moments of happiness from his past—in the midst of his father’s severe illness. A signifi cant moment of meeting occurred when Charlie shared with the psychotherapist about being pleased he could begin his own psychotherapy. In these moments, Charlie appeared to be communicating to the psychotherapist, “So far, I perceive you as being able to be a good fi t with me and my family. You continue to demonstrate interest in me, even though I have a great deal of sadness in my family.” He implicitly demonstrated that he was able to hold in mind the positive and adaptive cocreated moments of meeting in his past relationships. Stepping back and viewing the larger implicit relational fi eld, the psychotherapist’s subjective experience was, “I feel you are close to your family members. Your mother recognizes your strengths and does not fear sharing matters from your vantage point.” In this way, the psychotherapist—observing the child’s easy temperament, high cognitive fl exibility, and secure internal working models of attachment—concludes that they can work with each other to help the child (and the family) cope with the tragic sadness.

Facilitating Enactments Cocreating New Relational Schemas

Context After several sessions, Charlie shared his fear about how he was going to feel after his father’s death.

Patient : I am feeling really bad because my dad is not doing well; he is looking worse. He is in a lot of pain [genuinely sad and worried]. Psychotherapist: Your feelings are difﬁ cult to have, even if they are normal [intersubjectively also feels sad]. Patient : Will I get over all of this after he dies? 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 299

Intersubjective The psychotherapist feels Charlie has a good grasp of matters. Rather than listen further, the psychotherapist chooses to self-disclose and cocreate a moment of meeting that will be needed in future encounters, as his father’s condition was deteriorating.

Psychotherapist : I think your dad is a good teacher to you about matters of life. With your dad not doing well, I can see why you feel bad; you must know how he must be feeling, and you feel it too. I am impressed on how well you understand what you and he are going through. You will be able to overcome your sadness. Patient: I am glad you think I will get over the sadness and be OK after my father dies.

Intersubjective The psychotherapist implicitly provides Charlie a subjective feeling that there is a blueprint on how to cope with the death of a loved one. Charlie implicitly recognizes by the psychotherapist’s gestures and tone of voice that he is attuned to his painful feelings when sharing about his father deteriorating, “he knows how I feel and is not upset with me. He knows this will pass.”

Context Charlie shares a dream he had where he has a premonition about his father’s death on a speciﬁ c date.

Patient: I know it sounds crazy to think my dreams can come true. When I was younger, I dreamt about my best friend being in a car accident, and when I woke up, I found out that he was in a car accident. He wasn’t hurt though. Psychotherapist: I am not sure what your dream means, but dreams are typically about what people are happy or worry about [intersubjectively feels Charlie is engaging in age-appropriate curiosity]. Patient: Yeah, I know I worry about my dad—it sounds crazy too, but he will be happier after he dies. He hurts so much. Psychotherapist : I know of many people who worry about what is going to happen in the future and think of random events as lucky premonitions, like when baseball players carry a rabbit’s foot for good luck. It is difﬁ cult to make sense of those two events, a dream about a car accident and the actual car accident happening. I would like to think that your dreams are a way for you to put your worries in pictures and that in the dream there is a kernel of truth; your worry about your best friend and worry about your father. Patient : I guess you are right. I worry about my dad when I go to sleep, and sometimes I wish God would take him so he doesn’t have to go through all the pain he is going through. Maybe I want God to give me a date of when my Dad will die so I can wait and cry when it happens.

Intersubjective The psychotherapist’s intersubjective experience with Charlie is that he was aware that his dreams captured his worry and that he had a good grasp that his premonitions were nonconscious attempts to prepare him for the inevitable death of his father. The psychotherapist chooses to self-disclose and 300 12 Two-Person Relational Psychotherapy: Middle School Age Youth cocreate a here-and- now moment of meeting that can be nonconsciously accessed in the future as his father’s condition is deteriorating. The importance of the interaction described is not only on what transpires verbally but what occurs at the implicit nonverbal level. The psychotherapist and patient are attuned, and their tone of voice, gaze, and affective states allow both to know each other’s state of mind. In a traditional one-person model, this intervention may have been considered a countertransference enactment that circumvented Charlie’s further associations about his dream and worries with his father’s death. In encouraging associations, this may have allowed the psychotherapist to understand the child’s inner life or attune to possible transference manifestations available for working through . In a two-person relational model, it is best to understand the patient’s reference to his past within the context of the here-and-now mutual subjectivities of each person in the dyad, as each has inﬂ uenced what is remembered and has a front seat to their relevance in moving along the process to form new, more adaptive patterns of self- regulation and interaction with others. We reiterate the importance of what transpires at a nonverbal implicit level.

Subsequent Session

Context By the sixth session, Charlie’s father required a feeding tube and was deteriorating rapidly. Charlie shared that he had been crying during classes and was having difﬁ culties paying attention at school.

Patient : I can’t stop feeling sad and worried. It’s going to happen very soon. Have you seen kids whose parents are dying? Psychotherapist: Yes, I have, and I can tell you that for children, losing a parent is very difﬁ cult [intersubjectively feels Charlie is engaging in age-appropriate curiosity about his future without his father and is hoping for here-and-now genuine affective attunement]. Patient: I have a feeling this is also very hard on you. [An example of sloppiness: Intersubjectively Charlie becomes aware of the impact he has on the psychotherapist, and he demonstrates his use of prior moments of meeting between them by providing a new moment of meeting with the psychotherapist, which implicitly provides the experience of closeness, “We are in this together.”] Psychotherapist: You are right. I also feel sad that you are losing your father [intersubjectively allows Charlie to recognize that the psychotherapist genuinely feels sad and that it is normal for Charlie to have his feelings]. Patient : I like it that you are honest. You know, my mom tries to hide her sad feelings from me. I want her to show that she has sad and angry feelings like I do. I worry about her. Psychotherapist: Thank you. You know, many people handle happy and sad feelings differently. Some, like you and me, are open about them. For others, they are better at keeping them inside, and sometimes they think that it is better for their children to not see them cry or get angry. 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 301

Intersubjective The many moments of cocreation and the goodness of the implicit relational ﬁ t between Charlie and his psychotherapist played an important role in this sequence of interactions. Charlie intersubjectively knew that his reactions to his father’s worsening would be difﬁ cult on the psychotherapist, as if “I know it affects you because you have feelings too.” The psychotherapist experienced the moment of meeting as Charlie makes use of the experience of closeness, keeping in mind the psychotherapist’s belief in his strengths.

Timing Self-Disclosures

Context Charlie shared that being successful in his swim competition on his trip to Washington, D.C., was difﬁ cult for him.

Patient: It was difﬁ cult to do so well and not being able to share it with my father. I also felt bad that I actually did well and had fun with my friends. It was helpful to have planned a phone call to talk to you while I was there [smiling in a jovial manner] , like a lucky ritual. Psychotherapist : [Joining in mutuality with a smile] A lucky ritual that you had the control of whether you used it. Sounds like you are proud of the decision you made. Patient : Do you have any lucky rituals when you are stressed? [Smiling and feeling connected] Psychotherapist : Great question. Although I do not see myself as believing in them now, I do chuckle to think of when I was your age, I had thought that certain pencils and pens were luckier than others when taking exams. Even in college, I believed that certain shirts brought me luck during exams. I guess it helped me as much as it is helping you. It is all about who we are inside, right? Patient: It is good to know they worked. [laughing] You must have done well in the tests; you are a doctor who helps kids . [It is difﬁ cult to capture the nonverbal here-and-now feeling of relief and comfort the patient had.]

Intersubjective The psychotherapist chooses to cocreate a moment of meeting by self-disclosing a personal experience as a way to convey “I am glad that you allow yourself to ask me personal questions about how I manage difﬁ cult moments in life. It allows you to know that you are not alone; we all have stressful situations.” The psychotherapist intersubjectively notices Charlie’s comment about the psychotherapist doing well in exams and becoming a doctor and feels “Charlie sees himself in the future as a successful adult” and decides to join in laughter to implicitly convey “You (Charlie) will do well in school also.”

Context Charlie’s father was expected to die within a week.

Patient : I don’t mean to be rude, but you are old like my parents [appears worried about whether what he is saying will hurt the psychotherapist’s feelings], and I wonder if your father is still alive [has a sad and serious look]. 302 12 Two-Person Relational Psychotherapy: Middle School Age Youth

Intersubjective Acknowledging his worried and serious look, the psychotherapist experiences the question as meaning Do you really get over this uncomfortable feeling? With this in mind, he decides to cocreate a moment of meeting with self- disclosure with the intent of helping Charlie tolerate the experience of when his father passes.

Psychotherapist : No, my father passed away some time ago. Even now, just talking about him makes me have a good feeling inside. I remember many things he helped me with. I also feel sad and a little teary eyed that he is not here [noticeable] . Patient: It really helps me know that you still miss your dad. I was worried that I would forget my dad when I grew up.

Intersubjective The psychotherapist intersubjectively experiences Charlie as being relieved in knowing that the sadness does pass and that he will recover. He also experiences Charlie as recognizing that even his psychotherapist cries when sad and it is not a feeling to avoid.

Traditional One-Person Model

The above sequence seen from the lens of a traditional one-person model may have led the psychotherapist to address the many transference manifestations, such as in the comments “You are old” and “I wonder if your father is still alive .” These comments may have been viewed as Charlie also wondering about the psychotherapist’s mortality, which may have been further infl uenced if Charlie were angry at the psychotherapist or if experiencing him as tired and weak like his father. Additionally, Charlie saying, “I was worried that I would forget my dad,” may also have been considered as a transference manifestation to be addressed at some point. Herein, from a two-person relational model, the matters of transference are understood as a hypothesis emanating from the psychotherapist’s mind as an observer of the verbal and autobiographic constructs by the patient and not as an active participant of their mutual subjectivities. The relational psychotherapist intersubjectively notices that Charlie likely is refl ecting on issues of mortality of elders, including the psychotherapist. The psychotherapist chooses to affectively and in a nonverbal manner move along the process by conveying to Charlie “Deaths are painful, but you are resilient and will be fi ne,” accepting the possibility that Charlie may be worried about the psychotherapist’s mortality, which is best left as an implicit communication, and not to be addressed through an insight-oriented comment or interpretation.

Working with Parents Intersubjectively

The importance in meeting with parents throughout the psychotherapy process is not only for the gathering of past historical data and information about how the child is doing outside of the sessions. It also allows the psychotherapist to have here-and-now 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 303 experiences with the parent to learn the likely blueprint of the relational schemas used when communicating with their child. That is, it allows for the possibility that the style of relating with the psychotherapist is a replica of the relational model of attunement used with their child and is being nonconsciously repeated.

Context In the second appointment, the psychotherapist meets Charlie’s mother alone. The psychotherapist found her to be a very caring woman who recognized the struggles her son was having. However, when the psychotherapist asked about her son’s early childhood experiences—exploring Charlie’s temperament and internal working models of attachment—she was upset and the psychotherapist initially experienced her as somewhat emotionally distant and with a “let’s get on with it” attitude seen also in Charlie.

Psychotherapist : What was Charlie like as a child? Mother: She abruptly states, “How is this relevant? He has had a good life and has always been happy. He has done very well, even with his ADHD. He doesn’t need help with his past. I brought him for help with the stress of his father dying.”

Intersubjective The psychotherapist’s initial intersubjective experience is that Charlie’s mother has a mixed type of temperament, predominantly easy/fl exible with some feisty/diffi cult. The psychotherapist also notices that his intersubjective experience to Charlie’s mother initial comments is “Don’t tell me how to do my job.” He uses this to recognize that his feelings refl ect being attuned to her implicitly seeking an ally to her relational style— let’s get on with it. This was further supported when she made it clear that she had paid for competitive summer activities and did not want her son’s psychotherapy to interfere, as these activities were good for his self-esteem because his father had been taking him to them before he became ill. The psychotherapist further wonders whether Charlie has a similar implicit relational style and would want to get on with it once the psychotherapy began.

Psychotherapist : I am sorry. I was wondering about Charlie’s past because it would help me know what he has accomplished with the help of his parents, which I can use to capitalize on during the psychotherapy sessions. I hope it makes sense. Mother: Yes, it does. I also apologize. It has been so stressful lately. I just know it is important for me and his dad for Charlie to continue swimming. Recently, it is one of the few things they are able to do together.

Intersubjective The psychotherapist subjectively worries because he recognized that he had similar feelings to Charlie’s mother, in not wanting Charlie to miss swimming as this represented an activity in which he was close with his father. Most of the times he has available were after school hours, and it would conﬂ ict with Charlie’s competitive activities. He also notices that intersubjectively he had unknowingly agreed with Charlie’s mother’s pressure to “get on with it.” He used this to understand that helping Charlie should be a result of his careful work with him, through mutual understanding of their subjectivities and not on his mother’s schedule. 304 12 Two-Person Relational Psychotherapy: Middle School Age Youth

Psychotherapist: I will do my best but I do not have after school hours available for a few weeks. Mother: I apologize. The stress lately has made me so confused about what he needs. I just know I need to trust you. He really likes you and that means a lot to us. My husband and I think this is very important. I will make sure I get him here.

Intersubjective The psychotherapist intersubjectively experiences Charlie’s mother as likeable and caring for being attentive and proactive in bringing in her son for an evaluation, knowing it would involve regular psychotherapy appointments, thus demonstrating some good capacity for affective attunement with her son. The psychotherapist was surprised when Charlie’s mother said, “He really liked you and that means a lot to us—his mother and father—we think this is very important.” They had agreed that it was OK if he missed a swimming class once a week (the second weekly session was during school hours). The psychotherapist experiences the shift may have been a result of an earlier moment of meeting when the psychotherapist apologizes for asking about Charlie’s early childhood that may have implicitly helped her recognize “I can trust him with him to help my son.” Throughout the process she is very respectful of the appointment times and does not ask Charlie any questions about what he had talked about, which many parents do in order to gauge the benefi t from the process. The psychotherapist was surprised that she became an ally to the process and would encourage Charlie to call between sessions, as agreed, when his father’s illness worsened and required palliative interventions. The psychotherapist recognizes intersubjectively that Charlie had been in good hands all along—he had good and warm parents. In refl ecting on his fi rst intersubjective reactions to the “get on with it” line, he understands that the initial presentation was in essence how the family handled their anxiety, which changed in the context of a safe and secure environment the psychotherapist had provided.

Subsequent Session Weeks Later

Context Charlie’s appointment, scheduled the day that his father passed, was canceled. He called the psychotherapist as he got ready to go to the funeral. He shared that he had cried for 4 h and needed reassurance that it was OK to cry and that he will feel better.

Patient : I'm really going to miss my father. I started crying and I could not stop. I eventually went to sleep while I was still crying. [He was happy that his father was no longer in pain. He had an appointment 2 days later but felt he could not wait to talk and was very appreciative that the psychotherapist was able to talk to him over the phone.] Psychotherapist : Thank you for calling me and letting me be of help in such a dif- ﬁ cult time. I think your father would be very proud of you for crying, which acknowledges how important he is to you. I can assure that you will feel better 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 305

later, but for now I think you deserve to be sad and cry as long as you need to. I will see you in a couple of days, and I will remember this conversation.

Intersubjective The psychotherapist’s intersubjective experience was that Charlie needed to hear something personal, genuine, and not general supportive comments. We are aware that this intervention is similar to what a traditional one-person psychotherapist would have chosen to do, empathic attunement that can be analyzed later if necessary.

Two Months Later

Context Charlie’s mother begins dating.

Patient : Don't tell her, but I really hate that my mother is dating so quickly after my dad died; I do not need a new dad. Can you tell her how it affects me? She just tells me that I need to understand that she wants to be happy. I don’t care; I don’t even know him.

Intersubjective The psychotherapist’s initial intersubjective reaction to Charlie’s dilemma is “I agree with you. Your mother’s dating seems to have happened rather quickly.” He notices subjectively experiencing anger at Charlie’s mother and recognizes that he feels like a protective parent, as if he were standing in for Charlie’s father, protecting his son. In the intersubjective fi eld, the psychotherapist experiences that Charlie is angry because he believes his father is being replaced by a new person. He is uncertain about how to convey his anger toward his mother, “my mother needs to know I am angry and that her dating affects me.” The psychotherapist recognizes feeling attuned to Charlie’s anger at his mother for dating. The psychotherapist is reminded of his initial subjective experiences of Charlie’s mother, at the beginning of the treatment, when she conveyed a “let’s get on with it” attitude and wondered if this implicit relational style was being repeated. Nonetheless, the two-person relational psychotherapist also recognized he could not have been aware of the context of why she chose to begin a new relationship, and developing a hypothesis of why this had occurred would, at best, be uninformed and clearly speculative. With this in mind, the psychotherapist refl ects on the fact that the best way to help Charlie is to allow himself to be guided by the here-and-now subjectivities in the cocreated intersubjective fi eld. Charlie subjectively conveyed needing help managing his contextual and age-appropriate anger, and the psychotherapist is aware of needing to allow for a “holding pattern,” at an implicit level without need for insight-oriented comments. Charlie would need time to accept his mother’s decisions.

Psychotherapist: I have the sense that you wonder why she decided to date so quickly and why she likes this particular man. I also know that you have a 306 12 Two-Person Relational Psychotherapy: Middle School Age Youth

difﬁ cult time being angry for fear of hurting other people’s feelings, in this case your mother. I suspect your mother is OK with you being angry. Patient : Yeah. My mom tells me that she will never replace my father and that she also misses him. She knows that I still miss my dad. She is trying to be happy and said that she doesn’t want me to meet her friend until I let her know that I am ready. [With noticeable anxiety in considering this a possibility] What if I don’t like him? Even worse, what if I like him? [Seems pleased, smiles at the fact that he is now considering options of how things may develop]

This example captures several important issues. Charlie is learning to implicitly know that his anger is a normal experience and that the adults in his life can manage his feelings, as was modeled by the psychotherapist. Charlie is able to accept his angry feelings as being part and parcel of everyday life. Further, Charlie subjectively conveys that he is aware that his mother is implicitly and explicitly asking him to accept that her dating reﬂ ects her wishes to feel happier, without ignoring the fact that they both recently lost their loved one. Viewed from a traditional one-person perspective, Charlie’s mother’s dating may have been understood as Charlie now having to cope with a new oedipal rival and the guilt that he felt for his hostile wishes. Blos (1967 ) would consider that Charlie was struggling with the second individuation process, by the reawakening of regressive infantile ties to his mother with the threat of losing her psychological support. This may have been further complicated by the recent death of his father, which may have unconsciously led him to view the new situation as a threat to have his mother’s affection diverted from him. The psychotherapist would need to be obser- vant of Charlie’s comments and fantasies about his mother and her male friend, to tailor insight-oriented interventions in the form of verbal interpretations of what may be transpiring psychologically for Charlie. It is also likely the traditional one- person psychotherapist will make some inferences about why Charlie’s mother began to date (i.e., avoiding the mourning of the lost object, counterphobic reaction to her depressive feelings, impulsive action due to superego pressures, etc.), which is limiting as it does not account for the real-life complexities and context of the many reasons inﬂ uencing her deciding to date.

Letting Go

Context Charlie travels to the west coast to fulﬁ ll his father’s wish, to have his ashes thrown in the ocean.

Patient: I knew it was going to be sad but I didn’t know that it was going to be so hard. You were right…. You really helped me get through my painful feelings. I can handle them now. Psychotherapist : I am glad you had the courage to fulﬁ ll your father’s wish; he would be proud of you. I also know that it must have been very difﬁ cult, but I 12.4 Two-Person Relational Psychodynamic Psychotherapy in Middle School Age Youth 307

hope you know how well you managed things so painful. [Smiling, with an implicit it is over and you can manage matters just ﬁ ne]

Context He began to bring his smartphone to the sessions and would ask permission to text his peers.

Patient : They know I come to see you, and I like telling them what games we play. [He later asked if it would be OK to text his girlfriend during the session.] She wants to thank you for helping me. Psychotherapist : Of course. Please let her know I thank her for joining the group of people who are happy helping you with your feelings. Patient: She is really nice. My mother likes her a lot. No offense, I really think I am ﬁ ne now. I don’t need to come and see you, if that’s OK.

Intersubjective The psychotherapist recognizes that Charlie has made remarkable progress and felt better. He is happy going to school and recognizes that, at times, he is angered by his mother’s reminders to complete his homework or chores, although he knew it was normal. He is less worried about missing his father and talks to his father before bed, hoping he could listen. The psychotherapist subjectively experiences pride in Charlie’s progress and some sadness in letting go. After an open discussion, the psychotherapist intersubjectively recognizes Charlie is ready to move on. They both agree to invite Charlie’s mother to share that his psychotherapy process would end in four sessions, which occurred without diffi culties. In a traditional one-person model, this intervention may have been considered as an abrupt termination , as it did not allow time for working through the mourning of the relationship with the psychotherapist. Further, Charlie will need the psychotherapist to help him work through his reawakening of his oedipal strife. This is noted when he introduces his girlfriend into the session by phone, this can be seen as evidence of the resolution of the oedipal confl ict with a sense of triumph: “I have my own woman.” In a two-person relational model, there is attention to here-and-now subjectivities. The introduction of his peers and girlfriend to the sessions via smartphone refl ects progress in his developmental milestones. Additionally, letting go is not considered a termination; rather, it is considered a “Good-bye, I have provided a new emotional experience that allows us to now hold in mind our unique subjectivities of our work together in implicit nondeclarative memory.”

Uncertainties A month later Charlie returned for one session. He shared that he was having dreams of anxiety and premonition that his father was still alive. It was clear that he was not in signiﬁ cant distress and was self-assured and conﬁ dent.

Patient : I know exactly what you are going to say. I just knew that it would help if I saw you and shared that I learned from you how to handle my feelings. Psychotherapist: Thank you for coming and sharing that we made a good team. When you said that you knew exactly what I was going to say, it felt similar to 308 12 Two-Person Relational Psychotherapy: Middle School Age Youth

my feeling that you knew you could return if you had anything you needed to share, good or not so good. I am happy you are doing well.

Intersubjective The psychotherapist intersubjectively experiences Charlie returning for one session as reﬂ ecting his desire to share that he was successful in managing his anxieties. He, by all standards, is doing well in all areas. The psychotherapist recognizes wanting to ask about the reasons for Charlie’s return but quickly understands that this had to do with his own curiosity and is not what Charlie needed. He is able to stay present, in the here and now, and allow Charlie’s subjectivities to guide him on how to proceed. In a traditional one-person model, this session may have been considered as a manifestation of Charlie’s unresolved transference feelings to his psychotherapist. To this, the psychotherapist may have chosen several possible approaches. First, he may choose to explore the unconscious meaning for Charlie’s return. Second, he may not agree to only have one session, as unconsciously Charlie may have unﬁ n- ished work as represented by the reemergence of his dreams. In both of these hypotheses, although many others are also possible, a traditional one-person model does not rely on mutual subjectivities in the here and now to guide the process. Rather, it requires the use of verbal communications to explore hidden meaning in order to achieve some form of insight.

12.5 Dilemmas in Two-Person Relational Psychodynamic Psychotherapy

Clinical dilemmas in a two-person relational model of psychotherapy are ubiquitous. Dilemmas are to be expected in any dyadic relationship where there is bidirectional vitality and sloppiness . We are reminded of Shakespeare’s literary quote that captures the ubiquity of uncertainty in life, as well as in clinical dilemmas, “To be or not to be.” The set of relational schemas that a psychotherapist may hope to implicitly represent (to be) to his or her patients is dependent on the context of the interaction, and at times may intersubjectively learn that he or she represents a maladaptive schema that had not been considered (not to be), and will need to be repaired through a moment of meeting .

Context Charlie requested an urgent appointment the day before Father’s Day—3 months after his last appointment—fearing he would “not be able to stop crying.”

Intersubjective The psychotherapist experiences his request as demonstrating that by the use of a here-and-now two-person relational psychotherapy processes, in which intersubjective experiences are cocreated, it had provided Charlie an implicit atmosphere of safety that he was able to return to when needed. Additionally, the psychotherapist, a father himself, had plans to celebrate Father’s Day later that evening with his own grown child. He recognizes that internally he felt “It is just for an References 309 hour, I can help Charlie,” as well as, “Why am I agreeing to see him on such an important day for me? It may affect how I approach my own celebration.” The psychotherapist decides to have a brief telephone encounter with Charlie in which they both could gauge the urgency or if it could wait to be scheduled for another day, which it was. This interaction serves to demonstrate the complexities of how dilemmas can be managed. As captured by Scaturo (2002 ), an ongoing two-person relational process is “a constant series of clinical choices and recurring dilemmas for the psychotherapist. For the practicing clinician, such decision making is a part of everyday occupational life.” We are not advocating that the decision made by the psychotherapist is correct. Rather, we highlight the complexities of the present and active psychotherapist as a real person to real-life dilemmas.

References

Blos P (1967) The second individuation process of adolescence. Psychoanal Study Child 22:162–186 Call JD, Noshpitz JD, Cohen RL, Berlin IN (1979) In: Noshpitz JD (ed) Handbook of child psychiatry, vol 1, Development. Basic Books, New York Delgado SV, Strawn JR (2014) Difﬁ cult psychiatric consultations: an integrated approach. Springer Heidelberg Erikson EH (1968) Identity, youth and crisis. WW Norton, New York Furman R (1964) Death and the young child: some preliminary considerations. Psychoanal Study Child 19:321–333 Gill HS (1987) Effects of oedipal triumph caused by collapse or death of the rival parent. Int J Psychoanal 68:251–260 McDevitt T, Ormrod J (2010) Child development and education. Pearson, Upper Saddle River Menes JB (1971) Children’s reactions to the death of a parent: a review of the psychoanalytic literature. J Am Psychoanal Assoc 19:697–719 Scaturo DJ (2002) Fundamental dilemmas in contemporary psychotherapy: a transtheoretical concept. Am J Psychother 56:115–133 Two-Person Relational Psychotherapy: High School Age Adolescents 1 3

Change is the law of life. And those who look only to the past or present are certain to miss the future. —John F. Kennedy

Adolescence is a developmental period of life that commences with the onset of puberty and artifi cially ends with adulthood. The twenty-fi rst century saw substantial advances in understanding the biological, psychological, and sociological aspects of adolescent development. Moreover, accumulating data support the notion that adolescent behavior cannot be reduced to purely psychological or biological phenomena. Rather, an understanding of any aspect of adolescence is best derived from an appreciation of biology and psychology and their respective interfaces. For example, imaging studies of adolescent brains confi rm aspects of fl uidity in decision making and a number of other cognitive capacities (Giedd et al. 1999 ). Giedd explains that during adolescence, the area of the brain responsible for organization, planning, and strategizing is not fully developed, as the gray matter continues to thicken. In turn, these neuroanatomic changes likely occur in tandem with changes in the implicit relational memory processes. Further, the scientifi c literature confi rms the belief that adolescence is a period of inordinate risk taking and complexities in decision-making processes ( Reyna and Farley 2006). Thus, the psychodynamic understanding of adolescence has evolved considerably over the last century, from a foundation rooted in Freud’s structural and drive theories to a more contemporary understanding that has been informed by temperament, attachment, and relational theories. Adolescence has been reconceptualized from a period of instability and psychological turmoil to a period in which most adolescents successfully regulate the shifts in affective states and negotiate the complexities of the environment, developing the capacity for intimacy and stable interpersonal relationships ( Delgado et al. 2012 ).

© Springer-Verlag Berlin Heidelberg 2015 311 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_13 312 13 Two-Person Relational Psychotherapy: High School Age Adolescents

In this chapter, we provide the reader a case example of an adolescent receiving treatment in which a contemporary two-person relational psychotherapeutic approach is used, with attention given to the patient’s and her mother’s temperament, cognitive and affective ﬂ exibility, and internal working models of attachment, all within the context of intersubjectivity . A detailed description of the work that transpired is provided with additional comments about how the intersubjective experience in the here and now guided the psychotherapist interventions during the process. We also provide the reader with a view of the case from a traditional one- person model to serve as a broad review of the main differences that exist between both theoretical approaches. As a reminder, much of what transpires that promotes changes and moves along the process occurs at an implicit nonverbal level and is strongly inﬂ uenced by the patient’s and psychotherapist’s tone of voice, posture, and nonverbal expressions in the here-and-now moments.

13.1 Psychodynamic Psychotherapy in High School Age Adolescents

Contemporary psychodynamic understanding of the adolescent is strongly infl u- enced by attachment theory and intersubjectivity, the interaction between implicit nonconscious relational experiences of the self and others. The adolescent’s developmental task is to successfully regulate the shifts in affective states in order to develop the capacity for intimate and stable interpersonal relationships. The reasons for which adolescents seek help are typically due to emotional or behavioral problems. The adolescent psychiatrist or clinician will benefi t from a careful use of the contemporary diagnostic interview (CDI, Chap. 8 ) in order to understand the adolescent’s unique attributes—temperament, cognition, cognitive fl exibilities, and internal working models of attachment—within the context of the environment in which they live in, which includes family and culture. Furthermore, the contemporary psychodynamic theory has helped defi ne periods of healthy turmoil, with episodic moments of intense anger and isolation, as well as unhealthy turmoil as a result of adolescent psychopathology, with persistent patterns of acting out, self-defeating behavior, academic failure, substance abuse, and promiscuity.

13.2 Michelle

History of Present Illness

Michelle, a 16-year-old Caucasian female, was brought by her mother with a specifi c request to help her daughter cope with the sad feelings due to the breakup of a 2-year, long-distance relationship with a 17-year-old female peer—whom she 13.2 Michelle 313 never met in person. Since the breakup, Michelle spent much of her time in her room crying and requested that her mother “fi nd someone I can talk to. It is not right to feel this bad.” After the breakup, she had begun to struggle at school, and her mother found her to be more “moody at home.” Michelle ostensibly was happy during the 2-year relationship, and the couple had planned a summer trip to meet. The relationship was her fi rst same-sex experience. She had earlier dated a male adolescent, although she reported that she found him “boring.”

Past and Family History

Michelle was the product of an unplanned, uncomplicated full-term pregnancy when her mother was 16 years old. During the pregnancy, her mother lived with her parents, who were described as being unsupportive of the circumstances. After Michelle’s birth, due to the increased confl ict with her parents, Michelle’s mother moved in with her daughter’s 17-year-old father, who lived at his parents’ home. Michelle achieved her developmental milestones on time and was overall a healthy child. At the age of 3, she was sent to live with her maternal grandparents, as both of her parents were unable to care for her and had begun to use drugs heavily. Michelle’s grandparents proved to be very supportive of her care and covered the costs for her education in private Catholic schools. She remained with her maternal grandparents until she was 13 years old, at which point her mother asked that she once again live with her. Her mother had completed her substance abuse treatment, had remarried, and felt better able to care for Michelle. Michelle’s mother reported having a history of bipolar disorder with several hospitalizations as an adolescent and as a young adult. She was no longer in treatment, stating she had mastered the illness and was in the process of fi nishing nursing school. Throughout her early childhood, Michelle had a confl icted relationship with her mother, who would visit Michelle on weekends—although inconsistently—and would generally use Michelle as her supportive friend. Her father would visit her inconsistently, and when she was 10 years old, he stopped all communication without explanation, for which she was angry: “I clearly have issues with abandonment.” According to her mother, Michelle’s maternal grandparents, extended family, and teachers described Michelle as an easy, jovial, and intelligent adolescent. At the time of the evaluation, Michelle was an honors student. She had hoped to pursue a career in soccer, but due to a sport injury, she was in constant pain and required biweekly physical therapy, and she was told that she likely would not be able to return to competitive sports. Michelle was living with her 33-year-old mother, 38-year-old stepfather, and two half-sisters, ages 3 and 1 year old. 314 13 Two-Person Relational Psychotherapy: High School Age Adolescents

Contemporary Case Formulation Following Use of the CDI: Michelle Michelle : A 16-year-old Caucasian female who presents with new functional impairment timed with the breakup of a 2-year relationship with a female peer Internal working models of attachment (IWMA): Ambivalent/anxious Temperament: Mixed—predominantly easy/fl exible with some feisty/ diffi cult Cognition: Above average (see developmental milestones Appendix A ) Cognitive fl exibility: High/adequate Formal psychiatric disorder: Symptoms of dysthymia, although did not meet full DSM-5 criteria Treatment recommendation: Two-person relational psychotherapy to help her develop new and more adaptive models of interaction with others with improved affect regulatory functions

Contemporary Case Formulation Following Use of the CDI: Mother Michelle’s mother : A 33-year-old Caucasian female who presents with functional impairment in regard to providing the affective attunement needed by her 16-, 3-, and 1-year-old daughters Internal working models of attachment (IWMA): Avoidant/dismissive Temperament: Mixed—predominantly feisty/diffi cult with some easy/ fl exible Cognition: Average Cognitive fl exibility: Average to limited Formal psychiatric disorder: History of mood disorder and relational problems that, although did not meet full criteria, are within the realm of cluster B traits, predominantly borderline Treatment recommendation: Participation in her daughter’s psychotherapeutic process; suggest her own individual psychotherapy to help her develop new and more adaptive models of interaction with her daughter.

13.3 Case Conceptualization from a Traditional One-Person Model

In conceptualizing this case from the lens of a traditional one-person model, the formulation may be seen from several angles, depending on whether it is viewed from a drive theory, ego psychology, object relations, self-psychology perspective, or in a pluralistic manner—a combination of theories but without a clear delineation among them in spite of their differences. In the traditional psychoanalytic literature, abandonment by parents in early childhood is considered to have a signifi cant negative impact on the intrapsychic 13.3 Case Conceptualization from a Traditional One-Person Model 315 psychological processes of the child. Abandonment from parents contributes to a child making use of maladaptive ego defensive mechanisms to cope with the realities of the situation. They generally deny the reality of their abandonment , identify with the parental internalizations (e.g., being abandoned for being a bad child), or create a false sense of self to prevent closeness with others in order to prevent further abandonments. The patient generally presents to psychotherapy for the treatment of poor self-esteem and feelings of guilt for the abandonment. Further, in the case of Michelle, the diagnostic formulation of her problems may be viewed at many different levels. For example, her parents were adolescents when she was born, and the abandonment occurred at a young age. This clearly had signifi cant negative repercussions in her psychosexual development. Her environment was not conducive to providing the necessary warmth and mirroring, and as a young child she learned to make use of immature ego defense mechanisms to prevent feelings of loneliness. She likely developed narcissistic character traits to manage feelings of despair. The developmental interference in her growth further led to unresolved oedipal confl icts due to the abandonment by both her mother and her father, which did not allow for a successful work through the developmental tasks of this phase. The repercussions from her abandonment during this phase can be surmised by repressing her anger toward her father and wishes for reunion with an available mother (object representation). Thus, she had signifi cant problems negotiating the second individuation process of adolescence. As a note, Michelle’s struggles began at the same age that her mother gave birth to her. This can be considered a generational unconscious repetition of the problems of adolescent individuation. Additionally, it may lend to be viewed from the perspective of generational family issues, typical in family therapy schools. In a traditional one-person psychotherapeutic model, the treatment of an adolescent is best achieved by the psychotherapist’s empathy and self-object mirroring to help the patient feel safe and improve the therapeutic alliance. In this case, there may be the need for occasional moments of neutrality if Michelle’s projection of negative affect occurred, which would allow for the transference to develop and later be amenable to interpretation. The psychotherapist will likely be initially experienced as the helpful father or mother object, noted by an increase in positive identifi cations and idealizations of the psychotherapist. Further, by maintaining some neutrality and not gratifying Michelle’s wishes for closeness, the psychotherapist can help Michelle work through her anger toward her parents in the transference to the psychotherapist. Regarding Michelle’s mother, in the traditional one-person model, the psychotherapist may provide regular educational sessions to help Michelle’s mother understand her daughter psychologically and to support the psychotherapeutic process. Michelle’s mother may have initially been thought of as struggling with unconsciously not wanting to be reminded of the loss of her own loved object (her daughter’s father), akin to parents with “ghosts” in the nursery ( Fraiberg et al. 1975), which interfere with their ability to successfully parent and help the child develop adaptive ego functions. Additionally, in the traditional one-person model, Michelle’s mother’s phone call to the psychotherapist (see below) may have 316 13 Two-Person Relational Psychotherapy: High School Age Adolescents represented jealousy of her daughter’s biweekly sessions with the psychotherapist, hoping to also have a relationship with the psychotherapist to feel validated as a good mother.

13.4 Two-Person Relational Psychodynamic Psychotherapy in High School Age Adolescents

Two-person relational psychotherapy has evolved from the traditional one-person models of psychoanalytic treatment for adolescents. What began as a journey of discovery of the adolescent’s unconscious conﬂ icts has now broadened to be an asymmetrical interaction between patient and psychotherapist based on mutuality that promotes the cocreation of more adaptive experiences for the patient in the form of a new emotional experience, which is then stored in nondeclarative memory systems. The asymmetry refers to the psychotherapist’s personal healthy attributes, relative to the patient’s maladaptive attributes. The asymmetry allows the psychotherapist to be guided by the intersubjective experiences provided by the patient in the here-and-now moments. The relational psychotherapist makes careful use of timed enactments and self-disclosures to move along the process in what are called moments of meeting. Herein, together, the patient and psychotherapist cocreate new and corrective emotional experiences . We note that at times self-disclosures and enactments occur unknowingly to the psychotherapist and its presence is revealed by the patient.

Allowing Subjectivities to Meet

Context The child and adolescent psychiatrist went to the waiting room to greet Michelle (who had requested the appointment) and her mother, at which point Michelle quickly got up, approached the clinician, and pleasantly stated, “My mother wants to talk to you without me. I am OK with that; she can take the ﬁ rst half of the appointment.” Her mother remained seated and silent, implicitly waiting for the interaction between Michelle and the clinician to provide her the information she needed about how the interaction was to proceed.

Child and Adolescent Psychiatrist In knowing that both had clearly prepared for this moment and were asking for something that seemed reasonable, rather than challenging the patient and her mother, he agreed to accept their request and learn more about the implicit relational style. He made note about his intersubjective feeling: “I feel both of you are already attempting to control the interaction, and it seems something so natural to both. It must be sad not knowing how you inﬂ uence others to feel about you and unrealistically expect them to understand you.” The clinician intersubjectively experienced Michelle as assertive and comfortable with the caretaking role she had taken, compared to the passive role her mother took. 13.4 Two-Person Relational Psychodynamic Psychotherapy 317

Mother The clinician brought Michelle’s mother to his offi ce and attempted to engage her by pleasantly sharing the charming attributes of her 3- and 1-year-old girls, who were in a stroller (a technique common in a contemporary diagnostic interview, see Chap. 8 ). She did not address the comments and rather seemed pressured in wanting to let the clinician know the facts about her daughter’s problems or at least how she saw them. She opened the conversation by stating, “I am so glad to share my side of the story fi rst, so you can have a good picture.” She felt guilty for not being available to her daughter during the fi rst 13 years of her life and was now happy that Michelle was living with her—“She knows that I always cared about her. I just couldn’t do it until now.” In contrast, in her next comment she did not demonstrate any real happiness in having Michelle live with her, “The problem is that she is just like her father; he was very manipulative and vindictive,” and was worried because she felt her daughter was demonstrating the same tendencies. She believed that her daughter did not appreciate “that I am in her life now. She should learn that she needs to open up to me, like most daughters do, so I can help her emotionally.” She openly stated that she hoped for the clinician to help Michelle learn to open up with her and to understand that the relationship she had with her girlfriend was unhealthy and that she should get over it.

Intersubjective: Michelle’s Mother The clinician had a mixed set of intersubjective experiences. Initially, Michelle’s mother was experienced as likeable and caring about her daughter’s future in agreeing to seek help for her. Nevertheless, within a few minutes, the clinician experienced the contradiction of his emotions in the here and now. Intersubjectively, he thought, “I like her for trying to help her daughter, although I feel I am speaking with a teenager.” She seemed narrow-minded regarding the complexities about Michelle’s life experiences—growing up without having her mother available for many years—and was comparing Michelle to her father’s negative characteristics, even though Michelle excelled in school and asked for treatment. Further, he was saddened that the two young children in the stroller were actively seeking for some social referencing during the session, which he provided in an obvious manner, hoping that their mother would take over, which she did not during the entirety of the 30-min session. She did not seem to know how to soothe and reference back to them, clearly having problems in knowing how to be a good enough mother .

Michelle Upon entering the offi ce, Michelle seemed polite and jovial, and she pleasantly stated, “Finally I have somebody to talk to. I bet you wonder how I can live with my mother, who doesn’t know how to be motherly, even to my little sisters.” She added, “I thought it would be helpful for you to meet my mother fi rst. Most people have a hard time believing me when I say she is not a good mother, even though she thinks she is. Her not being part of my life until the last 3 years just confi rms that she doesn’t know me.” She was articulate throughout the session and shared that she now understood why people feel devastated after breaking up with a loved one. She accused her girlfriend of being a shallow person for not believing that a long-distance 318 13 Two-Person Relational Psychotherapy: High School Age Adolescents relationship—several states apart in this case—would work. She added, “We had two great years; we used a webcam when we slept. It was nice to get up and have someone that loves you to be there.” She was certain that her emotionally charged comments pushed her girlfriend away, whom had begun to date an adolescent male.

Intersubjective: Michelle The clinician had a mixed set of intersubjective experiences when talking with Michelle. Although she was a very likable adolescent, he noted that the experience felt as if he were talking to a young adult woman. He notices intersubjective feelings of being proud of her for having survived her life without knowing where her mother was and how brave she was in letting her mother enter her life in the last 3 years. Nevertheless, although he felt that she seemed resilient and knew about her mother’s limitations, “she doesn’t know how to be motherly,” she also seemed to have compartmentalized her feelings of loneliness. As the clinician listened, he intersubjectively felt, “Why does this adolescent not talk about friends? Why is she sharing matters as if we were distant friends catching up?” as in her narrative there was an absence of any reference to close peers who could have provided some support to her during her life and much more during the painful breakup.

Michelle As the session continued, Michelle proved to be exquisitely attentive to the clinician’s shifts in affect and seemed implicitly able to know what he (and likely adults in general) needed. For example, at a moment when the clinician was subjectively feeling at a loss as to what might best help Michelle develop more adaptive relational patterns, she seemed to recognize this at an implicit level and said: “I’m sorry I’m giving you so many details about my girlfriend. I just thought it would make it easier for you to understand why I am so stressed, which you clearly know my mother doesn’t. She just says it was an unhealthy relationship and that I should get over it.” In this, the clinician experienced Michelle as a lonely person with resilient skills in self-sufﬁ ciency and implicitly knowing how to seek others that may be able to understand her dilemmas in life. In doing so, she seemed unable to be aware that she came across as a person who did not know how to enjoy being with others in the here and now. This may have explained her preference for a long-distance, safe relationship, which may have been a representation of an implicit dismissive internal working model of attachment set in her early life—failures in affective attunement and social reciprocity by her caregivers.

Intersubjective The clinician’s initial goal, from a contemporary two-person relational model of psychotherapy, will be to become immersed in shared subjectivities—from both patient and her mother with the psychotherapist—that are unique and distinctive to their dyad. This will allow the psychotherapist to intersubjectively learn how others may feel being with them and to use this as a tool to later cocreate, in the here and now, more adaptive experiences that can be stored in implicit nondeclarative memory for later use. For this to occur, the psychotherapist will need to be in a frame of mind that will allow him to tolerate the many uncertainties regarding the origin of Michelle’s diffi culties without hypothesizing about how he or she 13.4 Two-Person Relational Psychodynamic Psychotherapy 319 believes they came about due to unconscious internal confl icts, which is common in the traditional one-person model. The psychotherapist will allow the patient to implicitly help him get to know what she is like when interacting with others, after which he can develop a blueprint that will guide the cocreation of a new organization of experiences in the here and now, promoting new and more adaptive ways of affect regulation and self-cohesion. This is not to say that the psychotherapist will know in advance which of the patient’s intrapsychic confl icts and past object relations trigger her maladaptive patterns; rather, he will intersubjectively attend to the experiences in the here and now (e.g., “I feel you are dismissive of me, and I will help you know that I am here, present and active. I will let you know how I think implicitly and nonconsciously I can teach you how to move along the developmental steps necessary in life”). In doing so, the psychotherapist, over time, will implicitly help the patient replace maladaptive relational behaviors that represent the old familiar—her mother, father, girlfriend, etc.—and nonconsciously move toward a new relational model cocreated with the psychotherapist.

Facilitating Enactments Cocreating New Relational Schemas

Context After completing the CDI over the course of three appointments, Michelle agreed to biweekly psychodynamic psychotherapy in a two-person relational perspective, and her mother agreed to meet once a month to support the process. All parties agree not to pursue the use of medication at that point. The appointment had been set up for the following week. Michelle’s mother called the psychotherapist the day before the appointment to ask for help on how to handle her daughter’s request, via text, to be excused from classes due to a throbbing headache. She added that she did not agree with excusing her and shared that she felt the incident was another example of her daughter’s manipulative behavior. She ended the conversation by stating that she would like the psychotherapist to focus on helping her daughter keep her bedroom clean. The psychotherapist intersubjectively experienced Michelle’s mother’s telephone call as not actually wanting any advice. Rather, she seemed to repeat the nonconscious implicit relational knowing pattern of “Look how difﬁ cult it is to be a mother,” which likely was inﬂ uenced by many facets of her own relationship style in her early and adolescent years.

Patient : I already heard that my mom called you yesterday. This should be interesting. Our ﬁ rst appointment and she already gets in the middle. That’s her. You go ﬁ rst. [ Smiling and seeming to feel connected with the psychotherapist, she conveys a subjective experience of curiosity and inquiry about what happened. ] Psychotherapist: Your mother called me and left a message that she was worried and wanted to talk to me before your appointment. As I told you, I usually return calls from patients and parents to have a better understanding about what may be happening outside of the sessions. Sometimes parents want to let me know about medical issues that I may need to be aware of. So I went ahead and called your mother. 320 13 Two-Person Relational Psychotherapy: High School Age Adolescents

Psychotherapist : [ At this point, the psychotherapist feels the connection with the patient has been lost—a now moment (Chap. 5 ). She begins to look at the psychotherapist with a dismissive attitude. The psychotherapist chooses to stay in the here and now and smiles. ] Psychotherapist: Your look makes me feel that you disagree with my returning your mother’s call. Patient : Go ahead. I am listening. [Indicating she is not ready to share her opinions .] Psychotherapist: Your mother shared that you had texted her to help you be excused from your classes due to a throbbing headache. The second thing she shared seemed rather silly, that your room wasn’t clean. I thought, with the amount of things that you do—drive yourself to school, complete your assignments, work for your grandfather, etc. [Smiling , hoping to reestablish the connection]—that this was a minor issue unless the Centers for Disease Control agency would deem it dangerous. [Use of sarcasm about her mother’s request of a clean bedroom ] Patient : Oh my God! I can’t call my mother from school if I am having a throbbing headache from a mental breakdown. A decent parent would prefer to have contact with their child. [With a demanding “Take my side” comment ] Psychotherapist : I need your help understanding what you hoped for your mother to have done when you texted. I liked that you reached out to her when you needed help due to a headache. [ The goal was to cocreate a here-and-now moment of “most adults think it is important for an adolescent and good student to ask for help.” ] Patient : I needed her support and gave her a chance to be motherly. She usually doesn’t know how to provide support. When I got back home, she didn’t even ask how I felt. Psychotherapist : Walk me through what happened when you got home after school. It would help me know what you go through. Patient : I went to my room and tried to take a nap in the dark to get over my headache, which I usually don’t have. Psychotherapist: It is sad that she did not ask how you felt. It also sounds like your mother did back off; maybe my advice helped her not be critical of you. [ With a tone of voice indicative of, “Maybe it worked!” ] Patient: I guess, to some extent. [Not wanting to accept the minor change in her mother ]

Intersubjective The psychotherapist’s intersubjective experiences during the ﬁ rst appointment are of confusion. He does not have enough of an understanding about the roles Michelle and her mother are accustomed to—the implicit and familiar. He also has some confusion about whether Michelle is actually reaching out to her mother hoping for understanding or whether she is implicitly relating to her mother in a manner familiar to them, conﬁ rming her mother’s unavailability and critical approach. The psychotherapist also notices experiencing Michelle as demanding, like her mother had described, when Michelle implies, “I want you (the psychotherapist) to agree with me and prove you care about me.” The psychotherapist is aware that he had just began to be immersed in Michelle’s subjectivities and that further time was needed to intersubjectively know how to best intervene. 13.4 Two-Person Relational Psychodynamic Psychotherapy 321

Context The psychotherapist experienced intersubjectively a great deal of loneliness in Michelle: not able to connect with her peers and often having to problem solve without help from others. He also recognized that she had an implicit wish for input from others about her affective states, although in a pseudo-mature manner, which prevented her from knowing that others had a different vantage point than hers that could be helpful.

Patient : My problem is in Latin. The teacher is just an idiot. I have the highest grade in the class, but it is just too stressful for me with that teacher. Psychotherapist : Interesting, I thought that Latin was a dying language. Patient: You’re a doctor; you should know that Latin is very useful. [Smiling and pleased she has a one up in the interaction, which the psychotherapist experiences as a repetition of her sadly skillful surviving attitude and not an example of a healthy, playful “I got you” moment .] Psychotherapist: You’re right; it is interesting how one takes certain things for granted. Thanks for pointing that out. [Verbally and nonverbally accepts the correction ]

Intersubjective The psychotherapist intersubjectively feels “This is going to be exhausting. I will have to time the self-disclosures and enactments very carefully, so as not to become an accomplice of your nonconscious implicit relational invitation for me to be a critic and conﬁ rming my lack of understanding and appreciation of your struggles. This is clearly a way that you implicitly maintain a constant feeling that you will be abandoned by others.”

Patient: Latin helps me a great deal with English, particularly sentence structure and vocabulary in my essays. [Here she seems calm and proud of what she has accomplished, with a sense of ownership and pride .] Psychotherapist : Aha, your talent shines. [Laughing and humbly accepts his mistake about the Latin language ] Patient: I would like to drop the class, but it won’t look good on my resume. I need to think about what to do next as I prepare for college. I hope you notice the fact that I don’t feel I’m good enough for anyone else or for myself. It makes it very easy to have mental breakdowns when teachers point out that I’m not applying myself. The teacher said, “You should have had your translation memorized.” She doesn’t know how stressed I am. She sounds like my mother; I should do what makes her feel better. She’s a nun and everyone calls her “Lucifer.” [The psychotherapist begins to laugh.] I’m not kidding. [She also begins to laugh .] That’s what we have called her for the last 2 years.

Intersubjective The psychotherapist’s intersubjective experiences during this appointment are twofold. Initially he experiences Michelle’s wish to live as strong, demonstrated by her banter and challenging of her psychotherapist about the usefulness of Latin in her future, being college bound. Further, the psychotherapist experiences a sense of mutuality in which she felt safe in disagreeing without being judged or criticized, which did not occur with her immediate family. The psychotherapist 322 13 Two-Person Relational Psychotherapy: High School Age Adolescents stays engaged in the here and now and openly shares his opinion of Latin and appreciates her correcting him, and he is hopeful that this sets the stage for a new and more adaptive form of implicit relational patterns of interaction.

Psychotherapist : By the way, did you ever get the results of the AP history test?

Intersubjective The psychotherapist intersubjectively feels that Michelle was beginning to demonstrate her fragility and that she was tired of self-soothing (e.g., “I am not good enough for anyone else but myself”). The psychotherapist notices being overly worried about the need to be careful and cautious about his comments, self-disclosures, and enactments. He begins to notice feeling tired and wishing for an in-the-moment reprieve to assess the reasons for the experience. To this, he nonconsciously makes a comment that provides the reprieve he was looking for, although this creates a disruption in the fl ow of the intersubjective experience. He subjectively shifts from her comments about her fragility and asks about the AP history test in another class that she was struggling with. Although the question may have been important at some point, during the back-and-forth of the session, his timing was not helpful to the patient. In refl ecting on his intersubjective feelings, the psychotherapist recognizes that he had wanted to verbally help Michelle achieve her academic potential, “talking her out of the feeling of not being good enough.” During the reprieve he is reminded of his own daughter when she was the patient’s age, who felt proud applying herself in her AP classes. The psychotherapist’s tired feelings seem to represent that he was becoming an accomplice to her critical mother and teachers: “Why don’t you apply yourself? If you do it you will be fi ne.” In noticing this, he corrects the disruption. In a traditional one-person model, the psychotherapist’s disruption may be considered a form of a projective identifi cation or a countertransference enactment ( Chap. 6) . He responded to the patient in a manner that was uncharacteristic to him. In such cases, the psychotherapist may fi nd that recognizing his or her reactions as due to transference manifestations from the patient will help him avoid further clinical pitfalls.

Psychotherapist: There I go; I want you to recognize that you can do well in all your classes, as if you didn’t already know. I must be trying to tell you that you can overcome the mental breakdowns. I need to pay better attention to how you feel and see how I can be of best help. [Accepts the temporary role of an accomplice of others—a critic ] Patient : Yeah, my mental breakdowns freak out my mother and grandparents, and they just say, “Get over it.” [She seems to accept the apology and feels comfortable allowing herself to experience closeness in the here and now . ]

Intersubjective The disruption seems to have been repaired by both parties, as at the implicit level the patient experiences the psychotherapist as accepting her psychological problems as serious without losing sight to her accomplishments. The here-and-now interaction occurs in the intersubjective ﬁ eld, and what helps is 13.4 Two-Person Relational Psychodynamic Psychotherapy 323 not necessarily the verbal dialogue, but rather the nonverbal communications: subjective shifts in the tone of voice, facial expressions, and body posture by both. In essence, the psychotherapist conveys, “I made a mistake and let me get back to feeling what you feel,” and the patient responds, “Yeah, I am glad you are not freaking out.” In two-person relational psychodynamic psychotherapy, disruptions in sessions are ubiquitous. They serve as “now moments” when the psychotherapist can reﬂ ect on the reasons for such shifts and recalibrate his or her approach by reviewing what is subjectively being experienced vis-à-vis the patient’s subjectivity of the psychotherapist as it pertains to familiar and maladaptive implicit working models of relation.

Returning to the Same Session

Patient : [Laughing and returns to the AP test question with more of a sense of playful mutuality with the therapist ] Yeah, but I am not saying. Psychotherapist : Really? [Inquisitive playful attitude ] Patient : OK. I am passing, a B+. Psychotherapist : I think I know that may not be good enough for you [Smiling and conveying “I am beginning to know how you think” ] Patient : It’s pretty bad. Psychotherapist : Getting a B+ on a test after a mental meltdown sounds reasonable to me. Sounds like your high expectations are similar to your teacher’s. You just began therapy. Let’s celebrate a B+. Patient : I guess. I had just broken up and didn’t have time to read any of the material. [Feels proud and recognizes her accomplishment ] Psychotherapist : Right. [Acknowledges and with excitement agrees with her reality ] Patient: It is still pretty bad; I should have known the material. [Is aware about self- imposed expectations ] Psychotherapist : Without reading it?

Intersubjective The patient and psychotherapist are intersubjectively in sync again; the disruption seems to have been repaired.

Context The psychotherapist chooses to move along the process by referring back to the important subject of the patient’s mother, as her support was essential for the process to continue. The psychotherapist also remained unclear about what had held their relationship together, albeit fragile, for the last 3 years.

Psychotherapist: If OK with you, I want to get back to what your mother may have said to you after I spoke with her. [Approaches it tentatively and allows the patient to disagree if needed ] Patient : She just said, “I spoke to your psychiatrist.” 324 13 Two-Person Relational Psychotherapy: High School Age Adolescents

Psychotherapist : I felt that she really cared when she called. [Which the psychotherapist feels was genuine. The patient looks annoyed by the thought that her mother cared and attempts to distance herself from the topic .] Patient : [ With the implicit communication that her mother was not attentive or caring ] Oh, she never looks at me or talks to me directly. She doesn’t care. Psychotherapist : The way I’m thinking about it, I will give your mom a thumbs-up for calling me and worrying about you, and a thumbs-down for not supporting you when you arrived home after a mental breakdown with a throbbing headache. Patient : I don’t think she’s ever worried about me. [Conveying it is unlikely that her mother could be affectively attuned] You know my history, right? [Jovial and smiling ] She doesn’t care. She probably calls you because she wants you to yell at me. Psychotherapist : To yell at you about what? [Jovial ] Patient : She is always telling me “You are disrespectful; you don’t obey me.” Let’s see, I bring myself to therapy, I take myself to physical therapy, I get to school and complete my projects, I go to work with my grandfather so I don’t have to ask for any gas money. She never knows what I’m doing; let’s see who’s disrespectful? Psychotherapist : Wow! [ Implicit agreement with her perceptions ] Patient : [ Laughing ] She’s nice to you. Psychotherapist : Not disagreeing with you on that one. Patient : [ Laughs and seems happy] Oh yeah, and on top of that she doesn’t even thank me for doing my own laundry. My mental problems are real. Are you going to tell a person who has cancer to get over it? I guess in America some people don’t believe mental health is real, like my mother. Psychotherapist: You and I agree on that. [ Both laugh] I hope you recognize what a deep thinker you are and how far you can go with those thoughts, maybe even in letting others help you. Patient : [ Shakes her head—she doesn’t agree, although she smiles .] Psychotherapist: I think you underestimate how many people would like to help you feel better. I am one of them. [Attempting to move along the process and using a tone of voice and facial expression that nonverbally encourages her to accept help by others as part of life ] Patient: I don’t believe that one. You have to pretend you care, no offense. [Giggling, although looking somewhat sad] The things I loved in life were taken away from me, I can’t play soccer, I don’t have my girlfriend. [ Sports injuries prohibit her from returning to competitive soccer .] Psychotherapist : Here’s how I think about you in the future. I think that by the time you are 23 years old, you’re going to be happy in a relationship with an outstanding person like you. Patient : [ She laughs and challenges the therapist .] If I’m around. [Alluding to suicide ] Psychotherapist : Fair enough, but what about my thoughts about you being as outstanding in the future as you are now. Will you allow yourself to accept your accomplishments? Patient: I don’t see myself capable of accomplishing anything worthwhile [Starts laughing at the irony of her comments ] 13.4 Two-Person Relational Psychodynamic Psychotherapy 325

Intersubjective The psychotherapist and patient are once again engaged in a lively interaction even though it involves reﬂ ecting on some sad aspects. It also allows the psychotherapist to intersubjectively make comments and be playful about his views of the patient’s future. The psychotherapist feels warmth when the patient obliquely refers to the fact the he cares, although she is playful about the reality that there is implicit asymmetry as she is a patient and he is paid.

Later in the Session

Psychotherapist: Sorry, I’m just feeling really sad that, at times, I just feel you’re a lonely teenager and your family doesn’t see that. Patient : [ She agrees and has tears in her eyes .] That would be correct. Psychotherapist : You had to develop the skill of being self-sufﬁ cient in order to survive the stress of your childhood. [Intended to let her know “I think I know you” and not in the traditional one-person model in making an interpretation to promote insight ] Patient: Yes, the few times I felt close, they abandoned me. I remember telling you on our ﬁ rst appointment that I have abandonment issues. The only person that I really opened up to was Shelby, and, well, you know how that is now. It was my fault I lost her. Psychotherapist : You can feel lonely, but you don’t have to be lonely. Patient : OK, how? [Smiling and being inquisitive ] Psychotherapist: Coming to therapy is one. [She agrees and seems relieved .] The other is letting yourself consider being close to someone again. Patient : No. [Shaking her head ] Psychotherapist : What is the risk? Patient : You really want to know? [ With a smile] Being abandoned again. [Her facial expression captures the fear. The psychotherapist feels intersubjectively that overall she is correct .] Psychotherapist: I think of it this way: If one is hurt when abandoned, it means that we were connected and attached. You want to eliminate both options. Patient : Correct, life makes no sense. Why do you think I hate myself? Psychotherapist : I would like to be one of the many that tries to help you feel better. I am happy you come to therapy and allow me to help, but I also feel that at times I say things, and your facial expression seems to me says, “No thank you.” Patient : Yep, that’s about right. Actually, you have kind of done your job a little bit. Just don’t take too much credit. I still have mental breakdowns. [A moment of meeting intersubjectively ]

Intersubjective There is a moment of meeting in which the patient accepts the psychotherapist’s impression of her, and she also compliments the psychotherapist for moving along the process. In a relational model, it is not necessary to make an effort to verbally discuss what has happened, but rather let the moment of meeting simmer in both. 326 13 Two-Person Relational Psychotherapy: High School Age Adolescents

Later Session in the Treatment

Patient: My mom hates me. [Pause ] She hates me, a teenager that doesn’t clean her room exactly how she wants it to be cleaned. But I would like to say, “Mom, thank God you don’t have a teenager who gets drunk every weekend and is preg- nant at age 16,” like she did. I’ll pull that card to see if she would understand how difﬁ cult it is to be a good student, not do drugs, not drink, not have sex, and not wanting to kill myself. I shouldn’t have to feel bad about my mother. Thanks, mom. [Sarcasm ] Psychotherapist : You really have done quite well! Patient : [ Smiling with a sense of futility ] Psychotherapist : It was a heartfelt compliment. Patient : I know you believe in me, thanks. [Comments made feeling understood and also safe to experience some degree of sadness ]

Intersubjective The psychotherapist intersubjectively feels it is important to be cautious, so as not to repeat her implicit relational patterns where others have high expectations and pressure her to achieve, which he recognizes and is also experiencing. He becomes an active participant of her life and not an observer, which in and of itself would be experienced as a repetition of the feeling of not being likeable or wanted.

Timing Self-Disclosures

Psychotherapist : I think you should consider a career where you have to listen to others’ problems. Patient : I actually am a good listener, but if I had to listen to a teenager like me, I would smack myself. [Laughs at the irony that the psychotherapist is eager to listen to her ] Psychotherapist : Because? Patient: I must be so annoying; I talk about the same things every time I see you. Don’t tell me you don’t ﬁ nd me annoying for not being able to get over my girlfriend and always being stressed [Inquisitive and challenging smile ] Psychotherapist : I am not there. I do not ﬁ nd you annoying. Patient : I’m glad you’re not, but I am there. I sound so annoying. [Points at self. Maybe that is why I am abandoned .]

Intersubjective The psychotherapist self-discloses that he does not fi nd her annoying, which helps move along the process and cocreate another moment of meeting. This comment is considered a countertransference enactment in the traditional one- person school of thought; it gratifi es the patient by answering her question rather that exploring the unconscious meaning of her comment about whether the psychotherapist fi nds her annoying. 13.4 Two-Person Relational Psychodynamic Psychotherapy 327

Working with Parents Intersubjectively

Context The psychotherapist meets with Michelle’s mother on the fourth appointment of the formal psychotherapy process.

Mother: I know I am not supposed to know what she is talking about, and that’s OK. I just want to make sure that you know that she is still obsessed with her ex-girlfriend, and it is not healthy. Psychotherapist : I agree, although when I see Michelle, I am reminded of the early relationships we all have when adolescents: obsessed and infatuated. Somehow feeling the world will come to an end when a loving relationship is over. I am sure you would agree it is complicated. Mother : [ Smiling ] I guess you are right. I met her father and was head over heels until I realized he was abusive. I just know that Michelle is not realistic. Psychotherapist : I am sure that you remember what you did as a teenager when your parents gave you advice about relationships. [ Hoping to cocreate a joining experience in the futility of telling Michelle what to do ] Mother : Yeah, that’s funny; you do the opposite of what they say. I just can’t tell Michelle to stop trying to talk to her ex-girlfriend; I just feel bad that she gets hurt. [The psychotherapist has a genuine feeling that she cares for Michelle, although her approach seems more like a peer .] What should I do? Psychotherapist : How does this sound to you? You let Michelle know that you are worried about her, and when she is ready to talk, you will be there for her. You can model how to help her get over it by not pressuring her to talk about it. Thoughts? Mother : I can do that, but I am not sure she can; she is so manipulative.

Intersubjective The psychotherapist experiences Michelle’s mother as wanting to be caring but is unable to contain her anxiety, as if she wanted matters about mothering her adolescent daughter to be over—a familiar implicit relational knowing from her life. The psychotherapist chooses to gently model, at an implicit level, how to help her not repeat what her parents had done when she was a rebellious adolescent—disapproval, distancing, and abandonment. He intersubjectively feels that she needs concrete tasks outlining how to best parent her daughter.

Psychotherapist : [ In a jovial manner and with humor] I of course know how difﬁ - cult it must be to parent Michelle. I wonder if you think something like asking Michelle to sit down and share the pictures of the projects she has completed at school would work? [The patient had shared pictures with the psychotherapist and shared she had submitted them for a national award .] Mother: I like that idea. It’s kind of funny, because I bought her the camera she uses. I think that would be easier because she has so many projects, and I might not have time to have her tell me about all of them. I have to take care of the little ones, you know! 328 13 Two-Person Relational Psychotherapy: High School Age Adolescents

Intersubjective Although Michelle’s mother verbally alludes to wanting to be available to her daughter, she implicitly wishes for someone else to take over her role as a mother. It is important to note that when working from a two-person relational model of psychotherapy, the goal is not to understand the patient’s or parent’s past object relations in order to understand the present. As an example, from a traditional one- person model, Michelle’s mother’s struggles in being a good enough mother may be understood as a result of her confl icted past object relations: She was abandoned by her own mother when she was 16 years old; she is raising her daughter in the manner in which she interjected her own mother’s pathologic object relations ; and she experiences her daughter as a refl ection of herself as an adolescent. Although these hypotheses may be plausible, in the two-person relational model, attention is placed on the here-and-now experiences from both mother and psychotherapist as they are contextual and unique to their dyad. In this case, intersubjectively the psychotherapist believes Michelle seems more ready and able than her mother to move along her developmental path with the use of a new emotional experience provided by individual psychotherapy. Whether the same patterns would have been present if the psychotherapist were a female or of a different personality style is unknown. Finally, some may suggest that this case could have benefi tted from a joint mother/daughter form of psychotherapy, which may have been reasonable if the psychotherapist had expertise in such a model.

Letting Go

Context The psychotherapist noticed that Michelle seemed to implicitly agree with his perception of her—a bright and talented adolescent.

Patient : [When talking to the psychotherapist about the break up with her girlfriend ] I just realized it wasn’t my fault, it was actually hers. The ﬁ rst time I broke up with her, it was because I didn’t want to be close to anybody. You know, for fear of abandonment. The second time I broke up with her it was because we were constantly ﬁ ghting, and we would go months without speaking to each other. No surprise to you, but I love to be in control when somebody begins to tell me what to do. I guess she didn’t accept me and wanted to change me. [Smiling ] Sounds like my mother, right? [Laughing ] At least she was more caring than my horrible mom.

Intersubjective The process described here is in the early phase of the treatment, and it is too early for the psychotherapist to consider issues of letting go. Nevertheless, due to the patient’s history of frequent abandonments by loved ones, it would be 13.5 Summary 329 important for the psychotherapist to openly discuss about any planned time off so as to not repeat the experience of being abandoned. To this, he may openly share that during his absence, he will miss the appointments and looks forward to resume them upon returning. The patient will beneﬁ t from some self-disclosure about the reasons for being away, allowing her to feel an important contributor to the process. In the two-person relational model of psychotherapy, letting go is generally considered a time of transition to more adaptive modes of relating with others—and open to returning for further appointments if needed—rather than an ending or termination . With this case, we remind the reader of the many implicit and nonverbal interactions that occur between patient, family, and psychotherapist, which are difﬁ cult to capture with the use of written language. Nonetheless, we hope to have provided the reader, at an implicit nonconscious level, a glimpse into the vast amount of nonverbal communication that transpires in a two-person relational psychotherapeutic process, with ubiquitous disruptions and carefully timed moments of meeting.

Postscript

After 4 months of twice-a-week two-person relational psychotherapy, Michelle is improving emotionally and academically and has begun to make friends. Of note, her mother has declined to attend a parent session stating, “Michelle seems better, I don’t think I need to come in. I trust you,” and has also declined to have a session over the phone with the psychotherapist. Sadly, the patient reminds the psychotherapist, “She has abandoned you too,” an example of her mother’s implicit relational knowings.

13.5 Summary

In this chapter, we provide the reader a case example of a 16-year-old adolescent female who has difﬁ culties negotiating her psychosocial development within the context of a critical and dismissive mother and the abandonment by her father. This is hoped to serve as a broad review of the main differences that exist between traditional one-person and two-person relational psychotherapeutic approaches. We provide the reader a case conceptualization from a pluralistic traditional one-person model and follow this with a detailed description of the work that transpired from a contemporary two-person relational psychotherapeutic approach, with attention paid to the patient’s and her mother’s temperament, cognitive and affective ﬂ exibility, and internal working models of attachment within the context of the psychotherapist’s intersubjective experiences. 330 13 Two-Person Relational Psychotherapy: High School Age Adolescents

References

Delgado SV, Strawn JR, Jain V (2012) Psychodynamic understandings. In: Levesque RJR (ed) Encyclopedia of adolescence. Springer, New York, pp 2210–2218 Fraiberg S, Adelson E, Shapiro V (1975) Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry 14(3):387–421 Giedd JN, Blumenthal J, Jeffries NO et al (1999) Brain development during childhood and adolescence: a longitudinal MRI study. Nat Neurosci 2(10):861–863 Reyna VF, Farley F (2006) Risk and rationality in adolescent decision making implications for theory, practice, and public policy. Psychol Sci Publ Interes 7(1):1–44 Supervision 1 4

The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed. —Carl Jung

In contemporary psychiatric practice and training, “ supervision ” consists of regular meetings between a supervisor —typically a psychiatrist with experience in the subject—and a supervisee , often a trainee. The meetings between supervisor and supervisee typically involve matters regarding patient care. To this, they may choose to review relevant scientifi c literature, discuss pharmacological approaches, or use clinical material to formulate diagnostic interventions about a psychotherapy process. In regard to the psychotherapy process, the supervisor attends to what has transpired between the supervisee and his or her patient, with the goal of providing guidance for how best to proceed in terms of moving along the patient’s psychotherapeutic treatment. However, the process of psychotherapy supervision has evolved considerably over the last 50 years due to the introduction of the concepts from two-person relational psychology and based on the fi ndings from neurobiology and developmental psychology as discussed in Chap. 3 . Thus far, these concepts have been studied and disseminated mainly by psychologists and social workers; it is our hope that with this book, we can bring the concepts of relational two-person psychology, including psychotherapy supervision, to the attention of young child and adolescent psychiatrists and psychotherapists. In this chapter, we begin our discussion of the supervisory process with a brief review of the traditional one-person model as it relates to supervision, followed by a review of the supervisor’s use of a relational two-person psychology model and the supervisee’s experience. Accordingly, we hope to provide an in-depth understanding of the different ways in which contemporary theoretical concepts can infl u- ence the process for both the supervisor and the supervisee. To create a “good

© Springer-Verlag Berlin Heidelberg 2015 331 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4_14 332 14 Supervision supervisor–supervisee ﬁ t,” it is important for supervisors to be well versed in the supervisory model and to tailor their teaching styles to the learning style of the supervisee and not vice versa (Carol 2010 ). Finally, this chapter provides a guide for the supervisee on what to expect from supervisors who utilize a contemporary relational approach. It is our hope that child and adolescent psychiatrists or clinicians who have trained in an academic institution where psychodynamic and relational concepts are part and parcel of the understanding and treatment of their young patients will make use of this book as they begin their journey toward becoming a well-versed supervisor.

14.1 Historical Background of Psychotherapy and Core Psychotherapy Competencies

The Accreditation Council for Graduate Medical Education (ACGME) has developed a series of core competencies that need to be acquired by child and adolescent psychiatry trainees. These include six general competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) (Andrews and Burruss 2004 ). In 2001, the Residency Review Committee (RRC) offi cially mandated psychotherapy training for psychiatry trainees, which included competency in fi ve core modalities of psychotherapy: (1) supportive psychotherapy , (2) psychodynamic psychotherapy, (3) cognitive behavioral therapy (CBT), (4) brief psychotherapies, and (5) combined medication management and psychotherapy. Additionally, exposure to family therapy, couples therapy, group therapy, and other evidence-based psychotherapies was also introduced as a requirement (Tucker et al. 2009 ). Nonetheless, it was recognized that fi nding trained faculty to teach all fi ve psychotherapy competencies was diffi cult. By 2007, it was clear that interest in psychotherapy had declined and the RRC made updates to the core psychotherapy competencies, which included reducing their required training to only three areas: psychodynamic therapy, CBT, and supportive therapy. Meanwhile, the training in family and group psychotherapy remained in the form of exposure only (Tucker et al. 2009 ) which is unfortunate in many ways. Of note, it limits the number of newly minted child and adolescent psychiatrists who are well versed in family and group therapies, which is an important, complex, and daunting task when working with children and adolescents, which benefi ts from training. In addition, it requires trainees to devote more time to pharmacological interventions, and it encourages referrals for psychotherapy to psychologists and social workers who have limited collaboration with the busy trainee due to the time constraints of training. Of interest, the American Psychiatric Association (APA) committee on psychotherapy developed the Y model for the use in teaching the three competencies required by the RRC (Plakun et al. 2009 , see Fig. 14.1 ). The model is effi cient, integrated, and evidence based, and it avoids pitting one form of psychotherapy against another. According to Plakun, “The place where psychotherapy education 14.1 Historical Background of Psychotherapy and Core Psychotherapy Competencies 333

Fig. 14.1 Eric Plakun’s Cognitive- Psychodynamic Y model of psychotherapy behavioral (Adapted from Plakun et al. (2009 ) )

Diagnostic formulation Defined boundaries Therapeutic alliance Empathic listening

Common factors begins in residency is conceived of as composed of the shared elements of psychotherapy across schools. Located among the shared elements are the current brief, supportive, and combined medication and psychotherapy competencies” (Plakun 2006). In the Y model, the stem consists of the core processes that are identifi ed as being common to all forms of psychotherapy: empathic listening; identifying dysfunctional patterns; developing a formulation; and attending to issues of boundaries, confi dentiality, crisis management, and involvement of signifi cant others. The Y model assumes that psychotherapy unfolds within the context of a therapeutic alliance (Plakun et al. 2009 ). The two branches of the Y model involve teaching specifi c aspects of CBT and psychodynamic therapy. Unfortunately, there are experienced cognitive and behavioral psychotherapists that openly reject psychodynamic psychotherapy for not being evidence based, which leads trainees to have confusing and unsettling experiences about the benefi ts in all forms of psychotherapy.

Psychotherapy Supervision as a Core Competency

The American Board of Psychiatry and Neurology (ABPN)—in association with the Accreditation Council for Graduate Medical Education (ACGME) and the American Academy of Child and Adolescent Psychiatry (AACAP)—recognizes psychotherapy supervision as a core competency in the treatment of children and adolescents. This provides the acquiring of clinical skills in major treatment modalities, which include brief and long-term individual therapy, family therapy, group therapy, crisis intervention, supportive therapy, psychodynamic psychotherapy, cognitive behavioral therapy, and pharmacotherapy. As Mellman and Beresin ( 2003 ) state, “[Psychotherapy supervision’s] eminence in psychotherapy education seems well established and well assured.” Watkins and Scaturo (2013 ) add, “Psychotherapy supervision has long been and remains a critical means by which the culture of psychotherapy is taught and perpetuated.” However, as Cardoso Zoppe et al. (2009 ) state, “There is still tension between biological and psychosocial tendencies,” and they go on to highlight that current teaching methods for 334 14 Supervision trainees routinely lack integration regarding the many elements of what is helpful to patients, due to the fact that the supervisors are inﬂ uenced by the setting in which the patient is seen, and their school of thought. Every trainee and every supervisor have a theory of cure that guides his or her approach. It is important for the supervisor and supervisee to understand what theory the supervisor is working from in order to be able to talk openly about its role in the current state of psychotherapy. Therefore, it is important to support and educate our supervisees about the value of an integrated approach in a world of Diagnostic and Statistical Manual of Mental Disorders , 5th Edition (DSM - 5 , APA 2013 ). Most supervisees are eager to learn about psychodynamic and relational theories if we demonstrate excitement in applying and teaching these dynamic concepts throughout their training. As Reiss and Fishel (2000 ) state, “Psychotherapy supervisors now represent only the residual backbone of psychotherapy programs. The importance of what these supervisors teach and how they teach it has never been greater as the time devoted to teaching the art of psychotherapy diminishes, and the trainee has fewer settings in which to learn the principles of psychodynamic psychotherapy.” Although the process of supervision continues to be embraced by many, it is also important to note that many outstanding psychiatrists and other clinicians have declined to supervise trainees in psychotherapy. In this regard, many have limited their supervision to pharmacological aspects of treatment. This trend parallels a larger trend over the past decade in which psychiatrists have reduced the time spent practicing psychotherapy (Mojtabai and Olfson 2008 ). We hope that our efforts serve to contribute to the enthusiasm of teaching the art of psychotherapy and supervision.

14.2 Becoming a Supervisor

The process of becoming a psychotherapy supervisor is an important developmental step for child and adolescent psychiatrists and psychotherapists. Moreover, this process is seen as an integral part in shaping future clinicians. As Berger and colleagues (1990 ) note, “The supervisory relationship is the main way that trainees develop their identity as psychotherapists.” A supervisors’ development of knowledge and skill is critical to their role as a mentor (Angus and Kagan 2007 ). Following the completion of his or her training, a newly minted child and adolescent psychiatrist may be asked to become a supervisor in psychopharmacology, consultation liaison, or psychotherapy. Some training programs may require recent graduates to take a course on supervision before they begin to supervise, while others may utilize ongoing supervisor conferences, and still others have no prerequisites. Needless to say, this important process in the formation of our future clinicians has not been standardized. In a recent discussion by the lead author with medical students and child and adolescent psychiatry trainees, they noted that they had little exposure to psychodynamic psychotherapy and that they were not aware of child psychiatrists who continued to practice such a form of treatment. 14.2 Becoming a Supervisor 335

Supervision: From a Traditional One-Person to a Relational Two-Person Model

The process of psychodynamic supervision has evolved considerably, from a foundation rooted in Freud’s structural and drive theories and Klein’s object relations theories to a more contemporary understanding informed by temperament, attachment, developmental psychology, neuroscience, and relational theories.

Supervision in a Traditional One-Person Model

Any discussion of psychotherapy supervision , particularly with regard to traditional psychodynamic tenets, requires a brief foray into the role of psychodynamic thinking within training programs. Traditional one-person psychodynamic psychotherapy has been taught in psychiatry training programs since the 1940s and is based on ﬁ ve fundamental assumptions: (1) a central importance of the unconscious in mental functioning, (2) the symbolic meaning of behaviors, (3) the existence of internalized unconscious conﬂ icts, (4) the idea that symptoms have meaning, and (5) the belief that transference-based thoughts and behaviors are critical to understand and help the patient change by overcoming the developmental interference on the emotional growth process ( Delgado et al. 2012 ). The traditional one-person supervisor runs the risk of being seen as an omniscient observer whose function is to enlighten the supervisee (Yerushalmi 1999 ).

Critiques of the Traditional One-Person Approach to Supervision

As discussed in Chap. 6, we have colleagues who continue to supervise trainees using the traditional one-person model. They perpetuate the archaeological inquiry of a child or adolescent patient’s unconscious inner life through the use of play, transference issues, and the interpretation of dreams. This form of inquiry allows the clinician to clairvoyantly know the patient better than the patient himself. Also, traditional one-person model supervisors give importance to oedipal conﬂ icts in elementary school age children and the loosening of the regressive parental ties in adolescents. Orange et al. (1997 ) state that this view represents a rather Cartesian approach in the understanding of our patients. This does not take into account the many important aspects of the patient’s and their family’s temperament and innate working models of attachment—nature—nor the important contribution from their environment, nurture, in forming their personality. It is unfortunate that supervisees learning about psychodynamic psychotherapy are generally not exposed to a relational two-person model, and if so, it is usually in the form of a minimal amount of lectures with the implication that it is not relevant or important for the child and adolescent psychiatry trainee to learn. It has become a problem in which those who adhere to the traditional one-person model often 336 14 Supervision criticize the relational two-person model without a thorough understanding of it. Further adding to this problem is that in some training programs, trainees are expected to complete the Psychodynamic Psychotherapy Competency Test (PPCT), a 2-hour multiple-choice exam that is administered once a year during their training and is based on traditional one-person model concepts (Mullen et al. 2004 ). In doing so, training programs imply what is correct and thus limit the trainee’s ability to learn about the importance of developmental research in regard to psychotherapy and have the freedom in deciding which model is best for their patients.

14.3 The Two-Person Relational Model and Its Relevance to Supervision

Over the last 30 years, with the emergence of a two-person relational psychology, there has been a signifi cant shift in the understanding and treatment of a person’s psychological problems—from intrapsychic and object relations confl icts to problems of internal working models of attachment, affective attunement, and implicit relational knowing. This shift has led to treatment interventions that focus on the bidirectional here-and-now subjectivities continually modifi ed by the reality of both persons, known as intersubjectivity. Supervision in psychotherapy is inherently bidirectional; the supervisor must be open to teach the supervisee as well as learn from the supervisee. In a relational two-person model of psychotherapy, the terms “cocreate” and “ intersubjectivity ” are sine qua non to the theory and technique. They refl ect the active participation by both patient and psychotherapist in the encounter, with continuous and novel changes created from each other’s nonconscious subjective experiences (Fig. 14.2 ). We offer Kierkegaard ’s quote as a reminder of our task in two-person relational psychotherapy supervision: “Instruction begins when you, the teacher, learn from the learner, put yourself in his place so that you may understand what he understands and in the way he understands it” (Kierkegaard 1998 ). Undoubtedly, the notion of a two-person, relationally based psychodynamic model of psychotherapy was not well received by supervisors of the traditional one- person psychoanalytic model, as it challenged the legitimacy of its tenets. As stated by Friedman (2010 ), “Many classically trained psychoanalysts may in their actual practice incorporate changes that have been advanced by relational psychoanalysis, [although] their basic stance remains unchanged.” As Frawley-O’Dea ( 2003 ) aptly states, “The relational supervisor holds that it is crucial to live out mindfully with the supervisee and eventually to make explicit with him relational patterns set in play within their relationship.” The relational two-person model has gradually become a concept that most psychodynamic psychotherapists must contend with, as it has served as an umbrella for several forms of psychotherapies that endorse implicit or explicitly well-timed self-disclosures and enactments (e.g., mindfulness, dialectic, cognitive, patient centered). However, training programs have struggled with a lack of experienced faculty who are qualifi ed and able to teach the complex and specialized courses needed to learn, embrace, and apply the relational two-person model. As such, for a trainee to 14.3 The Two-Person Relational Model and Its Relevance to Supervision 337

Two-Person Relational Supervision

Child + Family Supervisee Supervisor

- Case conceptualization Meaning making - Share prior supervisory experiences - Safety and spontaneity Social referencing - Conveygoals hoped to achieve - Help move along the process - Describe patient as a real person Temperament IF IF - How to time enactments Cognition - Share intersubjective experiences and self-disclosures Cognitive ﬂexibility - Bring doubts and concerns - Review video and audio recordings - Comfortable sharing diﬃcult moments - Assign readings -Working with parents or caregivers

Co-create now moments Ruptures (Non-declarative)

Implicit relational knowing New more adaptive emotional experiences Co-created moments Repairs of meeting

Fig. 14.2 Schematic representation of the intersubjectivity during a supervisor and supervisee encounter. Learning occurs in the intersubjective ﬁ eld (IF), the overlap of subjective experiences. Bold arrows in the IF represent here-and-now moments of meeting begin to master relational psychodynamic psychotherapy, the two-person model must be incorporated early in adult psychiatry training and continued in child and adolescent psychiatric training, and the trainee must be continually open to observation and discussion about the applicability of the theories to practical day-to-day patient care, whether it be on the inpatient unit, in the outpatient clinic, or on the consultation service. Additionally, regarding the art of two-person relational psychodynamic psychotherapy, the abilities to observe and share details about patients—to follow ongoing “threads” of subjectivities and make inferences of implicit relational patterns—are often passed down by experienced faculty orally and subjectively through their work. The importance of this form of teaching cannot be emphasized enough; it is not only teaching the “art” but also providing the men- torship needed for the next generation of colleagues. Reiss and Fishel (2000 ), in reviewing the literature on supervision, observe that “without adequate preparation, supervisors run the risk of boundary violations, breaching ethical codes of conduct, destructive reenactments, restrictive practice styles that limit the growth of their supervisees, inadequate coverage of the basic tenets of psychodynamic practice, and occupational ‘burnout.’” In this regard, we have known colleagues who were not well versed in relational psychodynamic tenets and declined to help the supervisee further learn these concepts. They often would state: “Relational is just a new word for what we already have a theory for. It is not that complicated; you just need to be empathic with your patient.” This could not be further from the truth. Supervision in a two-person relational model is not 338 14 Supervision only gratifying, it can also be difﬁ cult in helping supervisees overcome their anxieties when asked to become active and present in the psychotherapeutic process. The complexities of supervising psychodynamic psychotherapy are eloquently described by a colleague in a clinical case presentation on supervision:

In the beginning of a supervision, I try not to give any directions as to what the supervisee should or should not do—bring notes or not, stick with presenting one patient or not. I am curious about how the supervisee will organize him or herself in relation to the task of learning. Once I’ve understood the ways in which they do this, for better or for worse, I may suggest modiﬁ cations. For the obsessional supervisee hiding behind her notes, I may suggest she not bring them, explaining that I would like to hear how she ﬁ lters the information from her patient through her own psyche rather than rely on a per verbatim report. For a vaguer and more loosely organized supervisee, I may suggest he bring notes to better understand the interactions.

14.4 The Two-Person Relational Supervisor

At the outset of supervision, the supervisor should show his or her vitality and curiosity about the supervisee ’s previous educational and supervisory experiences: How does the trainee feel that his or her training is going? What have been their previous supervisory experiences (including the good and bad)? What does the supervisee consider his or her strengths and weaknesses as a psychotherapist? What would he or she most like to learn from the supervision? The answers to these questions will orient the supervisor with regard to his or her approach to the supervisee. The foundation of any good supervision, from a relational perspective, will include a review of the patient’s biological, psychological, and social history—as well as consideration of the internal working models of attachment used when relating to the psychotherapist—and a determination whether the supervision is for crisis intervention, relational psychotherapy, family process work, cognitive behavioral therapy, etc. Moreover, fl exibility and the ability to allow intersubjectivity to infl u- ence the supervisory dyad are of paramount importance, as described by Kernberg ( 2010 ): “I have found it very helpful to vary the intensity and rhythm of my contributions to the supervisory process, ranging from periods in which I might very actively try to convey information and infl uence the therapeutic process, to those in which I might sit back and position myself on the receiving end as I listen to what is going on with the patient, and to what new contributions the therapist may make.”

Goals for the Relational Supervisor

• The supervisor should be well versed in the theories that he or she is asked to supervise. • The supervisor must openly disclose his or her goals and objectives and should also disclose areas of limitation. 14.5 Case Conceptualization in Two-Person Relational Supervision 339

• The supervisor should encourage the supervisee to share his or her expectations of the supervision process. • The supervisor should carefully ascertain the level the trainee is at with regard to his or her development as a psychotherapist. • The supervisor must establish an atmosphere of safety for the supervisee to feel comfortable to present case material, as well as raise issues that he or she would like to further learn. • The supervisor—if at all possible—should openly encourage the use of video and audio recordings by the supervisee. • The supervisor should review theories that ﬁ t the patient’s needs and should be willing to explain differences between relational models (self-disclosure and enactments) and traditional models (boundaries) and cognitive therapies. • The supervisor should highlight legal and ethical issues when appropriate. • The supervisor should suggest readings that are pertinent to the cases that are being supervised. • The supervisor should encourage and facilitate the supervisee’s work with the patient’s parents or caregivers. • The supervisor should provide and request feedback about the supervisory process every 2–3 months.

Limitations to a Two-Person Relational Supervisory Approach

Some relational supervisors often continue to teach with concepts remnant of the traditional one-person psychology, a tendency that may be attributable to limited exposure to and reading of contemporary relational literature. This generally inter- feres with the trainee’s ability to develop a solid foundation of each theory.

14.5 Case Conceptualization in Two-Person Relational Supervision

Case conceptualization is of central importance in any psychotherapeutic work, regardless of modality. In relational supervision, it represents a careful scaffolding of the patient’s innate and environmental strengths and weaknesses with regard to the development of their personality. Neufeldt (2007 ) notes that the case conceptualization is a crucial component of psychotherapy supervision: “Without a sound case conceptual framework, supervision can become rather haphazard.” The relational supervisor will remind the supervisee that uncertainty is ubiquitous to relational psychotherapy. That is, in case conceptualization it is more about determining what the patient needs in order to develop more adaptive patterns of interaction rather than necessarily needing to inquire as to what created these patterns. In using intersubjective experiences, the supervisee can help cocreate new emotional experiences for both the patient and his or her parents or caregivers. 340 14 Supervision

It is common for the supervisee to initially conceptualize their psychotherapy patients in a traditional one-person model. In such instances, the supervisee may make broad statements such as “The patient is attention seeking and is splitting his parents as all good or all bad” or “The parents are intrusive, hostile, distant, and unable to mentalize the patient’s state of mind.” In essence, this type of case conceptualization represents a traditional one-person approach, as the supervisee ﬁ rmly believes that he or she knows the patient through the hypothesis developed in observing a child’s play or listening to their verbal narrative, which is considered to represent the truth.

The Supervisee Who Remains Loyal to a Traditional One-Person Model Jamie, a 10-year-old girl, comes for the treatment of her shyness and anxiety. Her mother shares that Jamie performs well academically, although she has problems in getting ready to go to school and avoids interacting with her peers at school. In contrast, she is very jovial, happy, and talkative when with her parents, older siblings, and cousins. Jamie’s parents are healthy and very social and are bafﬂ ed by their daughter’s anxiety. The female supervisee shares with her relational supervisor that her case conceptualization of Jamie considers her as “having problems with preadolescent issues. Her shyness and anxiety are a defense due to her fear in speaking up, as she assumes that her parents will be disappointed in her if she expresses her anger. She shared that her parents have high academic expectations on her.” Further, the supervisee believes that the parents come across as demanding and high achievers and that Jamie is likely correct in her perception of them.

In supervision, the relational supervisor helps the supervisee develop a case conceptualization from a relational perspective by using the same material.

1. The supervisor shares that he was struck that the patient was very verbal and not shy with the supervisee. The supervisor shares that by her description of the interactions, he subjectively felt that the supervisee was at ease and enjoying the process. He uses this to encourage the supervisee to notice that her patient seemed comfortable relating with her, although the supervisor subjectively felt the supervisee was describing an interaction akin to that of with a friendly adult. This allows the supervisee to reﬂ ect that the patient’s internal relational model when interacting with her was suggestive of an implicit comfort of dialogue with adults and not peers. The supervisor follows this with a discussion about the fact that the supervisee’s interaction with the child seemed to be more likely to be found with an older age child. The supervisee subjectively recognizes this and states: “That’s right. I noticed that I was experiencing her like a little adult. I wasn’t sure if she was comfortable playing, so we just talked.” This provides the supervisor an opportunity to review the importance for the supervisee to gently, and over time, provide Jamie a new emotional experience in the form of playfulness that she seemed to implicitly lack. 14.5 Case Conceptualization in Two-Person Relational Supervision 341

2. Later the supervisor wonders about what subjective experience the supervisee had of Jamie’s parents. This was to encourage the supervisee to use her intersubjective experience of the parents as a tool of whether they in fact were demanding and had high expectations of their child. The supervisee smiles and states that, to the contrary, she had found the parents as very loving and accommodat- ing toward Jamie: “They make sure she has plenty of time to get ready for school, and they go with her and let her know that they hope she can also have fun with her peers at school. They are very warm and caring but deﬁ nitely not playful.” This allows the supervisee to appreciate how she had cocreated with Jamie a negative perception of her parents, when in fact they were caring, and the reasons for their limited playfulness with Jamie remained unclear. This also allows for a discussion about the cultural aspects that may have been contributing to the implicit importance placed on education over play in the family. 3. The supervisor asks, in light of the new case conceptualization, what the supervisee subjectively feels would be helpful for Jamie. He adds that he subjectively had felt that the supervisee had not been her playful self with Jamie and wondered if she would consider letting her patient know in the here and now how she felt. She openly states, “I like her parents, and I think they will understand the importance of play, if I am sensitive to their cultural norms.” The supervisor reminds that only the supervisee’s subjective experience of Jamie and her parents, in vivo, will let her know if the approach “feels right to all involved.”

By contrast, a supervisee who is experienced in a relational two-person approach can focus on how he or she feels subjectively with their patient in order to discern the temperament and internal working models of attachment being used in the here and now. He or she can then formulate a case conceptualization that helps cocreate new, more adaptive experiences.

The Supervisee Who Works in a Two-Person Relational Model Jake, a 12-year-old boy, stated that his parents were mean and always ﬁ ghting. The female supervisee’s intersubjective experience of Jake was that he was not genuine and believed that he seemed to be exaggerating his complaints, as she had met the parents and found them to be likeable and caring toward Jake. In the here-and-now moments with Jake, the supervisee experienced him as treating her “as if I am a person he just met in the street. No real affective connection with me.” The supervisee shared that it took effort to be able to play and talk with Jake at his level. She used her intersubjective experience as a guide about his likely developmental and emotional delays. She felt this was further conﬁ rmed when she told Jake that she would be meeting with his parents the next session, and he became upset and angrily said, “You’re going to take my parents’ side.” She recognized that intersubjectively he felt that he was in trouble when she mentioned meeting with his parents. This likely implicitly reminded him of the many times his parents were called after his 342 14 Supervision

negative interactions with others, due to his misinterpretation of information from his cognitive deﬁ cits. She replied with a melodic, jovial, and calm voice, saying, “Jake, I want to take your side and help you feel better so you don’t always think that you are in trouble.” He responded by thanking her for helping him not be in trouble, “Nobody likes me.”

The supervisee shares that intersubjectively she feels that the patient’s parents— like her—“don’t know what else to do to help him.” She considers helping the parents begin to communicate actively with teachers and develop a behavioral plan to avoid his meltdowns. She adds that his parents are exhausted and frustrated that, cognitively, “the poor boy, he just doesn’t get it.” The relational supervisor helps the supervisee appreciate that her efforts in keeping the psychotherapy process in the here and now and at Jake’s developmental and emotional level have begun to provide elements of a new and corrective emotional experience—“He seems to begin to think together with you about what it feels to him being in trouble.” Moreover, in applying information about temperament, cognition, and internal working models of attachment, the supervisee has begun to consider that she will (1) obtain a thorough developmental history about his temperamental attributes, as she experiences him to have a feisty/difﬁ cult style and subjectively feels that his cognitive limitations impede what relational psychodynamic psychotherapy could provide; (2) discuss with his parents Jake’s potential cognitive weaknesses, which may explain his distortions of others’ intentions; and (3) discuss the need for formal cognitive testing to develop realistic behavioral, academic, and psychotherapeutic interventions. Additionally, Delgado (2008 ) states: “Although young residents and therapists have many theoretical choices regarding how they understand a case, or how they intervene, one important fact to remember is that our comments are only helpful if they make sense to the child. Once a child feels understood, she will guide us about what language to use and with which issues they need help.” Finally, it is critical for supervisors to have, without defensiveness, their own case conceptualizations of their supervisee’s patients. In short, this facilitates a two- way exchange of subjectivities in vivo. Such an approach will implicitly allow the supervisee to experience the curiosity and spontaneity that he or she will ultimately incorporate into his eventual role as a supervisor.

14.6 The Supervisee in Two-Person Relational Supervision

Child and adolescent psychiatry trainees begin psychotherapy supervision during the course of their general psychiatry residency, and in many ways their experience in supervision is not only affected by their own theoretical background and prior clinical experience with patients but also, importantly, by their previous supervisory experiences (Berger and Buchholz 1993 ). By the time they begin supervision in 14.6 The Supervisee in Two-Person Relational Supervision 343 their child and adolescent psychiatry training program, they have had nearly 3 years of supervision experience with other supervisors. In relational psychotherapy supervision of child and adolescent psychiatry trainees, we commonly hear their anxiety when they are not sure what, or how much, is appropriate to self-disclose during the process with the child or adolescent. Common statements are “I don’t want to interfere with what the child thinks is important” or “I am worried that they won’t like me if I say something wrong.” Needless to say, we have all gone through this phase of anxiety when beginning a psychotherapy process with children. In the relational two-person model, anxiety can be put to good use by educating the child or adolescent psychiatry trainee that they are not alone—the patient also struggles with the anxiety in being with them (Maroda 2010 ). Relational supervisors generally suggest that when the supervisee plans to openly share their impressions of the patient’s play or narrative, they would beneﬁ t from stating, “Let’s think together,” which allows for a new emotional experience and sets the stage for implicitly learning to ask for help from others. In essence, it is cocreating, in the here and now, a more adaptive way of managing the complexities of their life. It may be difﬁ cult for supervisees to understand that the patient’s improvement occurs at an implicit level and may occur in the absence of verbal feedback from the patient during sessions. In the relational model of supervision, it “strives to free those in training to use their minds and voices to challenge as well as to learn from those who have gone before them” (Frawley-O’Dea 2003 ).

Using Intersubjectivity in Two-Person Relational Supervision

As we have discussed, intersubjectivity is a critical aspect of two-person relational psychotherapy, and it plays an equally important role in supervision. Supervisees’ case formulations combine subjective and objective knowledge of their patients (Yerushalmi 1999 ).

Intersubjectivity with a Supervisor, a Supervisee, and His Patient A 10-year-old boy was treated in relational psychotherapy by a child psychiatry trainee to master his anxiety and fearfulness. The trainee, in supervision, shared that he saw the child as having an ambivalent/anxious attachment style because when he encouraged the boy to reﬂ ect about his worries, “he would shut down.” The supervisor, of a relational two-person school, had the intersubjective experience during the supervisory hour that the trainee in presenting the case material seemed anxious. He seemed to be playing out the child’s apparent ambivalent/anxious attachment style. The supervisor had the subjective experience that the trainee seemed to have cocreated a mutually anxious experience with the patient. The supervisor felt that what may best help both the patient and the trainee would be to demonstrate in vivo how to use intersubjectivity to access internal working models of attachment in both the 344 14 Supervision

trainee and the patient. In doing so, it would provide the blueprint for new emotional experiences. The supervisor, with sensitivity to the trainee’s anxiety, shared that he thought that joining them in a session to observe and participate in order to teach about intersubjectivity live could benefi t the process. The trainee noticeably became anxious and fearful about why the supervisor may want to join the session. The supervisor shared, “I would like to demonstrate how to use relational concepts in psychotherapy, and you and your patient can be my consultants about whether it is helpful or not.” To this the trainee recognized the atmosphere of mutual curiosity created by the supervisor and stated that he needed help in “getting better in play therapy” and appreciated the supervisor’s willingness to join and be open to feedback from his and his patient’s comments. In short, both trainee and supervisor cocreated a moment of meeting (Chap. 5 ) to move along the supervisory and psychotherapy processes. They agreed that the supervisor would join in the next session. In the next session, the trainee introduced the supervisor to the patient openly, saying, “He is going to help us help you feel better.” The three proceeded to play the board game Chutes and Ladders, typical for children from 3 to 7 years old. The supervisor noticed intersubjectively that both the child and the trainee were playing in the same superfi cial and nonplayful manner the trainee had described in supervision. The supervisor also experienced intersubjectively both being anxious while playing; it seemed that the trainee was comfortable being with the patient but avoided sharing his here-and-now experiences, fearing it would make the patient more anxious. When it was the supervisor’s turn to move, and in refl ecting on 10-year-old developmental milestones, he noticed that the child was quite bright but lacked the confi - dence in enjoying play, demonstrating independence, or challenging rules. He then proceeded to move and pass the child’s and the trainee’s pieces, knocking them over and saying in a cheerful although somewhat sarcastic manner, “Excuse me, I am just lucky to pass you two, and I thought, ‘Hmm, it just seems fun to knock you both over.’” Surprisingly, both the child and trainee looked at each other for a few seconds and began to laugh and make fun of the supervisor’s move. In this moment of meeting, the child engaged in social referencing and looked at the trainee for implicit permission to retaliate toward the supervisor’s piece as he was next to move. The trainee got the implicit request from his patient for permission to act like a 10-year-old, and with clear affective attunement to the child’s emotional state said, “Yeah, let’s go get him.” They continued laughing and enjoyed knocking over their pieces, and the child demonstrated his eagerness to play. It had become more important to for the trainee to be genuine with the patient, play and laugh together rather than to anxiously play by the rules base on the trainee’s anxiety. 14.6 The Supervisee in Two-Person Relational Supervision 345

From this vignette, we can see three important elements, characteristic of relational two-person psychology , as they relate to the supervision process:

1. The trainee had focused his efforts on establishing a therapeutic rapport with the child with caution rather than on outwardly introducing his intersubjectivity because he had conceptualized the case with a traditional one-person model. In other words, he felt there was a need to fi nd the “buried treasure” in the past that held the key to what led to the child’s anxieties. 2. The initial description by the trainee that the child had an ambivalent/anxious attachment style was not only what he observed but also what he contributed to the child’s reciprocity. As seen in the play between the child and trainee, when they joined forces and decided to team up against the supervisor in the session, it could be said that their observed attachment styles were safe and secure and with mutuality. Therefore, it is important to know that when working with children and adolescents, observed attachment styles are infl uenced by our personal proclivities. If the trainee would have been overconfi dent—using an intellectual approach to the problem and applying cognitive behavioral principles to conceptualize the case—he may have been able to take an active role in directing the child as to what the child should do to feel better. We can only speculate what path the child may have taken to interact with the trainee’s intellectual approach. For example, he might have withdrawn due to the intensity of affect in the room and appeared to be of an avoidant/dismissive observed attachment style. In stating that a child has observed behavior typical of a secure, ambivalent/anxious, avoidant/dismissive, or disorganized attachment style, this is only partially correct. We recommend that when referring to the attachment styles of patients, they should be noted as such: “The observed attachment style of the patient with me is [specifi c style]. I notice that this style changes to [alternative style] when he or she notices that I am [sad, angry, or tired] or when the patient is with [different person].” This allows noticing the important shifts in relational patterns that may provide clues about the internal working models of attachment and intersubjectivity of the patient that seem maladaptive. 3. The relevance of the interaction between the trainee and supervisor in this case is not refl ective of a standardized cookie-cutter approach to supervision. It is a relationship in which both parties are infl uenced by the patient, although in different manners. The trainee brought into the supervisory hour the patient that he remembered subjectively, which clearly is not the full picture. Unlike in the case of the 10-year-old boy, not all supervisors are willing to demonstrate how they work in front of their trainees knowing that they will be scrutinized. Likewise, in good relational supervision, the fear of how the trainee may feel if their work is intruded upon should be discussed openly, as this can only occur if there is a mutual sense of collegiality and safety cocreated during the process. 346 14 Supervision

Lying in Supervision: A Two-Person Relational Approach

Lying by supervisees is not a new concept. Supervisees lie to their supervisors for many reasons. Among psychotherapy supervisors, some think that “lying” may be too strong a word, and rather it is best to think of the supervisee as leaving things out until they feel safe enough and knowledgeable enough in the supervisory relationship to know it is safe to share their thoughts and actions ( Jacobs et al. 1995 ). We know that many of our young colleagues fear being judged and that there is a high likelihood they at times have edited out material—or simply lied—to their supervisors. Gabbard writes about lying to his supervisors during his psychoanalytic training ( 2009 ). Hantoot ( 2000) eloquently states: “Lying in psychotherapy supervision represents a failure on the part of the trainee to manage his or her impulses and affects in more adaptive ways. Such a failure may refl ect limitations in a particular trainee’s capacity to manage affects, as well as being a result of inadequate external supports. The ability of the supervisor to provide an adequate holding environment in the face of the regressive pressures of training is a key factor in avoiding the pitfalls associated with misrepresenting case material.” It is known that when the supervisee s edit the material taken for supervision, it is likely due to their knowledge of the supervisor’s preferred school of thought and a fear of being criticized for their actions if they are not consistent with the supervisor’s theoretical preference. Thus, at times, they learn how to present case material that may be praised rather than present material they are struggling with. This is similar to when patients implicitly learn what their psychotherapist is more likely to attend to when a traditional one-person model is used, be it dreams, confl icts, or transference issues. That is, the supervisee and the patient alike learn what is valued by the person that has been given the task of helping them understand the human mind. The supervisee may learn that process notes please the supervisor, just as the patient learns that dreams please the psychotherapist. They use this knowledge to share what they have implicitly learned is important to the other person, in order to please. The supervisee who is immersed in relational two-person psychology, when supervised by a traditional one-person supervisor, may be subject to criticism. This could include comments such as “Your approach is too supportive and will not lead to insight and change”; “It is not psychodynamic—the patient knows too much about you”; “I am not sure I am comfortable with your approach”; and so on. It is our hope that as supervisors, we must come to grips with our limitations, and when it becomes diffi cult for the supervisee to feel they are in an atmosphere of safety to explore traditional or contemporary concepts, an open discussion is needed to come to an agreement of how to proceed and help feel they do not have to leave things out. If that is not possible, ultimately a transfer to a supervisor with more expertise may be the best option.

Spontaneity in Supervision

An important element of the supervisory relationship is trust and the supervisor’s ability to tolerate spontaneity from the supervisee, both in their work with patients 14.6 The Supervisee in Two-Person Relational Supervision 347 and in supervision . The authors have found that in supervising colleagues and trainees, when the possibility of helping the child by observing them at their home, at their school, or in other places is introduced, their anxiety increases and they make comments like “Won’t the child feel bad if I show up at their home or school?” “Isn’t that breaking a boundary?” and “Will the child be able to trust me if they think I am taking sides with the parents or teachers?” These comments are more about the anxiety of the psychotherapist than about what is best for the child (Table 14.1 ).

Table 14.1 Common questions posed by supervisees in two-person relational psychotherapy supervision How long will it take me to understand my patients like my supervisors? Do I have to self-disclose every time the patient asks me a personal question? How will I know if the patient is getting better if it is not about insight? How do I tolerate the feelings generated: frustration, anger, sadness, and the love by my patient? Do I call these feelings countertransference?

The Supervisee’s Dilemma in Sharing with His Supervisor That He Has Gone to His Patient’s Home A child and adolescent psychiatry trainee had begun individual psychotherapy with a 15-year-old adolescent who had a 2-year history of depression. The patient was the third of ﬁ ve children born to an upper middle class, religious family who lived in the suburbs of a Midwestern city. After 6 months of weekly relational psychotherapy, the patient was improving, and the trainee felt less worried about him, as he seemed to have more adaptive working models of attachment, evidenced by his ability to relate better to his parents and peers. The trainee had intersubjectively found the patient to be increasingly likeable and more able to implicitly make use of the new emotional experiences provided by the trainee. However, toward the 8th month of the psychotherapy process, the patient called to cancel his appointments in two consecutive weeks. The trainee struggled to understand the reasons for the cancelations and subjectively struggled with his worry about the patient, as well as his sense of frustration with the patient’s unusual behavior. The patient would call and leave a message for the trainee: “Doctor, it’s Harry. I don’t have anything to talk about today; I’m not coming.” On the third week, about 20 min. prior to the session, Harry’s mother called to cancel his weekly appointment. The trainee was confused by the call, as typically Harry had been the one to call. He became worried, as the subjective experience was reminiscent of earlier psychotherapy appointments when Harry’s chronic depression and sense of loneliness were at their peak. The trainee, wondering about medical reasons to explain the cancelations, asks Harry’s mother if Harry had been feeling OK. She said that he was healthy but had recently begun isolating and they— his parents—were tired of trying to ﬁ gure him out. She added that they were 348 14 Supervision

surprised that he had requested his appointments to be canceled, and they were planning on making their own appointment to discuss their concerns. The trainee subjectively felt that something was uncharacteristic of Harry and his parents, and he also felt that waiting would risk matters worsening. It happened that Harry’s appointment was the trainee’s last one for the day, and he subjectively felt that it would be helpful for him to go to their home and see Harry. He asked Harry’s mother if the session could occur at the family’s home. She agreed and was pleased with such an offer. As the trainee drove to the patient’s house, he wondered, “How am I going to explain this one to my supervisor?” He thought, “If he were to criticize me, I’ll tell him that what I did was no different than what the family therapists of the 1980s would have done.” The trainee drove to Harry’s home, where he found Harry crying in his room after ﬁ ghting with his parents about his isolating to his room. The trainee saw that the room was adorned with awards won by his older brother. The patient stated: “Thanks for coming. My depression came back and I am disappointing my parents and you. I will never be as good as my brother.” Upon returning to his ofﬁ ce, the trainee worried that the supervisor would not “get what it was like to be in the room with my patient when he was depressed and feeling lonely.” However, the supervisor proved supportive of the trainee’s efforts to help the patient, and both were able to review the pros and cons of what had happened. What ensued resulted in the patient being able to work with the trainee in understanding the course of his chronic depression, and he agreed to take medication to help manage his symptoms with the help of his parents

This example highlights the many complexities that can emerge for the supervisee, and the supervisor needs to be able to tolerate spontaneity of action.

14.7 The Use of Video Recordings in Supervision

We wish to emphasize that with the technological advances that make it simple to video record our work, we are easily able to share our work with our trainees. This provides them a model and encourages them to share their work with their supervisors and in their didactic classes. We have been complimented for sharing our work, as it shows that we are not wizards that somehow always know what to say and do in sessions. It is helpful to demonstrate how, in certain moments, we became an accomplice to the patient’s maladaptive patterns of interaction. In a basic example, we nonconsciously became the critical or exasperated parent, as was evident by the material being shared. Of course, it is also helpful to share what we do well, as this is the best form of teaching. 14.7 The Use of Video Recordings in Supervision 349

Additionally, when supervisees share their work in the form of video recordings , they may ask, “What would you have said?” This provides the supervisor a valuable tool, as he or she is able to see and hear the intersubjectivities present during the moment that led to the question. This allows a better appreciation of the subjectivities—tone of voice, facial expressions, and body postures—between patient and supervisee during the process. The supervisor’s role is to facilitate the student’s discovery of ways of observing and forming intuitions from the clinical situation without the early encumbrance of theory (Goldberg 1998 ). We are not suggesting that supervision is a parallel process to psychotherapy, but rather a parallel process to mentoring and perhaps parenting. We need to be willing to compliment, support, and encourage our supervisees, as well as remind them of the arduous task of learning over time. In an atmosphere of mutual learning and without having the expectation that the material is always understood by the supervisee, supervision is open for sharing hypotheses and reviewing what the patient can teach us over time. We openly share our mistakes and our excitement when we get things right, without displays of erudition, clever- ness, or superiority.

The Well-Intentioned Supervisee A senior trainee shared with excitement a video recording of a 6-year-old boy he had been seeing in traditional psychodynamic psychotherapy for 6 months. In the video recording, the child was seen drawing and coloring strong characters and then giving the drawings to the trainee. The trainee’s previous supervisor had thought that the psychotherapy process was going well; he believed that the child’s drawings of strong characters were the representations of his abusive and unpredictable father. He suggested that the child needed to draw the strong characters to defend against his unconscious anger at his critical father. When the trainee changed to a relational supervisor, several aspects in the video recording were discussed within the context of contemporary diagnostic formulation. The child’s drawings were very simple, and the child did not provide any stories about the strong characters; rather, he would just name them and move on in a disorganized manner. Developmentally, milestones typical of 6-year-olds include being able to describe experiences, talk about thoughts and feelings, and think about their place in time and life, which the child had not achieved. With sensitivity, the supervisor noted that the trainee also seemed superﬁ cial in speaking about the child, as if he had little to say about the play observed in the video recording. The supervisor asked the trainee if he had felt engaged with the child’s subjectivity. The trainee paused and said: “I noticed that I am always the one that has to develop the stories to help the child not be so concrete, and I become tired and bored playing the same thing over and over. My other supervisor thought things were going well and that the child would eventually ‘gain insight’ through the play.” This led the relational supervisor to help the trainee review 350 14 Supervision

developmental milestones based on age, which the child was clearly behind. Formal cognitive testing was obtained and revealed that the child had borderline intelligence, which explained his concrete play. This information allowed for a shift in the approach by the trainee, which included providing more support and educational guidance for the mother, requesting from social services that visitations with his father be supervised and actively working with the child’s school to help develop realistic expectations and accommodations.

This vignette highlights the need for supervisors to help supervisees allow for their subjectivities to be used in a helpful manner. That is, the implicit relational mutuality between the supervisee and supervisor allows having a moment of meeting, which serves to catalyze and move the supervision along (BCPSG 2010 ). Before we leave this example, we note that we are aware that the traditional one- person supervisor may wonder if this is an example of a trainee simply complying with the new supervisors’ suggestions. The relational supervisor experiences the well-respected trainee in the video recording as feeling tired and bored during the child’s play and wonders in the here and now if his impressions are accurate. The supervisor opens the intersubjective ﬁ eld in that he asks for consultation from the trainee about his thoughts regarding his experience of his own work in the video recording. Had the supervisor experienced the trainee intersubjectively in disagreement, he or she would have proceeded to engage the trainee in an open discussion about the differences in understanding the child’s play. A note of caution: Some supervisors are not comfortable sharing video recordings of their work, and this may lead some trainees to assume that the supervisor is not actively practicing psychotherapy. In this case, we risk that supervision may not be valued or the supervisor may be seen as out of touch. This is of particular concern since the contemporary relational two-person model is a relatively new form of understanding and helping our patients (Chap. 3). As such, we would ask that supervisors consider having a set of personal video recordings to share that are generally well received by supervisees. It is beyond the scope of our book to review the many rules regarding video recording consents (reviewed in Chap. 9 ), and we refer the reader to their department or medical state policies for details on video recording for education, length of time valid for a consent, etc.

14.8 Concluding Thoughts on Two-Person Relational Psychotherapy Supervision

Indeed, the practice of supervision is an exciting endeavor, a sentiment captured by Kernberg (2010 ): “For the supervisor, seeing the supervisee’s growing independence in doing good work, supported by his or her capacity to convey new information and to provide new leads to the supervisor, is a gratifying experience of knowing References 351 one has contributed to the supervisee’s autonomous growth.” Thus, “Good supervision becomes an extremely interesting learning process for both participants. The supervisor’s self-refl ective function may be shared with the supervisee to an increasing degree over time, so that the supervisor’s speculations, uncertainties, and possible alternative formulations regarding the patient can be made available in more direct and open ways, facilitating the supervisee’s identifi cation with the supervisor’s self-refl ective attitude. Transmission of this attitude, in turn, broadens and deepens the supervisor’s pleasure in the supervisory process” (Kernberg 2010 ). Wachtel (2012 ) aptly states, “One of the most important things I try to teach my students is that they should notice inconsistencies on the patient’s part but should be wary of pointing them out as such, lest they seem more like district attorneys than therapists.” Therefore, the process of supervision is central to psychotherapy training and serves a number of important functions. Moreover, there are key responsibilities for supervisors engaging in the supervision of relational psychotherapy. In this regard, supervisors are tasked with codeveloping a case conceptualization of the supervisee’s patient and also establishing an atmosphere of safety for the supervisee to present case material and issues that he or she would like to learn more about. Moreover, the supervisor working with a supervisee who is engaged in relational psychotherapy will need to help the supervisee to understand differences between the two- person relational model and traditional one-person models (e.g., the differences of self-disclosures, enactments, and boundaries). We note that at times self-disclosures and enactments occur unknowingly from the psychotherapist and their presence is revealed by the patient in the form of a moment of meeting or of a disruption to the process.

References

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Delgado SV (2008) Psychodynamic psychotherapy for children and adolescents: an old friend revisited. Psychiatry 5(5):67–72 Delgado SV, Strawn JR, Jain V (2012) Psychodynamic understandings. In: Levesque RJR (ed) Encyclopedia of adolescence. Springer, New York, pp 2210–2218 Frawley-O’Dea MG (2003) Supervision is a relationship too. Psychoanal Dial 13:355–366 Friedman HJ (2010) Preserving the gap between Freudian and relational psychoanalysis: the case for maintaining the clarity of difference. Contemp Psychoanal 46:142–151 Gabbard GO (2009) What is a “good enough” termination? J Am Psychoanal Assoc 57:575–594 Goldberg DA (1998) Structuring training goals for psychodynamic psychotherapy. J Psychother Pract Res 7(1):10–22 Hantoot MS (2000) Lying in supervision. Why residents say one thing and do another. Acad Psychiatry 24(4):179–187 Jacobs D, David P, Meyer DJ (1995) The supervisory encounter. A guide for teachers of psychodynamic psychotherapy and psychoanalysis. Yale University Press, New Haven Kernberg OF (2010) Psychoanalytic supervision: the supervisor’s tasks. Psychoanal Q 79:603–627 Kierkegaard S (1998) The point of view. University Press, Princeton Maroda KJ (2010) Psychodynamic techniques working with emotion in the therapeutic relationship. Guilford, New York, p 6 Mellman LA, Beresin E (2003) Psychotherapy competencies: development and implementation. Acad Psychiatry 27(3):149–153 Mojtabai R, Olfson M (2008) National trends in psychotherapy by offi ce-based psychiatrists. Arch Gen Psychiatry 65(8):962–970 Mullen LS, Rieder RO, Glick RA et al (2004) Testing psychodynamic psychotherapy skills among psychiatric residents: the psychodynamic psychotherapy competency test. Am J Psychiatry 161(9):1658–1664 Neufeldt ML (2007) Supervision strategies for the fi rst practicum, 3rd edn. American Counseling Association, Alexandria, pp 71–86 Orange DM, Atwood GE, Stolorow RD (1997) Working intersubjectively; contextualism in psychoanalytic practice. Analytic Press, Hillsdale Plakun E (2006) Finding psychodynamic psychiatry’s lost generation. J Am Acad Psychoanal Dyn Psychiatry 34(1):135–150 Plakun E, Sudak DM, Goldberg D (2009) The Y model: an integrated, evidence-based approach to teaching psychotherapy competencies. J Psychiatr Pract 15(1):5–11 Reiss H, Fishel AK (2000) The necessity of continuing education for psychotherapy supervisors. Acad Psychiatry 24(3):147–155 Tucker PM, Garton TS, Foote A, Chander C (2009) In support of early psychotherapy training. Psychiatr Times 26:12 Wachtel PL (2012) Refl ections on the therapeutic process. Psychoanal Perspect 9:88–117 Watkins CE, Scaturo DJ (2013) Toward an integrative, learning-based model of psychotherapy supervision. J Psychother Integr 23(1):75–95 Yerushalmi H (1999) Mutual infl uences in supervision. Contemp Psychoanal 35:415–436 Appendix

Appendix A: Developmental Milestones

Developmental milestones: 2- to 3-year-old toddlers

Developmental domain Proficient Concerning

Social/emotional At 2 years old, plays mainly beside Poor affection for friends other children, does not like sharing, and may grab and push Aggressive forms of play

At 3 years old, shows affection for Poor self-regulation while playing friends without prompting, takes turns in games, shows concern for Does not know how to make use of a crying friend, and has a wide toys or enjoy play range of emotions Little interest in taking turns in games

Language/communication At 2 years old, average vocabulary Limited amount of words used should be 50–300 words Use of offensive words, likely heard By 3 years old, should have a from adults vocabulary of 1,000 words and be able to carry a conversation using Loud use of infantile voice two- to three-word sentences using plurals and pronouns

Cognition At 2 years old, completes phrases Play is simple or disorganized of two to three words and communicates needs (hunger, Poor ability to play make-believe and thirst, pain, etc.) speaks of negative view of others

At 3 years old, plays make-believe Concrete play without story line with dolls, animals, and people, completes puzzles with three or four pieces

© Springer-Verlag Berlin Heidelberg 2015 353 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4 354 Appendix

Behavior/motor At 2 years old, begins to run and Impulsive with poor self-regulation kicks a ball, builds a tower of six to seven cubes Repetitive behaviors or actions

At 3 years old, runs easily and Often aggressive actions climbs well, has control of bowel and bladder during the day

Parental “milestones” Creates a stimulating and colorful Unpredictable routines environment Abrupt and inconsistent discipline Reads to the child Poor recollection of feeding and sleep Displays consistent and predictable schedules discipline and routines Unaware of child’s distress during Attunes to child’s needs even conflict between parents during episodes of angry feelings Bothered by child’s needs and yells at child rather than attunes

Adapted from: Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention; Shelvov SP, Hannemann RE, Trubo R (2004) The American Academy of Pediatrics: complete and authoritative guide for caring for your baby and young child. Bantam Books, New York, NY

Appendix 355

Developmental milestones: 4- to 6-year-old children

Developmental domain Proficient Concerning

Social/emotional Enjoys exploring and is curious Restricted range of emotions about toys and games Ignores other children Increasing creativity with make- believe play Argues with persons outside of the family Wants to please and agrees to rules, although may change rules Shows extreme behavior, usually often aggressive or sad

Increasingly cooperates and plays Limited repertoire of games and with other children over playing activities alone No interest in make-believe or Likes to sing, dance, and act interactive games

By 5 years old, can tell the difference between pretend and real and is aware of gender

May be very demanding at times, and very compliant at other times

Language/communication Sings a song or recites poem from Speaks unclearly and is difficult to memory understand

Tells stories with full sentences Cannot retell a favorite story or video

Can say first and last name Frequent errors with pronouns

Increasingly uses future tense Unable to comment on daily activities or experiences Uses basic rules of grammar Limited and repetitive vocabulary By 5 years old, recites the alphabet and counts to 10 Poor use of grammar, especially plurals and past tense By 6 years old, average expressive vocabulary should be Imitates words of others and uses out 2,500 words, and receptive of context vocabulary should be 20,000 words

356 Appendix

Cognition By 6 years old, identifies many Has trouble scribbling colors and numbers Resists dressing self and toilet training Can draw a person and geometric shapes with increasing Difficulty staying focused on a single complexity activity for more than three minutes

Can count 10 or more things Difficulty distinguishing between pretend and real

Developing idea of “same” and Cannot follow three-part commands “different ” Speaks in infantile manner Remembers parts of stories and tells you what may happen next in No depth to their stories or play a story

Developing an understanding of time

Knows about things used every day, like money and food

Can draw a circle or triangle

Behavior/motor Can print some letters or Unable to jump in place numbers Unable to brush teeth, wash and dry Stands on one foot for 10 s hands, or get undressed without help or longer Draws pictures in very simple form Hops and eventually skips Restlessness, over-activity, and abrupt Uses a fork and spoon and behavior/motor sometimes can use a knife to spread

Can use the toilet on his or her own

Swings and climbs

Can dress independently; may need help with laces and buttons

Parental “milestones” Reads stories and attunes to the Frequently involves children in conflict child’s reactions to the story line between parents

Is consistent, repeats instructions Consistently displays affect in harsh with tone of voice and gestures manner reflecting care and firmness Inconsistent and abrupt discipline Is warm and affectionate when child expresses angry feelings Frequently shouts when the child needs attention Has predictable routine in parenting and playful activities Unrealistic expectations of the child

Use of corporal punishment

Appendix 357

Developmental milestones: 7- to 9-year-old children

Developmental domain Proficient Concerning

Social/emotional Fears of monsters, kidnappers, and Intense sadness or despair large animals Only smiles or laughs at the expense Play includes use of fantasy and of making fun of peer or adult imagination. May have imaginary friends Problems making and keeping friends, demanding of their loyalty Develops a sense of humor, expresses simple jokes and Displays anger, aggression, or temper rhymes tantrums

Initially desires to play with parents, Demands privileges of older siblings but gradually shifts toward friends Does not fear being alone in public Can play in organized sports and places follows rules

Develops a greater sense of empathy with same-sex peers, but still mostly self-focused

Language/communication Can describe with some detail a May steal or lie with a poor favorite activity, video, or book understanding of the consequences

Uses correct grammar and Poor comprehension of age- sentence structure most of the appropriate books and videos time Self-injurious behavior such as head Recognizes and reads simple banging, scratching, or biting when words angry

Able to thank others for help Frequently uses foul language

Cognition Develops the skills to process more Learning becomes increasingly abstract concepts and complex difficulty; avoids doing homework ideas Frequent disruptive behavior at school Is able to focus on the past and future as well as the present Continues to communicate with simple sentences Can draw a figure with a head, body, arms, and legs Does not pick up on humor

Identifies right and left easily Difficulty with changes in routine or transitions

Speaks in infantile manner

Seems younger than age

358 Appendix

Behavior/motor Usually has good balance and Frequently falls during simple enjoys running, jumping, skipping, activities and other forms of physical play Inability to hold and use writing Able to hold a pencil and clearly instruments write letters Repetitive behavior/motors such as Can copy triangles and diamonds hand flapping or rocking

Can ride a bicycle and tie shoes Frequent physical pains such as stomachaches, headaches, or Increasing height and weight vomiting

Frequent aggressive behaviors toward siblings and peers

Parental “milestones” Is involved in child’s extracurricular Often asks the child to take sides activities between parents when in conflict

Delegates age-appropriate Frequent complaints of other persons responsibilities within the home in the presence of the child

Works to reduce changes in child’s Usually is harsh; inconsistent life, shields children from parental discipline may include corporal conflict punishment

Always expresses anger verbally by yelling

Relies on child to listen to adult problems or loneliness

Appendix 359

Developmental milestones: 10- to 12-year-old adolescents

Developmental domain Proficient Concerning

Social/emotional Close friendships to same-sex Doesn’t smile or laugh, prefers to argue peers or demand

Becomes critical of adults Problems making and keeping friends

Has intense interest in belonging Angry and aggressive comments or to a team and enjoys organized behaviors, temper tantrums competitive games Dislike of organized games Anger is common, resents being told what to do, and rebels at routines. Reacts emotionally rather than logically

Experiences many fears and worries about physical changes and appearance

Language/communication Begins to be interested in world Does not see the consequences of and community events stealing or lying

Has strong urge to conform to Prefers to view age-inappropriate books peer-group morals and videos, which can include violence and sex Good abstract reasoning, with Self-injurious behavior such as head meaningful conversations with banging, scratching, or biting when peers stressed

Use of foul language

Cognition Challenges adult knowledge Frequent negative behavior at school

Increased ability to use logic Declining grades with increased difficulty May have interest in earning money Difficulty with small changes in routine or transitions Has interest in having privacy Avoids schoolwork, and it does not bring pleasure

Behavior/motor Rapid growth if in puberty and is Impulsivity is common increasingly aware of body changes (e.g., voice, body odor) Aggression is aimed at hurting others

Girls begin to show secondary Bullies other children who are not as sex characteristics strong

Increased coordination and Frequent use of physical aggression strength

360 Appendix

Enjoys sports and video games Begins to resort to self-harming activities with peers, both organized or in when angry or unhappy community Shift in sleep patterns

Parental “milestones” Is able to anticipate and discuss Undermines other parent pubertal changes Gives the child adultified role in caring Is understanding and supportive for younger siblings

Helps child set the rules and Unable to perceive academic or social decide own responsibilities struggles in child

Gives child opportunity to make Makes fun of child if child makes decisions mistakes

Provides for organized activities Increases use of negative comments in sports or clubs and blames the child often

Developmental milestones: 13- to 15-year-old adolescents

Developmental domain Proficient Concerning

Social/emotional Withdraws from parents, who are Irritability, mood swings invariably called “too old” Expects to fail and blames parents Needs less family companionship Bullies other children Worries about grades, appearance, and popularity Blames parents for unhappiness

Identifies with peer group Enjoys teasing others

Ambivalent about sexual Engage in self-defeating, aggressive, relationships antisocial, or impulsive behavior; may withdraw or isolate Body image and dieting patterns begin to have prominence Does not respect others’ property

Age-specific moodiness Body image avoids mainstream peers’ image

Language/communication Enjoys reading or being involved in Unable to enjoy being with peers school projects unless involved in negative behaviors Thrives on arguments and discussions by using logical thinking Argues with adults using foul language

Cognition Increasingly able to memorize Concrete thinking

Thinks logically and hypothetically Behaves as if societal rules do not about concepts apply 362 Appendix

Engages in introspection and Difficulties at school lead to disruptive probing into own thinking behavior

Has realistic plans for the future Use of nicotine, alcohol, and drugs

Behavior/motor Experiences sudden and rapid Aggression is aimed at hurting increases in height, weight, and others strength with the onset of adolescence No inhibitions of sexual or substance abuse activity Enjoys competitive sports and video games, both organized or in Bullies other children who are not as community strong

Participates in outdoor chores with Frequent use of physical aggression parents

Parental “milestones” Decision making is done as a Undermines other parent parental unit, even when divorced Unable to perceive struggles in Assists in navigating through peers pubertal changes Makes fun of other’s mistakes with Models emotional and behavioral foul language regulation during arguments Engages in unilateral authoritarian Engages in consistent support and parenting with limited collaboration limit setting Overly identifies with adolescent, has Models by engaging in altruistic poor limit setting, and is too activities permissive

Allows the adolescent to have an adult role when needed for selfish reasons

Developmental milestones: 16- to 19-year-old adolescents

Concerning Similar to deficits in 13- to 15-year- olds, although in more extreme Developmental domain Proficient form

Social/emotionalUsually has many friends and a Irritability, mood swings few in whom they confide Bullies peers and adults May be strongly invested in a single romantic relationship; may Blames parents for any mishap begin to become sexually active Begins to speak of physical actions Worries about failure toward others, self-harm, and suicide if demands to be liked or loved are Has conflicting feelings about not met dependence/independence Difficulties trusting Age-specific moodiness

Language/CommunicationAble to fluidly shift between different Enjoys being with peers only if they contexts, including ages and peer use the same foul language groups Involved in negative behaviors with Able to use more complex more planning communication to express ideas, including nonverbal and abstract Argues and threatens adults and uses ideas foul language without concern for hurting others Establishment of ethical and moral values Unable to form or maintain satisfactory relationships with peers

CognitionBeginning to integrate knowledge Concrete thinking is common leading to decisions about future Critical of parents and believes Makes steps toward intimacy societal rules do not apply

Conscious choices about which Difficulties at school lead to disruptive adults to trust. behavior

Respects honesty and Use of nicotine, alcohol, and illegal straightforwardness from adults drugs

Behavior/motorHas essentially completed physical Aggression is aimed at hurting others maturation; physical features are shaped and defined No inhibitions of sexual activity

Probability of acting on sexual Takes pleasure in bullying peers desires increases Frequent use of physical aggression May become sexually active or experiment with drugs

Parental “milestones” Discusses appropriate clothing in Unable to understand or dismisses context of changes in physical the adolescent’s struggles maturity Makes fun of adolescent if adolescent Is available to talk and to listen. makes mistakes Avoids ridicule of inconsistent behaviors 364 Appendix

Demands respect in angry and hostile manner Provides accurate information on consequences of sexual activity Unaware of adolescent’s whereabouts Gives limited supervision roles in household of siblings Failure to be aware of adolescent’s developmental needs Engages in promoting college or other adult roles Expects adolescent to be overly involved in parent role of younger siblings, although demands respect at other times

Appendix B: Contemporary Diagnostic Interview Case Formulation Tool

Contemporary Diagnostic Interview Case Formulation Tool

Patient Name: ______Age: ______Sex: Male Female Difficulties in Developmental Milestones for Stated Age: Social/Emotional Gross/Fine Motor Cognition Parental availability Language/Communication

Contemporary Diagnostic Interview Temperament Cognition Cognitive Flexibility Int. Working Model of Attachment

Easy/Flexible Above Average High Secure Slow-to-Warm-up Average Adequate Anxious/ambivalent Mixed Below Average Limited* Dismissive*/avoidant Difficult/Feisty* Intellectual Impaired* Disorganized* Disability* Specific LD* Non-Verbal LD*

* consider neurodevelopmental deficits, injury or psychological trauma: formal cognitive testing needed

DSM-5 Psychiatric Diagnosis based on Descriptive Criteria Intellectual Disability Brief Psychotic Disorder Language Disorder Schizoaffective Disorder Social Communication Disorder Schizophrenia Autism Spectrum Disorder Substance/Medication-Induced Psychotic Disorder Delusional disorder Attention-Deficit/Hyperactivity Disorder Major Depressive Disorder Bipolar I Disorder Substance/Medication-Induced Depressive Disorder Bipolar II Disorder Unspecified Depressive Disorder Cyclothymic Disorder Adjustment Disorder Substance/Med-Induced Bipolar Disorder Unspecified Bipolar and Related Disorder Cannabis Use Disorder Disruptive Mood Dysregulation Disorder (DMDD) Alcohol Use Disorder

Obsessive-Compulsive Disorder Intermittent Explosive Disorder (IED) Oppositional Defiant Disorder Conduct Disorder Separation Anxiety Disorder Social Anxiety Disorder (Social Phobia) Posttraumatic Stress Disorder (PTSD) Panic Disorder Acute Stress Disorder Agoraphobia Reactive Attachment Disorder Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anorexia Nervosa Bulimia Nervosa Unspecified Anxiety Disorder Unspecified Eating Disorder

Symptoms of ______although does not meet full DSM-5 criteria. Pertinent Environmental Factors (parents, peers, school environment, trauma): Sample Formulation: The patient is a __ year old [race and gender] presenting with [description of functional impairment]. The clinical interview suggests that the patient has [describe level of cognition] and also [has or does not have] a learning disability. Additionally, there is a [high/adequate/limited/impaired] cognitive flexibility. The patient’s early childhood environment is remarkable in that [describe]. Temperament, since infancy, is consistent with [easy/feisty/slow-to-warm-up/difficult/odd] style. Internal working models of attachment (IWMA) are observed to be [description]. In terms of formal psychiatric disorders, the patient [does or does not] meets DSM-5 criteria for [list DSM-5 diagnoses]. Index

A Avoidant/dismissive attachment , 73, 231 Abandonment , 232, 315 Axline, V. , 280 Abuse , 142 Adaptability , 220 Adler-Tapia, R. , 38, 291 B Adolescence , 132, 134, 220, 228, 229, 239, 311 Barnett, D. , 267 Adoption , 64 Barrett, T.F. , 133 Adult Attachment Interview (AAI) , 74 Bartlett, A.B. , 172 Affect attunement , 66 Basal cell carcinoma , 295 Affective attunement, 24, 64, 83, 116, 123, BCPSG. See Boston Change Process Study 186, 193, 203, 230, 234, 267, 273, 318 Group (BCPSG) Ainsworth, M.D.S., 73 Beebe, B. , 57 Alexander, F. , 102 Beeghly, M. , 265, 266, 274, 276 Altman, N. , 40, 50, 169 Behavioral , 243–245 Ambivalent/anxious attachment , 231 inhibitions , 75 Amerongen, M. , 170 Bereavement , 222 Amodal , 81, 95 Beresin, E. , 333 Amygdala , 187, 190, 194–196, 200, 201, 203 Berger, S.S. , 334 Andrews, L.B. , 332 Berman, E. , 42 Anterior cingulate cortex , 188, 194, 196, Bettelheim, B. , 176 200, 203 Bidirectional , 55, 57, 237, 238, 243 Anthony, E.J. , 47, 49 Biederman, J. , 87 Anxiety , 54, 220, 229 Bion, W. , 27 Anxious attachment , 73, 104 Biopsychosocial , 64, 207, 210 Aron, L. , 117, 163 Bleiberg, E. , 30, 31, 85 Aserinsky, E. , 159 Blos, P. , 29, 132, 170 Ashliman, D. , 178 Borderline , 138, 232 Association for play therapy , 281 personality , 29 Asymmetry , 51 Bornstein, B. , 23, 115 Atmosphere of safety , 242 Boston Change Process Study Group Attachment theory , 37, 70, 72, 73, 190, 207 (BCPSG) , 52, 66, 98, 100, 137, 156 Attention deﬁ cit hyperactivity disorder Boundary(ies) , 163, 164, 170 (ADHD), 172, 189, 295 crossings , 164 Atwood, G.F. , 152 violations , 164 Auchincloss, E.L. , 154, 158, 280 Bowen, M. , 133 Autism , 189, 199, 200, 202 Bowl, S. , 225 Autistic spectrum disorders , 243, 244 Bowlby, J. , 25, 29, 73, 75, 219 Autobiographic , 5 Brenner, C. , 121, 152, 158

© Springer-Verlag Berlin Heidelberg 2015 367 S. Delgado et al., Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience, DOI 10.1007/978-3-642-40520-4 368 Index

Bretherton, I. , 265 Craighero, L. , 82 Bromberg, P. , 9 Craniosynostosis , 268 Brooks, R. , 82 Creativity , 243 Buirski, P. , 152 Culture , 187 Curiosity , 214, 243 Curtis, R. , 151 C Cabaniss, D.L. , 164 Call , 294 D Capacity to be alone , 27, 28 Damasio, A.R. , 81 Cardoso Zoppe, E.H. , 333 Default mode network , 193, 196–198, 201 Caregiver-infant relationships , 4 Defense mechanisms , 57, 135, 283, 315 Cartesian , 335 Delgado, S.V. , 26, 73, 91, 118, 128, 131, Case 134, 141, 168, 173, 210, 254, 275, conceptualization , 339 279, 297, 311, 335, 342 formulations , 235 Depressive position , 26, 27, 137, 146 Chess, S. , 75, 219 Developmental disabilities , 210, 243 Child Developmental infant research , 70 and adolescent psychotherapy , 1 Developmental interference , 16, 34 psychoanalysis , 15, 17, 20, 22–24 Developmental lines , 23 Child-centered family treatment , 32 Developmental milestones , 280, 294 Cicchetti, D. , 266, 267 Developmental psychology , 47, 63, 219 Closeness , 215, 234 Developmental research(ers) , 63 Co-construct , 58 DeYoung, P.A. , 152, 172 Co-construction , 40 Diagnosis , 208 Co-create , 40 Diagnostic formulation , 209–211, 241, 242 Co-created experience , 7 Dialectical behavioral therapy , 174 Cognition , 222, 224, 240 Dickstein, S. , 85 Cognitive abilities , 222 Diener, M.J. , 84 Cognitive–affective schemas , 229 Disclose , 242 Cognitive behavior therapy , 174, 254, 332 Disorganized attachment , 84, 90, 108 Cognitive ﬂ exibility, 21, 31, 227–229, 231, 237 Disruptive mood dysregulation disorder , 221 Cognitive functioning , 218 Dodd, B. , 81 Cognitive testing , 223, 245 Dreams , 157, 159, 160 Cohen, D.J. , 24 Drell, M.J. , 22 Collateral information , 238 Drives , 73, 123, 124 The Complete Fairy Tales of the Brothers DSM-5 , 172, 207, 208, 234, 239, 334 Grimm , 178 Dyslexia , 245 Computed tomography , 268 Conﬁ dentially , 257, 258 Consent E of video recording , 259 Early adolescence , 293 to treat , 251 Ego , 16–18, 23–27, 30, 34, 65, 124, 127, Contemporary diagnostic interview , 12, 103, 135, 146 211, 213, 269, 280, 294, 312 defenses , 16, 24 Contextual , 46, 47, 53, 73 Einstein, A. , 145, 175 Conversational approach , 234 Electrocardiogram , 212 Corrective emotional experiences , 1, 33, 51, Electronic devices , 259 58, 92, 102, 122, 145, 149, 194, 273, Ellenberg, H. , 150 307, 316, 328, 342 Emde, R. , 64, 81, 85, 95, 130, 138, 175, 271 Couch, A.S. , 24, 27, 174 Emotional availability , 84, 103, 266, 276 Countertransference , 142, 161, 162 Emotion regulation , 227 enactment , 99, 322, 326 Empathy , 189, 195, 200 Cozolino, L. , 79 Enactment , 5, 39, 165, 166, 274 Index 369

Erikson, E. , 24, 25, 127, 293 Gifted student , 245 Esophagogastroduodenoscopy (EGD) , 268 Gill, M.M. , 154, 163, 296 Ethnicity , 187 Gilmore, K. , 79 Evenly suspended attention , 152 Goodness of ﬁ t , 75, 214, 219, 227, 251 Executive function , 227 Gottlieb, G. , 274 External attributes , 236 Granic, I. , 279 Greenberg, J. , 16, 45 Greenson, R.R. , 151 F Grimm brothers , 176, 178 Failure to thrive , 64, 268 Group therapy , 174 Fairy tales , 175, 176, 178 Family , 135 therapy , 174 H tree , 229 Haglund, P. , 152 Fantasy , 144 Halpern, C.T. , 274 Farber, B.A. , 165 Hans, L. , 17, 19–21 Farley, F. , 311 Hansel and Gretel , 176–178 Ferenczi, S. , 42, 147 Hantoot, M.S. , 346 Ferro, A. , 27, 166 Harlow, S. , 71 Finnish Psychiatry group , 176 Harmon, R.J. , 271 First-time mothers , 67 Hartman, H. , 25 Fishel, A.K. , 334 HIPAA , 257, 258 Flashman, A.J. , 23 Hippocampus , 189, 196, 201, 203 Fliess , 129 Hobson, J.A. , 159 fMRI. See Functional magnetic resonance Hoffman, I. , 15, 40, 121, 163 imaging (fMRI) Holmes, J. , 38, 44 Fonagy, P. , 70 Honig, A.S. , 159 Fosha, D. , 102 Hospitalism , 64 Fosshage, J. , 33, 59, 116 Hug-Hellmuth, Hermine von , 22, 27 Fraiberg, S. , 168, 272, 315 Frame of mind , 215 Frankel, J. , 150 I Free associations , 121, 158 Iacoboni, M. , 82, 138 Freud, A. , 17, 22–25, 27, 132, 135, 153, 272, 274 Id , 18, 124, 125 Freud, S. , 17–21, 24, 26, 42, 54, 119, 121, Idealizing , 31 123, 129, 135, 153, 158, 176, 185 Identiﬁ cation with an aggressor , 147 Freud’s method , 16 Implicit relational knowing , 37, 55, 67, 93, Friedman, H.J , 336 97, 117, 122, 123, 140, 147, Fromm, E. , 176 153, 215, 327 Functional connectivity , 187, 189, 201 Implicit relational patterns , 212 Functional magnetic resonance imaging Implicit relational schemas , 166 (fMRI), 190, 194, 199, 201, 202 Individualized education plan , 224 Furman, R. , 296 Infant development , 55, 63 Fuzzy intentions , 100 Infantile neurosis , 20 Insecure-ambivalent/anxious attachment , 89 Insecure-avoidant/dismissive attachment , 90 G Insecure-disorganized attachment , 90 Gabbard, G.O. , 47, 157, 172 Insight , 148 Gaines, R. , 40 Insula , 188, 190 Gene x environment interactions , 191 Intellectual disabilities , 244 Genogram , 298 Internal working models , 21, 25, 31, 88 Genome-wide association studies , 199 of attachment , 37, 88, 115, 138, 150, 166, Gerber, A.J , 39, 87 210, 215, 241, 243, 273, 338 Giedd, J.N. , 311 of social relationships , 73 370 Index

Interpersonal neurobiology , 71 Little Red Riding Hood , 176, 177 Interpersonal psychotherapy Lying , 346 for adolescents, 174 Lynn, D.J. , 151 Interpersonal theory , 45 Lyons-Ruth, K. , 93, 97 Interpretation , 26, 153, 156, 300 Intersubjective , 216 experience , 56, 58, 66, 221, 227 M ﬁ eld , 51, 53, 81, 87, 92, 96, 98–100, MacLean, G. , 22 103–107, 109 Magnetic resonance imaging (MRI) , 268 Intersubjectivity , 4, 31, 37, 38, 40, 69, 93–95, Mahler, M.S. , 28–29 101, 118, 130, 134, 149, 154, Main , 74 173, 213, 217, 218, 251, 285, Maroda, K.J. , 165 312, 336, 338 Mayes, L.C. , 24 Interview process , 235 McCarley, R. , 159 Intrapsychic , 16, 18, 24, 27, 28, 53, 116, 135 McDevitt, T. , 293 phenomena , 117 Meaning making , 5, 68, 81, 82, 120, 123, Introjection , 137, 142 273, 286 Medication , 245 management , 332 J Meersand, P. , 79 Jacobs, D. , 176, 338, 346 Mellman, L.A. , 333 Jaffe, J , 82 Meltzoff, A. , 69, 82 Johnson, J.S. , 88 Menes, J.B. , 296 Joining and holding , 235 Mentalization , 70, 101, 243 Jung, C. , 22, 129 Metaphor , 244 Middle school , 293–309 Mindsight , 71 K Mini International Neuropsychiatric Interview Kagan, J. , 75, 87 for Children and Adolescents, 207 Kandel, E.R. , 130 Mirroring , 31 Kaplan, M. , 173 Mirror neurons , 82 Kernberg, P.F. , 29, 30, 338 Mirror neuron system , 193, 198, 199 Kierkegaard, S. , 336 Mishna, F. , 170 Klein, M. , 22, 26–27, 31, 137, 283 Mitchell, S. , 45, 46 Kleitman, N , 159 Molenberghs, P. , 83 Kohut, H. , 31 Moment of meaning , 145 Krimendahl, E. , 280 Moment of meeting , 51, 97–99, 239, 286, K-SADS-PL , 207 299, 301, 308, 325 Montagu, A. , 44 Mood , 219, 220 L Motherese , 103, 104, 106, 169, 273 Lachmann, F. , 57 Mother’s Day , 224 Language , 186, 199 Mourning , 297 Laplanche, J. , 156 Munholland, K.A. , 265 Latency , 131, 280 Mutuality , 42, 52, 64, 238 Learning disorders , 222, 243 weaknesses , 222, 223 N Lester, E.P. , 157 Nealis, A.L. , 159 Levenkron, H. , 49 Negative maladaptive behaviors , 240 Lewis, A. , 16 Nelson, C.A. , 266 Like me , 214 Neufeldt, M.L. , 339 Like them , 214, 235 Neuroimaging , 185, 188, 190, 195, 196, Limbic system , 194, 196 199, 201, 202 Index 371

Neuroplasticity , 187, 192, 193 Pharmacological , 246 Neuroscience , 63, 211 Pine, F. , 16, 34 Neurotic symptoms , 119 Plakun, E. , 332 Neutrality , 150, 161, 249, 315 Plasticity , 192 New York Longitudinal Study , 87 Plastow, M. , 22 Nonconscious , 7, 25, 31, 37, 66, 83, 89, 116, Pontalis, J-B , 156 120, 122, 126, 136, 149, 166, 174, 186, Posttraumatic stress disorder , 200 213, 235, 299, 312, 321, 336 Preadolescence , 293 Noncritical , 240 Prefrontal cortex , 187, 189, 190, 195, 197, Nondeclarative , 307 198, 201–203 memory , 8, 58, 94, 98, 116, 117, 119, Prepuberty , 293 120, 124, 125, 130, 138, 147, Present moment , 96 176, 212, 214, 234, 276, 288, 316 Primate , 198 memory systems , 37, 93 Projection , 28, 31, 138, 142, 143 Normal disruptions , 231 Projective identiﬁ cation , 29, 31, 138, 142, Novick, J. , 168 143, 162, 322 Novick, K.K. , 168 Prosody , 49 Now moments , 96, 97 Pruning , 193 Nurture , 187 Psychiatric evaluation , 213 Psychic determinism , 53, 121 Psychoanalysis , 101 O Psychoanalytic pluralism , 16, 34 Object relations , 16, 17, 26–32, 118, 137, Psychodynamic , 243 138, 146, 328 psychotherapy , 49, 60, 332, 335 theory , 129 self , 218 O’Brien, J. , 173 Psychodynamic Psychotherapy Competency Obsessional neurosis , 283 Te (PPCT) , 336 Oedipal , 127 Psychosexual Oedipus complex , 18, 20, 27, 128, 129 developmental stages , 18, 24 Offer, D. , 134 phases , 17 Offer, J.L. , 134 stages , 127 One-person psychology , 116, 118 Psychotherapy , 39, 101, 244 Oral , 127 Puberty , 280 Orange , 156, 335 Orbitofrontal cortex , 201 Ormrod, J. , 293 R Ornstein, A. , 31–33 Rachman, A.W. , 42 Oxytocin , 200 Rank, O. , 42 Rapid eye movement , 159 Rapport , 215 P Rapprochement , 28 Paranoid position , 26, 27, 137 Real relationship , 96 Parapraxes , 158, 161 R e ﬂ ective functioning , 193, 203 Parietal cortex , 197, 199 Regulatory theory , 70 Passivity , 231 Reiss, H. , 334 Patterson, G.R. , 279 Relational , 50, 57, 101, 118 Pearson, R.M. , 149, 151, 158, 160, 162, 168, Relationalists , 47 267 Relational schemas , 136 Pediatric cardiology , 211 Relational two-person psychology , 345 Perlman, F. , 150 Release of information , 258 Personal attributes , 239 Renik, O. , 167 Personality , 135, 232 Residency Review Committee (RRC), 332 disorders , 101 Resistance , 16, 154, 155 Petrucelli, J. , 276 Resnick, J. , 159 372 Index

Resnik, J. , 16 Sroufe, L.A. , 67, 266 Revonsuo, A. , 160 Stekel, W. , 21, 22, 43 Reyna, V.F. , 311 Stern, D. , 65, 81, 100, 156 Rhesus monkeys , 71 Still-face , 68 Rizzolatti, G. , 82 experiment , 82 Rodman, F.R. , 6 Stockholm syndrome , 147 Roffman, J.L. , 87 Stolorow, R.D. , 33, 152 Ross, J.M. , 174 Strange situation , 89, 90 Rubin, J.B. , 151 Strawn, J.R. , 73, 91, 254, 297 Rustin, J. , 58, 273 Structural model , 18 Rycroft, C. , 44 Subjective experience , 236 Subjectivity , 234 Sullivan, S. , 45 S Superego , 18, 25, 27, 125 Safran, J.D. , 84 functions , 157 Salomonsson, B. , 272 Supervisee , 331, 334, 338, 341, 346 Samberg, E. , 154, 158, 280 Supervision , 12, 331, 334–336, 338, 343, 347 Sameroff, A.J. , 79 Supervisor , 331, 334, 338, 350, 351 Sander, L. , 274 Supportive psychotherapy , 332 Sandor, L. , 178 Surrogate mothers , 72 Scaffolding , 68 Suttie, I. , 44 Scaturo, D.J. , 309, 333 Symptoms , 208 Schaefer, C.E. , 281 Syntax , 224 Schafer, R. , 29 Schore, A. , 70, 91 Second phase of separation–individuation , 29 T Secure attachment , 73, 89, 230 Tamis-LeMonda, C.S. , 266 Sekaer, C. , 58, 273 Telepsychiatry , 260 Self-defeating behavior , 216 Temperament , 74, 75, 86, 115, 187, 193, Self-disclosures , 5, 58, 164, 166, 274, 289, 198, 200, 210, 218–221 301, 326 styles , 220 Self-esteem , 226 Termination , 291, 307, 329 Self-object , 315 Terr, L.C. , 29 Self-regulation , 68, 189, 218, 233, 241, Theory of ego development , 25 245, 266 Theory of Mind , 69, 202 Self-regulatory schemas , 138 Third party payers , 255 Separation–individuation , 28, 29, 65, 98 Thomas, A. , 74, 75, 219 Sequencing , 241 Three wishes scenario , 229 Setting the frame , 12, 249–263 Time-outs , 233 Siegel, D. , 71 Toilet training , 191 Slips of the tongue , 158 Topographic model , 17, 18 Sloppiness , 100, 308 Traditional one-person , 115, 119 Soavi, G.C. , 283 model , 55, 57, 59 Social cognition , 200, 202, 227 psychology , 1, 15–34, 293 Social customs , 187 Transference , 16, 17, 22, 24, 27, 31, 32, 34, Social reciprocity , 231, 318 142, 153, 154, 300, 315 Social referencing , 64, 85, 123, 193, 203 Transitional object , 28, 32, 139, 140 Sociocultural theory , 74 Transitional phenomena , 139 Something more , 156 Trauma-focused cognitive behavioral Songer, D. , 26 therapy , 174 Spezzano, C. , 39 Trevarthen, C. , 69, 81 Spitz, R. , 63 Tronick, E. , 68, 82, 177, 265, 274, 276 Splitting , 29, 31, 138, 143, 146, 147 Tucker, P.M. , 332 Spontaneity , 346 Tutter, A. , 172 Index 373

Twinship , 31 W Two-person psychology , 37–60, 101, Wachtel, P.L. , 15, 46, 55, 92, 127, 148 117, 118 Wallin, D. , 154, 155 Two-person relational model , 21, 25, 31, 152 Wasserman, M.D. , 59 Two-person relational psychology , 1, 15, Watkins, C.E. , 333 20–21, 24–26, 31, 33, 34, 38, 44–46, Wee-widdler , 19 54, 80, 116, 118, 120, 122–125, 130, We-go , 65 136, 154, 155, 159, 165, 207, 235, We-ness , 65 269, 272, 279, 331 Westen, D. , 47 Two-person relational psychotherapy , 51, 63, Winer, R. , 154 145, 164 Winnicott, D.W. , 6, 26–29, 139, 141 Typical conversation , 236 Wittels, F., 21, 22, 43 Worked through , 16 Working memory , 227 U Working with parents , 252, 274, 290, 302, 327 Unconscious(ly) , 15–18, 22, 27, 29, 32, 34, 59, 83, 119, 142, 162, 308 drives , 54 Y Yanoff, J.A., 17, 168 Y model , 333 V Vaillant, G.E. , 151 Video recordings , 349 Z Visual–spatial abilities , 226 Zipes, J. , 178 Vitality , 213 Ziv-Beiman, S. , 165, 166 Vygotsky, L. , 74 Zone of proximal development , 74